It is now five months since the Omicron variant was first detected in the UK – and although its impact was less severe than many initially feared, it’s estimated that more than 30 million people in England have been infected, with 200,000 hospitalised and even more suffering with long Covid across the UK, and over 20,000 deaths.
Behind these headline figures lies a more complicated reality, yielding important lessons about the impact of government-mandated restrictions that could help end disagreements between some scientists and help us deal with future waves.
The first Omicron (BA.1) wave, beginning in December, showed us that it was possible to get over a peak without a lockdown. The second (BA.2) wave from March to April was the first time a wave peaked in England without any government-mandated restrictions, as all legal mandates ended on 24 February.
And because England chose a different path on restrictions to the other home nations (and other western European countries) during the Omicron waves, this provides a very good “natural experiment” to assess how much difference the varying levels of restrictions made. International comparisons do have limitations, but in the absence of better evidence to judge the effectiveness of Covid restrictions, such natural experiments provide a useful guide, especially in comparing the UK home nations, which have similar populations, age structures, climate/seasons, healthcare systems and population-level immunity to Covid.
I should stress that given the uncertainty of the evidence at the time, it was perfectly reasonable for the home nations to choose different paths – and the extra restrictions outside England had widespread public support. But what will perhaps be surprising to many is that England has actually had a similar rate of infection and a lower rate of Covid deaths during the Omicron wave – and since 19 July 2021, England’s “freedom day” – than Scotland, Wales and Northern Ireland, despite having far fewer mandatory restrictions, and none after 24 February. This “natural experiment” shows that having more mandates did not lead to better outcomes.
There was also no significant difference in overall excess mortality across the home nations to the end of 2021. And England’s is now likely to be lower as – somewhat remarkably, given the Omicron wave – excess mortality is negative in England for 2022 so far, with the lowest age-standardised mortality rates (the best comparator to previous years, as it takes population ageing into account) since the series began in 2001.
Comparisons with countries in western Europe are more problematic as there are variations in how testing regimes operate and how deaths are coded – so data on excess deaths tends to be a better guide. But even here we see that although the UK did the third most tests, it had one of the lowest number of cases in western Europe. The UK has also had the lowest excess deaths in Europe from January to date – and one of the lowest since 19 July 2021 – despite having few restrictions.
This shows that there has been no clear relationship between levels of excess mortality and the intensity or longevity of mandatory restrictions across western Europe once vaccines had been rolled out. (The much higher Covid death rates in central and eastern Europe are mainly due to lower levels of vaccination.)
Last autumn, many were calling for England to follow the example of Germany (and other European countries) in bringing back mask mandates, vaccine passports and other restrictions, as they had lower case rates at the time. But as I and many others pointed out, once vaccination programmes were complete, these strategies were likely to be simply postponing infections to the winter, when health systems would have been less able to cope – which is indeed what happened. Germany has had more infections and excess deaths than the UK during the Omicron wave and since last July, despite having had earlier lockdowns and more government-mandated measures for far longer.
This is partly because voluntary changes to behaviour are as important as those mandated by the government (a majority of people in England still self-isolated and wore masks, even when the mandates ended). And also because it is now population levels of immunity (particularly in older age groups) – either through vaccination or natural infection– that really determines the level of deaths due to Covid. Restrictions make little difference in a highly immune population.
Since the removal of restrictions in England, we have also seen an improvement in measures of personal wellbeing, economic performance and unemployment – all of which are very important to our health.
New variants are all but inevitable, and there is no guarantee they will be milder than Omicron. We must be prepared for this and use this time to properly establish the evidence for the effectiveness of restrictions in case they are needed in the future. And given the focus is more likely to be on persuasion and relying on people to continue taking personal responsibility rather than mandates, we need those asking the public to follow the guidance to be credible – whether politicians, doctors or scientists. We as scientists must regain that trust by accepting our mistakes, explaining what went wrong and what has been learned; and politicians must follow the rules they make.
And finally we must also look at what lessons we can learn from those countries that have had much lower excess death rates than ours (such as Norway) and we owe it to all those who have died and their loved ones to have a proper public inquiry that looks at all the decisions made over the past two years to ensure we learn from our mistakes and see how we can do better in the future.
Raghib Ali is a clinical epidemiologist at the University of Cambridge and a consultant in acute medicine at the Oxford university hospitals NHS trust
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