Can Florida return to life as normal without containing the spread of the novel coronavirus?
The answer from Gov. Ron DeSantis is an emphatic yes. And, whether Floridians know it or not, he is pursuing a policy that will allow the virus to spread freely in the state until most of the population becomes infected — or is vaccinated with a yet-to-be obtained vaccine — while attempting to protect those thought to be most vulnerable.
Two months after a deadly summer surge and months before a realistic goal to begin rolling out a vaccine, DeSantis issued an order that opened up nearly every part of commerce, ended restrictions on restaurant dining, and barred local governments from enforcing mask mandates and social-distancing rules.
He has since spent more time and commanded more media attention to his “open-everything” policy than on encouraging people to prevent contagion. It is the same policy advanced by Scott Atlas, the controversial White House coronavirus adviser who does not have a background in infectious diseases.
It is also an approach that has made DeSantis the target of fierce criticism from Democrats who accuse him of pursuing a controversial and deadly “herd immunity” strategy, as well as from scientists, who usually use more diplomatic language.
“I sincerely hope that Florida doesn’t go down that path,” said Tom Inglesby, director of the Johns Hopkins Center for Health Security last month. “It’s pretty clear that a small minority of people have been infected at this point. If political leaders decide to go down that trail and encourage people to get infected … extraordinary numbers of people are going to die from this illness before immunity is achieved in the population.”
Community immunity
Herd immunity is the scientific term for what occurs when a large enough proportion of a population has enough immunity to slow the spread of a virus to a halt because fewer people can get infected. The safest way to achieve herd immunity is by vaccinating about 70 percent of the population. It also can occur “naturally,” if enough people survive the infection to develop long-lasting immunity. Or, as Atlas and DeSantis suggest, it can be achieved through a combination of both.
Exactly how many Floridians have been infected at this point is unknown. By Sunday, there had been 893,897 total reported COVID-19 cases in Florida, but public health experts say that is certainly an undercount — the question is by how much. Florida has 22 million people and the reported infections make up about 3.8 percent of the population. Advanced mathematical models put the estimated number of total infections closer to 4.2 million, which would be 19 percent.
Even if it is true that those who get infected have obtained long-lasting immunity — something that scientists are still trying to quantify — that would mean that even under the projection using the estimated total infections in Florida, the immunity rate would be only 19.7 percent.
Absent a widely accessible, effective vaccine, how many more Floridians would have to die to reach widespread immunity to offer the community protection DeSantis and Atlas propose?
The minimum threshold to achieve herd immunity in a population is around 60 percent, or triple the estimated percentage of Floridians already infected. Public health experts said that means you could expect the death toll — currently at 17,121 — to triple as well, to as many as 51,000 lives, assuming people return to their pre-pandemic levels with the current mix of inconsistent standards of masks and social distancing across the state.
‘You signaled an all-clear’
In a blistering letter sent to DeSantis Oct. 30, Miami Beach Mayor Dan Gelber, a former state legislator, accused the governor of pursuing a risky herd immunity strategy to address the virus: "Not the conventional herd immunity that arrives through widespread use of a vaccine, but rather the fringe version of herd immunity that occurs when you purposefully allow the virus to spread throughout the community,'' Gelber wrote.
He warned that DeSantis' failure to be transparent with the public about this strategy will give people a false sense of security that could endanger many.
"There will be people — even those who are vulnerable — who will unquestionably and unknowingly put themselves at serious risk because you have signaled an all-clear,'' he said.
DeSantis has not responded to Gelber or others who made similar claims, but Fred Piccolo, the governor’s communications director describes the policy this way:
"He believes the virus is containable through a vaccine and in focusing the resources first on those most vulnerable to complications due to COVID,'' he said. “Protect the elderly and those with serious health risks —and the virus becomes far more manageable.”
There is reason for optimism that an effective vaccine is getting closer. Pfizer said Monday that early results from its coronavirus vaccine suggest it may be 90 percent effective at preventing COVID-19, putting the company on track to apply later for emergency-use approval from the Food and Drug Administration and begin distribution by the end of the year.
But public health experts have warned for months it could be many months before vaccinations become widespread enough in the U.S. to increase community immunity, and it is it too soon to let up on efforts to contain its spread.
DeSantis has said he prefers “mitigation policies focusing on shifting infections away from the at-risk groups...rather than suppressing society as a whole.”
Experts doubt approach
But the strategy of letting the virus spread among younger age groups while “protecting the vulnerable” has been rejected by mainstream health professionals and epidemiologists, who warn that the policy is unrealistic and will lead to more severe illness and deaths.
