Hi folks,

I would imagine that my NWAEG and SftP comrade Katherine Yih is on this list and I would welcome her feedback. I am greatly disappointed with this interview with her and professor of medicine Martin Kulldorff. Their "radical strategy" boils down to building up herd immunity, not much different from what elements of the Trump or Johnson administrations favor, and which, despite Kulldorff's view, failed in Sweden.

In essence, during the course of their interview, both Yih and Kulldorff ignore the most problematic element of Covid-19 epidemiology, the high rate of transmission of the virus. In the process, they rely on the speculative (at this point) scenario of developing herd immunity.

Yih starts off by disavowing efforts to prevent transmission, particularly via lockdowns. In effect, then, she accepts the status quo handed to us by the Trump administration, which allowed rampant transmission to the point where it would now, as Yih rightly notes, be quite difficult (although not impossible) to contain. She also dismisses the development and efficacy of vaccines, at least within a reasonable time period and with sufficient accessibility. She is probably partially correct, here. Instead, she favors strategic approaches to building up herd immunity.

She advocates, "instead of a medically oriented approach that focuses on the individual patient and seeks (unrealistically) to prevent new infections across the board, we need a public health–oriented approach that focuses on the population and seeks to use patterns, or epidemiologic features, of the disease to minimize the number of cases of severe disease and death over the long run, as herd immunity builds up."

But, after pointing out that 90% of mortality occurs in older people, and the reality that mortality is differential among social groups for structural reasons, this rings hollow. The objection to a herd immunity approach is twofold. First, it's attainment would entail an unacceptable number of deaths. Given the nature of our capitalist society, with the inequity in co-morbidities and risks and accessibility of health care, and given the biology of ageing, and even the state of medical technology, Yih's words about "minimizing the number of cases of severe disease and death over the long run," are meaningless.

Second of all, herd immunity depends on the biology of the virus and the complexities of our immune systems. Earlier, in her dismissal of anticipating vaccines, Yih asserts, "neither the effectiveness nor the duration of immunity from any of these vaccines is known as yet." But, the same is true of herd immunity. We simply don't know the duration, exact mechanisms or efficacy of the human response to this coronavirus. There have been a growing number of apparent reinfections. We don't know how long immunity lasts. If it is of short duration, that would seem to preclude herd immunity or mean that an impossibly high proportion of the overall population must be infected at any one time for it to occur. We don't know why, in some cases, antibodies are not produced. We don't know why some of those exposed don't contract the virus. Most basically, we don't know what proportion of the population must be infected to attain herd immunity. In other words, the same caveats apply to herd immunity as to vaccines, but with much more statistical uncertainty, since these are not controlled experiments.

Then Kulldorf states, "Children and young adults have minimal risk, and there is no scientific or public health rationale to close day care centers, schools, or colleges. In-person education is critically important for both the intellectual and social development for all kids, but school closures are especially harmful for working-class children whose parents cannot afford tutors, pod schools, or private schools." Bewilderingly, his first argument abstracts from the very population health arguments he and Katherine seek to rely on. The rationale for closing "day care centers, schools and colleges" is not simply the risk to young people, who may have "minimal risk" for severe symptoms (which may turn out to not be so minimal, given what researchers and physicians are finding about chronic symptoms even among apparently asymptomatic cases), but not for infection. In fact, transmission rates among young people are the highest of any age-based demographic. The major risk, here, is to teachers, school staff and all the adults in those children's lives. Kulldorff's second argument simply rewarms the obvious and constant barrage of Hobbesian choices imposed on all working class people in our society, dilemnas which will only be resolved through socialist revolution. And the reforms that could mitigate those choices cut both ways. But, it is just as easy or easier to demand paid time off for parents to supervise home-bound, distance-learning children, as it would be to take some unspecified measures to prevent transmission among children in classrooms and from them to adults. Kulldorff's argument that "in-person" is better for intellectual development is specious if he considers himself a public health professional.

Kulldorff rightly rejects a theoretical dichotamy between vaccines and natural herd immunity, but he again reconciles these by asserting "Whatever strategy we use for COVID-19, we will eventually reach herd immunity, either with a vaccine, through natural infections, or a combination of the two. So, the question is not whether we get to herd immunity or not." But, yes, that is indeed the question. Or one of them. As he then states, "We do not know what percent immunity to the coronavirus is needed to achieve herd immunity, but we do know that if there are many older people in the group that are infected, there will be many deaths. On the other hand, if mostly young people are infected, there will be very few deaths." And, here, again, he ignores the issue of transmission. Kids are not boxed off from adults and seniors.

