“No one is safe until everyone is safe” is not just an old adage, it’s true”

“This idea that no one is safe until everyone is safe is not just an adage, it is really true,” said Andrea Taylor, the assistant director at Duke Global Health Innovation Center. ...it is becoming ever clearer that the tragedy for poorer countries could become a tragedy for every country.”[343]

This adage is most often used when the speaker is referring to the need for rich western countries to share their vaccines with the underdeveloped/less financially able to buy their supply of vaccine - i.e. vaccine nationalism. But the adage also has application to the U.S. and Canada’s domestic struggles to overcome vaccine hesitancy and achieve herd immunity. 

Previous chapters in the series

The first three chapters attempted to catalogue the brutal effects of the Covid-19 pandemic. My objective was to create a record of what happened/was happening in 2020 and early 2021 before the clipboard of our memories displaced this earlier information with the latest information. Chapter 2 - “Every cloud has a silver lining” (Subtitle The good of “The good, the bad and the ugly”) looks at the positive changes in behaviours and changes in conditions caused by the pandemic. Chapter 3 - “Here be dragons...” (Subtitle The bad of “The good, the bad and the ugly”) leaves the ’silver linings’ and digs into the major negative features of the pandemic.

Copies of these previous chapters can be downloaded from my Linkedin Profile page or send me an e-mail telling me which chapter you want and I’ll send you a PDF of that chapter. These thumbnail images of the chapters appear in the Featured section of my Profile.

Chapter 3 - “Here be dragons...” 

Abstract

When the world was considered flat (before the Flat Earth Society), ancient map makers are believed to have marked the lands beyond their knowledge with the expression ‘Here be dragons’ - i.e.” It was meant to warn people away from dangerous areas where sea monsters were believed to exist. It’s now used metaphorically to warn people away from unexplored areas or untried actions.” [344] Our fight with Covid-19 is being hampered by human fears of ‘the jab’ - the safety of these vaccines, historical mistrust of government, conspiracy theories about the vaccines, anti-vaxxers’ misinformation and human stupidity/stubbornness. While vaccine hesitancy (a metaphorical sea monster) is thwarting vaccination efforts, Covid-19 and the variants are infecting another 78,00 U.S. residents and 2,800 Canadians ‘each day’ as cases begin to increase in another surge. The massive logistical efforts to deliver doses of the vaccines to the populations are experiencing delays in delivering the right number of doses to the right locations. The race to vaccinate faster than new cases of infections can occur is driven by the desire to reach Nirvana - i.e. herd immunity (estimated at 70 - 85% immunization). Simultaneously, there is a mass drive by people infected with pandemic fatigue to get back to ‘normal’ by dropping their guard and heading to the nearest gatherings, bar/restaurant, beach/pool parties, etc. All of which has caused the Director of the CDC to publicly say “I’m going to lose the script, and I’m going to reflect on the recurring feeling I have of impending doom.” Yet, “No one is safe until everyone is safe” has yet to gain much muscle/mileage. Meanwhile, vaccine nationalism was described by Tedros Adhanom Ghebreyesus as a “catastrophic moral failure”. What has evolved is a medical version of a trade war where trade in vaccines by a few rich countries are controlling the export of vaccines, and some underdeveloped countries are accusing the developed world of ‘vaccine apartheid. These are just seven of the changes in behaviour and changes in conditions that have been included. Additional changes will be included in Chapter 4 which is under construction.

Contents of this chapter:

3.1 Covid-19 persists (in spite of increasing vaccinations) in causing severe illness and death

3.2 The coronavirus variants are “more infectious and, in many cases, more deadly”

3.3 “ Vaccinations are being treated as a get out-of-covid free card”

3.4 Vaccine Hesitancy - “Mistrust of a Coronavirus Vaccine Could Imperil Widespread Immunity”

3.5 “Anti-vaxxers Think This Is Their Moment”- The Atlantic

3.6 Covid-19 pandemic will become an endemic - meaning that it will continue to circulate in pockets of the global population for years to come

3.7 ‘Vaccine nationalism’ -“My nation first”

3.8 Closing comments

End Notes

Appendix B - Rumsfeld’s Heuristic

3.1 Covid-19 persists (in spite of increasing vaccinations) in causing severe illness and death

The first ‘bad’ is the persistence of Covid-19 (variants are covered later in this chapter) in spite of vaccines, masks and physical/social distancing behaviours.

Too many commentators are now talking-up ‘life returning to normal’ when the pandemic is still infecting and killing people. The Johns Hopkins University data for the U.S. on March 22, 2021 indicated that “The U.S. is recording at least 54,300 new Covid-19 cases and at least 1,000 virus-related deaths each day.” Although these numbers show a decline, 54.300 new daily cases is still a long ways from any ‘victory laps’.

The surge of cases from the variants is actually increasing the total numbers to 78,134 as of April 15,2021.

Has already caused widespread illness and death - 30,138,586 cases with an equally grim 548,013 deaths in U.S.

The adjacent graph, from Statista, illustrates the trend line of the daily new cases in the U.S. from the first wave in March and April, to the 2nd wave in the summer and then to the horrendous 3rd wave in the Fall and winter of 2020. The total cases, as of March 16, clocked in at 30,138,586 with an equally grim 548,013 deaths. [345]

“January 2021 was the deadliest month so far, when an average of more than 3,100 people died every day of covid-19. On six of those days, the number topped 4,000. On Feb. 22, the U.S. death toll surpassed half a million people. But the counts of new cases and hospitalizations had begun to fall in January, and in February, daily death numbers began to plummet as well.” [346]

But after several weeks at a plateau, Covid-19 cases in the United States are rising again,:

“CDC Director Dr. Rochelle Walensky said at a media briefing ““I’m going to lose the script, and I’m going to reflect on the recurring feeling I have of impending doom.”. Cases of the virus are up about 10% over the past week from the previous week, to about 60,000 cases per day, with both hospitalizations and deaths ticking up as well, Walensky said. She warned that without immediate action the U.S. could follow European countries into another spike in cases and suffer needless deaths. [ 347]

As of March 16, 2021, Canada has experienced 913,047 coronavirus cases and 22,495 deaths. [348] Given Canada’s population of 37.59 million is approximately 11% of United States’ population of 328.2 million) Canada’s Covid experience is lower than the US experience - i.e. Canada’s Covid-19 cases is roughly 3% of the US experience and 4% of the US deaths. In terms of the trend line (see adjacent graph from Statista) , Canada mirrored the US trend line with the exception that Canada did not have the Summer Surge (the 2nd wave in the U.S).

A superficial glance at the graphs illustrates the similarities between the U.S. and Canada as both countries experienced a 3rd surge in Covid daily new cases and a subsequent decline/levelling. Any initial hopes that the virus may be on its way out were dashed by Dr. Fauci’s interview in which he cautioned that the decline/leveling of new daily cases may be a precursor to another increase due to the variants.

 â€œNumbers lend perspective. They allow for rankings. But they can’t measure the true extent of loss. Pictures are insufficient. Words fail.”

The LA Times, in an article “ More U.S. deaths than World War I and Vietnam: How COVID-19 compares with other deadly events” tried to convey the death toll of Covid-19 in one year. The following Figure 7 is a comparison of the death tolls of various U. S. wars, epidemics, attacks and disasters. In the end, the author, Mark Z. Barabak, said “Numbers lend perspective. They allow for rankings. But they can’t measure the true extent of loss. Pictures are insufficient. Words fail.”

I included Figure 7 (U.S. deaths from wars, epidemics, attacks and disasters) because the deaths from Covid-19 (548,013 as of March) will continue to increase - this chart is a work-in-progress. I expect the Covid-19 deaths to surpass the deaths from the 1918 influenza and AIDS to become the new worst “deaths from wars, epidemics, attacks and disasters”.

Unless we have had a relative or friend infected or died because of Covid-19, it’s just a statistic - as Joseph Stalin said “ A single death is a tragedy, a million is a statistic”

“Death is now everywhere and yet nowhere in America. We track its progress in daily bar graphs. We note its latest victims among celebrities and acquaintances. Yet, in many parts of America, we carry on — debating holiday plans, the necessity of mask mandates, how seriously to take the virus, whether it’s all a hoax.” [ 349]

Hangover from early misinformation about the severity of the disease

Although the ‘facts’ such as the following published by the Harvard Health Publishing website should scare these non-believers, we know from other studies that you can’t convince ‘deniers’ with facts and data:

“Some people infected with the virus have no symptoms. When the virus does cause symptoms, common ones include fever, body ache, dry cough, fatigue, chills, headache, sore throat, loss of appetite, and loss of smell. In some people, COVID-19 causes more severe symptoms like high fever, severe cough, and shortness of breath, which often indicates pneumonia.

"People with COVID-19 can also experience neurological symptoms, gastrointestinal (GI) symptoms, or both. These may occur with or without respiratory symptoms. For example, COVID-19 affects brain function in some people. Specific neurological symptoms seen in people with COVID-19 include loss of smell, inability to taste, muscle weakness, tingling or numbness in the hands and feet, dizziness, confusion, delirium, seizures, and stroke. In addition, some people have gastrointestinal (GI) symptoms, such as loss of appetite, nausea, vomiting, diarrhea, and abdominal pain or discomfort associated with COVID-19.” [350]

“If we could watch what’s really going on in hospitals, there would be no more complacency.”

Roxanne Khamsi wrote an article with the subtitle “If we could watch what’s really going on in hospitals, there would be no more complacency.”

“We rarely saw patients as they gasped for breath. We rarely saw the suffering up close. Surely that’s due, in part, to our culture of death denial; but the dearth of more intimate, macabre videos and images is also a function of our medical privacy laws, which prevent hospitals from disclosing data such as identifying information from a patient.” [351]

Covid ‘Long Haulers’ are becoming the long term legacy of the coronavirus...

Although most people (about 80%) recover from the disease without needing special treatment, one European study found about one-third of 1,837 nonhospitalized patients reported being dependent on a caregiver about three months after symptoms started. ” [352] Ed Cara, in his article “The Challenges of Unravelling Long Covid”, noted "They call themselves long-haulers, and they number in the thousands across the country. Their symptoms include brain fog, shortness of breath, fatigue, muscle weakness, heart palpitations, and mood and sleep disturbances. Many have been unable to return to their normal daily activities.

"One study found that 75 percent of hospitalized COVID patients still had symptoms six months after discharge. But long-term symptoms don’t just affect those who were hospitalized; some long-haulers had only a mild initial infection, but continue to battle its effects months later.” [353]

What do we know that we don’t know

Known unknown:   New surge of Covid-19 cases ... We know Covid-19 cases in the United States and Canada are rising again, which public health experts fear/warn the country could face another “avoidable” surge in Covid-19 cases. “The director of the Centers for Disease Control and Prevention (CDC) on Monday warned of “impending doom” over rising coronavirus cases, telling the public that even though vaccines are being rolled out quickly, a fourth surge could happen if people don’t start taking precautions..” [ 354] What we don’t know is ‘is anyone listening’ to these warnings and willing to maintain the standard public health measures- “DR. FAUCI: Well, you know, the variants are playing a part, but it is not completely the variants. What we’re likely seeing is because of things like spring break and pulling back on the mitigation methods that you’ve seen. Now, several states have done that. I believe it’s premature ... you’re really in danger of a surge coming up.”[355]   

Known unknown:   Increasing awareness of “Long Covid-19 or Long Haulers” - We know medical experts are identifying an increasing number of ‘long haulers’. Devi Sridhar, one of Britain’s foremost experts on global health, pointed to a gaping hole in our knowledge about the affects of Covid-19 on the 15 percent of people who end up with severe symptoms: â€œThe one thing she says she did not see coming was what has become known as “long Covid” — the lingering damage wrought by the virus. What we don’t know is how many people will need rehab, physio, ongoing health care, or for how long,” she said.” [356]

3.2 The coronavirus variants are “more infectious and, in many cases, more deadly”

“The virus is doing what viruses do: evolving to find new ways to continue to infect people.” [357]

The manner in which investigators studying the coronavirus and its variants described the emergence of variants is akin to what one would expect from the renowned science fiction writer Isaac Asimov where they anthropomorphize the virus in some plot to take control of humanity - e.g. â€œmay have evolved enough changes to its spike proteins that help it escape the vaccine”.... “the virus outwits the human immune system”...it’s probably just getting into a more intimate relationship with our species.”

