- Interview by
- Nicole Aschoff
For the better part of a year the world has battled SARS-CoV-2, a novel coronavirus that has killed nearly a million people and sickened tens of millions. In the United States the virus has wreaked havoc, particularly on older members of the population. Americans aged fifty-five and older account for more than 90 percent of the nearly two hundred thousand US COVID-19 deaths, while roughly 0.2 percent were people under twenty-five.
Efforts to quell the virus have brought additional pain. As of late August, roughly nineteen million Americans were out of work as a result of the pandemic, and food and housing insecurity has increased dramatically. But the pain caused by lockdowns has not been shared equally.
Elites have seen their stock portfolios balloon in value, and many professionals have been able to keep their jobs by working from home. It is the country’s poor and working-class households, particularly those with children, who have borne a disproportionate share of the burden. Lower-income Americans were much more likely to be forced to work in unsafe conditions, to have lost their livelihoods due to business and school shutdowns, or to be unable to learn remotely.
Jacobin editorial board member Nicole Aschoff sat down with two public health experts to discuss the challenge of keeping Americans safe without forcing working people to bear the lion’s share of pain and risk.
Katherine Yih is a biologist and epidemiologist at Harvard Medical School where she specializes in infectious disease epidemiology, immunization, and post-licensure vaccine safety surveillance. Yih is also a founding member of the New World Agriculture and Ecology Group and a long-time activist in farm labor and anti-imperialist struggles.
Martin Kulldorff is a professor of medicine at Harvard Medical School. Kulldorff has developed methods for the detection and monitoring of infectious disease outbreaks which are used by public health departments around the world. Since April, he has been an active participant in the COVID-19 strategy debate in the United States, his native Sweden, and elsewhere. This interview has been lightly edited for clarity.
What features of the novel coronavirus have most surprised you? Do these features make the coronavirus more challenging for scientists and public health officials to battle than previous viruses, such as MERS and SARS?
Pandemics are recurring events in world history, and each pandemic is different. Nothing about this one is particularly surprising. What makes it more challenging and different from MERS and SARS is its contagiousness in combination with its spread through mildly symptomatic, presymptomatic, and asymptomatic individuals, which makes it impossible to contain in the same way.
On the positive side, there is a more than thousand-fold difference in mortality risk by age, which can be used to minimize mortality, although we have largely failed to do so.
The emergence of a pandemic like this shouldn’t have surprised us. Under capitalism, we have become a species that increasingly exploits other creatures and their habitats, and moves in large numbers and with great speed around the globe, making us ripe for a pandemic like this one.
I think I have been most surprised by the varied course COVID-19 can take and particularly some of the consequences that have shown up in some patients only later, like blood clots and long-lasting effects resembling myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). There is still a lot that is unknown about this virus and the disease it causes, and we need to acknowledge this.
The uncertainty surrounding the coronavirus has convinced many policymakers, at least in the United States, that the best course of action is to stay at least partially locked down until a vaccine is developed. What are your thoughts? Is it wise to wait for the vaccine?
I don’t think it’s wise or warranted to keep society locked down until vaccines become available. There are nine vaccines in large-scale efficacy trials as of mid-September 2020, and my guess is that at least one will be approved for use in the United States by some time in 2021. But this is not certain to happen. Furthermore, neither the effectiveness nor the duration of immunity from any of these vaccines is known as yet.
There are additional uncertainties about how many vaccines can be manufactured, distributed, kept at the requisite temperatures, and administered in a short amount of time after authorization or licensure, and whether a sizeable portion of the population will refuse vaccination. So we can hope but we certainly can’t count on a vaccine saving us either as individuals or as a population in the short term.
Regarding policy, early in the US epidemic, based in part on the experiences of Italy and Spain, the urgency of “flattening the [epidemiologic] curve” was emphasized. It was indeed crucial to take steps to ensure that hospitals and health care resources not be overwhelmed, as they very nearly were in parts of New York City, for instance.
