Spot the Vaccine

In order to try to encourage a higher number of page views for this blog we have decided that it is time to have a competition with an eye watering prize, an all-expenses paid* trip to a remote desert hospital where you can experience at first hand both the satisfaction and the challenges of providing health care in an austere environment. To enter is simple, all you have to do is look at the picture above which shows some of the donations of useful equipment and supplies received by the hospital for the Covid pandemic and put an X in the place where you think the Covid-19 vaccine is hidden.  The lucky winner is the person whose X is closest to the actual position of the vaccines.

*the trip includes full board and lodgings in Bardai for a 7 day visit and the necessary invitation letters but excludes the cost of a visa, international and internal charter flights to and from Bardai. It is also necessary to be in possession of a yellow fever vaccination certificate, a negative Covid PCR. and, recently added by the Ministry of Health, proof of Covid-19 vaccination. Always read the small print. Who ever said competitions were fair.

-----------------                    --------------------                      -----------------              

Bardai is a remote small town situated at 1043m (3400ft) above sea level, high up in a remote oasis in the Tibesti mountains of northern Chad. It has many thousands of date palms which fill the wadi (dry river bed) due to underground water at just 3-7m below the sandy surface.  Although little rain falls on Bardai itself, the wadi floods once or twice a year filled by rainfall on the thousands of square km of bare rocks in the surrounding mountains including Emi Koussi the highest point in the Sahara at around 3000m (10,000 ft). Access to the town is difficult, in all directions you have to cross the inhospitable Sahara Desert; a day’s travel to the North and you arrive in the desert towns of southern Libya, four days travel to the South and you arrive at the Chadian capital, Ndjamena.  Many of the world previous epidemics must have passed Bardai by, diseases are unlikely to travel great distances when the only access is by camel train or in the 20th century by slow moving lorries. But now, with the gold rush, there are many more fast-moving pick-up trucks and people coming and going. There is a thriving cross border trade with southern Libya from where most of the food and fuel for the local market comes, along with the possibility of corona virus transmission.

We have been aware of this risk from the outset, 18 months ago. At that time, it was unclear how easily the virus would spread and which age groups were affected. So, we prepared for the worst, with the help of BMS and the local authorities we created an isolation unit, and got supplies, of oxygen masks, pulse oximeters, cleaning materials, local made personal protective equipment and essential supportive drugs including dexamethasone ready. We got new small generators so that we could have oxygen 24 hours a day from our 3 functioning oxygen concentrators. At the same time health education messages were also made throughout the area, using mobile phones with local language films and with face to face, hopefully socially distanced, meetings.  We made the clinical diagnoses of the first cases in June of 2021, there was one death but thankfully probably due to the young age of the Chadian population, (50% under 18 years), and the fact that most of life is lived out of doors, there was not a major epidemic. For various reasons a large part of the population refused to admit that we had cases and we had no possibility of laboratory testing so could not 100% prove the diagnosis. Although we could take a specimen it had to be kept cold and get to the lab at Ndjamena in less than 48 hours, and that was just impossible. So officially there was no Covid in Bardai.

Despite that the Ministry of Health sent more supplies including the in-vogue Chloroquine and Azithromycin treatment, hand gels an extra oxygen concentrator a non-invasive ventilation machine (CPAP) and training materials. 

Throughout the first half of 2021 whilst we were in the UK it sounds as if there have been a number of our friends and colleagues who have has unusually heavy coughs and colds which have taken much longer than usual to get over, it always sounded like Covid to us, especially as we were aware of the growing number of cases and deaths in southern Libya. Fortunately during our time in the UK we had been able to receive 2 doses of vaccine.

Just after we returned from the UK in July a final piece of kit arrived, the most expensive yet, a Gene Expert PCR machine and associated protective equipment for the laboratory personnel. It has been sent so that we can look for Covid cases, and at the same time it can be used for tuberculosis testing and for monitoring HIV cases. It coincided with an outbreak of the more infectious delta variant in Libya and a number of weddings in Bardai. Soon afterwards people started coughing but the enthusiasm for testing in the local population is not great, most often patients refuse the test and return home saying its just a bad cold. Over the past 3 weeks we have tested just a handful of suspects and confirmed 3 cases. There must be many more in town, but thankfully so far this time, no complications. 

We would never have imagined that we would have so much equipment and supplies to deal with the pandemic, the Ministry of Health, WHO and BMS have really done a good job in getting us prepared.  However, in the face of a full local epidemic we have far too few nurses, and our supplies of single use PPI would soon run out. It would be so much better if our nurses were vaccinated, we would still need to take precautions but the risk of infection and possible transmission to other vulnerable patients would be so much less.

