Vaccination: the way ahead

Prepared by Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal – www.alan-whiteside.com

Introduction

This is being written as I quarantine in my Waterloo apartment. Getting here was surprisingly easy, despite a great deal of bureaucracy. The story began in December 2019 when I travelled from Waterloo to the UK for a year’s sabbatical. I planned a busy year, with visiting fellowships at two German and a British University, and visiting status with two English Universities. It was set to be a full, productive, and fun year. And then Covid-19 arrived, and everything was put on hold. I did not leave Norwich for over a year but making a trip to Canada was increasingly urgent. Travel was not easy, cheap or pleasant.

The first step was getting permission to leave the UK. International travel was not allowed until 17th May, unless the traveller has good reason. There is, of course, a government website. The “Declaration for International Travel” has a drop-down menu of about 10 reasons, from ‘Work’ to ‘Other reasonable excuse – please specify’. I dutifully completed and printed it. No one asked to see it at any point. There were no flights for my preferred route (Norwich, Amsterdam, Toronto) so I booked from Heathrow. There is extensive guidance on travelling to Canada on the Canadian government website. Only four airports accept international flights: Calgary, Montreal, Toronto, and Vancouver. At the moment, there is no recognition in the terms of travel and restrictions of vaccine status. I am fully vaccinated and have a flimsy little record card to prove it. I made photocopies for officials. No one asked or showed an interest.

To enter Canada (and various other countries) a traveller has to have a negative Covid test within three days of boarding. In the UK, private laboratories produce a “Fit to Travel Certificate for SARS CoV-2/Covid-19 Testing”. At a price of course. Also required is an arrival form to allow border officials to track you.

“Speed up your arrival process in Canada and spend less time with border and public health officers. Use ArriveCAN1 to provide mandatory travel information… Help … keep Canadians safe and healthy.”

The aircraft, a Boeing 787 Dreamliner, seats about 250 people. I booked myself in the premium economy section for more room. What a waste of money, there were only 19 passengers! There was a full complement of very bored cabin crew and consequently we had excellent service and some interesting conversations. Clearly, they had time to check the passenger list, halfway through the journey they began addressing me as Professor!

On arrival getting through the Canadian formalities was straightforward. The test is a nasal swab. There was no interest in my vaccination status – but there were a few comments on Canada’s failure to roll out a vaccine. Mind you I was on an empty plane; the next scheduled flight from Manila had 350 passengers. The government requires you to pay for three days’ quarantine in a hotel. My choice was a bog-standard business hotel, where the confinement included three meals brought to the door in large brown paper packets. I understand Pavlov’s dogs better now. Within 24 hours I recognized the rustle from the moment the delivery person exited the lift. There was nothing to get excited about on the menu though.

At Heathrow I bought a couple of bottles of duty-free wine and when I checked into the hotel, I asked for a third. The clerk said that he was glad I asked before he checked me in. He is not allowed to send alcohol to the quarantine rooms! There was no corkscrew in the room and the desk said they had none so here are some tips.

The numbers

The largest number of cumulative cases continues to be reported by the USA, at over 32,994,750 cases and 586,403 deaths; India is catching up rapidly, racking up 25,228,996 cases and 278,719 deaths; Brazil is third with 15,657,391 cases and 436,537 deaths. There is a gap to the next cohort led by France with 5,127,548 cases and 44,983 deaths and Turkey with 5,127,548 cases and 44,983 deaths. Russia, the UK, Italy, Spain, Germany, Argentina and Colombia have between three and five million. All other countries have fewer. Of interest to readers are South Africa with 1,615,485 cases and 55,260 deaths and Canada with 1,342,206 cases and 24,964 deaths.2

Globally there has been a steady decline in the number of new cases and deaths and the number of people vaccinated is rising steadily. This does not mean the pandemic is over, especially with the new ‘India’ variant, but the signs are hopeful. We have reached the point where it seems that rather than waves of the pandemic sweeping across the world there will be localised outbreaks. These may be very serious but can be contained. By the end of the year, we should have a clear picture of an endemic disease rather than a pandemic. That means working out how to respond in a less disruptive manner.

Of course, it must be remembered that these are total recorded cases since the beginning of the epidemic. The data should be assessed through two other dimensions, how many cases and deaths as a rate (usually per million), and what the trends are. Globally there were 105 new cases per million on 1st May 2021.3 The Seychelles and Maldives have the highest daily cases per million at 2,361 and 2,312 respectively but their populations are small. Figure 1, accessed 17th May 2021, shows daily cases per million for selected countries. The only country shown with a rising daily case number is South Africa but this is, at the moment, off a low base. Figure 2 shows the case fatality rate (CFR) for the same countries.

Chart showing daily new confirmed Covid-19 cases per million people, from Our World in Data

Figure 1: Daily new confimed Covid-19 cases per million people, from Our World in Data

The Case Fatality Rates (CFR) are shown on the map below. The highest CFRs in the world are in Yemen and Mexico. Although many African countries indicate high CFRs it must be remembered that recorded numbers are low. This may be changing as an article in the Telegraph indicates.4 The highest in Africa are currently Egypt and Sudan. This reflects the problems with data, China still shows a relatively low case rate but that reflects the situation of over a year ago.

Case fatality rate of the ongoing COVID-19 pandemic, May 17, 2021

Figure 2: Case fatality rate of the ongoing Covid-19 pandemic, May 17, 2021, from Our World in Data

Vaccination and other freedoms

On 13th May US President Biden walked into the Rose Garden, took his mask off and announced that vaccinated Americans no longer had to wear face masks. Of course, the devil is in the detail and I do not fully understand the current restrictions. Nonetheless it was an important step towards normality.

