Focused Protection: The Middle Ground between Lockdowns and “Let it Rip.”
Jay Bhattacharya, Sunetra Gupta, Martin Kulldorff
November 25, 2020
Both COVID-19 itself and the lockdown policy reactions have had enormous adverse consequences for patients in the US and around the world. While the harm from COVID-19 infections are well represented in news stories every day, the harms from lockdowns themselves are less well advertised, but no less important. The patients hurt by missed medical visits and hospitalizations due to lockdowns are as worthy of attention and policy response as are patients afflicted by COVID-19 infection.
In a recent JAMA sponsored COVID-19 debate with infectious disease epidemiologist Prof. Marc Lipsitch, Dr. Jay Bhattacharya argued against lockdowns and its collateral damage on medical care and public health. At the conclusion of the debate, the moderator, JAMA editor Dr. Howard Bauchner asked whether there may exist a middle ground in COVID policy. That is the right question. Is there a middle ground between lockdowns – with school, business and office closures, curfews, and isolation – and a laissez-faire “let it rip” approach?
In the Great Barrington Declaration, co-signed now by many thousand medical scientists and practitioners, we laid out such a middle-ground alternative, with greatly improved focused protection of older people and other high-risk groups. The aim of focused protection is to minimize overall mortality from both COVID-19 and other diseases by balancing the need to protect high-risk individuals from COVID-19 while reducing the harm that lockdowns have had on other aspects of medical care and public health. It recognizes that public health is concerned with the health and well-being of populations in a broader way than just infection control.
This may surprise some readers given the unfortunate caricature of the Declaration, where some media outlets and scientists have falsely characterized it as a “herd immunity strategy” that aims to maximize infections among the young or as a laissez-faire approach to let the virus rip through society. On the contrary, we believe that everyone should take basic precautions to avoid spreading the disease and that no one should intentionally expose themselves to COVID-19 infection. Since zero COVID is impossible, herd immunity is the endpoint of this epidemic regardless of whether we choose lockdowns or focused protection to address it.
The premise of the Declaration lies on two scientific facts. First, while anyone can get infected, there is more than a thousand-fold difference in COVID-19 mortality , between the oldest and youngest. Children have lower mortality from COVID-19  than from the annual influenza. For people under the age of 70, the infection survival rate is 99.95%. We now have good evidence on the relative risk posed by the incidence of chronic conditions, so we know that among common conditions, age is the single most important risk factor. For instance, a 65-year-old obese individual has about the same COVID-19 mortality risk conditional upon infection as a 70-year-old non-obese individual.
Second, the harms of the lockdown are manifold and devastating, including plummeting childhood vaccination rates, worse cardiovascular disease outcomes, less cancer screening, and deteriorating mental health, to name a few. The social isolation induced by lockdown has led to a sharp rise in opioid and drug-related overdoses, similar to the “deaths of despair” that occurred in the wake of the 2008 Great Recession. Social isolation of the elderly has contributed to a sharp rise in dementia-related deaths around the country. For children, the cessation of in-person schooling since the spring has led to “catastrophic” learning losses, with severe projected adverse consequences for affected students’ life spans. According to a CDC estimate, one in four young adults seriously considered suicide this past June. Among 25 to 44-year olds, the CDC reports a 26% increase in excess all-cause mortality relative to past years, though fewer than 5% of 2020 deaths have been due to COVID-19., 
The harms of lockdown are unequally distributed. Economists have found that only 37% of jobs in the US can be performed wholly on-line, and high-paying jobs are overrepresented among that set. By declaring janitors, store clerks, meat packers, postal workers, and other blue-collar workers as “essential” workers in most states, regardless of whether they qualify as high COVID mortality risk, the lockdowns have failed to shield the vulnerable in these occupations. The economic dislocation from the lockdowns has increased the number of households where young adults who have lost their jobs co-reside with vulnerable older parents, which may increase the risk of COVID-related death. In addition, school closures have contributed to shortages of nurses and other medical personnel who stay home to care for their children rather than work. Very clearly, exposing people to the medical and psychological harms from the lockdowns is ethically fraught.