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Herd Immunity as a Coronavirus Pandemic Strategy

Would letting coronavirus infect the broad US and global population be a safe and effective means of ending the COVID-19 pandemic? Jay Bhattacharya, MD, PhD, of Stanford University's Center for Primary Care and Outcomes Research is a signatory of the 'Great Barrington Declaration,' which proposes to 'allow those 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.' Marc Lipsitch, PhD, of the Harvard T.H. Chan School of Public Health, a signatory of the 'John Snow Memorandum,' which refutes the argument, responds.

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>> Howard Bauchner: Hello, and welcome to Conversations with Dr. Bauchner. Once again, it is Howard Bauchner, editor-in-chief of JAMA, and I'm delighted to be joined by two remarkable individuals today. Marc Lipsitch is a professor of epidemiology, very prominent nationally and internationally. An epidemiologist, he's a professor in the department of epidemiology at the Harvard T. H. Chan School of Public Health. Welcome, Marc. Marc's been on before, and I appreciate him coming on again. The other individual on today is Jay Bhattacharya. Jay's a senior fellow at the Freeman Spogli Institute for International Studies, and he's a professor of medicine at Stanford. And we're here to discuss what has emerged as probably one of the most fascinating yet challenging discussions in modern infectious disease epidemiology in the last 20 or 30 years. A few weeks ago, Jay, with two colleagues and then a number of other signatories published what has now become the Great Barrington Declaration. Marc and many other colleagues, in response, signed on to what was called the John Snow Rebuttal. So I'm going to start by asking Jay to describe what the Great Barrington Declaration is, and why it was called the Great Barrington Declaration, and then ask Marc to talk about the John Snow Rebuttal. But before I start, I just want to remind people of the most recent data. About 100,000 infections a day or more in the United States, record highs. Deaths, though, much lower in terms of the ratio: 100,000 to 1000 deaths. At the height of the struggles in New York, New Jersey was about 20,000 cases a day, but much closer to 2,000 or 3,000 deaths, so that ratio has changed, and people are very aware of that. But I think the great concern is whether the hospital systems in the US will get overwhelmed. We're approaching 50,000 admissions or hospital patient days each day, and that is a real issue. Now, the difference is that the outbreak is almost in every state, so that varies. And then the last piece of data I'll mention is the size of the US population that has potentially been infected with COVID-19 remains somewhat uncertain. An estimate by the CDC a few months ago was somewhere around 10 or 12%. Whether it's 15% now is unknown, but that would be 15% of 360 million people, and those data become important when you talk about herd immunity. Jay, I'll turn it over to you, the Great Barrington Declaration.

>> Jay Bhattacharya: Thanks, Howard. So let me just start very quickly with the premises of the declaration. The first premise is that there's not possible to get zero COVID. That is an impossible goal, and we should give that up. At this point, the disease is so widespread that zero COVID would be utterly disastrous to even attempt to achieve, and it's not technically possible. A second premise is something everyone will agree that this is an absolutely deadly disease for people who are older and for people who have certain chronic conditions. The infection survival rate from zero prevalence data -- There are now 50-some high-quality zero prevalence studies says it has a 95% survival rate for people who are 70 and older. For people under 70, it's 99.95% survival. It's much less deadly for people who are under 70, 99.95. And for children, frankly, the flu is worse. We've had more flu deaths among children this year than COVID deaths just in terms of mortality. Third premise is that lockdowns have absolutely catastrophic effects on physical and mental health of populations, both domestically and internationally. We'll talk about that, I think, you know, going forward, but that really sort of, you know, plays a big role in the thinking about the Great Barrington Declaration. So for people who are under 70, under 60 or 50, the lockdown harms, again, mentally and physically, are worse than COVID. And then finally, the vaccine's coming no matter what we do, whether we adopt more lockdowns like Europe has or we do a focus protection plan like the Great Barrington Declaration says. The vaccine is coming, and it will help no matter what when it comes, right? So between, my colleagues like to say six months and never, but it seems like we've made a lot of progress. Okay. So the only question is, what do we do until the vaccine comes? And so the Great Barrington Declaration is actually a call to return to sort of principles that we had followed for many, many other infectious disease outbreaks. We protect the vulnerable with every single tool we have. We use our testing resources. We use our staff rotations on nursing homes. We use PPE. We do all kinds of things so that where people live that are vulnerable, and older people are the main group, but also many other people with chronic conditions -- again, we can talk about strategies to do that. We do that. That's why it's called focus protection. For younger populations and people who are less at risk, frankly, COVID is less of a risk than the lockdowns. For them, letting them go back to normal life, again, taking precautions as necessary -- it's not "let her rip" like some people have mischaracterized -- but opening schools, for instance, is absolutely vital. Opening universities, letting people go back to the normal activity that would do that would prevent the lockdown harms is vital. So those are the basic ideas of the Great Barrington Declaration, and the premises.

>> Howard Bauchner: Jay, why was it called the Great Barrington Declaration, just out of curiosity?

