The Hard Truth About Long Wars
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It is time to say it out loud: the virus behind the COVID-19 pandemic is not going away. SARS-CoV-2 cannot be eradicated, since it is already growing in more than a dozen different animal species. Among humans, global herd immunity, once promoted as a singular solution, is unreachable. Most countries simply don’t have enough vaccines to go around, and even in the lucky few with an ample supply, too many people are refusing to get the shot. As a result, the world will not reach the point where enough people are immune to stop the virus’s spread before the emergence of dangerous variants—ones that are more transmissible, vaccine resistant, and even able to evade current diagnostic tests. Such supervariants could bring the world back to square one. It might be 2020 all over again.
Rather than die out, the virus will likely ping-pong back and forth across the globe for years to come. Some of yesterday’s success stories are now vulnerable to serious outbreaks. Many of these are places that kept the pandemic at bay through tight border controls and excellent testing, tracing, and isolation but have been unable to acquire good vaccines. Witness Taiwan and Vietnam, which experienced impressively few deaths until May 2021, when, owing to a lack of vaccination, they faced a reversal of fortune. But even countries that have vaccinated large proportions of their populations will be vulnerable to outbreaks caused by certain variants. That is what appears to have happened in several hot spots in Chile, Mongolia, the Seychelles, and the United Kingdom. The virus is here to stay. The question is, What do we need to do to ensure that we are, too?
Conquering a pandemic is not only about money and resources; it is also about ideas and strategy. In 1854, at a time when germ theory had yet to take hold, the physician John Snow stopped a cholera epidemic in London by tracing its source to an infected well; after he persuaded community leaders to remove the handle from the well’s pump, the outbreak ended. In the 1970s, smallpox was rampant in Africa and India. The epidemiologist William Foege, working in a hospital in Nigeria, recognized that the small amount of vaccine he had been allocated was not enough to inoculate everyone. So he pioneered a new way of using vaccines, focusing not on volunteers or the well-connected but on the people most at risk of getting the disease next. By the end of the decade, thanks to this strategy—first called “surveillance and containment” and later “ring vaccination”—smallpox had been eradicated. It is a twenty-first-century version of this strategy, along with faster mass vaccination, that could help make COVID-19 history.
For this pandemic, epidemiology also has tools to return the world to a state of relative normalcy, to allow us to live with SARS-CoV-2 as we learned to deal with other diseases, such as influenza and measles. The key lies in treating vaccines as transferable resources that can be rapidly deployed where they are needed most: to hot spots where infection rates are high and vaccine supplies are low. The United States, flush with vaccines, is well positioned to lead this effort, using a modernized version of the strategy employed to control smallpox.
Meanwhile, governments should exploit new technologies to get better at identifying and containing outbreaks. That means embracing exposure notification systems to alert people to their possible infection. And it means enhancing capabilities to sequence viral genomes, so that researchers can rapidly determine which variant is where and which vaccines work best against each. All this needs to happen as quickly as possible. The slower countries vaccinate people most at risk of spreading the disease, the more variants will emerge.
The international system for responding to pandemics must also be repaired. As the current crisis has laid bare, that system is dangerously underfunded, slow, and vulnerable to political interference. In a time of rising nationalism, countries need to find a way to work together to reform the global public health institutions that will be responsible for waging this long fight against COVID-19. These bodies must be protected and empowered so that they can work faster than they have.
The pandemic is in many ways a story of magical thinking. In the early days of 2020, many leaders denied that what began as a regional outbreak in Wuhan, China, could spread far and wide. As the months went on, governments imagined that the virus could be contained with border controls and that its spread would miraculously slow with warm weather. They believed that temperature checks could identify everyone who harbored the virus, that existing drugs could be repurposed to mitigate the disease, and that natural infection would result in durable immunity—all assumptions that proved wrong. As the body count rose, many leaders remained in a state of denial. Ignoring the scientific community, they failed to encourage mask wearing and social distancing, even as the evidence mounted. Now, governments must come to grips with another inconvenient truth: that what many hoped would be a short-lived crisis will instead be a long, slow fight against a remarkably resilient virus.
