A Safer Restart for the Economy
***** 10/11/2020 UPDATE — This turned out to be a really bad idea ******
I’ll leave the article up for the record, but know that the idea to re-open the economy with people who are at less risk from serious illness has not been working. The main reasons are that people who are at more risk just get left behind in the economy. Also, these people can still get sick because of the high levels of COVID-19 infectivity in their communities. And crucially, the people who are at ‘less risk’ still face the risk of death and lifelong infirmity. COVID-19 may not kill a higher % of young people than the flu, but it is much more contagious, so it infects many more people than the flu, and the result is that many, many young people have died from COVID-19.
A better idea is to continue to apply all we’ve learned since March about how we can do things safely in a world with COVID-19. When we wear masks around other people, and move our interactions outside, we significantly cut the danger of disease transmission. We can’t get our lives back to normal just yet, but the vaccines are coming, and we can be safe while we wait.
****** Here’s the original WRONG article from April 2020 ******
The first wave of the COVID-19 pandemic may be peaking now in the US. Non-pharmaceutical interventions (NPIs) implemented by all 50 states have, so far, successfully prevented hospitals from overflowing with COVID-19 patients. Soon it will be time to reverse the NPIs and send people back out into the world. We know that if everyone goes back to their normal lives we could set off another massive wave of deadly infections. We need to get the economy going again, but we want to do it as safely as we can. The basic idea outlined below is to start the restart with just the people who have the least risk of severe illness from COVID-19.
UPDATE: 5/2/2020 — There’s a lot of good policies being enacted now by governors that want to re-open safely, like requiring people to wear masks around others, and requiring businesses to keep people apart from each other. The ideas in this post should be one part of a plan that also includes these other good policies. And — to be very clear — I’m NOT saying the goal is to reach herd immunity with the least risky subgroups of the population. That would require way too many deaths.
UPDATE: The White House plan to re-open the economy almost agrees with me. They say “vulnerable individuals” meaning the elderly and those with health conditions should stay safe at home. But they don’t say what elderly means — if it means everyone under 65 is ok to go out, that puts a lot of higher-risk people back on the streets.
Not Everyone Faces the Same Risk from the Disease
COVID-19 has already killed over 136,000 people worldwide, and that figure is increasing by 5,000 per day right now. In Italy over 7% of all people known to be infected have died. But even though the disease can be very deadly, certain subgroups of the population have a greatly decreased risk of getting severely ill or dying. Many people who get infected don’t have a severe reaction. By some estimates between 50% and 95% of infected people don’t even feel sick enough to get a test for the disease. The only way to know if these people have been infected is for them to be tested for the presence of COVID-19 antibodies in their system.
People Who Have Recovered from COVID-19 Appear to be Immune
One obvious low-risk group are those that have already recovered from a COVID-19 infection. There have been scattered reports of people who have recovered from the virus and have gotten sick a second time, but it appears as though almost all those that have recovered are immune and would be safe to resume normal activities. As of this writing there have been over 639,000 confirmed cases in the US, meaning that there have likely been over 3 million infections, and the vast majority of those people will recover from the disease. The number of COVID-19 recoverees will continue to grow quickly. As antibody testing becomes more easily available we will be able to identify just how many people fall into this low-risk group.
COVID-19 is Less Dangerous to the Young
As we look at how COVID-19 attacks people, one point stands out very strongly.
The virus is very, very dangerous to older people. But the data indicates much smaller risks of dying for younger people. The graph above includes data from New York City as of April 14th. Here’s data from South Korea, Spain, China and Italy.
In these graphs we see that COVID-19 is more and more dangerous to people the older those people are. In fact, many young people might not even show symptoms.
Households with only young people are at a lot less risk of severe illness from the coronavirus. That includes young people living on their own and young parents with children. Using the graphs above to consider the risks of dying from COVID-19, people aged 30–40 have about half the risk of people aged 40–50, about a third of the risk of people aged 50–60, maybe 1/10th of the risk of people aged 60–70, and an even smaller fraction of the risk faced by those over 70. People under 30 face either about the same risk as the 30–40 group or much lower risk, depending on which country’s data is used. If the only people that came out from their homes to restart the economy lived in households with no one over the age of 40, the overall risk to that population of dying from COVID-19 would be greatly reduced compared to a restart with the entire population.
Healthy People are a Low-Risk Group
The health risk to the population and projected disease burden from an economy restart can be lowered much further by considering pre-existing health problems such as diabetes, heart disease or lung disease. The New York City Health Department is recording the presence of underlying health conditions for all deaths from COVID-19. They are finding that about 9 out of 10 people under the age of 44 that died from the virus already had one of these health problems. That means if the people that came back to restart the economy were restricted to those in households full of people under 40 without any known underlying health conditions — meaning everyone in the household was under 40 and relatively healthy — than the overall risk to the population would be even lower, about 10 times lower.
