By Foss Tighe
Once again Herd Immunity is in the news. This time in the form of a declaration facilitated by a Libertarian think tank: American Institutes for Economic Research (AIER). The Great Barrington Declaration suggests that governments essentially follow the Swedish approach to the Coronavirus. Protective measures should be put into place for the elderly and those at higher risk for bad COVID-19 outcomes, while those with lower risk should return to normal social and economic activity, and allow the virus to spread naturally. The authors postulate that this will result in the virus spreading among younger and healthier people, facilitating a transition to a form of herd immunity similar to what happens when a high percentage of a population is vaccinated against a virus. If the level of immunity within the community is high enough, the virus cannot gain a foot hold in the community, and the entire community, including those not already immune are protected.
Most main stream public health experts have been quick to condemn the approach as immoral and insane. I think the lack of meaningful discourse on this topic is a reflection of the deep partisan divide in the US and worldwide. I am not sure the approach makes sense for the US, but its not so out of the box that those who suggest it should be treated a pariahs. Of course the situation in the U.S. works against reasoned discussion, when the President promotes armed militias to take to the streets in opposition to virus control measures recommended by the Presidents’ own government. For some Herd immunity has become synonymous with Trump’s complete disregard for the virus and the dangers it presents.
However, this is not an entirely theoretical discussion. Unlike most the world, the government of Sweden pursued an approach to the coronavirus very similar to the that recommended by the Great Barrington Declaration.
Deaths per capita is among the big guns of COVID-19 metrics. During the initial months of the pandemic, Sweden experienced death rates higher than their European neighbors and there was extensive main stream media coverage showing open distain for Sweden. Fomenting social unrest, Trump’s armed “open up the economy” thugs suddenly found love for their social democratic comrades in Stockholm. The topic resurfaced just a few weeks ago, when the United States surpassed Sweden in total deaths per capita for the entire pandemic, and current deaths in Sweden were drastically lower than US deaths on a per capita basis.
This turn of events likely highlights the failure of the U.S. response more than it reflects positively on the Swedish experience. But it provides one example where a herd immunity policy orientation yielded results superior to those achieved in the United States. There are many differences between Sweden and the United States that make the strategy more practical in Sweden, but it illustrates that the idea itself should not be categorically ignored and declared unethical and impractical.
Public health experts often perform quick back of the napkin calculations to show that coronavirus with an R-naught somewhere between 3 and 5, will require 66 to 80% of the population to be infected before herd immunity is reached. This would mean for the United States, over 200 million people would need to be infected. If only a small percentage of those millions die, we will still have millions of dead. Hence the experts decree any thought of Herd Immunity through infection is immoral.
However, R-naught is a theoretical measure of the infectiousness of a virus. But the in the real world people are responding to the pandemic in a wide range of ways including personal measures, government recommended measures and government mandated measures. These actions have greatly reduced the rate at which the virus spreads. The website rt.live shows real time estimates of the effective reproduction rate of the virus (Rt). According to one web site (rt.livert), currently all states in the US fall in a narrow range from a little below 1 (infections are deceasing slowly) to a little above 1 (infections are increasing slowly). In this situation, immunity in an additional 10 percent of each state’s population would be enough to put all states into the deceasing slowly category. Now its important to remember that the estimates of Rt, have been achieved through a number of actions, some partial lockdowns, social distancing, hygiene, mask wearing, and any immunity already achieved by some people having already recovered from the virus.
The Great Barrington Declaration addresses this briefly with the following statement: “Simple hygiene measures, such as hand washing and staying home when sick should be practiced by everyone to reduce the herd immunity threshold.” They are suggesting that by doing a few simple actions to reduce transmission, it will be possible to reach some form of herd immunity without needing 60 to 80% of the population to be infected. Here we need to move beyond calling each other immoral and delve into the nitty gritty details. How much would hand washing reduce the percent of the population needing infection to achieve herd immunity? What other precautions could be on the table? If everyone wore masks, could that push the required percent needing infection down even lower? Would Libertarians tolerate the idea of a mask mandate to make a national herd immunity policy work?