 The truth is that despite all the efforts to prepare a diagnostic and treatment centre it would be so much better if we could prevent Covid by vaccination. Frustratingly, one year after the President of South Africa called for a TRIPS (patents) Waiver, the talks at the World Trade Organisation are still stalled and vaccines are still being sold at unnecessarily high prices. In the competition for the restricted supply it seems that booster doses of vaccines to ensure immunity amongst the vulnerable in the west is a higher priority than protecting the elderly, the vulnerable and health care workers in Africa with their first and second doses. Like the competition above, it is not fair, you have no doubt guessed that there is no vaccine hidden in the picture at the start of the blog, so you can’t win. The vaccine hasn’t arrived in Bardai  yet, hopefully it will soon, and there will be enough of it to be useful.

Why is it that potential low-cost producers in South Africa and elsewhere are having such difficulty getting access to the necessary technology and patent permissions to increase the vaccine supply? Future generations are likely to view this is a crime against humanity, albeit one done stealthfully by vested interests, rather than the usual bombs and guns. 

Which side of history would you like to be on? Are we a society of sheep or goats?

   “For I was hungry and you gave me food,

I was thirsty and you gave me drink,

I was a stranger and you welcomed me,

I was naked and you gave me clothing,

I was in danger of Covid and you gave me a vaccine.”  

                                                         Matt 25 (35-36) slightly altered NRSV

Neglected Tropical Disease?

So what is a neglected tropical disease, and why did UK aid announce new support for them in 2019?

To explain let’s start with a normal tropical disease that you will have heard about, Malaria. In the capital of Chad, N'djamena it is the wet season, the rains fall over 3 or 4 months filling the River Chari with life giving water that in its turn fills lake Chad and enables this otherwise arid zone of Sahel to be fertile and habitable. The water also collects in puddles and ponds and the mosquitos multiply and the same rains also give rise to the deadly malaria season. When we worked at the Guinebor II hospital we recorded the annual change between the months at the end of the dry season April and May with 20 positive malaria tests a month and September October with 600 positive tests. Overall malaria causes about 15000 deaths a year in Chad, mainly in children under 5 years of age. Malaria is acknowledged as a major health problem in sub-Saharan Africa and in Chad there has been for many years a national program of prevention with bed nets and free treatment, thus it is not a neglected tropical disease.

In Bardai, in the mid Saharan Tibesti mountains it only rains once or twice a year and, due to the fact that there is therefore little free-standing water, there are few if any mosquitos. Even the few that there are would have difficulty maturing malaria parasites as it is often too cold or even too hot for that to happen. The few cases of malaria that we see are amongst travellers who have bought the infection with them across the desert, in the same way as someone can have malaria in the UK after a holiday abroad.

 

However, there is another disease that is transmitted by an appropriately named sand fly that does not need pools of water to reproduce. It also kills children under 5 years of age and last year we treated 63 cases. It is fatal without treatment nearly 100% of cases die a slow death due to anaemia, bleeding, malnutrition and infection. The disease is called visceral leishmaniasis, you may or may not have heard of it. It is classified as a neglected tropical disease due to the fact that it kills a comparatively  small number of people and those in developing countries and so has not received the attention that it merited, and yet it is still a major problem communites affected like the Tibesti.

In order to understand better, lets look at death rates due to Covid in the UK. Around 2000 people have died in every million of the UK population, the young are usually less severely ill and it is mainly but not exclusively the elderly and those with underlying health conditions who have been most affected. We have organised fundamental changes in the way society functions, quarantining, lock downs, social distancing and mask wearing and have committed billions of pounds to find a vaccine and a cure. This has been a once in a generation, or even once in a century event.

Last year by treating 63 cases of leishmaniasis we treated at a rate of about 1400 per million of population. All had a fatal illness without treatment, that occurs every year, and yet treatment here only began 3 years ago. Assuming that we are not yet diagnosing and treating all the cases in this mountainous region the death rates up till 3 years ago when our treatment programme started was also about 2000 per million, (but there are only 45000 Teda). This time it is children under 5 years and not the elderly who are most affected. Imagine a similar scenario with an illness killing children, that many children in a small town of 45000 people in the UK, what sort of response would we have made?

To its credit, the British government has been at the forefront of the fight against neglected tropical diseases paying for research into better and simpler diagnostic tests and less toxic more effective treatments. It also has been supporting the treatment programmes in East Africa, where Sudan and Kenya have seen very large epidemics of visceral leishmaniasis, and tens of thousands of lives have been saved every year. 

We initially diagnosed in 2018, two typical cases that died due to lack of availability of treatment in Chad. It was the cause of much discussion in the Teda community and a  year later the Ministry of Health started to supply our hospital with free drugs (in 2019). A church in Birmingham supplied us with free tests so that we could be surer of our diagnosis and pick up earlier cases. Once we had the supplies we were amazed at the number of cases that we were able to treat.

Our results caught the attention of World Health Organisations Neglected Tropical Diseases unit, and they wanted confirmation that Chad was an endemic country. At their request we took specimens of blood from our patients with us on the plane to N'jamena  and they sent them or leishmaniasis PCR in Madrid. The results definitively confirm that the disease is in Chad. A national programme with support from the WHO is being set up and will also look for cases in other parts of the country. 

