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Jessamy: Hello and welcome to another episode of the Lancet Voice. I'm Jessamy Bagenal.
Gavin: And I'm Gavin Cleaver. Salim Abdul Karim is an epidemiologist with decades of experience in public health in South Africa. In 2020, he was chosen to lead South Africa's Ministerial Advisory Committee on the COVID 19 pandemic, and as such was at the forefront of the discovery of the South African variant of COVID 19, which is currently making headlines around the world for its vaccine resistance.
Jess and me spoke with him about the discovery, how much we know about the variant and what comes next.
Salim: I'm an infectious diseases epidemiologist and have spent many years studying epidemics. The minister called a meeting of over 50 scientists in mid March of last year. to get advice about what to do about the coronavirus.
And he invited me to attend the meeting. And at the meeting, were mainly HIV researchers, because that's what infectious diseases researchers in South Africa focus on, for obvious reasons. And so the meeting, talked about what is it we should be doing, how can the government draw on scientific advice, and so on.
And at the end of the meeting, the Director General just announced that I'm going to be the chair of this committee. It would be nice if he asked, but it was fine. I was going to do it anyway if he, if he asked. Because to me, this is just, this is my duty. I do it. In a voluntary capacity to assist in any way I can.
As we have worked on trying to give advice to the government, I've been amazed at how challenging it has been. Very early on in the epidemic in April, my colleague from downstairs runs the sequencing platform and they started a project sequencing the coronavirus. And in doing that, once a month, my colleague who is the director of CRISP Professor Tulio de la Vera, he comes to see me and he brings me the data.
And we sit together over a cup of coffee and we just go through the data. And month after month, I said, but there's very little change. There's just one or two mutations. And by the time it came to September, October, I was telling him, this is getting a bit boring. There's nothing much to look at here.
There's very little change. You can imagine that when he came to see me in November, I could see when he got to the door, he was ashen pale, quiet. Not his usual, effervescent self. And he came and sat down, he put the computer on, projected it on the screen, and he showed me the data. And he just quietly said, we have a new variant.
Goodness, you mean to say there are more than, a single mutation? He says 23 mutations, 20 of which lead to amino acid changes, three in the receptor binding domain. I said, you got to be kidding. We got a virus that's so different, I had never anticipated that. All the evidence, we spent month after month looking at a stable virus.
And then in one month, a complete change. That's how much we were taken aback. I said to him, we better be sure. This is not, are you sure? He says I'm pretty sure, but we had just one. So we said, okay let's establish if we actually dealing with something real here. So we collected more swabs from the Eastern Cape, tested it.
And we now got 10, and when we got 10, we said, no, we have to tell people. So we briefed the minister, we briefed WHO, and we informed various people. Now, in one of those briefings, our colleagues from the UK were present. And so they heard about this variant and they started looking for the variant in their dataset.
And, of course, they found one, too. It became something that we were not anticipating. Except, in hindsight, of course viruses mutate. It's just that we were fooled, not fooled, we were lulled into complacency because this virus has this proofreading step. Because of that proofreading step, it maintains its stability, and we thought that it would always be like that.
Jessamy: Wonderful answer. And I just wonder, there are two things that I was interested to pick up in. One of them is, why do you think that happened in November? What was there any external factors?
Salim: There are three ways in which a virus can mutate like this. The first is when it jumps species. We saw that in Denmark when the they, the minks got infected from the workers and then the virus mutated and when the workers got infected from the minks, they got a mutated virus.
We know that jumping species is one way. Now, I don't think that's what happened here. The second is by just random error. Now, that. It's unlikely to explain 23 mutations. And so the third way is probably the way in which it occurred, which is that an individual who had been previously infected had existing immunity and got infected, but wasn't able to clear the virus.
Either because there was some immune issue, and it's been shown now actually in a cancer patient that the virus Continues to replicate for a long time. So a virus replicating in the presence of existing immunity, the only virus that can survive is a virus that can escape that immunity. And so the 484 mutation, together with 417, and the N terminal domain mutations, that combination is what enables this virus to just escape natural immunity.
And we now know that the infection rates among those with past infection was the same as the infection rates as those who didn't have past infection. So past infection, but the other variants don't protect you. against the 501YB2 variant. We now know that, and that's something we didn't know even a week ago.
So that's new information that's helping us. Now, in order for, to create such a mutation, it would take quite a long time. It would take a substantial amount of time. It must have in a person or in a few people, cumulated the various mutations it needed to get to a point where it could escape in this way.
Jessamy: And that's where this sort of immunocompromised, long person with a, a long period of time, that, that sort of theory comes up.
Salim: Yeah. And it could be in one person over a long time, or it could be in a few people all of whom had past infection. And so that's how the virus Got some advantage with a few mutations, still was spreading, got into another person, developed more advantage.
