By Kimberly J. Soenen
French photojournalist Jean-Marc Giboux covered the modern-day polio (poliomyelitis) eradication campaign for nearly a decade, and still has vivid memories of the ruthless way the disease attacks children’s spines.
“I recall the mangled bodies of young children walking on all fours, living life chin-to-the-ground,” he told me from his home in Chicago.
Viruses do not respect geographic or political boundaries. They traverse the world indiscriminately, relentlessly, reminding us of our human interconnectedness and universal fragility.
TB, tetanus, visceral leishmaniasis (kala azar), measles, human African trypanosomiasis (sleeping sickness), malaria, polio and chagas – some of the most vaccine-preventable diseases – may not be front of mind today for Americans, but these diseases persist in countries around the world, and efforts to contain and eradicate them point the way forward as new diseases emerge.
“Viruses merely accentuate existing social inequalities, disparities and lack of health care infrastructure,” Giboux said. “Of the many countries I visited during the polio eradication campaign, many remain torn by wars and civil strife: Yemen, Afghanistan, Pakistan, Nigeria, Mali, Niger, Chad … the virus took hold of those already-distressed countries. The virus itself was a byproduct of deep societal dysfunction as much as a lack of access to quality health care. Now with COVID-19 in the United States, here we are.”
Despite being one of the wealthiest developed nations on the planet, the COVID-19 economic and health crisis is worsening in the U.S., where politicization of the virus persists, and there is much at stake as economic distress imposes mental health and physical health conditions that will have lasting effects on the human body and national psyche. Career public health experts are alarmed by this politicization, and they are speaking out.
Former U.S. Centers for Disease Control and Prevention director Dr. William Foege expressed his dismay and disgust with the U.S. response to the pandemic in a private letter to the current U.S. CDC director the week of October 5. “This will go down as a colossal failure of the public health system of this country,” Foege wrote. “The biggest challenge in a century and we let the country down. The public health texts of the future will use this as a lesson on how not to handle an infectious disease pandemic.”
That same week, Dr. Rick Bright, one of the nation’s leading experts in pandemic preparedness and response, and an internationally recognized expert in vaccine and diagnostic development, publicly shared that he was directed by the Department of Health and Human Services (HHS), the Food and Drug Administration (FDA) and the National Institutes of Health to remain quiet during a pandemic that has, to date, killed one million people globally and more than 220,000 people within the U.S.
In the midst of an unprecedented number of medical whistleblowers raising alarm, one topic that has people talking worldwide: vaccines.
HUMANITY vs. COMPETITION
Flash back to the spring of 2020, when New York City was under siege with an overwhelming number of COVID-19 patients and equal access to resources was anything but the norm. Physicians were circumventing the protocols of their hospital media relations, PR, marketing and communications departments, directly calling doctors in Italy, medics in Afghanistan and colleagues at hospitals up and down the East Coast for information, brain trust and expertise on what might work, while triaging an overwhelming number of COVID-19 patients.
While hospital CEOs, executive management and board trustees headed for the hills, in some cases literally – decamping to beach houses and summer homes in the countryside – physicians were in full-on Emergency Medicine mode, practicing like conflict medics. They called the families of patients from their personal cell phones, pooled tips with physicians at “competing” hospitals and scrounged together donations of PPE through their personal networks, all while holding the hands of terrified patients in the ICU.
For a short time, over a matter of several devastatingly morbid months, the walls of health care systems group management bureaucracy and restrictions by Managed Care fell, the litigious protocols of competitive corporate health care gatekeeping dissipated, and humanity revealed its courage and grace – with dignity, compassion and empathy. People cheered in the streets, shouted out their windows, and rallied for health workers from their balconies, beating the drums globally for health solidarity.
AN UNPRECEDENTED PRIVATE / PUBLIC SECTOR CALL FOR GLOBAL HEALTH SOLIDARITY
Worldwide, professionals are now calling for cooperation and unity when it comes to developing and administering a COVID-19 vaccine.
On August 25, physician and medical student members of the American Medical Association (AMA) publicly called for “slowing the process on vaccine development,” which they feel is moving at too rapid a pace. They called for “transparency regarding the process for authorization or licensure, standards for review” and safety and efficacy data as soon as possible.
