We are increasingly seeing the argument that the combination of available vaccines and a more infectious virus mean we should lockdown harder for ‘just a little longer’ as the vaccine rollout gathers pace. This is offered as the only way to prevent the NHS being overwhelmed. Tier 5 is looming.

What is Tier 5?
But what does this mean? What would Tier 5 entail? Tier 4 now covers most of England and is strikingly similar to the Spring national lockdown. The delay to school re-opening (including primary schools in some areas) has effectively introduced a higher tier of restrictions which take households in those areas further back towards the Spring restrictions. Even highly resourced professional sport seems to be struggling to maintain secure bubbles and may need a ‘circuit break’. So how much more scope do we have for restrictions? Curfews? Outdoor face coverings? Maybe, but it seems that even the architect of the UK lockdown, Professor Ferguson doesn’t see much left likely to have any real impact beyond closing schools. The fact is that in the UK, even the closure of all the things we deem non-essential still leaves a lot of people moving around. Someone has to staff the hospitals, and the supermarket, and make the deliveries, and repair infrastructure etc etc. It turns out that in our society we have a first world definition of ‘essential’, which means it’s quite a long list. But even if we aren’t able to lockdown to the degree a zero COVID strategy would require, the argument is increasingly made that we should strengthen our restrictions as far as we can tolerate for another few months. But is this really a logical conclusion?

Why suppression?
Those who support restrictive measures — and this includes the UK Government — generally do so because they believe that these measures can prevent, or at least impede, the spread of the virus. There are two reasons why this is a good thing. Firstly, it means that the health service is faced with a manageable flow of Coronavirus patients rather than a tidal wave. Everyone knows by now — flatten the curve, protect the NHS, save lives. Secondly it means that fewer people will get infected before they are able to get vaccinated. So the longstanding official position is that by suppressing the spread across society, we save lives.

The strategy of suppression depends on the measures we are taking being effective to reduce the speed at which the virus spreads (the R rate). And yet it seems that we are now faced with a Coronavirus variant that has become harder to contain. This raises an extremely important question. Are the restrictive measures that we have put our faith in — Hands, Face, Space (and throw in ventilation even though it doesn’t rhyme) failing us? And if they are no longer effective against this more resourceful version of the virus, is there any point in continuing with them?

By this point in the pandemic, for the vast majority, the alternative of abandoning these measures seems deeply irresponsible — unthinkable even. We would be firmly in ‘let it rip’ territory, with potentially dire consequences in terms of sickness and death. Abandoning the collection of measures that we have come to call ‘social distancing’ feels out of the question. So as much through fear of the alternative as for belief in the measures we are taking, we choose to accept the premise that restrictions of one sort or another can still help us prevent the virus from spreading. The question becomes not whether to use them at all, but how to achieve the best effect with the minimum of collateral damage to people’s health, livelihoods and well-being.

Lockdown Fatigue
For all that most sensible compassionate people are prepared to accept the need for restrictions, there is undoubtedly some reluctance. For some it is the loss of freedoms and the perception that we are drifting into Orwell territory. For others it is the collateral damage or the uncertainty of what lies ahead. Some feel it keenly and with burning anger, for others it is a dull constant sadness, waking up knowing that it is all still going on, and that once again we are faced with schools closed, social contact banned, and leisure activities unavailable. No question that some cope better than others, and that in most people’s minds the overall goal justifies the struggle. But the fact remains that we could all cite a host of reasons why living under restrictions is — at best — undesirable.

Ultimately we are all human. When we are asked to do undesirable things for any length of time, we have a tendency to slip up occasionally. And for the most part we are still trying to adhere to the (often very complicated) rules, so if we do break one, it is for good reason, through misunderstanding, or in a way that we perceive to do the minimum of harm. This is what we might call ‘lockdown fatigue’. Perfectly understandable, and on an individual level probably forgivable. But the problem is one of scale. Millions of minor breaches significantly increase the opportunity for the virus to spread. The purist or zealot has an easy answer. Stop breaking the rules. But most of us are less pure than that, so it is hardly surprising that there is an almost daily parade of politicians, lawmakers and high profile figures who have slipped up, let alone the rest of us.

The combination of a more infectious virus and growing lockdown fatigue puts pressure on the premise that we can still control the spread. We know that we cannot abandon the measures we have been using, so we need to find a way to refresh or reinvigorate them, both by using them more effectively and by finding a way to counter lockdown fatigue.

Protecting the vulnerable
The best way to re-examine our approach to the protective measures we are taking is to re-visit their ultimate purpose. That comes down to protection. To some extent that is protection of everyone, but we are particularly concerned in the case of Coronavirus with those most likely to suffer from being infected. Long COVID is clearly a problem for younger infected people, but a quick glance at mortality confirms that the ultimate price is far more often being paid by more elderly people and those with certain pre-existing conditions. Those preconditions may not have prevented the person in question from living a long and happy life, but with COVID added to the mix, the prognosis quickly becomes much worse. This is the reason for the ‘protect your gran’ messaging, although of course, it is not just your gran, but also your neighbour’s and so on. It is also the reason we are rolling the vaccine out to those who are most at risk.

While the logic of protecting the vulnerable is easy to grasp in the context of the vaccine rollout, it is less obvious how we would apply it to the protective measures we use. Focused protection strategies like the Great Barrington Declaration have been criticised for being impractical or ineffective, so how do we overcome those objections?

