Balancing economic and health realities has made navigating the coronavirus pandemic challenging. Early in the crisis, a lack of information was combined with potentially dire consequences that justified quarantine responses. As information and facts have come into focus, what is the right approach going forward?
Economic lockdown has been successful in preventing undue stress on health care systems, though many regions of the United States have not been stressed by the outbreak. With the peak in health care demand passed, it becomes time for lockdowns to end and adapting to persistent coronavirus to begin. How can policymakers make this transition with minimal risk?
A misconception is that economic lockdown can eradicate coronavirus, at which point the population can emerge without risk of recurrent outbreak. The high numbers of asymptomatic individuals put this goal out of reach. Dr. Anthony Fauci, director of National Institute of Allergy and Infectious Diseases, recently acknowledged the reality that a recurrent outbreak is inevitable. This inevitability is illustrated by the experience of the USS Kidd, where a Navy servicemen developed coronavirus symptoms a month after the ship’s last port of call. The shipboard spread of COVID-19 remained hidden by infections passing between healthy individuals. Widespread and hidden in much larger populations, coronavirus has moved beyond a pandemic. Coronavirus is here to stay.
Despite great emphasis, testing is an unlikely solution. Since the majority of cases are asymptomatic, it would require that every contact of sick patients be found and tested. Those testing positive would have to report all of their contacts for additional testing, and so on. This is in a nation of over 300 million people that has extensive foreign travel. The infrastructure needed for test and trace is astounding, and the potential for infections to escape test and trace is certain.
Fortunately, emerging data reveals that coronavirus does not present an equal risk to everyone. New York City has experienced the most widespread outbreak, with 12,287 deaths reported by April 28. While terrifying, the breakdown of deaths is informative. The relationship with age has been widely reported. How many under 18 years of age have been killed by coronavirus in New York City? Six. And even this small number doesn’t tell the whole story, as all six deaths were in patients with preexisting medical conditions. How many otherwise healthy people have died from coronavirus, regardless of age? Seventy, or about 1 in 175 deaths. The risk of death from coronavirus is highly concentrated in individuals with underlying health problems.
A serious problem with gauging the response to the coronavirus is knowing lethality, which has been complicated by the high proportion of asymptomatic infections. Recent sampling in New York City indicates that 21% of residents have been infected with coronavirus. This means New York’s coronavirus death rate is about 0.7%, significantly greater than from the flu. But for New York residents without preexisting medical conditions, the death rate is only about 0.00057%, or 132 times lower than for those with preexisting conditions.
A higher susceptibility to coronavirus clearly shows that social distancing and quarantine should be highly targeted to those with preexisting medical conditions. These measures must last until transmission of coronavirus between healthy individuals can be minimized.
Slowing transmission among the healthy can be accomplished by development of herd immunity, meaning that viral exposure has rendered so many in the population immune that an outbreak can never gather steam. For COVID-19, this requires that 60% of the population be immune. The safest way of reaching herd immunity is with a vaccine. Though there are encouraging signs from animal studies at Oxford, the development of a vaccine takes time and is not certain. Widespread use of a vaccine for coronavirus within one year would shatter an optimist’s best expectations.
The alternative path to herd immunity is by direct exposure to someone who is infected with coronavirus. Ironically, economic lockdowns prevent natural transmission among healthy individuals. What was required to adapt to coronavirus in the early stages of pandemic coronavirus prevents long-term adaptation to endemic coronavirus. In short, lockdowns and social distancing should be abandoned for health reasons, not just economic ones. In fact, social contact should be encouraged among the healthy and young. Counterintuitively, we actually want to spread coronavirus among the healthy population.
One objection to allowing development of natural herd immunity are concerns that immunity to COVID-19 is not possible. If true, this would also make a vaccine impossible to develop. In fact, inability to mount immunity would mean one could never overcome a COVID-19 infection, yet patients do recover. The most likely worst-case scenario is that antibody production generates limited long-term immunity, but would still reduce the impact of a later infection and boost immunity further.
Another objection is that lives will be lost and the health system taxed in pursuit of herd immunity. With selective social distancing and lockdowns for high-risk individuals, much of this will be mitigated. Yet some healthy individuals will indeed die. Achieving 80% immunity in New York City would result in the deaths of 210 additional otherwise healthy persons — this in a city that experienced over 550 deaths in a single day at the peak of the outbreak.
Achieving similar levels of herd immunity nationally would result in 11,000 deaths of otherwise healthy persons, far below the number of people who die in auto accidents every year or from a typical flu season.
Importantly, delay or prolonging development of herd immunity confers few advantages. Future deaths accumulate during strict lockdown, a result of delaying or omitting “elective” medical care as the health care system focuses exclusively on coronavirus. Illustrating this, deaths from cancer and heart disease alone result in roughly 1.5 million deaths per year in the United States. A 5% increase in death rate from delaying or omitting care for these diseases would result in 75,000 deaths.
A new risk focuses the human mind and the result is often not rational. The human mind underestimates risk for anything outside of its immediate attention (downgrading the risk of a stock market crash during economic boom, for example) and overestimates risk for anything in focus (the risk of being killed in a terrorist attack in the months after the 9/11 attacks, for example). Heightened attention is undoubtedly driving irrational reaction to the coronavirus.
Unfortunately, an instinctive “run and hide” response makes social distancing and economic lockdowns comforting, and transitions away from this policy are met with significant resistance. Nonetheless, the data clearly indicate that a major transition in managing the coronavirus is warranted. That transition means an end to broad economic lockdown and social distancing. Except for those at high risk, a return to full normalcy is urgent.
Marc Hansen is a professor of physiology and developmental biology at Brigham Young University. He holds a doctorate from Stanford University in cancer biology. His views are his own.