Sweeping public health measures to combat the COVID-19 pandemic, such as banning large gatherings, travel restrictions, closing all but essential businesses, closing schools, and “social distancing” for the entire population, have “flattened the curve.” But they are also flattening the economy, destroying millions of jobs and thousands of businesses. If they are maintained for much longer, we will suffer a deep and prolonged recession. The damage will not merely be economic: Social isolation is associated with depression, anxiety, mental decline, and increased risk of premature mortality.
Imposing public health measures is not an all-or-nothing choice. There must be an ongoing evaluation of interventions that detect infections, limit viral transmission, and minimize the number of deaths. We must continue expanding viral testing and contact tracing to identify infected people who must be isolated. As COVID-19 hospitalizations and deaths peak and decline, it is time to consider moving to less comprehensive mitigation measures that narrowly target the most vulnerable, with flexibility for different situations and geographic areas.
New data indicates that COVID-19 is far less lethal than feared and far more dangerous for certain groups than others. Early studies overestimated fatality ratios because the denominator (the number of infected people) was derived from testing only the sickest patients who were most likely to die, leaving those with mild or no symptoms uncounted. More recent data from California, New York, and Europe suggests that most infections are asymptomatic and go undetected. A new study of random samples in New York State reports at least 13.9% of the population were infected, recovered, and now have antibodies. The figure was higher (21.2%) in the hot spot New York City. These figures are undoubtedly low since it takes two to three weeks to develop antibodies, and people infected in the past few weeks will not yet test positive.
This means far fewer people who get infected will die than what was originally predicted. In New York, the infection fatality rate is 0.5% or less, higher than influenza but a small fraction of previous estimates. Moreover, 0.5% is a figure for the population as a whole. It includes kids and young adults (for whom the disease is usually asymptomatic or mild) and vulnerable groups, such as the elderly and chronically ill, for whom the risk of severe disease and death is much higher.
How much higher? In Europe, 95% of COVID-19 deaths occurred in patients older than 60, and 80% of deaths were in people with at least one underlying medical condition. In New York state, the U.S. epicenter with more than 15,000 deaths, 84% of the dead were 60 or older, just 6% were under 50, and there were only eight deaths in the age 19 and younger group. About 89% of New York deaths had a least one medical comorbidity. Unlike the 1918 influenza pandemic, COVID-19 deaths in healthy, younger people are rare.
Elderly patients are more likely to suffer from underlying conditions than younger people, but they constitute the overwhelming majority of deaths regardless of health conditions. They are also far more likely to have severe cases needing hospitalization. In the United States, consider the number of COVID-19 associated hospitalizations per 100,000 population in the following age groups: fewer than one below age 18, 10 for ages 18-49, 32.8 for ages 50-64, and 63.8 for people 65 and older.
Students with no medical conditions could return to school because the risk of severe disease below age 21 is practically nonexistent. Possible precautions include: temperature screening; excusing older and ill teachers and staff; requiring staff to wear masks; spacing desks widely apart; and limiting contact sports.
Restaurants and businesses could reopen if they can quickly screen customers and employees for fevers and COVID-19 exposure; limit capacity; provide adequate physical distance between tables, seats, and workstations; and require masks for workers. Hong Kong has kept its restaurants open with similar regulations. This would allow the 77% of the labor force in the lower-risk group aged 16-54 to return to work safely as long as they do not suffer from dangerous underlying conditions. Any resulting additional infections would likely be asymptomatic or result in mild illness. Additional hospitalizations should be few and manageable. The higher risk 55-64 age group (17% of the labor force) could be allowed back to the workplace as infections and hospitalizations continue to decline.
Shelter-in-place recommendations should be continued for the high-risk elderly and people with severe or multiple medical conditions. Elderly and sick people who live in multigenerational households (one-fifth of the elderly) should be isolated within their homes, just as people with known infections are. This better protects the vulnerable from exposure than the widespread school and work closures and stay-at-home instructions that ensure daylong, intergenerational mixing. The large numbers of previously uncounted people with antibodies no longer represent a threat to infect vulnerable housemates. Targeting future antibody testing toward vulnerable groups will reveal individuals who are immune and can be spared further isolation.
The optimal approach to controlling COVID-19 remains uncertain. Tailoring health measures to the realities of COVID-19 is a first step toward restoring and protecting our physical and economic health.
Joel M. Zinberg, M.D., J.D. is a senior fellow with the Competitive Enterprise Institute, a free market public policy organization based in Washington, D.C. He is also an associate clinical professor of surgery at the Mount Sinai Icahn School of Medicine and was senior economist and general counsel at the Council of Economic Advisers from 2017-2019.
