Mailbag Question #3: The lowdown on lockdowns

Have you read Jay Bhattacharya’s “A sensible and compassionate anti-COVID strategy” in Imprimis? I have heard some talk about a focused strategy for protection from COVID and I was not sure what that meant. Any thoughts you would like to share? - K from Michigan

Thoughts? As a matter of fact, yes, I have quite a few. So, buckle up...this is a long one.

Before getting in to Bhattacharya’s piece about lockdowns, I should clarify that although some have assumed I am in favor of lockdowns because back in March and April I advocated for social distancing and compliance with lockdowns, the reality is more complicated than that.

The scientific evidence is abundantly clear that diseases like COVID are spread through person to person contact. As a result, mitigation measures such as social distancing that reduce the frequency and duration of those interactions do slow the spread of disease. In so far as lockdowns cause people to adopt these types of behaviors, there is little reason to doubt that they work. However, what is less clear is whether lockdowns are the best way to achieve the behavioral changes needed to manage the spread of COVID-19.

In addition to the obvious drawbacks of lockdowns including significant social and economic disruption, lockdowns cause significant changes in the way people think and behave that are not all helpful.

First off, the act of making compliance mandatory activates the contrarian tendencies that seem to be so prevalent in American culture causing many to disregard public health guidelines simply because they don’t like being told what to do. If those guidelines were simply recommendations, perhaps some would be more willing to heed them. This is one of the reasons why we have seen such furor over stay-in-place orders even when following such orders was in the public’s best interest.

Secondly, mandates that are not enforced and that are not even enforceable, undermine the rule of law by creating an environment in which people view compliance as optional. This promotes conflicts between those who do and do not comply and fosters adversarial relationships with any authorities who seek to ensure compliance.

Thirdly, mandates create a legalistic environment in which people are focused on a set of rules and regulations instead of risk management and personal responsibility. There is no way to legislate responsible behavior. Rules that encourage wise behavior under most circumstances may make no sense in a few notable exceptions. We all know this, but government mandates leave little room for responsible discretion. And, when even government officials bend and break those rules, people are naturally outraged and accusations of hypocrisy abound.

Last but not least, government mandated closures and lockdowns often lead to the abdication of personal responsibility. Not only do people obsess over what they are not permitted to do, but they often assume that behaviors that are not explicitly prohibited are perfectly fine. For example, people assume that if restaurants are permitted to welcome patrons to dine in (with certain restrictions), then dining in a perfectly reasonable thing to do despite mountains of evidence to the contrary. They fail to realize that the existing rules and regulations are the result of negotiation and compromise. Some behaviors that are quite risky are permitted for political and economic reasons and not because they are safe or wise. Once the government takes it upon itself to determine what people and organizations can and cannot do, those same people and organizations often cease to think for themselves and once a prohibited activity becomes permissible again, few will give up said activity voluntarily, even if it would be prudent to do so. At that point, only government intervention can convince people of the urgency of behavioral changes.

None of this is to say that lockdowns are worse than the alternative. Indeed, some of the early models of the pandemic (which despite being greatly maligned have proven quite prescient) suggested that disruptive suppression measures would be the only way to prevent catastrophic loss of life and the collapse of health care systems. Given the embarrassing lack of compliance with even the most basic of mitigation measures (e.g. wearing masks), it is hard to imagine achieving large scale buy-in for dramatic suppression without compulsion.

However, I can’t help but wonder. If back in March, instead of “playing it down” and asking for a laughable “15 days to flatten the curve” (which was never going to be enough), our leaders had leveled with us about the danger, put on a bipartisan united front, and asked all Americans to do what was necessary, would things have gone differently? If they would have explained the risks and how to manage them and asked each of us to take responsibility for protecting ourselves and our neighbors, would we have been more willing to make sacrifices for one another? Would we have been done a better job of managing those risks and been more gracious with each other when taking small but justifiable risks? If they had provided clear recommendations without compulsion and promised to provide regular updates as our understanding of the pandemic changed, would we have been more willing to listen? If they had abided by their own guidelines, would we have followed suit?