I don't think that it's probably that. It's probably one or two people at most. Because the virus would struggle to do, to survive, and somebody would pass the immunity in a repeated manner in that way. We don't know the answer. I've just given you a whole lot of speculation.
Jessamy: What about reinfection with new variants?
Can we just talk about the evidence behind that and where we are?
Salim: So as it stands, we were unsure as to whether those with past infection with the pre existing variants had immunity to the 501YV2 variant. We now have clear evidence that comes from the Novavax trial that shows that the attack rate In those individuals who had no evidence of past infection, and those who had antibodies, indicating exposure to past infection, was exactly the same.
So there's no protection offered by past immunity.
Jessamy: And what does that mean for us?
Salim: That means that we essentially had no benefit in the form of any kind of protection. So all those individuals who'd been infected in the first wave. were now susceptible in the second wave. Of course, it has quite severe implications for herd immunity because it means you can't build herd immunity through sequential exposures.
So you can imagine that all those individuals who at one stage were punting this Barrington declaration that let the virus spread itself in the community and we'll build herd immunity. That's now total nonsense because there's no such thing. The virus simply. mutates and escapes and there you're back to square one.
Jessamy: And Salim, you've been very careful about using the correct nomenclature for this new variant rather than calling it the South Africa variant or anything else. What do you think needs to happen with how we're naming these variants? And why is that important?
Salim: When we identified the variant, and we shared this with a few people, including the WHO, we wanted to get some idea of what we should call it.
But there is no nomenclature. And there is no characterization of strains in this virus. The WHO hasn't defined that. What defines a strain? What doesn't define a strain? We have three lineages, the A, the B, and the C in the pangolin. These are all B strain or B lineage viruses. When we look at the way in which it's handled in pangolin it goes into the group of the B.
1. 351. But B. 1 is actually several different viruses. They just have a lot of mutations. So it's not just the 501YV2 variant. So it's, it is a good way to describe the virus, but it's not this is not the only virus that would fit into that category. When we talked about it, we thought we should give it a name.
That way we know what we're speaking about. It's this particular virus. And we said the main mutation was the 501. Because that's what we thought was the main mutation at that time. And we said the British have already described a 501 mutant. So let's call theirs version 1 and we'll be version 2.
So that's why we said the mutation is 501 to Y. And it's Version 2. And it was just to create a simple name that made sense. The 501Y Version 1 was already in the UK. This was Version 2. And now, of course, we've got Version 3 in in Brazil. That just became a convenient way in which to describe it.
The WHO has had several meetings to try and resolve the nomenclature issue because really, we can't carry on like this, naming viruses in an ad hoc way. There has to be a proper way in which to do that and only the WHO has the mandate to, to be able to guide all of us. And so the scientific community has to come together and find a way to name them.
Until then, we'll just keep calling it the 501YV2, even though it's a mouthful to say.
Jessamy: There's been a flurry of early reports and data around the 501YV2 variant and the vaccines. Could you tell us about where we are in our understanding about which vaccines might work or not work and what we still need to know?
Salim: When we look at the variants, There are four key questions we have to answer. The first is the new variant more infectious? When we look at the data, the answer is yes. When we look at the rate at which we reached 100, 000 cases in the Western Cape, it was 50 percent faster in the second wave compared to the first wave.
So there's little doubt that the new variant is more transmissible, in other words, more infectious. The second is it more severe? And that's not so easy to figure out. It's quite a complicated thing to do. Our colleagues in the UK showed that the 501 variant in the UK, the B. 1. 1. 7, is more severe.
And the way in which they did that was, it's only possible in the UK. The UK is just amazing. When it comes to genomic surveillance, they've contributed like half of all gene sequences. Nobody can do that. What the UK is able to do, we can't. We've only done about 10, 000 odd sequences.
We've had to do this in another way. And the evidence that we have from an epidemiological assessment is that it's probably not much more severe, if at all. So the early evidence does not suggest compellingly that it's more severe. So it looks like it's more infectious, but not more severe. The next question we want to know is, does it escape natural immunity?
The answer to that is yes. The evidence from the Novavax trial shows that quite clearly. And then the last question, which is the one that really is causing great consternation is the question of, is this variant able to escape vaccine induced immunity? Now there's three ways to assess that. The first is through laboratory assays.
either using a pseudovirus, which is just a fake virus with mutations, or to take the actual 501YV2 virus and grow it up in culture and then add the serum from vaccinease to see if it kills the virus, or to do clinical studies. Now, laboratory studies are helpful, but they don't Tell us what we need to know.