COVID-19 hit at an inauspicious geopolitical moment. An era of rising nationalism and populism made it frustratingly difficult to mount a collaborative response to a global pandemic. Jair Bolsonaro of Brazil, Xi Jinping of China, Narendra Modi of India, Vladimir Putin of Russia, Recep Tayyip Erdogan of Turkey, Boris Johnson of the United Kingdom, and Donald Trump of the United States—all these leaders evinced some combination of parochialism and political insecurity, which caused them to downplay the crisis, ignore the science, and reject international cooperation.
The two countries vying for global leadership are most to blame for allowing an outbreak of a novel disease to become a crippling pandemic: China and the United States. Even setting aside the question of whether the virus jumped to humans as a result of a lab accident or animal spillover, Beijing was less than forthright in sharing information about the scale of the problem in its early days. And although it may never be clear what Chinese decision-makers knew when, it was nonetheless irresponsible of them to allow international travel in and out of an epidemic area during a period of intense holiday travel—a decision that possibly created a superspreader event.
The United States, for its part, disregarded early warnings from dozens of epidemiological Cassandras and denied the gravity of the emerging crisis. The Trump administration treated COVID-19 as an abstract threat instead of the clear and present danger it was and failed to mount a coordinated national response. The U.S. government banned some but not all travel from China, waited way too long to control travel from Europe, refused diagnostic test kits developed abroad, and bungled the development of its own test kits. It failed to procure and distribute the personal protective equipment needed to safeguard frontline workers and the general population, leaving states to compete with one another for critical supplies. Politicians made mask wearing a matter of political identity. The result of all the chaos, delay, and stupidity was a largely uncontrolled spread and a heightened death toll. The United States is a rich, educated country that is home to the world’s leading scientific institutions and just over four percent of the global population. Yet in the first year of this pandemic, it had an astounding 25 percent of the world’s COVID-19 cases and 20 percent of deaths from the disease.
What many hoped would be a short-lived crisis will instead be a long fight against a resilient virus.
Some governments did take the threat seriously. At the beginning of the pandemic, the best predictor of a country’s success against this coronavirus was recent experience with an outbreak caused by an earlier coronavirus—SARS or MERS. When COVID-19 appeared, Taiwan, which had been hit hard by SARS in 2003, rapidly implemented screenings, closed its borders to residents of Wuhan, and activated a command center to coordinate its response. Fortunate to have an epidemiologist at the helm as vice president, the Taiwanese government acted transparently. It rolled out a program of comprehensive testing, tracing, and isolation and encouraged social distancing and mask wearing. As of May 1, 2021, Taiwan had reported just 12 deaths from COVID-19.
Vietnam had also learned from SARS. In the years following that epidemic, it built a robust public health infrastructure, including an emergency operations center and a national surveillance system to facilitate data sharing and case finding. When the current pandemic hit, the government was ready to implement a program of mass testing, contact tracing, quarantining, and business shutdowns. By April 2020, Vietnam had deployed a mobile app to over half its population that automatically notified users if they had been near someone with a confirmed case of COVID-19. Despite having a dense population of 96 million, the country reported no new deaths from September 2020 to May 2021. By early May, it had counted a total of just 35 deaths.
By contrast, the international response to COVID-19 was surprisingly inept, especially compared with previous campaigns to contain epidemics or eradicate diseases. With smallpox and polio, for example, governments and international organizations worked together to develop and fund cohesive strategies, around which response teams were organized worldwide. Not so for COVID-19. Politics undermined public health in a global crisis to an extent nobody had thought possible. The president of the United States silenced trusted public health leaders from the U.S. Centers for Disease Control and Prevention (CDC), the respected disease-prevention agency that the world expected to take the lead in that very moment, and he withdrew the United States from the World Health Organization (WHO) just as global collaboration was needed most. Emboldened by Trump, self-interested leaders elsewhere followed suit, pursuing disease-denying policies that further amplified the death toll and suffering.