“It’s infected millions of humans around the world now, and it’s probably just getting into a more intimate relationship with our species,” says Jeremy Kamil of Louisiana State University, who spotted a mutation that the virus appears to have evolved repeatedly in different parts of the United States.[358]

Psychology Today claims we anthropomorphize because “Attributing human intent to non-human animals, spirits, robots, or other entities, real or imagined, is one way that people make sense of the behaviors and events that they encounter.” [359]. Although the immunologists, infectious-disease researchers and virologists working on the coronavirus haven’t gone as far as giving these variants male or female names (as meteorologists do with hurricanes), they have captured the notion of prescient entities fighting the effects of vaccines in their struggle to survive.

The MAYO Clinic describes variants in a less anthropomorphic manner:

“Variant basically means a mutation that occurs in the virus over time. So just with natural evolution over time, as the virus infects people, it has the opportunity to replicate its genome, and every time it replicates its genome, there are chances for errors or mutations to occur.” [ 360]

The American Association for the Advancement of Science is equally clinical in their explanation of variants:

“All viruses mutate as they make copies of themselves to spread and thrive. SARS-CoV-2, the virus the causes COVID-19, is proving to be no different. There are currently more than 4,000 variants of COVID-19, which has already killed more than 2.7 million people worldwide during the pandemic.” [ 361]

Variants are an issue if they are more transmissible, more severe and resistant to vaccines and therapeutics

The immunologists, infectious-disease researchers and virologists are concerned about three aspects of variants: 1. Transmissibility - will the variant spread easier/faster from one person to another?; 2. Severity - will it cause more severe effects/symptoms in the patients it infects and will it cause more deaths?; 3. Impact on/of vaccines and therapeutics - will existing vaccines and therapeutics be less effective in treating the variant? [362]

The MAYO Clinic offered a note of reassurance on their website when they published the following:

“COVID-19 vaccines were developed based on the SARS-CoV-2 S protein before it had the mutations identified in these variants. While research suggests that COVID-19 vaccines have lower efficacy against the variants, the vaccines still appear to provide protection against severe COVID-19. Further research is needed. In addition, vaccine manufacturers are also creating booster shots to improve protection against variants.” [363]

7 variants of concern whose names are indistinguishable from stealth bombers

The MAYO Clinic provided the following description of seven variants [364]:

1. “U.K. (B.1.1.7). This COVID-19 variant appears to spread more easily and might have an increased risk of death.“A fast-spreading variant, known as B.1.1.7, was identified in December in the U.K., leading to travel restrictions and a widespread lockdown there. Since then, the U.K. variant has been detected in China and other countries, as well as in Colorado, California and Florida. Britain’s top scientific adviser said preliminary studies show that the U.K. variant might be 30% to 40% deadlier than previous variants.” [365]

2. South Africa (B.1.351). This variant appears to spread more easily. It also has a moderate impact on the effectiveness of monoclonal antibody medications and moderately reduces the effectiveness of antibodies generated by a previous COVID-19 infection or COVID-19 vaccine.“In South Africa, meanwhile, doctors and researchers battling a second surge of Covid-19 cases are studying another new variant and what role it plays in the rising tide of cases there. The variant, known as B.1.351, has been identified in samples dating back to October. It hasn’t been detected in the U.S. Emerging data suggests that this variant could be better at evading antibodies, the protective immune-system proteins that keep viruses from entering cells, and that existing vaccines may need to be updated in order to be effective. [366]

“Since the variant escapes immunity the body will not be able to fight the virus. “We’re starting to see the South Africa variant here in the U.S.,” he said.”[367]

3. Japan/Brazil (P.1). This variant has a moderate impact on the effectiveness of monoclonal antibody medications. It also reduces the effectiveness of antibodies generated by a previous COVID-19 infection or a COVID-19 vaccine.“P.1 has been designated a “variant of concern,” indicating evidence of increased transmissibility, and potential for more severe disease and reduced effectiveness of vaccines or other treatments. P.1 is considered to be highly contagious, and has even led to some cases of reinfection in persons who had already recovered from Covid-19. To date, at least 48 cases of the variant have been reported in over 16 states, and is now present in at least 25 other countries.

While experts have been predicting that variants will soon compromise the major source of infection in the U.S., the nation has been engaged in an ongoing race to vaccinate as many people as possible before that occurs.” [368]

4. U.S. (California) (B.1.427). This variant appears to spread more easily. It also has a significant impact on the effectiveness of some treatments and moderately reduces the effectiveness of antibodies generated by a previous COVID-19 infection or COVID-19 vaccine.

5. U.S. (California) (B.1.429). This variant appears to spread more easily. It also has a significant impact on the effectiveness of some treatments and moderately reduces the effectiveness of antibodies generated by a previous COVID-19 infection or COVID-19 vaccine.

6. & 7. The U.S. Centers for Disease Control and Prevention is also monitoring two variants identified in New York — B.1.526 and B.1.525 — and another variant identified in Brazil — P.2.

“The UK, South Africa, and Brazil variants are more contagious...”

“The UK, South Africa, and Brazil variants are more contagious and escape immunity easier than the original virus,” said Victor Padilla-Sanchez, a research scientist at The Catholic University of America. “We need to understand why they are more infectious and, in many cases, more deadly.”All three variants have undergone changes to their spike protein -- the part of the virus which attaches to human cells. As a result, they are better at infecting cells and spreading.” [369]

‘We now have two pandemics’

The Washington Post described the emergence of a 2nd pandemic as a loss of euphoria - “Then, the euphoria dissipated. The illusion — or, as one scientist puts it, the delusion — that science had bested the virus crumbled as mutation-ridden variants with concerning new characteristics were detected.” Just when Moderna and Pfizer vaccines were approved and being mass produced for distribution, the path to Nirvana became longer and Gordian:

“We now have two pandemics,” said Peter Juni, director of the science table and a professor of medicine and epidemiology at the University of Toronto. “The traditional pandemic, which is under control, and the new pandemic, which is not under control.” [370]

“For millions of unvaccinated Americans, however, the variants pose a heightened danger".

The emergence of two pandemics, prompted virologists and public health experts to re-issue/reinforce their warnings about the need for vaccinations and the continued need to wear face masks, practice physical/social distancing and avoid large gatherings to the point that these messages risk being ignored. This ‘bad’ of vaccine hesitancy is dealt with in a later section.

“For millions of unvaccinated Americans, however, the variants pose a heightened danger. More transmissible variants mean that activities such as travel, shopping, socializing, and dining carry a higher risk of infection; if individuals infected by variants do become ill, they may be less likely to benefit from existing therapies. This spring, people who haven’t been vaccinated—the vast majority of Americans—have reason to be concerned. The variants may well provoke another viral surge, especially as governors rush to reopen states and discontinue mask mandates. ” [371]

What do we know that we don’t know

Known unknown:      We know the UK, South Africa, and Brazil variants are the most transmissible and severe.” The most recent data tabled with Ontario’s science advisory table indicates “that variants substantially increase the risk of serious illness when compared to the initial strain of SARS-CoV-2, including: 60 per cent increased risk of hospitalization; 100 per cent increased risk of being admitted to an ICU and 60 per cent increased risk of death.”

What we don’t know is how pervasive they may become. The Washington Post was pessimistic in its article “Variants mean the coronavirus is here to stay — but perhaps as a lesser threat.

What we also don’t know is whether people with existing immunity are still protected and whether the existing vaccines still work. The STAT article, by Andrew Joseph, “What we now know- and don’t know- about the coronavirus variants”, notes “Scientists are testing vaccines against the mutations and variants, and results should be available in the coming weeks. But many experts have a fairly optimistic outlook on the vaccine question.... And even if a mutation reduces the vaccines’ effectiveness a bit, the shots have been shown to be so powerful that they should work just fine even if their potency is taken down a notch.”

3.3 “Vaccinations are being treated as a get out-of-covid free card”

We have FDA approvals for emergency use of the Moderna, BioNTech Pfizer, and Johnston and Johnston vaccines[371] AstraZeneca and Johnston and Johnston vaccines are being paused and assessed because of reported blood clots. The public perception is that we are on the way to getting back to normal.

“John Bell, an Oxford University medicine professor, told the BBC last week he expected society to return to pre-pandemic life by spring”

The roll-out of the vaccines and the nation-wide efforts to vaccinate enough of the population to get to the nirvaana of ‘herd immunity’ is resulting in a collective optimism that the return to normal is just around the corner:

“Dr. Anthony Fauci, the top infectious disease official in the U.S., told CNN on Sunday that he sees the country returning to a more normal version of life by between April and July, if “the overwhelming majority of people” elect to be inoculated.” [372]

“Ugur Sahin, a co-founder of BioNTech, Pfizer’s partner in developing its vaccine candidate, told the BBC’s Andrew Marr Show on Sunday that he believes that things could feel more normal in a year’s time, and thanks to vaccine efforts “we could have a normal winter next year.”[373]

“John Bell, an Oxford University medicine professor, told the BBC last week he expected society to return to pre-pandemic life by spring, adding “I am probably the first guy to say that, but I will say that with some confidence.” [374]

“University of Liverpool’s Julian Hiscox told the BBC in October “we won’t be ‘back to 2019’ for five years,”

There are nagging misgivings about any optimistic forecasts:

“However, the University of Liverpool’s Julian Hiscox told the BBC in October “we won’t be ‘back to 2019’ for five years,” saying the initial vaccines may not be perfect and that they “won’t necessarily” reduce the spread of the virus beyond a level at which the pandemic eases from a crisis state, but at which we’ll still need to wear masks and socially distance for years until better vaccines are developed.” [375]

A number of epidemiologists are having second thoughts about the reliance on herd immunity

The fundamental premise of the ‘nu normal’ was that vaccines would be able to deliver herd immunity at which point the pandemic would disappear and life would be good again. But a number of epidemiologists are having second thoughts. The main reasons for their rethinking the role of herd immunity in the path to the ‘nu normal’ are:

1. It’s unclear whether vaccines prevent transmission

“The COVID-19 vaccines developed by Moderna and Pfizer–BioNTech, for example, are extremely effective at preventing symptomatic disease, but it is still unclear whether they protect people from becoming infected, or from spreading the virus to others. That poses a problem for herd immunity.” [ 376]

2. It’s unclear how long SARS-CoV-2 immunity lasts

“ Data on immunity to other coronaviruses suggest that immunity to SARS-CoV-2 might be short lived, perhaps 12–18 months in duration. Whether past infection will prevent severe COVID-19 on re-exposure to SARS-CoV-2 is not known at present.” [377]

“Researchers know little so far about how long SARS-CoV-2 immunity lasts. One study of recovering patients found that neutralizing antibodies persisted for up to 40 days after the start of infection; several other studies suggest that antibody levels dwindle after weeks or months.” [378]

3. Irregular/uneven/unreliable vaccine roll-outs globally will leave reservoirs of the virus as sources of infections

“Across the United States, access to vaccines has been uneven. Some states, such as Georgia and Utah, have fully vaccinated less than 10% of their populations, whereas Alaska and New Mexico have fully vaccinated more than 16%. ...If it’s not possible to vaccinate children, many more adults would need to be immunized to achieve herd immunity, Bansal says. (Those aged 16 and older can receive the Pfizer–BioNTech vaccine, but other vaccines are approved only for ages 18 and up.) In the United States, for example, 24% of people are under 18 years old (according to 2010 census data). If most under-18s can’t receive the vaccine, 100% of over-18s will have to be vaccinated to reach 76% immunity in the population.” [ 379]

4. At the current pace of 14.5 million a day (global rate of vaccination), it would take years to achieve a significant level of global immunity

