Over the past two years, humanity has more or less been held hostage to public health and social measures (PHSMs) initiated to protect against the onslaught of a novel coronavirus disease 2019 (COVID-19).

Only two months into its inception in Wuhan city in 2019, the severe acute respiratory syndrome coronavirus type II (SARS-CoV2, the causative agent for COVID19) had spread nearly across much of the interconnected cities in the “global village “. This prompted WHO to declare COVID-19 a public health emergency of international concern (PHEOIC) by February 2020. Its airborne nature, resilience to survive for long on inanimate objects, and globalization (quick travel) perpetuated its sustained spread across the world.

Where the public health and social measures worth it?

As of January 31, 2022, approximately 373 million cases had been reported with 5.6 million deaths. This makes about 2.3 million deaths per year, far less than what road traffic accidents, tuberculosis, heart attacks, cancer etc. kill per year. This raises the question…, “were the rough restrictive measures implemented globally worthwhile?” It’s often difficult to undertake postmortem (back in time) audits of shifting phenomenon, yet in this case…. the idea becomes tantalizing to consider. Would there have been more deaths without these measures? Perhaps yes. Were they worth the effort and the issuing socio-economic impact? That’s difficult to answer in face of those that lost loved ones. But these are the sort of questions that become important to answer to pave way for a sustainable way forward. I beg that we pause this debate in the interim, and only return to it later, under the section-protecting the vulnerable and elderly”.

In comes the vaccines and hope for a return to normalcy

One of the most controversial times of vaccine immuno-biology knowledge, attitudes and perceptions), has accrued from COVID19 vaccines. And I am not talking about the speed at which they were developed, as this was pre-planned under the coalition for epidemic preparedness innovation (CEPI) in part as a response to the 2015 WHO paper stipulating disease X as the cause of the next pandemic. True to these predictions, just 3 years after the end of the 2013-to-2016 West African ebolavirus disease pandemic, COVID19 emerged on the global scene. So the plans to shorten the timelines for R & D plus deployment of diagnostics, therapeutics and vaccines against disease from the historical 15 to 20 years to within 9 months, was visionary. Albeit, I am talking about the earlier perpetuated efficacy data against infection, some of which were used to offer emergency use licensure for these vaccines that never lived to their expectations. It took the onslaught of the delta variant, to appreciate that, perhaps the current vaccines do not protect against infection and transmission (omicron further affirmed that), but rather, against severe disease.

The study from South Africa that found AstraZeneca vaccines not protective against the beta variant, had, however, already been deployed in policy….and South Africa opted for another but not very much different in design (J & J) vaccines hoping for better resilience against infection and transmission. The data we have seen emerge from Israel and other places clearly teach us many things.

First, that we cannot confidently rely on vaccines to control cases, since they do not primarily protect against infection or transmission. Second, we learn that vaccines, though protective against severe disease and possibly death, that protection wanes over time (six to nine months to be precise).

Third, that some variants can evade the ability of vaccines to protect against severe disease and death, necessitating a booster dose to restore initials of this protection. Fourth, that the call for boosters might be indefinite as long as new variants emerge…. posting an ambiguous feature of vaccination requirements especially in face of rampant inequity. This picture is rather fluid, one that will drive confusion in the minds of both the layperson and the specialist, warranting some harmonization. Are vaccine mandates scientifically valid or simply a tool to encourage uptake (and protect the care systems against being flooded with severe and critical cases)?  Alternatively, is it evidenced to prescribe a COVID19 test only for the unvaccinated while overlooking the fact that even the vaccinated get infected and spread the virus? Lastly, this can debate not be completed without talking about the rare but clear adverse events related to COVID-19 vaccines and the hesitations expressed by many across the world regarding their safety. Is the prevalence of the SAE within acceptable limits, in which case the fears are over exaggerations? Could there be an underlying risk for SAEs for a certain group that needs to be uncovered before one gets the vaccine? Personalized medicine might be far from reality but in this context, perhaps a cheaper way to look for that risk might suffice.

Revisiting the interventions or dropping the guard

Clearly, the cost of maintaining a proactive epidemic mode response across the world has been high, and this coupled with the negative socio-economic impact of the PHSMs, it becomes necessary that we revisit the guidelines, towards less stringent ones. Omicron has in part enabled us to achieve that due to its connoted ‘mild presentation' much as the same is only relatively factual and Omicron has proven deadly among many elderly and those with comorbidities.

