In this interview with Reaction’s Deputy Editor Alastair Benn, Martin Kulldorff, Professor of medicine at Harvard Medical School and leading figure in the field of infectious disease epidemiology, argues for an age-targeted response to the Covid-19 pandemic.
Lockdowns result in too much collateral damage, he argues, and impose unreasonable costs on the working class and the young in particular. He also has some fascinating comments on the uses and misuses of “the science” in the debate over public health.
Alastair Benn: This week Boris Johnson urged the British public not to “throw in the sponge”, a boxing metaphor. How helpful is the language of conflict when we are trying to deal with a disease?
Martin Kulldorff: It is an enemy, in a sense, so we have to use the weaknesses of the virus against it. The key feature with Covid-19 is the huge difference in mortality between the old and the young. The older people among us have more than a thousand-fold risk of death compared to the youngest among us. We have to use that in order to deal with this virus. So that means we have to protect the elderly among us and other high-risk persons while we wait for herd immunity which will either come via a vaccine or natural infections or a combination of the two.
AB: The British government tends to stress that everybody is at a similar level of risk. So whenever there is a specific acknowledgement of the threat of Covid to the elderly, it is caveated with comments about how young people can get seriously ill too.
MK: This is very unhelpful. There is an enormous difference of risk. For older people this is much worse than the annual flu. For children the risks are much less than the annual flu. This is not a dangerous disease for children. We don’t close schools because of the annual flu. We don’t ban people from driving cars because there are people who die in car accidents. We let people live normal lives with standard precautions.
AB: How much mortality should we tolerate?
MK: It’s not a question of whether we choose to tolerate infectious diseases. They are a part of life and have been for thousands of years. We had pandemics in the past. We are going to have many more pandemics in the future. Instead of going into panic mode, what we have to do is look at the particular disease and respond with public health measures that minimise the deaths. We haven’t done that.
AB: Where have the costs fallen primarily?
MK: The burden is primarily being put on young children who have not been able to access education. Instead of protecting the elderly and letting young people live their lives, we are protecting professionals who can work from home while older working class people, who work out in society, are getting infected and some of them are dying, even though they are at higher risk. Basically, we are throwing the working class under the bus.
AB: So we are almost through the looking glass in terms where the risks have been taken. Why has this been allowed to happen?
MK: That’s about sociology and psychology – and it is the professional class that controls the narrative in society through academics, journalists and other professionals.
What’s really missing here is proper public health thinking. A doctor has one patient in front of him or her. His or her responsibility is to this one patient. That is the doctor’s primary concern at that moment. For example, an oncologist will be concerned about a cancer that the cancer patient has. Even if you can prolong the life of a cancer patient by three to six months that is a very good outcome.
But public health is different. In public health you cannot only think of one disease like Covid-19. You have to look at public health overall. If we do a lockdown, that has consequences on other diseases and creates other public health issues. It creates collateral damage.
To postpone an epidemic outbreak by six months, that doesn’t really give you anything in public health as opposed to medicine. Some people who might die now might live for another six months. That’s good. On the other hand, we are all going to be a little older in six months from now. So we are all a little more at risk. Someone who would have survived for twenty years might die in six months if you postpone it like that. In personal medicine, with a single patient, we want to postpone death. In an epidemic, it is futile to do that unless we can postpone it until we have a vaccine or treatment. That might be a reason to do it but it is not a reason in and of itself to lockdown.
AB: I wonder whether there is a connection here with the way “the science” has often been invoked to mean suppressing the virus until there is a vaccine. Why do you think science has been used in this way?
MK: As a scientist I have worked with infectious disease outbreaks for a couple of decades. Then suddenly in the spring, I was hearing that we should “follow the science” by doing something that I think is contrary to science. That was absolutely stunning to me. I could not understand it. Maybe what happened was one or two epidemiologists would say something and then the media and politicians would fall on it and claim that that is “the science” and then one or two other scientists outside of the field of infectious disease epidemiology might agree to it.
Among my colleagues who I spoke with who are infectious disease epidemiologists, the majority are in favour of an age-targeted strategy. A minority are in favour of lockdowns and contact tracing. Those are the two different philosophies. There are many who are in favour of the age-targeted strategy like Sunetra Gupta at Oxford, Carl Heneghan at Oxford, and Francois Balloux at University College London, as well as many people in the US and other European countries.
AB: Worst-case scenarios extrapolated from the available data seem to have set the terms of the debate. The Imperial College Model in the UK, for example.
MK: In that model they used some input parameters. We didn’t know at that time what the correct values for those were, like the Infection Fatality Ratio (IFR). They made a guess, put that in the model, ran the simulations and something came out. But if the input parameters are a guess, then the output is also a guess. It is just sophisticated guesswork. Maybe journalists prefer to listen to scientists who are willing to make a wild guess rather than scientists who are honest about what they do not know.