Free treatment and testing is essential for a successful program. If we were to buy the branded medicine Glucantime® (Meglumine antimoniate) Sanofi-Aventis, it would cost us over £250 to treat a small child. In N'djamena I treated a small number of adults whilst working at the Guinebor II hospital at over £500 a case. That is about a monthly salary for a doctor or 4 times the minimum monthly employed wage, and an impossible sum for most Chadians. Thankfully the generic medicines provided by the government are less expensive and what’s more provided free to the population.

The hospital pharmacist with part of a recent delivery of drugs and tests for the next year.

And so, along with Royal Society of Tropical Medicine and Hygiene, I am deeply saddened by the 4 billion pound UK Aid cuts recently narrowly voted through in the face of cross party opposition including all the previous five living Prime Ministers, Theresa May, David Cameron, Gordon Brown, Tony Blair and John Major. As a result this year the  Neglected Tropical Disease budget is to be cut by 150 million pounds and one of the expected results is that funding for free treatment of Leishmaniasis the East Africa will no longer be provided by UK Aid, this will cost thousands of  lives and in my opinion diminish the standing of Britain in the world.

At the same time the Royal Navy is impressing the world with its newest ship, an aircraft carrier, on its maiden operational voyage through the Mediterranean, Suez Canal and now around the Far East. It will eventually have a full complement of 24 F-35 Lightning II fighter bombers at the cost of 190 million pounds for each plane. One plane costs more than the cut in the Neglected Tropical Diseases budget. The Queen Elizabeth aircraft carrier itself cost about 4 billion pounds, which happens to be the total UK aid cuts for this year. Perhaps the government hopes to re-define our post Brexit reputation as a leading world military power rather than as a leading compassionate world developmental power. I hope that this is not the case, and that the treatment of neglected tropical diseases will not become a forgotten part of British policy.

The prophet Micah spoke of a future time when God will act:

“He shall judge between the nations,

   and shall arbitrate for many peoples;

they shall beat their swords into ploughshares, 

and their spears into pruning hooks;

nation shall not lift up sword against nation,

neither shall they learn war anymore;

but they shall sit under their own vines and under their own fig trees,

and no-one shall make them afraid:”

                                                                                       (NRSV)

The prophecy is not only something that we should hope for, but also be something that we aspire to and work towards. May we all play our part in bringing it to pass both in the UK and throughout the world. Re-instating the UK Neglected Tropical Disease budget would be a good place to start. 

Crumbs from your table

At the start of this millennium the HIV pandemic was largely under control in the west but was still wreaking havoc in sub-Saharan Africa. The number of cases were rising at our TB hospital in Macenta, Guinea and there was little that we could do apart from palliative care. The required drugs would have cost over $5000 per patient per year and were way beyond the budget of a small NGO to pay.  

Amazingly all that changed after  a long fight between activists and pharmaceutical companies generic medicines became increasingly affordable for low income country programs but external funding was still required. Bono, from U2, had visited a hospice in Uganda where patients were sleeping and eventually dying three in a bed , the sisters who served there were simply overwhelmed, what could he do to help?

He recounted to Q magazine, 

“I went to speak to Christian fundamentalist groups in America to convince them to give money to fight AIDS in Africa. It was like trying to get blood from a stone.”

 His frustration and anger pours out in the lyrics to the song

Where you live should not decide

Whether you live or whether you die

Three to a bed Sister Anne she said

Dignity passes by ...

You speak of signs and wonders

I need something other

I would believe if I was able

But I'm waiting on the crumbs from your table ...

Thankfully HIV is now a treatable disease in sub-Saharan Africa. There are still hurdles of societal prejudice and shame to be overcome, but even in remote places like Bardai where we practice medicine in a Ministry of Health hospital, we have a good supply of tests and triple therapy available free. Unlike other parts of Africa HIV/AIDS is not the major health problem here but for those individuals that need treatment for themselves or to protect partners or their as yet unborn child, the medicines are still essential.

Some of the same frustration that Bono sang about is building now around the response to Covid-19. The Peoples Vaccine Alliance have spoken of the weak efforts to vaccinate lower and middle income countries with charitable donations as crumbs from the table. Last week the WHO was talking of the disparity between the high vaccination rates in the rich nations (56% of the UK population fully vaccinated) and the 1.5% of the African population. It has been suggested that as a minimum, all medical personnel and vulnerable people throughout the world should be vaccinated before we start administering 3rd booster doses of vaccines in the rich nations. Sadly it seems likely that this call for some sort of equity will  be ignored and the government will continue to talk of its financial support for COVAX and vaccine donations from the UK, rather than addressing fundamental questions of vaccine equity.

This week the UK has at last started to send 9 million Astra Zeneca vaccine doses manufactured in the UK overseas. The first of 30 million doses promised at the G7 summit are to be delivered by the end of this year, with a further 70 million by June next year. That sounds a lot but it is only enough to vaccinate 50 million people. The problem is that we live on a planet with a population of 7 billion, so that is  only enough to vaccinate a mere  0.7 % of the world population. About half of doses announced will be given to COVAX and will be distributed according to an equitable plan, the other half will be given directly as a gift from the UK as the government engages in ‘vaccine diplomacy’ supporting friendly nations with whom we have or aspire to closer ties. All  this amounts to crumbs from the table, albeit gratefully received. 