Vaccine development has been one of the few bright spots in this pandemic. Pharmaceutical and biotechnology companies worked hand in hand with governments to make powerful new vaccines in record time. The two vaccines based on messenger RNA, or mRNA—the Moderna and Pfizer-BioNTech ones—moved lightning fast. Just two months after the genetic sequence of SARS-CoV-2 was published, the Moderna vaccine was being tested in a Phase 1 clinical trial, and not long after, it moved on to Phase 2. At the same time, a number of actors—the Coalition for Epidemic Preparedness Innovations; Gavi, the Vaccine Alliance; the WHO; and many governments, companies, and philanthropies—were investing massively in manufacturing capacity. As a result, the companies behind the two vaccines were able to rapidly scale up production and conduct Phase 3 trials over the summer. The trials demonstrated that the Moderna and Pfizer-BioNTech vaccines were not just safe but also far more effective than many had thought, and by the end of 2020, regulatory agencies around the world had authorized them for emergency use. Vaccines based on a modified adenovirus also moved quickly. The United Kingdom authorized the Oxford-AstraZeneca vaccine in December 2020, and the United States did the same for the single-dose Johnson & Johnson vaccine in February 2021.
Although the creation of the vaccines was a triumph of international cooperation, their distribution has been anything but. Hedging their bets, the United States and other rich countries bought many times the number of doses they needed from several manufacturers, essentially cornering the vaccine market as if the product were a commodity. Making matters worse, some countries imposed restrictive export regulations that have prevented the wider manufacture and distribution of the vaccines. In May, pointing out that 75 percent of the vaccine doses had so far gone to just ten countries, the WHO’s director general, Tedros Adhanom Ghebreyesus, rightly called the distribution a “scandalous inequity that is perpetuating the pandemic.”
In the absence of global coordination for the purchase and distribution of vaccines, governments struck bilateral deals, leaving some unlucky countries with less effective or untested vaccines. For instance, China has exported more than 200 million doses of four homegrown vaccines—more than any other country—and yet there is disturbingly little transparent data on the Chinese vaccines’ safety. Anecdotal reports from Brazil, Chile, and the Seychelles have raised doubts about their efficacy. Meanwhile, India’s devastating surge in COVID-19 cases has reduced exports of its locally produced vaccines, leaving the countries that were depending on them, such as Bhutan, Kenya, Nepal, and Rwanda, with inadequate supplies. The United States made a lot of promises, but as of late May, the only vaccine it had exported was the Oxford-AstraZeneca one—which the U.S. Food and Drug Administration had not yet authorized—sending four million doses to its neighbors, Canada and Mexico.
To provide at least a cushion of vaccines for less well-off countries, and to help the WHO manage the challenge of global vaccine distribution, a coalition of organizations created a unique consortium called COVAX. The body went on to develop an “advance market commitment” mechanism, through which governments have agreed to buy large numbers of doses at predetermined prices. The goal is to raise enough money to provide nearly one billion doses to 92 countries that are not able to pay for vaccines themselves, allowing each to meet 20 percent of its vaccine needs. As of May, however, reaching this target anytime in 2021 seemed a long shot.
In fact, the barriers to access have been so profound that many low- and middle-income countries won’t have enough vaccines to inoculate even just their at-risk populations until 2023. This disparity has led to a jarring split-screen image. At the same time that Americans were taking off their masks and preparing for summer vacations, India, with only three percent of its 1.4 billion inhabitants fully vaccinated, was ablaze in funeral pyres.
Over a year and a half into the pandemic, it has become clear that the race to contain the virus is simultaneously a sprint and a marathon. Yes, the world needs to vaccinate as many people as possible as quickly as possible to slow the spread of the virus. But if every human on the planet were vaccinated tomorrow, SARS-CoV-2 would still live on in multiple animal species, including monkeys, cats, and deer. In Denmark, more than 200 people contracted COVID-19 from minks. Although there is no evidence yet of sustained transmission from humans to animals and then back to humans, the discovery of SARS-CoV-2 in so many species means that it is not just plausible but probable.
The dream of herd immunity has also died. Just a year ago, some newly minted experts were arguing that the virus should be given free rein to circulate in order for countries to reach herd immunity as soon as possible. Sweden famously followed this approach; predictably, it experienced dramatically higher rates of infection and death than nearby Denmark, Finland, and Norway (while suffering similar economic damage). Only after hundreds of thousands of unnecessary deaths occurred worldwide was this misguided strategy abandoned.
More recently, epidemiologists were debating what percentage of a population had to be vaccinated to reach herd immunity and when that threshold would be reached. But now it is becoming clear that the world cannot wait for herd immunity to contain the pandemic. For one thing, vaccination is proceeding too slowly. It is taking too long to produce and deliver sufficient supplies of vaccines, and a sizable global anti-vaccine movement is dampening demand for them. For another thing, there has been a constant flow of new variants of the virus, threatening the progress that has been made with vaccines and diagnostics.
