Public-health physician urges more targeted and less of a “shotgun” approach to stemming the pandemic

March 23, 2020 • 9:00 am

Update: This new article largely echoes the one below: it emphasizes the need to get healthy people back to work, which requires more testing, and to provide adequate protection to healthcare workers. Both pieces emphasize fighting the pandemic in ways to minimize long-term damage to our economy caused by extended periods of people staying at home while businesses are closed. As the article notes, “Paul Romer, who received the Nobel Prize in Economics in 2018, is a professor at N.Y.U. Alan M. Garber, a physician and economist, is the provost of Harvard University.”

A quote:

In the long run, we are likely to have better options — a vaccine perhaps, or effective drug treatments. And at some point, herd immunity, when so many people have immunity that others are unlikely to encounter and fall victim to the virus, will make this coronavirus a far more manageable threat.

But we cannot afford to wait and hope. John Maynard Keynes famously quipped that in the long run, we are all dead. If we keep up our current strategy of suppression based on indiscriminate social distance for 12 to 18 months, most of us will still be alive. It is our economy that will be dead.


David L. Katz (see also here) is a public-health physician and, according to Wikipedia, “the founding director of the Yale-Griffin Prevention Research Center that was founded at Griffin Hospital in Derby, Connecticut in 1998.” I can’t assess his credentials as an epidemiologist, but he’s surely no quack. In an article in yesterday’s New York Times (click on screenshot below), Katz argues that the U.S. is fighting the coronavirus pandemic all wrong. By using a scattershot approach in which everyone is forced to stay home and virtually everything is closed, he argues that we are depriving the most vulnerable (the elderly and immunocompromised) of essential care and equipment, exposing them to younger and healthier people who may carry the disease, and wrecking the American economy by forcing businesses (and maybe schools) to go under. 

Yet just today, the U.S. Surgeon General said of America, “This week it’s going to get really bad.”  I present Katz’s article because it’s worth thinking about, not to urge people to avoid the guidelines which have been laid down by American authorities, both federal and local.

You should read the article for yourself. I’m sure that many of you, like me, have wondered if mass closures of businesses and requiring everyone, young, old, sick, or healthy, to shelter at home, is an effective way to shut down the pandemic—and also maintain the fabric of our society. Katz argues no: that by getting the healthier population to acquire “herd immunity” while removing the susceptible from exposure to the virus, and by testing only the susceptible for the virus, we could stop the plague without wrecking the nation.

Now I doubt that anybody is going to follow Katz’s recommendations, as the “sequester-everyone-and-shut-down-every-nonessential business” mentality is too widespread and ingrained. Still, have a look at his arguments, which I excerpt below (again, read the whole thing). Katz’s quotes are indented.

The clustering of complications and death from Covid-19 among the elderly and chronically ill, but not children (there have been only very rare deaths in children), suggests that we could achieve the crucial goals of social distancing — saving lives and not overwhelming our medical system — by preferentially protecting the medically frail and those over age 60, and in particular those over 70 and 80, from exposure.

Why does this matter?

I am deeply concerned that the social, economic and public health consequences of this near total meltdown of normal life — schools and businesses closed, gatherings banned — will be long lasting and calamitous, possibly graver than the direct toll of the virus itself. The stock market will bounce back in time, but many businesses never will. The unemployment, impoverishment and despair likely to result will be public health scourges of the first order.

Worse, I fear our efforts will do little to contain the virus, because we have a resource-constrained, fragmented, perennially underfunded public health system. Distributing such limited resources so widely, so shallowly and so haphazardly is a formula for failure. How certain are you of the best ways to protect your most vulnerable loved ones? How readily can you get tested?

We have already failed to respond as decisively as China or South Korea, and lack the means to respond like Singapore. We are following in Italy’s wake, at risk of seeing our medical system overwhelmed twice: First when people rush to get tested for the coronavirus, and again when the especially vulnerable succumb to severe infection and require hospital beds.

Yes, in more and more places we are limiting gatherings uniformly, a tactic I call “horizontal interdiction” — when containment policies are applied to the entire population without consideration of their risk for severe infection.

But as the work force is laid off en masse (our family has one adult child home for that reason already), and colleges close (we have another two young adults back home for this reason), young people of indeterminate infectious status are being sent home to huddle with their families nationwide. And because we lack widespread testing, they may be carrying the virus and transmitting it to their 50-something parents, and 70- or 80-something grandparents. If there are any clear guidelines for behavior within families — what I call “vertical interdiction” — I have not seen them.

. . . There is another and much overlooked liability in this approach. If we succeed in slowing the spread of coronavirus from torrent to trickle, then when does the society-wide disruption end? When will it be safe for healthy children and younger teachers to return to school, much less older teachers and teachers with chronic illnesses? When will it be safe for the work force to repopulate the workplace, given that some are in the at-risk group for severe infection?

