Even as I am celebrating yesterday’s news that Pfizer may have developed an effective Covid19 vaccine, I thought this would be a a great time to reflect on the challenges ahead and on the things we can learn from other epidemics.
As it happens, I have spent a significant part of my career on the frontlines of the HIV epidemic, mostly in Eastern and Southern Africa.
While HIV is different in so many ways from a respiratory pandemic, there are a few fundamentals that these two epidemics (and maybe any epidemics?) have in common. Here are a few, in no particular order:
1. Behavior > Medicine
The HIV epidemic did not happen for lack of medical solutions. It also wasn’t solved by medicine alone. Sure, medication is a critical factor — and once treatment was reliable and affordable the whole dynamic changed radically to the better.
But what really turned the HIV epidemic around were things like:
- understanding how the disease works and spreads;
- in particular understanding the role of behavioral factors such as multiple concurrent partnerships, unsafe practices, beliefs and attitudes etc.
- individual preventative & protective measures;
- availability of commodities;
- availability of testing at scale — finding cases early and referring to treatment has an enormous effect on incidence;
- a shift in perception and social norms;
Sure enough, the majority of above factors have a powerful behavioral component. It doesn’t matter that testing is available, if no-one wants to test. It doesn’t matter that treatment is available if you don’t think you need it.
Individual behavioral change — using and/or requiring the partner to use protection. Treating and disclosing other infections. Understanding that by protecting yourself you are protecting the community. These things have driven the success of the global response to the HIV epidemic.
The Covid19 epidemic will require similar efforts, on a much larger scale. Billions of people — all of us, really — will need to adjust our individual behavior. Whether we are talking social distancing, masks, a shifting of our societal rituals, all of us need to understand that individual actions have an immediate impact on our communities. We will have to get used to doing things differently — not only for our own protection, but for the sake of our communities.
Vaccine or no vaccine, this is the only way we’ll get Covid under control.
2. Logistics challenges grow exponential
In the global HIV response there were a few important medical/ pharma milestones. Antiretroviral therapy. Reliable finger-prick testing. Prophylactic treatment.
Yet, each of them took years — if not decades — to roll out in any meaningful way. The costs and challenges of rolling them out increased exponentially. The proverbial last mile has never been gapped completely.
To this day, more than a million people contact HIV every year, and many others die, in spite of treatment being widely available, mostly for free.
These challenges will be exponentially higher for Covid19 vaccines. The Pfizer vaccine needs a cold chain maintained at -80C/ -112F. It needs to reach communities quickly. It needs to be delivered across population segments — which means that existing contact points that have been optimized for immunization (post-natal consultation, schools, etc) will not be enough.
As we run through our global scenarios we need to keep above in mind and plan for unprecedented levels of logistics needed.
3. Epidemics are political
HIV has been political from day 1. Not surprising, given its means of transmission and the sad state of social politics in the 80s.
But it remains political to this day. Because it has a behavioral component, and because it impacts individuals and communities.
Because addressing an epidemics takes money and money is always political. Because input-output-outcome correlations take longer than politician’s mandates, people in politics tend to shift blame and take credit as they fit them better.
Because different communities/ regions/ countries get hit differently and that fits into other communities’/ regions’/ countries’ political agendas.
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Like HIV, Covid19 has been political from day 1. Some countries reflected their own global political agenda in the way they approached it (“The Wuhan Virus”, as per a certain former US President). In short order, every politician worth their salt has coopted the pandemic at least partially to support some of political agenda.
It will get worse. The existence of an effective vaccine will raise equity questions. Conflicting interests will take political forms.
These are the sort of crises that our forbearers had in mind when they set up super-national structures (such as the WHO, among others). The fact that over the last few years countries have consistently weakened these institutions will make our work harder.
4. Misinformation is real
The amount of misinformation around HIV has been staggering.
In most affected communities, facts blend with superstition, quackery, religion, post-colonial suspicions and people’s general tendency to see conspiracies.
Denialism of scientific facts has plagued the global HIV response end-to-end and continues to be a significant barrier to prevention, testing, treatment or adherence.
Covid19 is no different. From insane stories linking 5G to the virus, to ridiculous DIY treatment methods, to complicated global conspiracies including the usual shadowy forces, misinformation has been rampant.
