Double Donuts
Moving between the US and Australia has revealed several areas of confusion. Among the many, many things I do not understand, the current coronavirus pandemic is one. I am not talking about the coronavirus itself. The virus, depicted as a ball covered in spikes, is clear to me, and I continue to hope I can avoid it bouncing down into my system. I know a little about how to be careful, and I have been vaccinated. No, it’s not the virus and its multiplying variants that have me confused, but rather what is being done about controlling or eliminating it.
For many years, medical scientists and public health authorities have been concerned about the likelihood of a pandemic. Largely invisible to most of us, they have been planning for and exploring future containment options. Yes, largely invisible, but you can’t keep a good topic away from cinema screens, and in 1995 Wolfgang Petersen produced a classic with Outbreak. Impressive at the time, it is even more prescient today. Based on a non-fiction survey of viruses by Richard Preston (The Hot Zone), Outbreak depicts a deadly virus emerging from Africa, and eventually reaching the USA. The core of the film covers various attempts to stop it spreading and is centred on dramatic events in the fictional town of Cedar Rapids. There are all the familiar characters, the CDC, the military, researchers and medical staff, and heroic volunteers. On more than one occasion I had thought of using it as a training film, great to focus the thinking of senior emergency services professionals. Today, it would provide an even more telling perspective.
The SARS epidemic of 2003 gave a boost to films about worldwide disasters. For those of you who like horror flicks, Steven Soderbergh’s Contagion, released in 2011, was a special treat. In this rapidly spreading fictional pandemic we watch what are now familiar scenes off people trying to control an escalating emergency, with social distancing and hand washing, the race to produce a vaccine, panic buying, deserted airports and closed borders, and, above all, the spread of conspiracy theories and misinformation. Apparently, in the past few months Contagion has become one of the most searched and downloaded titles on the web, even though it’s not available on Netflix nor on most of the other major streaming services. Soderbergh takes the story further than we have seen with COVID-19 – so far – as the pandemic generates widespread social unrest, panic buying turns into riots, looting, home invasions and kidnappings. Uncollected garbage piles up on the streets while sporting venues are turned into makeshift hospitals with thousands of sufferers lined up in camp beds, and we see scenes of mass graves in which the dead are covered with quicklime.
As the date of Soderbergh’s film makes clear, it’s not the case the current coronavirus pandemic is something new and unprecedented. As the COVID-19 outbreak grew, I remembered the SARS epidemic in South and East Asia. The Severe Acute Respiratory Syndrome in 2002 was a shock. At that stage I was travelling regularly to Singapore, Malaysia, Hong Kong and China. As we now know, SARS developed in Asian palm civets, tree dwellers that in some ways resemble possums (but are completely unrelated), and the virus was passed on via horseshoe bats in China’s Yunnan Province. Back then, we quickly discovered the disease was dangerous, with a mortality rate of 8-18%. After a slow start, travel was restricted, and areas quarantined. Eventually, there were around 8,000 cases, and some 1,000 deaths. However, by 2004, SARS-CoV-1 had effectively disappeared.
In the and epidemic aftermath, one outcome was fear, fed by the popular press with alarming articles describing how such a disease could emerge again. Time after time frantic revelations suggested a new SARS strain was slowly being hatched in a remote jungle area, about to cross over from a variety of exotic animals, ready to sweep the world in an instant. Around the same time as SARS, MERS appeared in the Middle East, another coronavirus disease: MERS spread to around 1350 people between 2012 and 2020, with 527 deaths, an even higher mortality rate than SARS. However, most attention to coronavirus epidemics was eclipsed by the Ebola outbreak in West Africa in December 2013. Two years later this had resulted in nearly 29,000 cases and 11,323 deaths. The Ebola virus hasn’t gone away and had been causing trouble since back in 1976.
Naturally, you would assume we were ready for the next pandemic. Naturally, you would be wrong. Back in 2014, the Barack Obama administration, collaborating with various countries and international organisations, launched the Global Health Security Agenda (GHSA), aimed at ensuring government pandemic preparedness. The Trump administration didn’t drop the US commitment to the GHSA but did so while reducing funding for support staff and international capacity building: overall, budgets for US pandemic preparedness fell to pre-2014 levels. In 2018, the Group of Seven (G7) agreed epidemic threats deserved the same level of attention as other serious threats confronting countries, but while the G7 committed to supporting up to seventy-six countries in building core capabilities on no less than four occasions, there was no monitoring of action, and this effectively rendered these multilateral commitments largely meaningless.
