Will Covid-19 ever end?

Our advice to all leaders is simple: assume a Covid-19 world at least until early 2023.

Some liken the Coronavirus pandemic to a marathon. At Thinking the Unthinkable we liken it to a steeplechase. There are big hurdles to jump, with plenty of opportunities to fall, and a long, wearying run at the end. But the course will be longer than most dare even think about.

Even then, we must not assume that the world will soon resume where it left off in March 2020. Sir Jeremy Farrar is Director of the Wellcome Trust and one of the UK’s most distinguished medical researchers and vaccine advocates. He has warned that Covid-19 is a human pandemic which “will be with us forever, we will have to learn to live with it”. He adds: “It’s no longer an animal infection which will pass and we will suddenly come out of Covid into a brave new world. We will have to learn to live with it. We will have to provide counter measures, vaccines and treatment, and we will have to realign our health systems.”

So this is not a war, but it is like war-time. As after any catastrophic shock, the world will be changed radically. Shocks in this Covid-19 world will include not just the health fallout, but also huge economic, political and societal upheavals that few of us have ever dared to imagine.

This is hard for almost everyone to understand - ourselves included.

Bold, bleak and honest

We all yearn for a return to the comfort and reassurance of the way it was at the start of 2020. But the northern hemisphere’s summer has shown what most scientists have warned us: assuming the ‘good old days’ can be replicated will lead to a second wave resurgence of the virus, and more after that.

2023 is much later than many predictions by policy-makers. But which politician facing re-election at some point in the next three years dares to be that bold, bleak and honest?

2023 contrasts with Bill Gates’ estimate last month that the pandemic will end for the rich world in late 2021. He has since tempered his estimate given his concerns about political leadership and its ability to impact on a fair and timely global rollout of vaccines.

Nine of the biggest pharma companies have become deeply concerned about political manipulation on vaccine introduction. They have fired their own warning shot.

Warp speed laced with caution

They pledged that vaccine development would be “in accordance with high ethical standards and sound scientific principles”. This was a measured response to President Trump’s declaration that he wanted a vaccine ready by November 3 - US election day.

On the very day of the pledge, one of the nine signatories, Astra Zeneca, referred to regulators the vaccine it is developing in partnership with Oxford University after one vaccine volunteer was hospitalised. It was a routine pause that happens in any such trial. It made headline news. But after independent analysis of the data, the trial restarted three days later in the UK.

Vaccine volunteer

I have spoken many times to one volunteer on the Oxford vaccine trial who I know well. I was with him on the day after he took the second dose of the trial vaccine – it could have been a placebo. Like all volunteers he doesn’t know yet which he has taken. Whichever it was, the dose had a powerful effect on him for that day. This is common with vaccines. He told me that all the volunteers are being carefully checked for any health conditions. He said that warp speed laced with caution is critical if the vaccine is to be the game-changer we all hope for.

It is vital that the vaccine is safe. As well as the logistical challenges there will be the persuasion challenges needed to convince the billions in the world who are “vaccine hesitant”, according to many opinion polls.

Dangers of new “infodemic”

This is not easy given the internet is full of Covid-19 fake news. So much so that the World Health Organisation (WHO) has declared what it calls an Infodemic. That confirms how hostility to masks and a Covid-19 vaccine are now a culture war, and many tens of millions of so-called anti vaxxers seem beyond the scope of persuasion.

Infodemic is certainly a snappy and catchy title. But the concept concerns me. It could be interpreted to imply that all who are vaccine information sceptics have succumbed to some sort of illness. I don’t think this is what the WHO intends, judging from the thoughtful public webinars they have hosted on the issue.

Leaders must level with the public

I have a number of acquaintances with whom I have had lively (and socially distanced) conversations about their frustration with government policy and scepticism about the vaccine.

I have challenged some of what they told me. They are understandably confused and angered by the contradictory messaging. They are highly critical of how leaders have failed to acknowledge changing evidence. Worst still has been the hypocrisy of leaders flaunting the regulations as if somehow their status means they are above it all.

The key to successful global rollout will be engaging sceptical people like my friends and acquaintances. Potentially they can be persuaded. But so far, clear and open messaging, plus honest policy-making, have been in far too short supply in many countries. Engaging the sceptics is the major hurdle to be confronted and then jumped. Any measured process of persuasion will take time.

It is a key reason why we believe leaders must level with the public that an end of the pandemic probably won’t come before 2023, if ever. And that assumes that one or more vaccines is cleared for rollout globally by the first half of 2021. That is the latest timing by Pascal Soriot, the CEO of Astra Zeneca, for what he defined as the three “vaccine front-runners”, among the many currently being trialled round the world.

“Longer, deadlier pandemic”

A second major hurdle will be if rich countries try to corner all the first vaccine supplies, thereby ignoring the warnings that “vaccine nationalism will prolong the pandemic, not shorten it”, as the WHO Director General, Tedros Adhanom Ghebreyesus defined the challenge.

