The Great Barrington Declaration and “natural herd immunity” versus public health three years later

It has been over three years now since the publication of the Great Barrington Declaration (GBD), whose authors in early October 2020 advocated a “natural herd immunity” approach to the pandemic, in which the young and healthy, who were (presumably) at very low risk of serious illness and death from COVID-19, would be allowed to go (mostly) about their business reopening society, while the elderly and those with chronic medical conditions, who were at the highest risk of complications and death from the novel coronavirus, would supposedly be kept safe with “focused protection.” The idea was that, by letting SARS-CoV-2 circulate in the “low risk” population we would reach “natural herd immunity” more rapidly—in six months!—all without the serious damaging consequences of business closures (which proponents of a GBD-like approach always called “lockdowns,” whether they were lockdowns or not) and all the other public health interventions instituted early in the pandemic to slow the spread of the novel coronavirus. Unfortunately, one of the requirements to achieve “natural herd immunity” is that postinfection immunity—which antivaxxers like to refer to as “natural immunity“—be durable, and, as we later learned with the Delta and Omicron waves, a coronavirus that was spreading widely through a population of billions was very capable of evolving into new variants that could not only become a lot more transmissible than the original Wuhan strain but also evade immunity acquired as a result of infection with prior variants. Then there was the problem that the GBD never really defined “focused protection” in a way that could be operationalized. It appeared to mean something akin to indefinite quarantine of the “high risk” their homes, ignoring that these people could never entirely avoid interacting with all those young healthy people spreading the virus. Moreover, in practice “focused protection” could never really have worked, anyway,

So from that consideration alone, “natural herd immunity” was always a pipe dream, but it also turns out that “focused protection” in practice could never really have worked anyway, something that even Gabrielle Bauer of the Brownstone Institute (the “spiritual child of the GBD“) implicitly admitted this year without actually admitting it. There are many good reasons why I referred to the GBD as eugenicist a mere week after it was published and continue to do so. It was (and is) eugenicist in that it basically advocated letting the elderly and unhealthy die in service of society. (Seriously, I kept thinking of the term “useless eaters” as I read the declaration.) Unfortunately, the GBD was highly influential in the US, UK, and a number of other countries and remains so to this day, even as GBD proponents, including the Brownstone Institute, have become increasingly antivaccine.

Indeed, what inspired this post were two articles, the first a bit of self-congratulatory wankery published by Jeffrey Tucker over the weekend on the Brownstone Institute website entitled The Declaration That Wasn’t Supposed to Happen. Contrast that to an article that appeared on the website of the John Snow Project, a group of public health professionals that pointed out from the beginning how misguided and dangerous GBD-like “natural herd immunity” approaches to a pandemic are, entitled ‘Endemic’ SARS-CoV-2 and the death of public health. Of course, once it had become clear to GBD advocates that “natural herd immunity” was nowhere near, much less just six months away, many of them pivoted to a shoulder shrug about how SARS-CoV-2 would just become “endemic” and that would be fine, ignoring all their claims of how the virus would be brought under control through the magic of “natural herd immunity.” I can’t help but contrast the two, particularly in light of last week’s charge—and completely accurate statement—by Dr. Jerome Adams, Surgeon-General during the Trump Administration, that advocates of a GBD-like approach to the pandemic wanted to use children as guinea pigs by letting them be infected in order to reach “natural herd immunity” faster, basically saying the same thing that we here at SBM, particularly Dr. Jonathan Howard (who even wrote a book about it) had been saying all along:

Sadly, Dr. Adams’ characterization of what happened is quite accurate. So let’s look at the Brownstone Institute’s shiny happy version of history and compare it to reality, shall we?

Martin Kulldorff of Harvard Medical School, Sunetra Gupta of the University of Oxford and Jay Bhattacharya of Stanford University at the American Institute for Economic Research in Great Barrington.

