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Gavin: Hello, welcome to another episode of The Lancet Voice. It's October 2021 and I'm Gavin Cleaver. Together with my co host, Jessamy Bagunel, we're going to look at some of the big questions and topics from around the world of health every two weeks. There aren't many bigger questions at the moment than, do we need booster doses?
The UK, the US, Israel, and just this week Portugal are embarking on a program of third doses for their populations, while many low income countries around the world have single digit percentages of their populations vaccinated. So what's the current evidence for booster doses? Will booster doses help end the pandemic in the UK, the US, Israel, and Portugal?
What are the wider policy implications? Later on, Jessamy will be speaking with Professor K. Srinath Reddy, the President of the Public Health Foundation of India, about the global policy implications of booster doses. And she'll also be getting an update on the COVID 19 situation in India, as well, following the wave there earlier this year.
First, though, I spoke with Professor Sir Richard Pitot, Emeritus Professor of Medical Statistics and Epidemiology at the University of Oxford, and he's one of the authors of a viewpoint published recently in The Lancet about booster doses. I wanted to find out what it is we know about booster shots and what that evidence means.
Professor Sir Richard Peto, thanks so much for joining me on this podcast to talk about the evidence around booster doses of COVID 19 vaccines. Let's cut straight to it. Your viewpoint published in The Lancet summarised the evidence currently available about booster doses. What do we currently know?
Richard: Since vaccination became widespread earlier this year, we're now several months after vaccination for many people. And so there's been lots of studies trying to compare vaccinated people with unvaccinated people to see how much difference is there in the risk of getting COVID or the risk of getting severe COVID, which is the most important thing for the individual.
It turns out that if you look at All of the reports of this separately, they're not reliable, but overall, on average, a weighted average of them shows that the vaccination is more effective against severe disease than against moderate disease, and that against severe disease, if you get just a reasonable vaccine, then it's about 95 percent effective.
At preventing severe disease and that's an extraordinary reduction. It's a 20 fold difference in the risk of getting severe disease and what isn't known is how long that protection will last because it's only a few months since the vaccination happened. There are claims that efficacy is waning when they say waning they're saying they've gone down to 85 percent and the claims it's got any lower than that really aren't well founded.
And therefore a third dose. would be useful. And again, I think we, we need better evidence on this. But I think that what we're trying to do is to string together all of these various reports. We've got references to all of them in our appendix. There's about a hundred of them. It's a complete mass of detail.
And then try and get some weighted averages out that were simply enough to just give the general picture. These are not randomized trials. They have defects that randomized trials don't have. But there is information in there because the protective effect against severe disease is so great and it's that protective effect that I think our article illustrates and also for people who are still considering whether to get vaccinated or not.
I think that the findings that you've got. 95 percent protection against severe disease. 20 fold reduction, the risk of getting hospitalized of having such bad disease that you've got to be hospitalized is an interesting finding. And it goes, it's somewhat later than the randomized trial results.
The randomized trial results were based on much smaller numbers, a few tens of thousands. These reports are based on billions and they followed them. really short term, a few months and then that's the results showing remarkable protection, really remarkable with the best vaccines with 95 percent protective even against mild disease.
And that's fantastic. But then they, then the trial stopped. There was no further observation. He went and vaccinated everybody using controls and so you could no longer find out. what the long term protective effect is. So we're a little bit longer term than the trials and considerably bigger numbers, but also the trials didn't have enough people in them to look at effects on severe disease.
And it wasn't known, for example, that the effects on severe disease would be zero or whether they'd be much less than the effects on any disease. And it turns out that they're actually much better, which is rather a nice result.
Gavin: So with the booster doses, obviously that's what your Lancet paper was about.
What is the evidence for the effectiveness of booster doses
Richard: currently? Our conclusion is, at least on that, that really the key priority still is trying to get the unvaccinated vaccinated. That's a lot more effective than re vaccinating those who've already been vaccinated. But still the question as to what re vaccinating those who've already been vaccinated would achieve is unanswered and needs to be answered.
