Focused Protection: The Middle Ground between Lockdowns and “Let it Rip.”
Jay Bhattacharya, Sunetra Gupta, Martin Kulldorff
November 25, 2020
Both COVID-19 itself and the lockdown policy reactions have had enormous adverse consequences for patients in the US and around the world. While the harm from COVID-19 infections are well represented in news stories every day, the harms from lockdowns themselves are less well advertised, but no less important. The patients hurt by missed medical visits and hospitalizations due to lockdowns are as worthy of attention and policy response as are patients afflicted by COVID-19 infection.
In a recent JAMA sponsored COVID-19 debate with infectious disease epidemiologist Prof. Marc Lipsitch, Dr. Jay Bhattacharya argued against lockdowns and its collateral damage on medical care and public health.[1] At the conclusion of the debate, the moderator, JAMA editor Dr. Howard Bauchner asked whether there may exist a middle ground in COVID policy. That is the right question. Is there a middle ground between lockdowns – with school, business and office closures, curfews, and isolation – and a laissez-faire “let it rip” approach?
In the Great Barrington Declaration, co-signed now by many thousand medical scientists and practitioners, we laid out such a middle-ground alternative, with greatly improved focused protection of older people and other high-risk groups.[2] The aim of focused protection is to minimize overall mortality from both COVID-19 and other diseases by balancing the need to protect high-risk individuals from COVID-19 while reducing the harm that lockdowns have had on other aspects of medical care and public health. It recognizes that public health is concerned with the health and well-being of populations in a broader way than just infection control.[3]
This may surprise some readers given the unfortunate caricature of the Declaration, where some media outlets and scientists have falsely characterized it as a “herd immunity strategy” that aims to maximize infections among the young or as a laissez-faire approach to let the virus rip through society. On the contrary, we believe that everyone should take basic precautions to avoid spreading the disease and that no one should intentionally expose themselves to COVID-19 infection. Since zero COVID is impossible, herd immunity is the endpoint of this epidemic regardless of whether we choose lockdowns or focused protection to address it.
The premise of the Declaration lies on two scientific facts. First, while anyone can get infected, there is more than a thousand-fold difference in COVID-19 mortality [4],[5] between the oldest and youngest. Children have lower mortality from COVID-19 [6] than from the annual influenza.[7] For people under the age of 70, the infection survival rate is 99.95%.[8] We now have good evidence on the relative risk posed by the incidence of chronic conditions, so we know that among common conditions, age is the single most important risk factor. For instance, a 65-year-old obese individual has about the same COVID-19 mortality risk conditional upon infection as a 70-year-old non-obese individual.[9]
Second, the harms of the lockdown are manifold and devastating, including plummeting childhood vaccination rates[10], worse cardiovascular disease outcomes[11], less cancer screening[12], and deteriorating mental health[13], to name a few. The social isolation induced by lockdown has led to a sharp rise in opioid and drug-related overdoses[14], similar to the “deaths of despair” that occurred in the wake of the 2008 Great Recession.[15] Social isolation of the elderly has contributed to a sharp rise in dementia-related deaths around the country.[16] For children, the cessation of in-person schooling since the spring has led to “catastrophic” learning losses[17], with severe projected adverse consequences for affected students’ life spans.[18] According to a CDC estimate, one in four young adults seriously considered suicide this past June.[19] Among 25 to 44-year olds, the CDC reports a 26% increase in excess all-cause mortality relative to past years, though fewer than 5% of 2020 deaths have been due to COVID-19.[20], [21]
The harms of lockdown are unequally distributed. Economists have found that only 37% of jobs in the US can be performed wholly on-line, and high-paying jobs are overrepresented among that set.[22] By declaring janitors, store clerks, meat packers, postal workers, and other blue-collar workers as “essential” workers in most states, regardless of whether they qualify as high COVID mortality risk, the lockdowns have failed to shield the vulnerable in these occupations. The economic dislocation from the lockdowns has increased the number of households where young adults who have lost their jobs co-reside with vulnerable older parents[23], which may increase the risk of COVID-related death.[24] In addition, school closures have contributed to shortages of nurses and other medical personnel who stay home to care for their children rather than work.[25] Very clearly, exposing people to the medical and psychological harms from the lockdowns is ethically fraught.[26]
The two main planks of focused protection and the Great Barrington Declaration follow logically from these two facts. For older people, COVID-19 is a deadly disease that should be met with overwhelming resources aimed at protecting them wherever they are, whether in nursing homes, at their own home, in the workplace, or in multi-generational homes. For the non-vulnerable, who face far greater harm from the lockdowns than they do from COVID-19 infection risk, the lockdowns should be lifted and – for those who so decide – normal life resumed.