We all know the pandemic is going to last longer than they tell us, at least based on when schools are set to re-open. But Katz’s alternative: get business back to normal while keeping the most susceptible people out of circulation, and limiting testing to that group or to people who show clear Covid-19 symptoms (my own doctor tells me it’s shortness of breath). Here’s what he suggests (I have to admit it lacks specificity, but differs substantially from what is being done now):

So what is the alternative? Well, we could focus our resources on testing and protecting, in every way possible, all those people the data indicate are especially vulnerable to severe infection: the elderly, people with chronic diseases and the immunologically compromised. Those that test positive could be the first to receive the first approved antivirals. The majority, testing negative, could benefit from every resource we have to shield them from exposure.

To be sure, while mortality is highly concentrated in a select groups [sic], it does not stop there. There are poignant, heart-rending tales of severe infection and death from Covid-19 in younger people for reasons we do not know. If we found over time that younger people were also especially vulnerable to the virus, we could expand the at-risk category and extend protections to them.

However, from what I hear, younger people can die from this virus without any underlying conditions. And if those people are at risk, then “expanding the at-risk category” pretty much means shutting down all schools and businesses—what we’re doing now. Katz doesn’t address this further.

He does, however, make the good points that current policy involves inundating the medical establishment with lower-risk people who don’t need treatment, burdening families with the job of educating and doing extra care of the young while schools and universities are closed, and, above all, forcing susceptible older people to mingle with their younger relatives at home.

One more bit of Katz’s solution:

If we were to focus on the especially vulnerable, there would be resources to keep them at home, provide them with needed services and coronavirus testing, and direct our medical system to their early care. I would favor proactive rather than reactive testing in this group, and early use of the most promising anti-viral drugs. This cannot be done under current policies, as we spread our relatively few test kits across the expanse of a whole population, made all the more anxious because society has shut down.

This focus on a much smaller portion of the population would allow most of society to return to life as usual and perhaps prevent vast segments of the economy from collapsing. Healthy children could return to school and healthy adults go back to their jobs. Theaters and restaurants could reopen, though we might be wise to avoid very large social gatherings like stadium sporting events and concerts.

And there you have it. Of course, this sounds good to those of you who are younger and healthy, as we’re all going stir-crazy, and psychologists warn of an epidemic of loneliness (certainly better than an epidemic of death). But would it work? I do worry, like Katz, that if everything shuts down for months or even longer, we’ll never recover socially or economically, and Katz’s solution deals with that by trading off employment and well-being against the possibility of extra deaths if his policy is implemented. That’s nothing new: we make such societal decisions all the time.

Again, assessing Katz’s recommendations is above my pay grade, and I am not about to tell people that he’s right and it’s fine to flout the regulations. After all, I’m following them, too. But as the months of quarantine draw on, and people start feeling the severe pinch of unemployment, no school, and social isolation, we might wonder whether there’s a kernel of truth to Katz’s arguments.

Please weigh in below.

93 thoughts on “Public-health physician urges more targeted and less of a “shotgun” approach to stemming the pandemic

  1. What I see this guy saying does not appear to be good science. How does he know that letting a couple hundred million people run around unencumbered will cause herd immunity? Who are these mythical people that will take care of the vulnerable without exposing them?

    Sorry, I don’t buy his story.

    1. Incredulity is not a sound reason to doubt something like this. Herd immunity is a well known though poorly understood phenomena and whether you believe it or not, it is critical to keeping most of us free of infectious diseases for which there is no vaccine.

      I think his proposal should be seriously considered because in the few places where the epidemic has been controlled, China, South Korea and Singapore, they did it by testing everyone, tracking people and quarantining the infected. IOW; we already have evidence on how to stop it and that evidence is similar to what is proposed here, though it may be too late for us.

      1. Herd immunity comes from vaccines. Natural herd immunity does happen – a few people are immune and the other 99% of the population dies off from the disease over many, many generations. It’s one of the mechanisms of evolution. Are you looking for that to happen?

        1. Herd immunity can come from vaccines. But it can also come as a result of people getting sick and recovering. Recovered people are the equivalent of vaccinated people.

          It doesn’t require that 99% die off. Nor does it have to happen over many, many generations. It only requires that a large enough percentage people become immune, however that immunity is gained.

          1. I heard a report that said recovering people only have immunity for a few weeks and that some people in China did get reinfected.

            The problem is that we know very little about this virus or how it reacts and interacts. A lot of scientific research needs to be done and that takes time.

        2. Well, natural herd immunity isn’t restricted to fatal diseases. Norovirus is a well known example that cycles through the human population with new strains that break out, causing epidemics. Epidemics which are ultimately attenuated by population based (herd) immunity. It was, in fact, the identification of some of the viral proteins which didn’t change from epidemic to epidemic which enabled the creation of a vaccine. Still, even with the vaccine, we go go through norovirus epidemics. Buggers.

          It is sometimes difficult to distinguish herd immunity from the natural history of viruses. It may be, for example, that the population immunity seen with epidemics of other kinds of cold viruses may reflect viral rather than host responses; after all, those viruses have evolved to as us as hosts. 2019-nCov has not, so that leaves open a lot of questions about our responses to it.

          Nevertheless, I am not sure of Katz’ solution and anyway, I think we’ve missed our chance.

