Focused Protection, Herd Immunity, and Other Deadly Delusions

Focused Protection, Herd Immunity, and Other Deadly Delusions

Focused Protection, Herd Immunity, and Other Deadly Delusions

Abandoning solidarity for the siren song of age-targeted reopening is a political error and a medical mistake.

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Many readers of The Nation may also subscribe to Jacobin, as I do. I am happy to have two progressive publications appear in my mailbox regularly, one a longtime favorite and the other a more recent pleasure. A few weeks ago, as I was browsing online at Jacobin, I found an interview, headlined “We Need a Radically Different Approach to the Pandemic and Our Economy as a Whole,” with Harvard professors Katherine Yih and Martin Kulldorff. I was excited to read it. My Yale colleague Amy Kapczynski and I have written about how to rethink our approach to Covid-19 in a series of articles for another great lefty journal, Boston Review, where we have called for a new politics of care to confront the neoliberalism and white supremacy baked into health care and public health in America. I was hoping to see a similar call emerge in Jacobin’s pages online.

However, after some acknowledgement of the impact the pandemic has had on the poor and vulnerable in the United States, the piece makes a sharp detour into a defense of herd immunity, the very same strategy supported by Scott Atlas, President Donald Trump’s most favored adviser at the moment—and roundly criticized by experts around the country, including more than 100 of Atlas’s own colleagues at Stanford. Fast forward to this week, where one of the Harvard professors in question, Martin Kulldorff, along with Dr. Jay Bhattacharya from Stanford University and Sunetra Gupta from the University of Oxford, were in D.C. meeting with Scott Atlas and Health and Human Services Secretary Alex Azar to promote their new “focused protection” strategy in which “schools and universities should be open for in-person teaching. Extracurricular activities, such as sports, should be resumed. Young low-risk adults should work normally, rather than from home. Restaurants and other businesses should open. Arts, music, sport and other cultural activities should resume.” In the words of Donald Trump, “America will again and soon be open for business,” across the board, if we follow the advice of these professors.

What has shocked and dismayed the vast majority of people working in public health and clinical medicine about this strategy is that it is heavy on the rationale for reopening or “liberating” states, cities, and towns and light on the “focused protection” part. Kulldorff, Bhattacharya, and Gupta are confident that we can sequester and protect the elderly and vulnerable from the virus, while the young and fit go about their business as usual and their getting infected is seen as their contribution to the building of herd immunity, presenting little risk to them.

Let’s put this into some real-world context. In the United States, only a small proportion of older Americans live in nursing or care homes, where we have shown little ability to keep our elders safe over the past eight months. The bulk of older Americans are integrated into our communities, living alone or with their spouses or their families. Even if we could make nursing homes into impenetrable fortresses impervious to viral entry, it’s not at all clear how we’d keep the millions of elderly “safe” as they live around, among, and with us. In fact, data from CDC suggests that we haven’t done a good job at all on this, and when virus cases surge in young people, the elderly are next in line for transmission.

Another group of people to whom these three august academics give short shrift are the chronically ill in America. The CDC estimates that nearly half of all Americans (47.5 percent) have underlying conditions that predispose them to severe Covid-19 outcomes. If it is a challenge to think of sequestering the elderly, what do we do with almost half of our fellow Americans who may be at similar enhanced risk of complications and death from Covid-19? Then there are the young. Kulldorff, Bhattacharya, and Gupta would have you believe that young people have little to fear from Covid-19, urging them to resume their normal lives. Yet if you look at hospitalizations for young adults with Covid-19 in a national study, 21 percent required intensive care, 10 percent required mechanical ventilation, and 2.7 percent died. Many of these young people had chronic conditions, which enhanced their risk—and over half of the young people hospitalized in this cohort were Black or Latino.

The herd immunity strategy, whether you call it this or “focused protection” or “age-targeted,” has already been tried without success, notably in Kulldorff’s native country, Sweden, which with less strict measures in places—particularly among the young—ended up with more deaths than its neighbors and didn’t avoid the economic impact of the pandemic, either. Furthermore, Sweden’s robust welfare state and national health care system probably averted even more serious carnage from its approach. In the United States, with our safety net in tatters, and where we don’t have such protections in place, pursuing a herd immunity approach could spell disaster.

There are other differences that would make the Swedish experiment an exercise in folly in America: Swedes have greater faith in their government and were willing to comply with voluntary restrictions; because of their national health system, they would not lose their homes or their livelihoods if they got sick; many Swedes live alone (not in multigenerational households as is common here); Swedes also have lower rates of the comorbidities I described above that put millions and millions of Americans at high risk for complications of Covid-19.

And that vaunted herd immunity? Even in Sweden, the proportion of the population exposed to the virus has been relatively low. Swiss epidemiologist Christian Althaus put it succinctly in an interview last month when he said the idea that Sweden would reach herd immunity was “always sort of ridiculous.… This idea that, basically 50 percent, 60 percent, 70 percent of people get infected and then the problem is solved, that was never really based on scientific foundation…. It’s very unlikely that something like that can be achieved, and even if it could be achieved, it would come—at least in countries with a population demography like European countries or the US—with a huge cost.”

The epidemic has taken a toll on all of us, with the full force of Covid-19 falling on the poor and vulnerable, as Yih and Kulldorff suggest. But the answer isn’t to indulge in wishful thinking, shoddily conceived notions of herd immunity, proposals unmoored to the realities of where and how we live, and who we are. We can do better.

We need more nuanced, targeted approaches using data on our local epidemics (which will require, in part, massive investments in testing), crafting interventions to address what is happening in our communities, evaluating them for their epidemiological, and social, and economic impact, adapting and changing them as the evidence changes, too. Though we slowed the pandemic this spring, the scattershot strategies we employed came without any real support for ordinary Americans from Washington, leaving most of us alone against the virus.

But Kulldorff, Bhattacharya, and Gupta’s plan, enshrined as the Great Barrington Declaration unveiled at the American Institute for Economic Research this week, is not the way forward. If we’re going to build toward a new politics of care, it will be by relying on progressive principles of justice and equality—not some notion of the survival of the young and the fittest. Nor by paying lip service to the hundreds of millions of elderly and chronically ill in this country, while having no plan to support them. We certainly won’t get there by giving cover to the White House and governors like Ron DeSantis—which is what Kulldorff and Bhattacharya have done explicitly in meetings with them over the past few weeks—to conduct business as usual. Business as usual for these men has led us to this precipice. Are we really going to follow them over the edge?

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