Lancet Paper Claims Zero Covid Is a Sensible Strategy, but It's Not Very Convincing

Yesterday, a short paper titled “SARS-CoV-2 elimination, not mitigation, creates best outcomes for health, the economy, and civil liberties” was published in The Lancet. The authors claim, “Countries that consistently aim for elimination – i.e., maximum action to control SARS-CoV-2 and stop community transmission as quickly as possible – have generally fared better than countries that opt for mitigation – i.e., action increased in a stepwise, targeted way to reduce cases so as not to overwhelm health-care systems.”

This claim is supported by three charts, each comparing “OECD countries opting for elimination” with “OECD countries opting for mitigation” (see below). The first chart shows that “OECD countries opting for elimination” had fewer deaths per million; the second shows that they had smaller declines in GDP; and the third shows that they had less restrictive lockdowns.

The authors note, “With the proliferation of new SARS-CoV-2 variants of concern, many scientists are calling for a coordinated international strategy to eliminate SARS-CoV-2.” They also note, “Countries that opt to live with the virus will likely pose a threat to other countries” whereas those “opting for elimination are likely to return to near normal”.

One might be tempted to conclude that “elimination” (or “Zero Covid” as it’s sometimes termed) is a sensible strategy going forward. However, I don’t find the authors’ analysis very convincing.

First, they don’t explain how they classified countries as either “opting for elimination” or “opting for mitigation”. For example, did they simply look at outcomes (which would be circular), or did they examine statements by politicians from the spring of last year? (E.g., “This Government will pursue an elimination strategy.”) It’s not clear.

Only five countries were classified as “opting for elimination”: Australia, Iceland, Japan, New Zealand, and South Korea. All other OECD countries were classified as “opting for mitigation”. It may have occurred to you that the five “eliminationist” countries are not exactly representative. Four are islands and one is a peninsula (with a fairly impenetrable border to the north). Two are East Asian. And in fact, these two – Japan and South Korea – are the only East Asian countries in the OECD.

As I argued in a piece for Quillette, all the Western countries that have kept their death rates low are geographically peripheral countries that imposed strict border controls at the start (Norway and Finland, plus a few islands). Their geographic circumstances not only made border controls practical, but also gave them a head start in responding to the pandemic.

It’s very unlikely that large, highly connected countries like France, Italy or the US would have been able to contain the virus during the deadly first wave. And although Britain is an island, we probably wouldn’t have been able to either. The epidemic was already more advanced in London and other international hubs by the time most Western countries introduced lockdowns and social distancing.

In other words, “elimination” was probably never a realistic option for Britain and other large Western countries – even if it could have a passed a cost-benefit test. But what about Japan and South Korea?

Although South Korea did use a combination of early lockdowns and strict border controls to contain the virus, the same cannot be said for Japan. According to the Oxford Blavatnik School’s COVID-19 Government Response Tracker, Japan has had only two days of mandatory business closures and zero days of mandatory stay-at-home orders since the pandemic began. (And the two days of mandatory business closures were the 25th and 26th of April this year.)

Japan did introduce border controls quite early, which may have protected it during the first wave. However, these were not sufficient to prevent an epidemic from burgeoning in the winter of 2020–21. (By early February, the number of daily deaths was in the 90s.) Yet this epidemic retreated without any real lockdown measures being imposed, which suggests that some other cultural or biological factor accounts for Japan’s success.

Second, even if you believe an “elimination” strategy was feasible for Britain and other large Western countries in the early weeks of the pandemic, that ship has arguably sailed. This is particularly true for Britain, where almost 70% of adults now have COVID antibodies. In other words: while it might have been sensible to “eliminate” the virus last spring (assuming that was possible), the costs of doing so now would almost certainly outweigh the benefits.

Overall, the Lancet study does not provide a strong case for “elimination” of COVID-19. And in fact, a survey by Nature of 119 experts found that 89% believe it is “likely” or “very likely” that SARS-CoV-2 will become an endemic virus. As Michael Osterholm – an American epidemiologist – noted, “Eradicating this virus right now from the world is a lot like trying to plan the construction of a stepping-stone pathway to the Moon. It’s unrealistic.”