In early September, a group of prominent biotech CEOs called on their peers and the federal government to hold themselves to the highest standards when it comes to developing and reviewing COVID-19 treatments. Among their demands: that biotech companies don’t simply release clinical trial data in press releases, and that federal regulators make it clear to the public that any vaccines or treatments will be approved strictly based on science. The recommendations were laid out in an open letter organized by the Biotechnology Innovation Organization.
Back in April, Dr. Tedros Adhanom Ghebreyesus, director-general of the World Health Organization (WHO), called the COVID-19 pandemic “one of the most dangerous challenges the world has faced in our lifetime.” He underscored the need for health solidarity and urged the United Nations’ 193 member states to “move forward in humility and unity in the face of the disease.”
“We must be guided by science and tethered to reality,” Ghebreyesus said. “Populism and nationalism have failed. Those approaches to contain the virus have often made things manifestly worse.”
Six months later, he is much more blunt: “In an interconnected world, it is high time to recognize a simple truth: health solidarity is self-interest. If we fail to grasp that fact, everyone loses.”
Last month, biotech leaders Sacha Sadan, Yo Takatsuki and Damiano De Felice publicly called on global pharmaceutical investors to increase their engagement and ask all governments and pharmaceutical companies to fully embrace the principles of collaboration in the response to COVID-19. “The process of developing, manufacturing, and distributing new medicines and vaccines will be faster and more efficient if governments and pharmaceutical companies work cooperatively and avoid a competitive race based on medical nationalism,” they pleaded.
THE “RACE” TO THE VACCINE
COVAX is the effort being coordinated by the WHO and Gavi, the Vaccine Alliance, along with the Coalition for Epidemic Preparedness Innovations (CEPI) to support the research, development and manufacturing of a wide range of COVID-19 vaccine candidates, and negotiate pricing and affordability, a major issue in the U.S. The aim is to have a vaccine available by the end of 2021.
“All participating countries, regardless of income levels, will have equal access to these vaccines once they are developed,” COVAX has published.
As this “Race to The Vaccine” and “Operation Warp Speed” have continued apace, some very quiet news broke on August 25, when the Africa Regional Certification Commission certified the WHO African Region as free of wild polio after reporting four years without any wild poliovirus transmission.
With this historic milestone, five of the six WHO regions – representing more than 90 percent of the world’s population – are now free of the wild poliovirus, moving the world closer to achieving global polio eradication.
The polio eradication campaign is now more than 30 years old. Its success is attributable to many factors, most importantly local health literacy education and in-person consult around the world. Building trust required visiting refugee camps, visiting village elders in remote areas on foot, using megaphones to alert people that physicians are coming and visits to homes.
“There are many lessons to be learned from the global fight to eradicate polio that could be useful in not only distribution of a future COVID-19 vaccine, but also in building community support and acceptance for a coronavirus vaccine, as well as ensuring the vaccine reaches vulnerable populations in hard-to-reach areas,” said Carol Pandak, director of Rotary’s PolioPlus program.
All pandemics, including SARS-CoV-2, disproportionately impact the poorest among us. It is no coincidence that Giboux and others who have documented infectious and neglected diseases have traveled to the regions with the highest poverty rates in the world – India, Nigeria, Pakistan, Afghanistan, Mali, Chad, Sudan, Sierra Leone – and every war, every climate disaster, has made these countries a breeding ground for the wild poliovirus and other viruses. In the middle of areas ravaged by conflict and war and in rural dwellings, the polio eradication campaign sought to immunize all children under five years old, thus shrinking the human reservoir of the virus one person at the time, year after year.
“The Global Polio Eradication Initiative (GPEI) has a proven history of utilizing its infrastructure and resources to respond to disease outbreaks, support and strengthen health systems and improve global health security, and the polio program has long supported countries in preparing for and responding to emergencies in order to protect vulnerable populations,” notes Pandak.
For example, when Ebola cases were detected in Nigeria in 2014, the polio Emergency Operations Center (EOC) model, alongside labs and surveillance workers, proved critical in responding to and controlling the outbreak. The program helped to avert a potential catastrophe and worked to stop the outbreak in Lagos within three months.
As a reminder of how imperative it is to combat virus outbreaks proactively and quickly, the world’s worst outbreak of measles has killed more than 7,000 children in the Democratic Republic of Congo (DRC) since 2018. The DRC minister of health has declared the outbreak over, but experts say with a relatively low rate of vaccination – only 60 percent – another one is looming. Health care workers there are delivering vaccinations by air, by water and on foot in an effort to reach remote areas.
