Searching for Normality

As the world increasingly eases its various lockdowns, first in Asia and Australasia and now with gathering momentum in Europe, we are moving from a simpler world of black and white into a very much more interesting and challenging one of shades of grey.

Scientists and politicians alike have realised from the start that this has the potential to be a difficult period.   The extreme simplicity of the rules under the earlier stages of total lockdown – in some countries, the rules were very strict indeed – are giving way to a more nuanced set of what is allowed, what is still restricted and what remains for the moment outright forbidden, and the ability of the general population to understand what it is and is not permitted to do is not guaranteed.  And that is before factoring in “lockdown fatigue”, as people who were willing to abide by the harshest of restrictions in the early stages of the pandemic increasingly chafe at the bit, wonder why they need to continue to do so and start to take liberties.

This is worrying those in authority, because of one very simple fact:  Covid-19 has neither been defeated nor gone away.  It is true that some countries appear to be increasingly in a “post-Covid” state – step forward above all New Zealand, with no new cases at all for well over a week and as of 31 May only one person (out of a population of 5 million) who is known to still have the disease.  But even in New Zealand, life is not yet fully back to normal, and their borders remain completely closed:  the country’s important tourism industry faces a long wait before it can once again welcome overseas visitors.

For most of the rest of the world, the fear that the disease may reappear at any time remains, whether it is already in the country and latent, or whether it might be brought in by international travellers.  And so the restrictions on normal life, while they are easing, do still remain, particularly the social distancing which makes much of society, especially urban society, so challenging if not outright unworkable.

There are at least three reasons why this is likely to remain the case, and rather neatly they fall into the three categories of Before infection, During infection, and After infection.  “Before infection” is concerned with controlling and reducing the passing on of the disease to new victims; “During infection” is concerned with the experience and survival rates of those that do catch the disease; and “After infection” is concerned with the status of those who have had the disease and have recovered.

Taking the first of these, Before infection, the biggest challenge society faces is knowing who might be a spreader of the disease, an infector of others.  This is because of two features of Covid‑19 that have been known for some time:  first, one can pass on the disease to another person before showing symptoms oneself, and second, there are a significant number of people who can both carry and pass on the disease without ever showing the symptoms themselves at all or therefore ever knowing the role they have played in the disease’s spread.

This process of apparently healthy people affecting others, technically known as asymptomatic transmission, is not unknown in other diseases.  The best known early example of an asymptomatic carrier was the well-documented case of Mary Mallon, a cook in New York City at the start of the last century who spread typhoid to almost every household she worked for, while showing no sign of having it herself.  In the end she was nicknamed “Typhoid Mary” by the media and was forced by the authorities to spend the last 23 years of her life in solitary isolation.

But Typhoid Mary was a rarity.  The same does not appear to be the case with Covid-19:  by some estimates – inevitably very uncertain – more people may have the disease without showing symptoms than those that show them.

This makes the world’s main current strategy for controlling the disease – track and trace – very difficult.  For as opposed to a world where people are assumed “healthy (and so safe for others) unless visibly sick”, we move closer to a dystopian world where the safest option is to assume that people are “unhealthy (and so a potential spreader) unless proved clear”.  And as well as being deeply unsettling in itself, such a world would imply a need for society-wide testing, even of the apparently healthy, at relatively frequent intervals.  If we do not know who is an asymptomatic carrier, the whole population might need to be tested fortnightly or even more frequently;  to put this in perspective, at the current rate of testing in the UK, it would take well over a year to test the population just once each.

And quite apart from the logistics of such a regime, the consequences for general mental health of telling everyone that they must be repeatedly tested because “at any time you might have the disease without even knowing it” are concerning.  It is not just the mentally fragile who might find such an atmosphere deeply unsettling,

The second challenge from Covid-19 is During infection, and concerns the asymmetrical way it affects people who catch the disease.  Put very simply, some people are much more likely to survive the disease if they are unlucky enough to catch it than others.  Many people – most people – who catch the disease seem to have only a relatively short period of illness, admittedly for some very unpleasant but nevertheless something they do recover from before too long.   Some people though suffer very much more, and of course a small number do not recover at all.