    2. I thought herd immunity was well understood. If most of the population has either has either recovered from the disease or been immunized against it, the density of infectable people is low and the disease can’t jump from person to person very often. What am I missing here?

      1. It can be difficult to disentangle viral responses from host responses. For example, the common cold is caused by a number of viruses, such as Rhinovirus (literally “nose virus”). These epidemics can seem to be controlled by population-based immunity. Enough people get sick then there is no long a pool of people to re-infect. But the attenuation of a Rhino virus epidemic may actually reflect the natural history of the virus itself, not any herd immunity host responses. Still, it is likely that it is a complex dance between viral and host responses that causes viral epidemics to peter out.

        One of the problems with 2109-nCoV is that we HAVE no natural history with it. We may be able to harness herd immunity to limit the pandemic, or it may change so quickly that we cannot. Right now, it appears that this virus mutates at a rate somewhat slower than the flu virus, which suggests that we may have some limited ability for herd immunity but also that we can expect future epidemics.

        1. I guess it depends on how much of this complex interaction one places under the “herd immunity” label. Isn’t it a bit of a misnomer anyway? It sounds like the “herd” has taken collective action (albeit unconscious) against the virus, which is not the case.

          1. It’s a metaphor. Of course we aren’t behaving like a herd. Think instead of a herd of muck ox forming a circle around the most vulnerable in their herd to protect them from a pack of wolves.

  2. I have been following Dr. Dena Grayson for several weeks. She advocates for a nationwide shutdown, not because it is ideal but because the US was so unprepared and waited so long to take this seriously that it’s now too late to do anything else. The goal with a nationwide shutdown is to slow the spread so that hospitals are not overwhelmed. No one wants to start making terrible decisions like sending people over a certain age home to.potentially die because there is no room and no equipment. Also, health care workers are being infected at alarming rates. It’s a mess.

  3. As a member of the over 60 crowd, a parent, and a critical care MD, I appreciate the pandemic from all sides. My own impression is that we are hanging our hopes on the ability to keep the world from falling into chaos long enough to invent a viable vaccine or successfully antiviral therapy, all unproven. If we are successful in flattening the curve enough to prevent the overload of our ICU’s and we are unsuccessful in achieving a pharmacological victory it will take many years to achieve sufficient population immunity to return to normal. Years our economies won’t survive. If we allow this virus to burn through the population unrestrained, it would be over by fall but at the cost of millions of lives that could have been saved by appropriate ICU care. On the other hand, how many people will die as a consequence of the economic ruin engendered by our current course? Are we saving a few this year only to see millions or even billions suffer and die in the future?

    1. You have presented in stark and realistic terms that the choices facing society are between very bad and even worse. No matter what decisions are made tens of millions will suffer through death, sickness or financial calamity. Other societies in the past have collapsed suddenly even though there were warning signs that were ignored by their leaderships. So, what is happening now in not unprecedented except perhaps in its scale. It is likely that the Baby Boomer generation will be the last that its members lived the bulk of their lives in relative prosperity. The notion that the world has never been better will be remembered as nothing more than a snapshot in time, a memory that will fade quickly with time as physical survival becomes the only important goal of most people.

      Perhaps in a year or two a vaccine will save us from degenerating back into a state of nature. But, even under this best case scenario the damage will take decades to repair, if even that can ever be accomplished. Hitler ruined Germany; Trump ruined America. In both cases, their loyal followers could not accept this. Delusional leaders created delusional followers. And that is why we are where we are at.

    2. I’m concerned that the economic aspects are being discussed enough. Yes, people are talking about the economy, but they usually don’t relate it to healthcare. Healthcare is expensive and an economic collapse will certainly cost lives.

  4. A friend of mine is a science professor in the U.S. and still has close family members in China. Before her university shut down, she had already decided to work from home. She told me the “herd immunity” theory terrified her because many people who survive COVID-19 have debilitating medical conditions — severe heart and lung disease. This is well known in China, but I haven’t heard anyone talking about it here. She said that it’s not like the flu; you don’t get sick and then bounce back. If you live, your life could be ruined. My husband and I are hunkered down for as long as it takes. Where I live, we have a stay-at-home order until April 24, but it’s just for our county and not the rest of the state.

    1. Yes physical life long disability not to mention the trauma the population will undergo watching loved ones die. Whole families could be wiped out. What is the cost of that in the long term when we can’t function properly after?

    2. I am glad you are able to hunker down for another month, hopefully you can for much longer than that. You comment helps to shine a light the giant, humongous gorilla in the room – most people don’t have the sources to weather this crisis for long. A month? Two? Many millions can’t go without even one paycheck but there seems no way now to prevent this epidemic from extending many months into the future. Most businesses, big and small, will not be able to withstand it. The layoffs are coming, by the tens of millions in the US alone. The economic wreckage world wide will be devastating and, quite frankly, we may not recover.

      1. Yes and people were living on the edge already. There had been many studies for years talking about how in Canada people couldn’t miss one pay cheque without serious issues like losing their house. Then there are the issues with high cost of living – rents have been going up like crazy in many areas, so have mortgages so people who make a good living are living pay cheque to pay cheque as well. All this has tapped people out for resources. No one has reserves.

