Better Luck Next Pandemic

Will we do better next time? Not from what I can see now

Columbia University’s medical school just held a week-long symposium on pandemic vaccines, which I attended and spoke at.*

We heard from 40 experts, virtually all (other than me) specialists at fighting infectious diseases, from the W.H.O., the C.D.C. and its Chinese counterpart, from Operation Warp Speed, Pfizer and the Serum Institute of India, from the Gates Foundation, the Wellcome Trust and the Coalition for Epidemic Preparedness Innovations.

In the end, I was struck as much by what was not said as by what was.

Everyone agreed that the vaccines were miraculous, that it was a shame that poor countries did not get them in time, that it was tragic that the anti-vaccine movement did so much damage.

But almost no one wanted to discuss mandates. No one defended the idea of negating vaccine patents. And no one suggested counter-attacking the anti-vaxxers — even though they have literally killed millions.

In their urge to be liked, public health leaders seem to have forgotten that their vocation was once, like the military, quite a tough-minded profession. Public health leaders were often hated — because they were expected to curtail the rights of an angry few in order to save the lives of the many. In abjuring that role, they are consigning innocents to die.

Here are the major points that were made:

It Isn’t Over

We in America are moving on — doffing our masks, crowding bars and offices, riding subways again. For those of us who are at least triple-vaxxed or who have survived a bout, the virus now is what Donald Trump and other denialists were claiming it was two years ago: roughly as threatening as the flu.

But it may not be finished with us yet.

Western Europe is suffering a second Omicron wave, noted Dr. Jeremy Farrar, director of the Wellcome Trust (Britain’s equivalent of the Gates Foundation). Airlines are scrapping flights as crews fall ill. In some countries, like Germany, it’s higher than the first and deaths are rising. We have not yet felt it here — but we still could.

Also, if China loses control of its “zero Covid” policy — which looks increasingly likely — it will have an explosive epidemic. Although 85 to 90 percent of the country is vaccinated, said Dr. George F. Gao, director of China’s C.D.C., vaccination is low among the elderly, the vaccines are not very effective and almost no one has protection from previous infections. Rapid spread among 1.4 billion people may mean many deaths — and a host of new China variants. (One has already been found in Jiangsu.)

On the other hand, China does not have a large population of partially immunosuppressed people, as southern Africa did because it has so many cases of untreated AIDS. Omicron’s 40-plus mutations probably took place in one person infected for many months, argued Dame Kate Bingham, leader of Britain’s equivalent of Operation Warp Speed. Any variants China produces may have incremental changes rather than wholesale ones.

Also worrying: the virus is finding more animal hosts, like white-tailed deer. Every new species could be a route to new variants. (The 1918 flu eventually found its way into pigs, which became vessels for brewing new strains in later decades.)

Deaths May Be Three Times the Official Toll

The “official” death toll of the virus is 6 million. The true toll, according to different epidemiological models, is probably between 16 and 20 million.

Different experts viewed this differently. Some felt the world should be congratulated on keeping per-capita mortality low compared to the 1918 flu.

Others felt the world has done poorly considering that about two-thirds of those deaths occurred after vaccines were approved.

Dr. Soumya Swaminathan, the W.H.O.’s chief scientist, likened the deadly delay to that of AIDS a generation ago: triple therapy became available to Americans and Europeans in 1996. But it took 10 more years until it was widely available in Africa at affordable prices.

One worrisome indication that excess mortality could rise further: shifting over to Covid vaccination has disrupted routine childhood vaccination in half the world’s countries, said Dr. Katherine L. O’Brien, the W.H.O.’s head of immunization. Millions of youngsters may now be unprotected against diseases like measles, whooping cough and diphtheria that are far more dangerous for children than Covid is.

Vaccine Production Great, Distribution Not

Although most Americans are familiar only with Pfizer, Moderna or Johnson & Johnson, the world is actually using 36 different vaccines, 10 of which are W.H.O.-approved. China, India, Russia, Cuba, Iran, Canada, Taiwan and even Kazakhstan have one or more home-grown ones. Despite all the attention lavished on mRNA technology, the vaccine that has probably saved the most lives is the Oxford/AstraZeneca one, according to an analysis by the Economist. It is approved in 176 countries and made in both Europe and India.

Vaccine production has been extraordinary: almost 12 billion doses so far. Before the pandemic, the world made only about 4 billion a year for all diseases. (Most vaccines are for the 130 million children born each year, noted Martin Friede, the W.H.O.’s chief of vaccine technology transfer. The market for adult vaccines, such as shingles and flu, is relatively small.)

But distribution has been inequitable.

