I see this all as proof enough that the GBD would not have worked. But itâs worth saying a bit more now about what focused protectionâseparating the vulnerable from the non-vulnerableâwould have looked like in practice. A foundational premise of public health practice is that people are imperfect, so we need to make it easier to exercise health behavior by bringing down collective risk. The Great Barrington Declaration fails in this respect.
It fails because their proposal for the elderly ends up setting a very high bar for personal performance. If a society decided to order itself such that the old were separated from the young, then by implication the elderly are closer together and an outbreak becomes of even higher consequence. I cite one example where Dr. Jay Bhattacharya says that we could house them in hotels during COVID waves. In this case, though really I mean this more generally, the onus for preventing a catastrophic outcome would be placed on whomever is serving those elderly people. This is precisely what happened with nursing homes, some of which suffered crushing losses while others did not, with no overarching explanation for why.
A transfer to individual, case-by-case responsibility for vulnerable lives seems highly variable in terms of outcome. Youâre asking family members and caregivers to assume quite a bit of risk. Because if overall case levels in my community are low, then screw-ups on my part are unlikely to harm Grandma. But if case levels in my community are persistently high, then moving Grandma, getting her supplies, having a caregiver come in and out and get up close daily, going to appointments, dealing with unintended risks such as voluntary behavior by other residents to expose themselves, etc. all become very high risk.
Some people will be able to do it but not all. And in the disastrous winter which came right after the GBD was published, the margin of error would have been extremely small. Itâs unclear to me that transporting many elderly personsâsome via public transport and some via privateâwouldnât have itself triggered a significant number of infections and therefore deaths. If that sounds unrealistic, note that our besieged nursing homes reduced their touchpoints as much as possible. It was through the few remaining touchpoints (minutes spent with masked caregivers, brief interactions with nurses, etc.) that they were exposed and subsequently died. An operation to relocate the elderly would add new touchpoints for many millions of people.
Think about it this way: there are 54 million elderly people in the US, with only 5% in nursing homes. There are many millions more vulnerable people. Shuffling them around safely and then supplying them consistently while a virus is out of control in your community is a massive logistical challenge. Even doing so in the best of times would be a huge undertaking I struggle to find a historical analogy for. By necessity it would require the help of a significant number of community members who were themselves unable to avoid infection. And this is assuming the best of intentions, when instead we see Americans willfully took a massive risk over both holidays knowing a vaccine was coming which then resulted in record deaths.
If youâre wondering how this would work, you couldnât get an answer from the authors of the GBD at the time. When asked in a court of law in October 2021 how the GBD would be implemented, Dr. Jay Bhattacharya ânoted that it would be for government to determine how best to implement principles of the declaration.â That is, the authors didnât have the specifics down. And if they didnât, who is to say that others would figure them out?
To send home the infeasibility of this idea, Martin Kulldorff would later claim Florida as an example of where focused protection was successfully implemented. Only months before he did so, Florida led the nation in terms of nursing home resident and staff deaths. Martinâs defense was that you needed to adjust for age and Florida looked as good as other states, which in plain language means: âWell we had more vulnerable people, so of course we had more deaths.â Itâs a statement he is correct in makingâand I wouldnât blame himâbut only insofar as he is willing to admit that focused protection doesnât work.
To all of this, I would add the perspectives of two people who do actual logistics. The first is an experienced project manager in the UK who helped with his local governmentâs COVID response. He notes that per the UKâs Joint Council on Vaccination and Immunization, roughly half of the population was considered to have a health risk factor such that they would be selected for early vaccination. Of those who remained, half would be children. I donât think anyone actually sees half the nation as needing focused protection, but even if the number were a more reasonable 20-30% this remains a huge rearrangement of society. Youâd be leaving many young people who are inexperienced in work, parenting, etc. to lead society while juggling the logistics of outbreaks and the time consumption of getting sick.
The second criticism comes from a British Minister of Parliament. He places the number to protect at 25%, and effectively comes to the same conclusion: âTrying to isolate and supply food to all these 15-16m people while the virus spiked would be a monumental undertaking.â I would add to this that likely logistical shortcomings would hurt the elderly, who were already suffering human rights abuses. Youâd be essentially taking a care arrangement well-past its limit and replicating its core features: disproportionate isolation + dependence on others for fulfillment of needs (food, medical, etc.).
Ultimately, I agree we should have done more to focus our resources on the elderly. I donât think you will find anybody who believes we did enough for them. But as concerns the events as they played out, asking people to take a sharp turn from our collective plan to a separate and ambitious one at the same time as things were falling apart was fundamentally unrealistic.