Jeffrey Tucker’s shiny happy “natural herd immunity,” championed by brave maverick doctors

For those of you who don’t remember, Jeffrey Tucker is the founder of the Brownstone Institute; indeed, it was he himself who, after having founded it in 2021, explicitly called his new institute the “spiritual child of the GBD.” And why not? Tucker was instrumental in creating the GBD. In the summer and fall of 2020, he was the editorial director of the right wing “free market” think tank American Institute for Economic Research, (AIER) whose headquarters in Great Barrington, MA provided the name for the GBD. It was at the AIER headquarters where Tucker, helped by a like-minded Harvard statistician and later GBD signatory named Martin Kulldorff, gathered the other two authors of the Declaration, Stanford health policy professor Jay Bhattacharya and Oxford theoretical epidemiologist Sunetra Gupta, for a press event where the three scientists just so happened to pen the GBD as well. Indeed, not long after the GBD was released, Tucker bragged on a podcast how he had invited Kulldorff to the AIER headquarters, found him so enthusiastic about opposing “lockdowns” that Kulldorff volunteered to gather other like-minded scientists for a “conference” (complete with press) where the GBD ended up being drafted and announced, and then been in the “room where it happened” (apologies to Lin-Manuel Miranda) as the GBD was being discussed and written. Basically, Tucker was the dark far-right wing ideologue who recruited Kulldorff as a useful idiot for his cause, and Kulldorff did not disappoint.

As such, Tucker remains very proud of his creation, as he brags in The Declaration That Wasn’t Supposed to Happen:

It’s been a continuing mystery for three years, at least to me but many others too. In October 2020, in the midst of a genuine crisis, three scientists made a very short statement of highly public health wisdom, a summary of what everyone in the profession, apart from a few oddballs, believed only a year earlier. The astonishing frenzy of denunciation following that document’s release was on a level I’ve never seen before, reaching to the highest levels of government and flowing through the whole of media and tech. It was mind-boggling.

And:

That was the period of the grant amnesia. The conventional wisdom turned on a dime toward full backing of regime priorities, a shift more extreme and mind boggling that anything in dystopian fiction.

This is some very seriously amnestic revisionist history. While it is true that the GBD was denounced by public health officials for the unworkable ideological (and eugenicist) example of “magnified minority” that it clearly was, such denunciations were nothing compared to the embrace of GBD-like policies by, for example, the Trump administration in the US and the Boris Johnson administration in the UK, as well as a number of state governments. Indeed, as Gavin Yamey and I noted in 2021:

In October 2020, Gupta, Kulldorff, and Bhattacharya met with two of US President Donald Trump’s senior health officials, Health and Human Services Secretary Alex Azar and Scott Atlas. Atlas was at the time on leave from his fellowship at the Hoover Institution, a conservative think tank affiliated with Stanford University. The meeting reportedly led the administration to eagerly embrace the GBD. Nor did the GBD authors limit their efforts to national governments. For example, in March 2021 Florida Governor Ron DeSantis hosted a video roundtable with Atlas, Gupta, Kulldorff, and Bhattacharya, where they expressed opposition to masks, testing and tracing, physical distancing, and mass vaccination. YouTube removed the video “because it included content that contradicts the consensus of local and global health authorities regarding the efficacy of masks to prevent the spread of Covid-19.” GBD authors, predictably, cried, “Censorship!” Bhattacharya continues to advise Governor DeSantis on Florida’s covid-19 policies, including providing legal testimony in support of DeSantis’s ban on mask mandates in public schools.

That’s not even counting how Kulldorff, Bhattacharya, and other advocates of “natural herd immunity”—e.g., Dr. Joseph Ladapo, who is now Florida’s Surgeon-General—had met with Donald Trump himself the previous summer:

Far from being the poor persecuted, “silenced,” and “cancelled” brave mavericks, GBD advocates were courted at the highest levels of government. While it is true that this courtship ceased when President Joe Biden was inaugurated in January 2021, they had had months of access to the highest levels of government before and after the GBD was announced.