As someone who likes the idea of small government, I want to believe that people would have risen to the occasion. I dislike the idea of a “nanny” state as much as the next guy, and I would love to have seen a responsible citizenry regulating itself. But, if the last year is any indication, I fear that we do not have a responsible citizenry. I suspect that no attempts at persuasion would have been enough to convince us to comply voluntarily. I worry that no one could have protected us from ourselves and that we have become our own worst enemies. Perhaps lockdowns were necessary after all.

So, in summary, I have not made up my mind about lockdowns. I am willing to consider the possibility that there are situations in which they are justified and even necessary, but it is not always clear what those situations are. I also readily acknowledge that one-size fits all approaches don’t tend to work all that well especially when the conditions on the ground can be radically different in different parts of the country. So, I think further discussion about when lockdowns are warranted is both appropriate and necessary.

Unfortunately, the national conversation around lockdowns has been incredibly unhelpful. Instead of helping people understand how to manage risk, a remarkable amount of time has been spent arguing over whether lockdowns work (of course they do), whether they have significant downsides (of course they do) and whether politicians are being hypocrites (of course they are) instead of the questions that really matter and that actually dive our disagreements such as:

1. What is the best way to motivate citizens and organizations to adopt the sorts of behaviors that mitigate the spread of a contagion like COVID-19? Is persuasion sufficient? Are there ways to incentivize these behaviors? Or is it necessary to use compulsion?

2. How do the benefits of lockdowns such as infections avoided and lives saved compare to the costs including both social and economic disruptions? How can we evaluate these tradeoffs?

3. And more fundamentally, what is the proper role of government? Under what conditions is it appropriate for government to intervene in the lives of citizens? How do you balance the need to guard the rights of citizens against the responsibility to protect lives and preserve order?

Amidst all the noise, there is a need for real substantive conversations about lockdowns especially as we enter what is certain to be the darkest phase of the pandemic over the next couple of months.

Enter Jay Bhattacharya. Jay Bhattacharya (or JB as I will call him) is a professor at Stanford University who has become a bit a celebrity in conservative circles for his vocal opposition to lockdowns. He has written a series of opinion pieces and controversial research articles arguing against them. His name came up in this blog previously when he was one of the four “epidemiologists” whose endorsement a certain college sought out when seeking to hold a large in-person commencement during the peak of the pandemic.

He recently published a piece entitled “A Sensible and Compassionate Anti-COVID strategy” in a publication known as Imprimis which despite its low profile boasts over 5 million subscribers (and just happens to be published by the aforementioned small college). In his piece, JB advocates for a lockdown-free strategy called “Focused Protection” in which

“we 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.”

Ultimately, the goal is to achieve herd immunity while preventing a significant loss of life.

This seems like a sensible idea at first, until you start asking questions. First off, what does minimal risk of death mean? Estimating mortality rates for COVID is tricky, but case fatality rates (deaths/cases) can give us a rough estimate. The state of California conveniently publishes a breakdown of their numbers broken down by age group which can serve as a good starting point. In California, the overall case fatality rate is 1.5%. However, when you break it down by age, you notice some big differences. For people under 50 it is around 0.2%. For people 50-70, it is around 2%. For people 70 and up, it is 14%. Which of those rates are minimal? Is 0.2% minimal? At that rate, achieving herd immunity (which requires about 2/3 of the population to get infected) would result in 450,000 deaths along the way. What about 0.6% (the rate for people under 70)? That would mean 1.3 million deaths. Even if we could somehow protect all of the high risk people and even if those fatality rates are overestimates (due to the fact that we are missing quite a few asymptomatic cases), the toll would be staggering. Especially now that vaccines are on the horizon, this would result in a great number of unnecessary deaths.

