Posted on October 23, 2020 at 3:09 AM
by Craig Klugman, Ph.D
In the last few weeks, you may have heard from central and left-leaning media that Scott Atlas, a radiologist who appears to be leading White House COVID policy, has managed to make “herd immunity” the official federal response to COVID-19.
If you prefer right-leaning media, then you may have heard of the Great Barrington Declaration, an international document led by three scientists that urges against lock downs, quarantine, and isolation, and instead suggests letting young people get COVID to help build herd immunity. “The most compassionate approach that balances the risks and benefits of reaching herd immunity, is to allow those who are at minimal risk of death to live their lives normally to build up immunity to the virus through natural infection, while better protecting those who are at highest risk.”
A recent Washington Postarticle looked at philosophical theories and how they respond to the Declaration. While possibly permissible under utilitarianism and notions of the “common good”, most other theories find this a problematic proposal. But what about a bioethics analysis?
To begin, the CDC defines herd immunity as “A situation in which a sufficient proportion of a population is immune to an infectious disease (through vaccination and/or prior illness) to make its spread from person to person unlikely. Even individuals not vaccinated (such as newborns and those with chronic illnesses) are offered some protection because the disease has little opportunity to spread within the community.” For example, if you had a flock of sheep and a virus was infecting them, at a certain point enough sheep would have been infected (and survived) that the virus would not have a sufficient number of new hosts to infect to keep the epidemic going. Not every sheep will have had the disease, but they will be protected by those who survived infection and developed immunity.
“Never in the history of public health has herd immunity been used as a strategy for responding to an outbreak, let alone a pandemic. It is scientifically and ethically problematic,” said WHO Director-General Tedros Adhanom Ghebreyesus. In humans, herd immunity is used to mean the percent of people who need to be vaccinated against a microorganism before the infection cannot get a toehold in the population. For measles, herd immunity is 93-95%. For polio, the rate is 80-86%. When that level of the population is immune (usually through immunization), then the disease will not establish in the population. This offers protection for people who cannot be immunized because they are allergic to a component of the vaccine or have had a bad reaction to receiving some vaccines previously. When population level immunity drops below that rate, then the infection can establish to infect, maim, and kill people.
For COVID-19, approximations are that 10% of the world has been infected. Based on its characteristics, epidemiologists estimate that the herd immunity rate is 58-65%, far lower than other diseases. But the death rate for COVD-19 is consequential. In the US, the death rate is 67.57/100,000 and the case fatality rate is 2.7%. To achieve the 58% herd immunity would mean vaccinating at least 192 million Americans. This can be achieved once we have a safe and effective vaccine, have produced it in sufficient volume, and have delivered it to the population. Since a vaccine is controlled (either a dead or weakened form of a virus, or a new technology that stimulates the immune system to act like it was attacked by the virus), the chances of getting sick with COVID from the vaccine are nil and death rates are equally low.
The Barrington proposal, though, says we do not have time to wait for a safe and effective vaccine, to have sufficient doses, and to deliver it. Instead, the writers suggest removing our public health restrictions for anyone not in a “high risk” group (co-morbidities, elderly) and let them get infected to build up to herd immunity. Knowing that if young people get infected and are then subject to life-long health issues (“long-haulers”) and that they are very likely to spread the virus to others, the life-cost of this approach would be between 2.3 and 5.1 million deaths in the U.S. alone. Unlike a vaccine which is safe and has no chance of giving the COVID disease to a person, this proposal is that people get infected with the live virus and that has a high risk of morbidity and mortality.
The proposal also makes a factually unproven assumption—that being infected confers long-term immunity. Studies show that people who have recovered from COVID infection do not have detectable t-cells (and in some cases antibodies) after a few months. Immune response over time (and we have been in this for less than a year) seems to correlate with severity of the infection (more severe=stronger immunity). This does not bode well to the idea of long-term immunity. In fact, for many months there have been stories of people being reinfected with COVID-19 and even peer-reviewed studies showing the same. Research in this area is stymied in part by lack of universal testing (every country seems to have its own tests) and by lack of surveillance testing (lack of data on how widespread infection really is).
Bioethics also encourages us to consider social justice in analyzing a case. COVID-19 disproportionately affects communities of color, people who are older, and people with co-morbidities. The Barrington Declaration is, in fact, an ageist sand ableist statement since it clearly states that the lives of the old and inform are less important that the young: The Declaration states, “We know that vulnerability to death from COVID-19 is more than a thousand-fold higher in the old and infirm than the young. Indeed, for children, COVID-19 is less dangerous than many other harms, including influenza”. Thus, even if the science and ethics were not enough to show the fallacy of this approach, it’s discriminatory basis and application certainly shows that this is a direction that should not be followed.
In response to this Declaration, 5,300 scientists have signed the “John Snow Memorandum” which argues against the Declaration and explains that public health measures are necessary for controlling the pandemic and saving lives. WHO Director-General Ghebreyesus in his biting response to the Declaration said, “Allowing a dangerous virus that we don’t fully understand to run free is simply unethical. It’s not an option.”
The bioethics principles of nonmaleficence and beneficence mean we have a duty not to cause harm and to protect from harm. The Barrington Declaration would lead to a large number of deaths on the level of a genocide of the aged, the disabled, and the sick. This concept would allow COVID to kill a population equivalent to the entire state of South Carolina or Alabama or the nations of Costa Rica or Norway. Not to mention, that this is a disease associated with a percent of people experiencing long term sequelae that includes terminal lung damage, kidney damage, liver and brain function changes. No one knows who gets the long term health problems and who does not. From a public health ethics perspective, solidarity is the key value—reducing morbidity and mortality. Barrington does the opposite, maximizing morbidity and mortality.
The Barrington/Atlas approach cannot be the approach of a civilized, compassionate, and ethical society. It is up to every one of us through our words (write, call, email) and our actions (voting) to make sure this draconian proposal is never enacted.