      2. Several European countries have plans to provide a livable income to [all?] citizens during the crises. The UK and Denmark print their own money, so their only problem is future inflation. How countries using the Euro will manage, I don’t know.

  5. My 2 cts:
    IF we had the nearly universal testing our administration promised, it would be easy to allow the negative/low risk to continue working. That would have prevented the universal shutdowns designed to protect the public from asymptomatic carriers.
    That would also allow the previously positive (assuming at least short term immunity)to return to work, esp. in high risk areas (health care, first responders).
    Presumably there will soon be antibody tests that can show prior/recent infections, esp. in those who never had symptoms, allowing them to return to work.
    All of this depends on having the resources and logistics for WAY more testing than is currently being done.
    Meanwhile it appears that testing is still being severely restricted in most areas–e.g., just to hospitalized/ICU patients, front like health care workers, etc.

  6. After I saw this interview with infectious disease expert Dr. Michael T. Osterholm
    I’m now reading Dr. Osterholm’s book, “Deadliest Enemy”. In the interview, he questions the wisdom of closing down the schools. I’ve been giving that a lot of thought, and I wonder how long we can go on with everything shut down. I’m guessing the rate of domestic violence will skyrocket. In any case, the reaction of shutting down everything possible does seem be questionable.

    1. It is. Basically we’re faced with choices that mean the deaths of tens of thousands, maybe millions no matter which one we make. We cannot avoid them now nor, I believe, can we avoid the coming world wide economic collapse. We are in very deep trouble.

    2. I recall Ben Goren (a frequent WEIT commenter)arguing against Trolley Problems as unrealistic. Mostly I agreed with him, but permutations like coronavirus scenarios can map very well to Trolley problems.

  7. I’ve thought for some time about his suggestions and think that they have merit. I’m 76 so i’m certainly vulnerable. A vaccine is probably 18 months away in the best scenario. Total shutdown for a year will damage more people than keeping more businesses open staffed by the less vulnerable (who need the work and money). Just looking at the numbers, there is no way the government can protect economically all the jobless people for even 1 year. For the next year or more herd immunity is the only long-term way to reduce the impacts on society.

    1. I’d like to know if we could fast-track a vaccine by cutting out some of the normal regulations? This would be a bad idea normally, but we are in exceptional times. We have been making vaccines for decades, so I assume that we could estimate the probability of success and adverse affects.

  8. Sounds like a great idea ‘in theory’…

    Let all those people who can survive wander around as normal, and get herd immunity – thus protecting those who are ‘vulnerable’

    How do we know how many of those at low-risk will die?

    How do we quantify what level of risk is acceptable?

    Sounds a bit iffy to me

    1. It’s even complicated by the fact those originally thought to be at low risk of dying- the young- are dying. And as has been mentioned already, even those who survive do not come out unscathed. There are lung complications that they will have to manage. I think it is better to err on the side of caution on this one.

    2. And we aren’t sure how the immunity works. How long are they immune for? Will this virus mutate?

      1. Well, fortunately we do know something about this virus’ mutation rate. It does not appear to diverge as quickly as the flu virus, but that’s not much consolation. Though we can make effective flu shots, they are generally effective only against a few clades of the virus and then have to be renewed each year. Probably any vaccine therapy against 2019-nCoV will be similar. It seems likely we will be able to generate vaccines to it but it seems also likely that it, like the flu, will be a slippery target.

        Here is a good resource for info on this topic;

  9. I believe there is much in his report that makes sense. We are assuming this shut down of business is going to work and be worth the pain but I don’t know. Also, Kansas shut down all the schools when no one in Kansas had the virus. Certainly no kids even have it now.

    Small business are going to need lots of help to survive and I don’t think they will get it. We always give more to the big companies who use the money to buy back stocks and give big bonuses to the top. That is where the argument is right now.

  10. I think a more targeted approach would be preferable but only in conjunction with enough testing capability to actually know what is going on. We’re flying blind here without a decent excuse.

    1. Yes and perhaps a targeted approach is what we evolve into but right now we have to take this one. If we get everyone tested then we can start letting out the immune (once we understand that immunity).

    2. Exactly, a ‘targeted approach’ is great, but we are as yet in no position to really target.
      I think a more targeted approach will be possible in the near future, but in the mean time I’d go for the ‘shotgun’ approach to ‘flatten the curve’.

  11. I would start here:

    But specifically,”Herd immunity” to viral diseases does not come easy.
    At this time, nobody is immune to SARS-Covid-2, with the possible exception of some people in rural China who might have been exposed to it in the past.
    But essentially nobody. With an R0 of 2.5, experts say that natural herd immunity could only be possible once 60% of the population has gone through the course of the disease.
    No matter what numbers you use for the percentage of people requiring medical intervention and the percentage who die, that would be horrible.

    The real insidiousness of this disease is that the best time to isolate a person is 5 days or so before they start showing symptoms.

    I would say the solution, the real solution, is a vaccine. That is how you achieve herd immunity without overloading the system.