Variants are an unavoidable byproduct of the pandemic’s exponential growth.
Variants are an unavoidable byproduct of the pandemic’s exponential growth. More than half a million new cases of COVID-19 are reported every day. Each infected person harbors hundreds of billions of virus particles, all of which are constantly reproducing. Each round of replication of every viral particle yields an average of 30 mutations. The vast majority of mutations do not make the virus more transmissible or deadly. But with an astronomical number of mutations happening every day across the globe, there is an ever-growing risk that some of them will result in more dangerous viruses, becoming what epidemiologists call “variants of concern.” Hyperintense outbreaks—such as the ones in New York City in March 2020, Brazil in March 2021, and India in May 2021—only increase the risk.
A number of variants have already emerged that spread more easily, cause more severe illness, or reduce the effectiveness of treatments or vaccines, such as the B.1.1.7 variant (first detected in the United Kingdom), B.1.351 (South Africa), B.1.429 (California), P.1 (Brazil), and B.1.617.2 (India). Although variants are often labeled with a geographic tag based on where they were first identified, they should be considered global threats. (In fact, given the uncertainty about where each variant emerged, as opposed to where it happened to be first reported, the geographic nomenclature would best be dropped altogether.)
To date, the three vaccines authorized in the United States—the Moderna, Pfizer-BioNTech, and Johnson & Johnson vaccines—are effective against the existing variants. But two variants, B.1.351 and B.1.617.2, have shown signs of impairing the efficacy of other vaccines and of therapeutic antibodies. Each new, more resistant or more transmissible variant may require additional booster shots, or perhaps new vaccines altogether, adding to the massive logistical challenge of vaccinating billions of people in nearly 200 countries. Other variants may even evade current diagnostic tests, making them more difficult to track and contain. The pandemic, in short, is hardly in its last throes.
As a wealthy, powerful, and scientifically advanced country, the United States is optimally positioned to help lead the long fight against COVID-19. To do so, the country must recover its reputation for global public health leadership. At a time of resurgent nationalism at home and abroad, it will need to rise above the forces of division and rally the rest of the world to join it in undertaking what may be the biggest experiment in global health cooperation ever.
To start, the United States must continue its trajectory toward zero COVID-19 cases at home. No country can help others if it is crippled itself. Extraordinarily effective vaccines, along with equally impressive vaccination campaigns in most U.S. states, have dramatically decreased the number of infections. When epidemiologists look at the United States now, they no longer see a blanket of disease covering the entire country; instead, they see scattered flare-ups. This means they can discern individual chains of transmission—a game-changer in terms of strategy.
One of the most important missing pieces of the U.S. vaccination program is an appreciation for the power of speedy, targeted deployment. Vaccines should be redistributed to the parts of the country with high infection rates to protect those most at risk of contracting the disease and reduce the potential for transmission. In many ways, this strategy represents a return to the basics of disease control. To eradicate smallpox in the 1970s, epidemiologists encouraged public health departments to report potential cases, looked for symptomatic people at large gatherings, maintained a “rumor register” to pick up new outbreaks, and offered cash rewards to people who found potential cases. They investigated every case, located the source of infection, and identified contacts who were likely to get the disease next. Those who were infected with smallpox, as well as the people they had exposed to the disease, were quickly isolated and vaccinated. By practicing “just in time” vaccination, epidemiologists were able to prevent new chains of transmission—quickly controlling the disease and saving as many as three-quarters of the vaccine doses as compared to if they had performed mass vaccination.
Of course, it was a different disease, a different vaccine, and a different time. Part of what makes COVID-19 so difficult to combat is that it is an airborne illness with so much asymptomatic transmission. Today, however, epidemiologists have the added benefit of powerful new tools for detecting outbreaks and developing vaccines. They can use these innovations to build a twenty-first-century version of surveillance and containment for the battle against this pandemic. Adopting a strategy of “just in time” vaccination, the United States and other countries with moderate infection rates should prioritize the immunization of people known to have been exposed (for whom vaccination can still prevent or mitigate symptoms), along with their contacts and communities, using old-fashioned or modern-day methods.
