Prominent epidemiologists and public health specialists have proposed a ‘more humane’ strategy for the management of the coronavirus pandemic that involves ‘focused protection’ for the vulnerable whilst allowing people at minimal risk to function normally and the economy to flourish.
A document known as The Great Barrington Declaration describes an alternative, compassionate and more effective strategy to manage the coronavirus pandemic.1
Originally written by three leading scientists – Dr Martin Kulldorff, Professor of Medicine at Harvard University, Dr Sunetra Gupta, Professor of Theoretical Epidemiology at Oxford University and Dr Jay Bhattacharya, Professor at Stanford University Medical School – it was signed by a further 35 doctors and scientists from around the world. It is now available for signature by anyone who is in sympathy with the proposed strategy.
In many countries, the current approaches to managing the coronavirus crisis are failing to limit the spread of disease but are having devastating effects on short- and long-term public health.
In the UK, the government policy is to ‘control the virus’ through lockdowns and related measures while waiting for the arrival of an effective vaccine. Lockdowns prolong the circulation of the virus rather than eliminate it – an analysis confirmed by recent independent modelling.2
In the meantime, they result in extensive collateral damage including delays to cancer diagnoses and treatment, falling vaccination rates and mental health problems. Because they are unselective – and lock down both those at minimal risk and those at high risk – the burden falls disproportionately on the young and the underprivileged. In addition, lockdowns strangle commerce and lead to the collapse of businesses. These are all significant consequences, and part of the price for the current policy.
The Great Barrington Declaration proposes an alternative approach bearing in mind that any public health strategy must take into account not only limiting the spread of disease but also the economic and social consequences. Current strategies for COVID-19 management have failed to do this and have generated enormous collateral damage, as a consequence, says Professor Kulldorff. It is of interest that a recent editorial has estimated that the cost of the COVID pandemic will be more than $16 trillion in the US. This estimate covers both lost economic output and health reductions, with a significant proportion relating to mental health.3
Much more is understood about SARS-CoV-2 than was the case in March 2020, and the declaration has been formulated with this new knowledge in mind. The virus has one great weakness, namely, its differential effects on the young and old. There is a 1,000-fold difference in the risk of mortality between the youngest and oldest individuals – and this is something that we should be exploiting, argues Professor Kulldorff.
The proposed strategy involves protecting or shielding the elderly and vulnerable whilst allowing those at minimal risk to go about their daily lives unhindered: going to work, to school, to sports venues and to restaurants. Creative use of social security systems could ensure that this is done without undue hardship, the authors of the declaration suggest.
Young people would contract the infection but be largely unaffected and it could reasonably be expected that the epidemic would peak and resolve in the space of three months, explains Professor Gupta. After this time, there should be a sufficient level of herd immunity to ensure that older and vulnerable people could safely be released from shielding. By this stage they would be protected because the virus would no longer be circulating.
Herd immunity
The achievement of herd immunity in the context of COVID-19 has been misrepresented as the ‘do nothing’ approach or characterised as ‘letting it rip’. However, this is far from what is intended here. “Herd immunity is not a strategy, it is a biological fact”, argues Professor Bhattacharya. Moreover, vaccination relies on herd immunity for its effectiveness as a means of controlling infectious disease.
“We will be relying on a combination of vaccine-generated immunity and naturally-acquired immunity to provide the level of protection that we need in future”, says Professor Gupta.
Whatever strategy is used the endpoint is herd immunity. If the ‘do nothing’ approach is followed, some old and some young people are infected and there are many deaths. If everyone is protected (that is, lockdown for all) the result is much the same, but it takes longer.
If a targeted (‘focused protection’) strategy is adopted that protects the elderly and vulnerable, then more young people than old will be infected and there will be fewer deaths overall than with the alternative approaches. Such a strategy could, for example, involve staffing nursing homes with individuals who have already had the infection (that is, have immunity) and/or carrying out frequent testing of staff and visitors, suggests Professor Kulldorff.
