As scientists-in-training, we are taught the parable of people drowning in a river. Medicine extends her hands to pull each person out while public health runs upstream to prevent people from falling into the water. The idea that some of these lives matter less than others is so unspeakable that we don’t name it.
But the recent naming of the COVID-19 variant Omicron places health inequity in headlines once again. Across pathogens and places, pandemics are nothing if not socially driven: Widespread global efforts to control spread reach a tipping point after which the burden of infectious diseases is shifted to the shoulders of the poor. Slowly, the lettered plagues — TB, HIV, COVID — recede from the front page. One might argue that their unfolding is not newsworthy, since we have tolerated the poverty traps of these plagues for centuries, decades, and years, respectively.
Recent advocacy side-steps the need for global vaccine equity in favor of strategies that are complementary at best, such as increasing genomic sequencing within viral surveillance or restricting country-specific travel. Last week, President Biden addressed the National Institutes of Health with an updated pandemic plan. His proposal overlooks the one thing we have known from the start: The global community is in this together.
When vaccines became available one year after the first known case of COVID, the epidemiologic strategy was clear: To save the most lives, vaccine campaigns would have prioritized populations in which non-pharmaceutical interventions were not feasible. Immunization efforts would have sought out those in overcrowded housing, densely populated cities, migrant-dependent households, and settings with a high prevalence of people who are immunocompromised — to say nothing of the 3 billion people who lack access to soap and running water at home. Instead, the first immunizations were administered in populations that had the means to prevent and reduce transmission with face coverings, ventilation, testing, and isolation strategies, distanced outdoor gatherings, and working from home.
No one taught me that epidemiology is political. But it is.
About three-quarters of all doses have been administered in resource-rich settings. About 10 percent of all residents in the United States and Canada have received a booster — the same percentage of the entire African continent that has received any shots. The shock deepens when we reflect on the irony that pre-modern smallpox inoculation was brought to the New World colonies (to Boston, in fact) by an enslaved African man. Our current triage has been as ineffective as it is unethical. Pandemics are global by definition, so the critical threshold for herd immunity needs to be met throughout the human population; infectious diseases move with the people they infect. Worse, failure to meet this goal will enable the coronavirus to circulate and evolve, making it all the more difficult to eradicate.
In settings with vaccine access, leaders undermined equity by neglecting those experiencing vaccine hesitancy. Just as virologists warned in 2017 to prepare for SARS-like viruses, vaccine hesitancy was designated as a top-10 threat to global health by the World Health Organization the year before COVID emerged. It is not too late, and now more important than ever, to address the complex reasons why people decline vaccination. Overcoming hesitancy means tackling its causes through consistent messaging from both political and public health leadership:
▪ First, we must combat misinformation, cited by Anthony Fauci and other health experts, as a primary driver of hesitancy, and disinformation campaigns targeting vaccines. Fraudulent science is more easily found in an online search than, for example, the fact that vaccines prevent about five deaths every minute (pre-COVID).
▪ Second, we must confront historic events that have generated mistrust of health systems or governing bodies. Safe vaccines are often caught in the middle.
▪ Third, we must communicate that vaccines are a paradox of their own success. Vaccine-preventable diseases fade from our lived experience, tempting the idea that vaccines are no longer necessary (when in reality, disease incidence declines because of continued vaccinations).
▪ Finally, we cannot forget that these causes and others take hold quickly in a vacuum of education and support. Not only is patient-blaming antithetical to our ethos, but evidence also shows that shaming and labeling someone for their health behavior reinforces those decisions. We can empower vaccine uptake by providing information, building trust in public health, and engaging in respectful public dialogues. Low-cost interventions save lives.
Pandemics are neither unpredictable nor unprecedented. The phases common to all of them are denialism, activism, scientific research, and economic arguments. But as with other diseases that have spread worldwide, we long ago reached a point where we know enough to act. We have passed the time for debate over patents, profits, or production logistics. It is past time to vaccinate the global population, or else face the moral injury. It’s not too late to run upstream. Until we do, we will live with the pandemics we choose.
Rachel R. Yorlets is an epidemiology PhD candidate at the Brown University School of Public Health.