Is the vaccine still going to work? Because unfortunately, the labor studies focus on the antibody side of the immune system, not the T-cell immunity. So we need to understand how all of these parts fit together in the human and whether they still work. So when we look at that. There is now evidence from three vaccine trials that have been done in the context of South Africa, where we have the 5 0 1 YV two variant that comprises about 80 to 90% of our circulating viruses.
So the first of those trials that released results was the NOVAVAX trial, and I was stunned. When I saw that I had a sleepless night. A vaccine that's 89 percent effective in the UK is only 49 percent effective in South Africa. That's a drastic reduction. Is this vaccine producing antibodies so low that this virus can simply escape?
That was of concern. Then we saw, thankfully, the Johnson results, which showed a 72 percent efficacy in the U. S. A 66 percent efficacy in Latin America, but only 57 percent efficacy in South Africa. Now, that difference was much smaller. And so that gave me a little bit more comfort. Especially because that study Also looked at severe disease and hospitalization and showed 85 percent efficacy because that's really what we're trying to avoid hospitalization.
So the Novavax trial didn't really have enough cases of severe disease of hospitalization. It was just focused on mild disease. And then this week, yesterday, we had the release of the evidence from the AstraZeneca trial. Now that was a very small trial done only of young people, all the elderly were excluded.
So it was really only cases of mild disease. And what it showed was what we saw in the Novavax trial, is that efficacy is diminished. Now we don't know whether that applies to severe disease. We don't know if that applies to hospitalizations. Because the study didn't answer the question. So the study creates new uncertainty.
In the midst of that uncertainty, we have to make a decision. Should we roll out the AstraZeneca vaccine regardless? And the answer to that is, no, you can't do that. What if we vaccinate a million people and then learn that it actually doesn't protect against severe disease or hospitalization? We would have given a million people that vaccine.
We can't do that. We put it on a temporary delay. What we've said is, let's answer the question. The question is, does it prevent hospitalization? Let's do that. How do we do that? We can only do that in South Africa. Because we're the only place that's got this variant that's so widespread, right? In the other parts of the world, it's not that common.
So they can't do that study. Only we can do it. So what do we do? The plan is, and the proposal is, that we do a two step rollout. In the first step, we vaccinate about 100, 000 people, and we measure what the hospitalization rates are. If the hospitalization rates meet our threshold, or they're below our threshold, then we continue.
We roll it out to the millions because it prevents hospitalisation. That's what we're really interested in. If it doesn't meet that benchmark, then we were prudent in not just rolling it out because then we need to stop and we need to look for other vaccines instead.
Jessamy: What's South Africa's other plans for vaccines options at the moment?
Salim: The South African COVID 19 vaccine strategy calls for diversity of candidates. And the diversity of candidates is quite important because that way, if you end up with a situation where one vaccine doesn't work and the other ones do, or there's a problem in manufacturing or something like that, it gives us many more options.
And so we chose to go with, for now, three vaccines, and we are looking at three others. The three we have already purchased. The largest quantity is the Pfizer vaccine. The second largest is the Johnson. And the third, which is actually, we only have a small quantity of AstraZeneca. So those are the three.
We're busy looking at the other candidates and we'll make a decision about whether they meet our requirements. And then, because we have a set of criteria that we apply, six criteria, and if they meet those criteria, then we include them in the portfolio.
Jessamy: In terms of broadening it out to the rest of sub Saharan Africa, which vaccines are you most hopeful for, the various sort of characteristics that they have, whether it's storage or, efficacy, number of doses, etc.?
Salim: I find one of the most impressive is the data that I have seen on a single dose. And the single dose of the Johnson and Johnson vaccine exceeds my expectations enormously. And it does better than almost all the other vaccines given as a single dose. And to get to 72 percent protection and 85 percent protection against hospitalization, in fact, 28 days post vaccination, it's 100 percent efficacious against hospitalization.
After a single dose. Of a vaccine that's easy to store, it's cheap. By any standards, the Johnson vaccine wins hands down. For countries that, don't have huge infrastructure to vaccinate, to have people not come back for a second dose is a big plus. And in my view, the best vaccine that's most appropriate for our setting is the Johnson candidate.
But we do not want to end up with a situation where everybody gets Johnson. We have to keep a diverse portfolio. Now we'd like to, as many people as possible to get Johnson because of just that advantage. We'll just wait to see what's available.
Jessamy: I just wanted to go back to something that you said at the beginning of our chat, which was that even from the very beginning, you felt that this was extremely polarizing and political, more so than HIV and AIDS, which is very striking.
Why do you think that is?
Salim: I think fundamentally, the main decisions that needed to be taken to deal with this virus were political, They were not health decisions. The health decisions were pretty easy, but they strayed out of our domain. The bulk of what we're doing interfering with the way churches work, stopping, people from getting married, and all these things interfere directly.
