Thoughts on the Great Barrington Declaration

Three epidemiologists have proposed a different approach to managing the covid pandemic, in the form of the Great Barrington Declaration:

“The most compassionate approach that balances the risks and benefits of reaching herd immunity, is to allow those who are at minimal risk of death to live their lives normally to build up immunity to the virus through natural infection, while better protecting those who are at highest risk. We call this Focused Protection.”

I’ve been happy to see the conversation broadening out a bit in this way, as I’ve long been a lockdown sceptic and feel that the level of fear in our narratives around this virus has reached unhealthy heights.

I haven’t signed it, though. Part of me wants to – there are definitely things I like in it (and in Sunetra Gupta’s commentary) that I’m just not getting from elsewhere:

• Recognition of the profound harm of lockdowns. A holistic public health perspective rather than one focused solely on the threat of covid. In the case of Sunetra Gupta, a voice in defence of the world’s poor: warnings that lockdowns will lead to starvation, reminders that being able to stay at home away from other people and be OK is a huge privilege that the majority do not have. And even for those that can, there are still harms.
• The understanding that the end-point of this pandemic is an endemic equilibrium. Nothing else really makes sense to me. This coronavirus is going to be circulating forever – or at least, we can’t realistically think we can ever eradicate it.
• Hence, an explanation – a ray of hope – for how the virus will become less of a threat. It’s causing a lot of severe disease because it’s novel. In an endemic equilibrium, we won’t see these big overwhelming outbreaks, because at any given time, many people will have immunity. Reinfections are also expected to be generally milder as the immune system still retains some memory of how to deal with it.
• Interesting to reflect that if this is true, it will never be a significant threat to today’s children or future generations because they will be first exposed during childhood, at which stage of life it’s generally a mild disease. Maybe the other four circulating coronaviruses would also be life-threatening to the elderly if they had never previously been exposed to them. For that matter, probably those viruses are responsible for deaths (I’m sure Prof Gupta has referred to that), and we just don’t hear about it because there aren’t big waves of serious infections (we have an endemic equilibrium)… and the cause of death is probably recorded as “pneumonia”, i.e. it’s the secondary complications that we consider significant, and the primary infection is almost irrelevant (and not even known). With covid we’ve somehow equated the secondary complications with the infection itself, despite the huge number of asymptomatic and mild infections. Fear fear fear. So, this is something I like and find helpful: framing the coronavirus beside its non-threatening cousins where it can best be understood, and so tempering the hysteria around its novelty.

I think the most obvious criticism of the idea is probably the logistical difficulty of shielding “the vulnerable” while letting the rest live normally. Maybe it would be feasible if we had rapid testing, so that care home workers could be tested at the start of each shift, and visitors tested in the same way. As it is, the physical separation of vulnerable people from their loved ones is extremely tough. And where they live in the same household, it’s hard to imagine ways it could be done. Sunetra Gupta has said she expects it would only take about 3 months for game-changing levels of immunity to be reached under the GBD proposals, so that the difficulties of shielding wouldn’t need to be endured for long – but I don’t think anyone can really know that.

And then there’s the question of how much protection would actually result from reaching endemic equilibrium. There’s been a lot of unhelpful shouty noise about herd immunity being impossible because individual immunity wanes. Herd immunity is not an all-or-nothing thing. Even with lifelong immunity and widespread vaccination, as with measles, the probability of a vulnerable person being exposed is not zero. With a coronavirus in an endemic equilibrium, where individual reinfection might occur every few years, the probability of a vulnerable person being exposed is clearly higher than in the measles case. But still, the GBD people are not wrong to say that a level of herd immunity is built up. The question is, is it enough? And how much would we consider “enough”? What do their models suggest the eventual probability of exposure will be, and what is it now? These are the kind of things that should be asked.

The other thing that bothers me is that we still need to recognise this virus can be dangerous to anyone at high viral loads. Young and healthy doctors and nurses have died of it for this reason. There are certain aspects of normal life – nightlife especially – that I don’t see being safely resumed until most of the population is vaccinated.