By David Wallace-Wells, NY Mag
Over the course of the spring, as American deaths grew first into the hundreds, then the thousands, then the tens of thousands, one after another early scientific observations about COVID-19 have been revised or discarded: As it turns out, the virus can be transmitted by asymptomatic people, masks do help, and ventilators aren’t that effective — to name just three.
But one observation from the early days of the pandemic has been confirmed again and again, in country after country: The lethality of the virus rises sharply with age. In the United States, we have spent much of the last few months enacting and debating uniform, universal public-health measures, which treat each citizen equally for the purposes of applied policy: social-distancing measures; “stay at home” or “shelter in place” guidelines; modified guidelines for essential workers, all 50 million of them; possible testing regimes, including “test, trace, and isolate”; and now a gradual reopening of those measures, typically state by state. Our policy, by and large, has treated every person as equally at risk, but the disease doesn’t treat us all equally. As we’ve known nearly from the start of this pandemic, but have chosen to downplay in our public messaging and public policy, COVID-19 is brutally lethal for the elderly, considerably less so for the middle-aged, and still less so for the young. The disease discriminates by age, in other words, so much so that at least one-third of all deaths from COVID in the U.S. have been nursing-home residents and employees. According to the Kaiser Family Foundation, the figure could be even higher: one-half.
This is not to say that the young are invulnerable: They are not. Even among the youngest age cohort, COVID-19 is a very scary disease and can be lethal. It is scarier among those in their 40s than those in their 30s, scarier still for those in their 50s, and so on. But according to the CDC, almost 60 percent of those who have died from the disease in the U.S. were 75 or older. Almost 80 percent were age 65 or older. Only 7 percent of deaths were those age 54 or younger.
The data is just as striking elsewhere. In Italy, the case fatality rate, or percentage of those falling ill who ultimately die from the disease, is zero for age groups 0 to 9, 10 to 19, and 20 to 29. It is 0.3 percent for those ages 30 to 39 and 0.4 percent for those age 40 to 49. It is one percent for those ages 50 to 59 and 3.5 percent for those 60 to 69. At 70 to 79, the number jumps to 12.8 percent. At 80-plus, it jumps to 20.2 percent.
In Italy, hospital systems were overrun and doctors had to prioritize treating the youngest and healthiest patients. Which makes the numbers from Britain perhaps more striking. To date, about 200,000 Brits have been hospitalized for COVID-19, and 25,000 have died in hospital; of those, 90 percent of deaths were patients older than 60. In a preprint paper posted May 7, researchers used NHS records of 17 million Brits receiving health care of any kind between February 1 and April 25, 2020, to compile a broad picture of relative demographic risks. Of 5,683 deaths the researchers tracked, 52 percent were patients over 80; 80 percent were over 70; 91 percent were over 60; and 98 percent were over 50, with just 0.7 percent of deaths occurring in patients under 40.
The researchers then calculated what is called the “hazard ratio” for each group — the risk of dying compared to some baseline — in this case, 50-to-60-year-olds. Roughly 3 million people in that age cohort were active NHS patients during this time, of which just 355 died of COVID-19. The hazard ratio for those over 80 was almost 13 times higher than that of those in their 50s, which was about 13 times higher than for those under 40. Which means, in the U.K., all things being equal, someone under 40 has 1/180th the risk of someone over 80 — in other words, a British octogenarian is 180 times more likely to die of the disease than someone in their late 30s.
The ratios vary across countries — different nations have different natural demographic skews and have approached the disease in some quite different ways, leading to somewhat different outcomes. But the overall pattern is very clear: There is a dramatic difference in vulnerability by age range, and the differences are most dramatic at the very old end of the spectrum. In a summary post recommended by the economist Tyler Cowen, Silicon Valley tech executive Elad Gil aggregated the numbers for the case fatality rate (CFR) — the fraction of confirmed cases that end in death – globally: “Depending on the country, the CFR for patients over 80 years old is 10-55X of CFR of patients in 50s, 30-100X of CFR of patients in 40s, and 60-240X of CFR of patients in 30s.” By those numbers, COVID-19 almost begins to look like a different disease from one age group to another. For those under the age of 45, COVID-19 has a case fatality rate of about 0.1 percent — roughly the all-ages fatality rate of the seasonal flu (though, as a novel virus, it is considerably more infectious). For those 75 to 84, it’s about 4 percent, which puts it in the neighborhood of whooping cough and makes it about twice as lethal as the all-ages fatality rate for the Spanish flu of 1918. For those 85 and above, it’s north of 10 percent.