    If the Chinese data is to be believed,
    there is no age group where the percentage of those infected who have “serious” symptoms is negligible. 0-14 years is low at .6, but in the US population that comes out to 200K very sick kids, assuming relative obesity vs. China is not a complicating issue.

  12. We should all Google the word “Vo”.

    It’s the town in Italy that experienced the first Covid death. They tested *everyone* in town and found a certain number of positives. Half of these positives had no symptoms of disease. All positives, including the asymptomatic, were isolated.

    The health officials feel this action was responsible for halting the infection in the town.

    In other words, the disease seems to be spread by infected people who are temporarily or permanently asymptomatic.

  13. He’s saying pretty much what I’ve been saying from the start, but I’m not an epidemiologist and don’t have all the data, so I’ve no idea if I am correct to think this.

    However, so far this year

    coronavirus deaths – 15K
    road deaths – 400K

    (according to wikipedia 1.35M road deaths last year, so about a third of that)

    When are we going to ban cars?

      1. It’s not foolish. It is a well known situation where we fear, say flying, or more specifically, crashing and dying in an airline disaster but happily hop in the car, drive 70MPH down the highway eating a Big Mac, texting, changing the radio station and changing lanes at the same time, along with thousands of other idiots doing the same thing. I’m sure someone can refresh my memory as to the actual term for this overestimating the probability of dying in one case verses the other. It is a logical question, why do we fear this disease, which has killed around 500 Americans over a few weeks yet we don’t fear automobile deaths which kill somewhere around 90 to 102 per day according to the NHTSA? I suppose it’s another one of Rumsfeld’s “known knowns”. It is a good question but maybe not one many of us are willing to ask until after the situation is under control and with the benefit of hindsight. After all, this virus is still one of our “known unknowns”, for lack of a better term.

        1. No. It’s foolish. A lot of people die in car accidents, but as GBJames points out below – that doesn’t wreck our healthcare system or our economy. Further, the death rate is FAR HIGHER than driving a car. If 1% of the people driving a car could expect to die, you bet your sweet bippy they’re be afraid of driving.

          A foolish argument.

          1. I’m not disputing your points, excepting your insulting someone trying to make sense of the situation. It is clear that nobody really has a good grasp of this situation yet, the fear and confusion reign supreme, and the ultimate outcome will depend on how we handle this fear and confusion. Asking questions is a good way to begin to make sense of it all though. TJR, like all of us, should be allowed to ask questions, wonder aloud, try to figure things out, and unless the commentator says some just off the wall nutty things (like Alex Jones and his colloidal silver toothpaste, perhaps) then what’s the point of hurling insults?

          2. Saying an argument is foolish isn’t insulting. If an argument is foolish, that’s what it is.

      2. Which argument? Virus strategy or banning cars?

        Of course virus strategy comes with all the caveats below (it could get much much worse, we don’t know enough yet, hospitals being overwhelmed etc) but they are all sufficiently obvious not to need saying (or so I thought).

        Banning cars? You can make a very good case for banning cars from residential and built-up areas. The fact that we allow giant metal death machines to roam the streets where children walk is just bizarre. Whenever you get in a car you are in effect saying “so a few hundred children die every year, but that’s a small price to pay for my convenience”.

        (Obviously the 400K was foolish – it should have said 300K).

      1. A valid point. Perhaps the same could be said as to the differences between our reaction to the daily gun murder and the much rarer mass shooting. The trauma of the first impacts a handful of people (family, medical staff) and one or two victims, and the local neighborhood while the second impacts whole or sometimes several hospitals at once, multiple families, multiple victims, and spreads fear throughout whole cities or the nations. But perhaps this is a weak analogy. This pandemic is something we haven’t seen in generations. Polio and the 1918 flu keep being mentioned. I wasn’t around for either, and the 1918 flu survivors are all dead of old age. Anyone care to share experiences of the pre-vaccine polio scare?

        1. There are history books for those who care to learn history.

          “I wasn’t around…” reads eerily like a creationist’s argument against evolution.

          1. Wow. I give up. When you can’t even ask questions, there no point to continue the conversation. Asking if people on this site have personal recollections of the polio outbreak is NOT the same as being a creationist refusing the whole of evolution.

          2. Apologies for triggering you. I was responding to your 1918 comment.

            I was around during polio. I have/had several cousins who got the disease. I don’t know how this pertains to the question, though.

            Your main case had to do with how this pandemic isn’t all that bad because of car accidents. You’ve been defensive about your exchanges. You don’t seem to be “just asking questions”.

            Finally “eerily similar” and “the same as” are very different things.

    1. US Traffic fatalities are around 35,000 annually.

      If we assume a case-specific mortality of 0.5% – which seems reasonable given estimates of asymptomatic infections and assume that half the population would become infected (probably optimistic) then an estimate of COVID-19 deaths in the US is of the order of 800,000. Against a population of around 331 million

      The worst flu years for comparison:
      1918 – 675,000 dead in the US – population then 103 million (fewer than the previous year!)