Some Math to Estimate the Risk of this Approach
Data from around the world in the figures shown above suggest a case fatality rate (CFR) of 0.2% for people under 40 who are confirmed to be infected. Since many people infected with COVID-19 don’t get sick enough to get a test for the virus, the actual number of infected people is likely much larger than the confirmed cases. Using an estimate of 80% for the people under 40 that are infected with coronavirus but do not show enough symptoms to get tested, then we arrive at about 0.04% of infected people under 40 have died from the disease, or 40 out of 100,000 people. About 171 million people in the US, or about 52% of the population is under 40. That means that if every one of those people was infected with COVID-19 we would expect just under 69,000 of them to die from the disease.
Now consider limiting the population to healthy people under 40, that is people with no underlying health condition such as diabetes, high blood pressure, lung disease, or something else. If we guess that 30% of the under-40 population has one of these conditions, and that these people will stay safe at home, then the total number of people going back out to restart the economy drops to about 120 million, or about 37% of the US population.
Since these 120 million people do not have any underlying health conditions, we estimate their rate of dying from COVID-19 will be 1/10th that of their entire age cohort, or 0.004%. Using the smaller population figure and decreased infection fatality rate we can project that if every healthy person under 40 in the US was infected with COVID-19 we would expect about 4800 deaths from the disease in that group.
This projected number of COVID-19 deaths only considers the low-risk cohort of healthy people under 40. If members of that cohort are sharing living space with people in higher-risk groups such as older people or those with an underlying health condition, then those people in the higher-risk groups are likely to get infected also. We’d need a separate set of projections to predict a number of COVID-19 deaths for those higher-risk household members.
I chose a somewhat arbitrary cutoff of 40 years old to calculate a projected death total and make the point that younger people are at less risk. The figures above show that every age bracket faces less risk from COVID-19 than the next older age bracket. In general, the younger the population that emerges from lockdown, the fewer deaths from COVID-19 we would expect.
How to Control Who Stays Safe at Home and Who Comes Out
There will be a strong economic incentive for people from higher-risk groups and those who live in households with a higher-risk person to also resume their normal activities, such as going back to work. Policies will need to be established to ensure that people living in households that have a high-risk member do not try to go out in a restart. Different levels of government can help by providing support for people to move into temporary housing so that younger, healthy, low-risk members of a household can temporarily move out of the house to work while high-risk household members stay safe at home.
One way to increase the number of young households is to put college students back in college housing. Colleges can open up the dorms and off-campus housing, and students can get back to taking college classes. Many colleges and universities are almost finished with their academic year, but we might still need a place for the students to stay for some time. If college housing can re-open — maybe staffed by students? — then students can live in young households away from their older, higher-risk family members while they take the jobs needed to restart the economy. Local businesses that catered to students could open if they were staffed by students.
Lower-Risk Groups Can Lead the Way to Recovery
Local and state governments have joined the US government in a concerted effort to decrease the loss of health and life in the fight against COVID-19. US citizens have adapted and adjusted to deal with this terrible, invisible threat. We are ready to take the next logical step of having the people who are at the least risk from this threat help us get through the long wait for a vaccine.
The views expressed above are my own.
 Verity R, Okell LC, Dorigatti I et al. Estimates of the severity of coronavirus disease 2019: a model-based analysis. Lancet Infect Dis. 2020; (published online March 30.) https://doi.org/10.1016/S1473-3099(20)30243-7
Also Tuite A, Ng V, Rees E, Fisman D. Estimation of COVID-19 outbreak size in Italy based on international case exportations. medRxiv. 2020. Preprint. https://doi.org/https://doi.org/10.1101/2020.03.02.20030049
 Combining information from the Verity et al. and Tuite et al. papers referenced above into an estimate that 80% of all COVID-19 cases are not reported
 Data from New York City Department of Health as of April 14th, 6 pm. https://www1.nyc.gov/site/doh/covid/covid-19-data.page
 New York City Health Department https://www1.nyc.gov/site/doh/covid/covid-19-data.page
Also Our World In Data https://ourworldindata.org/coronavirus#case-fatality-rate-of-covid-19-by-age
 New York City Department of Health https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-19-daily-data-summary-deaths-04152020-1.pdf
 US Centers for Disease Control and Prevention https://www.cdc.gov/nchs/data/hus/hus16.pdf — this figure is difficult to estimate. The guess of 30% comes from data on pg. 3, of people under 44, 21% visited an emergency room in the past year, 36% took prescription medication in the past 30 days and 7% were hospitalized.
 Using data from New York City Department of Health as of April 14th, 6 pm, https://www1.nyc.gov/site/doh/covid/covid-19-data.page, we see that in the 0–44 age groups, only 1/10th of the deaths from COVID-19 in New York City are people with no underlying health condition