In addition, most attention on pandemic preparedness was focussed on low- and middle-income countries for detection, preparedness, and response. It seemed agencies had fallen into the trap of believing global health security is only as strong as its poorest link. Possibly inevitably, since viruses don’t follow our bureaucratic rules, COVID-19 has had dramatic effects on prosperous countries as well as poorer ones, despite their relatively advanced health-care infrastructure. The capacity to respond was shockingly low in most nations, and high-income countries have joined the rest of the world in being overwhelmed by the pandemic. Countries that scored well on GHSA measures, including the US and UK, have struggled in their COVID-19 response: even they were underfunded and underprepared for no good reason. Why? It didn’t and still doesn’t make sense.
My next area of confusion concerns vaccines. Prior to the past couple of years, my superficial knowledge of vaccines was largely influenced by the method used in the eradication of smallpox. In simple terms, as best I understand it, vaccination against smallpox was initially achieved in the late 19th Century by infecting people with cowpox, a weak virus that leads to the production of antibodies to protect against the disease. In more recent years, and after the virtual elimination of smallpox, production of Dryvax, a calf lymph smallpox vaccine, ceased in 1980. Since then, some other animal-pox-based vaccines have been developed, just in case. That was what I knew: you were protected against a disease by being vaccinated with a weak or altered strain of the virus.
With the advent of COVID-19, the development of coronavirus vaccines has been truly astounding, with more than 20 approved for use, many achieving at least 95% preventive efficacy. For that we can thank laboratories and government funded researchers who had been trying to make sense of SARS and MERS. Some vaccines have been ground-breaking. Pfizer and Moderna use what is called ‘messenger RNA’ (mRNA) injected into the body, which stimulates a response by teaching the body how to identify and destroy the corresponding virus. An amazing new technology, all the more so as trials and subsequent tests have revealed severe allergic reactions are rare. The other major development has been in ‘adenovirus vector’ vaccines, which do not make new virus particles, but rather produce only the antigen which elicits a continuing immune response. These include the Oxford-AstraZeneca and Johnson and Johnson vaccines. Despite wild rumours, like the mRNA vaccines these are remarkably free of severe side-effects, but all vaccines carry some risk.
Can you see why I am confused? So far, what I can see is two things: first, the existence of coronavirus viruses and their contagious nature was well known, with variants already being researched. Second, some extraordinarily effective vaccines using new technologies have been developed very quickly. The conclusion is obvious. All should be good. Except it isn’t. Worldwide we are approaching 200m cases (and probably at least the same number again in undetected infections), with a death toll of around 4m, still growing. How can this be? That’s too big a question, so let me narrow it to the one that’s on my mind: what is going on in Australia?
As I see it, there are three issues at stake here: politics, people and perspective. Politics always plays its part any important event. While outright lying is far from common, ‘shading’ the truth is normal fare. Australia’s Prime Minister, Scott Morrison, is a marketing machine. He is able to put a good spin on almost anything: right now, he is reassuring us that his latest ‘recalibration’ of the path out of COVID-19 lockdowns will be achieved by a four-stage strategy. In announcing this, in yet another story to convince a rather credulous population that the government is in control, he observed “Australia gets vaccinated, Australia is able to live differently.” If only we had known this earlier! The details of the first phase of the approach are that this ‘pre-vaccination’ phase is based on ‘suppression’ of the virus spread, until more of the population is vaccinated. It involves widespread testing, extensive contact tracing, and – if required – community-wide restrictions, as are currently being imposed in several parts of the country. But, to be clear, as one epidemiologist explained, “Until we get the vaccination coverage a lot higher, we have to re-eliminate this virus each time, and doing that unfortunately requires these lockdowns.”
Hmm, but isn’t this first recalibrated phase the same as we have been experiencing for the past few months – cases emerging, contacts traced, partial or complete lockdowns, with moments when a state is clear of infections, before another case emerges and the cycle repeats? Scott Morrison’s ability to promote a good story was at the fore as this initiative was explained. Fortunately, no-one asked if we had the number of vaccines needed to vaccinate enough of the population, whatever that number might be. 80% of the population? 90%? More than that, some say. When will we reach this indefinable target? By the end of the year, maybe, or sometime in 2022 … or 2023. Another expert recently commented on what was being proposed: “Without supply and massive scale up of vaccination rates, as well as plans to vaccinate children, the roadmap is hypothetical.”
The politics of federal government reassurance are laughable enough, but in a federal system we have competition between the states, too. In recent months, Victoria was the favourite punching bag. They can’t control transmission, infections keep increasing, constant lockdowns, with NSW looking smugly on. Oops, while Victoria seems has been managing, now it is NSW, that previous paragon of virtue, that is having to use the word ‘lockdown’, even if it took the state Premier some days to learn how to pronounce this unfamiliar (Victorian?) word. As new cases pop up across various regions of Australia, snide comments abound, aggravated by jousting between the states run by Labor administrations and those run by the conservative coalition, (the same lot who are in power in Canberra). It would be fun to juxtapose comments by any one of the state leaders from different dates in the past few months as situations changed, except this pandemic isn’t funny.