The Foreign Secretary, who along with his advisors decides where the doses should go, said “ We are doing this to help the most vulnerable, but also because we know we won’t be safe until everyone is safe”. Meanwhile at the same time the UK and Germany are lobbying the  World Trade Organisation’s against a TRIPS (patents) waiver, this blocking the historic move, supported by a majority of nations including France and the USA, that would allow scaling up of manufacturing across the world, and the production  of the billions of doses needed in a quicker and less costly manner. Crumbs from the table charity is being used as an excuse not to talk about and implement just policies such as the TRIPS waiver that would be the real solution to the problem of vaccine equity.

It is not unknown for the government to selectively quote the bible when speaking, so  if reading the Bible is going to inform government policy perhaps ministers should read about some biblical  principles in story form starting with the rich man and Lazarus in Luke 16:19-31. It is quite a shocking story, both for a first century and a contemporary 3rd millennium  audience, and it speaks equally well to economic systems and individuals. 

Meanwhile the reproach from Bono about injustice and indifference towards HIV/AIDS remains relevant during the current  pandemic. Whether we like the music or not the words cut us to our hearts.

Where you live should not decide

Whether you live or whether you die

Three to a bed Sister Anne she said

Dignity passes by ...

You speak of signs and wonders

I need something other

I would believe if I was able

But I'm waiting on the crumbs from your table ...

 

Why does it have to be like this?

My neighbour in Bardai gave birth at home in her yard, just an hour or so after  I had been round at her house chatting. We had discussed the need to go to the hospital for the birth, the fact that she had often had difficulty delivering the placenta and had been taken to the hospital before for emergency treatment. There was a risk to her life if it happened again. In the end the desire to deliver in her own home, with her younger sister, won over. For many generations Teda women have given birth this way.  When they were travelling in the desert or living in isolated communities, who could be there to deliver the baby? Not a midwife or a doctor, so best to deliver alone on the sand .This time the placenta finally delivered just after she had called for help and as we had her husbands car ready to take her down to the hospital, a mere 5 minutes away. Her delight at not having to go to the hospital, with the risk of being seen by a male nurse or doctor and perhaps some shame at not achieving a delivery at home, was almost palpable.

Rapidly the main room was made ready with drinks, biscuits and sweets and the best seats and a low table bought out making a place where she could receive friends each day.  She remained  behind a curtain in one corner of the room so she would not be seen. After a week more celebration again as the baby was named and a big feast held. Then another month at home resting and being looked after by her family, her only responsibility feeding her new born.

It all sounds idyllic but what if the placenta had not delivered ,what if she had started to bleed and even if she had arrived at the hospital there hadn’t been a trained midwife or someone who  could organise a blood transfusion. All of which can easily be the case in towns like Bardai.

What if she had been forced to travel across the desert to another hospital and what if she like many women in Chad hadn’t made it  and had left her 5 children motherless. Maternal mortality remains a huge  problem in Chad with a maternal mortality ratio of 1,140 deaths /100,000 births making it one of the riskiest places in the world to give birth.

It seems a long way from the NHS with it's  clean hospitals, blood banks and doctors and midwives that we  know. With  ambulances ready  to rush you to help if you do decide to have a home birth and there are complications. As a consequence the UK the maternal death rate is 7 deaths /100000 births, 150 times lower than Chad

But there is also another statistic here hidden away, the sad fact that if you are a black woman in England you are also at a much  higher risk of death in pregnancy. In fact according to the latest MBRRACE report, the risk is 4 times higher. Many factors are of course involved such as a predisposition amongst black women to high blood pressure and diabetes as well as other illnesses. There are  also the many social determinants of health such as poor housing and low levels of  education but these don’t explain everything. The Royal College of Obstetricians is of course seeing what can be done in the medical world and has set up a race equality task force. But it seems there is so much more to it than that and we all have a part to play in how we behave towards  people of different ethnicities than  our own.

What can we make of the fact that  a study in America has shown that  black babies in the first 28 days  die at 3 times more often than white babies. However when black  doctors look after black neonates this disadvantage was reduced by 50%, an unbelievable number, what does it reflect? However the same effect is not seen amongst pregnant women when they are cared for by doctors of the same race. It is felt that for women  the effect of  structural racism is already too deeply ingrained to allow this to have any further  effect. Of course you may say these figures don’t compare to Chadian levels of maternal death , but that doesn’t stop it from being a huge injustice that needs to be  righted.

