Lockdowns, focused protection or rapid tests: the pandemic strategies compared
Jay Bhattacharya makes the case against lockdowns and for focused protection of the most vulnerable, Michael Mina argues that cheap rapid tests used at home were a powerful tool and explains why the US lacked them, and Francis Collins discusses rapid tests and getting out of the pandemic. Comparing the strategies that were argued for is a practical way to think about the next outbreak.
Three guests of the Lex Fridman Podcast, recorded within months of each other in 2021, argued for three different ways through COVID: focused protection, rapid tests at home, and vaccination first. They disagree most about who should be the target of policy, everyone or the vulnerable, and they overlap more than their fight suggests on testing, on vaccines for older people and on telling the public the truth.
Jay Bhattacharya, a co-author of the Great Barrington Declaration, rests his case on two ideas: the steep age gradient in COVID risk and the harms of lockdowns. His rule of thumb, for unvaccinated people before Delta, is an infection fatality rate around 0.2% at age 50 that doubles for every seven years older and halves for every seven years younger. Against that he sets hunger, disrupted treatment programs, missed cancer screenings and school closures. So he wants the old and the chronically ill protected, with nursing homes first, while businesses, schools and places of worship stay open. "The goal isn't to let the virus rip. The goal is to protect the vulnerable," he says.
Michael Mina says the missing tool was information. Cheap rapid antigen tests tell people whether they are infectious right now, and he says they are about 97 percent sensitive against infectious people. The United States lacked them, he explains, because they are evaluated as medical devices against PCR. Schools closed because nobody knew who was infectious: "That's not a biological problem that's an information problem." His program is a box of tests in every cupboard, used when wastewater monitoring or clinics show the virus rising.
Francis Collins, then director of the National Institutes of Health, put vaccination first: vaccinate the 64 million hesitant US adults, vaccinate kids, boost those due, keep masking and distancing indoors for now, and speed vaccines to low- and middle-income countries. He also describes the NIH's RADx program, which he says produced most of the home tests on pharmacy shelves.
The sharpest split is lockdown or focused protection. In an October 2020 email, Collins called Bhattacharya and his co-authors fringe epidemiologists. They also read the risk differently. Bhattacharya says 70% to 80% of deaths are in people over 60. Collins points out that the average ICU patient with COVID was under 50 and that about 700 children had died. On tests, Mina wants them judged by the CDC as public health tools, while Collins describes NIH helping companies through FDA authorization.
All three praise the vaccines, and Bhattacharya and Mina both say they do not stop transmission well. On honesty they converge in words: Bhattacharya says never to use fear as a tactic, Collins says to tell the truth, and Mina says people have a right to know their own status.
What to do with it: in the next outbreak, find the denominator first with early antibody studies, then find out who is at risk and aim there. Start with nursing homes, not bed counts, and give the vulnerable practical help such as grocery delivery. Keep a box of rapid tests at home and use them on a signal, before gatherings and to shorten isolation. Ask of any test what it is sensitive to. Tell people the real risks.
These are conversations from 2021, and their forecasts and figures belong to that moment. None of this is personal medical advice: decisions about vaccination, testing and isolation for a particular person belong with that person's doctor and current public health guidance.