COVID-19: Focused Protection Is Not A Thing
by Raywat Deonandan, PhD
Epidemiologist & Associate Professor
University of Ottawa
(I add my credentials to these COVID-19 blog posts in case they get shared. I want readers to know that my opinion is supposedly an educated and informed one)
This is a post I really didn’t want to write. I thought we were done with this topic. And I am loathe to give it more airtime. But people keep asking me about it. So here we are.
There is something called “The Great Barrington Declaration” (GBD), which is a proposal put forth by a handful of scientists who disagree with how COVID-19 is being handled in most countries. (You know, people opposed to economic restrictions, masks, distancing, etc.)
You can read the details yourself, but in essence the GBD signatories propose two things: (1) shield the vulnerable, i.e. those most likely to die of this disease. They call this “focused protection”. And (2) let the disease run rampant throughout the rest of the population in order to achieve herd immunity.
First, I talked about herd immunity and why “locking up the old folks” is not a viable strategy way back in April.
Second, scientists adhering to the orthodox view have created a response document, the John Snow Memorandum, advocating strongly against a herd immunity strategy. Full disclosure: I have signed the John Snow Memorandum in my capacity as a Global Health Epidemiologist. So you already know where I stand on this issue.
Third, disagreement is fine. Debate is welcome. We can address our opposing points civilly. So I will attempt to do so now. I hope you remember to do so if you choose to leave a comment.
Better scientists than I have already put forth strong scientific oppositions to the GBD proposal. My goal today is to explain in plain language why I personally think it’s a bad idea. Deep breath. Here we go.
Arguing in Good Faith
When doing a critical appraisal of any study, it’s good form to check to see if the authors of the study have any conflicts of interest. If they’re describing a drug trial, for instance, and happen to be in the employ of the drug company that makes the thing being tested, then that’s an important consideration. That information does not necessarily invalidate the findings of the study, but it does shade its conclusions somewhat.
So who are the authors of the Great Barrington Declaration? Yes, some are very prominent scientists –certainly far more prominent than yours truly. Many (most? all?) are not explicitly COVID-19 researchers. But again, neither am I. So that doesn’t really matter as much as many think it should.
However, the group appears to be sponsored by the American Institute for Economic Research (AIER), a libertarian think thank that is part of the right-wing Koch brothers’ organization. This is important, because the organization has links to Climate Change denial activities and other endeavours promoting pseudoscience for political and economic gain.
I am not saying that the signatories are pseudoscientists or that they are doing this for economic gain. I’m just saying that the political and pseudoscientific histories of one’s benefactors are relevant in assessing whether one’s proposal is truly put forth in good faith and for the genuine benefit of society. It’s a relevant factor to consider.
Now, the signatories also include scores, perhaps hundreds or thousands, of fake names. That’s not the organizers’ fault. I bring it up in case someone claims that these “thousands” of signatures imply that the scientific community is equally split on the matter. No it is not. Make no mistake. The Great Barrington Declaration represents a fringe contingent of scientists, much like Climate Change denial scientists are a stark minority.
It doesn’t mean their voices are not relevant. I’m simply pointing out that it is incorrect to say that scientists are equally divided. We are not. To the extent that a census of opinions matters, this is also a relevant observation.
Who Are the Vulnerable?
Okay, let’s get into the specifics of the proposal. “Focused protection” probably means protecting the people most likely to die of COVID-19. If they meant people most likely to have lingering morbidities, well that’s everybody. We have, at best, a minimal idea of who is going to be a “long hauler” or suffer lingering unpleasantness. So protecting them in a focused matter is simply impossible.
But if we focus just on those most likely to die, as I believe the GBD signatories wish, what do we know? I went through this in depth back in April, based on what we knew then. But I’ll put it again simply. The vulnerable are: (1) the elderly, (2) the overweight and obese, (3) the diabetic, (4) the hypertensive, (5) the immunocompromised or otherwise “unwell”. There are probably some other categories I’m missing.
Ask yourself who in your circles satisfies any of these descriptions. Probably lots of people. This list pretty much covers two thirds of North American society, I would guess.
As I tweeted once: you know who’s got “pre-existing conditions”? Everybody. You’d know this if you ever tried to buy travel health insurance.
So, depending on how you define “vulnerable”, the GBD might be asking us to lock up the majority and let a minority run about freely to seek infection.
How To Protect the Vulnerable?
I would take the Declaration more seriously if there were a plan presented on how exactly we are supposed to shield the vulnerable. Will a parallel society be constructed so that this vulnerable segment of the population (which, remember, might end up being the majority of people in some communities) never interacts with the invulnerable segment?
And what are the cut-offs for vulnerability? Overweight, sure, but by how much? What’s the BMI cut-off? Elderly, sure, but what’s the cut-off? 80? 70? 60? 50? Want to do it based on IFR (infection fatality rate)? Okay, then what’s the cut-off for that? Is an age group with 0.5% IFR too vulnerable but 0.4% is fine? How will these cut-offs be decided? What objective scientific metric?