So lets look at an example of a pregnant woman in the Bible and see what lessons we can  learn about how we could act. Many people look at Mary as the Holy Virgin calm and serene at all moments. Actually she was likely a  teenage mother of Jesus who had a very risky birth far from home and then became a refugee. She was also the inspired author of the Magnificat, full of references to justice and peace and to over throwing the powers of the age. So the true  reality may be that, far from being meek and mild,  she was a revolutionary figure. In the past the British in India forbade the singing of the Magnificat from fear it was too revolutionary; it was also banned in Guatemala in the 1980s for the same reason. Nowadays apparently almost all the songs we sing which include the Magnificat stop before we arrive at the parts mentioning bringing down rulers and sending the rich away. We need to stand up to the truth both in the way we use the  Bible and what we see in society.

We need to ask what is it we want, the Virgin Mary as mother of Jesus meek and mild or Mary as mother of Jesus, a revolutionary, challenging us to speak out against injustice in the U.K or in Chad? Challenging us to think what we will  do when faced with the injustices of our world?

Vaccine 5: Acting justly, loving mercy and walking humbly?

EXPEDITED ACCESS FOR COVID-19 IP

The following guidance explains how we approach licensing COVI-19 related IP to 3rd parties in these exceptional circumstances.

1.   OU and OUI will expedite access to Oxford IP to enable global deployment at scale of associated products and services to address the COVID-19 pandemic

2.   The default approach of the University and OUI regarding (1) will be to offer non-exclusive, royalty-free licences to support free of charge, at-cost or cost + limited margin supply as appropriate, and only for the duration of the pandemic, as defined by the WHO

The team at Oxford University started working on a vaccine  early, very early, in fact, before the problem began. With government  and charitable funding over many years, they had been working on how to quickly deliver a vaccine for an unknown epidemic, Disease X. As the first news reports of an outbreak of viral pneumonia were coming in from Wuhan,  the WHO confirmed on the 9th January 2020, the cause, a novel corona virus. The next day, even before the first reported fatality due to SARS-Cov-2, the scientists at the Jenner Institute of Oxford University had a planning meeting for an eventual vaccine for this  new problem.  Three weeks later the problem became a WHO -Public Health Emergency of International Concern, and that concern about Covid-19  officially became a  Pandemic on the 11th March 2020. So the UK based Oxford vaccine had started, much earlier by two months than an adequate  public health response.  But there was still, as we said last time, a long and uncertain wait.  Perhaps realising  that with 97% public and charitable funding it should give something back  to society,  perhaps inspired by Jonas Salk, the University  pledged a non exclusive, royalty free licencing system;  It  had clearly caught the spirit of the times. Here is their  undated web page in full 

Now over a year later we know  that the search for multiple vaccines has borne fruit which exceeded the most optimistic projections. According to the WHO by the 24th May 2021 a total of 1,489,727,128 doses of vaccine have been given, which is amazing. The Astra Zeneca vaccine is especially good for world health as even isolated places, like Bardai, have the necessary normal temperature refrigerator technology required for storage.  Unfortunately the early global solidarity expressed by Oxford University and many political leaders are long forgotten. An exclusive deal was struck for the Oxford Vaccine with Astra Zeneca on 30th April 2020. This has effectively shackled the manufacturing and rollout of the Oxford Vaccine.  Through deals, the details of which have not been published, Astra Zeneca has established manufacturing sites around the world, notably licensing  the Serum Institute of India, and aims to produce 3 billion doses of vaccine this year. This sounds good but firstly vaccines are not being produced as quickly as hoped, leading to undiplomatic wrangles between counties  and secondly the world has nearly 8 billion citizens, and has need of an estimated  14 billion doses of vaccine  for the initial  control the disease.

The Astra-Zeneca vaccine is said to be not for profit and should have been equitably distributed through COVAX for at risk populations and health workers around the world according to need. Unfortunately now the primary supplier of the Oxford Vaccine for Africa, is the Serum Institute of India.  It  will be unable to meet its obligations this year  as all of its production is needed to control the epidemic in India.  The Oxford University graph above demonstrates the richest countries are getting most of the worlds doses supplies and this will continue as long as supplies  are limited. For instance the UK has given 61 million doses  for its population of 68 million  compared to 18 million doses for the whole of African population of 1.35 billion people.

Everyone needs urgently  to have access to the vaccine which is why so many people in so many countries led by South Africa and India have been campaigning for a patent waiver and technology transfer similar to that originally  envisaged by Oxford University. Only by massively expanding the number of manufacturers can we right the injustice of having 60% of the total UK  population with a first dose of vaccine where as Africa has only vaccinated 1% of its population.  

Recently Dr Tedros Ghebreyesus (WHO- Director-General) said  at the World Health Assembley,

''There is no diplomatic way to say it: A small group of countries that make and buy the majority of the world's vaccine control the fate of the rest of the world.''

Despite great opposition from the major pharmaceutical companies the Biden- Harris administration has decided that the United States will support the planned patent waiver, saying

'' These extraordinary times and circumstances call for extraordinary measures''

The Bill and Melinda Gates Foundation, which has  supported global health an especially  childhood  vaccination over many years was strongly against the waiver but recently changed it's mind and  published,

''No barriers should stand in the way of equitable access to vaccines including intellectual property, which is why we are supportive of a narrow waiver during the pandemic''

Sadly the arguments at the WTO continue and about the only thing the UK and the European Union are capable of agreeing on is their strong opposition to the patent waiver.

