Free the Young, Protect the Elderly

by James A. Bacon

We can all be thankful that Governor Ralph Northam has ended the ban on elective medical procedures. At least one sector of Virginia’s economy, healthcare, can start the struggle back to normalcy. Hopefully, hospitals will staunch losses that have ran up to $200 million or more, 30,000 furloughed and laid-off healthcare practitioners will get back to work, and thousands of Virginians will receive long-delayed medical treatment.

The question now: What next?

The restoration of normalcy will take months. President Trump, Governor Northam and governors of most other states have suggested that the process will unfold in phases as the COVID-19 epidemic recedes. But many details have yet to be worked out. In the days ahead I hope to explore the what-next question in a series of posts that articulate logical principles that should drive the Governor’s decision-making.

The first principle is this: Public action should focus on protecting the most medically vulnerable members of society while allowing the least medically vulnerable to return to normal life and work as quickly as possible.

While there is still much left to understand about the COVID-19 virus, there is broad consensus in one area: Mortality rates are highest among the elderly; and among those with medical risk conditions such as asthma, diabetes, and heart disease. While the disease can strike anyone of any age, the risk of dying for an otherwise healthy 21-year-old patient is orders of magnitude lower than the risk for an unhealthy 71-year-old patient.

It makes no sense whatsoever to apply the same blanket shutdown to people of all ages and health conditions equally. Such an approach is immensely destructive to the economy, with all the indirect health effects that entails, while contributing only marginally to the reduction of virus-related fatalities.

Virginia public policy should encourage healthy young people to go back to work. I will lay out a conceptual approach of one way to do this, fully cognizant of the administrative challenges that would need to be hammered out. The first step is to agree on the idea, then we can agonize over the details.

The core idea is to create COVID-19 risk classifications based on age, the existence of health conditions, and previous exposure to the virus. If you’re 21 years old and have no health-risk conditions, you fall into the Low Risk classification. If you’ve recovered from COVID-19 and tests indicate the presence of antibodies in your blood, you fall into the Low Risk classification. If you’re 90 years old and have emphysema, you fall into the High Risk classification. If you’re 55 years old and healthy, you might fall into the Medium Risk classification. If you’re 30 years old and have diabetes, you might fall into the Medium Risk classification. I’ll leave it up to the medical practitioners and actuaries how to set up a classification system.

If you’re classified as Low Risk, you should be free to undertake a wider variety of activities under the assumption that if you contract the disease, the chances of dying, while not zero, are very low. Indeed, we should consider it a good thing for young people to get infected and then recover. It is sound public policy goal to build up herd immunity in the least medically vulnerable segment of society. Once 60% or more of the population has developed resistance to the disease, the ability of the virus to propagate itself plummets.

As we allow greater freedom for Low Risk members of the population, however, we need to redouble our efforts to protect the High Risk members. COVID-19 is most likely to spread in intimate family environments. If three generations are living under the same roof, there is a risk that Junior could contract the virus at his barista job (despite the sanitary measures in place), bring it home, and infect grandma.

Perhaps a greater fear is that if more members of the general population are walking around asymptomatic with the disease, it will be easier for the virus to infiltrate a nursing home, where it can run wild. We have seen the disastrous consequences at Canterbury Rehabilitation in Henrico County, where nearly 50 people have died.

Under a demographic risk approach to fighting COVID-19, the state would focus its resources — temperature checks, testing of patients and employees, contact tracing, social distancing mandates, and restrictions on who can enter the facility — on nursing homes, assisted living facilities and other locations where the elderly are sequestered in close proximity. (A second priority would be to apply resources to jails and prisons, where the disease has the potential to run rampant, though, perhaps with less devastating consequences.)

Any program of this nature would have to be accompanied by a public education campaign aimed at healthy young people that says, “Hey, healthy young people, we’re giving you more freedom, but freedom is not license. Think of the vulnerable people around you. You still need to abide by sanitary and social-distancing practices.”

