Why we need a more targeted approach to stopping COVID-19

The COVID-19 outbreak is an extraordinarily serious situation. Based on some predictions, this virus could kill 2.2 million in the U.S. — one out of every 150 Americans. There is uncertainty in these estimates, and the experiences in South Korea, Singapore, Hong Kong, China, and perhaps Japan — where viral spread has flattened — favor more optimistic models. Nevertheless, it is clear COVID-19 represents one of the biggest health threats our country has faced in recent years.

There will also be severe economic consequences to the COVID-19 outbreak. Some estimates suggest that half of American jobs — including those of the most vulnerable members of society — may be in peril due to the economic disruptions, closures and cancellations.

As a primary care doctor, I have observed both the health and economic threats firsthand. I have treated several patients experiencing symptoms likely due to COVID-19, including a retired firefighter who is teetering on the edge of hospitalization due to his worsening shortness of breath. The hospitals where I work are also filling with patients diagnosed with COVID-19, including some requiring intensive care. Yet some of the most challenging situations I have observed involve the economic and social consequences: an Uber driver on home isolation who cannot work and may miss his rent payment; a small-business employee who was laid off in anticipation of a prolonged shutdown; and an elderly woman whose depression flared due to increased social isolation.

The pandemic has also had an impact on my family. My children – ages 4, 6 and 9 – have been out of school since early March. While the first days have gone well – aside from an uptick in sibling quarrels and some cabin fever – I worry about the impact of prolonged school closures on their development, as well as the extra childcare burdens we will face. My wife worries about her small business: Will she need to lay off employees in the face of an extended disruption?

With these considerations in mind, I have found myself uncertain about the best response to this pandemic. Should we adopt strict and extended lockdowns in an effort to minimize the health consequences at all cost? Or, as President Trump has proposed, move quickly to “reopen the economy” in an effort to minimize social and economic damage? On the one hand, a rapid restart of the economy could backfire by prolonging the pandemic, worsening the social and economic consequences. On the other hand, might prolonged closures shatter the morale of society?

After some reflection, I have come to believe that the best approach may ultimately be somewhere between the extremes. While a dismissive approach would be foolish, extended lockdowns would have far-reaching consequences — on the economy, children, and our emotional health — that may prove just as harmful.

While a dismissive approach would be foolish, extended lockdowns would have far-reaching consequences — on the economy, children, and our emotional health — that may prove just as harmful.

What might an intermediate approach look like? The best concept I’ve heard so far was put forth in The New York Times by Dr. David Katz, who directs the Yale-Griffin Prevention Research Center. In the piece, Dr. Katz argues for a targeted approach in which we “focus our resources on testing and protecting, in every way possible, all those people the data indicate are especially vulnerable to severe infection: the elderly, people with chronic diseases and the immunologically compromised. Those who test positive could be the first to receive the first approved antivirals. The majority, testing negative, could benefit from every resource we have to shield them from exposure.”

As for the rest of us, we would, for the most part, carry on with our usual activities — school, work, and even modest-sized social gatherings (though perhaps not large festivals, concerts or sporting events). As Katz put it, this strategy — a departure from the current course of generalized closures and cancellations — “would perhaps prevent vast segments of the economy from collapsing.”

An additional benefit, he notes, is that resumption of many usual activities would lead to COVID-19 spread among many healthy individuals, generating immunity that might protect against subsequent spread (although there is some uncertainty as to whether previously infected individuals will prove completely immune to repeat infections).

To be sure, I’m not suggesting that we shift to a targeted approach overnight. I believe it would be prudent to continue the existing path of generalized closures and cancellations for at least a couple weeks (President Trump has suggested restrictions might be eased by the end of April). But after an initial period of strict closures, I believe that a targeted strategy could prove more sustainable and effective in the long run than a prolonged economic shutdown.

It is important to acknowledge that a targeted approach would have risks. Though COVID-19 is most dangerous among the elderly and chronically ill, it can lead to serious illness and even death among the young and middle aged. It is likely that a targeted approach would lead to casualties in these age groups. However, this would likely also occur with a more far-reaching strategy, particularly if this approach proves challenging to enforce – which preliminary indications suggest it would be.

Of course, protecting those at increased risk while the rest of society resumes near-normal activities would be a challenging needle to thread. Could grandparents be banned from visiting grandchildren? Could those with chronic medical conditions be prevented from working? Still, these hurdles seem more surmountable than a sustained society-wide shut-down.

We are in the midst of one of the most challenging periods in modern history. There is no ideal solution, and I strongly believe all Americans should follow the guidance of local officials.

However, a shift to a more targeted approach may allow for a more expedient reopening of the economy – providing relief to many suffering low-wage workers – while also protecting the medically frail. This approach may ultimately provide the greatest good for the greatest number of people — one of the central ethical tenets of managing a pandemic.

Dr. Michael Hochman is an assistant professor of clinical medicine at the Keck School of Medicine at USC, where he serves as director of the Gehr Family Center for Implementation Science.