The consequence of vaccine hoarding by rich states has been calculated by the Bill and Melinda Gates Foundation. It predicts almost twice as many people die, and the disease continues to spread unchecked for four months in three quarters of the world. This inevitably leads to “a longer, deadlier pandemic”. It concludes: “So far, the hoarding scenario currently seems more likely.”

Vaccine rollout can’t come fast enough

But big pharma has taken on board such anxieties in an unprecedented way. Pascal Soriot at Astra Zeneca has pledged that all recipient countries will be treated equally, especially those where vaccine trials have taken place. “There will not be a supply problem. It will be done through partners. We will have the ability to supply everyone at the same time. There will be enough vaccines for everybody.”

That may be easier pledged than achieved.

To get a sharper handle on the next huge hurdle in the steeplechase, I read the latest American draft plan for a fair allocation of the vaccine. The US National Academy of Sciences Engineering and Medicine (NASEM) document is frank. It makes abundantly clear the complexities ahead. This will be the case even in a single rich country like the USA with only (in numerical terms) 330 million out of the seven billion people globally.

Danger of fakes and frauds

The NASEM propose four phases for the US rollout. First, a “jump start” for high risk healthcare workers. Secondly, for people with pre-existing conditions or who live in over-crowded housing. Thirdly, a roll out for critical risk workers, teachers and the vulnerable – including, they suggest, prisoners and prison officers. These three stages would cover 40-45% of the population.

Fourth and finally, would come essential workers, children and young adults. The majority of the population - that is 40-50% - would only get their vaccine at this stage. The percentages are only an estimate. The NASEM report points out that no-one actually knows how many people are in each category. And self-evidently, the rollout will take time.

Reading this dense but thoughtful 115-page report, it doesn’t take much imagination to realise that leaders must resolve considerable tensions in advance. Many people will regard their place in the queue as unacceptable and try to circumvent it. This will be an opportunity for fraud and the selling of fake vaccines.

And what happens if the first vaccines are not as effective as hoped for, or only efficacious for some groups? What if - despite all the rigorous testing - there are unforeseen side effects when the vaccine is rolled out to millions, then billions?

A first in human history

Sir Jeremy Farrar at the Wellcome Trust is one of those leading medical researchers working to temper our expectations. He warns that: “The first generation of Covid-19 vaccines will probably be only partially effective. They might not be completely effective in all ages or appropriate in all health systems. It is very possible that they might provide immunity only for a limited period, even as short as 12 to 18 months. This might not be what we are used to from a vaccine. But there is no doubt that the first effective vaccines, even imperfect ones, can have a major impact and be a precious commodity.”

Farrar says to achieve an effective integrated response the virus will have to be accompanied by a complex set of measures. These include systematically and simultaneously improving public health systems, and also developing better therapeutic measures for the sick. In addition, testing and tracing will also have to be done systematically and simultaneously so that any resurgences can be confronted.

None will be a quick fix.

Huge distribution challenges

The biggest hurdle in the final straits will be the rollout of a hugely complex logistical operation. It has been estimated that even in tiny vials, vaccine doses for seven billion would fill 8,000 jumbo jets. Refrigerated glass vials will have to be kept in complex chilled supply chains and then delivered in challenging environments to clinics.

Achieving this multi-level simultaneous global rollout has never been done before in human history. Again, we are now hearing experts tempering expectations.

The CEO of the world’s largest vaccine manufacturer, the Serum Institute of India, Adar Poonawalla has warned the Financial Times: “It’s going to take four to five years until everyone gets the vaccine on this planet.” He said that pharmaceutical companies were not increasing production capacity quickly enough to vaccinate the global population. The Institute is key to the rollout in India and 90 other countries.

Good leadership will be vital

Of course, not the entire population needs to be vaccinated for it to be effective. Three-quarters of the world’s population could be vaccinated by mid-2023, according to Peter Hale, the director of the US Foundation for Vaccine Research, a non-partisan, privately funded group that seeks to increase funding for vaccine research. “That should be enough to curb the spread of infection and stall the pandemic — though not good enough to consign the virus to the dustbin of history,” he told the Financial Times.

Expressing caution, as we also do as non-medical experts, that the vaccine roll-out across the world is not a quick or magic bullet is not to gainsay for one moment the commitment and dynamism that is being displayed by the leadership of these projects. We need all the good leadership we can get.

This leadership is exemplary. The collaborative cross cutting international projects include the WHO’s Access to Covid-19 Tools (ACT) Accelerator and the COVAX collaborative effort. There are many others too numerous to name here. Collectively they give great hope.

However, international political collaboration on multiple other fronts is at its lowest. This is at the very time when we most need it as we enter the worst economic depression for a hundred years. 170 countries will be poorer by the end of this year than they were at the same last year. This will add to the challenges of a rapid and just rollout of a Covid-19 vaccine.

This is why we at Thinking the Unthinkable are counselling everyone, especially the leaders we engage with, that they and we all face a long and arduous test of stamina.

We have no option but to plan accordingly.