If the United States solves the puzzle of controlling outbreaks of COVID-19 at home and shields itself against importations of the virus from abroad, it will have a blueprint that it can share globally. It should do so, turning outward to help lead what will be the largest and most complicated disease-control campaign in human history. To that end, it should support expanded manufacturing capacity for COVID-19 vaccines worldwide and get to work distributing enough of them to reach the last mile of each country in the world—and do so faster than new supervariants can emerge.
There is other work to be done domestically, as well. The $1.9 trillion American Rescue Plan, passed by Congress in March, provided $48 billion for diagnostic testing and additional public health personnel to contain outbreaks. Such efforts have become all the more important as demand for vaccinations has slowed. As of May, barely half of the country was fully immunized. Even allowing for those with natural immunity from prior infection, that leaves about 125 million Americans susceptible to COVID-19. Thus, there is even more reason to build the capacity to protect these Americans from the inevitable importations of the virus, doubling down on efforts to find, manage, and contain all outbreaks.
Part of this effort will require building a stronger disease surveillance system in the United States. Hospitals, testing labs, and local public health agencies already routinely report data about COVID-19 to the CDC. But the CDC must continue adding more innovative ways to detect outbreaks early on. Already, epidemiologists around the world are experimenting with digital disease detection, combing through data on pharmacy purchases and scouring social media and online news stories for clues of new outbreaks. Taking advantage of electronic medical records, they are tracking the symptoms of emergency room patients in real time. And they have created participatory surveillance systems, such as the apps Outbreaks Near Me in the United States and DoctorMe in Thailand, which allow people to voluntarily disclose symptoms online.
The global framework for pandemic response is broken.
Together, these reporting systems could capture a high percentage of symptomatic cases. To find missed infections, epidemiologists can monitor sewage for virus shed in feces to detect unreported outbreaks. And to capture asymptomatic cases, an especially important task for interrupting the transmission of SARS-CoV-2, exposure notification systems will prove key. With these systems, users are alerted through their cell phones if they have come into close contact with someone infected with the virus, without that person’s identity being divulged—thus informing people who do not feel sick that they may in fact be carrying the virus. At the same time as they are notified of possible infection, users can be advised to get tested, vaccinated, or learn about government support for isolation. Although such systems are still in their infancy, early reports from Ireland and the United Kingdom, where they have taken off, are encouraging.
Adding newer forms of disease detection to conventional reporting systems would give public health officials the kind of situational awareness that battlefield commanders and CEOs have long been accustomed to. That, in turn, would allow them to act much more quickly to contain outbreaks. So would faster and cheaper viral sequencing, which would enable scientists to rapidly identify infections and variants. They could use that information to update diagnostic tests to ensure accurate surveillance and modify vaccines to maintain their efficacy. If a particular variant was found to be vulnerable to one vaccine and not others, the vaccine that worked best could be rushed to the areas where the variant was prevalent. Such a custom-tailored approach will become yet more important as new vaccines are created for new variants; those vaccines will inevitably be in short supply.
Everyone should be grateful for the remarkable vaccines that won the race to be first. But the United States and other wealthy countries must nonetheless invest in the next generation of COVID-19 vaccines, ones that are less expensive to manufacture, require no refrigeration, and can be given in a single dose by untrained personnel. This is no pipe dream: researchers are already developing vaccines that can survive heat, take effect more quickly, and can be administered through a nasal spray, oral drops, or a transdermal patch. Thanks to these innovations, the world could soon have vaccines that are as practical to distribute in rural India or Zimbabwe as they are in London or Tokyo.
Even though the United States must play a leading role in getting this pandemic under control, that will not be enough without efforts to reform the global framework for pandemic response. The current system is broken. For all the debates about who should have made what decisions differently, a simple fact remains: what began as an outbreak of a novel coronavirus could have been contained, even when it was a moderately sized epidemic. In a report released in May, an independent panel chaired by two former heads of state, Ellen Johnson Sirleaf of Liberia and Helen Clark of New Zealand, did not assign blame for that failure. But the panel did offer suggestions for how to prevent the same mistake from happening again.
