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One Size Does Not Fit the Virus

The attempt to protect everyone left the most vulnerable nakedly exposed
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The nation and Connecticut are reopening fitfully and unevenly from a prolonged shutdown that many think should not have happened – many including Pulitzer-Prize-winning columnist Thomas Friedman of the left-leaning New York Times and Dr. David L. Katz, a Connecticut MD and an expert with a public health degree from Yale.

Our “one-size-fits-all” shutdown policy is strange in the face of a virus which afflicts different population segments in such wildly different ways. For those over age 65, who comprise only 16 percent of the country’s population, the virus has been devastating. This age group has sustained about 80 percent of nationwide deaths94 percent of Connecticut fatalities have hit people over 60.

Additionally, it is just plain common sense that people with serious prior conditions would be at greater risk, and that transmission would be greatest in densely populated urban areas and in communal residential settings for seniors. An estimated one-half of national fatalities occurred in nursing homes, and almost 70 percent of Connecticut deaths occurred in nursing homes and assisted living communities.

To have imposed a uniform stay-home-shutdown policy was like a shoe store selling only size-8 shoes.

Before the U.S. shutdown began, data out of China and Italy were unambiguous that the virus attacked the elderly and spared those younger. Moreover, the first U.S. outbreak occurred at a nursing home in Washington State.

Tragically, the attempt to protect everyone left the most vulnerable nakedly exposed. A central precept of medicine in the context of scarce resources is triage. God knows, we had scarce resources as the pandemic broke out. When everyone can’t be saved, triage means focusing policy, effort and resources in a manner designed to maximize survivors – in the case of this virus, that means protecting those most clearly vulnerable.

Instead, nursing homes were overlooked at best, and, even worse, in New York and some states, governors forced them to admit infected seniors. Will these governors be held to account?

From the start, many saw a targeted approach without a total economic shutdown as a better approach. Unfortunately, partisanship has developed, with most Democrats supporting the universal stay-home-shutdown policy and many Republicans the targeted alternative. So, looking at the targeted alternative through the eyes of Thomas Friedman may help.

Just after the shutdown began, Freidman wrote a column entitled “A Way to Get America Back to Work,” articulating the same grave concern about the shutdown of the economy as expressed by The Wall Street Journal, this columnist and many others, then and now.

Friedman worried about “group think.” He was concerned that the exclusive focus upon the virus would crowd out treatment of other serious illnesses and conditions, e.g., someone in cardiac distress might hesitate to go to the hospital or be unable to summon an ambulance. He pointed out that a prolonged shutdown would make us all significantly poorer with consequently poorer general health.

Friedman referenced Dr. Katz, who had penned an op-ed two days earlier advocating a pivot from the “horizontal interdiction” strategy – restricting the movement and commerce of an entire population – to a more “surgical” or “vertical interdiction strategy” focused on protecting and sequestering those most vulnerable.

Katz said everyone should stay home for two weeks (the usual incubation time for the virus), rather than indefinitely. Those who develop symptoms should self-isolate; those who didn’t, if in the low-risk population, should be allowed to return to work or school.

Katz strategy is compelling, especially considering that our actual strategy has failed to prevent the highest infection and death rate in the world– and, here in Connecticut, one of the highest rates of fatalities in the nation.

Moreover, the one-size-fits-all strategy is almost certain to make things worse in the future. Had younger people not stayed home and socially distanced, they would have become infected – with only the rarest incidence of serious cases – and herd immunity would have developed, vastly reducing transmission and spread in the future.

The current approach has come at great economic cost. In contrast, the targeted approach would not have required a total shutdown, quite simply because it would have protected and sequestered almost exclusively people of retirement age.

The economic fallout of the shutdown has been catastrophic: about 38.5 million citizens unemployed nationally and, in Connecticut, over 500,000, or over one-third of the state’s private sector labor force (by contract, state employees cannot be laid off). GDP has collapsed, with economists projecting a terrifying 30 percent GDP drop in the second quarter. Income tax revenues will evaporate as businesses sustain losses and individuals suffer massive declines in income.

Some say focusing on the economy is “putting money before lives.” Does anyone seriously believe that these apocalyptic numbers do not spell extreme pain and decreased life expectancy for the vast majority of Americans?

What now? We have flattened the curve, our original objective. We are reopening, but painfully slowly. Some state governors, including Ned Lamont, are imposing myriad rules and regulations which effectively extend the shutdown and continue to scare the public. The likely result will be an anemic recovery.

We need to reopen aggressively to survive the economic apocalypse we have put ourselves through, and, in the public health arena, we need to focus almost exclusively on a comprehensive effort to protect the obviously vulnerable, not every single citizen. If the virus resurges before development of effective treatments and/or a vaccine, we should not shutdown again, but rather persevere with the targeted strategy.

A version of this column appeared originally in The Hill

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Joseph Markley

Excellent column and a great job bringing attention to the advice offered by Thomas Friedman, whose economic concerns for once outweighed his big-government instincts.

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