Every Yom Kippur we beseech the Almighty not to jettison us into “the Era of the Elderly.” It’s not old age per se we seek to avoid, but “Et-Zichnah” – that time of the aged, an era when we might be treated in a particular, “lesser” way. If anyone wondered what “Et Zichnah” really means- welcome to the age of COVID-19.
Some 45 years ago, a science fiction movie, named “Logan’s Run,” depicted a fascinating version of a supposedly utopian society. In this chilling portrayal of paradise, there was only one downside: To maintain an adequate supply of resources – everyone was euthanized at age 30. Flash forward a couple of decades to the “winter of COVID-19.” In this world of COVID, the age of devitalization is a bit older. But us oldsters are subject to truncation just the same.
In our new world, everyone older than 60 or 65 or 70 is locked up. If you get sick, you are told you are likely to die – especially if you have any underlying health conditions. Here in Israel, we were warned against visiting our family, especially hugging the grandchildren who pose a dire threat. In Italy, you aren’t treated. Some might call this euthanasia – or at least living hell for older folks living alone.
That doesn’t mean that oldsters have no purpose or value in our new coronaSaRS-2- world. “Bioethicists” Julian Savulescu and Dominic Wilkinson blogged in the Journal of Medical Ethics that this older population might volunteer for risky COVID trials which “generate usable knowledge of benefit to others.” In cases where these patients “will certainly die, they should be able to consent, while competent, to experimentation being performed on them for others, even if the experimentation may itself likely or possibly end their life sooner.” Saulescu and Wilkinson suggest suitable “uses” for this population include “organ donation euthanasia” and using “nursing home volunteers for risky research.” This is not fiction. This is real. And I have heard little outcry.
It’s time to expose the flawed basis on which morbidly dystopic and discriminatory responses toward the aged have been become public health policy– both as a warning that initial and instinctive public health responses must be constantly re-evaluated and updated – and as an alert that discriminatory responses can be couched as public health concerns, even as their main purpose is to further political goals.
At first glance, “protection of the vulnerable” seems laudatory and compassionate. Nevertheless, this approach should trigger concerns of discrimination. In the case of age-related discrimination, the dangers are, perhaps, exacerbated, as those affected are more likely to just accept it. Others accept these pronouncements without delving into the “scientific” or epidemiological underpinnings of the pronouncements. Even worse, is that rationale that might, in actuality, be political can be camouflaged as nobly “helping the needy.” Rather than prioritizing mask allocation, for example, it’s simpler and cheaper to just lock up the elderly, except that doesn’t sound so nice.
As of this writing, more than five million people have been diagnosed with COVID-19; more than 300,000 have died. Initially, deaths and severe repercussions were reported as affecting primarily older people. The focus on age as an explanation for higher deaths furnished an easy out for a panic-ridden public. Officials publicly couched their risks of serious consequence as low based on their age to reassure a freaked-out populace. In other words, the young don’t have to worry. Or at least didn’t have to worry -until recent reports emerged.
Suddenly, we are finding that the disease seriously affects all segments of the age curve, causing strokes in young adults, heart problems in younger children, and possibly a serious inflammatory condition called Kawasaki disease. Nevertheless, this finding has not diminished the assumption that “vulnerable” is mostly synonymous with age, impacting responses and exit strategies targeting this group, which remain unchanged.
For some two months now, most countries instituted lockdowns of various degrees. As a result, economies, world-wide, have suffered, mental health deteriorated, and lives were lost to suicides linked to quarantine or domestic violence. In Israel, which had achieved one of the lowest unemployment rates world-wide prior to COVID-19, one-quarter of the population is now unemployed.
Believing the end (of the pandemic) is near, or assessing that we cannot afford to wait till then, initiatives are being proposed to restart the “pause” and help reverse effects on financial and mental health. Among proposed responses are removal of the lockdown procedures, leaving only the “vulnerable” (aka the elderly) to remain shut-in, and allowing the rest to return, at least to their work-places. But differential relaxation of lockdowns is problematic, both from legal and public health perspectives. Thus, Governor Cuomo reported with great sensitivity on April 9, that when vulnerable populations disproportionately include African Americans and Latinos due to pre-existing co-morbidities– we need to be careful in our response. The dangers of racialization of disease (COVID-19, or any other) has been duly recognized and decried. Not so much for age.
Israeli grandparents accepted (although some with outrage) then Defense-Minister Bennet’s hysterics warning grandkids could kill their grandpappies and mammies with a hug, barricaded themselves, and are still reluctant to emerge, even as the restrictions are eased. In the US, elderly folks living alone suffered isolation, unless they chose to violate hunker-down restrictions for the sake of their quality of life and mental health (i.e., in order to “live”).
Based purely on early (and stagnant) reports, we bought into this protectivist age-related response: The elderly were — and are — to have their liberty disproportionately restricted –because they are considered “vulnerable”. It’s time to question this approach and unmask the rank discrimination behind it, or at the very least, reveal the dangers of blind acquiescence without serious inquiry into the scientific basis.
The Italian debacle, notably lots of deaths, was attributed to their older population. But these pronouncements were based on gross, oversimplified statistical calculations. Germany, with a similar age distribution, suffered far fewer deaths. So did Japan, with a population even older than Italy’s . Compare the case-fatality in Italy of 14% (as of March 19) with that of Germany (at 4.5%), or the even older Japanese demographic with a similar case-fatality (4.7%). Basic tools of epidemiological assessment, such as standardized age-adjusted rates, appear not to have been performed to sustain the extrapolation of the Italian experience to other countries. Basic epidemiological constraints, such as the ecological fallacy, were never even considered.
But there is more to the misleading assertion that the elderly are at greater risk than just flawed statistics. The approach obscures the key question: greater risk of what? Of disease susceptibility, of spreading it to others – or of dying?