Again, large scale randomized evidence would be ideal for answering it, rather than just jumping into, this country's going to go for boosting this one, isn't it? Nobody randomizes anybody. And those who get the extra vaccine aren't exactly comparable with those who don't. We need randomisation on an even larger scale than was done in the original randomised trials.
Gavin: So is it just too early to know with the Delta variant? How much of it, how much it's changed the efficacy of the vaccines?
Richard: Yes, it's certainly too early to know reliably what the delay between first dose and when you are looking how relevant that delay is. To what extent is there efficacy against severe disease?
I think what is clear is that the vaccines are surprisingly protective against Delta. Given that Delta has evolved to be more infectious, we are lucky that vaccines, which were essentially designed against the original Wuhan variants. Long before alpha still seemed to turn out to be effective against alpha and turn out to be effective against delta.
There's less evidence on beta and gamma, but there's ones that are relevant mainly in Europe and North America are alpha and delta.
Gavin: So you mentioned in the paper as well, the waning antibody titers, but that doesn't seem to be massively impacting the overall effectiveness like you just said against hospitalization.
What's
Richard: the mechanism there? Hospitalization is driven in a sense, not so much by the virus, but by the body's own reaction to the virus. And it's whether you have this overreaction to the virus. It turns out that if you're in the middle of this overreaction against the virus, one of the most effective drugs is just a simple steroid, dexamethasone, or various other things for turning down the immune response.
And it's, in other words, reduce your response to the virus and actually you're less likely to kill yourself with your own overreaction to it. So the hospitalization and this sort of curious dangerousness of this compared with some of the coronaviruses, for example, the ones which cause the common cold, is because of this peculiar overreaction.
And it's not clear exactly which aspects of your immune response are going to determine the sort of reaction. We can't really predict reliably what the efficacy of a vaccine will be against severe disease. It's the severe disease that kills. We can't predict that from what we can currently measure of immunological crimes as though people are trying to do maybe they will get to the point where they can, but at the moment you really do need evidence from how many people actually finished up hospitalized. And that's what, that's the main thing. There's one of the two main things that the Lancet article that we wrote was trying to do to say, if we take the reports currently available, on the incidence of severe disease particularly, then to what extent is there waning accuracy, is there efficacy against both alpha and delta?
The answer is yes for severe disease. Is that substantial even a few months after vaccination? Yes for severe disease. What would you mean by substantially effective? Of the order of 95 percent effective. Whether with a few months more follow up, One will continue to get that sort of efficacy. This is the question that people are worried about.
And the British and American governments are really betting on the idea that it isn't going to keep on being as effective as that. And so they're going to get a third dose into as many as possible of the. Of the older population, elderly population if you like, I mean we define it as over 50 65 in the US, but it's basically later middle age and old age, because these are the ones that are most at risk of this catastrophic severe disease.
which can land you in hospital and kill you.
Gavin: I wanted to ask you as well, we talked a little bit earlier about Delta and how it's still too early to know. A lot of the talk last year while the vaccine efficacy data was coming out was about elimination of SARS CoV 2, of COVID, because the efficacy numbers were so high against infection.
Now it would seem as we said that Delta is a lot better at evading the vaccines for mild infection. So do you think we're now more in a case of suppressing rather than the kind of herd immunity elimination strategy that was discussed last year?
Richard: Well, Delta is so infectious that if you just get a one or two cases coming in, as has happened in Australia and New Zealand, despite trying to keep them clean, then it's very difficult to control.
And it'll be interesting to see whether China can control Delta, no matter how ferocious their lockdowns are. Their lockdowns were sufficient to control the Wuhan variant, but then it progressed to a sort of D634, whatever it is, G variant, and then on to Alpha, and then on to Delta, and so on. It's just getting more and more difficult to control these things.
It's not clear that even the rather ferocious Chinese measures will suffice to control delta. And then there could be evolution to integrated transmissibility, it could become as transmissible as measles, for example, where there's no chance of. I'm sure we can keep the vaccination rates above 90, well above 90 percent.
Look this is in a sense going beyond what we did. What we did in that article, what I was particularly involved with in that article, was trying to bring together the evidence and say, okay, if we just look at what we know now, which is a few months after vaccination what sort of efficacy did we have against alpha, what sort of efficacy do we have against delta?