Lockdown proponents assert without evidence that the only way to protect the older vulnerable population is to limit general community transmission, in effect arguing that focused protection is impossible. We disagree. Standard public health practice regularly seeks creative ways to protect vulnerable people from a host of diseases and conditions that threaten them, and COVID-19 should not be an exception. In many publications[27],[28],[29] and at the Great Barrington Declaration site itself[30], we have delineated many practical policies to this end. These include, e.g., frequent on-site testing and limiting staff rotations in nursing homes, free home delivery of groceries for the home-bound vulnerable, providing disability job accommodations for older vulnerable workers, and temporary accommodations for older people living in multi-generational homes. The prospect of effective and safe COVID-19 vaccines offer an additional avenue for improved focused protection of high-risk individuals, both directly and by vaccinating caregivers. Still, better protection of the elderly cannot and should not wait until a vaccine is widely available.
Inconsistent with the standard pandemic preparedness plans that existed before the COVID-19 epidemic, lockdowns are, and have always been, a radical approach to infection control.[31] Focused protection is the middle ground that will end the pandemic with the least harm to the vulnerable and non-vulnerable alike.
References
1 JAMA Network (2020) Herd Immunity as a Pandemic Strategy. JAMALive. Nov. 6, 2020. https://www.youtube.com/watch?v=2tsUTAWBJ9M&feature=emb_title
2 Kulldorff M, Gupta S, and Bhattacharya J (2020) Great Barrington Declaration, Oct. 4, 2020. https://gbdeclaration.org/
3 Public Health Leadership Society (2002) Principles of the Ethical Practice of Public Health. American Public Health Association. https://www.apha.org/-/media/files/pdf/membergroups/ethics/ethics_brochure.ashx
4 Kulldorff M. (2020) COVID-19 Counter Measures Should be Age Specific. LinkedIn Memo. April 10, 2020. https://www.linkedin.com/pulse/covid-19-counter-measures-should-age-specific-martin-kulldorff/
5 Chikina M and Pegden W (2020) Fighting COVID-19: The Heterogenous Transmission Thesis. Mimeo. Carnegie Mellon University. March 16, 2020. http://math.cmu.edu/~wes/covid.html
6 CDC (2020) Provisional COVID-19 Death Counts by Sex, Age, and State. Nov. 24, 2020. https://data.cdc.gov/NCHS/Provisional-COVID-19-Death-Counts-by-Sex-Age-and-S/9bhg-hcku
7 CDC (2020) Estimated Influenza Illnesses, Medical visits, Hospitalizations, and Deaths in the United States — 2018–2019 influenza season. Nov. 24, 2020. https://www.cdc.gov/flu/about/burden/2018-2019.html
8 Ioannidis JP (2020) Infection Fatality Rate of COVID-19 Inferred from Seroprevalence Data. Bulletin of the World Health Organization. Article ID: BLT.20.265892. https://www.who.int/bulletin/online_first/BLT.20.265892.pdf
9 Public Health England (2020) Disparities in the Risk and Outcomes of COVID-19. August 2020. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/908434/Disparities_in_the_risk_and_outcomes_of_COVID_August_2020_update.pdf
10 CDC (2020) Effects of the COVID-19 Pandemic on Routine Pediatric Vaccine Ordering and Administration — United States, 2020. MMWR. 69(19): 591-3. https://www.cdc.gov/mmwr/volumes/69/wr/mm6919e2.htm
11 Ball S, Banerjee A, Berry C, et alMonitoring indirect impact of COVID-19 pandemic on services for cardiovascular diseases in the UKHeart Published Online First: 05 October 2020. doi: 10.1136/heartjnl-2020-317870
12 Rutter MD, Brookes M, Lee TJ, et alImpact of the COVID-19 pandemic on UK endoscopic activity and cancer detection: a National Endoscopy Database AnalysisGut Published Online First: 20 July 2020. doi: 10.1136/gutjnl-2020-322179
13 Vizard T, Davis J, White E, Beynon B (2020) Coronavirus and depression in adults, Great Britain: June 2020. Office for National Statistics, UK. https://www.ons.gov.uk/peoplepopulationandcommunity/wellbeing/articles/coronavirusanddepressioninadultsgreatbritain/june2020
14 American Medical Association (2020) Issue Brief: Reports of Increases in Opioid- and Other Drug Related Overdose and Other Concerns During COVID Pandemic. AMA Advocacy Resource Center. Oct. 31, 2020. https://www.ama-assn.org/system/files/2020-11/issue-brief-increases-in-opioid-related-overdose.pdf
15 Deaton A and Case A (2020) Deaths of Despair and the Future of Capitalism. Princeton University Press. March 17, 2020.