Older people in the workforce should work from home. “If we want to minimise deaths in the long term, an age-targeted strategy would be appropriate both for its impact on COVID-19 and on collateral damage”, he says. Once again, this overall analysis is confirmed by independent modelling which shows that a combination of case isolation, household quarantining and social distancing of the over-70s is more effective than general social distancing and that, perhaps counter-intuitively, adding school and university closures to the other measures actually results in a greater number of deaths.2
Current strategies protect low-risk college students and professionals, but older working-class people have to work because they are, for example, bus drivers or supermarket workers. “We are protecting low-risk people in privileged classes while putting the burden of generating immunity – that will eventually protect all of us – on the working class, especially the urban working class”, says Professor Kulldorff.
Focused or targeted protection of the type advocated would actually shorten the period of ‘isolation separation’ (when the vulnerable have to be separated from low-risk individuals) compared with current policy. The scientists envisage that the separation would only need to continue until young people no longer pose a threat to the vulnerable and elderly.
The proposed approach both reduces harm (from disease) to the vulnerable and reduces economic and social harm to those at little risk from the disease. It goes hand in hand with accurate public health messaging about levels of risk.
The middle path
There are many similarities between this approach and the ‘middle path’ advocated by the World Health Organization (WHO). Professor David Nabarro, WHO Special Envoy for COVID-19, describes this as, “holding the virus at bay whilst keeping economic and social life going”.
Such an approach is potentially achievable but will be challenging. In order to be successful this requires a robust scheme for infectious disease control, including testing, contact tracing and isolation. This needs to work in tandem with general measures – physical distancing, face protection, hand hygiene, self-isolation of infected cases and protection of those most at risk, he explains. Local actors need to be involved as much as possible, as local knowledge enables more effective responses to localised spikes of infection.
Thirdly, everyone needs to be “onside” and “all pulling together”. This involves providing people with accurate information so that they have a good understanding of the issues and the measures that need to be implemented. It is an approach that is working well in East Asia, Germany and parts of Canada, he says.
Lockdowns
“Lockdown should not be used as the primary control measure”, says Professor Nabarro. Lockdown serves only one purpose and that is to stop everything to provide a “breathing space” that should be used for rebalancing or reorganising the overall response or building up track and trace systems, he adds. In addition to the damaging social and economic consequences for local communities, lockdowns have far-reaching effects; reductions in the volumes of trade and tourism can have disastrous effects for some poorer countries.
The WHO anticipates a doubling in world poverty and childhood malnutrition by next year as a result of these effects. “Lockdowns have one consequence that you must never, ever belittle – that is, making poor people an awful lot poorer”, he said. Local, integrated responses would be preferable to lockdowns because they are more likely to bring about effective control and are far less damaging.
In the UK, data from the Office for National Statistics show that lockdowns have been almost completely ineffective at limiting the spread of infection with SARS-Cov-2; indeed, case numbers actually rose after the introduction of lockdowns. Leicester was the one notable exception – something that Professor Nabarro attributes to strong local engagement and an integrated approach.
Public Health England’s weekly COVID surveillance reports show that by week 39 (week ending 27 September) restaurants accounted for some 4% of incidents (confirmed outbreaks with two or more cases linked to a particular setting); far greater numbers of outbreaks were associated with care homes, educational settings and workplaces. In spite of this information, hospitality venues are now the targets of stringent lockdown measures.
The two approaches described, ‘focused protection’ and ‘the middle way’ are broadly similar. They should both reduce harm (from disease) to the vulnerable and reduce economic and social harm to those at little risk from the disease. They go hand-in-hand with clear, honest, accurate public health messaging about levels of risk and the measures required to minimise the risks.
References
- The Great Barrington Declaration. https://gbdeclaration.org/ (accessed October 2020).
- Rice K et al. Effect of school closures on mortality from coronavirus disease 2019: old and new predictions. BMJ 2020;371:m3588.
- Cutler DM, Summers LH. The COVID-19 pandemic and the $16 Trillion virus. JAMA. Published online: October 12, 2020. doi:10.1001/jama.2020.19759.