      1957-8 – 116,00 in the US – population 172 million

      These are not civilization ending numbers – COVID-19 is equivalent to a really really bad influenza year – but not a 1918 style pandemic (for example). But they represent a hell of a lot of pain and suffering. And are about 20 fold higher than the traffic deaths.

      As autonomous vehicles become safer than human drivers we will probably ban driving on roads- but that’s another discussion.

      1. It doesn’t make sense to use a mortality rate based on locations where the healthcare system remains largely intact (so far). The key number is that around 5% of confirmed infections require critical care. Once you overwhelm your critical care capacity (and without intervention you are likely to overwhelm it many times over) the mortality rate will approach that number.

        Our best guess as to what would happen in the US without suppression efforts is probably the report from Imperial College (link below)
        that predicted 2.2 million US deaths in the absence of intervention, and over a million with “mitigation” measures similar to what Katz is proposing. That’s not counting excess deaths from other causes once the healthcare system is overwhelmed.

        Admittedly, there is still a tradeoff between saving the economy and saving lives, but the human cost of not trying (or failing) to suppress the epidemic is likely to be high.

        1. We have more than 2.2 million people die every year from normal causes, so if it did cause a total of 2.2 million deaths (spread out over some time period), it’d represent a significant but not disastrous increase in our normal death rate.

          If 2.5 million people dying each year (mostly from other diseases) is totally normal for us and garners hardly a moment’s concern, I don’t see that a 30 or 40% increase for a few years should be such a big deal. If we didn’t have mass communications, perhaps we wouldn’t even notice…

      2. What makes you think the fatalities will be much less than from the ‘Spanish’ flu? Where did you get 0,5%? (I read between 0.4% to 4%) Why only half the population?
        I do not say you are wrong, I just wonder how you came to those conclusions.

        1. That estimate was from Amesh Adalja at the Center for Health Security at Johns Hopkins. He actually said 0.6% as the high end so I was rounding. But it’s all a guesstimate at this point.

          Half the population is extrapolation too – the 1918 influenza infected around a third of the world’s population. So 50% is likely not horribly wrong.

          For clarity, I’m not trying to minimize the danger, just to make the point that even an optimistic reading is much worse than road traffic accidents – which is the comment I was replying to.

  14. I saw another interesting article along somewhat similar lines on Andrew Sullivan’s Twitter here (he cautions… ignore the inflammatory clickbait title and just read the content).

    My general thoughts, in no particular order:

    – Uncertainty is a big part of the problem here. It would be good if the government could issue an organized and confident sounding action plan, but right now everyone is scrambling to figure this thing out.

    – Whatever happens, there will be a lot of “20/20 hindsight” crowing and accusations flying.

    – I think the right course of action right now is temporary social distancing with the idea that this is for the purposes of fact finding. Advertising it as doing something it might not do could backfire. What if, for example, it doesn’t flatten the curve? Or if we end up finding herd immunity is what’s needed, or the fatality rate is lower than expected, etc. It’s going to create a lot of anger if people feel like they lost their jobs for something that didn’t pan out. I think it’s better to call it what it is – fact finding, time buying time, and then use the time to do intense research as fast as possible. You can’t come up with a reasonable action plan when you don’t know what you’re looking at.

    – China needs to get it together with the wet markets. What the heck, China? Enough with bat to human transmission. Also enough with torturing animals. I know it’s probably a small percentage of the population but it’s got to stop.

    – We definitely need better plans for what to do if this happens, in worse form, in the future. We are globalized and there are more humans than the earth has ever seen before. Imagine if this were something more like ebola but with a two week, asymptomatic incubation period. We have shifted gears relatively quickly to doing things like making ventilators, but the process has been messy and could be faster. Also, there has to be some way to protect the supply chain so that hoarding consumers and doctors are not competing for things like masks in the future.

  15. All I know is what China did to deal with this outbreak; test, isolate the infected, track down who they had come into contact with, isolate them too. That does seem to work. Test-isolate-track-isolate. But we aren’t doing that. Some testing, yes. Some isolation, self isolation but there are stories of assholes ignoring that and going out anyway, and we sure as hell aren’t doing much if any tracking. The news always says they are but I have a coworker who came down with it, just got out of ICU yesterday, and not one person has been contacted or questioned about it.

    A significant portion of the population is still working, still interacting, even if they are called “essential”, they’re just hosts, warm, wet, meat vehicles, as far as the virus is concerned, and some of those “essentials” are things like Starbucks! Yes, in a pandemic one cannot he expect to make one’s of caffeinated beverage. Although many baristas have opted for the 30 catastrophe pay and are staying home. And there are plenty of other so-called “essential” services that offer rich rewards to the lucky virus who finds them. It sounds to me like what are actually doing is following the herd immunity method, but by accident rather than design.

  16. I fully agree with his idea of keeping the elderly separated (as much as possible) from younger folk who may have just come home from school.

    I also agree that lots more people should be tested. But whether by incompetence or not, the U.S. doesn’t seem able to do that.

    Some of his other stuff, though…

    If we succeed in slowing the spread of coronavirus from torrent to trickle, then when does the society-wide disruption end?