 Perhaps you would like to express support for this vaccine waiver which could change the world for the better? As well as considering  sending a donation to India and Nepal why not tackle the problem at the root, by campaigning to increase the production of low cost effective vaccines as requested by South Africa, India, the USA  and a total of 118 of the 164 members of the WTO.

You could petition the Prime Minister it takes a minute of your time or even write to your the Secretary of State for Trade, it takes a little longer but may make a huge difference if we all do it . 

Can we  ''act justly, love mercy and walk humbly'' and work for a better world? 

Yes we can! 

Should we ? 

Yes we should!

Must we ?

Yes we must!

A demonstration at the Department of International Trade during the recent G7 Trade Ministers  meeting

 

 

 

 

Vaccine 4. Prevention is better than cure

The Covid-19 satellite hospital at Bardai, a  re-purposed police station. 

Cast your minds back to April 2020, the first lockdown had begun on 23rd March, but despite this the deaths  due to Covid-19 were still rising at an  alarming rate.What could be done to stem the tide of the pandemic? 

 

Hopes were already being pinned on a vaccine, but would it be possible to make one? How much would it cost?  And more importantly how long would it take? According to the Welcome Trust, in normal circumstances $500 million over 10 years. The quickest ever was 5 years for a mumps vaccine. However fortunately there were new technologies, mRNA and adenovirus vectors, and so Sir Patrick Vallance, UK Chief Scientific Officer, was suggesting 12-18 months. There were grounds for hope but a long and anxious wait was just beginning.  

Meanwhile what could be done to help people before a vaccine would become available? The first response was already in place, an unprecedented lockdown to slow the rate of transmission, the second was to boost the capacity of the NHS to cope with the number of patients needing hospital treatment especially lifesaving oxygen treatment.

On the 3rd of April, 11 days into the first UK lockdown, to prevent the risk of NHS hospitals being overwhelmed, NHS Nightingale London was declared operational. The Excel conference centre had been converted into a hospital in  less than 2 weeks. The  initial capacity was 500 hospital beds with  the possibility of 4000.  More complex equipment was harder to come by,  innovative manufacturing was needed and in the meantime some came from surprising places, such as working ventilators given by the BBC's Holby City film set. The cost of the conversion and equipment was £57 million and 6 more provincial centres were to follow. 

In Bardai, at the hospital, we were trying to respond to the situation, by delivering health education messages on hand washing, mask wearing and social distancing in the community and improving hospital hygiene and infection control. Our ADP linguist colleagues made a health education film in Teda that passed from phone to phone.

We also realised that our small hospital was at risk of being overwhelmed by even a small number of cases due to  inadequate separation of Covid and non-Covid patients and uncontrolled visiting fuelling any epidemic. The local authorities offered a very good solution; the disused police station with a perimeter wall could be transformed into a separate Covid satellite hospital. Help from the WHO and Ministry of Health would eventually arrive but in the meantime BMS supported the rapid organisation of a water supply, triage area and other changes. The main  hospital had basic equipment such as beds and trolleys in storage and so within a couple of weeks we had a unit. We even had a small quantity of disposable PPE that had arrived by chance 6 months before, that was initially supplemented by surgical gowns and scrubs made in town and eventually further supplies from the Ministry. 

Orders for plenty of oxygen masks and other essential medical equipment were made from the UK and these eventually arrived along with essential medicines such as dexamethasone, paracetamol and antibiotics from N'Djamena.  

 

Rather like the UK Nightingale hospitals, our satellite hospital has been little used, although we did have a handful of highly probable cases in the town (we had no tests to confirm them). Thankfully we didn’t get sustained transmission, but having seen the scenes from the UK, Europe and the US we were right to prepare as much as possible. Despite all our preparations the day a more transmissible variant arrives in Bardai we will be at risk and  still would have difficulty coping. The reason for this is the same as one of the drivers of the unfolding tragedy in Nepal and India, a lack of oxygen.

From the outset we were aware that this was a major weakness. In the UK we assume that nearly every bed in a hospital has a piped oxygen supply, and if not, there is a full oxygen cylinder nearby. There is no chance of replenishing our empty oxygen cylinders in Bardai, but we do have four individual patient oxygen concentrators, an amazingly high number for such a small hospital but only two were working. Fortunately, one was repaired by missionary colleagues from Germany and the Ministry of Health sent us another one. BMS bought 2 small generators that could run 6 hours on, 6 hours off to supply the necessary electricity 24 hours a day.  Large numbers of oxygen concentrators have been given by the WHO and other donors to Chad, and hundreds of thousands throughout the world but as an article in today’s Guardian shows, once an epidemic strikes there is usually not enough oxygen to meet the 10 to 100 fold increase in demand. As a consequence  Covid is no longer a disease predominantly affecting the older population, many people of all ages die. We must of course help in any way we can to get oxygen and supplies  to everyone  that need it, but the volume of equipment and the training and skill required to do anything other than the simplest oxygen mask treatments means that this can never be the best solution for most of the population in low and low middle-income countries. Building Nightingale hospitals in advance all around the world is just not possible.