An important part of the strategy hypothesizes that as a society we could influence which segments of society get infected and which do not. This theoretically means that even though there would be more people being infected, they would be the people less likely to need hospitalization. We know that many countries, including both the United States and Sweden performed pretty miserably at protecting the elderly, particularly those in congregate care settings. The Declaration includes one concrete suggestion in this area. They propose staffing congregate facilities with staff who have already been infected and recovered from the virus. This is an interesting idea, but there are a lot of details that would have to be worked out. Since the reliability and accuracy of anti-body testing has been problematic around the world, how would we decide who was even eligible to fill these positions? Are there moral/ethical issues of making certain kinds of employment dependent on past medical conditions?
The Declaration makes an appeal to social justice by pointing out the lockdown/social distancing approach places additional burdens and risks on the working class. But there are many details that the Declaration does not currently address. For example, many well paid professionals in IT and finance have very comfortably adopted to the work at home and ship to home model. Will these people willingly set aside the safety of their new life styles, and increase their personal risk of infection all in the name of a new national herd immunity plan? Or would they likely continue a work and shelter in place even if the country officially declared it was safe for healthy individuals to return to the bars and bowling alleys?
There is also always the specter of Northern Italy. Allowing the virus to spread naturally among the healthy sounds good. But even younger people with no known underlying risk factors end up needing hospital care. Were we as a society to lower the barriers we have in place against infection, the infection rate is going to climb and even with increased protections for at risk populations, hospitalizations are likely to. How will we throttle the infection rate to make sure we do not exceed the capacity of our medical system. Its kind of sad, but current US policy feels a little like a herd immunity strategy already, with daily infections again above 50,000 and climbing, we are again seeing some states approaching hospital capacity. What is the maximum rate of infections per day we can tolerate without putting a crippling burden on our medical system? Can the US health care system tolerate 100,000 new infections each day? How about 200,000? So for example, if we need to infect say, an additional 25% of the population of the US. At 100,000 cases a day, that will take 27 months. That is a long time, we could easily have a vaccine in that time frame. To answer the question if it would work we need some serious discussions and focused science.
Those who call a herd immunity strategy crazy or immoral need to take a closer look at what is already happening in this country. We have an immoral system now. The wealthy and those that can work at home are paying people in low wage jobs to take on the exposure risk for the wealthy. They stock the stores, cook the food, make the grub hub deliveries, walk the Amazon packages up to the door. Their risk is further exacerbated by the insecurity of these jobs, little or no benefits mean they cannot take time off when not feeling well. Low wage earners live in larger households that are more likely to include high risk members, all leading to the poor and people of color falling ill and dying at a disproportionate rates. So what we are doing in the United States that passes for a Coronavirus strategy is already immoral.
The current U.S. strategy rests almost exclusively on the timely arrival of an effective vaccine with an adequate supply, that people will be willing to receive. If such a vaccine arrives herd immunity will arrive much faster via vaccination than by the method proposed by the Great Barrington Declaration. If a vaccine takes another 12 to 18 months, or its effectiveness is low, or if people refuse to take it, or a sufficient supply is not available, the people of Sweden may be the big winners.
Sweden has served as an important test case for the approach proposed by the Great Barrington Declaration. Additional study of the Swedish experience would be well worth the world’s attention. But it is important to point out that all public health strategies toward the coronavirus require unified collective action. It is not up to individual communities, cities or even states to choose a strategy. We are too interconnected to not pursue a unified strategy. For example, having one state pursue a containment and infection control with extensive testing and contact tracing while a neighboring state pursues a herd immunity strategy, with less testing and virtually no focus on contact tracing will result in both efforts being much less effective.
So while I advocate for having a balanced and rational debate about the herd immunity strategy, it does not mean that I feel individuals, communities, schools, cities or states are justified in independently adopting such a strategy, or in any way acting to undermine the current infection control strategies currently in place pending a change in national strategy. Pursuing herd immunity without the adoption of a national strategy toward that end would be immoral and undoubtedly lead to the unnecessary lose of live.