Is this a sustainable change of guidelines? It is difficult to say especially when we don’t know how possibly the virus will evolve…into a less fit variant and self-extinction, or a more deadly form. It would be wise to maintain a more fluid strategy, dependent on the level of threat rather than imagine that we can wish away the ‘epidemic response mode' for an endemic status. Clearly, even within the later refinements, when the situation evolves from epidemic to pandemic mode, countries have to be ready to respond if not to protect their most vulnerable.  Thus, we need a robust surveillance strategy….and of course a plan and budget for rapid redeployment in case of a resurgence of the epidemic (pandemic). We also need more affordable, equitably accessible biomedical interventions that are easy to use and rapid to yield results. This is in the context of all technologies from testing, isolation, referral, treatment and follow up. We need real-time data access and resolution only possible via deploying advanced artificial intelligence.

Complexity of COVID-19 disease outcomes

Most of our infectious disease knowledge has shriven on a simple linear model of outcomes, wherein those infected get the disease and possibly recover or die. SARS-COV2, however, has introduced a complex, non-linear picture whereby—depending on underlying genetic and environmental determinants, outcomes of infection are diverse. The majority of people get infected and remain asymptomatic or mild (85%) and only 15 % get a severe or critical disease, some dying. We know a few facts now about the characteristics of these 15%...many are elderly (and this too is relative) and most carry comorbidities (including children). This can enable us to target prevention measures to those at risk. Thus, a fundamental question arises, as we open up the space for the younger and healthier populace, how do we plan to protect the elderly and those with comorbidities?

Protecting the vulnerable and elderly

This is perhaps the most important yet complex question to answer if we are going to sustainably live with COVID-19 as an endemic disease. My five-year-old daughter with sickle cell anaemia is as vulnerable as my elderly mother with diabetes mellitus. In between are younger adults within their 30s and 40s, who for lack of a routine medical exam, have no idea that they carry covert diabetes, hypertension, cancer, heart disease, kidney disease all of which can become complicated by COVID-19. Israel had a model whereby school-going grandchildren were prevented from visiting their elderly grandparents, the UK cautioned against unnecessary visits to elderly homes. Within, the situation is different, while many orderlies reside in rural settings, there are those grandparents who raise and educate their grandchildren. Then, in a sense of routine medical exams and emerging NCDs, many middle-aged adults have no idea of their underlying comorbidities. Is it feasible to come up with strategies to shield the elderly and vulnerable amidst this ambiguous spectrum or should we play “Russian Roulette” (let the dice decide who dies and survives)? Is it ethical, legal and socially acceptable for the young and more healthy to claim a right to their livelihoods even when it puts the lives of their elderly parents and vulnerable siblings, parents and others at risk? As I said, answers to this question can help us rationally determine if the measures earlier implemented were worth it or not?

Lessons for global health security

Is this the end or this is just a drill? Amidst the widespread travel, globalization, encroachment on remote ecosystems by humanity and of course, the potential of some pathogens (viruses) to rapidly mutate, we can expect more outbreaks of either existing bugs, or new ones we have never detected in humans before. Are we ready to respond better? Perhaps…. given the moratorium toward rapid development and deployment of new biomedical interventions inspired by novel technology platforms and testing milestones, even when the same has not yielded the much-needed therapeutics to render life livable amidst COVID-19 on time. What of socio-economically, do we have a plan B, and perhaps C to deal with the negative impacts of a similar or worse global pandemic?

In conclusion, humanity might need to review its COVID-19 response so far in light of emerging evidence, rethink its ideals of what the concept of public health means, and devise more innovative (technological, social and humanities) and sustainable strategies for tackling future pandemics. This is the better part of the way forward rather than opting for a simple way out, seeming shortsighted, resigned or incapable of navigating the complexities that COVID-19 and other future pandemics, present us. It is said that it was at the time when humans began to let down their guard during the 1918 Influenza pandemic, that the worst of the mortality accrued. Do we risk a repeat of these events or it is merely being too cautious?

The writer is with the College of Health Sciences, Makerere University