>> Jay Bhattacharya: Oh, yeah. Sunetra Gupta, Martin Kulldorff, and I met in Great Barrington, which is a city in Western Massachusetts, so that's why it's called that.

>> Howard Bauchner: Okay. So Marc, I'm sure you've read the declaration. You and many other prominent infectious disease epidemiologists and public health epidemiologists have said, "It just can't work. It's just not reasonable. It's not feasible." What are the principle concerns and objections?

>> Marc Lipsitch: Thanks, Howard. The principle concern is that protecting the vulnerable while allowing transmission to proceed, which is what is recommended in the last paragraph of the Great Barrington Declaration, is to allow transmission to proceed among the so-called low-risk population. Doing that while protecting the vulnerable has not been possible in any place that I can think of. It has not been possible in Sweden, which has recently realized that not only did they experience high death rates in their nursing homes during their first experiment with herd immunity, but now has begun to put into place exactly the kind of control measures that this declaration opposes because they can't protect their healthcare system because they can't protect the vulnerable. In the United States, less than 10% of nursing home residents get tested within 24 hours, as is recommended by infection control professionals, and therefore, nursing home outbreaks have geographically followed the widespread community transmission that's been associated with exactly the policies recommended in the Great Barrington Declaration. So everyone agrees that we should do everything in our power to protect the vulnerable, but it is scientifically clear that, right now, in the United States and in most other places, if not all, we do not have the tools to protect the vulnerable without controlling transmission in society at large. So the John Snow Memorandum suggests that what we should be doing is, of course, making efforts to protect the vulnerable but also trying to control transmission in society at large, not by intense lockdowns unless absolutely necessary, but rather by very universal mask-wearing, social distancing, reduction of gatherings, and other types of approaches -- at least that's my interpretation -- in order to try to keep community cases down so that the vulnerable can be protected indirectly. Schools are not addressed, and my personal view is that schools should remain open in almost all circumstances for many of the same reasons as Jay just mentioned, but that's also because they are not foci of transmission, as best we understand it currently.

>> Howard Bauchner: Marc, why is named John Snow?

>> Marc Lipsitch: John Snow was, in many people's minds, the founder of scientific epidemiology of infectious diseases. There are a lot of legends around John Snow, but he did investigate the spatial distribution of cholera in London and concluded the mode of transmission. And so if you read the John Snow Declaration, it has a lot of science in it, and that's quite on purpose. We try to describe what's true about this virus and let the policy recommendations flow from that. One thing that's striking to me about Great Barrington is it has the word "should" in it 13 times but almost no reference to scientific plausibility or feasibility of any of the recommendations it makes.

>> Howard Bauchner: Jay, when you hear Marc's comment -- and I'm sure you've read the John Snow Memorandum -- that logistically, logistically, this simply is not possible in a country of 360 million, testing relatively still unavailable in certain places, a tremendous amount of political discord. Do you think it is logistically possible?

>> Jay Bhattacharya: Let me start by noting a couple of things. One, that the lockdowns themselves have created intermixing between the vulnerable and the nonvulnerable. They've essentially caused economic dislocations where young people have moved back in with parents. They've closed universities, sent young people to live back home, and created situations where this kind of mixing where vulnerable people would be exposed has occurred. The lockdowns have also -- They're not universal lockdowns. We've asked essentially core people, minorities, urban workers, even vulnerable ones, older ones, 63-year-old bus driver, you know, a 60-year-old Costco clerk with diabetes, to go work and expose themselves. Lockdowns themselves in fact create vulnerable people and put them in places where they are going to be at risk. Let me take another attack at the premises. The premises of the Great Barrington Declaration, contrary with what Marc just said, are actually scientifically based. I mean, we have scientific documentation for every single one of the comments, the premises that I said, the age stratification of the risk, the lockdown. So I think the question is not science. The question is, what should we do in the face of the science that we all agree on? Finally, let me just talk about in direct answer to your question. Can we protect the vulnerable? And I think the answer is, yes, if we try. We have relied on this crutch of reducing community spread as a way to protect the vulnerable, and that's clearly failed, right? You cited really sad facts about this epidemic. We've essentially had a lockdown policy. You can say it didn't work perfectly, but any public health intervention needs to take into account the environment it actually is going to be implemented in, not pretend like we're going to have it work perfectly. That includes the focus of protection as well. Let me talk a little bit about specific strategies that we had in mind, that we suggested. And actually, I invite your listeners and others to suggest more because I think public health folks are very creative about these things if we put our minds to it. So I think it depends on where people live. So if people live in nursing home settings, for instance, what are the problems there? Marc suggested one: testing, right? So I think we can deploy testing, but not just PCR testing, which is delayed, but, like, rapid antigen tests and other tests in those settings so that when visitors come, they can check to see -- We can deploy PPE there so nursing home residents can have access to sort of high-quality PPE as needed. We should provide mechanisms so that people who get sick in nursing homes can be segregated out and get better. Staff rotations in nursing homes should be limited so that people are [inaudible] a limited number of staff members. At the same time, we have to address the fact, loneliness is created in nursing homes if you lock down too much. So you have to think more holistically about the health of the people living in nursing homes. So nursing homes are very, very high priority. In multi-generational homes often created by these lockdowns, we need to think, again, creatively, right? So, again, I think we should deploy testing so that when a young person thinks they're exposed or sick, they can check and then provide alternate living arrangements temporarily, like we do hotels for homeless people. We can do similar things for people living in multi-generational homes. For workers, we can say, look, the disability laws present opportunities for employers to provide reasonable accommodations. So the Costco clerk of 63, maybe they don't have to go to work and be exposed to the virus there. They can have some other kind of work that protects them from the virus in the meantime, or we can use other mechanisms like Social Security to make it so that older minority workers who are at high risk can have some reasonable accommodations for this. I think there's a lot of ideas that are possible if we put our mind to it. But if we say, "Look, let's just rely on reduced community transmission and that'll protect everybody," well, we've seen that doesn't work. We have the record right in front of us. Marc mentioned Sweden. Sweden actually, the death rates are very, very low in Sweden right now, contrary to the rest of Europe. Focused protection seems to be working there. Marc mentioned that they have adopted a few strategies. Those strategies are consistent with focus protection. They're not against. They haven't locked down. What they're doing is focused protection, and you can see the result. The infection rates are going up in Sweden, but the death rates are not. They've not increased appreciably compared to the rest of Europe. So I think that's the basic argument, I'd say, in contrast to the John Snow Memorandum. Focused protection is possible.