In a cruel bit of irony, the very success of fights to end polio and smallpox and the extreme reduction of many other vaccine-preventable diseases can contribute to a collective amnesia as memories of pandemics past subside, making it hard for subsequent generations to recognize the gravity of new threats before them.
“I’d encourage younger people to ask their parents or grandparents what it was like to live in a world before vaccines were as prevalent as they are now – they may remember terrible outbreaks,” suggests Dr. Tunji Funsho, chair of Rotary’s Nigeria National PolioPlus Committee. “I’d also encourage young people to read or witness firsthand accounts of polio survivors to get a sense of how difficult life is to suffer from the disease. There are still people alive today who are survivors of polio but have spent their entire lives in an iron lung because they can’t breathe on their own.”
Alyce Henson, Rotary International staff photographer from 2004 to 2019, photographed polio eradication efforts from 2007 to 2019 in India and Cote d’Ivoire. “If the COVID-19 virus impacted people (visibly) like the polio virus does and people could see a physical impact, the response to the pandemic would be different – more urgent.”
Like the coronavirus, most people who got infected with poliovirus initially didn’t display any visible symptoms, but could spread the virus for two weeks, before and after being infected. A quarter of infected patients developed flu-like symptoms that would last up to five days. But a smaller proportion of people with poliovirus infection developed more serious symptoms that affected the brain and spinal cord, sometimes leading to permanent disability or death.
Also similar to COVID-19, the poliovirus struck without warning. Initially, nobody knew exactly how it was transmitted or what caused it. There was no known cure or vaccine. Before Dr. Jonas Salk developed a vaccine in 1955, polio was the most feared disease of the 20th century, causing millions of paralysis cases worldwide. Drug manufacturers made the vaccine widely available, which reduced the world cases drastically in one decade. By the end of the 20th century, the polio threat had all but disappeared in the developed world, but was still spreading in countries with fewer financial resources and weaker infrastructure.
In 1988, when the GPEI was formed, there were about 1,000 cases of polio every single day. In 2020, there have been less than 130 cases of wild polio in just a few countries.
“This speaks to the power and efficacy of vaccines. On the opposite side of the coin, if we were to stop vaccinating children against polio, within 10 years, there would be 200,000 cases of polio every year in all parts of the world,” Funsho wrote to me. “It’s almost unfathomable to think of where we’d be without vaccines.”
VACCINE TRUST PSYCHOLOGY
In speaking with physicians and infectious disease experts all over the world in recent weeks, I found that there are three psychological profiles related to taking vaccines: those who will take the vaccine immediately when it becomes available, those who will wait for the vaccine to be on the market for at time-tested period before taking it and the “anti-vax” movement population, which will not take vaccines.
The deep level of grassroots outreach deployed in polio eradication efforts will be needed to bring an eventual COVID-19 vaccine to as many people in that second category as is possible in every corner of the globe.
“With door-to-door visits, dedicated volunteers can convince people to accept the SARS-CoV-2 vaccine as a must. In India, we have a wide and strong infrastructure of civic and administrative officials … who remain ready to take care of their responsibilities with a zeal to approach every family in every rural and remote area of the country,” said Dr. Hemendra Verma, charter president of the Rotary Club of Shahjahanpur City in Uttar Pradesh, India.
“Though everybody wants to be vaccinated at earliest, it is also essential that vaccines should be launched after a time-tested period for the safety of the people. If the United Sates stops funding WHO in 2021, it will be very difficult for the rest of the world to face the impacts of COVID-19 pandemic. I’m optimistic about having trust in our great scientists working day and night in highly advanced laboratories of different countries to provide a safe and successful COVID vaccine earliest. Meanwhile, it is our responsibility to educate innocent people to live with exclusive precautions to save their valuable lives from the pandemic,” Verma added.
Family physicians are the first line of defense against disease spread. I wanted to hear their perspectives both on vaccine risks and efficacy.
Dr. Deborah Richter is a longtime practicing family physician in Cambridge, Vermont. She said by phone that she is heavily urging the need for flu vaccines this year in response to the threat of a “twindemic” tied to the flu. “I am finding fewer patients are declining the flu vaccine this year than in previous years, which is hopeful for when a reliable and safe COVID-19 vaccine arrives,” Richter said. “Right now, however, most patients are not expressing confidence that it is possible to develop a safe vaccine in such a short period of time.”
“If you were to get the flu, catch pneumonia and had to go to the hospital and be exposed to COVID-19, at any age, that will do you in.”