“Anthony Fauci, the top infectious-disease official in the U.S., has said that vaccinating 70% to 85% of the U.S. population would enable a return to normalcy. On a global scale, that’s a daunting level of vaccination. At the current pace of 14.5 million a day, it would take years to achieve a significant level of global immunity. The rate, however, is steadily increasing, and new vaccines by additional manufacturers are coming to market. ... It’s now a life-and-death contest between vaccine and virus. New strains threaten renewed outbreaks. In the early stages of a campaign, the effect of vaccinations are often outweighed by other factors of transmissibility: virus mutations, seasonality, effectiveness of mask use and social distancing.” [380]

5. Cases are on the rise again in several US states, despite the rapidly accelerating vaccine program

“ In a briefing yesterday, CDC director Rochelle Walensky made a plea to Americans to keep following public health measures, saying she had a “recurring feeling” of “impending doom.” The increase in US cases is most likely due to the effect of the more transmissible UK variant. The growing spread of variants makes it even more urgent for as many as people as possible to get vaccinated—not only in the US, but in countries around the world. Many countries are yet to vaccinate anyone. The more the virus is allowed to spread, the higher the chance of variants emerging—and potentially variants that can escape existing vaccines.” [ 381]

6. New variants change the herd-immunity equation

“... new variants of SARS-CoV-2 are sprouting up that might be more transmissible and resistant to vaccines. “We’re in a race with the new variants,” says Sara Del Valle, a mathematical and computational epidemiologist at Los Alamos National Laboratory in New Mexico. The longer it takes to stem transmission of the virus, the more time these variants have to emerge and spread, she says” [ 382]

“New viral variants have complicated the picture. They can threaten our ability to achieve herd immunity in two ways. More transmissible variants (with a higher R?) mean more people will need to be vaccinated. They can also directly affect vaccine efficacy, which we’ve seen in South Africa.” [ 383]

These reservations by the epidemiologists are not shared by the general population. The Atlantic described the attitude of the general population as one of “Even as infection rates tick up again, people are bending, stretching, and breaking the rules governing how they should act around others ...Slowly but surely, we’re losing our grip.” [384]

“Amid all the fudging, that sentiment is starting to become a constant refrain: Really, what’s the harm?”

In a recent GALLOP survey, the survey found that Americans are reducing their physical/social distancing practices - “Compared with a year ago, when almost every state had issued stay-at-home orders, the percentages avoiding these places[stores and restaurants] are down roughly 30 percentage points.” [385] The Atlantic described this ‘fudging’ behaviour as a rationalization - “What difference is a few days going to make?”:

“But across the country, states are rushing to lift mask mandates, tolerance for physical distancing is flagging, and vaccinated people are amending the new guidelines as they see fit. Some, like our would-be dinner-party hosts, are planning mixed-vaccination events, and pushing the boundaries of what makes a gathering “small.” Others are holding birthday bashes, or starting to creep back to in-person work. People are also shaving time off the two-week period that the CDC advises waiting after the final shot, so that immunity can mature. “What difference is a few days going to make?” a friend asked me the other day. [386]

The problem is the change in behaviour. Before the vaccines, more people were practicing physical social distancing, wearing a face mask and avoiding gatherings. Now they are reverting to their pre-Covid-19 behaviour and increasing their (and our) risks.

What do we know that we don’t know

Known unknown:   We know that the Moderna, BioNTech, Pfizer and the Johnson & Johnson vaccines have received FDA approvals for emergency use and are being used to vaccinate increasing percentages of the US and Canadian populations - beginning with the most vulnerable and health care workers. Vaccines with a high degree of efficacy in preventing infection. The unknown is whether vaccines prevent transmission, how long SARS-CoV-2 immunity lasts and how effective they will be in treating the new variants.

"Public health authorities have been stressing that the new variants aren’t solely responsible for the raging epidemics happening around the world. ...the most recent surge in cases was driven not by a more transmissible round of the virus, but because of lax policies and a lack of precautions... Slowing spread can buy time for more people to get vaccinated before one of the more transmissible variants becomes dominant... And the more the virus spreads, the higher likelihood that even fitter variants will emerge. Evolution is driven not only by the environment the virus finds itself in, but also, as Barclay put it, “the number of times you roll the dice.”[387]

3.4 Vaccine Hesitancy - “Mistrust of a Coronavirus Vaccine Could Imperil Widespread Immunity”

“What do you think?” I asked. “There’s no effing way I’m getting a vaccine,” she said.” [388]

“The vaccines won’t help us get back to normal if we can’t get enough people to take them,” said School of Public Health Dean Shawn Gibbs.” [389]

“Among those who do not plan to take a vaccine, many also believe that COVID-19 is not a serious threat. It will be very difficult to convince these individuals to take a vaccine. The efficacy, safety,country-of-origin, type of vaccine, and other characteristics of a hypothetical vaccine simply do not matter to this population, whereas for other Canadians these characteristics are critical for their decision to vaccinate or not.” [390]

The World Health Organization (WHO) defined vaccine hesitancy as a “delay in acceptance or refusal of vaccination despite availability of vaccination services, which can vary in form and intensity based on when and where it occurs and what vaccine is involved.” The WHO also identified vaccine hesitancy as one of the top global health threats in 2019. [391]

“Survey says...”

Public opinion polls/surveys of Americans’ willingness to accept a COVID-19 vaccine have found approximately 30%-50% resistant/reluctant to getting the jab:

“Though estimates vary, public health officials suggest that about 80 to 85% of Americans would need to be vaccinated for the country to achieve herd immunity. Vaccine confidence seems to be rising, but recent polling suggests that about 31% of Americans wish to take a wait-and-see approach, and about 20% remain quite reluctant.”[392]

“The proportion of adults in the country who intend to get vaccinated has increased significantly over the last several months, according to a survey released Friday by the Pew Research Center. 69% of the public now plans to get vaccinated — or already has...” [393]

The Kaiser Family Foundation COVID-19 Vaccine Monitor, that tracks the public’s attitudes and experiences with COVID-19 vaccinations, found a similar pattern:

“About a quarter (27%) of the public remains vaccine hesitant, saying they probably or definitely would not get a COVID-19 vaccine even if it were available for free and deemed safe by scientists. Vaccine hesitancy is highest among Republicans (42%), those ages 30-49 (36%), and rural residents (35%). Importantly, 35% of Black adults (a group that has borne a disproportionate burden of the pandemic) say they definitely or probably would not get vaccinated, as do one third of those who say they have been deemed essential workers (33%) and three in ten (29%) of those who work in a health care delivery setting.” [394] 

Knowable Magazine reported “Hesitancy rates are falling but they’re still sizable, especially among certain groups. Easy access and trusted community messengers are keys to moving the needle.” The question becomes ‘is that enough to achieve herd immunity? [395]

An Angus Reid survey of Canadian respondents (Jan, 2021) found similar support for vaccination:“...the increased willingness for an early vaccination seems to have come mostly from those who previously indicated they would wait a while, with a slight number coming from both the unsure, and refusal segments.” [396]

“In pockets of vaccine hesitancy, the coronavirus could continue to spread, kill, mutate, and escape”

Derek Thompson, in an article for The Atlantic, made a convincing case that vaccine hesitancy is not just one problem but rather a disparate collection of problems that are going to require “a portfolio of approaches to solve it.”[ 397] Derek Thompson used a rather different typology for describing the different reasons underlying vaccine hesitancy:

Dissent. Deliberation. Distrust. Indifference.

” I call it vaccine dissent,”

” I call it vaccine dissent,” Kolina Koltai, who studies online conspiracy theories at the University of Washington. It’s way more complicated than being anti-vaccine. It goes from highly educated parents who are interested in holistic, naturalistic child-rearing to conspiracy theorists who want to abolish vaccines entirely.”[ 398]

‘Intensive parenting’ is described by a Frontiers in Psychology article as parents who “feel more capable of taking care for the children without expert intervention or vaccines.”:

. ... research shows that intensive (salutogenic) parenting was an important rationale for refusing vaccines, as salutogenic parents have higher sense of advocacy and feel more capable of taking care for the children without expert intervention or vaccines.” [399]

The conspiracy theories regarding Covid-19 vaccinations

“An out-of-context real video from the BBC has circulated social media, with vaccine conspiracy theorists claiming it shows proof that vaccines are fake and that recent events intended to increase public trust are staged. The BBC explains that the clip is from a segment showing a health care worker using a safety syringe, whose needles spring back inside after a shot to prevent accidental pokes.” [400 ]

“ In some instances, vaccine-hesitant activists are manufacturing stories of deaths related to the vaccine that never happened. These groups are also latching onto reports of real deaths following the shot, blaming the vaccine and disregarding medical information that other causes are to blame.” [ 401]

47% of Republican adults would probably would not get the COVID-19 vaccine or they definitely would not get it.

The Robert Wood Johnson Foundation and Urban Institute reported new data from a survey of just shy of 8,000 non-elderly adult patients that revealed 47% of Republican adults would probably would not get the COVID-19 vaccine or they definitely would not get it.

“But there is another group emerging that could cause concern for public health officials working to drum up vaccine enthusiasm. Forty-seven percent of Republicans expressed some level of vaccine hesitancy, with 23 percent saying they probably would not get the COVID-19 vaccine and 24 percent saying they definitely would not get it. That is just two percentage points lower than vaccine hesitancy rates among Black adults.” [402]

“Today, resistance among the GOP seems to be the most significant problem for vaccinating the country. Just half of Republicans say that they plan to get the shot, while the share of pro-vaccine Democrats has increased to more than 80 percent.” [403]

But The New England Journal of Medicine cautioned against simply crafting messaging campaigns based on a Republican/Democrat duality:

“This is not a simple case of red-state/blue-state duality. Some elderly Republicans, for example, are quietly worried by their party’s failure to take the pandemic seriously, but are afraid to rock the boat; other elderly Republicans are defiant in their assertion of fearlessness. No common persuasive message will work for both groups: highlighting the virus’s danger would scare the former group but might reinforce the latter’s defiance.” [404]

“I call it vaccine deliberation,”

“I call it vaccine deliberation,” said Giselle Corbie-Smith, a professor at the University of North Carolina and the director of the UNC Center for Health Equity Research. “For Black and Brown people, this is a time of watchful waiting. It’s a skepticism of a system that has consistently demonstrated that their health is not a priority.”[ 405]

From a purely numbers perspective, Black and Hispanic people represent significant percentages of vaccine-hesitant adults - the Robert Wood Johnson Foundation and Urban Institute survey found “Black people comprise 18 percent of all vaccine-hesitant adults and Hispanic people 17 percent of all vaccine-hesitant adults”. The size of these demographic segments has resulted in research into the reasons for this hesitancy in the hopes of finding solutions that will overcome this resistance.

One source of hesitancy is concerns about the vaccine’s safety:

“Last month, the N.A.A.C.P., in conjunction with two other organizations, released a report, “Vaccine Hesitancy in Black and Latinx Communities,” which found that just fourteen per cent of African-Americans surveyed “mostly or completely trust” the vaccine’s safety. ... the N.A.A.C.P.’s report notes that only four per cent of Blacks trust the Administration; that distrust has apparently bled into perceptions of the vaccine.” [406]

One has to acknowledge the legitimacy of this concern about the safety of these vaccines when Dr. Douglas L. Mann, Editor-in-Chief, JACC: Basic to Translational Science says “Although the RNA vaccines appear to be safe in carefully monitored clinical trials, the stark reality is that we know very little about the long-term safety of RNA vaccines.’ [407]

Another source of hesitancy is the past abuse suffered at the hands of the medical community itself. For example, articles repeatedly refer to the infamous Tuskegee experiment:

“... the Tuskegee experiment. In that four-decade-long medical scheme, which began in 1932, nearly four hundred African-American men with syphilis were led to believe that they were receiving treatment, but were, in fact, left untreated, so that doctors could chart the course of the disease. In the nearly fifty years since the experiment was exposed, it has become a central reference point for understanding Black Americans’ relationship to the medical establishment. ... That history, chronicled in works such as Harriet Washington’s “Medical Apartheid” and Dorothy Roberts’s “Killing the Black Body,” is, in part, what hampered efforts to recruit African-American volunteers for the trials, and now hampers efforts to get African-Americans vaccinated.” [408]

The New England Journal of Medicine waded into these waters of race and made a case for recognizing the day-to-day racism black adults face in dealing with the health care systems:

“But attributing distrust primarily to these instances ignores the everyday racism that Black communities face. Every day, Black Americans have their pain denied, their conditions misdiagnosed, and necessary treatment withheld by physicians. In these moments, those patients are probably not historicizing their frustration by recalling Tuskegee, but rather contemplating how an institution sworn to do no harm has failed them. As Harvard historian Evelynn Hammonds told the New York Times, “There has never been any period in American history where the health of Blacks was equal to that of whites. Disparity is built into the system,” so we must acknowledge how medical history has institutionalized racism. But fixation on specific historical abuses distracts from the larger narrative of everyday contributions to distrust.” [409]

These references are barely scratching the surface of the Black community’s vaccine hesitancy. These brief references are acknowledgements/place-holders for this aspect of racial injustice. The space limitations of this article prevent a more fulsome treatment of the root causes and potential solutions.