I think there were some interesting answers there, and I think that these factual answers need to be separated from the question of what the policy implications of those answers are. I think the factual answers are interesting in themselves, and the conclusion was that Really for all vaccines, efficacy against severe disease is greater than efficacy against moderate disease or asymptomatic disease.
So in other words, they're better at preventing, in terms of proportional reduction, they're better at preventing the vaccinated individual from becoming severely ill or dying. They're about 95 percent effective for that. But they're not going to be. Sufficient really to eliminate the epidemic so that we're not going to get we don't seem to be getting long term strong protection against infection and therefore transmission and a lot of the infection would be so clinical be transmitted through school kids and to get enough coverage there.
I think it's probably unrealistic, but that's not my specialty. My specialty was trying to assess the evidence from what's currently observed. in people who've been vaccinated and people who haven't, preferably in populations where there's enough unvaccinated ones to the symptoms to be informative.
And so what's currently observed
Gavin: is there's no evidence that protection against severe hospitalization is dropping off in these vaccines.
Richard: I think that there's no evidence. I think we really do need a lot more evidence on that question. Strongest evidence on this comes from Israel, where they vaccinated quite a lot of people back in January, February.
And so by August, they were eight months after the vaccination. And so by introducing a third dose at the beginning of August, they Thought they were seeing appreciable rates in even in those who've been vaccinated. So dropping down to about 85 percent efficacy and considerably lower rates in those who got a boosted dose during August.
But you're observing during August, people who were vaccinated earlier in August, and that's not enough to be determining what global strategy should be. So we do need more evidence as to whether. efficacy does wane, and in a few, if you looked at somewhat longer follow up, whether it does wane, and if so, what the effect of third dose would be?
On that efficacy, my efficacy there, I'm talking about efficacy against severe disease and the moderately good vaccines and the very good vaccines were all several months after vaccination, highly effective against severe disease. What it will be like with longer follow up isn't known. We want all kinds of theories as to how to measure the parameters will tell us these things.
We do need also looking at the real evidence as to, what happens and trying to allow The differences between those who either did get vaccinated or chose to get vaccinated and those who didn't. And that's where randomization would have been ideal, it should have been done.
Gavin: Many thanks to Richard there for sharing the current evidence and it's very clear there's a lot we don't know and that we aren't currently set up to know. What are the policy implications globally of booster shots? Jessamy spoke to Professor K. Srinath Reddy, President of the Public Health Foundation of India, to discuss and also to get an update on the COVID 19 situation in India following the terrible outbreak there earlier in 2021.
Jessamy: Srinath, thanks so much for joining us. Could you briefly tell us which countries at the moment are following a program of third doses?
Srinath: The third dose can actually be looked at as either a homologous booster or a heterologous booster, which means that the third dose could be the same as the two given earlier, or it could be a vaccine made from a different platform.
So there are vaccine rich countries which have been using mRNA vaccines of which they had a great abundance and when they felt that they're getting breakthrough infections. or fading immunity among the people who are vaccinated. They have opted to go in for a third dose of the same vaccine. There are others who have used different platforms.
For example, there are the Gulf countries and others who have used either the Russian vaccines or the Chinese vaccines. And some of them getting a little anxious that these are probably not as effective are now switching over to a third dose when available. of vaccines made from other platforms. Israel has actually set the trend by using mRNA vaccines in a third dose booster.
And now they've decided that everybody above the age of 12 years will get it irrespective of whether they're immunocompromised or not. The United States of America and the UK have decided that people who are in the older age group, 65 and above, as well as those who are immunocompromised even below that age would get it.
And the same policy I think is going to be adopted at least for now by Germany and France and the Czech Republic and others are also falling in the same direction. There are others also who are considering the same. I think there is a consensus. That elderly people in whom the immune response may not have been strong in the first place and fades faster are certainly candidates.
And secondly, immunocompromised people of any age do need the boosters and will get benefit from them. Whereas other age groups should get it or not is still disputed. And I think that debate will go on, particularly when there is a global shortage of vaccines.