"There just is no evidence whatsoever that we know how to effectively protect the most vulnerable,'' said Marc Lipsitch, professor of epidemiology at Harvard T. H. Chan School of Public Health.
“Partly, we don’t know how to identify all those people. Some of them we do. Some of them, we can guess, based on their age, or their co-morbidities. But there are people who have very severe disease, who are not in pre-identified groups. For example, over 40,000 Americans under 65 have died of COVID-19, and that’s a small proportion of the total, but it is a very large, absolute number.”
Infectious disease experts, including several in Florida, point to the fact that when most of the state was shut down in April, health officials could not protect the elderly and vulnerable populations. And since DeSantis lifted all restrictions on Sept. 25, cases in people over the age of 65 have started to rise again, tracking similar trends in other age groups.
DeSantis' advisers
More than a third of the COVID-19 deaths in Florida, 6,873 out of 17,121 as of Nov. 8, occurred in residents of long-term care facilities, according to the Department of Health.
And while deaths have remained concentrated among older Floridians, hospitalizations are commonplace in younger and middle-age people, including those who become acutely ill and require treatment in an intensive-care unit. At Miami’s Jackson Health System, the bulk of COVID-19 admissions have been for people under the age of 65 throughout the course of the pandemic.
Atlas, the neuroradiologist who has replaced Dr. Anthony Fauci as the top coronavirus adviser to Trump, explained at an Aug. 31 “roundtable” in Tallahassee that: “The goal of the policy is absolutely not to stop all spread of COVID-19 to asymptomatic or very low risk individuals….The goal is to protect the vulnerable.”
But as cases among the most vulnerable continue to rise, DeSantis, and Trump, have attempted to raise doubts about Florida’s COVID-19 fatality numbers with the governor’s office leaking documents to a conservative blogger to push that narrative.
DeSantis has also relied on the advice of two professors, Jay Bhattacharya, a professor of medicine at Stanford University Medical School, and Martin Kulldorff, a biostatistician and epidemiologist at Harvard University. He invited them to Florida on Sept. 24 to discuss the Atlas approach.
Bhattacharya said that lockdowns are “absolutely catastrophic,” and opening everything, exposing many more to infection, while protecting the vulnerable, is the preferred approach.
"The mortality rate from the death of the disease itself is much lower than expected,'' Bhattacharya said. “If you are infected, it’s not an immediate death sentence....For young people, it’s really much less lethal even than the flu.”
The next day, two months after hospitals in metropolitan areas such as Miami-Dade were so overrun they had to rely on out-of-state nurses freshly trained for work in intensive care, the governor issued an executive order reopening everything.
He urged communities, and Florida’s colleges, to resume large gatherings and reduce social-distancing requirements. He also encouraged people to assemble without restrictions in gyms, theaters, restaurants and football stadiums.
That same day, the Johns Hopkins Center for Health Security recorded Florida as having 20 percent of all COVID-19 deaths in the country on that day.
Meanwhile, Richard Corcoran, Florida’s education secretary, began pressuring school districts that had not opened to in-person instruction, threatening to withhold state funds if they didn’t comply.
‘Focused prevention’
Bhattachara and Kulldorf have since published their controversial approach to managing the pandemic in a document called the Great Barrington Declaration. Named after a resort town in Massachusetts, it calls for “focused protection” and a “compassionate approach that balances the risks and benefits of reaching herd immunity.”
It says that those who are not vulnerable “should immediately be allowed to resume life as normal” and encourages “simple hygiene measures, such as hand washing and staying home when sick should be practiced by everyone to reduce the herd immunity threshold.”
"Schools and universities should be open for in-person teaching. Extracurricular activities, such as sports, should be resumed,'' the declaration reads. “Young low-risk adults should work normally, rather than from home. Restaurants and other businesses should open. Arts, music, sport and other cultural activities should resume.”
The document, signed by 12,000 people and sponsored by the American Institute for Economic Research, a libertarian think-tank, provides no details or policy suggestions for how to protect the vulnerable. It makes no mention of masks, which have been found by the U.S. Centers for Disease Control and Prevention to “slow the spread of the virus,” and it leaves it up to individuals to protect themselves.
"People who are more at risk may participate if they wish, while society as a whole enjoys the protection conferred upon the vulnerable by those who have built up herd immunity,'' the declaration states.
Gaps in strategy
The accepted methods for containing the virus, as adopted by everyone from the Centers for Disease Control and Prevention to Florida’s Department of Health, includes testing people for COVID-19, contacting the people they may have exposed, isolating those who may be contagious and treating those with symptoms.