But I have been struck by how this emphasis on keeping the numbers down at all costs has not evolved with time. There is a kind of simplistic goal of keeping people from getting infected, period. Now this may seem like a worthy goal, but with a highly contagious respiratory virus to which most of the world’s population is probably still not immune, people are going to get infected. The virus will spread, quickly or less so, until herd immunity is reached.
Instead of a medically oriented approach that focuses on the individual patient and seeks (unrealistically) to prevent new infections across the board, we need a public health–oriented approach that focuses on the population and seeks to use patterns, or epidemiologic features, of the disease to minimize the number of cases of severe disease and death over the long run, as herd immunity builds up.
We will have a vaccine sometime between three months from now and never, and we must do our utmost to protect older high-risk individuals until then. The US Food and Drug Administration (FDA) criteria for a successful vaccine is 95 percent confidence that it is effective in at least 30 percent of the recipients. Hence, if and when a safe vaccine is approved, it may not be able to protect us on its own, without the help of some immunity from natural infections.
Children and young adults have minimal risk, and there is no scientific or public health rationale to close day care centers, schools, or colleges. In-person education is critically important for both the intellectual and social development for all kids, but school closures are especially harmful for working-class children whose parents cannot afford tutors, pod schools, or private schools.
The vaccine and “herd immunity” are often presented in opposition to each other in strategic discussions, with the latter evoking viscerally negative reactions. . .
Somehow, herd immunity has become a toxic phrase, which is strange, since it is a scientifically proven phenomenon just like gravity. Except for the occasional skier, people do not argue for or against gravity. Whatever strategy we use for COVID-19, we will eventually reach herd immunity, either with a vaccine, through natural infections, or a combination of the two.
So, the question is not whether we get to herd immunity or not. The issue is how to get there with the minimum number of casualties. We do not know what percent immunity to the coronavirus is needed to achieve herd immunity, but we do know that if there are many older people in the group that is infected, there will be many deaths. On the other hand, if mostly young people are infected, there will be very few deaths.
I think the visceral reaction is against the notion that societies should do nothing and just let the virus spread unchecked throughout the whole population, thereby achieving herd immunity quickly, and killing a lot of older and vulnerable people along the way. The mere mention of “herd immunity” seems to conjure up this reckless, let-her-rip approach in people’s imaginations.
But herd immunity is something that simply happens with infectious diseases — when enough people have been infected (or vaccinated) and become immune, the pathogen is sufficiently blocked by the immune people that it can no longer spread in the population (although it doesn’t necessarily go extinct, due to newly susceptible people entering the population and importations of the pathogen from other human populations).
Herd immunity can be achieved by natural infection, effective vaccination, or a combination of the two. And the process of getting to herd immunity can be managed in such a way that the more vulnerable people are protected from infection while others help the population reach herd immunity, thereby minimizing the number of deaths.
Further, if many of us incorporate fairly sustainable measures like frequent handwashing into our daily lives, the proportion infected needed for herd immunity will be less than otherwise. Laissez-faire is certainly not the only way and certainly not the responsible way to get there.
Sweden, a social-democratic country with a population of roughly 10.4 million people, has eschewed a lockdown strategy and has received sharp criticism from nearly all corners for doing so. Martin, you have pushed back against this criticism, arguing that Sweden’s strategy is actually the most effective for getting the coronavirus under control. Should the United States act more like Sweden?
Sweden has pursued an age-targeted strategy, with the aim of protecting high-risk older people while children still go to school and young adults live reasonably normal lives. While there has been near universal criticism from international mainstream media, the strategy has wide popular support within the country.
Except for the failure to protect nursing home residents in Stockholm, the country has done well without a lockdown. For example, day care centers and schools were never closed for children aged one to fifteen, with zero COVID-19 deaths as a result and only a few hospitalizations. Moreover, teachers faced the same risk as the average among other professions. COVID-19 mortality is now close to zero in Sweden, and the United States has now passed Sweden in terms of deaths per million inhabitants, despite Sweden having an older, more high-risk population.
