Older and immunocompromised people don’t deserve to be second-class citizens

Every time I call my grandmother, she asks me the same question: “When is this going to be over?”

She hasn’t left the house since the first rumblings of the coronavirus reached her in early March, and she misses shopping at the mall, playing with her bridge club, and receiving visits from her great-grandchildren. “This will be over by summer,” she says, “right?”

I hate having to break it to her. This will not be over by summer. Not by a long shot — at least not for people who are, like her, especially vulnerable to severe Covid-19.

The economy may be reopening in some places, and some people may be going back to work. But that doesn’t mean it’ll soon be safe for those who’ve been enduring isolation and remain at high risk: seniors, those with compromised immune systems, and those with underlying conditions like heart disease or diabetes.

In fact, the opposite is true: As some people go out, they increase the number of human beings they’re coming into contact with. Particularly if they don’t take precautions like wearing a mask and maintaining 6 feet of distance, that increases the risk that they’ll pass on the virus to more vulnerable individuals.

Even if the latter group refuses visitors at home, they’ll occasionally have to go out for things like doctor’s appointments, and a more crowded world means more risk. So, as they watch many US states beginning to reopen despite not actually being ready to do that safely, many of these vulnerable individuals are scared.

The various roadmaps that have been devised for ending social distancing generally accept that older and immunocompromised people will have to self-isolate for longer than others — until community transmission of the virus dies down or a scientific discovery changes the calculus.

The great golden hope, of course, is that scientists will discover a vaccine that can prevent us all from getting the coronavirus. Vaccine trials are moving at warp speed, and some healthy people are even volunteering to be exposed to the virus to accelerate the development of a vaccine. But making one that’s effective and safe enough to be delivered to millions of people is exquisitely complicated and time-consuming. Experts estimate it could take 12 to 18 months, or even longer. And in the meantime, the virus could continue spreading or resurge in big new waves.

This raises a distressing set of questions: Will those who are most vulnerable to the disease have to stay isolated for months or years, paying the price for everyone else’s reopened economies and reasserted sense of normalcy? Will they become, in a sense, second-class citizens? And are we okay with that?

“As a culture, I think we unfortunately devalue the elderly and people who are infirm on a normal day,” Carolyn Cannuscio, a social epidemiologist at the University of Pennsylvania, told me. “It may be hard for some people to dredge up compassion for them now.”

But if we collectively fail to dredge up that compassion — and fail to allocate the resources to improve prospects for this population — we fail one of the biggest moral tests posed by the coronavirus.

The coronavirus puts us all in a moral bind

Almost from the beginning of this pandemic, we’ve known that the coronavirus is more dangerous for people who are elderly, immunocompromised, and who have underlying conditions.

Aging leads to decreased immune function, which makes people susceptible to more severe illness and even death. Early data from China revealed that the coronavirus gets deadlier with each extra decade of life you’ve got under your belt. In the UK, a new preprint paper shows that someone over the age of 80 is 180 times more likely to die of coronavirus than someone under 40. In the US, eight out of 10 people who have died of coronavirus were age 65 or older, and one-third of all Covid-19 deaths have been linked to nursing homes.

Preexisting health issues can also make it harder for the body to ward off infection. Among the 105 patients who had died in Italy by March 4, two-thirds had three or more conditions like heart disease or diabetes. Research conducted in China and published in The Lancet found that almost half of the 191 hospitalized patients in the study sample had a preexisting illness.

It’s important to realize just how many people fall into these high-risk categories. In the US alone, elderly people (over age 65) number around 52 million, or 16 percent of the population. An estimated 10 million people are immunocompromised due to conditions like cancer, lupus, or HIV/AIDS. Some 34.2 million people have diabetes, and 30.3 million adults have a diagnosed heart disease. These categories are not mutually exclusive — some elderly people may also have heart disease, for example — but even so, the numbers are sobering.

Throughout the first couple months of the pandemic, these groups have been urged to stay home and rely on others to deliver necessities straight to their doorstep. Even as some states reopen, these guidelines remain the same: Federal, state, and city reopening plans generally say these groups should continue to shelter in place.

The idea of so many people being stuck at home for months or years while others get to return to some semblance of normal in a reopened economy feels morally odious.