Rotary, and the united global polio eradication campaign provides a road map for eradication success. However, even in the era of unfiltered social media propaganda, health literacy education, establishing trust with communities and setting up vaccine distribution networks requires time, person-to-person attention and a lot of patience.
“The biggest challenge for me as a family practitioner during this pandemic is misinformation on social media,” Richter said. “It is, without a doubt, a very serious public health and health care concern. Physicians are now having to spend a lot more time educating patients than ever before about facts, health and science.”
Photographer Alyce Henson also raises concerns about the velocity of medical misinformation on social media but warns that it most likely won’t be counteracted by the same means.
“The success of the polio eradication campaign is the result of health workers knocking on doors, setting up education tables on sidewalks, going door-to-door, meeting with village elders and sometimes even proactively seeking out nomadic populations by foot to educate people about the polio vaccine,” she says. “That person-to-person trust cannot be supplanted by opinion on social media. Social media information may travel more quickly, but in the case of vaccine education, slow is healthy. Speed and haste actually have an opposite, and, I would argue, detrimental impact when it comes to virus containment efforts.”
Dr. Leonard Mermel, an infectious disease and bioterrorism expert, is optimistic about the public’s willingness to adopt a vaccine, but questions the health care infrastructure in place to prevent and contain the virus in the meantime, an important part of global health solidarity.
“I think there will be enough early vaccine adopters that will lead to a tipping point and a wider acceptance of the vaccine once the FDA approves a vaccine with a safe profile,” he said. “Once it is proven efficacious, others will come on board.”
Mermel, who is the medical director of the Department of Epidemiology and Infection Control at Rhode Island Hospital and holds professorships at the Warren Alpert Medical School of Brown University and at the University of Rhode Island College of Pharmacy, is less confident in the U.S.’s infectious disease health care infrastructure. It has been decimated by state and federal budget cuts over the last 50 years, while state and local facilities were left to fend for themselves during the first wave of the pandemic, with little to no national coordinating efforts. He reported that his hospital has been making its own hand and hospital sanitizers internally for months.
“In our health system of nearly 17,000 employees in Rhode Island, we still don’t have enough swabs, test kits, PPE, cleaning agents or masks,” Mermel said. “We don’t have the re-agents that we need to transport media and send results to the lab for the PRC test. How are we expected to educate people about the virus when we don’t have basic health care supplies?”
I also spoke at length with Dr. Fedir Lapii, an expert in the field of immunology in Kyiv. He is the head of the National Technical Group of Immunization Experts in Ukraine, which is similar to the Advisory Committee on Immunization Practices (ACIP) in the U.S., and a professor of pediatric infectious diseases and immunology at the National Medical Academy.
The Associated Press last week reported that the coronavirus infections in Ukraine began surging in late summer, and the ripples are now hitting towns like Stebnyk in the western part of the country where there seems to be a shortage of physicians. The weaponized health communication of Twitter bots and Russian trolls amplifies the vaccine debate with misinformation in Ukraine and eastern European countries especially.
“People have a very, very short memory regarding viruses and diseases and how quickly they spread,” Lapii said.
In Ukraine, a panel of vaccinations including TB, polio, rubella, measles, hepatitis B, mumps and others is mandatory for infants. Yet between 2017 and 2019, the country had the largest modern-day outbreak of measles cases in Europe. Parents and medical professionals remain at odds over vaccine efficacy to this day. Older physicians whose origins of study began in the Soviet era are sometimes opposed to vaccinations, while younger medical students advocate evidence-based medicine. Lapii and other physicians lead education campaigns with medical students, parents and patients, and publish guidelines for health management that replicate those of Canada, Australia and the U.S. Yet like elsewhere, the efficacy of vaccines remains an ongoing debate even amid the coronavirus pandemic.
Measles has slowed, but now after an aggressive education campaign, Lapii worries about a triple threat of measles, flu and COVID-19 all at once. “Add to that pneumonia and that combination will kill patients, especially those who refuse vaccines.”
“One benefit to public health in Ukraine is that the government pays for all physician visits and vaccinations so there exists no rural/city health disparity in that nobody is deterred from being vaccinated because of cost,” he stated.
“As of this day, Ukraine has had about 4,600 deaths from COVID. I’m optimistic about a vaccine for COVID-19, but there remains a divide on who will be willing to take it when it becomes available,” Lapii said.