Kulldorff applauds Sweden's strategy of looking to natural herd immunity to control the disease,"except for the failure to protect nursing home residents in Stockholm, the country has done well without a lockdown. For example, day care centers and schools were never closed for children aged one to fifteen, with zero COVID-19 deaths as a result and only a few hospitalizations. Moreover, teachers faced the same risk as the average among other professions. COVID-19 mortality is now close to zero in Sweden, and the United States has now passed Sweden in terms of deaths per million inhabitants, despite Sweden having an older, more high-risk population." Done well? If I am not mistaken, Sweden contributed among the greatest number of deaths in Europe. And his assertion begs the question, has Sweden achieved that herd immunity? Is it even close? And what will the final cost be IF it does? We may soon find out if it is there, with numbers of cases rapidly climbing in Europe. Further, Sweden has a sharp advantage over the United States. It's postwar Social Democratic regime succeeded in greatly leveling the social playing field. Income inequalty is vastly less and Swedes have access to a range of health and social services to which U.S. resdents are not privvy. Kullforff offers a misleading argument here: "To date, Swedish COVID-19 mortality has been higher than in some and lower than in other lockdown countries. While it is popular to compare COVID-19 mortality rates between countries, it’s not a great metric." The point is not to compare numbers, but to ask if any population is willing to accept tens of thousands of deaths, when these can be prevented. What is worth comparing are the strategies used to prevent deaths. And, in this, New Zealand and a number of other countries stand above the rest.

Kulldorff asserts that "a universal lockdown can successfully postpone cases into the future, as it has done in some countries, but in doing so it also postpones the buildup of immunity." The latter, of course, is the whole point: to out-wait the virus so either its R0 drops below 1, or until there is a vaccine. Nevertheless, his age-stratifed herd immunity approach essentially does the same, but for vulnerable sectors. The elderly and vulnerable protected under their hazy scenarios will, of course, not have the opportunity to build up herd immunity. They will continue to be vulnerable, unless they represent an insignificant proportion of the population, such that the overall population's herd immunity eventually protects them. Yet, for the epidemiological and immunological reasons given above, how likely is this latter scenario? Contrary to Kulldorff, the nursing home dead in Sweden were not "aberrations." Moreover, you cannot simultaneously protect the elderly and vulnerable if you allow free transmission of coronavirus in the general population while you are waiting for the Holy Grail.

Yih throws in an economic argument that muddies the water, somewhat: "millions of working-class people have lost their jobs and find it impossible to find new ones in the current shuttered economy." Well, yes. But we only have to go back 12 years to see that this is the nature of the capitalist economy. In fact, there were many signs of a looming major recession before the pandemic hit. Did the pandemic worsen the crisis? You bet. But, only a liberal with a classical productivist fetish would seek to resolve this by demanding that "younger" people be put back to work amid a pandemic. The correct answer is a broad program, like the pandemic-modified Green New Deal.

According to Yih, "Liberal elites, including the Democratic Party establishment, have actively ceded this terrain, instead emphasizing the importance of lowering infection rates (across the board) until a vaccine becomes generally available. I think the liberal elites’ adoption of this approach stems from the easy appeal of keeping “everyone” safe together with a class position for which the lockdown strategy is in fact safer as well as quite easy to ride out. Liberal elites simply can’t see or can’t feel how this strategy continues to fail the working class and also small business owners."

In fact, in a capitalist society, *both* (reopen the economy or lock it down) are ruling class options, because capital will throw workers under the bus in either scenario. And workers will be protected under neither. Given that, the BEST strategy is still a "curve-levelling" one, not to wait for the herd immunity Holy Grail, but to fight for adequate measures of prevention and protection, universal healthcare, paid leaves of absence and sick leave, the right to decent housing, a frontal attack on racism (and ageism) in all spheres, but now more than never in healthcare, housing, criminal justice and employment. In some cases, yes, we will need full or targeted lockdowns, as in China. Where economic activities must continue, workers must be assured PPE and stringent regard for numbers, ventilation and spacing. And, yes, schools and other indoor spaces of assembly must be shuttered as needed, with online education and necessary time off for parents provided. On a personal note, I'm 65 and will refuse to walk into a classroom with college students who just spent the weekend partying. Regardless of Kulldorff's (baseless) assertions.

Michael Friedman, MPH, PhD