16 Alzheimer’s Impact Movement (2020) The 2020 COVID-19 Pandemic and Dementia: Deaths Above Average. https://www.scribd.com/document/483085777/Dementia-Deaths-Above-Average-State-by-State-Table
17 Center for Research on Education Outcomes (2020) Estimates of Learning Loss in the 2019-2020 School Year. CREO Stanford University. October 2020. https://credo.stanford.edu/sites/g/files/sbiybj6481/f/short_brief_on_learning_loss_final_v.3.pdf
18 Christakis DA, Van Cleve W, Zimmerman FJ. Estimation of US Children’s Educational Attainment and Years of Life Lost Associated With Primary School Closures During the Coronavirus Disease 2019 Pandemic. JAMA Netw Open. 2020;3(11):e2028786. doi:10.1001/jamanetworkopen.2020.28786
19 Czeisler M , Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1049–1057. DOI: http://dx.doi.org/10.15585/mmwr.mm6932a1
20 Rossen LM, Branum AM, Ahmad FB, Sutton P, Anderson RN. Excess Deaths Associated with COVID-19, by Age and Race and Ethnicity — United States, January 26–October 3, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1522–1527. DOI: http://dx.doi.org/10.15585/mmwr.mm6942e2
21 CDC (2020) Provisional COVID-19 Death Counts by Sex, Age, and State. https://data.cdc.gov/NCHS/Provisional-COVID-19-Death-Counts-by-Sex-Age-and-S/9bhg-hcku
22 Dingel JI and Neiman B (2020) How Many Jobs Can Be Done at Home? National Bureau of Economic Research Working Paper #26948. April 2020
23 Evandrou M, Falkingham J, Qin M, and Vlachantoni A (2020) Changing Living Arrangements, Family Dynamics and Stress During Lockdown: Evidence from Four Birth Cohorts in the UK. University of Southampton Eprint Soton. https://eprints.soton.ac.uk/443865/1/family_dynamics_during_covid_19_final.pdf
24 Fenoll AA & Grossbard S (2020) Intergenerational residence patterns and Covid-19 fatalities in the EU and the US, Economics & Human Biology, 39. https://doi.org/10.1016/j.ehb.2020.100934.
25 Bayham J & Fenichel EP (2020) Impact of school closures for COVID-19 on the US health-care workforce and net mortality: a modelling study, The Lancet Public Health 5(5): e271-e278, https://doi.org/10.1016/S2468-2667(20)30082-7.
26 Cristea, I. A., Naudet, F., & Ioannidis, J. P. A. (2020). Preserving equipoise and performing randomized trials for COVID-19 social distancing interventions. Epidemiology and Psychiatric Sciences. https://doi.org/10.1017/S2045796020000992
27 Kulldorff M, Gupta S, & Bhattacharya J (2020) We Should Focus on Protecting the Vulnerable from COVID Infection. Newsweek. Oct. 30, 2020. https://www.newsweek.com/we-should-focus-protecting-vulnerable-covid-infection-opinion-1543225
28 Bhattacharya J (2020) It’s Time for an Alternative to Lockdown. Oct. 29, 2020. The Spectator. https://www.spectator.co.uk/article/it-s-time-for-an-alternative-to-lockdown
29 Kulldorff M and Bhattacharya J (2020) Lockdown Isn’t Working. Nov. 2, 2020. The Spectator. https://www.spectator.co.uk/article/lockdown-isn-t-working
30 Kulldorff M, Gupta S, Bhattacharya J (2020) The Great Barrington Declaration, Frequently Asked Questions. https://gbdeclaration.org/frequently-asked-questions/
31 European Centre for Disease Prevention and Control (2020) Influenza Pandemic Preparedness Plans. https://www.ecdc.europa.eu/en/seasonal-influenza/preparedness/influenza-pandemic-preparedness-plans