Unsurprisingly, Tucker tries to paint the GBD as being entirely reasonable. Unfortunately, he has to engage in a bit of more misdirection to do it:

For proof that nothing in the document was particularly radical, look no further than the March 2, 2020, letter from Yale University signed by 800 top professionals. It warned against quarantines, lockdowns, closures, and travel restrictions. It said such extreme measures “can undermine public trust, have large societal costs and, importantly, disproportionately affect the most vulnerable segments in our communities.” That document appeared only two weeks before the lockdowns announced by the Trump administration.

Let’s take a look at what the letter from Yale University actually said, shall we, as opposed to what Tucker claims that it said in his link above, which emphasized issues of social and economic justice in any pandemic response, including sufficient government funding to support people and businesses affected by pandemic mitigations; prioritizing voluntary over mandatory interventions (the only part that sort of overlaps with Brownstone and the GBD but where the comparison leaves out a lot of context, such as the part where it is demanded that people subject to mandatory quarantine or “lockdown” receive adequate financial support to minimize “job loss, economic hardship, and undue burden”); and noting that the “effectiveness of regional lockdowns and travel bans depends on many variables, and also decreases in the later stages of an outbreak,” a clear swipe at the Trump administration’s early institution of poorly thought-out travel bans in early 2020.

Enter the brave maverick of AIER and the GBD:

Seven months later, the Great Barrington Declaration said something very similar to the Yale document. It was a summary statement concerning what governments and society should and should not do during pandemics. They should seek to allow everyone to live as normally as possible in order to avoid guaranteed damage from coerced disruptions. And the vulnerable population – those who would experience medically significant impacts from exposure – should be protected from exposure insofar as doing so is consistent with human rights and choice.

It was nothing particularly novel, much less radical. Indeed, it was accepted wisdom the year before and for the previous century. The difference this time, however, is that the statement was released during the wildest and most destructive science experiment in modern times. The existing policy of lockdowns was utter wreckage: of businesses, schools, churches, civic life, and freedom itself. Masks were being forced on the whole population, including children. Governments were attempting a regime of test, track, trace, and isolate, as if there were ever any hope of containing a respiratory pathogen with a zoonotic reservoir.

“Zoonotic reservoir”? I laughed out loud reading that part, given how much Brownstone and Tucker have gone all-in with “lab leak” conspiracy theories. I can only guess that Tucker included that last part as a means of seeming reasonable.

In any event, once again, this is revisionist history and bad science. Those of us around and paying attention in October 2020 immediately recognized the GBD for what it was, a propaganda document, a technique of “magnified minority” like that previously used by creationists, climate science deniers, and HIV/AIDs deniers, designed to make it appear that a fringe scientific viewpoint has a lot of support in the scientific community. (I will repeat that the GBD was also eugenicist.) Again, it was a proposal that on a very practical basis couldn’t have worked because it never defined “focused protection” adequately and the measures needed to make focused protection work would have required something resembling “lockdowns” anyway, leaving aside, again, the requirement for durable postinfection immunity for “natural herd immunity” to be achievable. That’s just one reason why I was so amused when Brownstone flack Gabrielle Bauer admitted that the GBD “didn’t get every detail right,” one of those minor details being that “neither infection nor vaccination provides durable immunity against Covid, leaving people vulnerable to second (and fifth) infections,” you know, the single most important requirement for “natural herd immunity” being durable postinfection immunity. Of course, these days, Brownstone has a two year history of parroting antivax tropes like fantasizing about a “Nuremberg 2.0” in which “lockdowners” and supporters of vaccine mandates and other public health interventions will be called to account for their “crimes”; likening public health interventions to slow the spread of COVID-19 to slavery, religion, or a Communist dictatorship; or just plain spreading pure, unadulterated antivax misinformation.

Conveniently enough, in his narrative of “censorship” and “persecution” Tucker goes right there:

Reading those words today, in light of what we now know, we can start to make sense of the sheer panic at the top. Natural infection and immunity? Can’t talk about that. The end of the pandemic is not “dependent upon” the vaccine? Can’t say that either. Go back to normal for all populations without significant medical risk? Unsayable.