    I’m guessing in a few months. In China, the rates of new cases went into their steep downslope in something like 6-8 weeks. In the U.S> case it will be longer, both because we didn’t take measures as drastic, and because they weren’t really able to flatten the curve as much as we hope to do.

    We have have to live with Covid-19 a lot longer than that, of course, but I expect we’ll likely have a vaccine available and thus be able to return to normalcy via ring- or mass- vaccination by autumn or possibly winter.

    This focus on a much smaller portion of the population would allow most of society to return to life as usual and perhaps prevent vast segments of the economy from collapsing.

    I strongly disagree. Keeping the U.S. economy going is a question of will, not resources. Congress is already talking about $1,000/affected person/month in addition to separate help for businesses. They’re looking at $1 Trillion overall. We could easily double that and probably be okay in the short run. This is what running a deficit and debt is actually for – not tax cuts (and for perspective, IIRC Trump’s tax cuts cost the country an estimate $1.5 trillion in revenue. So, hey, if we want to pay for all this support, we could start by rolling back the tax cuts for 2021…)

    1. I do wish the pay-out from the government could be aimed more at those who need it. Many do, as they are out of work, but many don’t. I don’t as I am simply working from home (knock on wood). The ones who are out of work b/c of this should get a bit more $ this way.

      1. I’m pretty sure the first House bill did something like that. I’m not sure about the 2nd and 3rd bills.

  17. It’s also time for public employees to make sacrifices and help their community. My wife works at a university and her job is safe. She is trying to start a program where the university employees take a pay cut or donate part of their salary to help the people who are hurting or to improve the state’s budget.

    There are two main reasons for this. First and foremost, helping people in need is right thing to do. Second, the state’s budget is going to be a mess next year as revenues fall and expenditures skyrocket. There will major layoffs of state workers next year unless something changes.

  18. Trump is supposedly thinking of backing off fighting COVID-19. I guess he thinks a bunch of people dying will hurt his re-election chances less than a tanked economy. As I see it, the economy would tank in either scenario.

    He is also holding off on invoking the Defense Production Act, which would have the government paying companies to make masks, drugs, ventilators, etc. He fears that the company would slip into socialism “like Venezuela”. Of course, he really means that helping people this way is incompatible with his anti-socialism re-election platform.

  19. I quite fear the economic consequences of these shut down policies. If continued for more than a few months, they will cause a world wide depression. That certainly can be worse than the disease. The last world wide depression led to the rise of fanatical leaders and a terrible war. We cannot be single minded in the pursuit of this disease, and we need some contrarian opinion and ideas.

    1. You don’t think the accelerated advancement of the disease caused by not following shut down policies will have an even bigger economic effect? Right now most of us are directly experiencing the impact of the shut-down policies. It is natural to think they are worse than the disease but that’s bound to change.

  20. Why are young people generally only getting mildly sick or are asymptomatic? There is a theory that they possibly have some immunity due to prior exposure to other coronaviruses in day cares and schools which is giving them cross-immunity to Covid19. The young are also more likely to be asymptomatic which the CDC says asymptomatic people have a low risk of transmission to others. I do wonder given the above, if it makes sense to target everyone, and not have a more focused quarantine based on age and medically vulnerable people.

    I also wonder if enough of the population will vaccinate in order to achieve herd immunity. Will the young and healthy get vaccinated when they know that most likely it will cause only mild illness? Will parents vaccinate their children? Vaccinations work the least well in elderly people so targeting only them will not be enough.

    Personally, I think we need to err on the side of social distancing, at least in the short term.

    1. Why are young people generally only getting mildly sick or are asymptomatic?

      That’s the case with most diseases; the older and sicklier you are, the worse you tend to get it. Coronavirus is no different in this respect than regular flu, or chicken pox, or measles, or anything else.

      Now if you’re asking the general question of why human bodies seem to get less good at fighting off infections as they get older, well, I don’t know the answer to that.

      1. “Now if you’re asking the general question of why…”

        God’s punishment for living too long! Duh!

      2. That’s true of chicken pox but most other illnesses are much more dangerous for the very old and the very young. Things like flu and RSV tend to impact both ends of the age spectrum, for example. From what I understand, coronavirus is unusual in that previous strains (SARs, MERs) show the same pattern in terms of being much milder in children. I’ve seen various theories on this – that it’s because lung damage is usually cumulative with age and exposure to various toxins; that children have less developed immune systems which actually help them in this case (in that hyper reactive immune responses can actually be deadly); and that it’s something physiological, such as the receptors in children’s lungs varying in a way that makes the virus unable to attach itself.

  21. Isolation is our only currently effective strategy for limiting the spread of this pandemic. It protects the public and healthcare workers.

    In medicine, not completing a course of therapy may lead to relapse. If you are worried about the economic effects of isolation imagine what will happen if we cut it short and have another surge, then another, then another.

    We need a firebreak now. A shutdown will have major economic impact to be sure. But at this point that is a given. There is no scenario that ends without a major economic hit. Our best hope is to limit the damage by doing what is medically sound now, without consideration to the economy, so that the timeline of effects is as short as possible. The free market isn’t going to fix this.

