Immunity Passports: What If Catching COVID Was Better Than Lockdown?
Damon P. Coppola, MEM, ARM
Principal, Shoreline Risk LLC
Not since the Greatest Generation brought our country through World War II has the American people been asked to make such a great collective sacrifice for the common good. Confronted with stay-at-home orders issued in every state and territory, we are beginning to take stock of what will be required to save some untold number of lives — perhaps even our own. But make no mistake, this collective sacrifice has not been the same for everyone. We are unified in our collective desire to rid the world of this pathogen, so it might seem preposterous that people would seek to intentionally infect themselves. Such beliefs are perhaps the luxury of those who maintain a relative security under this current restrictive environment. But as long as proposals to issue ‘immunity passports’ are floated without accompanying plans that account for the disproportional suffering caused by lockdowns, many people will come to find the risks of COVID-19 exposure preferable to that of an uncertain future.
Unbalanced Suffering
Those with office or infotech jobs have much greater capacity to keep working, and likewise to keep their paychecks and benefits coming. They maintain a sense of security amidst what is otherwise anxiety-inducing uncertainty. For some people in this category, the new capacity to work from home has actually been preferable to their pre-COVID arrangements, despite the distraction of ‘kids in the office’ and embarrassing Zoom fiascoes.
But these are the lucky ones. Their sacrifice is characterized mostly as a temporary inconvenience. The interruption of recreational activities, of participation in faith- and community-based activities, and of visiting family and friends — these are legitimate sources of stress. But stressors for which simple solutions like video-happy hour and eased restrictions on walking and hiking at a distance have appeased.
And if we really want to celebrate sacrifice, we look to those employed in sectors deemed essential. Yes, these individuals’ incomes are maintained, but their willingness to risk for others their own health — and for many, their lives — has earned them a flood of impromptu words of gratitude from strangers, a overwhelming praise across social media , and in many cities and countries, the rise of an emotion-wrenching phenomenon wherein people emerge from their homes at set times to applaud their selfless efforts. Grocery clerks, medical staff, police, firefighters, public transit, members of the military, and so many others exchange for the common good their own sense of personal safety and those of their family members. There are no shortages of memes featuring people suiting up in armor or HAZMAT gear to shop at Costco, but for many essential sector employees, this represents their day-to-day reality.
But it is a third group for which the situation is most dire, and for which a lack of some clear societal recovery plan is most physically, economically, and psychologically detrimental. There are millions of people employed in the service industries, entertainment and hospitality, retail and sales — their sacrifices are stark and untenable. Income loss, interruption of health insurance, mortgage defaults and missed rent — these impacts contribute to a growing sense of helplessness. Their sacrifice cuts them deeply, and they need to know there is not just a bandage to stem the bleeding but rather a real cure.
The Current Outlook
We are best served when we hope for the best, but expect and plan for the most likely. With COVID-19, however, we continue to be resistant to the reality of the present crisis. Take the fact that lockdown orders expire in less than month in most states. But we know this isn’t going to end in less than a month. In fact, we know it won’t end in three months. Or twelve months. We aren’t treating this crisis as the long-term one that it is. We continue to believe that and to act as if an early end to COVID-19 is likely even though it is the most unlikely scenario. Barring a miracle, summer will come without any vaccine, or any highly-effective treatment, and certainly no magical disappearance of the virus. What should we expect? That the numbers of infected has continued to rise — with current hotspots brought under control as new ones have started to rage elsewhere in a manner that could accurately be compared to ‘wack-a-mole’.
If, then, we assume this most likely scenario to be the one we will experience — one where life outside our homes still doesn’t feel safe in one year; one where food and other product shortages persist because borders remain closed to hotspot countries; one where state and local leaders find their only options for action in the face of such uncertainty are the most conservative ones— what then do we do?
Keep extending the lockdowns? Or turn them off, only to turn them back on when second, third, and subsequent waves of infection appear as they have in several other countries?
From a risk management perspective, there is only one likely scenario and it is that life will not be ‘safe’ the way we want it to be — not in a month, not in three months, and not in twelve. As long as we resist coming to terms with this, the longer it has taken us to move forward. And with each passing week and month, our individual sacrifices become more pronounced.
For those whose sacrifices are greatest, the frustration has already turned to pain. Their tolerance to plans for extended lockdown is tenuous at best. Many will bend or break the rules out of financial or psychological necessity (this is already happening). And many will simply give up caring about the ‘greater good’, joining those who never took the threat seriously in the first place except in that their sentiments will not have been by choice.
COVID-19 Immunity
Amidst the flood of bad news on the course of this pandemic, and the growing uncertainty about its impact and outlook, a positive story line has persisted despite having yet to rise above the undercurrent of competing news interests. It pertains to the fact that many who have contracted the disease and subsequently recovered appear to have developed antibodies that protect them from future infection. This isn’t necessarily a surprising development given many (though not all) diseases do elicit a similar immune response.
Antibody tests are a standard resource in the epidemiological toolkit. They have been developed for many common diseases, and are often ordered by physicians to understand: 1) if a patient has an active infection with a disease-causing pathogen; 2) if a patient was infected with a particular pathogen in the past; and 3) if a patient has developed a strong enough immune response from past exposure (including exposure through vaccination) to bestow future immunity.
