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A compassionate country

Political and vaccine equity in COVID-19 Australia

I WORK ON diseases that affect the lives of poor and marginalised citizens. The scientific description of my work would be ‘immunology’ and ‘vaccinology’. The focus is on studying how the body’s immune system fights infectious diseases and to then build on that understanding – and, of course, the enormous amount of knowledge that others have accumulated – to develop vaccines. Working with colleagues and students at the Institute for Glycomics at Griffith University, and with scientists based in different countries, we have progressed to the stage where we have two vaccines in early-phase clinical trials – one for malaria (with great support from Rotary) and the other for streptococcal-related diseases such as rheumatic heart disease and necrotising fasciitis, or ‘flesh-eating’ disease. Collectively these diseases result in the loss of over one million lives per year – most among young people.

Now, my lab is also working to develop a vaccine for COVID-19. We are working with patients who have recovered from the disease and studying their immune responses to pinpoint the most critical parts of the virus to include in a vaccine. This novel approach is a collaboration between Griffith University and the University of Alberta in Canada.

The diseases I study exert a far greater impact on the lives of people in other countries than in Australia. Most of my PhD students have come from developing countries where these diseases are endemic. I take great pride that Australia spends significant resources, through grants, philanthropy and education, to reduce the suffering of people in countries such as Uganda, Thailand, India and Kenya, where malaria and streptococcus cause significant suffering. We are a compassionate country and care deeply for others. However, the emergence of COVID-19 is changing how we think and threatens to change how we care for others.

As scientists, our ability to work freely in our labs has been curtailed. In my own lab, a malaria vaccine clinical trial has been put on hold. Other universities have been more severely affected, many with complete closure of labs. In a recent article for the American Journal of Tropical Medicine and Hygiene, which I wrote with my collaborator Dr Stephanie Yanow, we argued that shutting down non-COVID-19 research will have severe, long-lasting repercussions on all aspects of health. Yet, one of the drugs that has shown efficacy against COVID is remdesivir, a drug developed to treat Ebola: when research stops in one area, all research suffers. The consequences of delaying malaria and streptococcal research and vaccine trials will also lead to a ballooning of these diseases that will take many years to rectify. More immediate, however, are disruptions to essential public health control measures such as the provision of insecticide-treated bed nets and seasonal malaria chemoprophylaxis campaigns. As a result, WHO fears the annual death toll from malaria could double – a view supported by detailed epidemiological modelling.[i]

While the freedom of many researchers to work to improve global health has been removed, our rights as Australians have more generally been severely impacted. I recently argued in The Sunday Mail that the decisions to close state borders lack logic[ii] and that borders determine neither how many Australians nor how many people in a particular state suffer from COVID-19. One way to think of this is to ask whether the overall number of cases would be the same if Australia did not have delineated states: the answer is ‘yes’. This argument assumes that the public health advice regarding social distancing and hygiene is the same in all states, and that the public follows this advice. With open borders (or no borders at all), a number of infected individuals (who are not sick, but still harbour the virus) would be expected to go back and forth across the borders in equal numbers. Some months, more infected individuals may go in one direction than the other, but over time it averages out. Over a period, the number of cases in any state is not affected by opening the borders. I suggested that the only justification for closing borders is that some premiers may not want to lend medical assistance to other Australians who might get sick in their state – an explanation the Queensland Premier seemed to validate when she said that ‘in Queensland, we have Queensland hospitals for our people’.[iii]

Currently, the national state of contagion is very fluid: the virus can easily slip through the nets that we have put in place, no matter how tight the mesh. It is easy to be frightened by this virus, but it is also important to think clearly to prevent further and unnecessary hardship. UNSW economist Gigi Foster has argued that the indirect effects of the virus may be worse than the direct effects.[iv] These effects include impacts on mental and physical health,[v] delays in medical services,[vi] increased domestic violence,[vii] and disruption to all levels of education and research.[viii] By closing borders, state governments are preventing families and loved ones from coming together, and they are damaging tourism and industry – all severely affecting our mental and physical wellbeing and the economy, without any net benefit to the lives of Australians. We need care, compassion and reason to deal with this virus in the most effective and least destructive ways.

If the federal government has argued for the need to open state borders, they have also put in place the need for ‘exit visas’ to leave Australia. These are denied to many applicants, impinging both free choice to leave and the implied legitimacy of a democratic right to freedom of movement. The ability to travel is essential to my work as a scientist. We currently have a streptococcal vaccine trial underway in Canada, and our COVID-19 vaccine research is also a collaboration with Canada. Fortunately, I was granted an exit visa for my last trip – from which I have now returned – but many are not.

An effective and safe vaccine will provide a solution to this, for sure, but we cannot put our lives on hold until a vaccine arrives.