The Swedish age-targeted approach is similar to the strategy used in South Dakota and the current strategy in Florida. It is the opposite of the strategies employed in New York and Massachusetts, where low-risk children are prevented from going to school and low-risk young professionals protect themselves by working from home, while older working-class people must go to work to feed their families, and where elderly infected patients were sent to nursing homes to infect other high-risk residents.
This strategy has caused enormous harm to the working class, especially the urban working class, since infectious diseases tend to affect urban areas more harshly than rural areas.
Ok, but what about Denmark, Norway, and Finland? Sweden’s death rate was five times higher than Denmark and roughly ten times higher than Norway and Finland?
You are correct. To date, Swedish COVID-19 mortality has been higher than in some and lower than in other lockdown countries. While it is popular to compare COVID-19 mortality rates between countries, it’s not a great metric. It’s like judging marathon runners by their positions after thirty minutes of the race.
Mortality rates also vary greatly between different regions within the same country despite a uniform strategy, depending on where and when the disease first arrived. Rather than deaths per population, a more relevant but elusive metric is the number of deaths per infected. A universal lockdown can successfully postpone cases into the future, as it has done in some countries, but in doing so it also postpones the buildup of immunity.
Some experts have warned that the US lockdown strategy could have serious long-term consequences in other spheres of public health, such as cancer screenings and mental illness. Do you agree?
Yes, there are various kinds of preventive care, including routine immunizations, that have been delayed and might continue to be delayed because of this epidemic. It may take some years to see the actual effects of this deferred preventative care in terms of diseases that would otherwise have been prevented or caught at earlier stages, but there will surely be an impact. In just one example of this, a recent study in Italy estimated that delays in colorectal cancer screening beyond four to six months would significantly increase the number of late-stage colorectal cancer cases, and delays beyond a year would increase the number of colorectal cancer deaths.
Like Dr Yih, I am very concerned about the collateral damage of lockdowns. In public health policy, we cannot just consider the present consequences of one single disease. We must think more broadly, considering all short- and long-term health outcomes.
For example, we must consider the effects of postponed cancer screenings, less favorable cardiovascular disease outcomes, plummeting childhood vaccination rates, fewer dental cleanings, worsening mental health, and more house evictions.
Another example is school closings. Good education is not only important for academic achievement and financial well-being; it is also critical for the mental and physical health of children and into their subsequent adulthood. Kids have minimal risk from this virus, and it is sad that we are sacrificing our children instead of properly protecting the elderly and other high-risk groups.
Another major concern is the impact that the coronavirus and subsequent lockdown has had on working-class households in the United States. While professionals have largely been able to work from home, and elites have seen their stock portfolios balloon in value thanks to infusions from the Fed, the majority of the population is really struggling.
Locking down society is a blunt instrument whose goal has been to keep the overall numbers down at all costs. Lockdowns have been vastly unfair in their impact and have exacerbated disparities in wealth and power. Millions of working-class people have lost their jobs and find it impossible to find new ones in the current shuttered economy. (It is remarkable that the media pay so little attention to the extreme economic hardship being endured by millions of people who were already struggling to make ends meet before the pandemic.)
Millions of others must continue working in high-risk jobs. Many white-collar workers, on the other hand, have been able to work safely from home. Thus, workers on the front lines, like health care workers, mass transit drivers, grocery workers, meatpackers, and many, many other occupational groups, are contributing disproportionately to the herd immunity that will ultimately protect everyone.
Yes, I think the lockdown is the worst assault on the working class in half a century, and especially on the urban working class. In effect, we are protecting low-risk college students and young professionals who can work from home at the expense of older, high-risk, working-class people that have no choice but to work, leading to more deaths overall. There have been studies, for example in Toronto, that show that lockdowns have primarily protected high-income, low-minority neighborhoods, but not low-income or high-minority neighborhoods.
