More herd immunity, less herd mentality

Our delayed response to COVID-19 has been rash and driven by fear, not data. This may end up costing us double because health depends on many factors. As we learned in the aftermath of the 2008 market crash, economic shocks have a direct impact on public health. The United States experienced a historical decline in life expectancy due to an epidemic of deaths of despair. In a matter of months, people lost their jobs, lifetime savings, and their homes. A strikingly similar situation is happening now.

Fact is a public health and stable economies go hand in hand. But in the current COVID-19 response, we have pitted these against each other. We either save lives by going on total lockdown or we go back to business as usual and sacrifice the lives of those most at risk. I stand for a middle of the road approach: maximize protection for seniors and vulnerable people, while letting the young and healthy with proven immunity to the virus go back to work. In order to do this, we need more data about immunity.

While we pay attention to the growing number of COVID-19 cases, we are overlooking the fact that there are now nearly 200,000 people worldwide who have recovered from it and survived. Many have yet to be tested, but the majority of survivors are young, healthy and eager to reengage in life and work. We also know that reinfection cases are extremely rare and unlikely.

As a physician on the frontlines of the new epicenter of the pandemic in New York City, I see first-hand how COVID-19 is causing fear and besieging hospitals. The hyperacute nature of this epidemic is tragic and overwhelming. But as a global health practitioner, I am used to looking at the big picture with facts on hand, which is why I urge policymakers to replace fear and anxiety with a level-headed approach based on data-driven messages, strategies and policies. 

It is true that the epidemic caught us unprepared, but we are still flying blind into the worst storm in a generation. Nevertheless, I believe with better data the big picture may be less bleak than thought if we consider a new approach, one gaining traction in countries like Germany. 

The Germans are doing massive testing and isolating confirmed cases while ramping up hospital care capacity and incentivizing innovation. Most importantly, they are progressively reopening their economy by issuing “certificates of immunity” to frontline workers and others who test positive for antibodies of the virus (i.e. serology test). A crazy idea? Not if you value both public health and the economy.

Let’s face it, in the U.S. we are playing catch up to containing the spread of COVID-19 but the virus is like a moving iceberg. We only see the tip of it: the rapidly increasing number of new infections confirmed cases and deaths. It is scary and placing a sudden burden on health systems and families. What we don’t see is the submerged part of the iceberg. The vast swath of the population that is silent or mildly infected and transmitting the virus to others. Epidemiology intelligence is hampered if we only test the sickest patients.

Unfortunately, serology testing has been missing in U.S. data-gathering efforts during the initial period of the epidemic. Serology tests measure COVID-19 antibodies in our blood rather than the virus presence in our bodies and are critical for understanding and managing an “iceberg epidemic.” Why? Because at the end of the day, super-spreader COVID-19 is likely to infect a majority of the population, no matter how far apart we stay from one another in the coming weeks. The good news is that once immune, most people can go back to work. Our containment efforts must focus on the most vulnerable: the elderly and patients with underlying cardiopulmonary diseases.

We need to flatten the curve for the elderly but accelerate herd immunity for the healthy so that we don’t kill the economy trying to outrun the pandemic in lockdown. While home isolation for one month might stop an outbreak, it merely sets the clock back as the virus may return if it is not globally defeated.

Most economies, including that of the U.S., can’t survive the strong lockdown medicine for a whole year. Let’s use data from serology tests to get a full picture of the iceberg, craft policies that protect the elderly and avoid an economic catastrophe that will negatively impact public health for years. 

Ariel Pablos-Mendez, M.D., MPH is a professor of Medicine at Columbia University Medical Center, New York and former head of global health at the U.S. Agency for International Development (USAID).