>> Howard Bauchner: Marc, when you hear Jay describe it, you know, I always wish -- I had Nicholas Christakis on earlier, and Nicholas had mentioned, he thought we were missing this opportunity to do kind of grand experiments. Not randomized clinical trials, but you know, there was just that report from Germany where they opened up a small group of -- Like 1,200 people came to some event, distance, testing to see how much communication of disease there would be, and there wasn't much. There had been a report earlier from Germany about a gym that had opened up to try to understand it. When you hear Jay's description, to me, it feels almost logistically impossible. But how do you respond, Marc?

>> Well, I think it's a great aspiration. And as I said, we should be inventing and testing and trying as many ways to protect the vulnerable as we can, but to say we can do it when, in fact, Sweden did have a very high death rate in its nursing homes and is putting in place more general societal restrictions on contact, mostly voluntary because it's Sweden, but they think that their hospital system and their death rates are going to be in trouble unless they act now, and that's why they're doing it, even Sweden. So I think, you know, we should be as creative as we can be, but you don't let your guard down while you're experimenting. You experiment with generalized protection. And I think part of the other issue, what Jay doesn't mention, is that when viral transmission is widespread, that destroys the economy. It reduces consumer confidence, as was reported this morning on NPR. It reduces people's willingness to go out and buy stuff, and, I mean, the uncontrolled spread of the virus is not a solution. And what happened over the summer in the United States, as the economy continued to be in trouble and as mandatory restrictions were lifted and viral transmission increased again was, we had the worst of both worlds. We had uncontrolled spread, we had economic problems, and now we have increasing death rates among the vulnerable in places that are seeing more cases. So I think it's a great idea to experiment. I think it's a great idea to look for creative solutions, but nobody responsible would abandon what we know works, which is controlling viral spread, not with involuntary lockdowns, unless it's an absolute emergency, but with other combinations of measures. The last thing I'll say is, I think the coupling of this good idea of trying to protect the vulnerable with this fringe idea of trying to increase the level of immunity in the population through permitting more transmission is missing the opportunity to have a serious conversation about how to help people who have been harmed by both the virus and the mitigation measures. So the same administration in the US that has adopted herd immunity as an official policy has also blocked the appropriation or the spending of money to try to help people deal with the economic consequences, and that should be the focus, rather than trying to do experiments on people when we don't have a good backup.

>> Howard Bauchner: Jay, on these conversations, we've talked about schools at length. I'm a pediatrician by training, and, you know, the pain of not having schools open is -- There are going to be consequences for decades. Children will lose school years, and I think next year, if we're in a better shape, we'll have to figure out if a lot of the kids should go back to the same grade. But in a more open policy -- And part of the struggle for schools has been the age of teachers, and the same is true with colleges, but I know, Jay, you're aware of that. How do you explain to people -- there's potentially greater societal benefit, more of the economy open, some children in schools, less social isolation, but the cost will be deaths. There will be deaths. So I know the data that you presented about the percent of deaths under and over 70 or under and over 60, but that doesn't mean there are no deaths in individuals under 60. How do you explain to people that that's likely going to result in some additional deaths?