Children live with their parents. Will children be compelled to live in group homes run by healthy older teens, while all the parents are shipped off to the Gulag of the Vulnerable?
Who will care for the elderly and infirm? Young people with PPE? We know from endless institutional outbreaks that no amount of PPE seems capable of keeping the disease out of institutions, even when the case load is low. Imagine trying to do it while we are encouraging cases to accelerate outside.
So what exactly is the plan here?
Societies are complex. We don’t exist in hermetically sealed bubbles defined by our demographics and underlying medical conditions. On its face, the proposal of “focused protection” must be rejected because it is not actionable in any realistic sense.
Hasn’t It Already Been Tried?
I submit to you that Sweden has tried it already. I know, all the Swedish officials deny that “herd immunity” was never their official goal. But then everyone quietly says that it is. So which is it? If indeed, it was their goal, then part of that goal was the protection of their elderly.
And they failed. Even Anders Tegnell admits that he failed to shield the most vulnerable in his society, despite that being a primary goal.
The reason that they failed is that it is really really difficult to keep a raging infection out of an institution. And that’s when you’re actively trying to limit it’s transmission in the community.
Ethics of Intentional Exposure
The focused protection plan says, in essence, that the young and fit must go forth and intentionally seek infection. The faster the better. In that way, they argue, herd immunity will be achieved.
It is true that the young and fit are much less likely to suffer and die from COVID-19 than are the elderly and unfit. But they are not invulnerable.
In Canada, about 25 million people would need to become infected and recover in order for the nation to achieve herd immunity. (Let’s leave aside for the nonce whether natural infection confers sufficient and lasting immunity to actually get us to herd immunity —rest assured that the jury is still very much in doubt over that.) Even with this healthier selection of people, a tiny fraction will die.
Let’s say for those under 40, the IFR is 0.01%. When applied to a base population of 25 million infections, that means 2500 deaths and many more seriously ill and possibly long term disabled. Even if we focus on the deaths alone, the implication is that we are asking –nay, compelling– our children to go forth and seek a disease we know little about, knowing that 2500 will die.
The hallmark of medical research ethics, enshrined in the Declaration of Helsinki, is that we shall not have a human subject engage in an activity that deliberately puts them in harm and for which there is no obvious benefit.
We would never tolerate a drug, like a vaccine, having the same risks posed by COVID-19 on a healthy population. As Harvard’s Bill Hanage puts it, “Have you imagined the stink there would rightly be if a vaccine had the risks associated with Covid-19?” And yet somehow we are supposed to be okay with deliberately exposing our children to this scenario.
The Trump In The Room
The most powerful and protected man in the world, Donald Trump, contracted COVID-19. This is despite having all those who surround him tested regularly, and despite having access to literally the best medical care and preventative technologies and strategies imaginable.
If the most shielded man in the world –okay, second most shielded man (I see you, Vladimir Putin)– cannot be rendered unreachable by this virus, what hope is there for a 75 year old diabetic grandma living alone in a mid-size city?
What To Do When It Fails?
Finally, what if we were to try this plan? What if we were to somehow attempt to shield the vulnerable and then remove all infection control systems in the country. Let ‘er rip.
And what if I’m right and the infection cannot be contained, and suddenly the elderly, the obese, the diabetic, the micronutrient deficient, those with genetic predispositions we don’t understand, and the unlucky start to become infected? What if, as a result, the ICUs become overwhelmed and our health care system starts to fail?
What do we do then? It would be too late to go back to our current restrictions. Mask wearing, distancing, reduced travel –all of that could not be enacted in time to slow the spread. We would be in public health Hell with no option except to endure the suffering and death.
And it would fail. Remember, to achieve herd immunity, sufficient numbers of people need to recover from the illness and achieve lasting immunity. We don’t know if that is possible. In fact, it might be that any immunity only lasts for a few months, in which case this “wild” population will have to become re-infected again and again.
In the words of Bill Hanage, “What’s being suggested here, given the expected duration of immunity, is endemic transmission, which means the virus will present a continued risk of outbreaks in older age groups indefinitely.”
A vaccine, by the way, does not present the same challenge. We can likely calibrate a vaccine to confer sufficient immunity safely, perhaps via a booster shot, and repeat annually if need be. No need to experience those thousands of preventable deaths again and again.
In my opinion, this is not a risk worth taking.
I am fond of saying that public health is the art of the possible. (Yes, people used to say that about diplomacy. But it works better for public health.) I do not think it is possible to (a) identify the vulnerable, (b) protect the vulnerable, and (c) ethically infect the rest without additional suffering.
In essence, the GBD plan is asking members of society to sacrifice their health to improve the economy. I feel that this is backwards thinking. People’s wherewithal does not exist in service of the economy. Rather, the purpose of the economy is to empower further human well-being.
That is all. I am bracing myself for the predictable flurry of hate in the comments section.