Dec 18, 2021 Volume 398 Number 10318 p2207-2306
COVID-19: where do we go from here?
The end of 2021 brings a sense of uncertainty. Parts of the world are approaching a transition or a new phase of the COVID-19 pandemic. The window for pursuing the elimination of SARS-CoV-2 has closed. Moving towards a so-called post-pandemic world will be far more complicated than scenarios such as “Zero COVID”. The challenge now is to determine the level of COVID-19 that is acceptable for individual nations in a fundamentally interconnected world. In the first Lancet Editorial of 2021, we noted: “Countries might justifiably start to look inward to repair the damage after COVID-19. But equitable access, whether to a vaccine, food, or finance, will require global collaboration.” This requirement has not been met. Science has provided the tools and evidence to control the COVID-19 pandemic, but the response has been shaped by political factors and a lack of cooperation, often to the detriment of health.
For all its peaks and troughs, 2021 should be heralded as the year of extraordinary COVID-19 science. 2021 began with several new vaccines showing efficacy in randomised trials. There are now 26 COVID-19 vaccines authorised by at least one national regulatory agency and another 200 candidates are in development. Novel treatments have provided further options to prevent death and disability. These achievements allowed for a new sense of hope that should have been the basis for an equitable global response, carried out with the urgency and seriousness that a devastating pandemic demands.
Massive vaccine roll-out programmes have also taken place with remarkably high participation in some countries, including Portugal (88%), Chile (86%), Cuba (83%), and Singapore (83%). Yet vaccination rates are notably lower in other countries that had early access to a COVID-19 vaccine—eg, Russia has reached only about 48% of its population as of December, 2021. Of all Americans who are eligible, only 61% are fully vaccinated. Although in vastly different contexts, those who are unvaccinated in Russia and the USA cite the same reasons: a mistrust of government, distrust of data, and few consequences for not being vaccinated.
The USA provides a potent demonstration of the structural barriers and stymied progress in COVID-19 that can originate from political obstacles to health. Socioeconomic disadvantage is a substantial contributor to vaccine hesitancy in low-income communities. Compliance with public health interventions, such as indoor masking, are often fomented by political ideologies. Lawsuits filed in federal appeal courts by Republican political action groups have thwarted vaccine mandate legislation for health-care workers and federal employees that would go into effect in 2022. A sizeable proportion of unvaccinated-by-choice Americans remain so even though they are eligible to receive a booster. Without incentives to reduce hesitancy, durable mandates for masking, and near complete vaccination, optimism dims for curtailing the next potential COVID-19 wave.
Political failures to cooperate and find solutions at the global level have shaped the pandemic too. Leaders of high-income countries have spoken of the importance of equitable access to COVID-19 vaccination, and pledged to donate doses, but have consistently been unable to deliver. Vaccine manufacturing continues to be hindered by a lack of agreement on relaxing intellectual property rules to increase and diversify capacity. The enormity of the situation has not been matched by the response. Leaders have been unable to realise that the status quo should not apply in a pandemic. As of this month, 75% of the population in high-income countries have received at least one dose of a COVID-19 vaccine compared with 46% in lower-middle-income countries, and just 7% in low-income countries. The emergence of new variants such as omicron jeopardises all.
Politically driven decisions are undermining health security. The most recent Global Health Security Index shows that risks to political stability and security have increased in nearly all countries, and those with the fewest resources have the highest risk. There is greater risk of social unrest. Most countries score low on accountability of public officials and human rights. All countries remain underprepared for the next pandemic and countries should be more transparent about their capacities and risk factors for better global preparation.
The emergence of omicron threatens new setbacks and further compounding of the harms of the pandemic. Science will no doubt continue to provide the means to respond. But doing so effectively and equitably will require greater recognition of the political determinants of health and action based on a robust global multilateral system and strong individual national leadership—which too often has been, and continues to be, lacking.