Preventing the next Pandemic. Vaccine Diplomacy in a Time of Anti-science.

By Peter J. Hotez, MD, PhD.

Johns Hopkins University Press

Peter Hotez, hitherto unknown to me, is, it transpires, a very distinguished American scientist and physician with substantial experience of working in the fields of vaccine development and application. His particular interests are vaccine development for the so called neglected tropical diseases and vaccine diplomacy, the latter resulting in part from his appointment as a Science Envoy by the Obama administration to work in the Middle East and North Africa. He was named in 2017 by Fortune magazine as “one of the 34 most influential people in healthcare”.

I started reading this book on the day that the death toll from COVID 19 in the UK topped 100,000 and when the evidence that the UK has been the worst affected developed country seemed irrefutable. And a day or two later I heard the expression Vaccine Diplomacy for the first time on the Today programme in the context of the UK and the EU sharing their “surplus” vaccine supplies with other countries. For, as Libby Purves pointed out in a recent Times article “This is a global pandemic, nobody is safe until we’re all OK”

So a publication of interest for me who as a child witnessed the impact of poliomyelitis on my own generation; and much later, lived through a truly historic event – the global eradication of smallpox – a disease that was enough of a potential hazard in the UK even in the 1970s to require me as a practising public health doctor in Wolverhampton, to have to screen residents recently returned from their Indian subcontinent homeland with suspicious signs and symptoms by sending lesion samples for electron microscopy to exclude the variola virus.

But this is an even more important and timely publication for a lay readership in this age of misinformation and anti-science.

As Bill Gates has remarked dealing with the COVID pandemic is easy compared with dealing with Climate Change. For history has taught us that there is one sure way of preventing infectious diseases, pandemic or otherwise, namely vaccination. As the author points out, throughout modern history vaccines have surpassed all other biotechnologies in terms of their impact on global public health.

It was Edward Jenner’s discovery of vaccination in the eighteenth century that allowed us over two hundred years later to eradicate smallpox. The key word here is “us” because the eventual eradication of the disease was only possible through global collaboration including, importantly, between the Soviet Union and the USA during the 20 year period of the Cold War that began around the time of the Sputnik satellite launch and mostly ended in 1977. This constituted Vaccine diplomacy’s first full expression.

And this is not the only example of East / West collaboration on vaccination leading to the prevention through eradication of viral diseases. Poliomyelitis is on the brink of elimination and measles is not far behind. So dealing with the COVID pandemic will require the development of appropriate vaccines and promoting global collaboration through diplomacy and scientific cross fertilisation.

Admittedly, smallpox, polio and measles are particular kinds of virus which are easier to vaccinate against than the corona viruses because they do not mutate and have no obvious animal main host. But the general principle of prevention through vaccination supported by international cooperation still applies as in the case of influenza, a corona virus which mutates and has an animal main host. With influenza the aim of eradication is not realistic because of these two characteristics, so the winning strategy is to keep pace with the mutations by appropriate manipulation of the flu vaccine. Thus we can control the impact of the disease and live in a sort of harmony or truce with it. Many of us are now fully adapted to having our annual flu vaccination and think nothing of it. Herein lies the model for our future coexistence with the COVID 19 virus.

So preventing pandemics is simple in concept. The problem lies in the areas of commitment and competence in implementation.

Large coronavirus epidemics have become an important new threat in the 21st century. Previously, human infections were considered moderately important causes of upper respiratory infections which sometimes resulted in more serious lower respiratory tract involvement. The exception was the 1918 influenza pandemic, an unusually deadly event caused by the H1N1 influenza A virus. Lasting from February 1918 to April 1920, it infected 500 million people – about a third of the world’s population at the time – in four successive waves. The death toll is typically estimated to have been somewhere between 20 million and 50 million, although estimates range from a conservative 17 million to a possible high of 100 million, making it one of the deadliest pandemics in human history. A second pandemic caused by the H1N1 influenza A virus was the 2009 swine flu pandemic.

It is interesting to consider why the Spanish flu pandemic died out at a time when no specific remedies such as vaccines were available. One view is that the virus lost its virulence over time, like the later SARS and MERS viruses, and ceased to be a problem. Could this be a natural end point for the COVID pandemic one wonders, but at what cost in terms of lives lost ?