Its headline recommendation was to elevate pandemic preparedness and response to the highest levels of the UN through the creation of a “global health threats council.” This council would be separate from the WHO, led by heads of state, and charged with holding countries accountable for containing epidemics. In order to rebuild public trust in global health institutions, it would have to be immune from political interference. The report envisioned the council as supporting and overseeing a WHO that had more resources, autonomy, and authority. One vital contribution it could make would be to identify those diagnostic tests, drugs, and vaccines for COVID-19 that merit investment most and allocate resources accordingly, so that they can be rapidly developed and efficiently distributed. Although many details remain to be worked out, the recommendation of such a council represents a brave attempt in the middle of a pandemic to reform how pandemics are managed—akin to rebuilding a plane while flying it.
The most urgent need for global public health is speed. With a viral epidemic, timing is nearly everything. The faster an outbreak is discovered, the better chance it can be stopped. In the case of COVID-19, early and rapid detection would let decision-makers around the world know where to surge appropriate vaccines, what variants are circulating, and how to triage resources based on risk. Fortunately, when the next novel pathogen emerges—and it is a question of when, not if—scientific advances will allow global public health institutions to move faster than ever before. Scientists at the CDC and at the WHO’s Global Outbreak Alert and Response Network, or GOARN, have made huge strides in compiling a range of data streams to quickly learn of new outbreaks. Twenty years ago, it took six months to detect a new virus with pandemic potential; today, it can be done in a matter of weeks.
COVID-19 is not yet the worst pandemic in history. But we should not tempt fate.
But the global system for disease surveillance has ample room for improvement. The latest surveillance technologies—digital disease detection, participatory surveillance systems, and exposure notification systems—should be available everywhere, not just in the richest countries. So should viral-sequencing technologies. It is time to move beyond the old model of global health, in which samples of pathogens were sent from poor countries to rich ones to be sequenced, with the countries that sent the samples rarely sharing in the test kits, vaccines, and therapeutics that were developed as a result. This is a matter not only of fairness but also of epidemiological necessity, since the closer to its origin a new epidemic can be detected, the faster the world can respond.
Even if a novel pathogen escapes national borders, there is still time to contain it regionally. Governments should encourage the sharing of data about emerging diseases among neighboring countries. To that end, they should back Connecting Organizations for Regional Disease Surveillance, or CORDS, a group that brings together three dozen countries, several UN agencies (including the WHO), and a number of foundations, all in an effort to share early warning signals of infectious diseases and coordinate responses to them. In the same spirit, the WHO should work with governments and nongovernmental organizations to put anonymized case-level demographic, epidemiological, and sequencing data all in a single database. The end goal is a global health intelligence network that would bring together scientists who can collect, analyze, and share the data needed to inform the development of diagnostic tests, drugs, and vaccines, as well as make decisions about where to surge vaccines to control outbreaks.
COVID-19 is not yet the worst pandemic in history. But we should not tempt fate. The past year and a half revealed how globalization, air travel, and the growing proximity between people and animals—in a word, modernity—have made humanity more vulnerable to infectious diseases. Sustaining our way of life thus requires deep changes in the way we interact with the natural world, the way we think about prevention, and the way we respond to global health emergencies. It also requires even populist leaders to think globally. Self-interest and nationalism don’t work when it comes to a lethal infectious disease that moves across the globe at the speed of a jet plane and spreads at an exponential pace. In a pandemic, domestic and foreign priorities converge.
Most of the planet is still mourning for what has been lost since this pandemic began. At least three and a half million people have died. Many more are suffering from lingering effects of the disease. The financial toll of the pandemic has been estimated at some $20 trillion. Virtually no one has been spared from some grieving or some loss. People are ready for the long nightmare to be over. But in most places, it is not. Huge disparities have led to a Dickensian tale of two worlds, in which some countries are experiencing a respite from the disease while others are still on fire.
The psychiatrist Elisabeth Kübler-Ross famously and controversially outlined the stages of grief that people go through as they learn to live with what has been lost: denial, anger, bargaining, depression, and acceptance. Almost everyone has experienced at least one of these stages during the pandemic, although in many ways, the world is still stuck in the first stage, denial, refusing to accept that the pandemic is far from over. To these five stages, the bioethicist David Kessler has added one more that is crucial: finding meaning. From the devastation of COVID-19, the world must work together to build an enduring system for mitigating this pandemic and preventing the next one. Figuring out how to do that might be the most meaningful challenge of our lifetime.
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