“Hesitancy and distrust regarding the entire government,”

“It’s not vaccine hesitancy among American Indians, but rather hesitancy and distrust regarding the entire government,” said Margaret Moss, an associate professor at the University of British Columbia School of Nursing and an enrolled member of the Three Affiliated Tribes of North Dakota. “After decades of distrust, on top of centuries of genocide, now they appear and say, ‘Here, you have to take this!’ [410]

Although Margaret Moss centered her comments on American Indians, other articles describe vaccine distrust as a component of Black people’s vaccine hesitancy:

“Here in Toronto and across North America, Black people have the highest positivity rates for COVID, the lowest access to testing and the lowest acceptance of the vaccine as a shield against the virus. When Public Health Canada surveyed citizens and asked if they planned to take the vaccine, two-thirds of white people said yes, the Indigenous population was split 50-50. Blacks? Just one in three planned to roll up their sleeves.”

The reasons are voluminous and rooted in a history of racism that created the landscape ripe for positive tests — call it pre-existing conditions. And the lack of trust and vaccine hesitancy is grounded in a litany of stories of how when Black people intersect with the scientists in lab coats, somehow Black folk end up more like lab rats than other people do.” [411]

“Let’s not forget vaccine indifference”

“Let’s not forget vaccine indifference. Two-thirds of Republicans under 30 without a college degree say that they are “not concerned at all” about COVID-19 in their area, according to polling from Civiqs. The same percentage of this group says that they won’t take the vaccine, making them the most vaccine-resistant cohort among all of those surveyed.” [412]

Dr. Douglas L. Mann, in his article “Now That We Have an Effective Vaccine for COVID-19, Will It Also Inoculate Us Against the Virus of Indifference?”, raised the issue of ’indifference’ by quoting from a recent speech of Pope Francis: “Pope Francis warned recently that “indifference is a virus that is dangerously contagious in our time . . . for it is indifference that paralyzes and impedes us from doing what is right even when we know that it is right”...

Johnson & Johnson’s vaccine discovery of six cases of blood clots

The specter of blood clots from Johnson & Johnson’s vaccine, no matter how small, exacerbates vaccine hesitancy, especially following the problems with AstraZeneca:

“The pause in the use of the Johnson & Johnson COVID-19 vaccine announced Tuesday is virtually certain to exacerbate vaccine hesitancy, dealing a fresh blow to the nation’s efforts to recover from the pandemic.” The real danger of the Johnson & Johnson news, Wilson suggested, lay not in its capacity to reinforce the views of hardline skeptics and conspiracy theorists, but in its potential to weigh on those who are ambivalent.

“The biggest element in terms of the J&J fallout is likely to be an increase in hesitancy levels among those who think, ‘Maybe they are telling me it’s only a small chance but blood clots are very bad,’ ” he said, adding that humans are notoriously bad “at evaluating low-probability events.” [413]

“It is a constellation of motivations, insecurities, reasonable fears, and less reasonable conspiracy theories.“

“Vaccine hesitancy” isn’t one thing, they said. It is a constellation of motivations, insecurities, reasonable fears, and less reasonable conspiracy theories.“You shouldn’t say that people are idiots for believing false or misleading information, because they’re not idiots,” she said. “That’s part of what makes this such a hard problem to solve.” [414]

What do we know that we don’t know

Known unknown:  We know the trends in vaccine hesitancy are indicating a decrease in the number of people resisting the jab, the pockets of hesitancy still persist, thereby threatening the 70% to 85% needed for herd immunity”....” What we don’t know is will there be a sufficient number to inhibit/stall/prevent the achievement of herd immunity. “A poll in late June by researchers at the University of Miami found that 22 percent of white and Latino respondents and 42 percent of Black respondents said they agreed with this statement: “The coronavirus is being used to force a dangerous and unnecessary vaccine on Americans.” [415 ]

Known unknown:   We know Republicans represent the most significant segment of resistance to vaccination. “Dr. Peter Hotez - We underestimated how powerful this is and the deadly consequences that it’s had for the American people, not only around anti-vaccine, but actually against science more broadly, because this is what led to defiance of masks and social distancing. The anti-science platform is now mainstream with the Republican Party.” [416] What we don’t know is will this segment continue this resistance and will it delay/stall herd immunity?

Grey Rhino:  We know vaccine hesitancy has been identified as the major barrier to reaching herd immunity. But until the rest of the world is vaccinated, the risk of possible contamination/infections from travellers from other countries, the global supply chains persists and from wildlife reservoirs. What we don’t know is when the wealthy western countries are going to get serious about donating surplus vaccines and/or funding to enable those countries to vaccinate their people. The U.S. and Canada have been struggling with the logistical challenges of delivering the vaccines they pre-purchased and really not paying much attention to this Grey Rhino that’s coming at us. “But globally unequal distribution will harm all of us – leaving reservoirs for the virus across the world in which new, potentially more dangerous variants will emerge and spread.” [417]

3.5 “Anti-vaxxers Think This Is Their Moment”- The Atlantic

“More lives have been saved by vaccines than any public health initiative, save clean water – yet millions of people worry that vaccines are a threat to themselves and their children. Such fears result in vaccination rates dropping, opening the door to outbreaks of preventable diseases such as measles, mumps and whooping cough.” [418]

The anti-vaxxers are not ‘lone wolves’ or isolated aberrations. They are an international community of believers, experts and advocates. They should not be dismissed out of hand because they have demonstrated their power/influence in getting parents to decline vaccinations for their children for preventable diseases such as measles, mumps and whooping cough. Clearly, anti-vaxxers and their movement are inhibiting/preventing the adoption of a desired behaviour (i.e. getting vaccinated to prevent spread of Covid-19) and therefore deserve being included in the category of ‘bad’.

“A paper falsely claiming that the measles, mumps, and rubella vaccine had the ability to cause autism”

Dr. Peter Hotez, a professor of pediatrics and molecular virology at Baylor College of Medicine, described the anti-vaxxers in an interview with The New Yorker:

“... But the modern piece of this really started to accelerate in the early two-thousands, after a paper by Andrew Wakefield and his colleague was published in The Lancet, falsely claiming that the measles, mumps, and rubella vaccine had the ability to cause autism. Back then they called it pervasive developmental disorder.

“That whole thing was debunked by a journalist for the Times of London, a guy named Brian Deer, who wrote a series of articles, first in the Times and then in the British Medical Journal, the BMJ. And that Lancet paper ultimately got retracted, but not until 2010. So that period enabled an anti-vaccine movement to flourish in the U.K., and then it took off in the United States... And then it really took off with Robert F. Kennedy and his anti-vaccine group, Children’s Health Defense, which became one of the first major national anti-vaccine groups.” [ 419]

The Archives of Disease in Childhood (an international and peer-reviewed journal specialising in child health) reported on a study by Davies, Chapman and Leask that examined the content of 100 antivaccination websites:

“Antivaccination groups sought to present themselves as legitimate authorities with scientific credibility: about one in four websites implied official status at national or international level...“Over half of all sites cited rank breaking doctors speaking out against vaccination. Implied division within the medical community reinforced the notion of a “debate” among authorities. One third of sites promoted themselves as sources of non-partisan information on both sides of the immunisation “debate”. Despite these claims a mere 15% contained any information supportive of vaccination. Only a third of sites had links to such sites.” [420]

“It is a well-organized public health destruction machine.” 

Anti-vaxxers are recognized by the public health community as more than a nuisance:

“This is a self-inflicted wound,” said Hotez, who has written a book about the anti-vaccine movement entitled “Vaccines Did Not Cause Rachel’s Autism.” “I have been trying to make the point now that the anti-vaccine movement is starting to inflict real public health damage. It’s taken a few years,” Hotez added.

“This should be a wake-up call that the anti-vaccine movement is not a fringe movement. It is a well-organized public health destruction machine.” [421] 

Anti-vaxxers and Covid vaccinations

The uncertainty/resistance of groups hesitating to get vaccinated provides an ideal environment for anti-vaxxers and their messaging:

“... these anti-vaccine groups staged anti-vaccine rallies in Harlem in 2019. So I think there was specific targeting of African-American groups. The movement targets specific groups. It went after the Somali-immigrant community in Minnesota in 2017, and it basically generated a measles epidemic. Then they went after the Orthodox Jewish community in New York in 2018, 2019. And they use very inflammatory, exploitative language, comparing vaccines to the Holocaust.”[ 422]

“Today’s anti-vaccine activists, however, enjoy a speed, scale, and reach far greater than those of Dr. Bond’s day. Bottom-up networked activism is driving the spread of anti-vaccine COVID-19 propaganda. Americans are about to see a deluge of tweets, posts, and snarky memes that will attempt to erode trust in the vaccine rollouts. Society’s ability to return to a semblance of normalcy depends on how effectively public-health authorities counter this misinformation and how assiduously media outlets and internet platforms refrain from amplifying it—but also on whether average Americans recognize that the material they click on and share has real-world consequences.” [423]

“They speculated, without providing evidence, that the vaccines could cause infertility in women”

Their misinformation spreads across international boundaries - “a survey by the Kaiser Family Foundation found that 13% of unvaccinated people in the United States had heard that “COVID-19 vaccines have been shown to cause infertility.”

“Late last year, a semi-retired British scientist co-authored a petition to Europe’s medicines regulator. The petitioners made a bold demand: Halt COVID-19 vaccine clinical trials. Even bolder was their argument for doing so: They speculated, without providing evidence, that the vaccines could cause infertility in women.

“Social media quickly spread exaggerated claims that COVID-19 jabs cause female infertility. Within weeks, doctors and nurses in Britain began reporting that concerned women were asking them whether it was true, according to the Royal College of Obstetricians & Gynaecologists. In January, a survey by the Kaiser Family Foundation (KFF), a non-profit organization, found that 13% of unvaccinated people in the United States had heard that “COVID-19 vaccines have been shown to cause infertility.” [424]

“Anti-vaccine activists tried to blame deaths of nursing home residents on vaccine”

“On a larger scale, anti-vaccine activists tried to blame deaths of nursing home residents, also from COVID-19, on vaccines – although the fatal outbreak began before vaccines were given, and the victims were unvaccinated.