You need only reflect on the astounding barrage of vaccine propaganda that began immediately upon release, the attempt to mandate it on the whole population and now the addition of the Covid jab to the childhood schedule even though children are of near zero risk. This is all about product sales, as you can easily discern from the unrelenting ad videos made by the new head of the CDC.

As for the product effectiveness itself, there seems to be no end to the ensuing problems. It was not a sterilizing inoculation, and it appears that the manufacturers always knew that. It could not stop infection or transmission. The hazards associated with it were also known early on. Every day, the news gets more grim: in the latest revelation, the CDC seems to have kept two separate books on vaccine injury, one public (showing harms without precedent but which has been deprecated by officials) and one yet to be released.

Even now, therefore, there is every effort being made to keep a lid on what surely ranks as the greatest failure/scandal in the modern history of public health. Some brave experts called it out before the whole calamity unfolded even further.

The problem with the Great Barrington Declaration was not that it was not true. It’s that – unbeknownst to its authors – it flew in the face of one of the most funded and elaborate industrial plots in the history of governance. Just a few sentences sneaking through the wall of censorship they were carefully constructing was enough to threaten and eventually dismantle the best laid plans.

Spare me, Mr. Tucker. In actuality, it was those trying to counter the GBD narrative, which was being promoted by far more than just a right wing think tank and three contrarian scientists, who were the ones drowned out by misinformation. Tucker and the Brownstone Institute can portray themselves as persecuted truth telling heroes all they want, but in reality they represented interests who saw pandemic mitigations as a threat to their ideology and profits.

Which brings us to the depressing article published at the John Snow Project, ‘Endemic’ SARS-CoV-2 and the death of public health.

The downward trajectory of public health since the pandemic

Regular readers might recall that the John Snow Memorandum was a document released by public health scientists in response to the Great Barrington Declaration. John Snow, of course, is considered one of the founders and pioneers of epidemiology, having been the 19th century physician who identified the source of a cholera outbreak in London’s Soho, a particular public water pump. The John Snow Memorandum noted, correctly:

Any pandemic management strategy relying upon immunity from natural infections for COVID-19 is flawed. Uncontrolled transmission in younger people risks significant morbidity(3) and mortality across the whole population. In addition to the human cost, this would impact the workforce as a whole and overwhelm the ability of healthcare systems to provide acute and routine care.

Furthermore, there is no evidence for lasting protective immunity to SARS-CoV-2 following natural infection(4) and the endemic transmission that would be the consequence of waning immunity would present a risk to vulnerable populations for the indefinite future. Such a strategy would not end the COVID-19 pandemic but result in recurrent epidemics, as was the case with numerous infectious diseases before the advent of vaccination. It would also place an unacceptable burden on the economy and healthcare workers, many of whom have died from COVID-19 or experienced trauma as a result of having to practise disaster medicine. Additionally, we still do not understand who might suffer from long COVID(3). Defining who is vulnerable is complex, but even if we consider those at risk of severe illness, the proportion of vulnerable people constitute as much as 30% of the population in some regions(8). Prolonged isolation of large swathes of the population is practically impossible and highly unethical. Empirical evidence from many countries shows that it is not feasible to restrict uncontrolled outbreaks to particular sections of society. Such an approach also risks further exacerbating the socioeconomic inequities and structural discriminations already laid bare by the pandemic. Special efforts to protect the most vulnerable are essential but must go hand-in-hand with multi-pronged population-level strategies.

All of which was reasonable and remains reasonable, unlike the “let ‘er rip” approach championed by the GBD, which, contrary to the claims of Tucker and his fellow “natural herd immunity” advocates, was not just “reasonable” and standard public health science. Indeed, this article argues just that, laments what has happened to public health, and expresses fear for the future the next time a new pathogen emerges.

The John Snow Project begins by noting, depressingly:

SARS-CoV-2 is now circulating out of control worldwide. The only major limitation on transmission is the immune environment the virus faces. The disease it causes, COVID-19, is now a risk faced by most people as part of daily life.