Jessamy: Exactly, and it's brilliant that we can come on to that.
So just removing the heterologous Dosing regime and talking more about these vaccine rich countries who are thinking about third dosing, either prioritizing vulnerable groups and then potentially going down the list to less vulnerable groups. What are the holes in evidence that we have at the moment to either make an argument for or against that and do you see that we'll be able to answer those questions in the next six months?
Srinath: If you take the whole world population? into consideration, then the benefits conferred to some individuals with a third dose. Pale in comparison to the benefits conferred to the global population by giving two doses to more people across the world, especially when we know that in Africa, only 4% or so have received VA vaccination so far.
So there is the danger that variants can start emerging in under vaccinated populations and those variants. can not only be more infectious, but they can have vaccine escape, or they can evade the impact of the vaccines. And if they track back, as they certainly will, even to these vaccine rich countries, which have been giving third doses or even talking about the fourth doses, then these doses will not be protective against those variants which have the vaccine escape properties.
It is in the interest of everybody in the world to try and vaccinate as widely as possible across the whole human population with two doses and protect those who are particularly at high risk, that is the immunocompromised as well as the elderly people with the third dose when necessary, but rather than splurge it on everybody about the age of 12 and have under vaccinated pockets in various parts of the world.
Where the variants can breed and cause fresh threats to the whole global population. So for all of these reasons, I believe that we do not have convincing evidence that even within a population or across the global population. A third dose is at the present state of knowledge with the present variants in circulation.
We have a convincing case for a booster for everybody, particularly since we know that there is clear cut evidence that we have enough protection against severe infection, even from the current doses, two doses. If you take all infections, including very mild infections, yes, the efficacy may have declined after two doses.
And a third dose may confer a little additional protection. But what we are really aiming for is protection against severe infection, which lands a person in hospital or in intensive care or likely to kill. And there we have convincing evidence that even with the current variants that are circulating, available vaccines are sufficiently protected.
And even in the mRNA vaccines, we have had recent reports that there are differences between the two vaccines. For example, if you're looking at the VA waning efficacy of Pfizer, it's been reported that the efficacy against all infections declines from 91% in the trials to 77% after the fourth month.
Whereas with Moderna, the decline is only from 93 to 92%. So all vaccines again are not created equal, but even with the Pfizer, even with the Pfizer, we know that against serious infections and hospitalization and intensive care and death, it is still protective even after four months. So for the relatively marginal benefit of trying to protect against mild infections, why should we actually splurge on vaccines at the cost of protecting the global population?
And what is the proof? Currently, there is no proof that this is going to be very protective against new variants. So
Jessamy: Certainly, this seems to be the thinking of the WHO, who previously came out against third doses and boosters. What do you think it says about the multilateral system that these recommendations have been ignored and countries have gone on to carry on doing their own measurements, regardless of those recommendations?
Srinath: Unfortunately, countries have been responding to what they see as their primary duty to protect their own population as well as possible before they start reaching out to support others. It works to an extent, I believe every government has a responsibility to its own population. But it should start looking at whether they are having a scientifically validated use of the vaccines or are they acting over enthusiastically and making a grand gesture of trying to provide additional protection to their population without weighing the risks.
of variants being created elsewhere in the world and coming back. Delta should be an object lesson. Delta was not something that emerged either in the United States or in the United Kingdom or, for that matter, in Israel. But Delta did enter, despite all the precautions that they were taking. And similarly, if variants actually come up in under vaccinated populations across the world, where particularly vulnerable people are not vaccinated and they are infected with a virus which can have a prolonged stay in their bodies and has enough time for experimentation with multiple mutations and some of those mutations actually become dominant.
They can track back to highly vaccinated countries which have had the third dose of booster and that can be dangerous. So it's not only important to protect your population adequately with the standard doses. But try and protect the whole global population with the standard doses while reserving the booster doses for the people who are most likely to be in danger of a severe infection and who are most likely to benefit from a booster rather than spreading it too thin across the entire population.
Jessamy: It would be remiss of us to not ask you about the situation in India at the moment. It's dropped off the headlines for a while, but might you be able to give us an update of what the picture is there?