    If we continue to employ a half-hearted approach trying to balance economics with medicine, the outcome is likely to be the worst of both.

  22. I not sure we know enough about this new virus and COVID-19 to take Katz’s advice. How do you effectively isolate the most vulnerable from the healthier segment of society that has herd immunity in the early stages of the outbreak? Health care workers are thought to be the source of introduction of the virus into the nursing home near Seattle. There is so much we don’t know about this virus and vulnerable population. More testing would be good. But that even has some weaknesses. The RT-PCR test test for viral RNA in the pharynx. But we still don’t know how many viral particles are needed to “infect” a person. How long does it take before that person tests positive? People could be swabbed and then shortly there after encounter the virus. How frequently should we re-test people? A serological test may be ready soon and that may help to know how widespread the virus is among asymptomatic or mildly symptomatic people. That may also help with models and simulations of the spread, but by the time we analyze the data the outbreak has progressed even further. There is just too much unknown.

  23. The health system in Italy is floundering about a month after lock-down. Other services will likely do the same in a short time.
    I lived in Milan for 25+ years and am hearing a lot of horror stories from my friends there.
    I flew out of Milan the day (18th Feb) before they started special measures (I then self-quarantined for two weeks).

    A long-term approach (3-4 months or more) probably can’t be sustained if it involves full lock-down (quarantining and social-distancing).
    Quarantining the high risk individuals would seem obligatory in any case.
    The option of the low risk people taking their chances and continuing “normal” activity may be the only possible option in a long haul, if the number of infected cases far exceed the capacity of the health services.
    They can either “social-distance” (which may only put things off)and survive without infection (little “herd-immunity”)
    they can face the risk of normal contact (a certain number will succumb to the virus, the Italian experience showing that even some healthy, young adults fall victim).

    The latter MIGHT develop herd immunity though also likely a fair number of healthy people will also die.

    There is a plague village in Derbyshire (Eyam) which voluntarily quarantined the plague INSIDE (the surrounding area had no disease, only the village itself). They “locked-down” for 14 months quarantine until they beat the plague. Fatalities were 35-55% but they stopped it spreading.

    Katz is advocating quarantining Corona OUT which is scary.

    Fatality in Italy is of the order of 8% and not 1-2% as expected. Trying to develop herd-immunity against that is a risky shot.
    If 50% of the population get the disease, mortality would be 4% or 3 million people.

    Sorry to be gloomy but even so, Katz may have a valid strategy.

  24. I like to look at the data. China seems to have gotten a handle on this thing by using sever lockdown. Korea is doing very well based, I think, tight control and on early action and jumping on cases and tracing the contacts. This tells me that it would be most helpful to suffer a few weeks of complete shutdown in order to better handle the load. If people knew this was the plan, they could more easily handle the sense of loss knowing there was a light at the end of the tunnel. The economy should recover.

    1. Singapore and Hong Kong were able to control their epidemics the same way too. I would caution accepting without question anything China says, however. The government there lies even more than Trump. If that’s possible.

  25. There is an issue with the Katz approach, to the extent that young people are passing around the disease to each other without showing symptoms, then giving it to their parents who get very sick indeed.

    The very first case in Bergamo Italy was a 38 year old marathon runner, who had been without symptoms till he started showing some pneumonia. 36 more cases showed up within 1 day. They don’t know for sure, but it looks like a cluster of infections not getting noticed at first, then erupting and swamping the hospitals.

  26. If we keep up our current strategy of suppression based on indiscriminate social distance for 12 to 18 months, most of us will still be alive.

    Has anyone actually suggested this? If so, I’m unaware of it.

    My completely not-an-epidemiologist guess is that even with a successful ‘flatten the curve’ strategy which tends to lengthen the time the disease is affecting people, we’ll reach the down side of the curve (where the number of new cases per day decreases, even without strong interventions) in probably 2-3 months. I base this on the fact that in China, South Korea, and Iran, that period was less than a month.

  27. Covid19 is unique in the aspect that the young are less affected.

    H1N1 2009 Pandemic mostly affected younger people. The CDC believes that older people had some cross immunity from previous H1N1 viruses. From the CDC: “the 2009 flu pandemic primarily affected children and young and middle-aged adults…” Also from CDC: “Globally, 80 percent of (H1N1)pdm09 virus-related deaths were estimated to have occurred in people younger than 65 years of age”.

    The 1918 Flu affected everyone: all ages and healthy individuals.

    Children under 5 are particularly vulnerable to influenza viruses.

    1. And unfortunately people are hearing the message wrong. This virus affects everyone. If you’re older or have complications, you have a higher likelihood of dying but the people most affected by this virus are the so-called “people of working age” – basically late 20s into middle age. And as has been mentioned previously, it can be disabling causing life-long lung issues. I really wish the communications were more clear on this. The young think they won’t get it. They already don’t care if they spread it (shame on their parents for raising kids with low empathy) but they really think they will be completely fine if they get sick or they won’t get sick.

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