On some level, this spread should not be surprising. Aging makes one increasingly vulnerable to any illness, as we all know, most of us from personal experience. And indeed, as the CDC data shows, the age skew of the coronavirus is not all that different from the age skew of death from all causes in the U.S, where, during the pandemic, 31 percent of all deaths in the U.S. were patients 85 and older, 56 percent were 75 and older, 76 percent were 65 and older, and just 12 percent were 54 and younger. But this skew tracks with the general provision of health-care services in this country — however broken that system is, it does emphasize elder care and end-of-life care, often at the expense of more effective interventions earlier in life, because the needs are starker, and demands greater, at older ages. But when it comes to COVID-19, health policy and public messaging simply do not reflect that spread — in the U.S. or really anywhere in the world.
In the U.S., over the last few months, this age skew has become almost exclusively a talking point of the COVID-skeptical right. On March 24, Texas lieutenant governor Dan Patrick suggested that plenty of grandparents would happily die to preserve the health of the American economy for the children and grandchildren, later doubling down on the point to suggest “there are more important things than living.” The radio host Ben Shapiro, who once raged against Obamacare’s “death panels,” said, “If grandma dies in a nursing home at age 81, that’s tragic and that’s terrible, also the life expectancy in the United States is 80” — ignoring or overlooking the fact that the life expectancy of someone who is today 80 is about an additional decade. And perhaps most egregiously, there was the Twitter thread, last week, from conservative writer Bethany Mandel. “You can call me Grandma Killer,” she wrote. “I’m not sacrificing my home, food on the table, all of our docs and dentists, every form of pleasure (museums, zoos, restaurants), all my kids’ teachers in order to make other people comfortable. If you want to stay locked down, do. I’m not.”
But noting that different groups are differently vulnerable is only an argument for throwing up your hands and “letting it rip” in a political and social environment in which you only have two options: total lockdown or total indifference. Strangely, that has been, for the most part, how the U.S. has chosen to fight this disease, embracing “stay at home” and “shelter in place,” which are effective quarantines, all across the country without even attempting to impose, in most parts of the country, less invasive social-distancing measures and without rolling out anywhere in the U.S. anything like the expansive testing programs that have allowed many countries, particularly in Asia, to avoid the need for extended lockdowns.
Perhaps this fast action — moving within days from limited social-distancing guidance to full shutdown — was necessary in states like Washington and New York, where the disease seemed to be spreading so quickly intermediate measures would’ve quickly proved ineffective. And given our abysmal testing capacity through all of March and much of April, it would’ve been difficult to know precisely where different levels of precaution were necessary. But today, with somewhat better testing, in parts of the country where the disease had hardly or not at all announced itself, such measures can already look, in retrospect, premature — and, coming perhaps too soon, may have deprived those communities of some amount of political will to endure lockdowns if and when they become considerably more necessary when case and death counts grow.
Yet, even now, the public-health debate continues to proceed in a maddeningly binary, quite partisan manner, with advocates of “reopening” on one side and those pushing for continued lockdowns on the other. This has not been especially productive politically, though very strong majorities, on both sides of the aisle, continue to support restrictive shutdown measures. Presumably, even if we wanted to, we couldn’t properly “reopen” almost anywhere in the country, since research has shown that the collapse of social and economic activity across the country began before lockdowns were put into place, as citizens learned about the threats of the disease, and in those places that have “opened up,” businesses have seen only a very limited rebound. And, on the other side of things, we can’t very easily endure continued stay-at-home orders until a vaccine arrives perhaps a year or two, or more, from now.
But while a number of the plans put forward as guides to reopening from lockdown, including the one produced by the White House, have suggested different regions and communities could be classified differently, according to COVID risk, and could implement different levels of caution as a result, there has been much less emphasis, in any of the plans, on how different groups within each community should be advised and how public policy could be shaped to focus most on those most in need. Indeed, there has been remarkably little communication in general directed at individuals beyond “stay at home” and “wash your hands” — often the extent of the messaging to the most vulnerable is to say: “If you are over 65 and/or have a preexisting condition, you should be more vigilant.” But not all conditions are created equal, and the risk faced by a 70-year-old female survivor of non-liquid cancer is very different from that faced by an 85-year-old male survivor of liquid cancer. As Julia Marcus writes for The Atlantic, these guidelines are like abstinence-only sex education: It doesn’t give you anything like the information you need to actually succeed at managing your own risk, in part because it’s one-size-fits-all and in part because that size simply won’t fit everybody — or perhaps anybody — in the long run.