Srinath: At the moment, things are relatively quieter after the huge surge of the second wave from March to May.
From June onwards, the cases started declining, and now the cases have had a steady decline in terms of case count. The test positivity rate is very low, and the death counts are also coming down every day. There have, however, been a few areas in India where there was a plateauing effect rather than a sharp decline, like in the state of Kerala, and there have also been some spikes in some of the northeastern states.
But everywhere now the case cases have started declining. We'll have to still wait and see what the situation will be with the festive season coming up in October and November. But antibody survey done a couple of months back, which was a national survey, revealed a national average of about 67 percent of the people being testing positive for antibodies.
Our vaccination rate has increased to about 20 percent being fully covered with both the doses and about 50 percent and above being covered with at least a single dose. So given the fact that there has been an active exposure to the virus during the second wave. And many have tested positive for antibodies even though some of the levels may be declining.
We believe cumulatively there is reasonable amount of immunity in large sections of the population, which may protect against a severe third wave in the next couple of months. However, we also recognize that the immunity wanes. And we still have to be on guard against a fresh variant. The need to continue public health precautions, like wearing masks, ensuring that people move in ventilated spaces, and most importantly, keep away from crowds, while waiting for their turn to get vaccinated fully.
These are important elements that we are continuing to message to the people.
Jessamy: Just out of interest, with your vaccine policies, did you do a longer distance or longer space between the first and second dose in
India? I can't remember reading that.
Srinath: Yes, in fact, it happened that way because Partly, I think it was opportunistic, but backed by some science, which was essentially dependent upon the British policy and the British research results.
Because we were producing two vaccines at the beginning of January, which were licensed. One was a AstraZeneca vaccine, which was licensed for production in India, which went by the name of Covishield. The other one was a inactivated virus vaccine developed in India and also being manufactured in India.
And that also was given approval in January. The volume of production of the AstraZeneca counterpart that Cov shield was much higher than the virus vector vaccine because inactivating a virus requires a BSL three or BSL four labs, and there are limited numbers in India. It was really for cov shield that the spacing was decided on the basis of what UK did with AstraZeneca when UK decided that there will be a three month space.
India decided initially that there would be a six to eight week spacing, then went in for a 12 to 16 week spacing, whereas for the other vaccine, the virus vector vaccine, which was trialed with only a four weeks span, interval between the two doses. That interval was maintained because we did not have a similar type of evidence available for that vaccine that longer spacing works or works better.
So at the moment, we are still continuing with the 12 to 16 weeks spacing between the two doses of the Covishield or the AstraZeneca counterpart.
Jessamy: And you've just approved, India's just approved this new DNA COVID 19 vaccine, is that right?
Srinath: Yes, it has approved a new DNA COVID 19 vaccine, which is the first DNA vaccine in the world.
It has claimed a high level of efficacy, but we'll have to wait and see, and also safety. Interestingly, it is not an injectable vaccine in the traditional sense. It is administered intradermally it's not intramuscular without the use of a needle. It's a, like a jet into the Skin where you get an intradermal deposit of the vaccine.
It has a requirement of three doses rather than two doses. So it is different in a number of ways. So it's being studied now at the moment in terms of its rollout. While the regulator has cleared it. We are still waiting for full details of its publication. But at the same time, we are also trying to see what will happen in the post release surveillance phase.
Jessamy: And are you quite hopeful about that one? Do you think it will make a difference to your vaccine rollout program in India?
Srinath: We have several other vaccines also, not only those which have been manufactured in India or under license from abroad, but also those which have been developed in India and have been trialed in India, which are all now poised for a regulatory approval.
There is the Johnson and Johnson vaccine itself, which has been cleared for manufacture in India in one of our factories, the biological E. Then you have the Russian vaccine, the Sputnik vaccine which is also being produced by about seven manufacturers in India and that will also be scaled up. And we also have, uh, protein subunit vaccine that has been again developed here and is being trialed in India.
And that's also almost ready for regulatory review. So there are a number of vaccines that are rolling off India's vaccine manufacturing Factories and we are hoping that at least some of them, if not all of them will make the grade soon.