Of course, the economic toll on working families has been immense, but the impact of COVID-19 in terms of death and illness has been disproportionately visited upon the elderly, particularly those living in nursing homes. Recent estimates suggest that more than four out of ten Americans who died from COVID-19 lived in nursing homes or assisted living facilities. Katherine, do you think this was unavoidable?
Nursing home residents are in a sense a captive group, whose caregivers circulate daily from the community at large to work and, inside nursing homes, from patient to patient. Personal protective equipment (PPE) for nursing home staff was also in short supply early in the US epidemic. So, without a doubt, infection control has been and remains a big challenge in that setting.
But the number of deaths from COVID-19 in nursing homes didn’t have to be as high as it was.
Adequate PPE and strict implementation of measures such as mask-wearing and frequent handwashing very likely could have markedly reduced the number of nursing home residents who became infected and died. Also, the policy of bringing COVID-19-positive patients into nursing homes to receive skilled nursing care was terribly misguided, and clearly led to disease transmission and death that could have been avoided.
Currently, there are more options than there were earlier, including frequent testing of staff and residents, requiring infectious staff to stay home, restricting visitors to those with very recent negative test results, and arranging for direct patient care to be provided only by staff with a positive antibody test or a history of confirmed COVID-19. These testing-based measures, together with more traditional infection control measures, should be implemented to protect nursing home residents as we head into fall and winter.
Experts say black and Hispanic Americans have been hit harder by the coronavirus in terms of illness and death, but they’ve also suffered more as a result of the lockdown in terms of job loss and food and housing insecurity. This creates a policy dilemma for progressives. What are your thoughts on how to deal with this dilemma?
First, the main reason for this is that black and Hispanic Americans are overrepresented among the urban working class. Second, it is not a policy dilemma, since the solution is the same for the two problems.
With an age-targeted approach that protects older people while younger adults live more normal lives, older working-class people will be better protected, and the devastating effect of the lockdowns on working-class families will be much less severe. For the working class, the age-targeted approach is a win-win strategy.
The dilemma is for the managerial class. Many of us pay lip service to equality and anti-racism, but we have chosen lockdowns to protect ourselves while throwing the working class under the bus.
If the lockdown in our communities is lifted responsibly, such that schools, colleges, stores, restaurants, museums, parks, beaches, and most other places where people congregate reopen, while the elderly and others at risk of severe disease and death are protected, infection rates will go up, but this will happen predominantly among younger, healthier people.
With this approach, life for most can go on somewhat normally, people who have been especially harmed by COVID-19 directly and by the lockdown — including black and Latinx urban workers and other exploited and marginalized groups — can rebuild their lives and livelihoods, and herd immunity will be reached more quickly than under lockdown, while minimizing the number of cases of severe COVID-19 disease and death.
Of course, it is easier said than done to protect the elderly while society’s institutions open up and people get back to work and school. I don’t mean to minimize the difficulties of keeping elders safe, particularly in communities where families tend to live in multigenerational households, whether for economic or cultural reasons.
I agree with Dr Yih that we shouldn’t minimize the difficulties. Compared to current efforts, there are several ways to better protect high-risk people above sixty. If those still in the workforce cannot work from home, they could be allowed to use social security for a temporary one-year sabbatical. Groceries can be delivered so elderly people do not have to expose themselves while shopping. Empty hotel rooms could be used to temporarily house older people from multigenerational households.
For nursing homes, the key is to utilize staff with acquired immunity and to frequently test other staff members as well as all visitors. It is also important to minimize the number of staff that each nursing home resident is exposed to. While it is not possible to provide 100 percent protection to everyone, these are just a few examples of what could and should be done.
Thinking more broadly about the raging debates about how best to handle the economic and social fallout of the coronavirus, it is striking how politicized the discussion is in the United States.
