The ‘terrible vindication’ in COVID-19

The medical anthropologist and physician Paul Farmer once wrote that “the emergence of multi-drug resistant tuberculosis is a terrible vindication for those who predicted that a social disease could not be eradicated without social action.” He was reflecting on the fact that despite the discovery of antibiotics and vaccines, TB is not only still around, but also stronger than ever, with the emergence of drug-resistant strains that are impervious to all but the most expensive antibiotics. Meanwhile, the social determinants of tuberculosis remained unanswered in many parts of the developing world.

We are reminded of Farmer’s words as we continue to grapple with the COVID-19 pandemic. Now on its second year, even as people are beginning to see silver linings with the hoped-for arrival of vaccines, we suddenly must contend with a growing number of variants, some of which are deemed more infectious and can potentially make vaccines less effective.

As our experience with TB and other infectious diseases has shown, the more a virus or bacteria circulates in the population, the more it mutates, evolving into a potentially more infectious variant. Based on available information, SARS-CoV-2 variants may emerge in areas where physical distancing and quarantine protocols are incomplete or inadequate, thereby pushing the virus to evade the mechanisms meant to control it. This either means inconsistent implementation or a lack of social support system that will enable citizens to comply with such practices—both elements that we continue to see in the Philippines.

The existing data already point to this association. In the January 2021 Lowy Institute COVID Performance Index, which ranked countries based on their respective response, countries where the variants arose all ranked in the lower tiers: the United Kingdom, where the B.1.1.7 variant was discovered, placed 66th; South Africa, with the B.1.135 variant, in 82nd; and Brazil, with P.1, last at 91st. The Philippines ranked 79th, and also saw the G614 variant that caused spikes in June-July 2020, and now has rising cases of the UK variant in the Cordilleras and Cebu.

Conversely, countries that scored high in the Lowy Index, such as Taiwan and New Zealand, have low cases of COVID-19 and have not been linked to any local variants. What these countries have in common are social protection measures that allow people to go on quarantine without losing income. By providing financial support to those exhibiting symptoms or had contacts with positive cases, a key barrier to ensuring 14 days of close observation to prevent transmission is eliminated. In the Philippines, there is such a bill (House Bill No. 7909), but it has barely hurdled the committee level in Congress.

Vaccines will doubtless save countless lives and are already doing so in places like Israel, which seems to be having early success in its immunization program. But if we are to truly put an end to the pandemic, urgent social action is required. The inequity of vaccine distribution—both among and within nations—means that many countries and communities will have to continue to deal with the threat of COVID-19 for years. Moreover, the potential emergence of new variants in these places means that the whole world will have to face this threat. As such, a strong global and national commitment to universal and equitable vaccination is indispensable.

The need for an effective government response is very much needed at any stage of the pandemic—from provision of protective equipment and removing exemptions for the privileged, to free, accessible testing and efficient contact tracing. Genomic surveillance is becoming integral in many countries to identify and control the spread of the variants. Locally, only the Research Institute for Tropical Medicine, the Philippine Genome Center, and a few other laboratories can detect mutations and variants in samples, albeit at a delayed rate. This only highlights the need to boost support for our scientists and research institutions.

While vaccination can afford us protection from both COVID-19 infection and severe disease, only with a strong health system and proactive social action can we ensure that variants—themselves a “terrible vindication” of the failure to consider the pandemic’s social determinants—are comprehensively addressed to provide lasting protection beyond immunization.

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Joshua San Pedro, MD, and Gideon Lasco, MD, PhD, are both physicians and anthropologists.