This poses a difficult question:  should the great majority of society, who risk only an unpleasant but survivable spell of illness, continue to have their lives heavily curtailed to protect a more vulnerable minority?  Or should we now move to a state where, now that the threat of overwhelming our health services has receded, the majority are allowed to live much more normal lives (including meeting others socially) while the more vulnerable minority are still encouraged to observe greater care, social distancing, even isolation?

The question is made more awkward by the fact that the identity of those who are likely to suffer more is not random.  The evidence is overwhelmingly that men are on balance rather worse affected than women, that the disease is more serious for the BAME population, that people who suffer from obesity are many times more at risk, and that the disease is particularly dangerous for the very old.

This poses society with a direct dilemma.  To ask such people to take especial care, maybe even to the point of requiring them to observe stricter isolation, goes against all of society’s equality agenda.  No government would be able to promulgate rules that say, for example, “you can visit your mother but not your father”, while making overweight people subject to extra restrictions would run into a torrent of criticism that they were being “fat-shamed”.  And even to suggest that “the BAME population must observe a separate and stricter lockdown” raises the spectre of apartheid and would destroy racial harmony.

It is perhaps revealing that the only sector that does not have a raft of equality legislation and lobby groups galore defending their status is the very old, and the only overtly discriminatory feature of the lockdown that the government has felt able to bring in is the extra curtailment of freedom for those over 70.

But society does need to address this question, because the willingness of the young, fit and healthy to go on accepting restrictions on their daily lives to protect those more at risk will not be unlimited.

Lastly, we have the challenge of After infection.  A lot of hope is riding on the discovery of a vaccine – in the absence of being able to banish the disease completely, the next best solution is to make the general population immune to it.  But this does rather assume two things:  firstly that after a mild dose of the disease, one cannot catch it again (this is how vaccination works), and secondly, the period for which one is protected is long, ideally for the rest of one’s life but at any rate long enough to have just infrequent booster jabs.

Unfortunately, scientists have yet to show even that those who have had the full blown disease are fully immune to catching it again – there are examples of people testing positive a second time after having had and recovered from the disease.  If these are more than just isolated incidences, it calls into question whether any vaccine can be reliably effective.  And certainly there is as yet almost no evidence for how long immunity lasts.

There is therefore a risk that medical science will not find a reliable vaccine, not this year, nor even next year, perhaps never.  We do not, for example, have either a cure for or a vaccine against the common cold.  At which point, society will have to make an interesting choice:  if we cannot become immune to the disease, should we simply become inured to it and accept it as part of human existence?

This question revolves around how much risk society is willing to take in its pursuit of a normal liveable life.  There is no such thing as a totally risk‑free existence and we all take risks every day, from crossing the street to meeting a stranger to walking around our cities.  Driving at speed is one of the most dangerous things we do, but society long ago decided that the advantages from allowing private motoring far outweigh the costs of injury or death from road accidents;  the requirement for cars to travel at less than 4 mph and to have a man carrying a red flag walk in front of them has long since been abolished. 

In the same vein it is possible that in time we would become as resigned to and accepting of Covid‑related deaths as we are of road deaths, and decide that life must go on despite them, because the alternative, a life in permanent semi-lockdown with stifled economies and limited social engagement, travel and the like, is worse.

We have not yet reached this point.  A vaccine remains the first best solution and progress in finding one is encouraging.  As long as this remains the case, the world is probably right to stick to plan A:  semi-lockdown and social distancing to hold the fort until we can all be made immune.

But at some point, if a vaccine is delayed and delayed, we may yet have collectively to consider plan B:  more normal lives but with slightly elevated death rates.  The alternative, a semi‑existence, afraid to live because we are afraid to die, has never in the end been mankind’s way.