The Challenge will be to Distribute a Vaccine to the Entire Population

Dr. Roberto Bertollini is Advisor to the Minister of Public Health of Qatar. He is an MD and public health expert who has worked for more than 30 years in the field. Bertollini has held senior positions in the Italian National Health Service and the World Health Organization (WHO), where he worked for 25 years. His entire career has been devoted to the improvement of public health in areas such as chronic diseases, maternal and child health, and in the relationship between environment and health.
 

Dr. Bertollini, have in your opinion policymakers and scientists worked together successfully on the COVID-19 pandemic?

Roberto Bertollini: In some cases, politicians and policymakers paid close attention to what the scientific community was saying; in other countries there was a systematic attempt to deny scientific evidence. Italy, Germany and New Zealand made scientific evidence the basis for their policies, which resulted in better control of the epidemic although at a high economic and social price.

And then there were U.S. President Donald Trump, the Brazilian president Jair Bolsonaro, and even U.K. Prime Minister Boris Johnson, as well as others, who refused to accept scientific opinion. When the facts became overwhelming they needed a scapegoat and blamed WHO and the scientific community. They also supported drugs and actions not justified by scientific evidence such as the use of hydroxychloroquine for treatment and even as a prophylaxis for COVID-19 infections.

We need to stress that medical science is an evolving discipline, and particularly when dealing with a new disease initial assessments can change with the accumulation of knowledge. For instance, in an early report of WHO on the first epidemic in Wuhan, China, published in February 2020, the role of asymptomatic or pre-symptomatic subjects was considered minimum, while it is now found crucial to explain the rapid spread of the epidemic.  

We all know that political decisions have to be taken on the basis of a number of considerations, some of which go beyond just science. However, when science is rejected, politicians should take responsibility in front of their constituencies and justify their choices without looking for scapegoats.
 

Why was there so much confusion about the crisis, especially at the beginning?

RB: In my view, especially at the very start of the crisis, media played a very negative role. They really fuelled anxiety and prompted irrational reactions. This was particularly true for social media. Politicians and citizens were heavily influenced by the media’s images and confusing claims.

Take for example the early and frankly surreal discussion over serological tests, which detect the presence of antibodies to COVID-19 in blood. At the moment we have perhaps a handful of serological tests that can be used reliably but with problems related to their interpretation. Early in the epidemic, the Italian and English media, for example, and then ordinary people were pushing governments to buy on-the-market, unvalidated serological tests and start testing campaigns. Some called for “immunity passports,” which is simply impossible. Immunity following this disease is not fully understood yet because we do not know the duration of the immunity.
 

Did you expect something like the COVID-19 pandemic happening in your lifetime?

RB: When working at WHO I was involved in epidemic preparedness and response. Indeed, I was at WHO during the SARS, H1N1 [swine flu], and the Ebola epidemics. All of us were expecting a serious pandemic to happen sooner or later but I wasn’t expecting something so widespread and with such destruction of the global economy.
 

WHO has faced severe criticism of its initial reaction to the virus. How do you assess its performance?

RB: Considering the circumstances, WHO’s response was quite good. I was in Geneva in early February and all of the relevant information at that time was disclosed. What was known was made available for member states. The director general, Dr. Tedros Adhanom Ghebreyesus, repeated many times that there was a window of opportunity for countries to prepare their health systems. China perhaps at the beginning of the crisis was not giving all the information it had, and this might have delayed the response, maybe by one or two weeks.  This said, WHO never proposed to halt aviation to and from China early in the pandemic. This was probably the biggest mistake.
 

How could WHO do a better job?

RB: Humanity faces health problems related to global causes, conditions and exposures. We need global responses. You need an international institution like WHO that guides responses, evaluates the science, proposes standards, provides guidelines to policy-makers, and supports the implementation of such policies. The latter though remains the responsibilities of individual countries.

It is extremely important that WHO makes its assessments and delivers its recommendations and policies in a way completely independent from member states’ singular interests and other interference. The main problem is WHO’s very limited funding. The budget at the moment is three billion dollars a year, less than a medium-sized U.S. American hospital. There’s a staff of more than 6,000. Twenty to 25 percent of the budget comes from direct, obligatory contributions from member states on the basis of their GDP. The amount of this funding has not changed for years. The rest of the financial resources come from voluntary donations, both from rich countries and big institutions like the Bill & Melinda Gates Foundation, Rotary International and others.

If you have three-quarters of your budget coming from private contributors, one way or another you need to listen to these people. Even if these countries or donors don’t ask for anything specific, institutions are likely to listen to them, to meet their expectations and perhaps be influenced by their strategic approach to problems. If the world wants a new WHO, countries, who are the ultimate “owner” of the organization, have to completely transform financial support to the organization. Countries have to increase their yearly fees and cover a much higher proportion of the budget. Voluntary donations can be solicited for specific issues but not be the largest proportion of WHO’s financial means.
 

Why was Italy hit so hard and what you think about Italy’s handling of the pandemic?