>> Jay Bhattacharya: I mean, the key thing is context because, you're right, this is a deadly pandemic, and there's no good outcome from it. There's only minimizing harm and death by choosing policies wisely. Let me document some of the harms of the lockdowns, as I've advocated for all the way through the epidemic. Among young children, the child abuse has skyrocketed. Often, it's picked up in schools. Our schools have been closed, so it doesn't get picked up there. There's domestic abuse that's happened. The CDC estimated in June that one in four young adults seriously considered suicide. One in four. You know, normally that's something that's on the order of 4% is now one in four. The school closures have led to vast harm in terms of inequality, right? So there's going to be kids -- This is probably the single biggest generator of inequality since segregation is the lockdowns of the schools and society more generally. Physical health, cancer screening was at an 80% drop. I think you all just published a report about that, in colonoscopy and mammograms. There's going to be more stage four breast cancers and colon cancers than we've seen in a very long time. Cancer, we actually made a lot of progress against in past few years. That's about to be reversed, if it not already is. Cardiac procedures, there's a drop in angioplasty, a very, very sharp drop. People stayed home. They're more afraid of COVID than getting treated for heart attacks. That's happened already with the lockdowns. Internationally, the UN estimated in April that 130 million people are on the brink of starvation or potentially at risk of starvation because of the economic dislocation and harm caused by the lockdowns. Marc said that the viral transmission destroys the economy. I hear that, and I hear something like, in the Vietnam War, we have to destroy the village to save it. That's not right. The economy responds to the policies we pick. If we tell all our businesses to close, our schools to close, the economy will be harmed. The economy rebounded when we lifted up some of those restrictions in the third quarter, right? Now, we talk about economy as if it were just dollars, but it's not. I've documented, I think, already, all of the devastating physical and mental harms that are caused by lockdowns, both nationally and internationally. Hundreds of millions of people thrown into poverty worldwide. If you're sitting at $2 a day of income and you have a GDP hit of, you know, 20% and 10% or whatever the number turns out to be, you're going to starve because, you know, it's a disproportionate hit. It's an incredibly unequal, unfair, immoral policy that we've adopted, and to say that we can't protect our vulnerable, again, I think that's just a failure of imagination. Logistically, it's not impossible. It's difficult, but we have to put our minds to it. I think reducing community transmission has become a crutch that has prevented us from putting our minds to it in appropriate ways. So, you know, Marc mentions voluntary restrictions in Sweden. Look, I think those voluntary restrictions make sense. Those aren't restrictions. Those are guidance to people who tell them honestly what the risks are. So for instance, I think a major public health message that we failed at is describing the age grading and the risks. Older people think they're at lower risk than they actually are, and younger people think that they're at higher risk than they actually are. And I think it's an enormous public health mistake. I think there's a lot we can do to correct that, and Sweden is a good example. Let me do some counter examples, right? Germany and Argentina and Spain had lockdowns. The UK's about to go back into one, and yet community transmission has exploded. I don't think the lockdowns --

>> Marc Lipsitch: Once the lockdown was off, not while the lockdown was on.

>> Jay Bhattacharya: Yeah. Then we just keep the lockdowns on for how long? I mean, I think Argentina's had a continuous lockdown, actually, and the cases have exploded. I mean, I don't think the lockdowns have a very good record here at actually reducing the spread. What the lockdowns do is, if they do anything is, they delay when the cases occur. They don't actually eradicate the disease or eliminate the disease. And while they're in, they cause absolutely catastrophic harms to people who are relatively low risk from the disease.

>> Howard Bauchner: Jay, when you -- Go ahead, Marc. Go ahead.

>> Marc Lipsitch: Massachusetts was one of the most cautious states to reopen, and I'm looking at the document on reopening Massachusetts from May 18th. So all these harms that Jay's describing have been happening in May and June and July and August and September. And I think we agree on opening schools. I think that probably we shouldn't spend more time on because I think we both agree that that's a high priority, and I think it's also a relatively safe thing to do. But it feels to me like Jay is describing as lockdown everything that causes harm, even when it's not locked down. We were not locked down in June, and these things that were being described happened in June. The lockdown in the United States was about a two-month or less period of time in the spring, and all of these harms, I agree, are real, but they are because the normal life of our society is being interfered with by viral transmission and by people's inability to live their normal lives.

>> Jay Bhattacharya: Businesses were closed, schools were closed in Massachusetts. People don't interact in public. Churches are closed. I have not been able to go to church in person, really, in seven months. I think to describe what we've gone through is not a lockdown. It's a mischaracterization. The social isolation and dislocation that's happened are a consequence of the lockdown policies we've adopted. Sweden is not the same as that.

>> Howard Bauchner: Jay, when you talk about moving away from the lockdown -- there's a question that came in. For better or for worse, I'll pick age 60 and under. Is that to allow people out into society without social distancing, without masking, without handwashing, that they proceed in their live as they normally would?