“Other stories are less clear, but lack of clarity does not prevent anti-vaccine activists from seizing on them. For example, a report on the Norwegian Medicines Agency’s investigation of 23 deaths after the vaccine – with a cautious recommendation to consider not vaccinating the most frail patients, for whom even mild symptoms can trigger issues – became, on anti-vaccine sites, a claim that these 23 deaths were caused by the vaccines, which is not what the report from Norway claimed.” [425]

What do we know that we don’t know

Known unknown:  We know vaccine hesitancy is a barrier to herd immunity. Anti-vaxxers have the potential to reinforce the resistance of some individuals and groups to being vaccinated, NBC News in an older article remarked about anti-vaxxers as ”This should be a wake-up call that the anti-vaccine movement is not a fringe movement. It is a well-organized public health destruction machine.” [426] What we don’t know is will the anti-vaxxers be a significant force convincing people not to get vaccinated and if so, what can public health officials do about it? Sophie Mylan and Charlotte Hardman suggested “a more constructive perspective could view the anti-vax movement as a religious phenomenon, involving a whole spectrum of ideas, and focus on the essential need to understand the beliefs that are involved to avoid further marginalisation. Hence, implying that anti-vaxxers are beyond the reach of community engagement activities could result in increased anti-vax activities. We suggest a more inclusive approach, where the same inquisitive dialogue and contextual understanding that was suggested for vaccine hesitancy should be extended to members of the anti-vax movement.” [427]

3.6 “Covid-19 pandemic will become an endemic - meaning that it will continue to circulate in pockets of the global population for years to come”

If NATURE’S sample of 100+ immunologists, infectious-disease researchers and virologists working on the coronavirus are right - i.e. that the coronavirus won’t be eradicated, rather it will become endemic and like the flu, continue to circulate in pockets of the global population for years to come - we need to stop thinking we can eradicate it and come to grips with the facts that the coronavirus and some variant is here to stay. [428]

These experts argue that failure to wipe out the coronavirus does not mean we will have to live with the existing scale of its infections, hospitalizations, long haulers and deaths:

“The future will depend heavily on the type of immunity people acquire through infection or vaccination and how the virus evolves. Influenza and the four human coronaviruses that cause common colds are also endemic: but a combination of annual vaccines and acquired immunity means that societies tolerate the seasonal deaths and illnesses they bring without requiring lockdowns, masks and social distancing.” [429]

NATURE’S sample of immunologists, infectious-disease researchers and virologists were also quick to note that “Eradicating this virus right now from the world is a lot like trying to plan the construction of a stepping-stone pathway to the Moon. It’s unrealistic.” Furthermore “The virus becoming endemic is likely, but the pattern that it will take is hard to predict.”

“Endemic means when there is an infection within a geographic location that is existing perpetually.”

The Mayo Clinic defined the difference between the terms pandemic and endemic as “ A pandemic is when there is an outbreak that affects most of the world. We use the term endemic when there is an infection within a geographic location that is existing perpetually.”

“And even if it is no longer an immediate pandemic-level threat, the coronavirus will likely become endemic – meaning slow, sustained transmission will persist. The coronavirus will continue to cause smaller outbreaks, much like seasonal flu. ... The only disease that has been eradicated through vaccination is smallpox. ....” [430]

“This coronavirus is going to be here to stay,” explained Dr. John Brownstein, chief innovation officer at Boston Children’s Hospital. “Eradication of this new coronavirus is basically impossible.”... It is possible, experts say, that COVID-19 could become a seasonal illness, like the flu. Virologists call this an “endemic” disease -- one that is constantly circulating among us. ...” [ 431]

“... we are going to be in an arms race with this virus, just like we are with flu,”

Clinicians at Addenbrookes Hospital in Cambridge, UK, found...

“... along with others now being detected such as the South African and Brazilian variants, has shone a spotlight on how the coronavirus is mutating as the pandemic rumbles on. It has also raised concerns about how it might continue to change in the future as we try to fight it with vaccines.” [432]

“... we are going to be in an arms race with this virus, just like we are with flu,” says Michael Worobey, a viral evolutionary biologist at the University of Arizona. Each year the flu vaccine has to be updated as the influenza virus mutates and adapts to escape the immunity already present in the population, says Worobey. If the coronavirus shows similar capabilities, it could mean we will have to adopt similar tactics to keep it at bay, by regularly updating vaccines.” [ 433]

In addition to ‘pockets of the global population’, there are animal reservoirs

“As the virus is spreading around the world, it might find entirely new reservoir hosts [outside of] China,” says virologist Ralph Baric at the University of North Carolina, Chapel Hill. “We don’t know. It is something every country needs to be thinking about as the epidemics wind down.” [434]

This question of animal reservoirs for zoonotic diseases such as SARS indicated from the very beginning, that SARS was originated from animals - “Animal food handlers who handle, kill, or butcher “exotic” animals for food were over represented among early-onset SARS cases - These data pointed to the fact that animals being sold in markets as a likely source of the virus.” [435]

“Outside the lab, animals including pet cats and dogs, tigers and lions at zoos, and farmed mink have also caught the virus — probably from people.” [436]

But experts say that it’s possible the virus could take hold in a new species and build a redoubt for re-infecting people in the future.

A new strain is being reported in mink farms in Denmark and the Netherlands

One development that Baric and other scientists are closely watching is the emergence of new strains found on mink farms in Denmark and the Netherlands that have been shown to infect humans.

When a virus evolves in a way that allows it to circulate in an animal species, “it becomes more difficult to eradicate that virus,” he says.” [437]

“...Four influenza viruses in pigs that have some of the “building blocks” for a pandemic waiting to happen”

Most of us have forgotten about H1N1 virus. The H1N1 virus was spread by pigs from Mexico in January 2009. It spread to California and Texas and by June, it was in 74 countries. By 2010, just one year later, between 151,700 and 575,400 people had died from it. Although the H1N1 pandemic was brought under control by a massive global vaccine effort, the H1N1 virus is still with us - as the seasonal flu, causing sickness and deaths.

“To better understand what we’re up against, a massive collaboration has been taking place across 2,500 European pig farms, sampling more than 18,000 individual pigs....“So far, they have found four influenza viruses circulating which already have some of what they call the “building blocks” of a pandemic. They are viruses that can infect humans, have the potential to spread from human to human, and for which there is no vaccination or innate immunity.” [438]

“There are more than 827,000 viruses in the animal world that have the potential to infect humans”

Columbia’s Center for Infection and Immunity, has long been aware that the animal world is teeming with pathogens our immune systems have never experienced—a small, influential cadre of researchers who believe that such epidemics can be prevented—if viruses can be detected before they make the fatal leap.

“By one estimate, there are more than 827,000 viruses in the animal world that have the potential to infect humans. We encourage these spillovers whenever we cut roads through the wilderness, clear forests to grow crops, catch wildlife to sell as trophies or butcher for food, or pen chickens and swine in places where bats and wild birds can mingle with them.” [439]

Scientific American noted “Scientists have long warned that the rate of emergence of new infectious diseases is accelerating—especially in developing countries where high densities of people and animals increasingly mingle and move about.

“It’s incredibly important to pinpoint the source of infection and the chain of cross-species transmission,” ... to discover new viruses in wildlife... estimated that there are more than 5,000 coronavirus strains waiting to be discovered in bats globally.” [440]

“Widespread immunity eventually will end the Covid-19 crisis. But it won’t end wildlife-related pandemics”

The pandemic experts have been warning us that the current pandemic will persist (in spite of a vaccine that will be only 50% effective and which 30% of the population will be anti-vaxxers) well into 2021, and possibly longer. Furthermore, the continuing losses of biodiversity and intact ecosystems by large-scale conversion of land for agriculture, will release viruses in the animal world that have the potential to infect humans.

Comparisons of zoonotic diseases to the annual episodes of the flu trivialize the severity, morbidity and mortality of these alien viruses. Risk management would suggest that governing entities should include the probability of future pandemics in their analysis of the balancing act between shuttering economic activities to keep people alive and re-starting the economy, in whole or in part. The probability of future pandemics should be classed as an ‘unknown knowns’ - things that we know but remain hidden because of unconscious biases - “what we do not like to know”.

“Scientists agree that more viruses capable of causing a global pandemic will emerge, says Amesh Adalja of the Johns Hopkins Center for Health Security in Baltimore, who predicted respiratory RNA viruses were a particular threat a year before the emergence of Covid-19 — a respiratory RNA virus. Virologists are also worried about several flu viruses, and about the lethal Nipah virus of Asian fruit bats, which is evolving the ability to spread person-to-person. If nothing else, there are lots more coronaviruses — and probably infections we have no clue about yet.” [441]

Notwithstanding the inevitability of another zoonotic disease, Covid-19 as an endemic is “just another virus that we’ll have to live with”

“Erica Ollmann Saphire, professor at the La Jolla Institute for Immunology, says she thinks Covid will be “a permanent part of the human existence.” Here’s what that could mean for you:

? If Covid becomes endemic, people will fare better as a whole, and not get as sick from the virus;

? “Once the endemic phase is reached and primary exposure is in childhood, SARS-CoV-2 may be no more virulent than the common cold.”;

? That said, some people who have underlying conditions will still fare poorly from Covid, the same way that the cold or flu can lead to severe illness and death in certain populations;

? Covid could be another virus that we’ll have to live with — but the social distancing and mask wearing to the degree that we currently won’t be permanent;

? It’s possible that annual single-dose coronavirus booster shots will become the norm, just like you get an annual flu shot. If the virus mutates, vaccines will need to be updated to handle variants. [442]

What do we know that we don’t know

Known unknown:      We know we probably can’t eradicate Covid-19. “The only disease that has been eradicated through vaccination is smallpox. ....” [443] There are just too many reservoirs (human and animal) where the virus can survive and re-emerge to cause another round of infections. What we don’t know is will the prediction that the Covid-19 pandemic will become an endemic - “just another virus that we’ll have to live with”? Or will the variants keep Covid-19 flourishing and the pandemic continuing for years to come? “The worst may be over if too many people don’t let down their guard too fast, if the more dangerous variants don’t make cases surge before enough people get vaccinated, and if the vaccination campaign doesn’t stumble badly.” -[444]

Unknown known:  We know our governments are not dealing adequately with the countervailing force - vaccine hesitancy. Even if herd immunity remains theoretically within reach, 15 percent of Americans say they will never get a COVID-19 vaccine, making that threshold all the harder to hit.” [445] Although vaccine hesitancy is mentioned/acknowledged as a factor that can adversely affect herd immunity, the authorities are not launching programs at the scale needed. What we don't know is if this problem of vaccine hesitancy potentially/probably thwarting herd immunity fits Zizek’s ‘unknown knowns’ - what we do not like to know. Zizek tells us that the most important category of knowledge for humanity is the Unknown Knowns. An example of the ‘ Unknown known’ is the data that shows Black, Asian and minority ethnic group are more likely to contract and die of the virus than their white counterparts, but we have not been prepared to do anything substantial about it, except write articles about it.

Possible Grey Rhino:  Columbia’s Center for Infection and Immunity, has warned the animal world is teeming with pathogens [more than 827,000 viruses in the animal world that have the potential to infect humans] our immune systems have never experienced. We know that such epidemics can be prevented—if viruses can be detected before they make the fatal leap. What we don’t know is which species are the most likely potential reservoirs. â€œThe risk of the virus taking hold in a new species—and then those animals quietly hosting it for a while before passing it back to humans—is low, says Lin-Fa Wang, a virologist at Duke Global Health Institute in Singapore. But it’s still worth preparing for, Baric says, because the consequences could be a resurgence of the pandemic.... It is something every country needs to be thinking about as the epidemics wind down.” [446]

3.7 Vaccine nationalism -“My nation first”

“This pandemic won’t end at home until it ends worldwide.” - Secretary of State Antony Blinken

Vaccine nationalism is the natural desire and constitutional obligation of countries to protect their citizens from threats ‘both domestic and external’. Vaccine nationalism becomes problematic when wealthy governments sign agreements with pharmaceutical manufacturers to supply their own populations with vaccines while limiting/preventing the supply of vaccines to less wealthy countries. Given the limited capacity of the pharmaceutical industry, when a few wealthy countries get ‘a lock’ on the future supply of vaccines, the rest of the world is left without access to what has become a scarce commodity that they cannot afford.

