- Autores: Tiago Correia
- Ano de Publicação: 2021
- Journal: International Journal of Health Planning and Management, 36(5), pp 1387 - 1391
- Link: https://doi.org/10.1002/hpm.3253
Vaccination represents a new chapter in the management of the SARS-CoV-2 pandemic. So far, the hospitalisation and death curves in most countries have tended to follow the epidemic curve. As vaccination increases, new infections are not expected to lead to a corresponding rise in deaths and hospitalisations, with overwhelmed health services and a lack of response to non-Covid-19 patients.
High-income countries are hoping that this will be the final chapter in the pandemic, and Israel and the United Kingdom have been earmarked as the main case studies. Pilot events have been held to work out how to hold larger gatherings safely. Lockdowns are being lifted and restrictions on people’s mobility within and between countries are being loosened.
Nonetheless, no-one is really sure about the plot in this new chapter. Or even if it will be the last chapter. There are still many questions to be answered and, as previous chapters of the pandemic have shown, political management can do nothing other than tread very carefully.
Surprisingly, the Kantian concept of ‘prudential reason’ has been used little in political analysis and in helping political decisions during the pandemic. Simply speaking, ‘prudential reason’ means ‘an ultimate reason grounded in the agent’s own well-being, good or welfare’. If we look at the actions of democratic states and international institutions, we realise how complex the issue might be. Something that fosters the well-being of some may collide with the wellbeing of others (individuals, socioeconomic groups, ethnic and cultural communities or citizens of different countries).
It becomes even more complicated when political decisions are made for the first time in history, with no basis for comparison. The practical significance of prudence might be not making decisions if there is not sure about the outcome. It might also be choosing less repressive or harmful methods.
This means that governments were facing the need to make tough decisions. Without the gift of prophecy, it seems that the current phase of the pandemic has changed little from this point of view.
Prudence is needed firstly because of the scientific answers that we do not yet have about this virus. Contradictory evidence comes to light every day, which means that rules and technical guidelines are criticised by the scientific community, political deciders and the general public.
In April 2020, I published another editorial in which I mentioned the ‘lack of critical reflection on the short- and long-term planning and management of COVID-19’. My intention was not to criticise any lack of scientific evidence. On the contrary, science has been extraordinarily fast and cooperative in the pandemic. My intention was, and still is, to criticise political and scientific management of the lack of scientific evidence. Management of risk, uncertainty and expectations is decisive until a more solid scientific consensus can be reached.
The problem is when scientists advise political deciders with absolutely no idea of how to manage the risk, uncertainty and expectations of a public that is scared and fed up. The problem is when scientists advise political deciders but have absolutely no idea of the answers that they do not yet possess and pass on evidence peremptorily and in simplified form. But the problem is also the pressure put on the scientists by politicians, the mass media and the public to find a quick fix for returning to normal. The problem is also that there are still too many disciplinary boundaries in science limiting the ability to perceive this pandemic as a syndemic.
What the scientific communities have to do is conduct a critical assessment of what they do and do not know, set aside the media and political ego that drives them to simplistic solutions that ignore other scientific fields and wake up to the ecological or systemic dimension of this pandemic. It takes more than epidemiological indicators to manage a syndemic.
The second reason why prudence is necessary has to do with the political choices made by the countries that have been the most successful in managing contagion (e.g., Australia and New Zealand) and those that are forging ahead with vaccination (once again paradigmatic Israel and the United Kingdom). There has so far been a common denominator between them: first you manage the pandemic within your borders; after that who knows?
The only solid evidence right now is that vaccination takes the pressure off health services and reduces the incidence in the community in the context of relative border control.
What we have before us is greater pressure to open borders, especially to boost tourism. While some countries will choose to maintain restrictions on foreign travel, others will decide to return to international mobility, which the politicians believe to be a calculated risk. After all, vaccination is progressing, incidence of the virus has been falling, test, trace and isolate plans are working and mobility certificates are being implemented to attest to immunity or a negative diagnosis.
Setting aside the ethnical debate on mobility certificates, I would like to focus on uncertainties about international travel. There are some well-known doubts in the debate: one is whether immunised people (by natural infection or vaccination) can transmit the disease and the other is the evolution of virus variants.
The first doubt lies in the fact that the vaccines were initially tested for preventing serious disease, and there were not enough studies of their role in reducing transmission of the virus. Even so, the current evidence is promising in this regard. The second doubt springs from disagreement in the debate. Some say that familiarity with other coronaviruses shows that we cannot expect a SARS-CoV-2 mutation that reduces the efficacy of the vaccines, while others say that it is impossible to predict the behaviour of the SARS-CoV-2, given that no other coronavirus has ever achieved such simultaneous global circulation. There are also some who say that, in spite of the SARS-CoV-2 mutations compromising vaccine efficacy, we are not back to square one thanks to what we have learnt and increased capacity to produce and distribute vaccines worldwide. Nonetheless, recent data have shown that variants of concern have been associated with higher transmissibility and severity of disease, with potential implications for acquired immunity or the effectiveness of current vaccines.