What is needed is a vaccine freely and equitably available for all, after all prevention is better than cure.  

CAMPAIGN FOR A COVID FREE World Click for news 

JOIN THE GLOBAL CHRISTIAN MOVEMENT FOR EQUITABLE VACCINE ACCESS

 

VACCINE 3: The present

Bardai 2018: Launch of  National Polio Vaccination day

 At the end of the last post I encouraged you to sign a BMS petition which expresses solidarity with those countries who are proposing a TRIPS (patent) waiver.  This would enable production of COVID vaccine in sufficient quantity so that it  can be rapidly  and  equitably available throughout the world. BMS, through the  Peoples Vaccine Alliance, are partnering with many organisations ,one of whom has produced a 5 minute video that explains the gravity of the situation and offers a solution, Manifesto for Life.

The problem over commercial medicines may seem to be enormous: changing international treaties to allow patent free drugs may seem a very difficult thing to do. But actually it is not  necessary, because it has already been done.  The TRIPS waiver mechanism was negotiated at the 2001 WTO talks in Doha as a response to the AIDS epidemic sweeping southern Africa and elsewhere. It paved the way for widespread distribution  of low cost HIV treatment. Previously the  annual cost of branded triple therapy of $10,000 per year made it impossible for all but the citizens of the  richest nations to be treated.  Suddenly, with a generic equivalent made in India, the price fell to $350 per year. This has  saved many millions of lives in middle and lower income countries. By 2018 the price was as low as  $75 a year, that is 15p (20 cents US) a day; as a consequence effective  drugs to treat HIV are supplied by the Ministry of Health to all hospitals in Chad, including Bardai, for free distribution. 

 Dr Tedros Ghebreyesus, the Director General of the World Health Organisation, recently said 'the gap between the number of vaccines administered in rich countries and COVAX (supplying low income countries) is growing every single day and becoming more grotesque every day' He proposes using the same already established mechanism of the TRIPS waiver to address this situation,saying, ' These provisions are there for use in emergencies......if now is not a time to use them, then when?' 

The recent posts on this blog have been exploring the history of the campaign against polio and there is at least one more lesson that we can usefully apply to the current situation with COVID-19 

                                'NO ONE IS SAFE UNTIL EVERYONE IS SAFE'

In 2011, one year after our family's arrival in Chad to live, work and attend school, there was a spike in polio infections. One hundred and thirty two cases of paralytic polio were recorded and probably many more cases were missed. That amounted to 41% of the total cases in Africa, and Chad was considered a reservoir of infection that risked contaminating the neighbouring countries. A new programme of National Vaccination days was started, the first being inaugurated by President Debi Itno, with representatives from WHO and UNICEF, plus, from GAVI, Bill Gates in person.

The campaigns rapidly bought the situation under control and by 2014 there were no reported cases. The photo at the top of the blog is of the last mass campaign in Bardai, 2018. After that routine polio coverage was continued through routine childhood vaccinations.

In 2019 there were a concerning  10 cases of paralytic polio and then in February 2020 (not on the graph)  a serious outbreak began resulting in 99 cases across the country. This spread across the borders to Sudan and The Central African Republic. The Chadian epidemic accounted for about a quarter of the worlds cases. Due to the COVID-19 pandemic it was difficult to get the resources to mount a response, but finally in November 2020, two vaccination campaigns 14 days apart managed to vaccinate 3,3 million children across the country including Bardai and the Tibesti.

This rapid reversal of the progress in eradication of polio  shows that the WHO estimate of 200,000 cases of polio a year worldwide , if we fail to eradicate it in the last remaining endemic countries,is not a fiction, but an alarming reality. As we noted before.

                             'NO ONE IS SAFE UNTIL EVERYONE IS SAFE'

The Covid-19 virus presents a much greater problem than polio. It is spread by aerosol and that makes it much more difficult to control by simple hygeine measures than a disease like polio which is spread by food and water .In addition the Covid-19 virus is also capable of mutating and so can escape from the  antibodies that are produced  by vaccines. The polio virus does not mutate and the vaccines have remained effective for many years. Therefore for COVID even completely  vaccinated  countries could be reinfected by a vaccine resistant strain coming from non vaccinated countries. Logically We need to seize this opportunity to vaccinate everyone in the whole world. Then we can hopefully eliminate the disease. If not we will spend the next few years or decades with intermittent  lock-downs, always be  chasing a new vaccine and adding increasingly complex and expensive travel restrictions.

A year ago, when fear reigned at the height of the first wave, vaccines were but a distant hope. The President of the European Commission spoke for many when she said ',We need to develop a vaccine. We need to produce it and deploy it to very single corner of the world. And make it available at affordable prices. This vaccine will be our universal common good'

Even now, as vaccine nationalism takes hold and the vaccine gap between the haves and the  have-nots widens every day, let us get back to a spirit of true international co-operation, pass the TRIPS waiver and organise technology transfers so that as many doses as possible of vaccine can be made this year.