But DeSantis has spent more time urging people to reopen the economy than he has spent informing people about what the state is doing abut contacting and isolating individuals. He has also recently scaled back state-run testing at hospitals and assisted living facilities at the same time he has encouraged homes to reopen for visitors.
The governor’s open-everything approach also has few guardrails for protecting the vulnerable, and his strategy appears to solely consist of restricting visitors at senior-care homes with active cases and flooding skilled nursing facilities with rapid tests.
DeSantis has defended his policy by saying he has protected the vulnerable by delivering personal protective equipment to senior care homes, transferring patients to COVID-only facilities to limit the spread, barring hospitals from discharging patients back to nursing homes before they have tested negative, and for everyone else who is vulnerable but doesn’t live in an elder-care home he said he has “stressed caution.”
Beyond the elderly, DeSantis hasn’t outlined any policy for how to handle healthcare coverage for uninsured people who are hospitalized with COVID-19, have high medical bills or face long-term symptoms, including organ damage from the virus. And the state has no message for what should happen to people who miss work in order to remain in isolation.
‘Population immunity’
Ira Longini, a biostatistics professor at the University of Florida’s Emerging Pathogens Institute whose models have been sent to the DeSantis administration, told the Times/Herald that most people have misconceptions of “herd immunity” and how population immunity works.
Hard-hit parts of Florida such as Miami may see more muted outbreaks than explosive ones in the future, but there is no way to stop severe illnesses and deaths from accelerating while simultaneously relaxing restrictions.
“As soon as mitigation is lifted, things will start up again,” Longini said. “It won’t be quite as steep, because of the ‘partial herd immunity’ in the population.”
DeSantis, however, has interpreted the data differently. At the Sept. 24 roundtable, he expressed confidence that the spread of the disease had slowed because the replication rate of the virus in the community was a sign that “population immunity has built up.”
Piccolo, the governor’s spokesperson, described DeSantis' thinking this way: "I wouldn’t say it’s a policy of herd immunity,'' he said. “But if the replication rate continues to drop, I mean, what do you say about that? You say it’s because the virus is losing its punch.”
But Longini cautions that even in the hardest-hit areas, there is probably about 30 percent to 40 percent of the population infected, well short of what it would take to halt transmission.
"You could have pockets where hardly anyone was infected in the last wave,'' Longini said.
‘Nonsense to say we’re out of the woods’
All the experts interviewed by the Times/Herald agreed with the premise that everyone would like to have their lives back to normal but also doubted it was realistic now.
"There is some kernel of truth there that some populations [in Florida] are being partly protected by the immunity that has been built up,'' said Lipsitch of Harvard. “It’s not nonsense to say there is some herd immunity right now. It is nonsense to say that means we’re out of the woods.”
Public health experts also note there is little data about the risk of transmission when opening certain businesses, and little analysis of contact tracing data in Florida that could inform these policy proposals.
Natalie Dean, a biostatistician and assistant professor at the University of Florida who is one of the most respected infectious disease scientists in the country, said she is concerned there is not enough data on which to understand the risk in the policies advocated in the Great Barrington Declaration.
"Businesses are not all created equal in terms of their riskiness,'' she said. Dean emphasized that the risks are also not equal because some people have no choice but to face them.
“The patrons have a choice,” Dean said, “But the employees who they are relying on do not have the same choice.”
As DeSantis has openly advocated for accepting broader community spread of the virus, not everyone in Florida has embraced his no-restrictions approach.
At least 24 of the state’s 67 counties have some form of a local mask mandate, as do at least 72 cities, even though they are barred by his order from enforcing them.
Miami-Dade County has kept its curfews in place, and a court this week just said the rule could stand despite DeSantis' order. And businesses like Walt Disney World, professional sports teams, and colleges have imposed their own limits on crowds.
Even the state Capitol, where DeSantis and his staff work daily, remains closed to the general public because of the coronavirus. And Republican legislative leaders are planning to meet in an organizational session later this month with self-imposed testing of everyone who attends and mask and social-distancing mandates.
Meanwhile, DeSantis chose not to wear masks at rallies with Trump and openly questioned the value of masks. Advisors told the Times/Herald last week that the governor considers Trump’s win in Florida a vindication of the governor’s coronavirus policies.
And Atlas, who appeared two weeks ago on Russia-backed television to call lockdowns “an epic failure,” and who has been accused of misleading the public by suggesting that masks don’t work, considers DeSantis a standout disciple.
"The governor is one of the first if not the first governor to understand that the strategy overall is really prioritizing who’s going to be vulnerable here,'' he said. “We feel very comfortable with the policy of Gov. DeSantis because it’s exactly right on target.”
• • •
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