Gavin: Thank you, Srinath. And thank you, Jessamy. And also, hello, Jessamy, who joins me now. Two enjoyable and informative interviews. What have we learned?
Jessamy: Both those interviews are quite nice in that Richard Peto gives a great summary of the evidence and this sort of call to just stop and think about where we are in the pandemic and where we are with the evidence that we don't have enough evidence at the moment to suggest that blanket, third doses boosters is appropriate.
That's not to say it might not become that way in the future, but at the moment, that there isn't that evidence.
Gavin: It's a gamble, isn't it? And everything in this kind of emergency situation is, to some extent, a gamble.
Jessamy: Yeah, exactly. And I thought that point that he made about the fact that governments are gambling, that now is the right time to give this booster to try and prevent some kind of, surge over winter, is completely correct, but for me, it really fails to think about the broader global aspect of, the fact that as we've discussed, it's more likely that a variant is going to be thrown up elsewhere where they're unvaccinated.
And that's going to cause huge problems, even in vaccinated populations, if it escapes the vaccine, rather than trying to revaccinate the people that have already got quite good effectiveness.
Gavin: And it really hits it home as well, doesn't it? The problems of national concern versus international concern for the countries that have all the vaccines.
It's become clear, as we were talking about from this gamble with the third booster shot, that it's really their main concern is the people that live in their country. And the international community is a very distant second to that. And I really think this booster shots debate has, served to more than highlight that it's really cast it in a very harsh light.
The actions of. Of the countries that are, that have all the vaccines.
Jessamy: Yeah, and we've seen that throughout this whole pandemic, haven't we? The forces that are pulling us apart are the ones which are the America first, China first, or whoever first, but it's about your own country rather than the global response.
And that's where we've seen continued problems and a continued failure to really appreciate that aspect of what a pandemic is, in that it is global.
Gavin: The bit as well that really stands out for me is the kind of moving of the goalposts. I think we talked briefly about it in the Richard Peto interview, but when these vaccines were first being created in 2020, everyone was mainly focused on the prospect of them preventing severe disease and hospitalization.
And when they came out, it turned out they were actually very good at presenting disease full stop, far better than anyone could possibly have dreamed. But, so now that seems to have, in rich countries, become the main purpose of these vaccines, to stop disease and transmission, rather than, as was the original goal, to prevent severe disease and hospitalization.
So you're left in a situation where some countries are so far advanced with their vaccine programs that they're trying to stop COVID altogether, which as we said in the discussion with Peter, we don't really have the evidence that suggests that these vaccines are good enough to stop Delta, which is a whole different thing.
And other countries are left completely unprotected with no protection against severe disease and hospitalization whatsoever. It's it's two different pandemics, really, it's two different solutions to two different pandemics.
Jessamy: And we've seen that time and again, when you have these rapidly moving situations with lots of evidence coming out, and the sort of consensus converging to an answer which might not necessarily be the right answer, based on potentially the wrong outcomes, or just looking at things from a slightly different angle.
And that's where I think that this paper and, Richard Peto and his group is, important but it calls a halt to that and says look this is actually when we're objectively looking at the evidence and what is going on right now there is not enough evidence to be doing broad widespread third doses and boosters it might be okay in prioritized groups but again you know as i think that you and i have discussed it's still very hard for individuals making those decisions and that's not to say that people shouldn't be taking up their booster doses or their third doses when they're offered them from governments Just, when you're thinking about, you have to think about things on an individual level.
And on a global level and that's where the, that's where on an individual level, you really can't be expected to do anything else other than think about what you've been offered or advised if you're offered a booster, you take the booster, and it's, very important to continue to be very positive about vaccines.
But our policy makers, our governments should be thinking about things not just a national level, but on a global level so that we can focus on an individual level when we're offered things. So that's where the, it's very difficult, isn't it?
Gavin: Yeah, it's quite difficult ethical debate, actually, because, if you're someone that believes that other countries should have more vaccines than they do, then for you to accept a third dose feels selfish.