“Ms. Pelosi’s rules have been tied to guidance from the Capitol’s attending physician, who late Thursday issued updated policies for lawmakers and their staff, saying that those who were fully vaccinated could “resume activities that you did prior to the pandemic” But the physician, Dr. Brian P. Monahan, said face coverings would still be required for now around the House floor and everywhere on the campus for unvaccinated people.”5

Biden wrote that the present mask requirement and other guidelines remain unchanged until all members and floor staff are fully vaccinated. The U.S. Centers for Disease Control and Prevention (CDC) announced new recommendations for mask wearing on Tuesday, April 27th. The guidance is that fully vaccinated people no longer need to wear a mask outdoors, except in crowded settings.6

It is clear that having a vaccination will also become a precondition for various activities and we can expect there to be unhappiness and challenges from this. My personal view is that this is entirely reasonable, the vaccine not only protects the individual but everyone else. I am used to carrying a yellow fever card so I really don’t have a problem. I also think arguments about people being discriminated against can be overcome, and we will all be safer. In South Africa ‘Covid-19 fatigue, causing people not to wear their masks, wash their hands and maintain physical distancing, has been identified as a major possible driver of a potential third wave of Covid-19 infections in South Africa, the director-general of the National Department of Health said this week’.7

On the 17th May the next stage of relaxing the lockdown in England was implemented. I do hope it is not too soon. As the Guardian wrote:

“Monday’s change in the rules was supposed to be a moment of celebration – but the new variant spreading in the UK meant it came with a cautionary note. Can the next stage of the government’s ‘irreversible’ plan go ahead?”8

There were scientists warning the accelerating spread of the India variant of coronavirus meant the UK ‘should proceed carefully – and even consider slowing down’. … and the plans ‘came with a heavy dose of caution and warnings that the last stage of the relaxation set for 21 June could be delayed.9 Will the government’s “irreversible” plan to end lockdown actually be irreversible?

An interesting article in the British Medical Journal asked why so many African Leaders have died of Covid-19 between February 2020 and February 2021.10 They counted 24 national ministers and heads of state, more than would be expected. Seventeen of these deaths are from the African continent (and number has risen since). That puts the Covid-19 death rate at 1.33% among national ministers and heads of states—seven times above estimates of the world’s average for a demographic profile of similar sex and age average. The BMJ notes:

“While comorbidities such as obesity or diabetes cannot be ruled out as a cause of such African specificity, other hypotheses include the lower quality of healthcare and a halt in international medical transfers used by African elites as well as, later, the incidence of the so-called ‘South African’ variant (501Y.V2) of the virus. …The deaths have an important symbolic value and have been associated with shifts in COVID-19 policies in some countries. They are also likely to result in some reconfiguration of the political space.”

We noted similar issues early in the AIDS pandemic.11

Conclusion

So where are we at this point in the pandemic? There are half a million new cases and over 10,000 deaths a day. While these numbers have begun going down, they are still high. Countries have seen multiple waves but globally this has smoothed and the two peaks, so far, were in January and April 2021. It is likely that the rapid rollout of vaccines will prevent further waves of infection but there is still much to learn. It is possible that a third booster dose will be required in the early winter in the north to ensure protection. Vaccines offer the main hope for life to get back to a level of normality, but the pandemic offers us the chance to ask what sort of normality we can expect or want.

What we really have not grasped is the cost of this pandemic to the poor, of whom there are ever increasing numbers. While it is tempting to listen to the forecasts of economic growth and recovery being put forward by politicians and (shamefully) central bankers, this is ‘magical thinking’. Over a year ago I noted the number of aircraft stored on the tarmac in Norwich. They are still there, although they do get moved about and exercised. Hope for the best but prepare for a long haul.

Publications: Michael Lewis, The Premonition: A Pandemic Story, (Allen Lane. London, 2021 301 pages) is excellent and absolutely a book for these times. Lewis, an investigative journalist, has written extensively on financial and political malfeasance: Flash Boys, Liar’s Poker and The Fifth Risk are among his output. This covers the first year of the pandemic. The limitation is it primarily takes a western perspective.

Thank you for reading, reposting and providing comments. What I write is public domain. Please share, forward and disseminate. My contact is: awhiteside@balsillieschool.ca In the next instalment I hope to cover vaccine passports and economics.


  1. Presumably the desire is to keep everyone healthy!
  2. https://coronavirus.jhu.edu/map.html
  3. https://www.ourworldindata.org/covid-cases accessed 2nd May 2021
  4. https://www.telegraph.co.uk/global-health/science-and-disease/big-difference-first-variant-one-mozambiques-growing-covid-crisis
  5. https://www.nytimes.com/2021/05/13/us/politics/washington-mask-guidance.html
  6. COVID-19 News and Client Highlights from Rabin Martin https://rabinmartin.us6.list-manage.com/subscribe?u=2ec992c445622e8cffdf51007&id=3f1d97461d
  7. https://www.dailymaverick.co.za/article/2021-05-01-fears-that-covid-19-fatigue-could-be-the-major-driver-of-a-third-wave
  8. https://www.theguardian.com/world/audio/2021/may/18/how-worrying-is-the-india-coronavirus-variant-for-uk-plans-to-unlock-this-summer
  9. ibid
  10. https://gh.bmj.com/content/6/5/e005587
  11. These are issues we reflected on with regard to HIV, see for example Whiteside, A., A. de Waal and T. Gebre-Tensae. 2006. ‘AIDS, security and the military in Africa: A sober appraisal’. African Affairs 105 (419): 201–18.

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