 

SO, WHERE ARE we with developing that vaccine? As of mid-September, there were fifty-one clinical trials underway for COVID-19 vaccines. Of these, nine are in late-stage trials (Phase III), which are aimed to determine vaccine efficacy, and all have shown promise in their ability to induce antibodies that can kill the virus in vitro. This is encouraging. These vaccines mostly use the surface ‘spike’ protein, or the gene encoding this protein, as their ‘antigen’ (the substance that will stimulate the production of antibodies); they deliver this antigen to the immune system in various forms of packaging. These Phase III trials will also test safety. It is important that proper due diligence around safety is neither rushed nor abbreviated: overlooking any side effects, even in a very small fraction of the population, could have dramatic ramifications for community acceptance and uptake of all vaccines.

Once a safe and effective vaccine is identified, we will need to consider very carefully the rollout of a vaccination campaign. Those most at risk of COVID-19 are the elderly: a study from Switzerland shows that for those aged sixty-five years and over, the risk of dying from the virus (the ‘infection fatality rate’) is approximately one in twenty. However, for children and teenagers, the infection fatality rate is only about one in 300,000.[ix] There are no other diseases, of which I am aware, that have such a dramatic age-related range in mortality rates. This will pose unique challenges in equity around vaccine campaigns. Governments may wish for everyone to be vaccinated so that ‘herd immunity’ is generated. This may be possible with a good vaccine if 60 per cent of the population is vaccinated, assuming that the vaccine is 100 per cent effective in those who are vaccinated. But young people may question why they need to be vaccinated when their risk of illness is so much lower than for the rest of the population. This is a legitimate concern that will demand significant community engagement.

This issue aside, there will also be significant delays in vaccine manufacture. Billions of doses of vaccine will be required, and vaccine equity will be further tested if individuals desiring the vaccine are not at the front of the queue. It is encouraging that 165 countries so far have joined the COVAX Facility to guarantee equitable access to COVID-19 vaccines worldwide. A notable exception is the United States. How equitable access to any vaccine will actually prove to be can only be assessed after we have one.

COVID-19 is testing all spheres of society, from governments and multinational vaccine manufacturers to individuals – students and teachers, young and old, the healthy and less healthy, those who are suffering from COVID-19 and those who are doing everything right to avoid it. Many people now feel very vulnerable, understanding that the world they once knew no longer exists. Australia should seize the opportunity to show compassion based on reason and equity to all.

 

Author’s note: Thanks to Dr Stephanie Yanow for critically reviewing this manuscript.

 

References

[i]Hogan, A.B., Jewell, B.L., Sherrard-Smith, E., Vesga, J.F., Watson, O.J. and Whittaker, C., et al. (2020). Potential impact of the COVID-19 pandemic on HIV, tuberculosis, and malaria in low-income and middle-income countries: A modelling study. The Lancet Global Health, 8(9), pp. e1132–e41; Sherrard-Smith, E., Hogan, A.B., Hamlet, A., Watson, O.J., Whittaker, C. and Winskill, P., et al. (2020). The potential public health consequences of COVID-19 on malaria in Africa. Nature Medicine.

[ii]Good, M.F. (2020). State of division not in people’s interests. The Sunday Mail, 6 September.

[iii]NSW, Qld trade barbs over ‘astonishing’ hospital restrictions. (2020). The New Daily, 19 August.

[iv]Foster, G. (2020). Correctly counting the cost shows Australia’s lockdown was a mistake.Australian Financial Review, 25 May.

[v]Reger, M.A., Stanley, I.H. and Joiner, T.E. (2020). Suicide mortality and coronavirus disease 2019—a perfect storm? JAMA Psychiatry; Brooks, S.K., Webster, R.K., Smith, L.E., Woodland, L., Wessely, S., Greenberg, N., et al. (2020). The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. (2020). The Lancet, 395(10227), pp. 912–20.

[vi]Pattisapu, P., Evans, S.S., Noble, A.R., Norton, S.J., Ou, H.C. and Sie, K.C.Y., et al. (2020). Defining essential services for deaf and hard of hearing children during the COVID-19 pandemic.Otolaryngol—Head and Neck Surgery, 163(1), pp. 91–3; Centers for Disease Control and Prevention. (2020). CDC ’s recommendations for the next 30 days of mitigation strategies for Seattle-King, Pierce, and Snohomish Counties based on current situation with widespread COVID-19 transmission and affected health care facilities.

[vii]Boserup, B., McKenney, M. and Elkbuli, A. (2020). Alarming trends in US domestic violence during the COVID-19 pandemic. American Journal of Emergency Medicine.

[viii]Yanow, S.K. and Good, M.F (2020). Nonessential research in the new normal: The impact of COVID-19. The American Journal of Tropical Medicine and Hygiene, 102(6), pp. 1164–5.

[ix]Perez-Saez, J., Lauer, S.A., Laiser, L., Regard, S., Delaporte, E., Guessous, I., Stringhini, S. and Azman, A.S. Serology-informed estimates of SARS-CoV-2 infection fatality risk in Geneva, Switzerland. The Lancet Infectious Diseases. www.thelancet.com/pdfs/journals/laninf/PIIS1473-3099(20)30584-3.pdf

 

18 September 2020


 

 

This article is supported by the Judith Neilson Institute for Journalism and Ideas.

It's the thirteenth in an occasional COVID-19 chronicle series published as part of Griffith Review's Friday Great Reads.

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