Such tests were quickly developed to test for the antibodies the immune system develops to fight COVID-19. The first tests that were developed were those that identify the presence of the virus itself. These are the tests that involve a nasal swab and which are administered in drive-through test centers and in hospitals where patients with suspected COVID-19 are being admitted. These tests replicate the virus’ own genetic material over and over until it grows to levels that can be detected by specialized assay systems. To work, the sample must have collected the virus itself, a challenge that has been highlighted in reports about false negatives and defective testing systems. It is also inherently problematic in that a person who has had COVID-19 but has recovered will no longer test positive using this type of test — and will therefore not only have no information about whether they remain at risk from future infection, their experience will not contribute to the growing epidemiological knowledge base.
There are, therefore, two important pandemic-management benefits of a test that looks for the presence of COVID-19 specific antibodies versus one that tests for presence of the virus itself. The first is that it is possible to capture and count a larger number of the asymptomatic and mildly symptomatic cases in epidemiological tracking systems. By having a better grasp of these numbers, we are better able to disaggregate the probable outcomes for different demographic groups, and to understand the general case fatality rate (CFR) of the disease for forecasting purposes. For instance, if with current testing practices we find that there are 500,000 confirmed cases in the United States, and 20,000 COVID-related fatalities, then the assumed CFR is 4% (or 0.04). If, however, we discover through antibody testing that an additional 2 million people were infected but presented either asymptomatically or were misdiagnosed due to mild symptoms, then the CFR would drop to 0.8%, or 0.008. The second benefit is that those who show the presence of antibodies will be given the peace of mind that comes with knowing one need not worry the disease will sicken or perhaps kill them — at least in the near term.
Special Status
With the knowledge that one has acquired an immune response to COVID-19 as a result of exposure to the disease comes the realization that lockdown is no longer necessary or even relevant. The point of developing a vaccine for this or any other disease is to provide the same immune response, which means those who have been infected and recovered have effectively leapfrogged the vaccination process.
This is important information because we know that the members of this previously-infected group will collectively come to represent the herd of what is being called ‘herd immunity’ (wherein the vulnerability and risk of those who are still yet uninfected drops with as the number of people capable of becoming infected and who can therefore infect others likewise drops). There is great value in understanding the extent of this group as through modeling we can begin to understand how and when the virus is being constrained in its quest to move through the population.
It is a second effect of having immunity data that adds an interesting twist to the discussion about societal risk — one that will quickly become of increasing interest to the billions worldwide facing lockdowns of uncertain duration.
As countries gain the capacity to test for antibodies, they likewise gain the capacity to better inform the process by which lockdowns are implemented. If such countries could establish a standardized system by which those individuals who have developed immunity could be tracked and certified, it would be possible to allow them to fully negate lockdown requirements, and thus better balance the costs and the value of such measures for those same individuals. Logic holds that those with immunity have infinitely more to lose remaining in lockdown than in escaping it.
In light of this realization, several countries’ governments, including that of the United States, have begun investigating whether it is possible to bestow a kind of ‘special status’ on immune individuals, often called an ‘immunity passport’. With such a document or certificate in hand, one need not observe self-isolation, curfew, personal protection (from COVID), and most importantly, a sacrificing of one’s current or future income. For anyone currently enduring lockdown conditions, there is an understandable envy in anyone who might find themselves in possession of such a certificate.
It should seem preposterous to imagine anyone might seek to become intentionally infected with this horrible disease, especially given its catastrophic potential. But in light of this special status that is being proposed, the benefits that accompany immunity will not be negated as those who have already lost so much from extended lockdowns assess their own future outlook. Much like the special employment preference status veterans receive on account of their national service to their country, those with immunity will find they are more employable than their peers. We can imagine a scenario where those with immunity certificates become a resource in high demand. They will come to represent for small businesses, for community governments, for schools, and for so many more entities, a source of stability in otherwise unstable times. We may even come to see this group as the cornerstone in our efforts to flatten the curve long enough to develop a treatment or cure.
And with this in place, we need a pandemic management framework that does a better job of balancing our collective sacrifices. One that better balances the risks we must make with our health for the benefit of others. And one that gives us all the same sense of hope that we will emerge from this crisis with dignity, financial security, and a place in society — even if it takes years for a vaccine or a cure to materialize.
Yet the same protections we have today will still be warranted.
We need a better plan than just ‘extending the lockdown.’
With each newly reported COVID-19 infection, we discover more about the different ways it affects different people. Whether by age, by gender, by presence of pre-existing medical conditions — we see that this disease does seem to discriminate. But one group seems to be emerging as the least at-risk.
The present lockdown was warranted given the explosive growth in infections last month. We must exploit this initial 45-day period of restriction, which rests on our collective sacrifice, wasting no time to stabilize the situation and establish a system of operational awareness. Only then can we move forward, working ‘with the lights on’. This baseline comes only through testing all who need it, testing all who want it, and testing random population samples in the process. There is no getting around this, not now, not in the future, not ever.