>> Jay Bhattacharya: No, I think the Swedish policy is the right one. We tell people, "Look, it is a risk. You should social distance when you can. Definitely use masks when you can. Social distance, handwashing." So I think all of those mitigation measures are really important, and I think it's a mischaracterization to say we say let it rip. I don't want to create infections intentionally. What I want is to allow people to go back to their lives as best they can with the understanding of the risk that they're taking when they do it, right, 99.95 survival, right? So I think that's the basic idea. The harmful lockdowns are worse for most people. I'm sorry, for many, many, many people. So I think when you say "Do no harm," it's following that principle in the context of these nonvulnerable people, people that are not vulnerable to the COVID but much more vulnerable to lockdowns.

>> Howard Bauchner: Marc, is there a middle ground?

>> Marc Lipsitch: Well, I think Jay is moving towards a middle ground, which is not really what the Great Barrington Declaration seems to promote in the sense that, nowhere there does it say we should use masks. Nowhere there does it say we should social distance. It just says we need to go back to normal life. So maybe we are actually approaching some common ground. But I want to pick up on something Jay mentioned about lockdowns don't prevent infection, they delay it. In a literal sense, that's true. If you still have virus around, then you still have susceptible people around, then delay is all you can hope for. But if we are anticipating having a vaccine available for some proportion of the population, and if we're anticipating continued improvements in therapeutics, then delay is preventing death. A case today is worse than a case tomorrow and a lot worse than a case six months from now because that six months from now case might be prevented by vaccination or might be treated by a better therapeutic. And so with infectious diseases, of course, you can't prevent them spreading until you eradicate them, but delay is not nothing. It's actually the goal, as I see it. And as the John Snow Memo says, we want to keep the virus under control in such a way that the vulnerable people are not at risk. The other thing I want to just mention is, this dichotomy between the elderly and comorbid people, on one hand, and everyone else on the other is not as simple as it seems. First of all, in the UK mortality studies, it's been clear that, after adjusting for age and after adjusting for comorbidities, there's still a very strong socioeconomic gradient that the less money you have, the more likely you are to die from COVID. In this country, it's clear that if you are black or Latino, you are more likely to die from COVID. Those are, in some cases, identifiable, some cases not. Socioeconomic status is not something everybody can just tell, nor is ethnicity, in all cases. And so this idea that they're "them" and "us" is really quite fluid. And, you know, 45,000 almost Americans under 60 have died -- under 65, sorry, have died of COVID. So it's really not -- It maybe a low individual level risk as a percent probability, but it's a lot of people.

>> Howard Bauchner: Jay, when you hear that -- So, you know, I've had people on where we've talked about the different phases of the vaccine, and phase one is easy in the sense that we know who it's going to be. Virtually everyone agrees it's going to be healthcare workers. It's about 20 million. Vaccine will be distributed by hospitals. I generally have faith that hospitals can store and distribute the vaccine. The next hundred million is really a struggle because that is a very large group, and distribution will be a logistic nightmare. But people have said, in part because of race, ethnicity, and obesity, that that second group is 50 or 75 million people. How do you think about that group of people? Then you're talking about 100 million people somehow being at elevated or increased risk, 200 million not? How do you think about, you know, the policeman or the fireman or my grocery store person who's fantastic, but who's 65 and tremendously overweight?

>> Jay Bhattacharya: Yeah, I mean, we absolutely need to deploy the vaccine to the most vulnerable, and we have, I think, pretty good characterization from that new case study that Marc mentioned of who they are.

>> Howard Bauchner: Yeah.

>> Jay Bhattacharya: I mean, I think the vaccine delay issue -- the waiting of the vaccine, the question is, who are you harming in the meantime with a lockdown, right? A life of a child in Africa dying from starvation because of the lockdown harm, on the margin, is just as valuable as a life here. The life of a child abused in the United States because of the lockdown is just as valuable of a life of someone who dies from COVID who's under 65. It's all tragic, but the question is, how do you minimize that harm, that death and human misery in the meantime? That's the only question, right? It's not a question of, like, we shouldn't, in public health, be looking at only one thing. We should be looking at everything. We need to think about health much more holistically. We're not just here for infection control. We're here for maximizing human wellbeing, right? That's what public health and medicine's about. And I think that singular focus on one disease has created this blind spot, I think, for the harm that we're going to cause, that we are causing with these policies. So the idea of waiting a vaccine, yeah, the vaccine's coming no matter what, I really hope very, very soon. In the meantime, we shouldn't be causing extra harm. That's why we're arguing against the lockdowns. Marc mentions the socioeconomic status issues with, you know, in suffering from COVID. I completely agree with that, but I think the lockdowns are, in part, responsible for that. We've asked poor workers, deemed them essential, and asked them to go out and get exposed. We have not adopted policies that protect them, in part because we haven't thought of them as vulnerable. Focused protection basically says, let's figure out who the folks actually are vulnerable. And like I said, I think we now, scientifically, have a very good idea, and adopt our policies around that. I mean, I mentioned using disability laws, accommodation laws to protect folks like that. There's lots of other possibilities, I think. We spent trillions on the CARES Act. Why did we not spend money on that, right? I mean, I think these kinds of ideas are not pie in the sky. They're not fringe. They're absolutely central to how we normally deal with regular policy issues. And instead of that, we've taken this absolutely extraordinary step to say, well, let's just lock down society and by doing that, that'll protect everybody. But it hasn't. I think that's the key thing, I think, that I want to get across to folks in the audience. This is not a question of, well, let's let it rip through society and be irresponsible. The issue is, let's be responsible but much more comprehensively than we have. COVID is not the only public health danger we face in society, and by locking down, we end up with a much worse outcome for many more people, not just in the United States, both from COVID and non-COVID, but also around the world.