The first thing to establish is who we focus on? This is a real stumbling block for many proponents of focused protection but there is a neat answer. Everyone can choose for themselves whether they should be in the protected category. In making their choice, people naturally have to consider not just themselves but also their household/family/work mates etc. So someone who would otherwise be classed as less vulnerable may live in close proximity with someone who is extremely vulnerable. By allowing everyone to choose for themselves we can focus on those who want protection with no exclusions and no arbitrary judgements. It is also important to recognise that people’s positions will change. They may recover from infection or get vaccinated. Or more data may emerge to indicate a higher/lower risk than they had previously believed. By allowing people to make their own assessment of risk, they retain the flexibility to adjust their position as things change.

Allowing this self-identification of the need for protection means that the group requiring protection would be much larger than a traditional view of who is at risk. It might form the majority of the population, depending on how risk was being presented and the attitude to personal risk that people took. But given that we are all currently asked to apply the same measures irrespective of the context or who we are in contact with, treating large numbers of people as requiring protection would be no harder than what we are currently undertaking.

Once we know who, we have to establish how we do it. Essentially we would rely on existing measures, tweaked by whatever further advice emerges, but these would be applied only when sharing a space with a person who has indicated that they require protection. The website has suggested a shorthand way in which people could signal to others whether they wanted protection or not. This is one suggestion, but people could communicate their position in whatever way they chose. This would provide a higher level of protection because it would allow people and venues flexibility to cater better for each other’s needs.

This is easiest explained with some examples. Food is the most obvious essential item so let’s take a supermarket chain. Imagine that in one area they operate two stores which can each cater for 1,000 people a day shopping in store following current restrictions. But it is decided that reducing flow of people through the stores could help suppress the virus. So now each store can only accept 500. The stores would probably introduce some type of booking system, or might limit amount of visits per week but they would have trouble getting everyone in. Instead of that, what if we could open up one store without any restrictions while the other is restricted to 500? If 1,500 of their clients classed themselves as not needing protection then the problem would be solved. Even if the numbers were reversed so that 1,500 needed protection, the chain could allow a window of opening where no restrictions applied to allow the 500 to get through faster. If they were able to take care of the 500 who did not require protection more quickly that would make more time/space for the protected group.

What about a small high street pharmacy? If staff all class themselves as not requiring protection then they could also choose to divide up their opening time into windows for customers who require protection and those who don’t, enabling them to get more customers through in total, and making more space for the protected ones. If some staff want protection then they might work the protected shifts, or if all staff required protection then the business would operate fully on a protected basis, which is no different to what is required currently.

In some cases the particularities of a venue might allow a mixture. A cinema could re-open with protected screens and non-protected. The common areas would have to insist on full protective measures being employed. And for those who would worry about being in a confined space even with full distancing/masks etc, they always have the choice not to attend.

There are limitless examples at all ends of the spectrum. For some there will be few options beyond their current position, but for a great many the innovative spirit and endeavour that went into staying afloat in 2020 can be directed towards a faster recovery in 2021.

The result
So by allowing more flexibility in the choices we give people and how those choices are catered for, we avoid the worst economic, social and health impacts of a full lockdown, we offer more opportunities for businesses to cater for clients who are still willing to attend in person, and we make more space for businesses to open in an ultra-secure way, if it is deemed that extra measures would help. No-one is forced into a situation where they are not comfortable, or which makes them more vulnerable. In fact the opposite. We are able to reduce contacts and therefore to offer more opportunities to those who do not just want to isolate at home. And for the section of the population who do not consider themselves at risk — whether due to their age/health, prior infection or vaccination — they are able to lead a life with far fewer constraints.

All of this is achieved with simpler rules which directly target anti-social behaviour. Failure to respect the needs of someone who has indicated that they require protection would be deemed selfish and anti-social by society and thus society would enforce the rules effectively with less intervention from authority. Compare that to the difficulty that society has condemning, for example, gathering with one’s consenting family at Christmas after all parties had been self-isolating for a week to ensure minimal risk. These rules, based on people declaring their own need for protection, would be in place in the same way throughout the country and would not need to be tweaked or repurposed on a weekly or daily basis.

Even in the absence of a vaccine, this system of rules would provide a much more sustainable alternative to the cycle of restrictions that we are currently locked in. But the rollout of vaccines means that the numbers of the vulnerable should quickly reduce, allowing more and more people to identify as no longer in need of protection. This will make the wait for the point when all people have been offered a vaccine (and all restrictions can be abandoned) that much easier to endure and by allowing us to better protect the most vulnerable, should help us to ease pressure on the health service in the meantime. This system would also hold true in the unfortunate circumstance of the vaccine not working as anticipated. Should there be a short duration of immunity, logistical issues in getting the second vaccine rolled out within an appropriate window, or poorer efficacy for certain subsets of people, this set of rules that everyone understands would just be enacted for longer and allow life to continue.

The current Tiers legislation expires on 2 February. By then we should have significantly increased the number of those who have been vaccinated. Even at time of writing, the number of people who have received the vaccine in the UK is over 3.5x the total number of people who have been hospitalised in the UK during the entire pandemic and close to 40x the number of people in hospital with Coronavirus at the moment. This is a staggering success, and has been achieved at a pace that few believed possible.

MPs and the Government must now take the opportunity to build on that success and start the process of moving the country decisively towards the normality that most crave by replacing the current legal restrictions with a system that protects better by giving people a choice of how to live. Rather than adding an additional tier, four tiers should now shrink to two categories. Protected or not. Same rules across the nation. The vaccines are the finish line, but rather than stumble towards it, we have the opportunity to sprint.

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