While some are better than others, no national or regional government is making serious efforts towards infection prevention and control, and it seems likely this laissez-faire policy will continue for the foreseeable future. The social, political, and economic movements that worked to achieve this mass infection environment can rejoice at their success.

Those schooled in public health, immunology or working on the front line of healthcare provision know we face an uncertain future, and are aware the implications of recent events stretch far beyond SARS-CoV-2. The shifts that have taken place in attitudes and public health policy will likely damage a key pillar that forms the basis of modern civilized society, one that was built over the last two centuries; the expectation of a largely uninterrupted upwards trajectory of ever-improving health and quality of life, largely driven by the reduction and elimination of infectious diseases that plagued humankind for thousands of years. In the last three years, that trajectory has reversed.

It’s definitely hard to argue with this depressing characterization of the state of public health today. There is now little or no effort in the US or elsewhere in infection control and prevention; it is the ultimate success of disease mongers like Jeffrey Tucker and the Brownstone Institute, along with all the other ideological forces and organizations promoting the same message and politics, that any public health interventions are an unacceptable assault on personal “freedom” that must be resisted at all costs. “We want them infected,” indeed.

The authors go on to provide a brief history of public health, noting key developments that led to its upward trajectory over the last few centuries. These include germ theory, John Snow’s identification of the source of the 1854 London cholera outbreak, vaccination, recognition of the importance of workplace environments and ventilation, and other developments. These trends continued into the 20th century, and a number of diseases were brought under much better control, including diphtheria, pertussis, hepatitis B, polio, measles, mumps, rubella, etc., because of effective vaccination, while diseases like malaria, typhus, typhoid, leprosy, cholera, tuberculosis, and many others, although not eradicated, faded from prominence because they were under better control, at least in industrialized temperate countries.

All of this history led to a recognition:

Furthermore, the idea that infectious diseases should not just be reduced, but permanently eliminated altogether began to be put into practice in the second half of the 20th century^3-5 on a global level, and much earlier locally. These programs were based on the obvious consideration that if an infectious agent is driven to extinction, the incalculable damage to people’s health and the overall economy by a persisting and indefinite disease burden will also be eliminated.

Basically, the eradication of some diseases became possible and was even within sight, after the successful eradication of smallpox, with the John Snow Project noting ruefully:

When the COVID-19 pandemic started, global eradication programs were very close to succeeding for two other diseases – polio^11,12 and dracunculiasis¹³. Eradication is also globally pursued for other diseases, such as yaws^14,15, and regionally for many others, e.g. lymphatic filariasis^16,17, onchocerciasis^18,19, measles and rubella^20-30. The most challenging diseases are those that have an external reservoir outside the human population, especially if they are insect borne, and in particular those carried by mosquitos. Malaria is the primary example, but despite these difficulties, eradication of malaria has been a long-standing global public health goal^31-33 and elimination has been achieved in temperate regions of the globe^34,35, even though it involved the ecologically destructive widespread application of polluting chemical pesticides^36,37 to reduce the populations of the vectors. Elimination is also a public goal for other insect borne diseases such as trypanosomiasis^38,39.

Noting that, because of zoonotic reservoirs of a number of diseases, this principle in dealing with emerging infectious diseases became paramount:

Because it is much easier to stop an outbreak when it is still in its early stages of spreading through the population than to eradicate an endemic pathogen, the governing principle has been that no emerging infectious disease should be allowed to become endemic. This goal has been pursued reasonably successfully and without controversy for many decades.

The most famous newly emerging pathogens were the filoviruses (Ebola^44-46, Marburg^47,48), the SARS and MERS coronaviruses, and paramyxoviruses like Nipah^49,50. These gained fame because of their high lethality and potential for human-to-human spread, but they were merely the most notable of many examples.

Such epidemics were almost always aggressively suppressed. Usually, these were small outbreaks, and because highly pathogenic viruses such as Ebola cause very serious sickness in practically all infected people, finding and isolating the contagious individuals is a manageable task. The largest such epidemic was the 2013-16 Ebola outbreak in West Africa, when a filovirus spread widely in major urban centers for the first time. Containment required a wartime-level mobilization, but that was nevertheless achieved, even though there were nearly 30,000 infections and more than 11,000 deaths⁵¹.