Such an approach entails risks. But every approach has risks, including the measures currently in place. But we can’t let an unremitting focus on COVID-19 mortality destroy the economy, ruin lives, and undermine the long-term ability of our healthcare system, dependent as it is upon revenues generated by a functioning economy, to save lives.

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28 responses to “Free the Young, Protect the Elderly”

  1. Yes, to all of the above.

    I’ll lob in my view of the need to integrate geographic risk also, envisioning a heat map with medical risk as described above along the X axis and geographic risk on the Y axis. Medium medical risk in a low risk geographic (not dense) environment could/should be ‘green’, whereas Low medical/High geography (dense, urban) would be ‘yellow’, requiring additional caution. More complicated approach, but logical (to me at least) extension of the concept outlined above that lower risk people should be able to start to return to the ‘new’ normal.

    The fly in the ointment with all of this that most concerns me most though is human nature.
    “Any program of this nature would have to be accompanied by a public education campaign aimed at healthy young people that says, “Hey, healthy young people, we’re giving you more freedom, but freedom is not license. Think of the vulnerable people around you. You still need to abide by sanitary and social-distancing practices.”
    Nearly everytime a beach or something gets opened, it gets shut down again because people won’t follow rules. (Spring break in FL!) I have zero faith that “You still need to abide by sanitary and social-distancing practices” gets any real traction.

    1. ARL, you have anticipated my next column — geographic risk.

  2. “Indeed, we should consider it a good thing for young people to get infected and then recover. It is sound public policy goal to build up herd immunity in the least medically vulnerable segment of society.”

    That’s the core of your argument, Jim. Completely neglects the contribution those asymptomatic but infected young people will make to the spread of covid among the rest of us decrepit sorts!

    I don’t think you can have your cake and eat it too this way. The rest of the population cannot stay so completely behind a wall of isolation that they remain unaffected.

    More importantly, there are young people who will die as well. The more they learn about the blood clotting caused by this virus, the scarier it gets. Now if this Remdesiver (sp?) drug proves to be a real palliative, maybe we should re-think the balance, here.

    1. I don’t think you can have your cake and eat it too this way.

      Well, let’s see how things work out in Sweden. I have gotten some of my thoughts from the Swedish minister of health.

      I’ll concede that there is a big difference between the U.S. and Sweden. Most Swedes exercise personal responsibility in acting for the public good. Far too many Americans think about no one but themselves.

      1. LarrytheG Avatar

        re: ” Far too many Americans think about no one but themselves.”

        and these are the folks you are going to ask to be “responsible” ?


        1. Nancy_Naive Avatar

          No. He’s going to ask the virus to obey the “KEEP OUT ” signs.

  3. LarrytheG Avatar

    The problem here is that Jim is not thinking about “shared space” in the world we all live in.

    How can the “vulnerable” go to a dentist or buy tires for their car or get eyeglasses if they have to venture into a world of rampant infection?

    It’s just a different version of “stay home or you’ll die because the rest of us are going to let it all hang out’.

    No one in the US, not a single State, not a single credible medical person is advocating this. It’s coming from the fringe world. How about we
    name the folks in the US who are advocating this?

  4. Steve Haner Avatar
    Steve Haner

    Read Jim’s post and then saw the meme he posted later. Fairly dumb one, but it leads to a point. If you stopped all driving for 14 days, you would indeed have no fatal accidents. The same was not done for COVID. In the now seven week of “shutdown” I’ve been to grocery stores a dozen times, pharmacies perhaps four five, hardware stores four or five times, had 20 things delivered, been to restaurants for pick up, and have had workmen in and out of the townhouse. We never actually did 14 days of shutdown….That’s one reason why continuing the current situation is so questionable, because the idea we are in isolation is ludicrous. We’ve just picked a bunch of economic winners and losers and created a stable situation of simmering (but not disappearing) spread. Even protecting the nursing homes — where this all first presented — has proven illusive. With all the cries of “follow the science” it is clear the experts are feeling their way and the political will to do what China did (really clamp down) has never been there. Had we done some weeks of hard, brutal, stay at home, maybe – but we never did.