Secondly, how exactly do you “protect those who are at highest risk” when a pandemic is raging through the population? The only way to do that is to cut people off completely from the rest of society. That means no shopping, no travel of any kind, no indoor gatherings, etc. That means taking the precautions that many people are adopting right now and turning them up to 11. These precautions would have to be significantly more strict because the levels of community spread would be overwhelming.

Thirdly, how do you persuade a huge chunk of the population to cut themselves off to an even greater extent than they already have? Around 10% of the population is over 70, 10% has diabetes, and there are millions more with cancer, asthma and other comorbitides). That makes up a huge chunk of the population! And people aged 50 to 70, (which in my case means my parents) still face substantial risks. Do they need to quarantine too? What about those that are still working? What if they do not want to isolate? And who exactly is going to care for these people? Who is going to staff the nursing homes and long-term care facilities and hospitals? How do you prevent those workers from bringing the virus into those communities? JB’s proposal offers no concrete solutions to these problems.

Fourth, what about hospitalizations? How is the health care system supposed to manage the deluge of hospitalizations from this "sensible" strategy. According to the COVID tracking project, there are currently over 100,000 people hospitalized with COVID in the US even with all of the restrictive measures we have in place right now. Many hospitals are running out of beds, and with JB’s strategy the situation would be much worse.

The reality is that the strategy that JB and his cosigners of the “Great Barrington Declaration” offer isn’t all that different from what we are already doing. This type of solution has created conditions under which the reported number of deaths has rivaled that of 9/11 FOUR DAYS IN A ROW! They are advocating for most of us to do even less than we are already doing and essentially to just let COVID happen. Their idea of protecting the vulnerable sounds great until you realize that their strategy for doing it is essentially to just tell them to be more careful so those of us who are low risk can keep living our lives. So, the short answer to the reader’s question is that I was not particularly impressed by JB’s “strategy”.

Now, I could stop here, but I find pieces like this one aggravating because people like JB should know better. So allow me to rant for a moment. I cannot come away from reading it without asking the question: What is the purpose of his essay? Who exactly is he writing to? Is he writing to inform the uninformed? Provide new insight into the situation? To make a persuasive argument in favor of a new strategy? All of those seem like noble goals, but I would argue that his piece does none of those things.

If his goal was to inform or provide insight, then why would he spend so much time emphasizing things that are obvious to anyone who has been paying attention of the last 9 months. He goes out of his way to point out that COVID isn’t equally dangerous to everyone, lockdowns have downsides, and most people recover. These points have been made time and time again, so who exactly is he informing? Is he talking to people who have completely ignored the news since this started? Perhaps, but if that is the case, I would ask, is “don’t worry, COVID is no big deal” really the message those kinds of people need right now? Perhaps, a more complete portrayal of the situation including a balanced assessment of the risks would be in order.

On the other hand, the piece makes little sense as a persuasive argument for a new strategy. First off, I would question his choice of venue given that the readers of Imprimis overwhelming lean to the right and the people who would need to be persuaded to abandon lockdowns as a strategy tend to lean in the other direction. I think it is safe to assume that Andrew Cuomo is probably not a subscriber. Even if we set that aside, there plenty of other reasons that is hard to reconcile that aim with the contents of his essay. Claims like “It still seems to be a common perception that COVID is equally dangerous to everybody”, in addition to being false, are of no use to decision makers who obviously already know that as do the vast majority of their constituents. If he wanted to help persuade decision makers, JB would provide hard data and yet his article provides nothing of the sort. For example, in his digression on the “Deadliness of the Lockdowns” he talks about millions of starving children, millions of missed vaccinations leading to increased vulnerability to disease, large numbers of Americans skipping medical care, and one in four young adults considering suicide. Unfortunately, he provides little context and no citations for any of these claims. How does this compare to non-pandemic conditions? How does this compare to other humanitarian crises such as natural disasters? He attributes them to lockdowns but fails to articulate how exactly lockdowns caused these tragedies. The reality is that although these sorts of consequences are likely real, many of them were unavoidable consequences of the pandemic itself and would have occurred with or without lockdowns. Although I am sympathetic to the argument that lockdowns exacerbated those problems, JB makes no attempt to demonstrate that. In other words, he offers little in the way of actionable evidence that could allow policy makers to evaluate the pros and cons of lockdowns and instead leaves readers with the superficial notion that lockdowns have consequences (fun fact: so do uncontrolled pandemics).

