The Long Battle We Face with Covid-19

 If you are one of those lucky enough to live in a country with the money and the foresight to purchase significant amounts of the Covid vaccines as they were being developed, you probably feel rather secure being fully vaccinated.  The pharmaceutical companies performed wonderfully in producing effective vaccines in record time.  However, those products were tuned to version of the virus that is no longer a dominant strain.  As new mutations make the virus a more efficient infector of humans, the existing vaccines are beginning to lose some of their effectiveness.  And we still don’t know how long their protection will last.  The fact that so many choose to reject the opportunity for vaccination means that even in the best of circumstances, outbreaks will continue to occur, and new mutations will continue to appear.  Most of the world’s population is still unvaccinated, ensuring a vast breeding platform for Covid.

People seem desperate to resume their former lifestyles, and governments seem desperate to allow that to happen.  Is that a sane strategy?  Given that we have not had the resources to vaccinate the world’s population this time, and more vaccine development with boosters and redistribution will be required going forward, what does this mean for the fight to control Covid?

The journal Foreign Affairs assembled a panel of experts to address Covid issues and a possible path forward.

“LARRY BRILLIANT is an epidemiologist, CEO of Pandefense Advisory, a firm that helps organizations respond to COVID-19, and Senior Counselor at the Skoll Foundation.

LISA DANZIG is an infectious disease physician, a vaccine expert, and an Adviser at Pandefense Advisory.

KAREN OPPENHEIMER is a global health strategy and operations adviser and a Principal at Pandefense Advisory.

AGASTYA MONDAL is a doctoral student in epidemiology and computational biology at the University of California, Berkeley.

RICK BRIGHT is Senior Vice President of the Rockefeller Foundation and former U.S. Deputy Assistant Secretary of Health and Human Services for Preparedness and Response.

W. IAN LIPKIN is Director of the Center for Infection and Immunity and John Snow Professor of Epidemiology at Columbia University, Founding Director of the Global Alliance for Preventing Pandemics, and an Adviser at Pandefense Advisory.”

Their findings were presented in the article The Forever Virus: A Strategy for the Long Fight Against COVID-19. 

“It is time to say it out loud: the virus behind the COVID-19 pandemic is not going away. SARS-CoV-2 cannot be eradicated, since it is already growing in more than a dozen different animal species. Among humans, global herd immunity, once promoted as a singular solution, is unreachable. Most countries simply don’t have enough vaccines to go around, and even in the lucky few with an ample supply, too many people are refusing to get the shot. As a result, the world will not reach the point where enough people are immune to stop the virus’s spread before the emergence of dangerous variants—ones that are more transmissible, vaccine resistant, and even able to evade current diagnostic tests. Such supervariants could bring the world back to square one. It might be 2020 all over again.”

The authors identify the failure of the international system we thought was in place to contain pandemics.  Major nations seem to be able to cooperate when some remote population is at risk but are unable to do so when their own citizens are in danger.

“An era of rising nationalism and populism made it frustratingly difficult to mount a collaborative response to a global pandemic. Jair Bolsonaro of Brazil, Xi Jinping of China, Narendra Modi of India, Vladimir Putin of Russia, Recep Tayyip Erdogan of Turkey, Boris Johnson of the United Kingdom, and Donald Trump of the United States—all these leaders evinced some combination of parochialism and political insecurity, which caused them to downplay the crisis, ignore the science, and reject international cooperation.” 

A collection of public health institutions capable of a global response was what was needed.  What we had was weak, underfunded, and subject to the whims of the wealthier countries. 

“The pandemic is in many ways a story of magical thinking. In the early days of 2020, many leaders denied that what began as a regional outbreak in Wuhan, China, could spread far and wide. As the months went on, governments imagined that the virus could be contained with border controls and that its spread would miraculously slow with warm weather. They believed that temperature checks could identify everyone who harbored the virus, that existing drugs could be repurposed to mitigate the disease, and that natural infection would result in durable immunity—all assumptions that proved wrong. As the body count rose, many leaders remained in a state of denial. Ignoring the scientific community, they failed to encourage mask wearing and social distancing, even as the evidence mounted.”