Your innate sense is this dose that you're taking up should be redistributed, but it's not it's not a zero sum game like that anymore. The vaccines you refusing a dose doesn't mean that it's going to go to another country and be used somewhere else. Otherwise, I think you'd see a lot of people refusing the doses, but it's it's very unlikely that you'd be put in such a scenario.
It was your choice to get a third dose, and if you didn't, it went to someone else who had no doses, because I think, Most people, reflexively, ethically, would refuse a third dose in that circumstance. But, like you say, it's completely a personal choice, and the choice of people in countries with all the vaccines to accept this third dose is not going to affect anything in the wider global situation.
That's still the responsibilities of the governments, as it has been for, what, are we coming up on a year now, since these vaccines first started being used in the US?
Jessamy: Yeah, and I remember those conversations that we were having about bilateral agreements and countries buying up all of the COVID 19 vaccines, even before they'd been, approved from a regulatory point of view.
And it feels, this is all down the same path of, Not necessarily greed, but just a real lack of vision on a broader scale.
Gavin: It makes you wonder what the turning point for this will be, and I'm sure we all hope it's not another variant like Delta, but it feels very short sighted, and it feels at the moment like the only way that these vaccines will be fairly shared around the world, especially in Africa, which I think as we speak has a vaccination rate of below 4%.
Will be some kind of disaster which affects the people in the country that has all the vaccines.
Jessamy: It's very interesting to understand what it is that will make that change because there's a very clear economic case for it. I think the International Chambers of Commerce have estimated that the global economy will lose 9 trillion a year or something if developing economies do not have access to vaccinations.
From that point of view, from a sort of, conventional point of view, you thought that you would have thought that would be a push and an incentive to have some vaccine equity, but it doesn't appear to be that way at all. And traditionally you would have thought that these economic arguments would have some sway with governments, but it doesn't seem to be at the moment.
Gavin: I think I naively thought while I was doing my PhD in politics that you could almost always make a government move with an economic argument, that aside from the kind of. Moral, political spectrum policy side of things. If you manage to be able to display to the government that actually this is the really smart economic thing to do.
You can save billions and trillions of pounds down the line by getting, by doing, by enacting this particular policy, which helps everyone, doesn't particularly disadvantage anyone. I thought naively at the time, I think, when I was doing my thesis, that it would. that would be a kind of slam dunk, something that could be immediately brought into policy, but it's just becoming more and more clear that's not really the case anymore, that kind of ideological selfish concerns override the economic side of things so often.
I was thinking particularly of climate change there, but also you see it in In the horrible treatment towards refugees and people moving into other countries, and for some reason in the UK we ban refugees from working when they arrive, which is a lose for everyone. So these sort of economic arguments, I don't know, I don't know where you go from here.
I, I, again, I, we shouldn't end podcasts by just throwing our hands up in the air and despairing. But it's difficult to know how to move the needle when you've got such a compelling economic argument and you have the resources to achieve it.
Jessamy: There's the only hope, I think, is that the multilateral system is somehow able to kick in over the G20 or some other, events in the coming months to try and just, sway that a little bit more, but they're, and now you're, nobody's saying it's easy to manage a pandemic or to make these decisions in government.
It's obviously extremely hard, but there are these knee jerk reactions to suddenly we've got to, do roll out third doses, suddenly we've got to do this. And having the kind of, capacity to think about things on an international scale doesn't seem to be in the system at the moment. And I'm not sure how you get that capacity Back into the system during a pandemic when there are so many things that are competing for, time, resources, thought, effort.
And now we're down this route of how, this is how we respond. This is how we've responded the whole way. How do you stop responding in that, how do you stop responding in that way? From a sort of political government point of view, I don't know.
Gavin: Yeah, you're exactly right. And it's also worrying that this structure that actually that we're talking about really, it is Visualized like a kind of charitable situation where it's only by the good graces of the vaccine rich nations that other nations get vaccinated.
The kind of redistribution in that sense when it absolutely shouldn't be the case. It should be a case of international justice.
Thanks so much for listening to this episode of the Lancet Voice. You can of course subscribe wherever you usually get your podcasts. And we look forward to seeing you again next time.