So who exactly is he writing to? His article doesn’t inform the uninformed and it doesn’t provide new insight to the informed. It doesn’t offer new policy ideas or even sound justifications for old ideas. So what purpose does it serve? The answer is that this piece wasn’t written to educate or inform. It was written to energize a particular audience: the COVID skeptics who long for a justification for their deep held beliefs that the pandemic is overblown and that lockdowns are unjustified. He tells them exactly what they want to hear. He presents lockdowns as if they were instituted under false pretenses by setting up a policy maker straw man who thinks all people are equally vulnerable and who is blissfully unaware that lockdowns come with a cost. That way he can easily defeat the lockdown straw man as a justification for his “sensisble and compassionate strategy”.

But is his strategy sensible or compassionate? He and his cosigners like to point to Sweden’s response as the example for other countries to follow in that they tried to protect the vulnerable without locking down. However, Sweden’s chief epidemiologist even admitted that their attempts at protecting the vulnerable were unsuccessful:

"We knew that group was very fragile and that we would get a lot of deaths if they got infected. But we didn't know that the disease would enter so easily and for the spread to be so big," https://www.cnn.com/2020/06/03/europe/sweden-coronavirus-lockdown-intl/index.html

Largely because of their inability to protect the vulnerable, the death rate per capita in Sweden greatly exceeds that of their locked down neighbors (1.8x Denmark, 4x Norway and 5.3x Finland) and for all the vaunted economic benefits of not locking down, their economy suffered as much or more than those countries (https://ourworldindata.org/covid-health-economy). It seems protecting the vulnerable when a highly contagious virus is spreading through the population is easier said than done. So perhaps the so-called sensible and compassionate strategy is neither sensible nor compassionate. Perhaps the truism that “the definition of insanity is doing the same thing over and over again expecting different results” applies in this situation and perhaps, placing the entire burden of the weathering the pandemic on the vulnerable is not compassionate at all, perhaps it is just an excuse for the healthy to resume normalcy at the expense of others.

To make matters worse, JB’s piece offers up a host of dubious claims, misrepresentations and inaccuracies. For example, the claim that “the COVID fatality rate is in the neighborhood of 0.2 percent” only makes sense if 30% of the US population (99 million people) had been infected by mid-September, when even the most aggressive credible estimates based on serological studies put that number below 10% (https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2773576). He also claims that “hospitals were never at risk of being overwhelmed” which is laughable under the current circumstances (try googling COVID hospital to find any number of stories to the contrary). But the facts don’t matter if your goal is to ingratiate yourself to a particular audience by telling them what they want to hear. These days scientists can become conservative darlings by repeating a few talking points in support of the party line. In this way, they give shoddy arguments and half-baked plans a veneer of credibility. As long as you are willing to check your integrity at the door, cushy TV spots and positions of power await those who lend their scientific credentials to a political movement (see Atlas, Scott). Sadly, JB’s recent piece is just the latest example of this. It is not an argument, it is an audition, an audition for a central role as the “go to” expert for the contrarians and skeptics, and I begrudgingly have to congratulate him, because if that was his aim, he nailed the audition.

PS. The fact that JB's essay fails to make a compelling case for ruling out lockdowns doesn't mean we should go to the opposite extreme and lock everything down. Although I did not focus on the economic hardship people are experiencing in this post, it is very real and should not be ignored. This is compounded by the emotional and psychological toll as well. Hopefully the people who are making these decisions are taking those costs into account and weighing them against the costs of inaction. These are difficult decisions and all of the options are bad. We need more objective assessments of the situation and less superficial and partisan diatribes.