Public Health Reality

By | David R. Henderson & Charles L. Hooper | In an ironic turn of events, a Stanford University professor whom Francis Collins, the former head of the National Institutes of Health (NIH), attacked, has been nominated to head that very agency. While the personal aspects of Jay Bhattacharya’s altercation with Collins matter, it’s more important to understand why Bhattacharya was right and Collins was wrong. Bhattacharya—his Senate confirmation hearing is set for March 5—was right because he, trained as both an M.D. and an economist, reasoned through the challenges of COVID-19 as an epidemiologist and an economist. As an epidemiologist, he got three main things right; as an economist two. Collins struck out on all counts.

Here are the three things he had right as an epidemiologist: First, for years, researchers have analyzed the effectiveness and appropriateness of the tools available to governments to address and control pandemics caused by respiratory viruses such as influenza. The paper “Disease mitigation measures in the control of pandemic influenza” from 2006 is one example. The paper concluded that while vaccines can top the list of efficacy, masks and handwashing have limited benefit. Except in unusual situations, quarantines and lockdowns should be rejected: “As experience shows, there is no basis for recommending quarantine either of groups or individuals.” Luckily, these conclusions also applied to the SARS-CoV-2 virus that causes COVID-19. Bhattacharya understood this point.

Second, early data coming out of Italy suggested that the infection fatality rate was much higher for older people than for younger ones. According to a March 2020 study, “Within Italy, COVID-19 deaths are mainly observed among older, male patients who also have multiple comorbidities.” Subsequent studies confirmed this relationship and showed that the fatality risk for older people was one thousand times that for young children. Bhattacharya understood this point.

Third, in April 2020, Bhattacharya and others conducted a study to measure the prevalence of antibodies to the SARS-CoV-2 virus in Santa Clara County, where Stanford is located. The key finding: “The estimated population prevalence of SARS-CoV-2 antibodies in Santa Clara County implies that the infection may be much more widespread than indicated by the number of confirmed cases.” Every virus has an infection fatality rate that is calculated by dividing the number of deaths by the number of infections. If the number of deaths were known and the number of infected people were higher than previously estimated, mathematics dictated that the infection fatality rate was lower, meaning the virus was less deadly and less scary than repeated media messages communicated. Bhattacharya understood this point.

As an economist, Bhattacharya got two things right. He knew that we must consider tradeoffs and that we must compare costs with benefits. We want our children to be safe from viruses, but we also want them to get good educations, make friends, play outside, and be able to visit family members. There are tradeoffs among the things we want in life. A single-minded goal of preventing viral infections necessarily compromised other goals; getting a little more of this requires giving up some of that. Stated differently, everything has costs and benefits. The cost/benefit tradeoff of a nine-year-old is different from that of a working parent, which is not the same as that of a retired 80-year-old. The benefit of going about normal life is high for the child while the risk of disease is small. The benefit of being out and about for the typical 80-year-old is low while the risk is high. Simple cost/benefit analysis, therefore, suggests that the young person should not be secluded while the 80-year-old should be. The working parent has high benefits from working and a much lower risk than the 80-year-old and, therefore, should be allowed to work. This is called focused protection.

Jay Bhattacharya, Martin Kulldorff, and Sunetra Gupta put all these insights together in the tersely worded Great Barrington Declaration, which was the spark that ignited Collins’ ire. In an email to Anthony Fauci, Collins urged a “quick and devastating published take down of its premises.” We have no evidence that Collins and Fauci, two of the leading figures in public health during the pandemic, understood the three main epidemiological points presented here. We do, however, know that Collins understood the economic points—afterwards. He admitted that his priority was keeping people alive and said, “You attach a zero value to whether this actually totally disrupts people’s lives, ruins the economy, and has many kids kept out of school in a way that they never quite recovered.” That is precisely why we need to make public health decisions that reflect both medical and economic insights. You can’t do a cost/benefit analysis of a policy by considering only the benefits.

Bhattacharya has said that the Great Barrington Declaration was the least original thing he had ever written. Why? Because well before 2020 people in the public health field knew how to fight respiratory virus pandemics. But tragically, in the heat of battle, many people who were consumed by fear, ignorance, or baser motives, discarded clear thinking. We all can be grateful that Bhattacharya took on the difficult and fraught task of thinking clearly and publicly reminding many of us what we already knew or strongly suspected. The fact that Jay Bhattacharya showed such courage and clear thinking during a difficult period suggests that he would make a fine NIH Director.

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