Even 12 billion is only half of the total need: If it takes three shots to reliably cheat death, that’s 24 billion doses to protect the whole world.

Of that 12 billion, less than 2 billion reached the poorest countries. Rich countries have now consumed about 200 doses per 100 people, or 2 shots per person. Poor countries, including most of Africa, have consumed only about 32 shots per 100 people — one-third of a shot per person.

Nonetheless, uptake has flat-lined. Some countries, including South Africa, asked vaccine makers to stop sending doses because people aren’t taking them.

The delay is not just because wealthy countries bought up the early doses. In poor ones, it can be hard to deliver any refrigerated vaccine outside the capital cities because of power failures and shortages of basics like syringes and trained vaccinators. Also, while outright hostility to vaccines is quite low, “vaccine apathy” is high, as Wilmot Godfrey James, a South African social sciences researcher and leader of the symposium noted. In surveys, many Africans said they knew little about the vaccine or felt that other threats they faced — everything from unemployment to malaria — were more pressing.

The populist solution to shortages — seizing vaccine patents and handing them over to local companies — is doomed to fail, numerous vaccine experts argued.

Any new vaccine may involve up to 20 patents, each with a different licensee, and most aren’t registered except in wealthy countries. The real obstacle is that producing millions of identical contamination-free doses requires know-how that is not patented, deep benches of medical and engineering talent and infrastructure that poor and lower-middle-income countries lack. Even the Serum Institute of India, the world’s largest vaccine maker, seeks out partners for new vaccines instead of trying to build them from scratch, said Dr. Gagandeep Kang, an Indian vaccine researcher. Also, vaccine companies will not create competitors who hope to steal their best customers, argued Moncef Slaoui, the head of Operation Warp Speed; about 80 percent of profits, he explained, come from the world’s richest dozen countries, so a plant that can make 200 million doses for $1 apiece cannot survive without the few customers who want only 20 million doses but will pay $30 each. When countries build their own vaccine industries, as Brazil, Cuba and others have, they end up relying on old technology: vaccine plants must be run and updated constantly. They can’t be mothballed between crises.

No argument in favor of seizing patents was made. (Pfizer was one of the symposium sponsors.)

‘Trust Cannot Be Surged’

Vaccines aren’t accepted unless there is trust, all the communications specialists agreed: trust in science, in political leaders, in the vaccine industry.

But it must be in place before the crisis. “Trust cannot be surged,” said Dr. Thomas R. Frieden, the former C.D.C. director.

Trusting government, however, is almost antithetical to the nature of democracy. We cling to democracy precisely because it lets us vote out leaders we lose faith in.

It is also hard to predict which governments will end up trusted. Some democracies do well at vaccinating their citizens — Australia, New Zealand, the Scandinavian countries, Canada, Portugal, Chile and Argentina. But so do some autocracies: China, Cuba, Vietnam, the United Arab Emirates. Meanwhile, some of each do poorly. In vaccine acceptance, our democratic United States is below virtually all of western Europe and Japan and on a par with Iran and Saudi Arabia. But the autocracies of the former Soviet Union — Russia and most of eastern Europe — do even worse.

The defining factor seems to be whether citizens trust their government on health issues. Cuba, for example, may jail political dissidents, but it gives all citizens health care. The U.S. has free speech but leaves millions of Americans uninsured.

Trust in the pharmaceutical industry is also low in the United States because it charges us the highest prices in the world and its lobbyists stop Congress from fixing that.

“Trusted messengers” are key to instilling trust. They can be anyone from a family doctor to a religious or sports figure…or even a traditional leader or local shaman. But messaging works best when it comes from the top.

Dr. Frieden held almost daily briefings during the 2009 swine flu, Ebola and Zika epidemics. His Covid-era successor, Dr Robert R. Redfield, held almost none — and ceded leadership at White House briefings to President Trump, the most untrustworthy messenger imaginable. (Even Trump’s adoring fans reject his advice on boosters.)

More than one speaker cited the example of the King of Morocco, who sat at his desk in his undershirt for the cameras as he got his first shot. Morocco and tiny Rwanda (also autocratic but good on health issues) are the most-vaccinated countries in Africa.

By way of contrast, Nathália Pasternak Tashner, a Brazilian microbiologist and visiting scholar, described Brazil’s top-down failure. Once a model of successful vaccination, with 90 percent acceptance rates, Brazil had its own industry and no anti-vaxx movement. That was almost single-handedly wiped out by one man: President Jair Bolsonaro, who claimed that Covid vaccines could transmit AIDS and turn people into alligators. After his health minister and some doctors began echoing him, even childhood vaccinations began sinking. Polio immunization, once near-universal there, is now at 68 percent — risking the return of even that all-but-eradicated virus.