SARS was also contained and eradicated from the human population back in 2003-04, and the same happened every time MERS made the jump from camels to humans, as well as when there were Nipah outbreaks in Asia.

Again, it makes perfect senses that it is easier to eliminate a new pathogen before it becomes endemic. Note that I said “easier,” not “easy.” As the example of SARS demonstrates, eliminating such a pathogen before it spreads to become pandemic is nowhere near easy. It takes a lot of resources and effort, as well as a public health infrastructure to implement containment measures. The authors also note that HIV/AIDS could not be contained because (1) it integrates into the host genome, making it nearly impossible to eliminate completely and (2) it had made the jump to humans decades before its discovery and recognition, “long before the molecular tools that could have detected and potentially fully contained it existed.” The authors further note that the threat of the emergence of a new pathogen like SARS-CoV-2 had been known and planned for a long time before SARS-CoV-2 actually did emerge, adding that its appearance “should therefore not have been a huge surprise, and should have been met with a full mobilization of the technical tools and fundamental public health principles developed over the previous decades.”

Unfortunately, that actually did not happen, except fitfully, leading the authors to lament the  resulting “death of public health and the end of epidemiological comfort,” which brings the authors to a message very much like that of Dr. Adams, Dr. Howard, myself, and many others, namely that containment was actively sabotaged:

After HIV, SARS-CoV-2 is now the second most dangerous infectious disease agent that is ‘endemic’ to the human population on a global scale. And yet not only was it allowed to become endemic, but mass infection was outright encouraged, including by official public health bodies in numerous countries^81-83.

The implications of what has just happened have been missed by most, so let’s spell them out explicitly.

We need to be clear why containment of SARS-CoV-2 was actively sabotaged and eventually abandoned. It has absolutely nothing to do with the “impossibility” of achieving it. In fact, the technical problem of containing even a stealthily spreading virus such as SARS-CoV-2 is fully solved, and that solution was successfully applied in practice for years during the pandemic.

“Endemic,” of course, means that the virus is just out there and with us, uncontainable because, well, it’s everywhere, despite examples of nations that did successfully contain many COVID-19 outbreaks before abandoning the effort, including Australia, New Zealand, Singapore, Taiwan, Vietnam, Thailand, Bhutan, Cuba, and China, the last of which, according to the John Snow Project, had “successfully contained hundreds of separate outbreaks, before finally giving up in late 2022.”

Contrary to what GBD proponents will tell you, it’s not as though the tools to contain outbreaks of respiratory diseases haven’t been known for decades:

The algorithm for containment is well established – passively break transmission chains through the implementation of nonpharmaceutical interventions (NPIs) such as limiting human contacts, high quality respirator masks, indoor air filtration and ventilation, and others, while aggressively hunting down active remaining transmission chains through traditional contact tracing and isolation methods combined with the powerful new tool of population-scale testing.

They note that using nonpharmaceutical interventions (NPIs_ to break transmission chains and driving the effective reproduction number (Re) to well below 1.0 and keep it there would have been much easier when Re was around 1.3 than it is with Re around 3.0, at least before a new variant emerges to bypass immunity, noting that it was not a technical failure, but rather a failure of will:

This is not a technical problem, but one of political and social will. As long as leadership misunderstands or pretends to misunderstand the link between increased mortality, morbidity and poorer economic performance and the free transmission of SARS-CoV-2, the impetus will be lacking to take the necessary steps to contain this damaging virus.