Zeba Khan, an immunocompromised woman in Texas, told Vox she’s frustrated with Americans’ rush to end social distancing. “Other people’s aversion to boredom can kill me,” she said. “I don’t think that’s fair. I don’t think that’s right. And it certainly is selfish. And it’s disappointing that people only take the disease as seriously as it affects them personally.”

The problem is, if we delay reopening and stick to a strict stay-at-home policy, that won’t necessarily shorten the duration of this group’s isolation.

The point of all our social distancing was to delay the peak of the outbreak, buying us time to prepare and preventing hospital capacity from getting overwhelmed, thus saving lives. But there’s no denying it comes with a downside, too.

“The activities many of us are doing to keep individuals safe — social distancing, hygiene, etc. — are meant to ‘flatten the curve’ and slow transmission of the virus,” explained Tara Smith, a professor of epidemiology at Kent State University. “This also has the effect of lengthening the duration of the epidemic, meaning those at risk will need to be isolated even longer.”

Which leaves us in a terrible moral bind, with no great options to choose from.

An infographic that shows the goals of mitigation during an outbreak with two curves. The X-axis represents the number of daily cases and they Y-axis represents the amount of time since the first case. The first curve represents the number of cases when no protective measures during an outbreak are implemented and displays a large peak. The second curve is much lower, representing a much smaller rise in the number of cases if protective measures are implemented.

Christina Animashaun/Vox

That said, there are still better and worse courses of action. For example, if states reopen despite not being ready and community transmission of the virus spikes, that could undo some of the good work we’ve done by social distancing, setting us back and ultimately prolonging the pandemic.

A phased reopening that shields the elderly and immunocompromised is not necessarily wrong. But it makes the moral burden of doing it right — reopening in a way that minimizes risk — that much heavier.

Albert Rizzo, a pulmonary physician and chief medical officer at the American Lung Association, told me many of his patients are anxious as some states begin to reopen their economies. “It’s individuals who are immunocompromised and have chronic lung diseases who are unfortunately going to be even more concerned about going out, and are going to remain shut in,” he said. “They know they’re compromised, so they’re scared.”

Dina Elshinnawi, a video producer at Vice who has lupus, recently wrote a piece titled “I’m Immunocompromised and Freaking Out About the World Reopening.” She’s been having nightmares:

I almost always dream of everyday scenarios like waking up in my childhood home, but with strangers crowding every room. They coughed and sneezed on me and laughed at the terror on my face. I begged them to leave and they ignored me. In another dream, people followed me as I nervously ran through a parking garage looking for my car. Once, I even dreamt I was abducted by aliens but then realized I was safer with them than on Earth.

Elshinnawi, who envisions having to stay at home until a vaccine is available, added that it’s hard to hear her friends “brag about what they’ll get to do when this is over. I know telling them I resent that won’t make me feel any better.”

Her words highlight the fact that there is, and will continue to be, a fundamental unfairness in how the pandemic unfolds. Whichever way you cut it, the most vulnerable in our population will suffer longer.

At the very least, we should acknowledge this disparity, and then ask ourselves: When states meet the criteria for reopening safely, how can they do that as responsibly as possible? What will be the emotional toll on those left at home? And what can those of us who are more fortunate do to minimize the impact on them?

Invest in the ways out: Testing and treatments

We don’t have to wait for a vaccine if we want to get the most vulnerable people out of isolation sooner. There are two other major avenues we can pursue, and researchers are hard at work on both of them: tests and treatments.

Experts say we need much more widespread testing before it’ll be safe to lift lockdowns. The US is now performing more than 300,000 tests a day, but we still need lots more (estimates range from 500,000 to tens of millions).

We also need better tests. Ideally we’d have cheap, accessible, accurate tests that allow people to figure out — quickly — if they’re positive, which would let them know whether or not they can visit their grandmother that day.

Right now, we’ve got three different types: molecular tests, antibody tests, and antigen tests. Each comes with its own drawbacks.