So what would a more targeted public-health approach look like? Let’s take just the age-skew data and rewind to late February, when the first two residents of the Life Care nursing home in Kirkland, Washington, died from COVID-19. At that point, given the striking clarity of the data as it was coming out of China, a national effort to focus on protecting the health of the country’s elderly could have begun in earnest. We could’ve immediately prioritized the supply of PPE to old-age homes, perhaps deploying a sort of national monitoring force of public-health officials to hold these facilities (notoriously poorly run) up to standard and ensure that new, coronavirus-specific hygienic protocols were enforced. We could’ve done the same for testing materials, requiring residents and staff to be regularly tested, as New York has just now started to do, only months later, after nearly 5,000 have died in nursing homes in the state. We could’ve stopped discharging from hospitals elderly patients who were going to return to nursing homes and potentially spread the disease, instead establishing a more centralized quarantine system like those in Hong Kong and Wuhan. We could’ve been much more emphatic and explicit in issuing behavioral guidelines for the elderly, their families, and those interacting with them, so that it was much clearer precisely what the risks to the old were and how all of those around them could try to minimize them. We could’ve provided additional support for those living alone, or trying to isolate, in part by ramping up meal- and prescription-delivery programs. We could’ve deployed the limited resources we had capable of real contact tracing to focus on elderly communities, and as we expanded those resources, we could’ve continued that focus even as the contact tracers expanded their purview to deal with more and more of the pandemic.
All of this would have presumably required a much more competent federal government, and one much more genuinely focused on the need to protect its citizens, than the one we had or have. And yet it is also the case that it would’ve been considerably less costly, and less invasive, than the general-lockdown measures we have taken so far, or than those we are discussing now as a path forward: mass testing, contact tracing, and isolation for the population as a whole. Indeed, all of these options are available to us now — we could secure nursing home and elderly communities around the country today for a fraction of the cost of population-level mass testing and an even tinier fraction of the cost of economic shutdown. Population-level mass testing is of course preferable to this more targeted approach from an epidemiological perspective — its protections fuller and broader, and the information it yields more useful in planning future policy interventions. But given how slow those programs have been to get going, and how much easier the lift of a targeted approach would be, in theory, it’s not clear we’re likely to ever get anything more universal than targeted support. At the very least, we could be providing information to people about just how high a risk they face, personally.
Of course, age is not the only vector along which COVID discriminates. The disease also discriminates by ethnicity; in the British data, blacks and Asians faced higher hazard ratios, even accounting for preexisting risk factors, for instance; and gender, with men facing about twice as much risk; class, of course; and “preexisting condition,” with transplant patients, for example, facing almost five times as much risk. Many of the disparities — particularly those of ethnicity and class — are in part created by disparities in treatment and wealth and social status, of course. Which helps explain, I think, why public policy and public messaging have been so unremittingly universal: There is something unsettling, even at an informational level, of discussing differences between these groups, and something even more unsettling about imagining the arrival of a medical surveillance state in some of those communities and not others. Universalism is how we pretend, as a country, to be impartial, nonprejudicial. Often, it is an alibi for cruelty and injustice; other times, it can be a rhetorical gesture toward democratic ideals. Frequently, it’s both.
But the age skew of the coronavirus trumps all of these disparities for scale. According to that British data, none of those other demographic qualities more than doubles risk, and most have a much smaller effect. None of the preexisting conditions multiplies it by more than five, with, again, most conditions increasing risk by a much smaller amount. Being over 80, remember, multiplies coronavirus risk 13-fold, compared to someone in their 50s. Compared to a 30-something, it multiplies it 180-fold.
For at least a generation, American political elites have taken it for granted that universal programs were more salable than targeted ones — the benefits essentially buying support from those who didn’t need the help but who might oppose a more targeted approach, insisting on at least “means testing” the benefits and probably trying to strip them away from those who were truly in need. But COVID-19 has scrambled so much of our political conventional wisdom it can be hard to keep up, with many commentators worrying now that American anti-authoritarianism, libertarianism, and general suspicion of government means the U.S. couldn’t possibly mount a national mass-testing regime — even though the country has just willingly endured quarantine for about six weeks, with majorities more worried the shutdowns will end too soon than that they will go on too long. And while new polling does show broad suspicion of medical surveillance, it’s hard to know how that suspicion will fare once brought into contact with the relative social and economic normalcy that surveillance would bring. The shutdowns we have already endured are much more restrictive than any test, trace, and isolate program, which we are, by the way, quite a long way from implementing, with perhaps only 1/25th the testing capacity we’d need. In the meantime — radical thought — perhaps our public policy should start from the most vulnerable, doing what we can to protect them, and proceed outward, and upward, from there.