Editor’s Note (12/21/21): This article is being showcased in a special collection about equity in health care that was made possible by the support of Takeda Pharmaceuticals. The article was published independently and without sponsorship.
The past few days have been awash with news of the emergence of the latest concerning variant of the virus behind COVID-19, which the World Health Organization has dubbed Omicron. Scientists detected this new variant through genomic surveillance in South Africa, but in a quickly evolving pandemic we still don’t know where it originated, and we still don’t know how important Omicron will be.
I am a global health scientist, with a background in public health research and infectious disease epidemiology. I believe this new variant is a consequence of vaccine inequity in parts of Africa, where the vaccination coverage in many countries is less than 10 percent.
One of the consequences of uncontrolled outbreaks has been an increased risk of new SARS-CoV-2 variants of concern. We have seen this in the U.K., where the Alpha variant was first detected while vaccines were still early in deployment and the vaccination rate was low. And one consequence of the humanitarian emergency in India in early 2021 was the emergence of the Delta variant. A strong vaccination rate can reduce transmission and thus stop outbreaks. But only if people have access to the products.
In my field, many people have thought that richer countries grabbing the vaccine supply would inevitably come back to bite us on our backsides at some point. Omicron looks to be the variant with sharp teeth. Only time will tell how dangerous Omicron will be, but inequitable access to vaccines means this scenario could keep happening. Until COVID-19 is conquered everywhere, it can be reintroduced anywhere.
The main focus of my international research is West Africa, particularly Ghana and Togo, with ongoing projects around the pandemic response and COVID-19 vaccine hesitancy. I wrote back in July 2020 that, to coin a British phrase, there’s no “I’m alright, Jack” about this for those of us in higher-income settings. Eighteen months on, COVID-19 very much remains an issue for us all.
The international picture around vaccine distribution and uptake is stark, with the “haves” and “have nots” geographically obvious. Only around 11 percent of people on the African continent have received even one dose of a COVID-19 vaccine. Approximately 7 percent are considered fully vaccinated. Compare that with South America and Asia, where 72 percent and 63 percent respectively have received at least one dose.
Despite the low vaccine rates and limited public health resources, I’d argue much of sub-Saharan Africa has done very well at keeping outbreaks under control. For example, in Ghana, the Delta variant arrived in July 2021 based on sequencing data, and there was community transmission. Yet, the Ghana Health Service and public health teams have managed to control that outbreak, a feat that many richer countries have repeatedly failed to manage.
However, there is a highly susceptible population across Africa without any immunity from vaccination or prior infection. We see from the evidence base that COVID-19 vaccines reduce rates of new infections and onward transmission There is some early speculation from virologists that Omicron emerged from a person chronically infected with SARS-CoV-2, and that the index case was in an area of poor genomic surveillance outside of South Africa. It is harder to identify new variants in near real time if there is an overall lack of genomic infrastructure and expertise.
Other countries in Southern Africa have observed cases of Omicron. This includes Botswana, which weathered an uncontrolled outbreak in August 2021. There was a big spike in cases and a positive test rate of more than 50 percent. This is a high percentage, and with so many positive cases in those tested, it is very likely there were many more cases in circulation that weren’t picked up by the testing program.
Getting more people vaccinated in countries where the rate has been low is key to stopping the next variant.
The problems in resolving vaccine inequity are wide and varied. They include increasing the supply in resource-poor areas, and not just vaccines that have been “generously donated” just as they are about to expire.
What we do here in the Global North is observed and absorbed in the Global South.
When health workers do arrive in communities armed with immunizations, the people there need to be willing to be immunized. Our research in Ghana has shown that willingness to vaccinate varies over time, but was at 71 percent in June 2021, down from 82 percent from our previous survey in April. Where individuals expressed hesitancy, a common reason was to make reference to the inconsistent approaches to use of the Oxford AstraZeneca vaccine in the Global North. Specific comments often focused on the reactions to the blood clots as possible adverse events. To quote one of our participants: “Why would I want that damaged white-man product?” News travels fast and easily in a globalized world.
Then there are the conversations around waivers on vaccine patents. Granting these waivers has long been discussed during the pandemic, but therein lies the issue. On November 25, Ngozi Okonjo-Iweala, the head of the World Trade Organization, described the protracted negotiations as “stuck.” There are agreements in place for some level of vaccine manufacturing in South Africa, albeit at the end stage of the process, which is termed “fill and finish.”
Many companies based in India, Thailand and South Africa have the potential to develop their own mRNA vaccines, described by Tom Frieden, the former director of the Centers for Disease Control and Prevention in the United States, as “our insurance policy against variants and production failure.” But these are all still works in progress, and in the meantime, Omicron spreads, and what comes after it is surely percolating in areas of low vaccination rates.
We don’t yet know how severe Omicron will be in unvaccinated populations, or the extent and severity of breakthrough infections. There is little known about its transmissibility, or whether it is likely to outcompete Delta and become established as the most common type of coronavirus variant. These are all important questions that a global thirst for knowledge will seek to answer over the coming weeks.
But why wait for those answers? We need the richer countries and other key stakeholders to go beyond mere platitudes and actually deliver on their commitments to share doses. A variant can emerge anywhere, but we can minimize the chances of an outbreak and therefore reduce likelihood of notable new virus mutations and the need to learn another letter of the Greek alphabet.
How long do us rich folk want the pandemic to continue? Some people may consider that we are done with this novel coronavirus; however, it’s very clear that the coronavirus is nowhere near done with us.