“High-income countries have purchased 55 per cent of the worldwide vaccine supplies, even though they only account for 16 per cent of the world’s population; Ottawa, for its part, has contracts in place that total five times our population. This lopsided supply in favour of affluent nations means that poorer countries are not expected to have access to vaccines until 2023.” [447]

“ By one recent estimate, nations representing just one-seventh of the world’s population have already reserved more than half of all the promising vaccine supplies. According to leaked internal documents, funding and supply concerns have placed COVAX, the global initiative to share coronavirus vaccines, at “very high” risk of failure.” [448]

“...According to a new report, published in the British Medical Journal (BMJ), the US has secured 800 million doses of at least six vaccines in development, with an option to buy about one billion more. The UK has purchased 340 million shots: approximately five doses for each citizen. Although, on the surface, it may seem these countries have ordered more doses than they need, the truth is many of these orders were put in during trial phases of the vaccines when they did not know for sure which vaccines would be successful.” [449]

Vaccine nationalism is not just a moral question (Tedros Adhanom Ghebreyesus called it a “catastrophic moral failure”) but also an epidemiological one - “the risk in allowing the SARS-CoV-2 virus to remain rampant in some parts of the world is that it will have more opportunities to develop dangerous variant reservoirs, which will inevitably make their way elsewhere and may not be neutralized by existing vaccines.” [450]

“My nation first”

An examination of “my nation first” approach to developing and distributing potential vaccines or other pharmaceutical treatments, reveals just how far wealthy nations have gone to capture vaccines.

“No one expects governments with early access to forgo vaccinating vulnerable members of their populations first. These include frontline health-care workers, residents and staff of long-term care facilities, and essential workers. But the current signs suggest that wealthy nations will seek to vaccinate their entire populations, even low-risk individuals, before sharing their vaccine supplies with others.” [451]

This is not the first time

The Harvard Business Review, in their article “The Danger of Vaccine Nationalism”, described how high-income nations crowded-out poor countries in the procurement of vaccine for H1N1 virus (aka Swine Flu):

“In 2009, the H1N1 virus, also known as Swine Flu, killed as many as 284,000 people worldwide. A vaccine was developed within seven months, but most high-income countries turned to pharmaceutical companies within their own borders for production. High-income countries directly negotiated large advance orders for the vaccine, crowding out poor countries. Although several of those rich countries, including the United States, agreed to make vaccine donations to low- and middle-income countries, they only carried out these donations after ensuring they could cover their own populations first. As a result, the distribution of the H1N1 vaccine was based on high-income countries’ purchasing power, not the risk of transmission.” [452]

Hoarding more than just vaccines

Although the international attention was drawn to the Eu’s requirement that companies wanting to export their vaccines had to get approval from the country where the vaccine was being manufactured and from the EU itself, some restrictions were more subtle:

“Exports of syringes and hypodermic needles need approval. And both the Trump and the Biden administration have invoked the Defense Production Act to direct inputs towards vaccine-making. On March 4th Mr. Poonawalla [of India’s Serum Institute] said that such curbs were creating shortages of inputs for vaccine-making, including bags and filters.

“This is not the first time in the pandemic that governments have turned to trade restrictions. At their peak in April [2020] there were 137 export curbs on personal protective equipment 9PPE) and other medical products applied in over 70 jurisdictions... Many of these, which ranged from bans to authoritarian schemes, have been lifted...” [453]

The term ‘hoarding’ has pejorative connotations. Wikipedia explains - “The term “hoarding” may include the practice of obtaining and holding resources to create artificial scarcity, thus reducing the supply, to increase the price, so that they can be sold to customers for profit.” Economists see hoarding through a ‘price’ paradigm:

“Hoarding is widely criticized for creating real-economy shortages of goods. A process of speculation, self-fulfilling prophecies, and inflation can be generated through hoarding....Hoarding is sometimes blamed for shortcomings caused by price checks, fixed exchange rates, and other government policies.” [454]

Vaccine nationalism is a less pejorative term for hoarding.

Global transmission matters - ‘no one is safe until everyone is safe’

“If countries with a large number of cases lag in obtaining the vaccine and other medicines, the disease will continue to disrupt global supply chains and, as a result, economies around the world.” [455]

“Hoarding vaccines is a mistake. No nation is likely to end its epidemic with a vaccine alone. Roughly 70 percent of the population would need to be immunized to achieve herd immunity, an objective that remains unrealistic in the near term... The legacy of resentment against vaccine-hoarding nations will be intense, imperiling the future international cooperation needed to prevent the next pandemic..”[456]

“All countries have to remember that it is the virus, not each other, that is their foe. A nationalistic stance toward the pandemic will prolong this global health and economic crisis. A vaccine must be allocated on the basis of the best evidence of what will stop transmission and protect the most vulnerable groups — no matter in which nation they reside. A vaccine can end the pandemic but only if all countries ensure timely, equitable, global access to it. Selling vaccines to the highest bidders is not the way to go.” [457]

A nationalistic stance toward the pandemic will prolong this global health and economic crisis.

The LANCET said it bluntly “The COVID-19 pandemic is unlikely to end until there is global roll-out of vaccines that protect against severe disease and preferably drive herd immunity. ...“Yet having licensed vaccines is not enough to achieve global control of COVID-19: they also need to be produced at scale, priced affordably, allocated globally so that they are available where needed, and widely deployed in local communities.” [458]

“However, according to a December 2020 paper,Trusted Source high-income nations representing 14% of the world’s population now possess up to 53% of the global supply of promising vaccines.” [ 459]

COVAX (COVID-19 Vaccines Global Access) for low-to-middle-income countries

COVAX coordinates international resources to enable low-to-middle-income countries equitable access to COVID-19 tests, therapies, and vaccines. By 15 July 2020, 165 countries – representing 60% of the human population – had joined COVAX.

“COVAX now has agreements in place to access nearly two billion doses of several promising vaccine candidates, and laid the groundwork for further doses to be secured through contributions from donors. These agreements mean that all COVAX’s 190 participating and eligible economies will be able to access doses to protect vulnerable groups in the first half of 2021. At least 1.3 billion donor-funded doses will be made available to 92 economies eligible for the Gavi COVAX AMC, targeting up to 20% population coverage by the end of the year..” [460]

 â€œBut even if they are successful, it does not get countries close to herd immunity.”

“COVAX is necessary but not sufficient,” Ms. Taylor said. “It is the only mechanism we have for global equity. We need it and we need it to succeed. But even if they are successful, it does not get countries close to herd immunity.” [461]

Orin Levine, the director of global delivery programs at the Bill and Melinda Gates Foundation, said

“The COVAX scheme has some elements of a treaty: countries and funders have promised to contribute funding and vaccines for the most vulnerable people in countries with the greatest need. This is an important initiative, and was designed to ensure that all of the world’s most vulnerable people could be vaccinated first. However, it is clear that donor countries are waiting for vaccines to be rolled out to their own citizens before they release supplies to COVAX for recipient countries.” [ 462]

The Economist Intelligence Unit research group made an important observation about COVAX’s factors of success - COVAX’s efforts have been throttled not by a lack of money but a lack of supply:

“... COVAX’s efforts have been throttled not by a lack of money but a lack of supply. And so far the limited doses that are being made have mostly gone to the U.S. and other rich countries. As it stands, parts of Africa, South America and Asia will not achieve widespread immunization until 2023 at the earliest, according to a recent report by the Economist Intelligence Unit research group.” [463]

“But as new variants like the one discovered in South Africa migrate to more countries, the tragedy for poorer countries could become a tragedy for every country.”

“But as new variants like the one discovered in South Africa migrate to more countries — including the United States — it is becoming ever clearer that the tragedy for poorer countries could become a tragedy for every country. The more the virus spreads, and the longer it takes to vaccinate people, the greater chance it has to continue to mutate in ways that put the whole world at risk.[ 464]

“The Serum Institute of India (SII) - which produces Novavax and AstraZeneca vaccines - recently raised concerns about raw material shortages. Its chief executive, Adar Poonawalla, attributed this to US export bans on specific items needed to make vaccines, such as specialised bags and filters. [465]

“The chief executive of the Serum Institute of India, the world’s largest producer of vaccine doses, said most of its vaccine “would have to go to our countrymen before it goes abroad.”[466]

“On May 21, the United States pledged as much as $1.2 billion to the company in order to obtain at least 300 million doses, with the first to be delivered as early as October. The pledge to AstraZeneca is part of the Trump administration’s Operation Warp Speed for securing vaccines for Americans as early as possible.” [467]

“Vaccines are considered to be a truly global public good.”

Even the Secretary General of the UN made his appeal:

“It’s in the interest of everybody to make sure that as soon as possible and in a fair way, everybody gets vaccinated everywhere and that vaccines are considered to be a truly global public good.” Guterres criticized wealthy countries for buying into vaccine nationalism, in which nations secure shots for their own populations, limiting supply elsewhere. â€œWe have been appealing to developed countries to share some of the vaccines that they have bought. And in many situations, they have bought more than what they need,” he said.” [468]

But it is more than Vaccines

The Economist published a disturbing article in April 2021 entitled “A vaxxing problem - American export controls threaten to hinder global vaccine production”. 

“That was shortly after the Biden administration announced, on February 5th, plans to use the Defence Production Act (DPA)—legislation that grants the president broad industrial-mobilisation powers—to bolster vaccine-making. But American firms that supply products essential to vaccine production say the DPA hinders their ability to export them. They must seek permission before exporting goods, which requires time and paperwork, and if America’s government decides they need the goods, firms may be barred from exporting them at all. ... Together, export controls and stockpiling risk gumming up the global supply chain.” [469]

So it is not just the vaccines but also the supply chains that are critical to global vaccine inequity.

What do we know that we don’t know

Known unknown:      We know that it is universally recognized that, as the UN Secretary General said, â€œâ€œIt’s in the interest of everybody to make sure that as soon as possible and in a fair way, everybody gets vaccinated everywhere and that vaccines are considered to be a truly global public good.”  What we don’t know is when the wealthy countries will have completed their vaccination of their populations and begin to share their supply of vaccines with the less wealthy/lower income countries? All wealthy countries know that Secretary of State Antony Blinken was right when he said “This pandemic won’t end at home until it ends worldwide.” It is just a matter of time when they reach herd immunity in their own countries.

Possible Grey Rhino:  We know China is sharing its vaccine, from Sinovac (CoronaVac) and Sinopharm, to an increasing number of low-income countries (“Several Asian countries including Singapore, Malaysia and the Philippines have signed deals with Sinovac, and in January 2021 Indonesia began rolling out its mass vaccination campaign with their vaccine. Turkey has also approved the Sinovac vaccine for emergency use. The company is also known to have secured other deals with Brazil and Chile. The United Arab Emirates and Bahrain have approved the Sinopharm vaccine.”) [470] What we don’t know is the fullest extent of China’s ‘vaccine diplomacy’ and how the wealthy West will react to this ‘highly probable, high impact yet neglected threat’ of China.

3.8 Closing comments Chapter 3

To define the term ‘bad’ that I appropriated from Clint Eastwood’s movie “The Good, the Bad and the Ugly”, I have based this chapter on “negative/adverse changes in behaviours and/or changes in conditions” caused by the Covid-19 pandemic on stakeholders. For example, the most adverse change in behaviour caused by the pandemic is vaccine hesitancy. The most adverse change in condition of society/stakeholders is the new infections by the variants which are suspected of faster transmission, increased severity of the disease and an uncertain veracity of existing vaccines. The fundamental proposition underling the mammoth drive to vaccinate the population is herd immunity through vaccination ( as opposed to letting the disease run rampant through the population thereby creating immunity) has been a long-held premise of public health campaigns to halt/eliminate childhood diseases such as mumps, measles, chickenpox, and polio. The measles epidemic in Europe in 2017-2018 illustrated the fragility of the concept of herd immunity:

“Every new person affected by measles in Europe reminds us that unvaccinated children and adults, regardless of where they live, remain at risk of catching the disease and spreading it to others who may not be able to get vaccinated. Over 20 000 cases of measles, and 35 lives lost in 2017 alone, are a tragedy we simply cannot accept,” [ 471]

As such, there is a growing recognition that herd immunity (at 70% to 85%) is easier said than done. Hence, my choices of the major factors/forces that are currently inhibiting vaccination rates.