In fact, evidence that the elderly are more susceptible to contracting COVID-19 or more likely to spread it to others is wanting– unless, of course, they were exposed in a contained facility, such as an old-age home, which, by definition is inhabited by the elderly. That conflation of circumstances, i.e., habitation in a closed vessel plus a specific demographic, is uniquely applied to the elderly. Compare the situation with cruise-ship passengers, who by virtue of the same mechanics (close proximity in a tight, shared space) were also more likely to sustain and perhaps transmit disease. Using the same rationale applied to the elderly, perhaps those more likely to travel on cruise-ships, such as the financially flush, should also be restrained, even when not cruising?
Whether the spread in elder-care facilities and cruise-ships was primarily due to facility-frailties (lack of disinfection, substandard air handling systems, tracking by personnel), or close contact of the inhabitants, or co-morbidities, or a combination — is yet unclear. Regardless, disproportionate adverse consequences suffered by this population would not necessarily apply to “elderly” living at home. And as there is no showing that the elderly are more prone to transmit the virus or infect others, a la Typhoid Mary, it appears their lockdown is not for the purpose of directly protecting the public from infection or stopping transmission – to “flatten the curve.”
In fact, it appears that 65-74 year olds are a bit less susceptible to infection than 45-64 year olds.
NYC Case Rates
While the elderly do not seem more “vulnerable” to contracting the disease, however, it does appear they are more likely to die from it. Nevertheless, even if older people are more susceptible to death, that should not impact decisions to restrict their movement– if, that is, the purpose of the lockdown is to flatten the curve for the purposes of decreasing transmission.
The best that can be said is that locking down the elderly is to assure greater availability of hospital beds, ventilators, anesthetics, trained personnel, and the like – to younger members of society. In fact, at one point, Italy denied ventilators to anyone over 60. Conserving resources so they might be disproportionately deployed to a specific population segment is a questionable public health policy, one fraught with bioethical concerns — which are not even being raised. Even insofar as conserving resources to protect the public welfare, other– less restrictive or legally invasive means -such as priority allotment of respirators -would be preferable – at least from a legal perspective.
Are oldsters really at a greater risk of dying?
But even statistics supposedly illustrating that older folks might be at greater of dying or disproportionately taxing the health care system – might be confounding for other variables. Prof. Micheal Levitt raised the question, “Is the coronavirus killing the elderly, or is it a background factor, with the disease only slightly accelerating the unavoidable result of the prior medical complications? In other words, the statistics do not separate age from co-morbidities, which may also be suffered by other groups, such as the poor, or of different races. True, generally, co-morbidities are more prevalent in older people. But not always. Just yesterday, Israel reported its youngest victim, a 33-year-old who was suffering from leukemia.
Another confounding variable is sex. Thus, while the vulnerability of men to CoVid19 is recognized, we find no specific restrictions directed at this segment. In fact, it appears men are slightly more susceptible to contracting the disease. But when it comes to death and hospitalization, the differences are even more marked.
NYC Case Rates by Sex, as of May 21, 2020 for all ages
NYC Deaths By Sex- as of May 21, 2020 (below) – for all ages:
The discrepancy between the sexes becomes even greater when age is combined with sex. In fact, it appears that it is not age, per se, that is death-related, but rather age and sex. In Italy, for example, deaths for men ages 60-69 is about the same as female deaths for ages 70-79. And virtually all deaths 40-49 were in men. Similar statistics have been reported in Israel, where men are also differentially affected. So, perhaps we should quarantine men over 40 – to protect the welfare of the rest of us?
Politics, Pressure, and Pariahs
The deficiencies in furnishing an epidemiological basis for age-based policies — especially of the female persuasion — bring us back to the point raised at the outset – the pernicious impact of politics on public-health policy.
The Israeli exit strategy, as initially proposed, focused on maintaining restrictions for those above 60. Later reports proposed continuation of lockdown practices for those over 67, summarily labeled as the “high-risk” group. The Finance Ministry agreed, proposing those over 67 would remain in lockdown indefinitely, although the idea was opposed by the Minister of Social Equality, who noted that there are 100,000 people over the age of 67 in Israel, of which 80% are healthy and able-bodied.
Interestingly, there are no data calibrated to assess risks based on a demographic cut-off of 67. (Most epidemiological studies focus on risks over 60 in five-year increments, e.g., 60, 65 and 70). In fact, hard data in Israel reflected that the majority of deaths were over 70, and the average age of those who succumbed was 81.
Obviously the 67-year old cut-off has no legitimate connection with disease susceptibility or vulnerability, but rather is a surrogate for retirement age and economic contribution. Those in that category, with the exception of rarified individuals like the Prime Minister, don’t contribute to the economy – and hence are dispensable. Those banned from contributing to the economy – are also to be committed to involuntary confinement. In fact, when questions were raised as to why the Prime Minister would be exempt – the answer was that he was already employed, even though none of the directives reflecting age mentioned anything to do with employment.
In sum, focusing on discreet population segments, such as age, allows politicians to scapegoat groups of little consequence to them or their political philosophy. It is, therefore, not surprising that capitalist economy-focused Bennet and his cohort, Libertarian MK and former computer-marketer Ayelet Shaked, also targeted 67 as the cut-off for lockdown. Perhaps it is also not surprising that of the economic sectors slated for priority in reopening, the glamourous Mme. Shaked identified Hi-Tech and Hairdressers.
I suggest that before further knee-jerk crisis responses based on early, unadjusted statistics are implemented, care must be taken to examine the repercussions, the basis for the statistics, and possible confounders. Deviating from time-honored considerations designed to preserve democracy should be met with extreme caution when exercised during an epidemic. Otherwise, when the pandemic is over, we may not have a democracy to come home to.