    When the ABC stores were deemed essential, all credibility died.

    1. LarrytheG Avatar

      There is a LOT of frustration and genuine fear of economic devastation – and rightly so but it’s leading people to desperate and stupid answers.

      No, the science does not know all the answers and yes there is some feeling their way along – but they’ve got more right than wrong – as opposed to the “lets stop driving to stop auto accidents” crowd.

      The thing that really astounds is that folks think the govt is causing this and that if they stopped the faux “lockdown” that everything would get back to normal.

      That’s not dealing with the realities… which are ugly and harsh but never-the-less – the way things really are.

      The reality is that this thing is not going away and too many just refuse to believe it.

      1. Steve Haner Avatar
        Steve Haner

        “The thing that really astounds is that folks think the govt is causing this and that if they stopped the faux “lockdown” that everything would get back to normal.” I haven’t heard anybody talking about just releasing all restrictions and seeking “normal.” Not Jim, not me. You, as you often do, invent a position to attack out of whole cloth. Me and my N95 will be friends for a while :). Plenty of venues will need to stay closed.

        1. LarrytheG Avatar

          Well, I HAVE HEARD of folks who say that we should let the young folks go back to work and the older and sick go hide.


          What exactly are you (or Jim) REALLY advocating?

          Have you made it clear what restrictions you still support and which ones you want to do away with?

          You told me – or implied that NNS is STILL WORKING and asked why the test of the economy could not also do that?

          And have you read what Jim is advocating “Sweden-like” in terms of less restrictions? Using “common sense”. Is that what you advocate?

          How about a clear and concise response from you on what you advocate for in terms of restrictions and which you want removed?

          1. “Well, I HAVE HEARD of folks who say that we should let the young folks go back to work and the older and sick go hide.” — BINGO.

  5. Jim Loving Avatar
    Jim Loving

    Risk Management as an approach to determine a path for re-opening is sound. Former DHS Secretary Michael Chertoff speaks to this in a recent editorial in USA Today.

    The Federal Government needs to establish guidelines for the creation of a Risk Management template that the state governors could use. The governors will implement this Risk Management approach for their plans for re-opening. The Federal government will need to address the movement of people and goods across state lines for those states that have dramatically different policies and approaches taken for Risk Management – i.e. border controls within the USA.

    Their will be huge challenges in this approach:

    “Risk management must be thoughtfully executed.” It must… “balances the marginal gains in safety against the costs of what is being surrendered. This balance is not an exact science; it requires recalibrating the balance as more information is collected and analyzed. Most important, risk management demands strategic vision and judgment that is neither reckless nor overly timid in weighing real risk.”

    “Managing the risk and adjusting the stringency of restrictions will be a dynamic process and not just one-size-fits-all. Our federal and state officials, therefore, must avoid promising an expiration deadline for these restrictions, but must assure the public that they will be adjusted as more data and analysis refine our understanding. Objective criteria based on accurate data should be used to determine the reopening of businesses, schools and other public venues. For example, after medical mitigations are in place, health systems have adequate capacity and the country has passed the inflection point for new infections, regions of the country should be able to return to normal. But that should not occur until these measures and outcomes have been validated through an objective process.

    As with threats from human terrorists, threats from an invisible pathogen demands a whole of society campaign of risk management, with leaders being transparent, and citizens being cooperative. Americans always rise to the occasion when we need to be tough. But that spirit needs to be sustained with credible public communication, and realistic confidence that we will be neither reckless nor timid in scaling back from red alert.”

    1. LarrytheG Avatar

      Oh I’d totally agree with the core sentiment but he’s whistling in the wind with regard to the Feds and a LOT of the “open up now” states.

      He talks more like Cuomo or Newsom or Inslee… than anyone in the current Federal administration.