Data Can Be Surged

Another element of creating trust is data — especially big, fast data.

For new vaccines, large trials with 50,000 participants engender trust, said Daniel Salmon, director of the Institute for Vaccine Safety at the Johns Hopkins School of Public Health.

Fast data is particularly important for countering the lies of the anti-vaccine movement. When Andrew Wakefield claimed in 1998 that measles vaccine caused autism, it took 18 months to produce a single study proving him wrong. During that interim, no one could prove that his Lancet paper — now retracted — was nonsense.

Unfortunately, the U.S. health-care system is weak at producing numbers. In Israel, citizens belong to one of four HMOs who report anonymized data to the health ministry. In Britain, the National Health Service tracks medical records. With datastreams like that, health departments can quickly spot adverse vaccine events like blood clots or Guillain-Barré syndrome — and can also calculate how common such such events are in subsets of the population. For example, if you know what the background rate of myocarditis is among young healthy males, you can quickly tell whether a few well-publicized cases after vaccination are normal or something unusual and dangerous. Our fragmented American health care system makes that impossible, so we must rely on smaller datasets like military recruits or VA hospitals, which don’t reflect the whole population. We have V-Safe, as Dr. Rochelle Walensky, the C.D.C. director, pointed out, but it relies on voluntary cellphone texts — not a comprehensive or objective source.

Faced with an anti-vaccine movement prepared to exaggerate any rumor, this is a serious weakness.

‘Don’t Say Mandate’

One issue I was surprised to not hear raised the entire week was vaccine mandates.

Mandates have been saving American lives since George Washington inoculated his troops against smallpox in 1777. A growing mountain of evidence shows they work. They did in 2014, when California got rid of religious and philosophical exemptions to school vaccines after a large measles outbreak that began in Disneyland; vaccination rates among first graders shot up. They worked last year for many hospital systems whose nurses resisted until they were told their jobs depended on it. They worked for New York City’s public employees and for admission to New York City restaurants. They worked for United Airlines and many other employers, including even Fox News. In the end, very few resisters decided it was worth losing their jobs, high levels of immunity were achieved and there was no epidemic of adverse effects.

And yet not a single public health leader all week even mentioned them. The only defender was a politician: Kyriakos Mitsotakis, the Greek prime minister. In an interview with Meg Tirrell of CNBC, he described how he turned around his country’s dangerously low vaccination rate. Greece has one of the world’s oldest populations but by late last year had achieved only 50 percent immunization, one of the European Union’s lowest levels. As a result, it suffered high death rates in both the Delta and Omicron waves. Starting in January, Mr. Mitsotakis said, he decided to “make life difficult for the unvaccinated.” The government used carrots and sticks, but with a twist: Healthy young adults aged 18 to 25 got the carrot: a payment of 150 euros (about $166) to get a shot. The elderly got the stick: resisters over age 60 were fined 50 euros in January and 100 euros a month after that. Vaccination rates quickly shot up to above the European average.

Ceding The Field

Another issue not even raised all week: countering the anti-vaccine movement.

While many experts expressed sorrow at how effectively it had eroded trust in vaccines and how many lives that had cost, there was not a single suggestion that the medical profession actually fight back.

No discussion of revoking the licenses of MD’s who oppose safe vaccines, tout false cures or even issue medical exemptions without seeing patients.

No discussion of the fact that many of the loudest anti-vaxxers are motivated by money: they sell alternatives like vitamins or ivermectin or they run clinics for “vaccine-damaged” children or they solicit tax-deductible donations for the “charity” that pays their salary.

No discussion of prosecution for spreading lies that kill.

In 2010, the British Medical Council revoked Andrew Wakefield’s license for his ethical lapses. In this country, even though more than 90 percent of all hospitalizations and deaths are of unvaccinated people — including some who have been prescribed worthless treatments, no prominent physicians have yet been disciplined. State medical boards in Oregon, Maine, Connecticut and elsewhere have moved only against a few relatively obscure practitioners.

The upshot? All the experts agreed that this would not be our last pandemic. Right now, I hold out little hope that there will be fewer deaths in the next.

I discussed this article on the podcast “Beyond Politics” with Matt Robison and Paul Hodes. You can listen to it here.

*Disclosure: I was paid a consulting fee by the Program in Vaccine Education of the Vagelos College of Physicians and Surgeons to sum up the five days of discussion and add my own thoughts, as I’ve done here.

P.S. A younger friend of mine, Colin McGreal, started battling cancer last month and is writing about it with brave humor. You can read his work on Medium here.