To make things even more challenging, this pandemic is also happening on a background of social-media saturation which amplifies the spread of misinformation to levels never seen before.
5. Politics and misinformation are a dangerous combination
Alas, misinformation is not the exclusive domain of regular people with limited access to information. True for HIV, true for Covid19.
South Africa’s Minister of Health during the peak of the Southern African HIV Epidemic promoted beetroot, spinach and potatoes as a viable treatment for HIV. She kept her job for 10 years.
She raged against scientific consensus and did what she could to undermine any scientific efforts. Her actions might have costed half a million unnecessary deaths in South Africa and nearby countries.
She is just one of the better known examples of the dangers of mixing politics with misinformation. Sadly she was not an isolated case, nor is this deplorable combination a thing of the past or an exclusive property of sexually transmitted epidemics.
The covid19 epidemic has taken this dangerous combination to new levels, already. Unprecedented, Government executives from places like the US or Brazil have this time embraced misinformation and reflected it in their policies. We have seen a US president promoting household chemicals as effective treatment and denying scientific facts on a daily basis.
Imagine how difficult it will be, in such a political environment to go our and vaccinate people by the billions.
6. It takes more time than you think
How many HIV epidemics were there? From the 80’s San Francisco epidemic, to the Eastern European one in the early 90s to the Southern African one in the mid 2000s. Or was there a South-East Asian one as well?
What is certain is that HIV has ravaged throughout the world for decades. And even now, almost 50 years later, it is still out there, spreading and killing people.
The HIV epidemic has transformed but it is still out there. We have just learned to live with it, and have developed the technology to make that possible while maintaining a lifestyle close enough to the one before.
Our biggest success in the HIV response is that we have managed to convert the disease from an acute one into a chronic condition.
At various points in the history of the HIV epidemic, scientists, activists and politicians made predictions on the disease been “beaten” in 5–10–15 years. They were all wrong.
Partly, this is garden variety Planning Fallacy: “A phenomenon in which predictions about how much time will be needed to complete a future task display an optimism bias and underestimate the time needed”.
Almost everyone always underestimates how hard it actually is to coordinate a global epidemiological effort.
Covid19 will not be any different. It will almost certainly take many years until we will have the thing under control one way or another, and by that time we will be fully immersed into a “new normal”.
7. People adapt
HIV has changed sex forever: the attitudes, behaviors, etiquette and logistics.
We understood how things work and did what every living creature on this planet does: we adapted. We learned to live with it.
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This is what we need to do with Covid19. We have to live with it. And with other pandemics that will come. Will have to adapt and craft a new way of life for ourselves and our communities. This is not necessarily bad news. The “new normal” provides us with opportunities that we should make use of.
8. Collective trauma is real
HIV has messed up entire communities. Generations of children raised by grandparents. Entire villages with no grownups in sight. Children wasting away from AIDS or hunger. Economies collapsing.
This stuff has had an impact on the collective consciousness. People who grew up/ lived with these realities share a trauma that will take generations to heal.
The realities of Covid19 are often lost in the newscycle. Zoom funerals and Facetime Weddings. Socially distant relationships. Millions of people out of jobs, facing economic ruin. Covid is scarring the collective consciousness as we speak. We need to acknowledge that and make real efforts to heal our communities, long after we have had the pandemic under control.
9. There is not ONE solution
In spite of endless hopes and decades of research, there is no cure for HIV. Yet, the most impactful response has been a combination of actions, that compound to help control the epidemic. None of them would work alone, yet together they do the job. These include:
- Prevention efforts combining prophylactic treatment, behavioral change and thinks like male circumcision and others;
- Wide-spread availability of testing leading to early detection;
- Availability of affordable, effective treatment;
- A certain level of trust in the system
This will be true for Covid as well. There is no one thing that will make this pandemic go away. There will be many things that will compound towards us managing to get the thing under control. As a benefit, we will be better prepared for other pandemics, of which there will be more to come — in our lifetimes or after.
10. We will get over this
The good news is that it will get better. I don’t know when or what the price will be, but we will get over this as a people. And I can guarantee that in spite of all the suffering there is a silver lining.
Perhaps, we will even come out of it as a better people. More caring and respectful of the world around us. That will help as, just around the corner, the next crisis is waiting to test us.