“Now, governments must come to grips with another inconvenient truth: that what many hoped would be a short-lived crisis will instead be a long, slow fight against a remarkably resilient virus.”

 Pharmaceutical companies have been able to quickly provide effective vaccines and produce them in large numbers.  However, the need far exceeds the supply, and the distribution is weighted heavily towards a few of the wealthier countries. 

“Although the creation of the vaccines was a triumph of international cooperation, their distribution has been anything but. Hedging their bets, the United States and other rich countries bought many times the number of doses they needed from several manufacturers, essentially cornering the vaccine market as if the product were a commodity. Making matters worse, some countries imposed restrictive export regulations that have prevented the wider manufacture and distribution of the vaccines. In May, pointing out that 75 percent of the vaccine doses had so far gone to just ten countries, the WHO’s director general, Tedros Adhanom Ghebreyesus, rightly called the distribution a ‘scandalous inequity that is perpetuating the pandemic’.”

“In fact, the barriers to access have been so profound that many low- and middle-income countries won’t have enough vaccines to inoculate even just their at-risk populations until 2023. This disparity has led to a jarring split-screen image. At the same time that Americans were taking off their masks and preparing for summer vacations, India, with only three percent of its 1.4 billion inhabitants fully vaccinated, was ablaze in funeral pyres.” 

It would help if everyone in the world would be administered an effective vaccine, but that is not going to happen, at least not as fast as necessary.  And global herd immunity will not happen either.  With such a large number of people who refuse vaccination, it is not clear that a wealthy country like the United States could ever reach that stage for itself.  Rather, there will continue to be enough infections worldwide that a string of dangerous mutations will continue to emerge, gradually eroding vaccine effectiveness and natural immunity after an infection. 

“Variants are an unavoidable byproduct of the pandemic’s exponential growth. More than half a million new cases of COVID-19 are reported every day. Each infected person harbors hundreds of billions of virus particles, all of which are constantly reproducing. Each round of replication of every viral particle yields an average of 30 mutations. The vast majority of mutations do not make the virus more transmissible or deadly. But with an astronomical number of mutations happening every day across the globe, there is an ever-growing risk that some of them will result in more dangerous viruses…” 

Is the situation hopeless?  The authors suggest that a modern version of an approach called “surveillance and containment” is needed for application across the globe. 

“In the 1970s, smallpox was rampant in Africa and India. The epidemiologist William Foege, working in a hospital in Nigeria, recognized that the small amount of vaccine he had been allocated was not enough to inoculate everyone. So he pioneered a new way of using vaccines, focusing not on volunteers or the well-connected but on the people most at risk of getting the disease next. By the end of the decade, thanks to this strategy—first called ‘surveillance and containment’ and later ‘ring vaccination’—smallpox had been eradicated. It is a twenty-first-century version of this strategy, along with faster mass vaccination, that could help make COVID-19 history.” 

“For this pandemic, epidemiology also has tools to return the world to a state of relative normalcy, to allow us to live with SARS-CoV-2 as we learned to deal with other diseases, such as influenza and measles. The key lies in treating vaccines as transferable resources that can be rapidly deployed where they are needed most: to hot spots where infection rates are high and vaccine supplies are low. The United States, flush with vaccines, is well positioned to lead this effort, using a modernized version of the strategy employed to control smallpox.” 

For such an approach to work, nations must be willing to recognize that in a pandemic, an outbreak anywhere in the world imperils the entire world.  The authors provide an appropriate conclusion.

“COVID-19 is not yet the worst pandemic in history. But we should not tempt fate. The past year and a half revealed how globalization, air travel, and the growing proximity between people and animals—in a word, modernity—have made humanity more vulnerable to infectious diseases. Sustaining our way of life thus requires deep changes in the way we interact with the natural world, the way we think about prevention, and the way we respond to global health emergencies. It also requires even populist leaders to think globally. Self-interest and nationalism don’t work when it comes to a lethal infectious disease that moves across the globe at the speed of a jet plane and spreads at an exponential pace. In a pandemic, domestic and foreign priorities converge.”