And especially in South Africa, where alcohol is a big part of our restrictions. It's amazing to control and deal with an infectious disease. Alcohol is a big thing that we control. It's a major component of what we do in our restrictions. And the reason is very simple, that the bulk of our health care services are utilized in alcohol related injuries and medical conditions in non COVID times.
So in non COVID times, we deal with the alcohol related motor vehicle accidents, the interpersonal violence, and so on, and then the pancreatitis and the liver disease, and those illnesses those, the motor vehicle accidents and so on. They use the emergency room, they use theater time, they use the ICU, they use our oxygen, all the things we need for COVID.
So the doctors can't cope, we can't cope with the alcohol problems and the COVID, both need the same things. So we have to control and restrict alcohol so it clears the ICU, and then we can put the COVID patients in there. So it's a very odd way. I consider it really hard that we deal with COVID by controlling the amount of alcohol available.
Jessamy: We're at quite a sort of capricious time in the pandemic. It feels a little bit dangerous. What are your hopes and concerns for the next couple of months?
Salim: I'm just very hopeful that the first variant of substantial escape has now been identified. And it's now giving us a methodology that we can follow for all the new variants that come along.
That we're now better prepared, we're ready, and we'll be able to make new vaccines or adjust our strategies more readily. What we're doing now is that we are cutting out the path, because this is the first. Anytime you're starting something for the first time, you've got to figure it out. But once we have, we'll be in a better position.
I
Gavin: think in the chat we should point out that it's probably not right to keep saying South African variant, and it does feed into this nationalism that we're trying to avoid in terms of COVID 19. But it is a very useful shorthand and that's an interesting debate in itself, isn't it? It's a lazy way of talking about it, but it is an instantly recognisable way of talking about it as well.
Jessamy: Yeah, and we have an interesting chat about that with Salim because he essentially says that, at the moment we're in this strange phase of not really having a proper nomenculture for these variants in that we're using a kind of an adjunct. then with a version one, version two, or version three that isn't at all accurate.
And we're waiting really for the WHO to give us guidance to what to call these specifically in an immortal sort of scientific way. It
Gavin: seems to be very upfront, doesn't it, about saying that unless everyone in the world is safe from COVID, no one in the world is safe from COVID. That's the kind of phrase people are using at the moment.
And I think this sense of talking about it in country divided terms like the South African variant or the British variant, it feeds back into the problems that we're facing on that kind of nationalistic front, doesn't it?
Jessamy: And it's extremely unhelpful as well, because these variants might have been picked up anywhere.
Just because they were discovered first in South Africa doesn't mean that necessarily that's where they first emerged. And therefore it's very. unhelpful and not at all informative for public health policies of countries, to say, oh therefore we're going to ban flights from South Africa, but not Zambia or not Zimbabwe, it doesn't make any sense because saying that it's the South Africa variant, primes people to say that's the country that we could, we should focus on.
But we know from past experience that's just not the case at all.
Gavin: To move on then to talking about, in circumspect language, the variant that you and Salim were discussing. Sounds like it's both kind of good and bad news, at least in terms of vaccine resistance. It sounds like there isn't a lot of resistance for contracting the virus and for having a kind of moderate case.
There is at least a lot of hope for it still protecting quite heavily against hospitalization and death. And of course, that's really what you want the vaccine to do.
Jessamy: Yeah, the 501YV2 variant, I think. There are similar aspects to the UK variant and we are again in very early days of this and things are likely to change a lot over the next, couple of weeks, month, but there is still hope that this will prevent severe hospitalization and severe disease.
And that's what, as you say, is the most important, whether it prevents mild disease or transmission. that's important from a sort of public policy point of view as to what then non pharmaceutical interventions do we keep in place. But the key is to prevent that sort of very high burden on health systems.
Gavin: Yeah, I think if we'd been offered a vaccine that essentially eliminated hospitalisation and death, but kept the virus around as as something that could cause, as the UK politicians are so fond of saying over the last week or so, the sniffles. would have taken that basically in this position a few months ago?
Jessamy: Yes. And, we really were very uncertain as to whether vaccine efficacy would be as high as it was. And I think everybody was very pleased and, pleasantly surprised at having vaccine efficacy up to 90%. That's just, I don't think that's something that many people really expected.
So if it's reduced to under 50%, then that's a problem. But if it's reduced. to, 60 percent or just reduced a little bit, then that's not such an issue. But obviously, we've got to look at it now from the long term point of view. And we now have a pathway for how to deal with these variants, what it is that we need to know very quickly, and what it is that we need to think about in terms of vaccines.
And that's the long term game. This is going to keep happening and the variants might get worse, they might get better. But we need to really be focused on what are the strategic ways that we deal with them. What does that mean for vaccinations? What does that mean for public policy?