“Five reasons why COVID herd immunity is probably impossible”

The thought process that resulted in my selection of these 7 adverse ‘changes in behaviour and change in conditions’ was Christie Aschwanden’s article in nature.com â€œFive reasons why COVID herd immunity is probably impossible”. The nature.com article argues that there are 5 uncertainties that take issue with the goal of herd immunity:

1. “It’s unclear whether vaccines prevent transmission - it is still unclear whether they protect people from becoming infected, or from spreading the virus to others. That poses a problem for herd immunity.”

2. “Vaccine roll-out is uneven -  A perfectly coordinated global campaign could have wiped out COVID-19, he says, at least theoretically. “It’s a technically feasible thing, but in reality it’s very unlikely that we will achieve that on a global scale,” he says. There are huge variations in the efficiency of vaccine roll-outs between countries and even within them.”

3. “New variants change the herd-immunity equation - new variants of SARS-CoV-2 are sprouting up that might be more transmissible and resistant to vaccines. “We’re in a race with the new variants.”

4. “Immunity might not last forever - People who have been infected with SARS-CoV-2 seem to develop some immunity to the virus, but how long that lasts remains a question ... “We’re still lacking conclusive data on waning immunity, but we do know it’s not zero and not 100,” Bansal says.”

5. Vaccines might change human behaviour - At current vaccination rates, Israel is closing in on the theoretical herd-immunity threshold, Aran says. The problem is that, as more people are vaccinated, they will increase their interactions, and that changes the herd-immunity equation, which relies in part on how many people are being exposed to the virus. “The vaccine is not bulletproof,” he says. Imagine that a vaccine offers 90% protection: “If before the vaccine you met at most one person, and now with vaccines you meet ten people, you’re back to square one.” [472]

What do we know that we don’t know ...“the evidence is still limited”

If nature.com is accurate in their misgiving, what happens when the vaccines are found wanting, vaccine hesitancy persists at a high level and we don’t achieve the 70-85% herd immunity? I am inclined to settle on the proposition that the pandemic will morph into an endemic, like the flu, and become an annual part of the 'nu normal'.

End Notes for Chapter 3

[343] Lynsey Chutel and Marc Santora, “As Virus Variants Spread, ‘No One Is Safe Until Everyone Is Safe’”, The New York Times, Jan 2021

[344] “What is the meaning of the phrase ‘Here be dragons’?”, English Language & Usage Stack Exchange, 2017

3.1 Covid-19 persists (in spite of increasing vaccinations) in causing severe illness and death

[345] “Daily New Covid-19 Cases in U.S.-from Jan 20,2020 to Ap 15,2021”, Statista 2021

[346] â€œMore than 533,000 people have died from coronavirus in the U.S.”, The Washington Post, March 2021

[347] Zeke Miller, “Biden, CDC director warn of virus rebound if nation lets up”, WCAX.com, MAR 2021

[348]” Daily New Covid-19 Cases in Canada-from Jan 15, 2020 to Mar 24. 2021”, Statista 2021

[349] William Wan and Brittany Shammas, “Why Americans are numb to the staggering coronavirus death toll”, The Washington Post, Dec 2020

[350] “COVID-19 basics”, Harvard Health Publishing, https://www.health.harvard.edu/diseases-and-conditions/covid-19-basics

[351] Roxanne Khamsi, “This Pandemic Must Be Seen”, WIRED, Nov 2020

[352] Sarah Toy, et al, , “ Doctors Begin to Crack Covid’s Mysterious Long-Term Effects: Severe fatigue, memory lapses, heart problems affect patients who weren’t that badly hit initially; ‘It’s been so long’ , Wall Street Journal, Nov 2020

[353] Michelle Crouch, “This Is What It Feels Like to Be a COVID-19 Long-Hauler”, AARP, March 2021

[354] Nathaniel Weixel, “CDC director warns of ‘impending doom’ on potential new COVID-19 surge”, THE HILL, March 29, 2021

[355] Margret Brennan, “Transcript: Anthony Fauci on “Face the Nation”, CBS News, March 2021

[356] Andrew Gregory and Tony Allen-Mills, “When will coronavirus end?”, The Sunday Times - UK, Oct 2020

3.2 The coronavirus variants are “more infectious and, in many cases, more deadly”

[357] Rob Stein, “Worried About Coronavirus Variants? Here’s What You Need To Know”, npr, March 2021]

[358] Ibid

[359] “Anthropomorphism”, Psychology today”, https://www.psychologytoday.com/ca/basics/anthropomorphism

[360] “What is a COVID-19 variant strain?”, The MAYO Clinic, https://www.mayoclinic.org/what-is-a-covid-19-variant-strain/vid-20508903

[361] “How UK, South Africa coronavirus variants escape immunity”, AAAS and EurekAlert!, March 2021

[362] Dr. Matthew Binnicker, “How emerging variants could affect COVID-19 testing, vaccines and spread”, https://newsnetwork.mayoclinic.org/discussion/how-emerging-variants-could-affect-covid-19-testing-vaccines-and-spread/

[363] â€œWhat is a COVID-19 variant strain?”, The MAYO Clinic, op. cit.

[364] Daniel C. DeSimone, M.D., “COVID-19 variants: What’s the concern?”, https://www.mayoclinic.org/diseases-conditions/coronavirus/expert-answers/covid-variant/faq-20505779

[365] “How UK, South Africa coronavirus variants escape immunity”, AAAS and EurekAlert!, March 2021

[366] Daniela Hernandez and Sarah Toy, “New Covid-19 Strains: What Scientists Know About Coronavirus Variants”, The Wall Street Journal, Jan 2021

[367] “How UK, South Africa coronavirus variants escape immunity”, AAAS and EurekAlert!, March 2021

[368] Robert Glatter, MD, “P.1 Variant, Dominant Strain In Brazil, Reported In New York”, Forbes, March 2021

[369] “How UK, South Africa coronavirus variants escape immunity”, AAAS and EurekAlert!, March 2021

[370] Kelly Grant, “‘We now have two pandemics’: Variant COVID-19 cases soar in Ontario”, The Globe and Mail, Mar 2021

3.3 “Vaccinations are being treated as a get out-of-covid free card”

[371] [Jonathan Gardner, Ned Pagliarulo, Ben Fidler, “The first coronavirus vaccines have arrived. Here’s where the rest stand.”, biopharmadive.com, Feb 2021

[372] Carlie Porterfield, “Here’s When Experts Say Things Could Get Back To Back To Normal After Coronavirus”, Forbes, Nov 2020

[373] Ibid

[374] Ibid

[375] Ibid

[376] Christie Aschwanden, “Five reasons why COVID herd immunity is probably impossible”, Nature, March 2021

[377] Roy M. Anderson, et al, “Challenges in creating herd immunity to SARS-CoV-2 infection by mass vaccination”, THE LANCET, Nov 2020

[378] Megan Scudellari, “ How the pandemic might play out in 2021 and beyond”, Nature, Aug 2020

[379] Christie Aschwanden, “Five reasons why COVID herd immunity is probably impossible”, op. cit.

[380] “More Than 559 Million Shots Given: Covid-19 Tracker- In the U.S., 146 million doses have been administered; rollout goes global”, Bloomberg, March 2021

[381] Charlotte Jee, “ The Moderna and Pfizer vaccines are 90% effective at stopping infection in the real world too”, MIT TECHNOLOGY REVIEW, March 2021

[382] Christie Aschwanden, “Five reasons why COVID herd immunity is probably impossible”, Nature, March 2021

[383] Liselotte Sabroe, “Herd immunity is the end game for the pandemic, but the AstraZeneca vaccine won’t get us there”, THE CONVERSATION, Feb 2021

[384] Katherine J. Wu ,“Vaccine Cheat Day Are Adding Up”, The Atlantic, Ap 2021

[385] Jeffrey M. Jones , “Social Distancing Behaviors Drop as U.S. Vaccinations Rise”, GALLOP, Mar 2021

[386] Katherine J. Wu ,“Vaccine Cheat Day Are Adding Up”, op. cit.

[387] Andrew Joseph, “What we now know — and don’t know — about the coronavirus variants”. STAT, Jan 2021

3.4 Vaccine Hesitancy - “Mistrust of a Coronavirus Vaccine Could Imperil Widespread Immunity”

[388] Lisa Rosenbaum, M.D., “Escaping Catch-22 — Overcoming Covid Vaccine Hesitancy”, The New England Journal of Medicine, Feb 2021

[389] Caitlin Clark, “Understanding Vaccine Hesitancy In Pursuit Of Widespread Immunity”, Texas A&M TODAY, March 2021

[390] Taylor Owen, et al, “Understanding vaccine hesitancy in Canada: attitudes, beliefs, and the information ecosystem”, munk school of global affairs & public policy, jan 2021

[391] Jeffery V. Lazarus, et al, “ A global survey of potential acceptance of a COVID-19 vaccine”, naturemedicine, Oct 2020

[392] [Lisa Rosenbaum, M.D., “Escaping Catch-22 — Overcoming Covid Vaccine Hesitancy”, The New England Journal of Medicine, Feb 2021

[393] Ruth Graham, “Americans are increasingly willing to get vaccinated, according to a new survey”, The New York Times, March 2021

[394] Liz Hamel, “KFF COVID-19 Vaccine Monitor: December 2020”

[395] John H. Tibbetts. “How to convince people to accept a Covid-19 vaccine”, knowable Magazine, Mar 2021

[396] Marc Montgomery, “More Canadians ready and willing to get COVID-19 vaccines: survey”, RADIO CANADA INTERNATIONAL, Jan 2021

[397] Derek Thompson, “The Surprising Key to Combatting Vaccine Refusal”, The Atlantic, Feb 2021

[398] Ibid

[399] Kaja Damnjanovi?, et al, “Parental Decision-Making on Childhood Vaccination”, frontiers in Psychology, June 2018

[400] Russell Falcon, “COVID vaccine fake news and conspiracy theories”, news10.com, Dec 2020

[401] Ashley Welch, “How Conspiracy Theories Undermine People’s Trust in COVID-19 Vaccines”, healthline, Feb 2021

[402] Sara Heath, “What Role is Politics Playing in Vaccine Hesitancy, Messaging?”, PatientengagementHIT - https://patientengagementhit.com/news/what-role-is-politics-playing-in-vaccine-hesitancy-messaging

[403] Derek Thompson, “The Surprising Key to Combatting Vaccine Refusal”, op. cit.

[404] Stacy Wood and Kevin Schulman, “Beyond Politics — Promoting Covid-19 Vaccination in the United States”, The New England Journal of Medicine, Feb 2021

[405] Derek Thompson, “The Surprising Key to Combatting Vaccine Refusal”, op. cit.

[406] Jelani Cobb, “African-American Resistance to the COVID-19 Vaccine Reflects a Broader Problem”, The New Yorker, Dec 2020

[407] Douglas L. Mann, “Now That We Have an Effective Vaccine for COVID-19, Will It Also Inoculate Us Against the Virus of Indifference?”, JACC: Basic to Translational Science, Jan 2021

[408] Jelani Cobb, “African-American Resistance to the COVID-19 Vaccine Reflects a Broader Problem”, op. cit.

[409] Simar Singh Bajaj, and Fatima Cody Stanford, “Beyond Tuskegee — Vaccine Distrust and Everyday Racism”, The New England Journal of Medicine, Feb 2021

[410] Derek Thompson, “The Surprising Key to Combatting Vaccine Refusal”, op. cit.

[411] Royson James, “Vaccine hesitancy in the Black community is deeply rooted in a history of racism. Overcoming that lack of trust will be a tough task”, The Toronto Star, Feb 2021

[412] Derek Thompson, “The Surprising Key to Combatting Vaccine Refusal”, op. cit.