AB: Whereas Sweden’s age-targeted response is rooted in its traditions of social democracy, in the UK and the US, that philosophy is viewed as an extreme libertarian position.
MK: I am a native of Sweden. In the Covid-19 debate in Sweden I am a raving socialist. In the US, where I live, I am a right-wing fanatic. But it is critical in a pandemic that we keep it apolitical. As a public health scientist I have to put my own political beliefs aside. I want to get out to as many as possible the right public health message that will minimalise mortality in the population as a whole. Some scientists have failed to do that. They have been mixing their public health message with their political beliefs. That is very damaging both for our pandemic response and general trust in scientists.
AB: The key thing seems to me to be a proportionate understanding of who is at risk and sustainable policy decisions. In the UK, the measures are adjusted by diktat every few weeks according to the latest fad. A lot of it doesn’t seem to be evidence-based.
MK: Correct. Lockdown is a new invention of 2020. Every European country had prepared pandemic plans. We knew one was going to come along. Except for Sweden, all the countries threw it out of the window when Covid-19 arrived. Of course, we don’t know the specific nature of the next pandemic so the plans have to be adjusted accordingly. But basic public health practice was ignored.
There is a difference between those who want to pursue an age-targeted approach and those who want to do a lockdown combined with testing and isolation. Testing and isolation is a very common way to deal with infectious disease outbreaks. When we had an Ebola outbreak in the US there were a few cases so we had to isolate them and then we had to check all their contacts and isolate other people. For many infectious diseases this is the right approach. But it doesn’t work for Influenza. It doesn’t work for Covid-19 or Measles before we had a vaccine. By definition, it doesn’t work in pandemics.
Maybe if you do very extreme measures and you keep lockdowns forever until there is a vaccine or a cure, then contact tracing can do a little bit on top of that. For example, that has happened in New Zealand. But that strategy does require a lockdown until we have a vaccine, which may never happen.
AB: The idea that we lockdown until a vaccine seems like just another Western myth – you smash the virus, this intrusion of the natural world on civilised society, and then scientific endeavour comes to the rescue as if by magic. But this is an illusion, a Faustian story. In the end, it is self-destructive.
MK: Quite – you have enormous collateral damage in the process if this goes on for more than a few weeks. Back in April I had a debate with an oncologist Stefan Einhorn in a Swedish newspaper. He argued that we should lockdown Sweden because in a few months we would have a cure. He mentioned that the drug Remdesivir was already in clinical trials. My counter to that was that we could not trust that. For other viruses, it has taken a long time to get treatments and vaccines. For some, we still don’t have them.
If there had been a quick cure it might have been worth hunkering down for a while. From the bottom of my heart, I wish that had been the case. But I was right and a cure has not come along in a few months.
There are many costs. In the US, childhood vaccination rates plummeted in the Spring. That might lead to outbreaks of preventable diseases some time in the future. Cardiovascular disease outcomes have been worsening. Cancer screenings are not happening. That will not increase mortality this year because if you get cancer this year, you won’t die this year. But someone who might have lived 15 or 20 years might now only live 3 years.
The measures also have a huge effect on mental health. Suicide is the most direct effect but there are longterm effects too. In the US we have evictions because people cannot afford the rent because they have lost their jobs. Evictions are not good for physical or mental health. Those of us like you and me who are in a privileged position – you are a journalist, I am an academic, we can work from home, our salaries are guaranteed. We are not affected very much compared to the working class. It is really the working class who are bearing the brunt of the burden of lockdowns and extending this pandemic over time. They are also suffering because they are the ones building up the herd immunity that will eventually protect all of us.
AB: I am reminded of an essay by Susan Sontag in which she comments on the way people see cancer as the illness that “does not knock before it enters”. That replays the cultural anxiety around TB in the 19th century. It is an unspeakable illness. The fear of Covid-19 strikes me as a similar phenomenon.
MK: The reason for that is that cancer often hits people in their fifties and sixties. Cancers can hit anybody out of the blue when they are middle-aged. But in a way, Covid-19 is worse in this respect because we begin to fear each other. We cannot infect each other with cancer. This pandemic and the fear around it has made people fear each other. This is very tragic for children that they have to learn that they cannot be close to each other and that they might infect their parents and grandparents.
This is actually true to some extent of influenza but children are at higher risk of passing on influenza than Covid-19. For children now growing up, this is all they know. How will this experience effect them throughout their lives?
For those of us who are older, we can hopefully revert back to our old patterns of thinking. It is unclear how it will impact on the psychology of our children.