Moreover, as we have noted all along, starting when the GBD was first declared, powerful political and economic interests aligned to oppose measures necessary to contain the emerging outbreak of SARS-CoV-2 before it got out of control. Gavin Yamey and I wrote about them two years ago, and the John Snow Project reiterates our point now:

Political will is in short supply because powerful economic and corporate interests have been pushing policymakers to let the virus spread largely unchecked through the population since the very beginning of the pandemic. The reasons are simple. First, NPIs hurt general economic activity, even if only in the short term, resulting in losses on balance sheets. Second, large-scale containment efforts of the kind we only saw briefly in the first few months of the pandemic require substantial governmental support for all the people who need to pause their economic activity for the duration of effort. Such an effort also requires large-scale financial investment in, for example, contact tracing and mass testing infrastructure and providing high-quality masks. In an era dominated by laissez-faire economic dogma, this level of state investment and organization would have set too many unacceptable precedents, so in many jurisdictions it was fiercely resisted, regardless of the consequences for humanity and the economy.

None of these social and economic predicaments have been resolved. The unofficial alliance between big business and dangerous pathogens that was forged in early 2020 has emerged victorious and greatly strengthened from its battle against public health, and is poised to steamroll whatever meager opposition remains for the remainder of this, and future pandemics.

Notice how much different this reality-based view is compared to the narrative promoted by Jeffrey Tucker. The one thing that I don’t like to have to admit is that Tucker is correct when he says that the GBD won. Where we differ is that, unlike Tucker, I do not view this victory as a good thing. Quite the contrary. Neither do the authors behind the John Snow Project, who sadly note:

The long-established principles governing how we respond to new infectious diseases have now completely changed – the precedent has been established that dangerous emerging pathogens will no longer be contained, but instead permitted to ‘ease’ into widespread circulation. The intent to “let it rip” in the future is now being openly communicated⁸⁴. With this change in policy comes uncertainty about acceptable lethality. Just how bad will an infectious disease have to be to convince any government to mobilize a meaningful global public health response?

I would go even further. I would argue that eugenics has basically won out over public health. Because SARS-CoV-2 killed mainly—although far from exclusively—the elderly and those with chronic illnesses, views aligning with that of antivaccine crank Del Bigtree, in June 2020 encouraged his followers to “catch this cold” in order to help achieve “natural herd immunity.” The unspoken subtext that reveals the eugenicist intent—usually denied and maybe even not acknowledged, but there nonetheless—is how Bigtree also ranted about those most at risk of COVID-19 having made themselves that way by engaging in high risk behaviors that led to chronic disease, such as drinking and smoking to excess and overeating. (Obesity is a major risk factor for severe disease and death from COVID-19.) Of course, the one risk factor for severe disease and death from COVID-19 that no one has any control over is how old we were when the pandemic hit, given that the risk of severe disease and death climbs sharply with age. I like to point out that, as much as GBD proponents claim that “focused protection” would keep the elderly safe, it couldn’t, can’t, and won’t, because unless you quarantine all the elderly indefinitely they will have interaction with the “low risk” younger people out there necessary to help take care of them. One only has to look at the debacles that occurred in nursing homes early in the pandemic to appreciate how “focused protection” was always a pipe dream, a concession tacked onto the eugenicist vision of the GBD to make it seem less eugenicist.

If you think I’m going too far, just look back a bit. Do you remember how often COVID-19 minimizers would justify doing less (or nothing) to stop the spread of disease because it “only kills the elderly”? I do, and such rhetoric came not just from bonkers antivaxxers like Del Bigtree, either. Do you remember the arguments against vaccinating children against COVID-19 because it “only” kills a few hundred of them a year? I do. Never mind that, on a yearly basis, COVID-19 kills about as many children as the measles did before the vaccine was licensed 60 years ago, adjusted for population? It’s a leading cause of death among children now. “Bioethics”-based arguments not to vaccinate children against COVID-19 are the same old antivax arguments against vaccinating children, just recycled for a new virus, with “esteemed” doctors telling us that we need to accept children dying of COVID-19 “as a matter of course.”