Yes, the discussion of COVID-19 policy has become polarized into two camps, with most liberals advocating some form of lockdown and people on the Right arguing to open up. It is difficult to insert a reasoned argument into the debate without being categorized as taking one of these unnuanced positions and then being dismissed or actively vilified by “the other side.”
It is unfortunate that the Right has so easily been able to appropriate the anti-lockdown position as their own, which conceivably has gained them supporters in the fraught political arena. Their motivation, for the most part, has been to protect the economy, not public health. But their stance appeals to a wide range of people who have been hurt by the lockdown.
Liberal elites, including the Democratic Party establishment, have actively ceded this terrain, instead emphasizing the importance of lowering infection rates (across the board) until a vaccine becomes generally available. I think the liberal elites’ adoption of this approach stems from the easy appeal of keeping “everyone” safe together with a class position for which the lockdown strategy is in fact safer as well as quite easy to ride out. Liberal elites simply can’t see or can’t feel how this strategy continues to fail the working class and also small business owners.
I am aligned with the Left when I defend the COVID-19 strategy in my native Sweden. But here in the United States, when I defend very similar strategies implemented by the Republican governors of South Dakota and Florida, I am perceived as being aligned with the Right. It is a little weird. Among my infectious disease colleagues that favor an age-targeted strategy rather than lockdowns, most are left-wing progressives, while most of my Twitter followers are on the Right.
As a public health scientist, it is my duty to fight for public health independently of partisan politics. I hope that people from across the political divide can come together to end a lockdown that is so damaging to public health, and instead advocate for age-targeted counter measures that properly protect high-risk individuals. After all, we live in this world together, sharing both its beauties and its viruses.
What should the position of the Left be, whether progressive scientists or just ordinary people, in all of this? What should we be demanding? Also, where can we get more information?
An age-targeted strategy protects all older high-risk individuals until herd immunity is reached, whether rich or poor, while keeping schools open for our children and letting young low-risk adults live their lives and support their families. For more information, I recommend reading a fantastic interview with Professor Sunetra Gupta at Oxford University. In my view, she is the world’s preeminent infectious disease epidemiologist.
The responsibility needs to be shared. Progressives need to reject the unquestioning lockdown approach, which is simply inappropriate unless and until hospitals and other health care facilities are in danger of being overwhelmed. We need to be scrupulous about protecting the elderly and other high-risk groups. Others should be permitted to go about their business and keep society functioning. Workers must have access to personal protective equipment, COVID-19 testing, and sick pay.
Schools and universities should reopen, but elderly teachers, professors, and administrative staff should teach/work from home. Feasible infection control measures should be taken, and students and staff who become ill should stay at home, in a dedicated COVID-19 dormitory, or, if necessary, in the infirmary.
Similar procedures should be followed in the wider world of work, whether it be white-collar or blue-collar work. At long-term care facilities, staff and residents should be frequently tested for COVID-19. Those who test positive for active infection should stay home for at least fourteen days or until any symptoms are gone. Patient care should be handled by those having had COVID-19 in the past. The incarcerated should be protected using similar measures.
The moralistic finger-wagging must also stop. It makes no sense to try to shame or, worse, expel from college young people who go to parties or bars. My colleague Julia Markus has written persuasively about how counterproductive this attitude is. Infectious diseases will spread, and exposures in young, healthy people contribute to the herd immunity that will ultimately benefit all.
Progressives should be advocating for a sustainable, communitarian approach that is informed by the knowledge that the virus will spread until herd immunity is achieved, acknowledges the need for stringent protections of the vulnerable in order to minimize deaths, and recognizes the harm caused by crude across-the-board lockdowns and their disproportionate impact on workers and people of color.
The pandemic has laid bare the glaring and growing inequalities in our society, if they weren’t evident before. We must continue to fight for a radically fairer society, including, of course, Medicare for All. The need is greater than ever.