      Part of the problem here is talking about “complete” solutions when everyone has their own idea of what that ought to be… and in the end, we have to agree on a consensus, not adopt one guy’s ideas.

  6. Peter Galuszka Avatar
    Peter Galuszka

    This all seems so obvious. Anyway, with nothing to do on this stormy day, i am reading “the Great Influenza” by John M Barry. It is about the so-called spanish flu but is really the Kansas flu. Fantastic book with eerie similarities. Recommended

    1. LarrytheG Avatar

      Movie: Contagion 2011

      Soon after her return from a business trip to Hong Kong, Beth Emhoff dies from what is a flu or some other type of infection. Her young son dies later the same day. Her husband Mitch however seems immune. Thus begins the spread of a deadly infection. For doctors and administrators at the U.S. Centers for Disease Control, several days pass before anyone realizes the extent or gravity of this new infection. They must first identify the type of virus in question and then find a means of combating it, a process that will likely take several months. As the contagion spreads to millions of people worldwide, societal order begins to break down as people panic.

  7. TooManyTaxes Avatar

    Steve, well stated. We’ve done a partial shutdown, and many people are masking/gloving up and trying to stay 6 feet from other people. And, indeed, some winners and more losers were picked.

    I’m hesitant to criticize the initial decisions. I don’t think a total lockdown would be possible. People need access to food, utilities, medicine, as well as some government services, such as police and fire (K-12 education in many places but not Fairfax County). A total shutdown would have spurred food riots.

  8. Ichabob Avatar

    NO ONE is talking about the financial ramifications of the insured and under insured to the sick-care industry.

    What do you think the bill looks like for a month of round-the-clock hospital care with a ventilator? Even with insurance, the catastrophic limit can be anywhere $7,000+.

    Sure, go back to work for $8/hr. It will take 30 weeks just to maybe earn what will be owed to the sick-care industry.

    The whole system is now borked except for the capitalists at the top.

  9. Ichabob Avatar

    PS – Current plans on have catastrophic limits of ~$16,000 for a family plan. Of course, this amount resets yearly (and doesn’t include monthly premiums).

    PPS – Any guesses on the percent increases for monthly premiums NEXT year? Virginia was already doing a lousy job in that regard before Coronavirus.

    PPPS – Of course, UVA made headlines for collections tactics pre-covid19. Here’s a sample out from WVU:

    1. I will want to see the insurers’ financials when the offset of some long ICU hospitalizations are offset by the far more vast health care that is not taking place. I don’t see how the carriers cannot come out way ahead.

  10. The echo chamber is really ramping up. This from Politico today: “Admit It: You Are Willing to Let People Die to End the Shutdown” and “Conservative Americans see coronavirus hope in progressive Sweden”. Earlier this week, I found this on an out-of-town newspaper, “Reopening the American economy is better than committing economic suicide” and “‘Business lives matter’ is GOP’s mantra”.
    I get Jim’s point, sacrifices have to be made, but we still have to go to the grocery store and just this week, about 10% of the shoppers in there were no mask, no gloves. And has anyone been able to practice social distancing in grocery aisles? Until Jim, Steve, et al. demand that grocery stores enforce at the door “No mask, No gloves, No service no matter if your are in the low risk category”, I can’t buy the premise.
    Finally, what am I and the other geezers who are to be sacrificed on the alter of business as usual suppose to do about the 15% to 20% of the population who will disregard any sort of restriction on their freedom to congregate in bars, beaches, etc.? After your brave new world plan is enacted do you support arrest powers for those who violate any mask/gloves/distancing restrictions? As you said, “The fly in the ointment with all of this that most concerns me most though is human nature.” Well, I’ve learned that you just can’t fix stupid. Bosun

    1. djrippert Avatar

      Yes, I am willing to let people die to end the shutdown. Maybe even myself. I’ve been willing to let people die over every flu season in my 61 years of life. I’ve never once insisted on a national shutdown during flu season and people have died. I’ve been willing to let people die by not demanding a 15 MPH national speed limit. And people die in car crashes every year who would not have died if everybody drove 15 MPH.