PUBLIC HEALTH and HOPE
The outbreak of COVID-19 proved that this world is just like a global village where our own safety is interconnected with each other’s. So, when one single country anywhere across the globe remains infected, transmission of COVID-19 will still exist. Polio is the great example where, still, the whole world is worried for Pakistan and Afghanistan. We can defeat COVID-19 through proper planning both at government and public level,” said Dr. Tayyaba Gul, past president of Rotary Club Islamabad.
As citizens of the U.S. contemplate scientific facts, the efficacy of vaccines and personal health choices, more than 24 key government public health officials have resigned over the last nine months citing the politicization of public health.
“Possibly we might consider the need to legislate protecting the CDC from the political will of administrations going forward,” Dr. Mermel says. “Congress might consider empowering the CDC to be protected from political disruption.”
Although the U.S. health system has cut human capital, access to health technologies and resources for health literacy education in public health since the dawn of managed care in the early 1990s, Mermel said the Southern Hemisphere’s success in prevention and containment this winter could be achieved here with a unified professional response and an independent CDC that is insulated from political whims.
“That is reason for hope,” he said.
WHAT CAN WE LEARN?
South Korea is another bright spot.
In 2015, the country experienced a MERS-CoV outbreak that impacted the national pandemic response and contributed to sweeping public health reform, restructuring of the South Korean CDC and reorganizing investments, guidelines and laws. Today, South Korea has a unique public health center system with some 250 facilities equally distributed across the country. They have both administrative functions (regulation of health care facilities, outbreak investigation) and direct provision of health care services (vaccinations, clinical services). These public health centers were the mainstay of South Korea’s nimble COVID-19 outbreak response, investigating, contact tracing and communicating risk to contain the virus spread.
Dr. Young June Choe, assistant professor in the Department of Social and Preventive Medicine at the Hallym University College of Medicine in South Korea, has some thoughts on stumbling blocks that could prove to be obstacles in the way forward.
“From a ‘vaccination’ standpoint rather than ‘vaccine,’ I think there is a different layer of difficulty in terms of deployment, prioritization, distribution, and supply chain management, in comparison to the research and development part,” he said. Prioritizing whom to give vaccines to first is foremost, but so is international competition in vaccine procurement.
“I feel once we do have the useful vaccine in hand, and actionable vaccination plans made, then there might be a tug of war between countries on securing vaccines – which might soon raise the issue of health security in each country,” Choe said. “I hope I am wrong.”
Dr. Tunji Funsho is hopeful. “I feel that if the global health community can come together, uphold and push an agenda that upholds a common belief in science and vaccines, and provide sufficient funding and government support for the effort to protect the world from COVID (including equitable distribution of a future vaccine), then the world will have success against COVID-19,” he said. “A return to the tenets of trust, belief in science and health solidarity will certainly be necessary in order to make this happen.”
Similar to the wild poliovirus, no country will be free from the risk of the coronavirus until all countries are free from it. The infrastructure must be in place to distribute the vaccine at an affordable or taxpayer-financed free price once it is developed. Competition-driven health care will not work in the distribution of the coronavirus vaccine.
Then there are some very practical concerns. Vaccines are difficult to transport and store safely. They must be kept cool, or they risk losing their effectiveness. The polio “cold chain” – the system used to distribute polio vaccines while keeping them at the correct temperature and in good condition – has been replicated by other disease prevention and immunization programs.
The polio cold chain system – made up of freezers, refrigerators and cold boxes – was developed to allow polio workers to store the vaccine and transport it over long distances in extremely hot climates. “While we don’t yet know what the future holds for a vaccine against COVID-19, it’s feasible that the polio eradication infrastructure and cold chain system could play an important role in vaccine distribution in many parts of the world,” Carol Pandak said.
As of October 22, 2020, more than 40.6 million people around the world have been diagnosed with COVID-19 according to the Center for Systems Science and Engineering at Johns Hopkins University. The United States is the worst-affected country, with more than 8.2 million known diagnosed cases and at least 220,609 known deaths.
Not long ago, Jean-Marc Giboux had a friendly conversation with a stranger about the importance and efficacy of masks, distancing, preventive care, vaccines, a cohesive national response and health solidarity. The stranger asked him what he predicts will happen in the months ahead. His answer was as unsatisfactory then as it is today, but it remains just as true.
“Only time will tell,” Giboux told the stranger, “Only time will tell.”