A WHO official weighs in on Covid, vaccines, and mistakes that were made

The Covid-19 pandemic has entered its third year, with no end in sight, and the world is fed up to the gills. A new and even more highly transmissible variant, Omicron, has been scorching through holiday gatherings over the past couple of weeks. People who are thrice vaccinated are among the infected.

Hard to believe as it seems, the start of 2022 may be even more unsettling than the beginning of 2020.

As we have several times over the past few years, STAT turned to Mike Ryan, head of the health emergencies program at the World Health Organization, looking for some insight about where we’ve been and where we’re heading. He and his team first learned a new virus appeared to be circulating in Hubei province, China, in the waning days of 2019, and have worked flat out since then trying to help the world navigate the worst pandemic in a century. 

We asked Ryan if he expected the pandemic to last as long as it has, who should make the call on whether to update Covid vaccines, and what he thinks are the main mistakes the world has made.

“What’s shocked me most in this pandemic has been that absence or loss of trust,” he said of people’s unwillingness to follow the advice of public health leaders and the containment policies set out by governments.

A transcript of the conversation was edited for length and clarity.

Given what you knew about pandemics going into this, are you surprised that this one is still in full swing two years on?

Disappointed, not surprised in a sense. I mean, we went through one before. It was in 2009. It took two years to work through the system.

But the H1N1 flu pandemic was much milder and it didn’t last two years everywhere. It was in distinct waves.

When you deal with a highly transmissible respiratory virus you would expect the virus to go through multiple waves. We didn’t know how those waves would develop in terms of geography, temperature, seasonality, and everything else. But the history of respiratory epidemics is they do tend to go through those wave-like transmissions. 

Then if you add in the fact that each of the waves has been driven by different variants, then you’re really dealing with viruses that are evolving and presenting a new challenge to the immune system. 

You’d expect some waning of immunity over time; if the viruses continue to evolve, then you’ve got a double whammy. 

And at the same time, if your vaccines aren’t as effective in preventing infection or potentially in reducing severe disease [in the face of a new variant], then you’ve really gone backwards in terms of your control over the virus. It’s snakes and ladders, you know? You’ve just taken a big trip down the scoreboard.

Where do you see us getting to in the next year? 

It’s very, very, very hard to predict. Many people thought the Delta variant was the fittest, fastest. It was highly adapted, highly evolved. A lot of people thought, well, if we get a variant that beats that, it will be some variant. And we may be on the verge of having that.

I think a lot of this is going to hinge on what level of protection current vaccines give. And if there’s a need to switch vaccine composition, how quickly that can be done? There are a lot of factors there that are dependent one on the other. You can’t think in predictions, you can only think in scenarios. There’s so many variables that affect the outcome in extreme ways.

If it’s determined that the vaccine needs to be updated and we need an Omicron-specific vaccine, do you think wealthy countries will buy another round of boosters to vaccinate their people a fourth time? That would mean the developing countries that are still waiting to vaccinate most of their people will have to wait even longer.

Potentially, yes. That’s what happened the last time. I don’t see a whole lot of difference in the way the world is approaching it right now. 

And the other issue you have to take into account is you might get a booster or another vaccine for Omicron that protects against Omicron, but will not protect against Delta infection. There’s no guarantee because this virus was quite different.

It’s a big decision to move to switching that production into a brand new variant. So there’ll be lots and lots and lots of discussions around about how that should occur and what’s the best sequence to use or what is the best virus to use in order to build that. And then there’ll be question marks over whether or not you should keep production of two types. Whether we should be combining vaccines. Whether we should go a third way and have a sequence somewhere between the Omicron and the other. And there’s an awful lot of unknowns there and an awful lot of lab testing and trialing that would need to be done to get those answers.

We believe that these are going to be big decisions and they’re going to have real consequences. They need to be done quickly but they also need to be done carefully.

