The more we accept our coexistence with covid, the more it becomes an inevitability, writes John Middleton

There has been much talk about Boris Johnson’s negotiated plan for taking England out of lockdown, and it seems the scientists have won over the political pressures to relax restrictions quickly. We know that national economies have done better where the virus has been suppressed to very low levels so the aims of public health and economics are the same in this case. The prime minister is to be encouraged in his efforts not to make the mistakes of the past, but the virus is not negotiating. England’s roadmap still contains major weaknesses, which threaten to see us bounce back into future lockdowns because there is not the political will to stamp out the virus. 

The road is running on weak foundations

Community infection rates are still nearly four times the level they were when lockdown was reduced last May. The ONS community infection survey estimates that there were 657 600 infections in the two weeks to 12 February, compared with 184 400 in the two middle weeks of May 2020, and 25 900 at our lowest levels at the end of June 2020. Modelling assumptions show just how precarious covid-19’s level of transmission is—coming down but able to shoot back up with any weakening of current resolve. The SAGE/SCI-MO modelling scenarios released on Monday show how even under the most optimistic conditions, we can still expect thousands more people dying from covid-19. The government cites improvements in test and trace, but it is still inadequate. Support for self-isolation is also still not sufficient to enable people to stay off work and is bureaucratically operated. Reliance on lateral flow testing risks false negatives and clusters of new cases.  

With community infection rates so stubbornly high it is entirely fair to ask, why relax now? What is imperative enough not to continue lockdown, through to the Easter holiday and get the community levels down as low as possible? There have been extraordinary commitments made across the breadth of society and to throw those away before the virus is returned even to the low levels of the last summer would be to waste our communal sacrifice. 

The road is uneven

England’s data on cases, deaths, and hospitalisations assemble together a national position that is made up of varying pictures around the country and in different communities. Areas where vaccination rates are lower, added to areas where people belong to higher risk ethnic minority groups and work in higher risk environments, will undermine progress in reducing the virus. These pockets provide foci for new outbreaks, potentially in younger ages, leaving us vulnerable to new variants. 

Three promising papers were published earlier this week showing that vaccines do what they should in real world conditions. But we still do not know how long immunity will last in vaccinated individuals. It’s not a case of either vaccination or containment strategies to control covid; we need both to give us our best chance of success.

The pandemic is not a straight road  

Doing a deal with the virus is not a linear process—if we do this, the virus will do that. People continue to be surprised at the ever changing pattern of the virus’s behaviour, yet new variants will continue to appear; some will be more infectious (like the Kent variant) and some may be more deadly (as early reports show the California strain may be).

Driving on the right—the schools big bang 

While the roadmap may be cautious, its first action clearly isn’t. Sending all children back to schools in the so called “big bang” is a major risk. In Johnson’s roadmap, we are all eventually going to drive on the right hand side; the schools are going to do it first, and if that succeeds we will all do it. 

The government has set out a compelling case for children to be in school; we can all agree how important it is for their learning and education, and even more so on the grounds of its impact on children’s socialisation and mental health. Five year olds have lost a fifth of their lives to covid-19. It has long been accepted that children generally are not severely affected by the infection and more evidence is appearing that suggests children are not major sources of spread. However, schools are major foci for gatherings of adults in any community; their opening involves teachers, parents, services, and all will be major users of public transport. High circulating levels of virus in the community can interact with the spread of virus in schools. Scotland has opted for a phased return of children to school. While Israel, further ahead than the UK in vaccinating its population, began by only reopening schools for preschool children to year 4. The government’s justification for the big bang seems weak and high risk. 

And are we assured that everything has been done that could be done to create safe environments? Not really. It appears that schools will be going back with very few additional protections. Masks are required in classrooms for secondary school pupils but not for others. The vaccination of teachers is not planned, even though teachers are now the fourth highest occupational group likely to test positive for covid-19. Lateral flow testing in secondary schools for staff and pupils presents a “logistical nightmare,” and the tests cannot be relied on. False negatives mean fresh outbreaks could kick off. During lockdown, there appears to have been very little extra provision for improving ventilation in classrooms, despite the roadmap acknowledging the role of aerosol transmission in spreading the virus. The government has given no consideration to a phased return with alternating year groups, rotas, or shortened daytime attendance. 

Road blocks—messaging  

The prime minister seems to be seeking to avoid the mistakes of the past, yet despite his talk of going slowly and leaving gaps between the new rules to measure their effect, this was at odds with other parts of his rhetoric. What, for example, will some people have made of talk of the plan being “cautious, but also irreversible”?  It’s perhaps no wonder that many people will be working to the dates set out in the plan, rather than the cautions of “no sooner than.” The “one way road to freedom” is likely to join “Happy Monday,” “Operation Last Gasp” and “Whack a mole,” and “Have yourself a merry little Christmas and I do mean little.” We can all recognise the desire to do something, but the government needs to emphasise that it is still more in hope, than in knowledge and expectation. Maybe it is the best we can expect given the political pressures within government.  

The more we accept our coexistence with covid, the more it becomes an inevitability and a self-fulfilling prophecy. Perpetual covid. It feels like we are on a road to nowhere rather than a road to freedom.  

John Middleton, president of the Association of Schools of Public Health in the European Region (ASPHER). Twitter @doctorblooz

Competing interests: None declared.