Other significant coronavirus events included the SARS epidemic which emerged in 2003 in southern China and spread to Toronto, ultimately causing more than 8000 cases with a mortality rate of 10%. And MERS which emerged on the Arabian peninsula and caused serious epidemics in Saudi Arabia and South Korea.

Just a few years ago many in the global health policy community were thrilled at the prospect of eliminating catastrophic infectious and tropical diseases via vaccination. Two of the Millenium Development Goals targeted these diseases recognising that they perpetuate poverty because of their ability either to devastate families or cause debilitating health effects. One Goal focussed on killer childhood infections preventable by vaccines while the other aspired to combat “the big three” infections of HIV/AIDS, TB and Malaria. Then there are the so called neglected tropical diseases – a group of approximately 20 chronic and debilitating tropical diseases such as hookworm infection, schistosomiasis, leishmaniasis and Chaga’s disease; and emerging diseases such as Ebola, covid 19 and nipah viral infections.

Yet another category is the major vaccine preventable diseases of childhood such as measles and polio referred to above and near to eradication; plus diphtheria, pertussis and tetanus.

The Global Burden of Disease study projected a rise in non communicable diseases more or less equal to the decline in the poverty related infections.

Unfortunately, in 2015 we began to see unexpected and fundamental changes leading to a new order. The factors driving this reversal include political instability, internal displacement and human migrations, urbanisation, ant-science, nationalism, and climate change.

In respect of this new order, the Dutch Nobel Laureate, Paul Crutzen, has coined the term Anthropocene which posits that the human species is entering its first new geological epoch since the end of the Ice Age when the Holocene epoch began, 12,000 years ago. The major argument for the Anthropocene relies on geological evidence indicating that humans have so profoundly changed our planet that we can now mark our time as a distinct epoch.

The author has some interesting comments on the rise of the anti-science movement. Key to this, he suggests, is the low profile of scientists which he has worked hard to counter in the USA by being very visible and available in the current pandemic crisis. Unsurprisingly, he has appeared on several BBC Radio 4 programmes over the last few weeks. In the UK the visibility of members of the scientific disciplines relevant to the pandemic has been high and one wonders whether this will have any long term impact on the standing of science and scientists among the general public.

The author’s interest in the growing anti-science movement is, at one level, very personal because he has an autistic daughter and one of the central tenets of the movement is that vaccines cause autism. A claim which we know to be entirely false.

So does this book tell us anything fundamentally new? The answer is no; but it is nevertheless a useful and timely tour d’ horizon, plus a fascinating description of one doctor’s involvement in both the development of new vaccines and in the more difficult area of promoting collaboration with governments in areas of conflict – vaccine diplomacy – to secure their application. As well as describing his years working in laboratories developing new vaccines, he recounts his travels around the world to forge vaccine partnerships to deal with major health problems including in what he terms the Middle East killing fields as well as Africa and Latin America.

Put simply, vaccine diplomacy comprises large scale vaccine delivery employed as a humanitarian intervention and the delivery or refinement of new vaccines achieved jointly between scientists of at least two nations

It is especially relevant that scientists from nations in opposition or even outright conflict can work in research organisations or that they are able to work together and engage in collaboration under conditions of political instability or stress.

Hotez believes that the technology of vaccines and their widespread delivery represent our most potent counterforce to war and political instability in modern times. At first sight this seems to be an exaggerated claim but on examination it does indeed seem that promoting and securing the health of one’s country’s population is a universal imperative, sufficient to overcome transient enmities. Evidently, Cicero’s maxim that “the health of the people should be the supreme law” seems, surprisingly, to apply universally, even in what some would regard as pariah states.

It is an eminently readable and accessible book. The author is a good written communicator and from my limited exposure to his verbal communication he does well at this too.

I have to confess, however, that I was put off the book initially because of its use of the term vaccine diplomacy. To me the word diplomacy is tainted by heavy overtones of power politics in pursuit of imperial ambition. But does this matter if the skills in negotiation that diplomacy provides could save millions of lives and prevent a world wide humanitarian and economic catastrophe ?

Paul Walker

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