If the moral imperative to alleviate suffering and death overseas is no longer enough to motivate the WTO and world leaders then surely long term self interest economic and social should lead them to the same conclusion.

                                   'NO ONE IS SAFE UNTIL EVERYONE IS SAFE' 

Today is Easter, a day of hope for new way of life, as we are writing this we received a Franciscan blessing from a friend, it speaks of striving for justice, we pass the last part on to you.

...may God bless you with the foolishness to think

that you can make a difference in the world,

so that you will do the things which others tell you

cannot be done

VACCINES 2: Thirty years later

Macenta, Guinee Forestiere, where we arrived to work in 1993,  Polio was still rife.

In my last post I explained  how polio, a disease that was feared by my mothers generation, was rapidly bought under control in the western world by new vaccines which, as they were not patented, were able to be made rapidly available by multiple pharmaceutical companies. This is an interesting lesson for dealing with the current COVID-19 pandemic.  Are there any  other lessons that we can we learn from this story?

By the time that I first went to school, although there still were occasional cases, the threat of annual polio epidemics in the UK was already the memory of a previous generation.  Later in my final year at medical school (1984),the last case of polio in the UK caused by transmission of the wild virus was recorded. 

However despite the amazing generosity of Jonas Salk and Albert Sabin the problem worldwide was still a massive one. In 1988 there were still an estimated 350,000 cases of paralytic polio each year, with about 10% of the children dying. That was the year  that the WHO launched the Global Polio Eradication Initiative.  

Five years later, Andrea and I arrived in the hot and humid town of Macenta, Guinee Forestiere. It was forty years since  the discovery of the vaccine, yet tragically polio was still endemic. Each year I would see young children who had been either recently  paralysed or were living with the consequences of contractures. Often they were  crawling on their knees unable to use any  muscle strength that they had regained to walk. At the Centre Medical we worked together as a team; the physiotherapists taught exercises, the orthopaedic workshop made callipers and splints, and in the operating theatre we did tendon release procedures guided by the newly published WHO manual.

Thankfully prevention was also beginning,  polio vaccines were being distributed to  the fridges in the  new health centres that the Mission Philafricaine were building in collaboration with the Ministry of Health. For the first time the people of the region had access to  routine childhood vaccinations. In addition each year, on two special national vaccination days, every child under 5 in the country received a dose of oral polio vaccine. Healthcare workers passed from door to door with a polystyrene insulated cardboard vaccine carrier emablazoned with "KICK POLIO OUT OF AFRICA" No-one was exempt,my daughters must have recieved a total of 12 doses by their fifth birthday. Within a couple of years of the campaigns beginning I no longer saw newly paralysed children, but there were still plenty who needed help from the time before the vaccine. Similar campaigns were taking place everywhere with dramatic results, the graph below shows the global situation. 

In Macenta the  dramatic change was bought about by the arrival of the cold chain. In 1991, just prior to our arrival, there had been an epidemic of meningitis and the only way to get vaccines into the region had been in a truck from the capital alongside deliveries of frozen fish.These were being made by a family of Lebanese traders to a chain of depots selling fish to the local markets. Thanks to this unusual support lives were saved, but the need for the provision of a dedicated medical cold chain had become clear.

The WHO estimates that their polio campaign has lead to 80% of the worlds population now living  in polio free countries and that 18 million less children have been paralysed as a consequence.  There were only 22 cases of wild polio virus reported in 2017, a great success but we  not quite there yet, and it has taken 60 years.

Sadly despite the potential supply of large volumes of patent free vaccines it took 30  years before adequate supplies arrived in Guinea because of the lack of development of the healthcare systems in low and middle income countries, notably, cold chains. Thankfully cold chains are in place now even in remote places such as  Bardai, our current somewhat dryer home mid Sahara.

The Provincial hospital where we work  has  an excellent solar powered fridge supplied by UNICEF and we are able to supply polio vaccine to the most remote villages each year for the National Polio Vaccination Days. Due to the terrain it actually takes about a week to get around them all using the hospital ambulances. 

So with the current COVID-19 pandemic, we are fortunate that the necessary infrastructure is already in place, but where are the vaccines? So far 25 million doses have been given for the African population of 1.35 billion  whereas we in the UK have given 32 million doses for 68 million people, that is a 25 fold difference. This disparity represents  what the WHO has called a potential 'catastrophic moral failure' of inequality. We need to campaign for  our government and the World Trade Organisation to enable sharing the knowledge and technology so that a low cost vaccine  can be equitably and freely available throughout  the world. This is best done by a TRIPS (patents) waiver, which is supported by the majority of nations  but opposed by  pharmaceutical companies and rich western nations. If you want to show solidarity with your global neighbours click on  the BMS petition.

CAMPAIGN FOR A COVID FREE   WORLD

JOIN THE GLOBAL CHRISTIAN MOVEMENT FOR

EQUITABLE VACCINE ACCESS