Nurses collect swab samples for Covid-19 testing at a drive-thru testing site in Los Angeles on April 14.
Sarah Reingewirtz/MediaNews Group/Los Angeles Daily News via Getty Images

The most common is a molecular test like an RT-PCR test, which can detect the genetic material of the virus. However, that virus is not necessarily still active, so the test can yield a false positive: It might say you’ve got the coronavirus even if your body has already beat the infection. Plus, these tests have run up against lots of supply-chain problems, they’re only offered at certain sites, and it can take days to get a result.

Then there are antibody tests, also known as serological tests. Using a blood sample, they search for antibodies to the virus, which would indicate that you had Covid-19. However, it can take days or weeks after infection for your body to produce these antibodies, so the test can yield a misleading negative result: It might say you’ve got no antibodies even if the virus is present. And, if prevalence of the virus is low to begin with, this test can produce a lot of false positives. Note that even if you do test positive for antibodies, that doesn’t necessarily mean that you’re immune or that you can’t spread the virus to others.

On May 8, the FDA authorized a new type of test: antigen tests, which detect viral proteins on the outer surface of the coronavirus, using a nasal or throat swab. They’re cheap to manufacture and could theoretically be performed at home (though at-home versions aren’t available yet). That makes them very appealing: “If we had home-based antigen testing as we do for pregnancy tests, potentially we could know quickly if individuals were infected or if they were ‘safe’ to be around those who were at risk,” Smith said.

Unfortunately, antigen tests are less accurate than molecular tests or antibody tests. We’d ideally want to design more accurate versions before rolling them out en masse. However, Michael Mina, a professor of epidemiology at Harvard, told me it may make sense to accept a lower level of accuracy if it means we can test ourselves and visit vulnerable people more frequently.

“We’ve been so focused on developing the most sensitive test that we can get, which will detect one molecule of the virus in somebody’s saliva or nasal swab, and that’s useful in some ways,” he said. “But if you could relax some of the requirements of the test and say, ‘We just need to make sure that someone isn’t floridly positive today; we can tolerate a test that’s less sensitive but cheap enough to use every single day’ — then somebody could actually just carry around a carton of these tests, and before they walk into their parents’ house, they test themselves.”

But what if the person is positive, and the not-very-accurate test just doesn’t show it?

“Maybe even if they’re positive, if they’re positive at such a low level that the test doesn’t detect it, then maybe for that day it won’t be the end of the world,” Mina said. “But if they find out they’re positive the next day, they won’t go in to see their parents that day.”

Designing tests that are specific to daily use may not be a far-off dream. “Four or six months down the road, I suspect we’ll have pretty good test strips that people will be able to buy like a pack and test themselves every few days or if they’re considering going back to school or work,” David R. Walt, a diagnostics expert from Harvard Medical School and doctor at Brigham and Women’s Hospital, told CNBC.

However, Eleanor Murray, a professor of epidemiology at Boston University, was dubious about how quickly the supply chain could accommodate this vision. “The amount of those tests that would have to be manufactured for everyone to test every day would be astronomical,” she said.

But the problem of how to manufacture tests at scale is something we can devote resources to figuring out right now. Investing more in helping companies scale up manufacturing would be one way to show that we care about shortening the duration of vulnerable citizens’ isolation. Another way would be to invest heavily in the army of contact tracers that will be needed as part of any massive testing program: If someone tests positive, tracers will need to ascertain who they’ve come into contact with so they can isolate themselves.

Aside from testing, the other major hope lies in therapeutic treatments. Treatments generally only help people once they’re already ill, and in that regard, they’re less appealing than tests. But they could make some elderly and immunocompromised people feel less nervous about socializing before a vaccine becomes available.

“If we have a decent therapy in our pocket, we can use that if someone really starts to go downhill in a hospital,” Mina said. “That really does change the equation in terms of what level of risk at a population level we’re willing to take. So in some ways I’m really rooting for the therapies.”

From left to right, Director of the Department of Intensive Care Medicine Stefan Kluge, head of Infectious Diseases Marylyn Addo, and head of the Institute of Transfusion Medicine Sven Peine deliver a press conference on the start of a study with the Ebola drug Remdesivir in Hamburg, Germany, on April 8.
Ulrich Perrey /POOL/AFP via Getty Images

There are a few different types of treatments in development. First, there are antiviral drugs, which inhibit the replication of the virus. Remdesivir, for example, has already been given to some Covid-19 patients, showing some early promise, but more rigorous study is needed to determine its true effectiveness.