It’s very hard to come up with the right answer.  And therefore, there has to be some collective wisdom driving this. It can’t purely be the decision of one manufacturer to say, “Well, this is what we’re going to make, and this is what you’re going to buy.”

Do you have a sense that manufacturers are willing to be led on this?

The question is: Are they partners or masters in this process?

It should be done together. It should be done with the best interest of the world’s population at the center, with science and evidence driving that decision-making.

Whether manufacturers want to go along with that or not, I’m not their keeper or master; neither is WHO. We would only argue there are some big unknowns here and we’re all really trying to get those answers. We just need to be really focused at this point on pulling the best data together that we can, the best evidence and make good decisions together. 

If it’s purely left to be a commercial decision, I’m not so sure that decision will necessarily be the best one.

Are there things you wish the world had done differently from the jump? Where did we make our biggest mistakes?

This interview could go on for a while.

The biggest collective failing has been that we’ve underestimated this microbe. We’ve always made judgments assuming the best-case scenario. And I’m not one for assuming the worst-case scenarios as a modus operandi, because otherwise, you can strangle society. But I think at every opportunity we’ve seem to have taken the best-case scenario as the basis for our policy. And this virus, I think, has sequentially exploited that.

In the end, the virus doesn’t have a brain. It’s just, from an evolutionary point of view, exploiting opportunities. And we seem to have consistently and persistently given it the opportunity.

There’s been tremendous social, economic, and political pressure to go back to normal. 

Time and time again governments have tried to get back to normal and have overshot that runway by opening up too early. Releasing restrictions too early. They haven’t really convinced people or empowered people to continue with these basic measures to reduce the risk of infection. I think that’s been a problem, the whole way through the pandemic.

I don’t mean getting rid of lockdowns. To me lockdowns have been last resort measures in most cases. Many countries in the East have managed to forgo lockdowns. But they’ve maintained quite strict measures in terms of mask wearing, in terms of crowds, in terms of testing and other stuff. So they’ve taken a much more comprehensive, layered strategy. They’ve maintained an intensity of control measures without ever going for full lockdown, without ever going for full open. They’ve taken the corner without under- or over-steering.  They’ve gotten people to buy into the idea that it’s going to take a long time and it’s going to have to be a sustained effort. I think if everyone had done that maybe we’d be in a better place. 

But I think for me just personally as a public health physician, the biggest tragedy has been the vaccine equity issue. It really has been horrific. Horrific. The world just has not ever come to terms with the fact that vaccinating the most vulnerable people first would have been a better bet, not only epidemiologically but just from an equity perspective. 

The idea of coherence and coordination and solidarity — these are all lovely words. But it’s very hard to deliver that in societies that don’t trust governments, [don’t buy into] that social contract, that inherent trust that a community should have in its government to say, “Yes, you are there to protect me.”

What’s shocked me most in this pandemic has been that absence or loss of trust.

It’s staggering to read about public health personnel quitting their jobs, being subjected to death threats during a pandemic. They’re facing hatred and vitriol from the people they’re trying to protect. 

It’s tragic. And it’s tragic to think that there are millions of people right now in the Northern Hemisphere who are not vaccinated because they don’t believe their government. Whatever the reasons for that are, whether it’s because governments perform poorly in building that trust, or whether they’ve been actively undermined by misinformation and by other things, historians and social historians will be talking about that one for decades.

If we’re looking at pandemic preparedness for the future it’s not all going to be about technology and the machines that go ping and surveillance systems and AI and all of this stuff. We need a social solution for future pandemics, much more than we need a technological solution. Because we’re dealing with a fractured world, fractured communities. We’re dealing with a breach and prolonged breakdown in trust. 

I shudder to think of going into a more severe pandemic with that level of community distrust. It has had a real negative impact on people’s awareness and willingness to sustain measures. Because they can constantly find lots of material and reasons not to do what they’re being asked to do, because there’s so much out there telling them that what’s going on there is a government conspiracy, what’s happening is hurting them.