>> Howard Bauchner: Marc, do you think Massachusetts, my home state, did it the right way? And do you think the future is to allow places of business to open, but, for example, with mandatory masking, which now, with the likelihood that Vice President Biden will obtain enough electoral votes to be president, has certainly been something he's alluded to? Is that the common ground? To open up schools, to open up businesses and restaurants, but to insist on masking, which seems to have become so political in the United States? Is that your sense, Marc?

>> I think that's the right place to start, and I think that is happening, for example, in Massachusetts pretty well, but not very well. And our case numbers are growing, and the governor has recently added relatively modest level of restrictions to certain kinds of activities. So I think the common ground is that, you know, we haven't been in lockdown in the United States in any serious way in most of the country since May, or since at least June, with the exception of places that got really out of control and had to take special measures over the summer. And so I think the common ground is, there's a lot of harm to people from the economy, and we can argue about what's causing the economic harms and from the social problems that have arisen and that we should try to minimize those. And I think the point about trying to protect vulnerable people who are not in the older age groups but to try to protect essential workers, as they've been labeled, is another point of common ground. And another point of common ground is opening schools. I think it's worth noting that this is not, in fact -- You know, I'd like all of those points, but this is not, in fact, what the Great Barrington Declaration says. It says that the most compassionate approach is to build up herd immunity through natural infection while protecting those at highest risk. So it's pro-infection in the young and healthy, and that's very different from what we're hearing today. I would also add that Dr. Bhattacharya has contributed a statement in support of a lawsuit against the county of Santa Clara, which is essentially trying to block it from imposing any public health restrictions. So there's a little bit of disconnect here between the areas of common ground intellectually and the policy recommendations that are being made publicly.

>> Jay Bhattacharya: Let me just respond to that. That's not fair. I've argued for clear public health messaging. If the public health messaging is "Wear masks, social distance when you can voluntarily," I'm completely in favor of that. I think people will naturally do that when infection risk is high. I'm not against that. The issue is the lockdowns, these mandatory measures that close schools, close churches, close art, close all of culture, close all of society, close businesses and end up harming people psychologically and physically, that's what I'm against. That's what the Great Barrington Declaration calls for. For those voluntary measures, fine, absolutely.

>> Marc Lipsitch: But that's contrary to the process of building up herd immunity through natural infection. You can't have it both ways.

>> Jay Bhattacharya: It's not contrary at all, Marc. The spread of the disease will happen naturally, but because people are doing the natural things they normally would do to prevent harm from other sources, right? So the issue is not counting cases. The issue is preventing harm to people who'd face more harm and damage from the lockdown -- mentally, physically -- than they do from COVID. Basically, the lockdowns say, "Look, you take this harm, you 63-year-old bus driver. You go take this harm. You know, 15, 10-year-old kid, you can't go to school. You know, you can't go pray. You can't open your business. You have to go out of business." That's what it says. That's what the lockdown policies that actually have been adopted in the United States have been.

>> Marc Lipsitch: But we're not in that policy right now.

>> Jay Bhattacharya: We are in that policy. Businesses are still closed. Churches are still closed, a few. I mean, I think schools are still closed. I'm glad you agree with that, but that's not the American policy.

>> Howard Bauchner: Can we just -- I know we wanted to move on from schools, but as a pediatrician, schools are a huge issue for me, and I think everyone has come to recognize the closing of schools in the spring may not have been the right approach, but let's put that aside. You know, hindsight's always easy. There's 80 million children under the age of 20 in school, starting at about age 3 up to age 17 or 18. My understanding is 25 to 30% of teachers are older than 65, and another 20 or 25% would be considered higher risk because of other demographic factors. Although it's easy for us to agree to opening schools, that's not what school unions have said. And Mike Osterholm, who I interviewed when we were talking about schools and children, he said, "Around children, it's simply the numerator. It's not the denominator. One death in a school, and that school will be forced to close." I really do appreciate the loss in education, the consequences of screening for child abuse, but how do you explain that to a public that, at the moment, seems to be in two very different camps? That's the struggle. Did we miss that opportunity? Did the executive leaders of this country, did public health messaging, did it go awry, and can we recover a message that represents solidarity about the approach? I'm just not sure we can get there. Marc, can you comment first on my diatribe? I apologize.

