In the last UK government report on coronavirus policy, the word “shielding” is mentioned 36 times. The UK, Sweden and the Netherlands have all shown much interest in this strategy of cocooning vulnerable groups in their homes or shelters while attempting to reopen economies outside.
To date, shielding has meant asking those who are clinically extremely vulnerable to coronavirus not to leave home, to avoid any face-to-face interaction, and to restrict human contact to the digital realm. What goes unsaid is that this strategy of shielding is distinctly western, and has not proven particularly effective at protecting these individuals.
The first vocal proponent of shielding was Boris Johnson, who announced in mid-March that the UK would keep its economy open and achieve “herd immunity”. In the meantime, those at high risk of coronavirus would need to protect themselves by shielding from the rest of society. David Halpern, the chief executive of the behavioural insights team, which is part-owned by the government, said, “there’s going to be a point, assuming the epidemic flows and grows, as we think it probably will do, where you’ll want to cocoon, you’ll want to protect those at-risk groups so that they basically don’t catch the disease – and by the time they come out of their cocooning, herd immunity’s been achieved in the rest of the population”.
This plan turned out to be disastrous. Deaths ravaged care homes and households, and the UK quickly reversed tack and introduced a national lockdown on 23 March. The UK now has one of the highest death tolls in the world. Yet shielding strategies stuck: governments in the US, UK, Sweden and other western countries still advise confinement for vulnerable populations. Most (with the exception of Sweden) recommend shielding in conjunction with a national lockdown.
In contrast, east Asian governments have adopted policies focused almost exclusively on mass testing, tracing, and isolation of infectious individuals. In South Korea and Taiwan, governments made two face masks a week available to citizens and registered non-citizens across the country. The core objective in these countries was to drive the virus out and prevent both young and old people catching it.
Two key assumptions underlie shielding use in the UK. First, that if 15% of the population, say, were vulnerable to severe infection from coronavirus, this group could reasonably be isolated from the remaining 85%, who were likely to contract only a mild illness. And second, that those who have contracted coronavirus would develop protective immunity. Yet we still don’t know if people develop immunity once they have become infected with coronavirus.
And in practice, the first assumption falls apart. According to one study in China, 80% of coronavirus transmissions occurred at home, where multi-generational living complicates attempts at shielding. Elderly people who are shielding and living with family members under one roof are especially at risk as countries move to reopen their economies. This risk shouldn’t be understated. In the US, 13 million Americans over 65 live in multigenerational households. Some don’t have the space for their own room. For members of this group who are clinically extremely vulnerable, shielding isn’t really an option.
Even elderly people who live alone need regular contact for care and services. According to the Institute on Aging in the US, 65% of older adults rely exclusively on family and friends to provide them with assistance. Another 30% receive paid assistance alongside their family support. Every point of contact in the network of care for an elderly person who is shielding increases their threat of infection.
Beyond immediate family and friends, people who are shielding are also more likely to need regular contact to receive medical care, grocery deliveries, and transportation. The extent to which at-risk populations must rely on others for essential care and services is a huge challenge to the efficacy of any shielding strategy.
We’ve seen that despite attempts to shield people in nursing and care homes, death rates in these places are consistently among the highest in national tolls. Consider Sweden, which remains lockdown-free, despite deaths ravaging its care homes and elder-care services. At least 50% of the country’s coronavirus deaths occurred within nursing homes, according to Anders Tegnell, the chief epidemiologist of the Swedish public health agency.
In the UK, where a national shielding strategy was temporarily adopted, care homes also became hotbeds for infection. Care home deaths were found to be higher than 22,000 by academics at the London School of Economics. Inefficacies aside, shielding itself is harmful to the mental health of those who are vulnerable. Older adults are already at heightened risk of depression and suicidal thoughts; according to the Kaiser Family Foundation, social isolation from shielding can exacerbate these mental health challenges. It’s unlikely that the mental health of members of this group who have to shield will improve from being asked to shield indefinitely.
And the elderly alone don’t bear the risks of coronavirus. Many younger individuals live with key risk factors that put them into vulnerable groups, and some will be deemed clinically extremely vulnerable to coronavirus. Earlier this month, the world’s largest patient study by the London School of Hygiene and Tropical Medicine and Oxford University found that key factors relating to coronavirus deaths included uncontrolled diabetes, severe asthma, obesity, poverty and ethnic minority status.
As western countries ease lockdown, suggestions have been made for those being shielded to stay “cocooned” away indefinitely until a vaccine or antiviral therapy is found or natural herd immunity is reached. What we suggest instead is a general strategy of suppression, where governments make a commitment to keeping daily new cases as low as possible through an active testing-and-tracing programme and real-time monitoring of transmission.
At the same time, the government should advise those in “shielded groups” about their individual risk, as well as provide them with data about transmission within their communities, and then leave these individuals to make an informed decision about how and when they would like to engage in society.
For a government to pursue shielding alone, with its proven inefficacies and intrinsic harms, would be nothing but an Orwellian strategy – one that presides over the fates of those at greatest risk, against all evidence. There are serious ethical and moral questions around building a society where the healthy and young are left to circulate, and the elderly, the disabled and the vulnerable are hidden away.
Prof Devi Sridhar is chair of global public health at the University of Edinburgh; Yasmin Rafiei is a research assistant at the University of Edinburgh and an MD candidate at Stanford University