RB: Italy should have been much faster from the beginning. Incoming direct flights from China were blocked but not those through other locations, such as Frankfurt or Paris. I must say though that Italy was the first country to face such a huge surge of cases: it has a very old population, about 23 percent is older than 65, and particularly in the north many are in nursing homes. Age is the greatest risk factor for mortality due to COVID-19 and nursing homes facilitate the spread of the disease. The country eventually acted with a lot of energy and courage in the face of a very big challenge. It did what was necessary.
 

Sweden is an interesting case because it tackled the epidemic differently than in most other European countries. It’s faced a lot of criticism, too, as there have been more deaths there than elsewhere in the Nordic region.

RB: Only once the pandemic is over and the dust has settled will we know which countries were the wisest. I suspect that we will see that the course of the disease in general terms will not be too much different from an influenza pandemic in terms of the number of deaths. What we are missing now is an accurate evaluation of the denominator, meaning how many people have actually been affected. The Swedish assume that there is a large proportion of people who are asymptomatic or exhibit very mild symptoms, particularly among the younger people.

Sweden circumvented the economic, social and health consequences of a full-scale, prolonged lockdown. But Sweden did not leave everything open; it invited people to do social distancing and focused on protecting vulnerable groups. Sweden thought a controlled spread of the disease would accelerate herd immunity. Indeed, a strict lockdown may not be the best recipe. If you strain the economy to much, it will produce other problems in the future, such as widespread poverty, which is one of the main determinants of deaths and disease. However, a more balanced approach that prevents the collapse of the health system and at the same time protects the economy still needs to be found.

I suggest suspending judgement on the Swedish experience for now and waiting to see how things pan out in the long term.
 

What countries have handled the crisis the best so far?

RB: I think New Zealand did a great job. It has a fantastic leader, Jacinda Ardern, the prime minister, who took the right decisions at the right time. She is an incredible lady and together with Angela Merkel one of the best leaders in the world. She saw the problem coming since the disease arrived later to New Zealand. She was thus able to implement an early lockdown that prevented the spread of the disease and that allowed the country to reopen more quickly than other countries.
 

Qatar is a very special case. The number of infections for the overall population is high, but it has one of the lowest mortality rates in the world. Why?

RB: In Qatar, the most important factor to explain the course of the epidemic is age. The population is very young. Only about 30,000 people are over 65 years old and the country has a very good health system. The most severe cases of COVID-19 with respiratory difficulties were hospitalized very quickly and were often taken to the intensive care unit very early in the course of the disease. Moreover, the country did very extensive testing, about 10 percent of the population has been tested so far. This allowed Qatar to have a fairer representation of the distribution of the disease in the population, and isolate a large number of people with mild disease or no symptoms who would otherwise have gone undetected.
 

What upcoming challenges do you see and how do you advise countries to react? In Germany many people fear a second wave.

RB: I am relatively optimistic. Nobody really knows what will happen next, even though it is very likely there will be a second wave. In general, the immunity that has been acquired in recent months by people who were affected by the disease will be there for at least a few months. The second wave may come with the cold weather, but it is possible that fewer people will be infected since part of the population will be, at least partially, immune.

A second aspect is medical knowledge: COVID-19 is not a new disease anymore. We know how we can manage the most severe cases, although not always successfully, and this can limit the most severe complications and mortality.

Thirdly, we should be able to promptly identify clusters and use contact tracing earlier and in a much more effective way. I expect surveillance and monitoring to be faster and more efficient. This means that we may be able to isolate areas or small communities and stop the disease from spreading. Of course, we’ll need to re-introduce certain restrictive measures in society to ensure social and physical distancing, but perhaps in a more targeted fashion and for limited periods. All of this will be necessary until we have a vaccine or a very effective therapy for severe cases.
 

But are you confident that there’ll be a vaccine at the latest by next year?

RB: Eventually we will have one or perhaps more than one. I do not think this will happen earlier than the summer of 2021, and perhaps later. The real challenge will be to produce and distribute a vaccine to the entire world population. The vaccine will have to be considered a common good and, although the cost of its development and a decent profit should be granted to the developer, it should be produced by many factories around the world and made available at a cost affordable to all communities.
 

Lastly, do you think that this pandemic will change something long term in our world, for better or for worse?

RB: I am not sure about the world, but I can say what it has taught me. The pandemic stressed the importance of solidarity among countries and among people, the importance of speaking to the facts, and the importance of taking decisions on the spot, even when there isn’t full certainty. It has shown that we are all part of the same family: a problem arising in China can touch me and everyone in matter of days and this means that we need to work together to protect everyone.

In addition, I hope that in the future there will be more confidence in science. I can already see that in Italy people listen more to scientific opinions than before. This is a good initial signal because there was recently a time when science was considered a useless activity. But it is a very fragile achievement that can be reversed very quickly by fake news campaigns and political populists.

In this vein, I hope that science will be listened to not only when dealing with health or infections but on all of the big challenges facing the world, such as climate change. This is a long-term, very big challenge that people continue to underestimate.