One of the battles, it is clear, lies with the broader population. It doesn’t seem to matter how often we are asked to act on behalf of the community, nicely or assertively, there are always some people who put personal needs above everyone else. In a country obsessed with sport, one such need is for devoted fans to get to watch a game at any cost, and some escape quarantine to do just that. Others need their favourite food, want to see a close friend, go to a party; the list is never ending, but, without fail, every lockdown sees restrictions ignored by a minority who simply won’t do as they have been asked. We live in a selfish world, as our approach to the ravages of COVID-19 in the developing world show: our lack of adequate support is embarrassing. The happy land down under has thrived on selfishness for the past 40 years. Why should we have to change now?
Politics and people. Both those issues are playing a role in the unfolding COVID-19 pandemic in Australia. However, neither are confusing. Politics has always seen a focus on telling good stories, and a necessary one-upmanship between the states. People are people. Some care about others, and some care only about themselves. It is in relation to the third issue, seeing things in the right perspective, that I am in need of some clarification.
This is what I have read and understood. COVID-19 is a contagious virus. Some variants are more readily passed on than others. The death rate, now we better understand both the illness and post-infection care, seems to be around 2-3%. As with other diseases, the key strategy is to vaccinate at least 85-90% of the community to achieve ‘herd immunity’, at which point any new infection has a very low probability of spreading. Since vaccines first appeared very early in 2021, many countries are already well on the way. The UK and the USA have at least 50% of their populations fully vaccinated, closely followed by countries including Spain, Germany and Canada at 40% or more, and not far behind them are Italy and France. In contrast, Australia’s progress is slow, now approaching 15% fully vaccinated, but full coverage is said to be unlikely before March 2022.
Is this because the government’s perspective is that we are an island, able to shut ourselves off from other countries, and keep infected visitors out? For the past six months, it seems we consider it a success to have ‘double donut’ days, days without any new community infections or deaths. Yes, I agree that is a significant achievement. Against that, we remain vulnerable. A slowly incubating but highly transmissible version of the virus could sweep through the country with ease, because so few Australians are protected. Insulated from the rest of the world, we are assuming we have time, time to continue to keep the barriers in place and ensure the virus stays out while we gradually build up protection. A comforting perspective, but previous pandemics have taught us two things. Containment is critical, as is immunisation. However, they also teach us that cases continue to appear. It is impossible to stop new cases getting out. COVID-19 is already back in Victoria.
As another round of infections is reported in Australia, a big moment on the evening news program is when a state declares its ‘double donut’ day. Several double donuts suggest suppression is going well. Here’s my source of confusion. I admire the staff who are doing so well at containing the spread of the coronavirus. However, I want to celebrate significant jumps in the percentage of people vaccinated. Rather than hearing there are only a few new cases in Victoria, or none at all, I would like the lead story to be how many thousands have been vaccinated in the preceding 24 hours, and how many more this was than the day before. Isn’t that the metric that’s the more important, measuring progress to the critical goal that should be uppermost – achieving herd immunity? In saying this, I am betraying all the characteristics of a selfish Australian. An equally important metric must be how many tens of millions of doses are being delivered to other countries, especially in the developing world. If we are unable to give them free of charge or give the manufacturing process away, then we must help cover a part of the international bill. The virus doesn’t need a passport, and if we care about the community, nor should we. The whole world is in this together, and we should be making a major commitment to our neighbours.
My other confusion? Albeit with a much higher mortality rate, I think about COVID-19 in the same way as I think about influenza. The coronavirus isn’t going to be eliminated, certainly not for a few years. It will continue to change, new variants will appear, and existing vaccinations will no longer be as effective. We know that world. Every year, we go to the doctor or clinic have this year’s ’flu ‘jab’. There are hundreds of scientists working extremely hard at present to develop an approach to coronavirus protection for the future, not just for COVID-19. Some of this is concerned with boosters, to add protection against specific new variants. Others are trying to find a rather more powerful approach, a form of vaccination that detects and eliminates all forms of coronavirus.
We have regularly thanked those nurses and doctors helping infected patients (the UK did an exceptional job in this regard). I would like to hear regular news reports on the scientists and their work, and give them the recognition and praise they deserve, too. Instead of having 5 minutes of my nightly news program showing the vaccine being injected (time filling at its worst), let’s have regular updates on the research and development side of pandemic prevention. Double donuts are nice, but ultimately indulgent (and dangerous to waistlines and health). Increasing number of vaccinations, enhancements in vaccine strategies, aren’t these also news items that matter?