Gavin: Yeah, you're absolutely right.
It's a very long game in this term, isn't it? And the lower the efficacy of the vaccines, the longer the game becomes. But as we mentioned, as Salim mentioned, unless we can have a decent vaccination program for Everyone in, in, in countries that are reflected around the world, then we're going to see these variants popping up because this is what happens when you let the virus, not run wild, I don't think any country has let it particularly run wild, but this is what happens when you have such a huge number of people infected by the virus.
Jessamy: And in that sense I hope it might be a sort of useful wake up call for many high income countries and governments who have, stepped to first of the queue for the vaccine line and have not been thinking so much about lower and middle income countries, and that this has made it absolutely clear that we need a clear way forward, which is going to be evenly distributed and allow equity to that vaccine.
Because otherwise we're going to be in this situation for a much longer time.
The 1918 flu pandemic was the last pandemic to have a simultaneous major effect on the global population. Coming off the back of World War I, the virus killed at least 50 million people worldwide. Laura Spinney's book, Pale Rider, the Spanish flu of 1918 and how it changed the world, is one of the most comprehensive overviews of the pandemic.
She joined us to talk about the parallels between now and then.
Gavin: To kick off then, I guess we could talk a little bit about, obviously we're here to talk about the 1918 flu pandemic, the kind of parallels between that and the Covid pandemic that we're all living through at the moment. If we could kick off a little bit by talking about kind of memory formation.
You said in the book it takes a long time to form a solid memory of a pandemic. Do you think it'll be any different for this pandemic?
Laura: I think it's a really good question because in general, if you look back over history, we have been really bad at remembering pandemics in comparison with, say, wars.
And as you say, I explore some of the reasons for that in the book. I think it has to do with the difficulty in part of getting data about pandemics. Because To start with you're by definition dealing with a novel pathogen, so you may not have the diagnostic tests and a whole host of other reasons.
But I do think, and there has been some really interesting debate on this in the memory studies community, that this one may be different. Why? Because it's the first really serious pandemic in the internet age, in the digital age. And so we have Just, you, you've been there too.
You can watch the infection rates, the death rates going up and down in practically real time if you want to. There's so much data on this pandemic, most of which is being logged. Some of it's ephemeral and that's another story. But there is also a massive collecting effort going on, has been since the beginning.
Maybe it will escape that. curse of the pandemics, and we will remember this one better. Of course, there are problems within that, like for example, the fake news problem. What is the information we're collecting? Are we getting the really relevant stuff? And how much of it is false? How much of, what's the contamination problem?
Gavin: We've only really come to as you say in the book, talk about the 1918 flu pandemic quite recently, why do you think that was?
Laura: We didn't have the data. For most of the 20th century, we didn't have the data. The numbers only started really getting big in terms of the estimates of the global death toll towards the tail end of the 20th century.
And then you get into a sort of depending on your point of view, virtuous or vicious circle because people realize, oh, this was big. So then they go and do some more research into it and then they get better figures and then they're like, oh, we better do some more research into it. And also the kind of breadth of people who are interested in it, the breadth of specialities who've been interested in it has broadened out.
So to begin with, it was only really virologists actuaries for insurance companies epidemiologists, maybe some medical historians. And then it became economists, sociologists, psychologists. public health people historians, art historians of literature. Everybody realized that a pandemic has something to say to them and had something of relevance to their discipline and geographically also the interest expanded.
So I think it's like a snowball and that's very different from the way that a memory of a war is built, I think. And It gets accelerated periodically when another pandemic comes along and people start reaching for historical examples and that provides another stimulus to research into the historical ones too.
Gavin: As you said, of course, we're talking about a novel pathogen whenever we talk about a pandemic. So in 1918, what were some of the ways that governments dealt with the arrival of the pandemic? Were they comparable with modern day? Were there things like lockdowns, travel restrictions, that sort of thing?
Laura: In one way, it was dramatically different context, which was that there was the World War going on as well.
And in those countries that were deeply implicated in the war certainly to begin with, and even later on when it really was very clear that this was a serious disease and that it was global they It wasn't their priority. You have to remember that the first wave of the 1918 pandemic was relatively mild.
It wasn't that different from a seasonal flu. So it wasn't really until the late summer in the whole northern hemisphere autumn, that people began to realize that they were dealing with a really bad flu. Very properly lethal disease. And another, I think, important contextual thing to bear in mind is that infectious diseases back then were still the major killer of humanity.
So it was a different world in that way. And flu, It took a little hard, it took a little more to reach the threshold of thinking this was a serious disease amongst all the other serious diseases that were a problem at the time. For example, TB was rife in the world. And then public health was much younger and less organized and less well thought out.