[413] Niall Stanage, “The Memo: Specter of vaccine hesitancy rises after J&J blow”, THE HILL, Ap 2021

[414] Derek Thompson, “The Surprising Key to Combatting Vaccine Refusal - It’s not just one problem—and we’re going to need a portfolio of approaches to solve it.”, The Atlantic, Feb 2021

[415] Jan Hoffman, “Mistrust of a Coronavirus Vaccine Could Imperil Widespread Immunity“, The New York Times, Sept 2020

[416] Yamiche Alcindor, et al, “Why 41 percent of Republicans don’t plan to get the COVID vaccine”, PBS News Hour, Mar 2021

[417] Madlen Davies and Rosa Furneaux, “World is on course for a coronavirus vaccine ‘apartheid’, experts warn”, The Bureau of Investigative Journalism, INDEPENDENT NEWS, Feb 2021

3.5 “Anti-vaxxers Think This Is Their Moment”- The Atlantic

[418] Tamara Bhandari, “Fighting the vaccine wars on the side of science”, Washington University School of Medicine in St. Louis, Sept 2018

[419] Isaac Chotiner, “The Influence of the Anti-Vaccine Movement”, The New Yorker, Dec 2020

[420] P. Davies, S. Chapman, J. Leask, “Antivaccination activists on the world wide web”, Community child health, public health, and epidemiology - https://adc.bmj.com/content/87/1/22

[421] Maggie Fox, “Measles cases up 30 percent worldwide, WHO says”, NBC News, Nov, 2018

[422] Isaac Chotiner, “The Influence of the Anti-Vaccine Movement”, op. cit.

[423] Renée DiResta, “Anti-vaxxers Think This Is Their Moment”, The Atlantic, Dec 2020

[424] Steve Stecklow and Andrew Macaskill, â€œThe ex-Pfizer scientist who became an anti-vax hero”, REUTERS, Mar 2021

[425] Dorit Rubinstein Reiss, “COVID-19 Vaccine Misinformation and the Anti-Vaccine Movement”, Bill of Health, Harvard Law, Jan 2021

[426] Maggie Fox, “Measles cases up 30 percent worldwide, WHO says”, op. cit.

[427] Sophie Mylan and Charlotte Hardman, “Covid-19, cults and the anti-vax movement”, THE LANCET, March 2021

3.6 “Covid-19 pandemic will become an endemic - meaning that it will continue to circulate in pockets of the global population for years to come”

[428] Nicky Phillips, “The coronavirus is here to stay — here’s what that means”, NATURE, Feb 2021

[429] Ibid

[430] “How do pandemics end? History suggests diseases fade but are almost never truly gone”, THE CONVERSATION, Oct 2020

[431] Arielle Mitropoulos, “COVID-19 could become a seasonal illness like the flu, experts say”, abc News, Feb 2021

[432] Richard Gray, “How will Covid-19 evolve in the future?”, BBC FUTURE, Jan 2021

[433] Ibid

[434] Anthony King, “The hunt for the next potential coronavirus animal host”, National Geographic, April 2020

[435] Zhengli Shi and Zhihong Hu “A review of studies on animal reservoirs of the SARS coronavirus”,   Virus research, April 2008

[436] Smriti Mallapaty, “Animal source of the coronavirus continues to elude scientists”, NATURE, May 2020

[437] Brenda Goodman, “Study: New Mutation Sped Up Spread of Coronavirus’, WebMD, Nov 2020

[438] Harriet Constable, “ The reasons swine flu could return”, BBC News, Jan 2021

[439] Maryn McKenna, “The Virus Hunters”, The Smithsonian Magazine, July 2020

[440] “How China’s ‘Bat Woman’ Hunted Down Viruses from SARS to the New Coronavirus”, Scientific American, June 2020

[441] Debora MacKenzie, “There are worse viruses than Covid-19 out there. How do we avoid the next big one?”, ensia.com

[442] Cory Stieg, “Experts say Covid could become endemic — here’s what that means for you”, cnbc.com, Feb 2021

[443] “How do pandemics end? History suggests diseases fade but are almost never truly gone”, THE CONVERSATION, Oct 2020

[444] Rob Stein , “The Future Of The Pandemic In The U.S.: Experts Look Ahead”, npr, March 2021

[445] Sarah Zhang, “What If We Never Reach Herd Immunity?”, The Atlantic, Feb 2021

[446] Anthony King, “The hunt for the next potential coronavirus animal host”, National Geographic, Ap 2020

3.7 Vaccine nationalism -“My nation first”

[447] Ubaka Ogbogu and Lorian Hardcastle, “The worst part of COVID-19 vaccine nationalism? It will have the opposite effect on the world”, The Globe and Mail, March 2021

[448] Thomas J. Bollyky and Chad P. Bown, “Vaccine Nationalism Will Prolong the Pandemic”, FOREIGN AFFAIRS, Dec 2020

[449] Dr Amir Khan, “What is ‘vaccine nationalism’ and why is it so harmful?”, ALJAZEERA, Feb 2021

[450] James Paton, “How Vaccine Nationalism Risks Prolonging the Pandemic”, The Washington Post, Ap 2021

[451] Thomas J. Bollyky and Chad P. Bown, “Vaccine Nationalism Will Prolong the Pandemic”, FOREIGN AFFAIRS, Dec 2020

[452] Rebecca Weintraub, et al, “The Danger of Vaccine Nationalism”, Harvard Business Review, May 2020

[453] “Shots Fired - The many guises of vaccine nationalism”, The Economist, Mar 2021

[454] â€œHoarding”, cleartax, Feb 2021

[455] Rebecca Weintraub, et al, “The Danger of Vaccine Nationalism”, op. cit.

[456] Thomas J. Bollyky and Chad P. Bown, “Vaccine Nationalism Will Prolong the Pandemic”, FOREIGN AFFAIRS, Dec 2020

[457] [Rebecca Weintraub, et al, “The Danger of Vaccine Nationalism”, op. cit.

[458] Olivier J Wouters, et al, “Challenges in ensuring global access to COVID-19 vaccines: production, affordability, allocation, and deployment”, THE LANCET, March 2021

[459] Jennifer Huizen, “Herd immunity may take 4.6 years due to vaccine nationalism”, Medical News Today, Ap 2021

[460] “COVAX Announces additional deals to access promising COVID-19 vaccine candidates; plans global rollout starting Q1 2021”, WHO, Dec 2020

[461] Lynsey Chutel and Marc Santora, “As Virus Variants Spread, ‘No One Is Safe Until Everyone Is Safe’”, The New York Times, Jan 2021

[462] “The world must learn from COVID before diving into a pandemic treaty”, NATURE, Ap 2021

[463] Alexander Smith, “COVAX: Why Biden’s billions won’t fix Covid vaccine inequality worldwide”, CBS News, Feb 2021

[464] Lynsey Chutel and Marc Santora, “As Virus Variants Spread, ‘No One Is Safe Until Everyone Is Safe’”, op. cit.

[465] “India coronavirus: Can its vaccine producers meet demand?”, BBC News, March 2021

[466] Rebecca Weintraub, et al, “The Danger of Vaccine Nationalism”, op. cit.

[467] Ibid

[468] Raisa Patel, Rosemary Barton, Philip Ling, Â· “Vaccine nationalism an issue of ‘enlightened self-interest,’ UN Secretary General warns”, CBC News, Mar 2021

[469] â€œA vaxxing problem - American export controls threaten to hinder global vaccine production”, The Economist, Ap 2021

[470] “Covid: What do we know about China’s coronavirus vaccines?”, BBC News, Jan 2021

[471] “400% increase in measles cases in Europe”, Feb 2018 - https://www.vaccinestoday.eu/stories/400-increase-measles-cases-europe/

[472] Christie Aschwanden, “Five reasons why COVID herd immunity is probably impossible”, naturer.com, Mar 2021

[474] Michael Shermer, “Remsfeld’s Wisdom”, Scientific American, Sept 2005

[475] Michele Wucker, â€œThe Gray Rhino: How to Recognize and Act on the Obvious Dangers We Ignore”, St Martin’s Press, April 2016

[476] J. Peter Scoblic and Philip E. Tetlock, “A Better Crystal Ball - The Right Way to Think About the Future”, Foreign Affairs, Nov-Dec 2020

[477] AJ Justo , “The knowns and unknowns framework for design thinking”, UX Collective, Feb. 2019

[478] “Black Swan”, Investopedia, Aug 2020

Appendix B - Rumsfeld’s Heuristic

Donald Rumsfeld, former U.S. Secretary of Defense from 1975 to 1977 under Gerald Ford, and again from January 2001 to December 2006 under George W. Bush, popularized this framework for analyzing wicked problems/issues. It was first mentioned by Kirk Borne, an astrophysicist employed as a data scientist at NASA Goddard Space Flight Center in an April 2013 TED talk.

“‘There are known knowns. There are things we know that we know. There are known unknowns. That is to say, there are things that we now know we don’t know. But there are also unknown unknowns. There are things we do not know we don’t know.’ [474]

With so many unknowns regarding the current pandemic, Rumsfeld’s heuristic is an useful method of sorting through the myriad of issues/impacts/projections and predictions:

1. Known Knowns - things we know that we know (the facts). This category can also include what John KennethGalbraith called “conventional wisdom” - commonly accepted ideas and expert opinions that are accepted as true regarding the issue being analyzed/discussed. However, many things we take as facts are not as solid as they initially appear. See Chapters 1.1, 1.2 and 1.3

2. Known Unknowns - things that we now know we don’t know .. These things/events are sometimes call Grey Rhinos -” It’s a metaphor for missing the big, obvious thing that’s coming at you. And the important part is that it gives you a choice. Either you get trampled or you get out of the way, or you hop on the back of the rhino and use the crisis as an opportunity.” [475].

A “gray rhino” is a highly probable, high impact yet neglected threat. Gray rhinos are not random surprises, but occur after a series of warnings and visible evidence. The housing bubble and the underlying sub-prime mortgages problem that led to the financial crisis in 2008 was known in advance but unknown when the bubble would burst. The coronavirus pandemic has suddenly brought visibility and recognition to the ‘virus hunters’ who have warned us that there are more than 827,000 viruses lurking in the wilderness forests that have the potential to infect humans”. The biologists, ecologists, etc. have been lobbying the policy-makers for increased actions to prevent biodiversity losses of large-scale conversion/destruction of these wilderness forests but little action has been forthcoming - this “gray rhino” has/is being neglected. See Chapters 2, 3 and 4.

Then there are the “invisible gorillas” - “threats in full view that should be noticed but aren’t - so named for a psychological experiment in which subjects watching a clip of a basketball game were so fixated on the players that they missed a person in a gorilla costume walking through the frame. Even professional forecasters, including security analysts, have a poor track record when it comes to accurately anticipating events.” [476]. Covid ‘long haulers’ would probably be an ‘invisible gorilla’ . ‘Long haulers’ have severe symptoms long after their infection is supposed to have cleared-up. The early cases were ignored and only recently getting the recognition and treatment they require.

3. Unknown Knowns - things that we know but remain hidden as unconscious biases and prejudices that we are not aware of (bias, latent assumptions about some phenomenon), “what we do not like to know”[“Zizek tells us that the most important category of knowledge for humanity is the Unknown Knowns. He gives the example of Climate Change: we all know it is happening, but we fail to act on it in our daily decisions.” [477].

Another example of the ‘ Unknown known’ is the data that shows Black, Asian and minority ethnic group are more likely to contract and die of the virus than their white counterparts, but we have not been prepared to do anything substantial about it, except write articles about it.  See Chapter 3 and 4.

4. Unknown Unknowns (aka unk unks) - things we do not know we don’t know (anything that will significantly alter our thinking/plans/solutions). Black Swan Events (popularized by Nassim Nicholas Taleb ) have been included in this category - “A black swan is an unpredictable event that is beyond what is normally expected of a situation and has potentially severe consequences. Black swan events are characterized by their extreme rarity, severe impact, and the widespread insistence they were obvious in hindsight.” [478] Taleb defined the fall of the USSR and the terrorist attacks of 9/11 as of unprecedented magnitude and unpredictability, hence classing them as a black swan events.

This article was created by R.J. (Robb) Ogilvie, Managing Partner, Ogilvie, Ogilvie & Company - April, 2021

Researcher, policy wonk, facilitator, author and curator of information about ‘wicked’ policy issues