      You want to be safe? Have your groceries delivered. The delivery person can leave them at your door. Wait 30 minutes before opening your door after the delivery. Wear an N95 mask. Wear a fresh set of gloves when you pick up the groceries. Quarantine the groceries for 5 days before touching any of the packaging.

      You’re making my point. Right now the economy is shut down and you’re still not safe. Do you really think that mask I wear to the grocery store will keep you safe? Do you really think 6 feet of separation is foolproof?

      Unless you dramatically increase your level of isolation you are probably going to get sick. Flattening the curve doesn’t end the disease it just spreads it out. COVID19 is stalking you every time you leave your house. It’s going to keep spreading. It’s going to slow down and then speed up again. Even the flu vaccine only reduces your chances of getting the flu by 60%. People get vaccinated and then still get the flu.

    2. idiocracy Avatar

      I’d be happy if the people with the masks and gloves could deposit them into the trashcan when they are done using them instead of throwing them on the ground or leaving them in the shopping cart.

      But I expect nothing less from the slobs I know as fellow Virginians.

  11. djrippert Avatar

    You have two choices – hide under your bed or probably get the virus. Steve Haner is right. There’s no lockdown. There never was a lockdown. Only semi-isolation designed to slow the spread. Arguably, a person who really, really wanted to avoid COVID19 could self-isolate through extreme and dramatic means. I call this “hiding under the bed’. For those of us unwilling to hide under the bed this ends in one of a few ways:

    1. We get COVID19 and die.
    2. We get COVID19 and recover – presumably with immunity.
    3. We get lucky, avoid COVID19 and the virus mutates to a safe form.
    4. We get lucky, avoid COVID19 and herd immunity kills the virus off.
    5. We get lucky, avoid COVID19 and receive an effective vaccination.

    I’m not willing to hide under the bed. Anybody who wants to hide under the bed should do just that.

    I am willing to voluntarily restrict some of my usual behaviors to avoid getting COVID19 in hopes of either a treatment that renders the disease non-fatal or a vaccine.

    I will play golf with people who I know to be sensible but I won’t go to a live hockey game. I’ll go to a restaurant or bar that has reasonable social distancing but I won’t go to a crowded music concert.

    Note that none of my decisions affect the people hiding under their beds.

    In the likely event that I come into contact with someone who is infected I’ll get tested and self-isolate until the results are known. If I have COVID19 I’ll notify medical personnel and self-quarantine (i.e. hide under my bed) until I get better or have to go to the hospital. If I get tested and don’t have COVID19 I’ll resume the activities with the risk profile I am willing to accept.

    The testing, contact tracing and isolation are meant to continue to slow the spread so that medical facilities do not become overwhelmed.

    As Steve notes – even in this shutdown economy you will probably get sick. I filled up my truck with gas this morning. Forgot to put on gloves before I pumped the fuel. Didn’t realize what I did until I got home. Ugh! Yes, I washed my hands but was it enough? Who knows?

    This disease is stalking us. Eventually it will catch up with us. Killing the economy doesn’t change that.

  12. LarrytheG Avatar


  13. To DJR:. I would add another option: 6. We get lucky and avoid COVID19 until there are drugs to treat its symptoms well enough to be reasonably confident we’ll survive it. With this option, delay is a win even without escaping covid entirely — a delay after which, for most, it becomes just a nuisance like the flu.

  14. Bosun Avatar

    DJR – Everyone has their own level of acceptable risk. Mine happens to be a little bit lower than yours since you think that opening up the economy with be the salvation of America. Good luck and stay safe. Bosun

  15. Acbar, with the long cycle past pandemics have had (2 years for H1N1) I don’t see how waiting is an option. The cost of waiting for an if/when drug to treat or vaccinate will the world in a state that will have some of us begging to die. The expectation that COOVD-19 deaths are avoidable will lead to gross suffering—I’m a quality over quantity value holder.

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