But with all those caveats, when the second wave came along, yes, countries did put in place measures, nothing like the kind of national lockdowns we've seen this time, but that is really unprecedented. And these were very patchy across the world, even across countries within cities, depended on the authority in charge.
It wasn't really any joined up thinking, even when they were put in place. early and were quite well thought out. They often tended to be lifted too soon. Yes, they were put in place. People were in some ways more compliant because it was an era when you were just more compliant, generally more likely to listen to voices of authority.
It was wartime, so it got tangled up with being your patriotic duty. But people weren't stupid either, and when they saw that things weren't working or that their their lives were being constrained in a way that they found unacceptable, the same fatigue we're seeing today compliance fell off.
So there are many similarities and, but also many differences.
Jessamy: I think they run up to This pandemic, there's been years of pandemic preparation, and I suppose one of the things that wasn't really factored in was political incompetence in dealing with infectious diseases on a wide scale.
Do you think that there's evidence of that, of a similar sort of political incompetence in 1918? They were stretched, they were also fighting a war. How did governments even go about these huge logistical Challenges of the pandemic and a war,
Laura: I think they, they struggled. I think I have to start by saying, I think it is really difficult to be a politician managing a pandemic.
I think it's a kind of lose, lose situation, whatever you do. And of course there's no, no controlled experiment to be done. It can't be compared to what else you could have done. And then of course. There's the whole discussion about how helpful democracy is in a pandemic. Because, the structure of our democracy is the way that we keep people in check who have power is that we turn them over quite quickly.
And that and the price we pay for that is a sort of lack of institutional memory. Now there are ways around that, and one of them might be considered the W. H. O. or equivalent, something that kind of keeps memories of these things and feeds it back to the governments as they need it. That's maybe another discussion about how effective the W.
H. O. is at doing that. But I think it, again, we come back to the problem of it was rather a unique experience in 1918 in that the war was going on at the same time. So there were all these priorities fighting against each other. And if you look at both the U. K. and the U. S., they definitely put the war first every single time.
For example, you had these. transports leaving New York, plowing backwards and forwards across the Atlantic with troops infested with flu, having to throw bodies overboard because they didn't have the space to keep them as well as the sick. Terrible scenes on board and this went on, this continued.
Because Woodrow Wilson in the United States considered that it was more important to keep the war effort going. U. S. had finally entered the war in 1917 than to stop the transports and try and control the infection problem. And yet his medical advisors were telling him, Stop them. Stop them, because it's gonna be counterproductive in the end.
But his generals were telling him something else, and he preferred to listen to them. Similar things happened in the U. K. The war was prioritized. And, of course, when you get to that level of decision making, which is the ultimate level of decision making in our nation. Nations. The the government has the last word.
That's the way it works.
Jessamy: It's such an
Laura: interesting topic because
Jessamy: there are obviously examples in the world of countries that have managed to, successfully deal with this through a variety of, non pharmaceutical interventions and things like that. And that, that kind of how we put resilience into a political As well as a sort of health system is the crucial question for the future for how we deal with crises, whether it's, climate crises or future pandemics, putting that kind of resilience in, putting that ability to make decisions, ability to analyze previous data that is crucial for how we're going to be able to deal with things in the future, which Inevitably, it will happen again.
Laura: I think you're absolutely right. And I was writing the other day about the Global Health Security Index, which was published, unfortunately for it, for the first time in late 2019, I think, if I remember correctly. And ranked countries in the world, 195 countries, according to their ability to contain infectious disease outbreaks.
And number one and two in that ranking were the U. S. and the U. K. Exactly. And China, New Zealand, South Korea, Vietnam were way down. African countries were way at the bottom. And I think if you dig into that data, it's very instructive because it's not that it was wrong on the things that it measured.
So it measured, the ability to mount an emergency response the expertise and size of the epidemiological workforce. All of these things are important and necessary but they're not enough. And I think there's this other suite of things, which is either very hard to measure or does not reveal itself do not reveal themselves until the chips are down So to speak and those are things like good leadership trust between the people and their government and their experts and also very importantly Solidarity, the sense that I will make a sacrifice for somebody else's welfare and not just for my own.
And
Jessamy: from a health point of view, the baseline level health of a population and, all of the other factors that we've seen come into this, inequality and how, those things that are difficult to measure and our institutions.
Laura: Although those things I think, sorry, those things I think we have been aware of for a while, pretty much since 1918.
And those are things that, We should have done better on those things, I think. Those are the things that we know count, that we can measure, and that we still have failed on this time.
Gavin: What were trust and solidarity like in 1918 with people and the government?
Laura: I think I touched upon this before.