In addition to these doubts, there are the lessons to be learnt from what has happened so far. When discussing certainty about the future, we need to think about the certainties of the past that have since been refuted: that lockdowns were unnecessary in containing the exponential growth of infections; that SARS-CoV-2 would behave like the flu viruses; that infection would lead to herd-immunity; that SARS-CoV-2 would not spread to all countries and then that there would not be a second wave (just look at India).
To regard resuming foreign travel as the next natural step is to ignore where we are at the moment. It is true that at the beginning of May 2021, almost 30% of the US population and 22% of the people in Europe had had at least one dose of vaccine. It is also true that only 8% of the world’s population has been vaccinated, mainly because of the situation in Africa and Asia (1% and 5% of vaccinated population, respectively). At the current vaccination rate, global immunity can only be expected by October 2022.
In the face of such an imbalance in the world vaccination rate, we need to discuss how much pressure for foreign travel might cause setbacks in the longed-for return to normal. There is no way we can be sure that a mutation in the virus in the next few months will not compromise the efficacy of vaccines and diagnostic tests. Neither can we say what percentage of the population needs to be vaccinated to reach the herd immunity threshold. There are many factors affecting this magic number, including duration of immunity, epidemiological monitoring measures, people’s behavior in relation to local epidemiological situations and the diversity and intensity of human contacts. Furthermore, there is still no consensus as to the efficacy of the vaccines that the low- and medium-income depend on. Reinfection also seems possible, though we do not know for sure how much and in what circumstances it can occur. This means that we cannot be sure if global immunity is achievable.
These theoretical issues are being reflected in reality in Chile. So far Chile is the exception that proves the rule: it has reached the peak of its second wave with around 40% of the population vaccinated. The answers are obviously complex and multifaceted. Some of the factors are open borders, premature relaxation of personal protection measures and dependence on one vaccine (Sinovac in this case) that is apparently less effective than the most common vaccines in the high-income countries (AstraZeneca, Moderna, Pfizer and Janssen).
Experience has shown where to go next. Over more than a year we have learnt how much management of the pandemic requires intersectoral, multilevel policy approaches that foster interconnection between ‘in-border’ policies (which may be national, federal, statewide, regional or local) and ‘beyond-border’ policies (foreign travel).
So far, vaccination only allows a limited degree of certainty as to the effectiveness of ‘in-border’ policies. Furthermore, there seems to be a persisting, naïve idea about the systemic interconnection between countries and the international circulation of people. It will certainly not be individual restrictions between countries that will guarantee effective prevention of unwanted human contacts. Destinations are interconnected by many networks and means of transport, plus the fact that the quality of countries’ epidemiological vigilance varies considerably.
Finally, it is necessary to consider how far the apparent success of the high-income countries in managing the pandemic compared to the obvious failure of the low- and medium-income countries may encourage new, unexpected migratory flows to escape the virus and economic deprivation.
It is obvious that the low- and medium-income countries were left out of international management of the pandemic. Once again, good intentions and good will have lost out in political decision-making. But the high-income countries must not forget a recent past that they are trying not to repeat. The situation is still far from ideal. For now, the way to move forward in policy design and planning should take into account prudence in the following principles:
- It is not prudent to relax border management until the country’s epidemiological situation is under control and the vaccination of priority groups has been completed. The negative impacts of restricting international travel are not as great as in-country mobility to prevent possible collapse of health services, more avoidable deaths, partial or general lockdowns and higher unemployment.
- In view of global imbalances in vaccination rates and vaccine availability, it is not prudent to open borders without keeping up epidemiological vigilance within borders, due to the potential risk of unexpected effects. This includes pharmacovigilance of vaccines and genomic studies of variants.
- It is not prudent to say, like at the end of the first wave, that it is all over, because there are still doubts about individual and herd immunity. Science needs more time.
- A pandemic cannot be beat within a club of countries. Worldwide cooperation is a vital condition of success.
If these principles are not implemented in policymaking, then we have learnt nothing about global health and have not realised that public health emergencies have everything to do with politics, economics, international asymmetries and ways of life.
It was recently announced that the Biden Administration would support the request from South Africa and India to the World Trade Organization to temporarily lift patent protection for coronavirus vaccines. Only time will tell the extent to which the shortage of vaccines in the world resulted from protection of intellectual property or a lack of manufacturing components worldwide. Regardless of this conclusion, two political messages stand out when it comes to beating the pandemic. One is a growing awareness of the need to search for inclusive, global-scale solutions; the other is that governments must be doing all they can and have no conflicting interests with global corporations in sensitive times of public health emergencies.