The John Snow Project speculates about how much deadlier COVID-19 would have to become in order to spur the political and social will to actually do something to try to contain it again and come to a depressing conclusion that, even more depressingly, I have a hard time arguing with, namely that, based on the death toll during the Delta and Omicron waves, “12–15,000 dead a day is now a threshold that will not force the implementation of serious NPIs for the next problematic COVID-19 serotype.” They’re not wrong. Over 1 million Americans died during COVID-19, a number that would have been unthinkable in 2019 but now only inspires a collective shrug. That is why the authors, also correctly unfortunately, state that there “can be no doubt, from a public health perspective, we are regressing.” Of that, there is no doubt.

Perhaps the most depressing—yes, even more depressing than the above observations—part of the whole article is how the John Snow Project relates the regression in public health science with respect to infectious disease to all of public health, including vaccines:

We can also expect previously forgotten diseases to return where they have successfully been locally eradicated. We have to always remember that the diseases that we now control with universal childhood vaccinations have not been globally eradicated – they have disappeared from our lives because vaccination rates are high enough to maintain society as a whole above the disease elimination threshold, but were vaccination rates to slip, those diseases, such as measles, will return with a vengeance.

We are, of course, already seeing this, with antivaxxers rejoicing over declines in childhood vaccination rates provoked by the antivaccine sentiment provoked by COVID-19 vaccination mandates. Particularly relevant to what Dr. Adams and Dr. Howard said about the push to reopen schools and let the kids be infected:

Infection, rather than vaccination, was the preferred route for many in public health in 2020, and still is in 2023, despite all that is known about this virus’s propensity to cause damage to all internal organs, the immune system, and the brain, and the unknowns of postinfectious sequelae. This is especially egregious in infants, whose naive immune status may be one of the reasons they have a relatively high hospitalization rate. Some commentators seek to justify the lack of protection for the elderly and vulnerable on a cost basis. We wonder what rationale can justify a lack of protection for newborns and infants, particularly in a healthcare setting, when experience of other viruses tells us children have better outcomes the later they are exposed to disease¹⁰⁰? If we are not prepared to protect children against a highly virulent SARS virus, why should we protect against others? We should expect a shift in public health attitudes, since ‘endemicity’ means there is no reason to see SARS-CoV-2 as something unique and exceptional.

Note what I said above about how much the antivax ethos that children don’t need to be vaccinated because COVID-19 supposedly doesn’t kill that many of them has infected the discourse about whether or not children should be vaccinated against the disease. What we are seeing is the same “shoulders shrug” attitude that antivaxxers encouraged before the pandemic, when they would point to episodes of The Brady Bunch and The Flintstones from the 1960s or an episode of The Donna Reed Show from the 1950s, old sitcoms in which measles was played for laughs and treated as something that nearly all children inevitably had to endure, in other words, no big deal. This same attitude has now become common, if not dominant, about COVID-19, stoked by the likes of Tucker and the antivaccine movement. It is the same attitude that antivax doctors like Bog Sears promoted in 2015 and before about measles and other vaccine-preventable childhood diseases.

Unfortunately, as the John Snow Project argues, this lack of concern for mitigating the spread of infectious disease is likely to metastasize to other areas of public health, including worker safety or preventing nosocomial infections in healthcare facilities. After all, earlier this year mask mandates fell in hospitals, even cancer centers:

Worse, we have now entered the phase of abandoning respiratory precautions even in hospitals. The natural consequence of unmasked staff and patients, even those known to be SARS-CoV-2 positive, freely mixing in overcrowded hospitals is the rampant spread of hospital-acquired infections, often among some of the most vulnerable demographics. This was previously thought to be a bad thing. And what of the future? If nobody is taking any measures to stop one particular highly dangerous nosocomial infection, why would anyone care about all the others, which are often no easier to prevent? And if standards of care have slipped to such a low point with respect to COVID-19, why would anyone bother providing the best care possible for other conditions? This is a one-way feed-forward healthcare system degradation that will only continue.

The stress caused by the pandemic has indeed already induced major damage to our healthcare system, damage that is unlikely to be reversed during whatever years remain in my surgical career. What bothers me the most is that I find it difficult to say that the John Snow Project is wrong in its dire predictions. If anything, they might be overly optimistic.