It really depends, of course, which country you're speaking about. It's really difficult to generalise. But if you talk about those countries closest to where we are, that were most implicated in the war, because let's face it, we call it World War, but it was mainly a Western European war and they dragged their colonies into it.
People were exhausted, physically, economically, psychologically worn down by four years of war. And yet I think it was a, the war in some ways Yes, wore them down, but it was also a reason to remain solid to maintain solidarity because we are we have to, beat the enemy. And there was another enemy but now there was the virus as well.
And but I think within the context of the pandemic, you saw the same loss of trust over time, the same fatigue, you saw people in positions of authority who appeared in public with their masks on. Stangling from their ears, and that had the same effect as Dominic Cummins great Northern Run had today, people it's massively important to see role models doing what you're expected to be done, to be doing and and so you see this gradual falling off of compliance because inevitably over time.
People make mistakes or people forget themselves or people just get fed up. And they want to go back to normality and we're not very good as a species I don't think in being patient and understanding that it's a small sacrifice but we may have to maintain it over a certain amount of time and that the price of not doing that will be much higher than the small sacrifice we're being expected to make.
But yeah, that is a problem. How do you maintain that momentum? How do you maintain that motivation? I think it's a lot about, unfortunately, it's a lot to do with the trust and confidence that were in place when you started. You can't do much about that. But afterwards, it's to do with the way the role models behave.
It's to do with good messaging. And it's to do with support of the people you're asking to make those sacrifices. Which need to be indexed to the extent the sacrifice is impacting on them. The people who are being asked to make the greatest sacrifices, who tend to be the least who are the poorest in society suffer most already in terms of inequality, they need to be supported the most.
And these are lessons we should have learned from previous pandemics.
Gavin: Do you think, obviously we've talked quite a lot about the parallels, but is there a lot a hundred years on that kind of doesn't really apply? from the 1918 pandemic to the modern day?
Laura: I think it's fairly safe to say now that this is the worst pandemic since 1980, though there have been others, of course.
But I don't think it will reach those numbers. I don't think there's any chance of that. And certainly let's hope not. The most conservative estimate of the death toll from 1918 is 50 million people. In the world. And so we're nowhere near that. I think a really important difference is who are the most vulnerable groups in society.
Until recently, although I have to, it seems to be changing the age profile of who's most impacted in this pandemic and becoming younger. But until recently, and and still it's been a really quite significantly just an elderly disease and a disease of people with comorbidities. Whereas the people who are being asked to make the sacrifices in terms of economic hardship and lockdown and so on, tend to not be that group, because the elderly people who are in the firing line for this disease are very often out of the workplace.
But the people who are being asked to make the sacrifices are the ones who are younger and still productive. And that's a problem. In 1918, I guess you could say the problem was different in that you had this middle aged group of 20 to 40 year olds who were very vulnerable to the disease. They died in shockingly high numbers and those tended to be the the pillars of society, the producers, the parents at a time when there was very little social safety net.
So although we've, as we've discussed, there wasn't lockdown in the sense we mean today, there were restrictions. The same age group, that they saw those restrictions as protecting themselves from the disease. Whereas today, the people who are being asked to make the sacrifices are protecting a different group in society.
And so there's more strain on that sense of solidarity, on that sense of collectivity, on the idea that we need to do this for other people. And it's a civic duty.
Gavin: Yeah, I think it's interesting to think about the kind of differing economic impacts of the people that were impacted, like you said there was, obviously, in the case of 1918, you're wiping out their working age population in a lot of places, whereas now, I would think that, when we can move past this to some extent, when the vaccines do take hold, that actually economies will bounce back Quite fast compared to 1918.
Laura: Actually the economic research I think is fascinating because it seems to suggest that, in general, humans bounce back at the population level from pandemics much more quickly than they do from wars. And the reason for that is fairly simple. It's that the pandemics destroy wars destroy capital.
They destroy infrastructure. Pandemics don't. They destroy people and they destroy activities. But the infrastructure is still there afterwards. I think that's the kind of general explanation. But yes, in, if you're speaking within the context of pandemics a pandemic that wipes out the productive class, the people at the, in the most productive phase of life, is obviously going to be more damaging and take longer to bounce back from than one that takes out The elderly or the very young, the people who are not yet in the, in, in the productive phase of life.
That's not to say it doesn't cause as much human misery, of course it does. But from a population point of view, and the ability of coming back economically, socially it's easier, I think, if you haven't taken out that productive class.
Gavin: Do you think, just to finish up, there's a kind of danger of us telling these pandemic stories from a North American and European perspective, whereas actually, of course, a pandemic is something that can really affect everyone on Earth.
Laura: Totally. That's the reason I wrote my book, is that the relatively few accounts of the 1918 flu that existed at that point for a general audience were heavily skewed towards mainly America but also Europe. And there's a good reason for that. The data from America until, for a very long time, were the best.