>> Marc Lipsitch: Yeah. I think it's a very hard problem, and I think, you know, the science is getting more solid. I published a paper in the Journal of Infectious Diseases this week that reviews some of that science. I still don't think it's absolutely lock-tight solid, but it is quite compelling that schools with reasonable amounts of mitigation are not sites of major transmission. So I think that teachers' unions, understandably, have little trust in our national government because it's abandoned the effort to try to control or even teach us about this pandemic, and locally, they have different experiences with different state and local governments. But lack of trust in government, unfortunately, is endemic right now and it is sometimes justified. I think that we need to treat teachers as essential workers in the positive sense. I agree with Jay in the sense that essential workers sometimes just means poorly paid and not well-treated, which is not a bad description of many teachers also, unfortunately. So I think we need to treat them as essential workers in the positive sense and that there's a lot of interest in prioritizing teachers for vaccination. I think that offering testing, although probably not necessary as a public health measure, might be a good investment as a measure for confidence building. And I think we have to do everything we can to rebuild the sense of trust in public health, but that's been really damaged by the handling of this pandemic.

>> Howard Bauchner: Jay, is the society so fractured, is it so blue and red that we can't get there?

>> Jay Bhattacharya: I mean, Sweden kept its schools open all the way through the epidemic, under 15, with no deaths, you know, and the deaths among teachers were roughly in line with the other occupations, essentially. I don't see any reason why we should keep our schools closed. We're out of line with the rest of the developed world and much of the developing world as well, who've kept their schools open. The second wave of lockdowns has not resulted in schools being closed in Europe. So I'm gratified to see that there's this movement now toward recognizing that schools are safe. I think we likely knew that before based on what we saw early in the epidemic, and I hope that people will now follow this evidence because it is absolutely devastating to keep schools closed for this long. We're robbing our kids of a human right and creating vast inequality as a consequence of it, including health consequences that last a generation.

>> One of the questions that came up -- So about four or five weeks ago, someone sent me an email about long-haulers, and I said, "Why are you writing me about truckers?" I know it sounds -- And then I read our own news story about long-haulers, and then Carlos del Rio and colleagues wrote a wonderful piece about what we are about long-haulers, which I now have come to realize is the long-term consequences of someone who gets COVID-19. I have said the data are limited. Most of the material that's come across my desk has been limited case series, and so you don't really know how common it is or what the long-term consequences are, but Jay, when you and your colleagues who wrote the Great Barrington Declaration hear about long-haulers and this growing concern that people really may have long-term consequences, the percent, the numbers are unknown, does that give you pause in thinking about putting more and more people at risk of getting disease through opening up society?

>> Jay Bhattacharya: Well, I mean, again, you have to counter it against the -- balance it against the lockdown harm, right? But I do think that that's a thing to take seriously, right? So flu, you know, also has extra respiratory consequences, right? So my son, for instance, when he was 10, had the flu, despite having had the flu shot that year, and he woke up one morning and couldn't walk. So I'm, like, thinking back to med school, you know, like, "Oh my God, is it Guillain-Barre?" I mean, horrible nightmares, as any parent might. Luckily, it was benign myositis, and he was able to walk a few days later. I mean, those are consequences of respiratory infections that look relatively benign, and certainly I think it wouldn't be surprising to see that they would have some here as well. But I want to emphasize, we don't know -- What I've seen so far is that almost all the reports sort of overplay how much we know about it and create an impression that we know for a fact it's going to have vast consequences. Almost all of the reports, in fact, all of them, don't emphasize the denominator, how many people are infected. It's going to be -- It's very likely going to be rare and terrible, and we should think carefully on how to manage it. Absolutely, that should enter the consideration just as much as the physical and mental harms from lockdown.

>> Howard Bauchner: It's interesting. Every time we get a piece, I always make the authors put in a caveat that this is numerator data, highly selective, people who've come to medical attention. Is it one in 100, one in 1,000, one in 10,000, or one in 100,000? And so until we really know that, I think people need to understand, there is concern. This is certainly a group of people, but we don't really know what percent or number it is. There's a continued request. Mike Berkowitz is sending me some questions. He said there's a lot of chatter on social media. So I just have two questions for the both of you, but I'll start with Marc with question number one. Can you please define what you mean by a lockdown?

>> Marc Lipsitch: What I mean by a lockdown is what happened in Spain and many European countries and in parts of the United States in March and April where people are not allowed out of their house except for -- the conditions vary. Spain was much more strict than some other places, for example, but where they're not allowed out of their house except for, say, going to the grocery store, going to the pharmacy, doctor's visits, other truly essential purposes, and virtually all places of employment except for so-called essential businesses are shut.

>> Howard Bauchner: Jay, your definition of a lockdown?

>> Jay Bhattacharya: I mean, I would call that quarantine, and those quarantines were selective because, of course, essential workers had to work. I would call lockdown what we're currently doing. Businesses are closed, schools are closed, churches are closed, art's closed. Almost every normal aspect of society is restricted in some way. It's not as strict as a quarantine, but it is a lockdown, and to pretend like these are minimal interventions is -- I mean, I think everyone listening understands that can't be true. These are absolutely extraordinary interventions, and they need to have extraordinary evidence behind them. They fail, to date, to control the epidemic, and they will continue to cause absolutely enormous harm if we keep doing them.