Another option is manufactured antibodies — similar to what your body would produce in response to the virus but created in a lab. Mina said he’s hopeful that we’ll see such antibodies being used by the end of the year.

“That’s an attractive product for a number of reasons: First, it can be used as a treatment early in the disease,” Scott Gottlieb, a public health expert who served as President Trump’s first FDA commissioner, told Vox. “It can also be used as a prophylaxis — as a bridge to a vaccine. You might be able to give a monthly injection or bi-monthly injection to people that would prevent them from getting infections.”

While the first doses of such a product would go to Covid-19 patients and health care workers, they could also go to elderly and immunocompromised people once we’re manufacturing them at scale. Manufacturing is going to be a big obstacle, but again, Gottlieb said, that’s something we should be solving for “in time for the fall, so that if one of them does work, we’re able to turn on the spigot and produce millions of doses a month.”

Scientists are also working on another strategy: gathering convalescent plasma — the liquid part of blood — from Covid-19 survivors. Since it contains antibodies to the virus, it might help people with active infections get better, or even serve as a prophylactic to prevent infection in the first place.

None of these options is likely to be a silver bullet. But a combination — antibodies to prevent healthy people from getting sick, treatments for those who are already infected, and widespread testing to identify who’s infection-free — could make it safer for elderly and immunocompromised people to socialize.

“I think the answers are likely to be not in one strategy that produces a watershed in the near term but many strategies that, when layered on top of one another, offer a greater degree of protection than we have right now,” Cannuscio said.

Other things we can all do to help in the meantime

We all have a moral obligation to consider the needs of the most vulnerable and to make sure reopening is as low-risk for these groups as possible.

Many of the measures that will be most effective at protecting them are things that only scientists, government officials, or policymakers can enact. We need researchers to work on better tests and treatments, and funding to keep them going. We need federal and state leaders to coordinate with each other, not stage internecine fights over resources. We need policies that ensure vulnerable adults can stay home without worrying that they’ll get laid off as a result and lose health insurance precisely when they need it most.

But there are also some things the rest of us can do. Murray pointed out that some grocery stores are reserving certain hours exclusively for elderly shoppers. Various small businesses could do the same, making sure to do extra cleaning before that group of shoppers comes in.

Nursing homes and long-term care facilities are in immediate need of more resources: more PPE, more tests, universal masking, and more money to pay staff so they don’t have to work multiple jobs at different sites. The AARP and other groups are advocating for such changes in the US, where one-third of all coronavirus deaths are residents or workers in these facilities, and in Canada, where it’s a whopping 81 percent.

“I don’t see any evidence that we’ve diverted sufficient resources into actually protecting the vulnerable. We’ve still seen infections flourish in nursing homes. That to me is very troubling,” Mina said. He suggested making these facilities safer by improving their ventilation systems. “That might be very expensive, but the cost of keeping these people safe right now is essentially the shutdown of the economy — and that’s trillions of dollars. So can we take some fraction of that and start to really revamp the structure of the locations where senior citizens live?”

For her part, Cannuscio said everyone needs to accept a difficult reality: “This is a marathon, not a sprint, and we are absolutely in the early miles of the marathon. The most important thing is for people to accommodate the idea that we need to settle into — and therefore plan to survive in — this altered state for a long time,” she said. “Every family should be making a plan for what life will look like over the coming months.”

For some families, she specified, that might mean that a student moves back in with his parents so he can provide care if needed. Other families might designate one person who lives separately but who’s limiting their social contact (ideally someone who can work from home) to be on standby in case they need to drive a grandparent to the hospital.

Ultimately, Cannuscio’s simplest piece of advice may also be the most effective: “Every single person who has decision latitude should still — regardless of whether states declare that we’re now open for business again — keep holding back on our social engagements and continue to work from home if we can, so we reduce the likelihood that people who are elderly or infirm will get Covid-19.”

Viewed one way, this is a big ask: We’re all eager to get out and have fun with our friends and colleagues again. But viewed another way, some measure of continued sacrifice may be everyone’s moral responsibility toward the most vulnerable.

Are we so eager to return to normal that we’re willing to make others disposable? Is that even a normal worth having?


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