So it was the easiest story to tell. But, with this kind of raising of awareness of that pandemic over the 20th century, more people doing research, it was possible to tell the story of what happened in other parts of the world. And it's now absolutely abundantly clear that the that the continents that bore the brunt of that pandemic in 1918 were Africa and Asia.
What I think is really interesting this time is that Lots of people were saying for a very long time throughout 2020, including me, that probably this pandemic was going to also have its greatest burden in those continents. But it doesn't seem to be doing that. We don't have all the data yet, it may change, we're not sure what's going on.
But it doesn't look to be the case that Africa and Asia are suffering nearly as badly. As wealthier parts of the world with older populations and people with more comorbidities. And I'm not pretending that we understand why that's happening, though it probably has to do with the youth of those populations in part, perhaps climate factors and things that we still don't understand.
But I think it's really interesting that in fact, at this moment, it looks as if This pandemic is really taking most of its toll in the continents that were most spared in 1918 North America and Europe.
Gavin: Obviously the main thing that Laura was straining to point out about the 1918 flu pandemic is just the sheer death toll.
And in that sense, it's not really comparable to the current pandemic. It was such a kind of short, sharp shock of a pandemic. It was basically took a year. It was two waves. And the death toll was. Absolutely unbelievable. Whereas in that sense, this is quite a different pandemic, we've been talking about how we're in this for the long term, how are we going to see these variants, but there's no particular evidence so far that the more deadly variant has emerged, for example, and the infection fatality rate is still, compared to something like the Spanish flu or to MERS or SARS, really relatively low.
Jessamy: Yes, and there are a couple of things to say about that, really, I think. On the one hand, we've talked before about the sort of group think, of thinking that this was flu, and therefore trying to impose policies that were based on a flu pandemic, which isn't the case. Yeah,
Gavin: Jeremy Hull was very keen to point that out a couple of weeks ago, yeah.
Jessamy: Exactly, and lots of people have said that, I think, and it's a really good point, and an important one in terms of how we develop preparedness for the future. But I think the other important point to make is that, Yes, the death toll is not as high, but in a way that makes dealing with COVID 19, when we look even very back to the first days, that's what makes COVID 19 so difficult to deal with, because this virus has a sort of great balance of being able to survive in people and be able to, easily transmitted.
If people You know, that's why, for instance, SARS CoV 2 was easier to control because the death rate was much higher. So you people died and that was terrible, but it stopped the virus. Whereas in SARS CoV 2, what we've got is a virus that has a great balance in terms of It, its sort of agenda of being able to survive in people for a long period of time and transmit therefore very easily to lots of other people.
And that's a very difficult, although it doesn't have such a high death toll, it's an extremely difficult virus to control.
Gavin: Yeah, absolutely. And I also think perhaps maybe the lower death rates and the kind of lack of visibility of death itself, to talk in philosophical terms perhaps makes the public take it a little bit less seriously, perhaps.
it, this kind of feeds back into the public going actually it's not that bad. This is what you were just saying at the start there that actually, it's essentially the flu. A lot of people said at the start of the pandemic, it isn't, it's a lot more deadly than the flu, but it's not so much more deadly that we get to a kind of Spanish flu, SARS or MERS level.
Jessamy: Yes. Again, I think that the virus has this. incredibly difficult balance, which, which has made particularly our societies, Western societies find it difficult to compute and to perceive. And one of those is, those voices that we've had about, Oh it's only going to infect and potentially kill older people.
Is that as important, what's the value of life. And obviously that's, that's not something that any of us would ever want to. agree with, but that has been, there has been those voices during the pandemic and it's, that's completely wrong. But I think that corrosively meant that people have felt differently about the pandemic than if this was affecting young people to the same degree.
And then I think there is the issue that, when you look at even that that first study that was published a year ago, or, on the 24th or whenever it was of January, patients were staying in hospital for 22 days. So when they do go into hospital, then the burden of being in hospital is for a very long time.
And that's, again, extremely difficult to deal with from a sort of health systems point of view. I think It's a really, it's a really difficult one because it has, the virus has characteristics that almost seem to be just incredibly aligned to the weaknesses of our society. You know what I mean, in terms of the reflection of our societies, of inequalities, how we value old people, how we value care, how we value health.
This is the perfect storm, the virus that exposes all of those. It became a reflection,
Gavin: didn't it?
Jessamy: Exactly. And that's been extraordinary, really. Thank you for listening to this episode of The Lancet Boys. You can subscribe wherever you usually get your podcasts and we'll be back in two weeks time for a Black History Month special focusing on the health of black people in the USA.
We'll see you then.