>> Howard Bauchner: Okay. Now the last question to the two of you. So we've published extensively on this. Steve Wolf, the CDC had the same numbers. We're at about 225,000 or 230,000 deaths that are attributable to COVID-19, but the excess deaths, the excess deaths are about 50% higher. Jay, you already mentioned some of the reasons: not seeking care for myocardial infarction, probably stroke care, thrombectomies declined. So we know that, by the end of the year -- and I just looked at the data again this morning -- we will have 40,000 excess deaths by the end of the year. Could be 500,000. We average 2.8 million deaths a year in the US over the last couple years. It will be well above three million. So Marc, what's the next few months look like? We will have a vaccine approved hopefully by the first quarter of next year. It's going to take an additional six months before a large number of people get vaccinated. Tony and others have made the cases repeatedly that people need to understand it's 70% effective. We will still need to mask. We will still need to socially distance. We will still need to handwash, even when 100 million people get vaccinated. But Marc, what's your sense of what the next two, three, four, or five months are going to look like, given that the predictions of spread in the fall have come true, that people were really concerned about cold weather? We haven't yet hit flu season, but at 100,000 cases a day, it's concerning. What do you think the next the next three, four, or five months look like, Marc?

>> Marc Lipsitch: Yeah. I mean, 100,000 known cases a day, which is a lot more -- That means there are a lot more that aren't happening. So the first thing, when I'm asked to make predictions, it's not that I don't want to make them. It's that I think making projections gives the impression that it's not in our hands. It's not that it's sort of some kind of hurricane that we can duck or we can stand there, but we can't do anything about it. This depends on our response, and at the current tempo, it's going to continue to grow exponentially because we are, in most places, not very close to significant herd immunity. In some places, we may well be, the places that were hit the hardest early on. It may be that the spread will be somewhat slowed by the accumulation of immunity in the population if immunity is protective. And I think there's reason to expect it to be at least partially protected for some period of time. So I think that if the case load doubles, the detected case load doubles in the next month, I will not be at all surprised if it goes more than that. I would be somewhat surprised, but not completely shocked. Beyond that, I think it really depends. I think, you know, whether we like it or not, if the intensive care units are overloaded again in large centers or in large parts of the country, there will be a responsive lockdown of the type that I defined, which I don't endorse as a general matter. I'm not in favor of that as our default position, just to be clear, but I think that we will take strong reactive measures because we have to slow transmission. And it will be, unfortunately, a delayed outcome because transmission-slowing measures only take effect on deaths and ICU cases three to four weeks later. So unfortunately, the worst outcomes might produce a reaction that then starts to moderate them. So I think it really depends on how much capacity has been built up over the time that we've had to prepare, thanks to the intense control measures that were put in place early on in some places and how much places continue to get overwhelmed.

>> Howard Bauchner: Jay, the next three or four months?

>> Jay Bhattacharya: Let me agree with Marc. It depends on what we do. If we adopt a focused protection idea, we'll have much better outcomes. Let me just give you one statistic on this. You mentioned the excess deaths in the US. Absolutely tragic. A hundred thousand excess deaths over and above the COVID [inaudible], right? I think it will be worse going forward because of the lockdowns. In Sweden, 6,000 deaths to date from COVID, and only 1,800 total excess deaths. They have fewer excess deaths total, all cause, than COVID deaths. That's lockdown harm avoided. If we keep this policy of lockdown, we will have the same kind of outcomes we've already had: high excess deaths and sort of indifferent control of COVID. If we adopt a focused protection idea, I think we'll have much better outcomes. It's still a tragic thing. We're still going to have misery and death going forward, you know, until we reach a point where there's sufficient immunity either through a vaccine or through natural infection. The only question is, how do we minimize the total harm in the meantime? And I think if we adopt focused protection, we'll have a better outcome in the next three months.

>> Howard Bauchner: This is Howard Bauchner, editor-in-chief of JAMA. We could go on much longer. I really want to thank Jay and Marc. Oftentimes, the hardest thing is to actually talk with people who you disagree with or have a different sense, and one of the goals of conversations is to bring back this notion of conversation with civility and decency, and both of you have shown that, and I really want to thank the two of you. We've been discussing the Great Barrington Declaration and the John Snow Memo. Marc is a professor of epidemiology at the Harvard T. H. Chan School of Public Health, and Jay is a professor of medicine at Stanford University. Marc and Jay, thanks very much. In the words of Mike Osterholm, I'm happy to have you back in a few weeks so we can correct all the mistakes that all three of us have made today. And Marc, I can't agree with you more. Occasionally, people ask me to project, and I go, I'm not in the projection business. I just do conversations. So to everyone, I say stay healthy, and thank you both for joining me today.

>> Jay Bhattacharya: Thank you, Howard.

>> Marc Lipsitch: Thanks for having us.

>> Howard Bauchner: Bye-bye.


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