COVAX - Time to reconsider the strategy and its target.

COVAX, the international initiative supporting COVID-19 vaccination campaigns globally, is budgeted to be the costliest public health initiative in low- and middle-income countries, with over 16 billion US dollars already committed. While some claim that the target of vaccinating 70% of people worldwide is justified on equity grounds, we argue that this rationale is wrong for two reasons. First, mass COVID-19 vaccination campaigns do not meet standard public health requirements for clear expected benefit, based on costs, disease burden and intervention effectiveness. Second, it constitutes a diversion of resources from more cost-effective and impactful public health programmes, thus reducing health equity. We conclude that the COVAX initiative warrants urgent review.

The danger of the single storyline obfuscating the complexities of managing SARS-CoV-2/COVID-19.

Chimamanda Ngozi Adichie showed how a single story is limited and thereby distorts the true nature of an issue. During this COVID-19 pandemic there have been, at least, three consecutive single stories-the 'lethal threat' story, followed by the 'economic threat' story, and finally the 'vaccine miracle' story. None of these single stories can convincingly and permanently capture the dynamics of the pandemic. This is because countries experienced different morbidity and mortality patterns, different socioeconomic disadvantage, age and vulnerability of population, timing and level of lockdown with economic variability, and, despite heavy promotion, vaccines were beset with a significant and variable degree of hesitancy. Lack of transparency, coherence and consistency of pandemic management-arising from holding on to single storylines-showed the global deficiency of public health policy and planning, an underfunding of (public) health and social services, and a growing distrust in governments' ability to manage crises effectively. Indeed, the global management has increased already large inequities, and little has been learnt to address the growing crises of more infectious and potentially more lethal virus mutations. Holding onto single stories prevents the necessary learnings to understand and manage the complexities of 'wicked' problems, whereas listening to the many stories provides insights and pathways to do so effectively as well as efficiently.

COVID-19: an 'extraterrestrial' disease?

BACKGROUND: Since the beginning of the pandemic, COVID-19 has been regarded as an exceptional disease. Control measures have exclusively focused on 'the virus', while failing to account for other biological and social factors that determine severe forms of the disease. AIM: We argue that although COVID-19 was initially considered a new challenge, justifying extraordinary response measures, this situation has changed - and so should our response. MAIN ARGUMENTS: We now know that COVID-19 shares many features of common infectious respiratory diseases, and can now ascertain that SARS-CoV-2 has not suddenly presented new problems. Instead, it has exposed and exacerbated existing problems in health systems and the underlying health of the population. COVID-19 is evidently not an 'extraterrestrial' disease. It is a complex zoonotic disease, and it needs to be managed as such, following long-proven principles of medicine and public health. CONCLUSION: A complex disease cannot be solved through a simple, magic-bullet cure or vaccine. The heterogeneity of population profiles susceptible to developing a severe form of COVID-19 suggests the need to adopt varying, targeted measures that are able to address risk profiles in an appropriate way. The critical role of comorbidities in disease severity calls for short-term, virus-targeted interventions to be complemented with medium-term policies aimed at reducing the burden of comorbidities, as well as mitigating the risk of transition from infection to disease. Strategies required include upstream prevention, early treatment, and consolidation of the health system.

The COVID-19 pandemic: diverse contexts; different epidemics-how and why?

It is very exceptional that a new disease becomes a true pandemic. Since its emergence in Wuhan, China, in late 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, has spread to nearly all countries of the world in only a few months. However, in different countries, the COVID-19 epidemic takes variable shapes and forms in how it affects communities. Until now, the insights gained on COVID-19 have been largely dominated by the COVID-19 epidemics and the lockdowns in China, Europe and the USA. But this variety of global trajectories is little described, analysed or understood. In only a few months, an enormous amount of scientific evidence on SARS-CoV-2 and COVID-19 has been uncovered (knowns). But important knowledge gaps remain (unknowns). Learning from the variety of ways the COVID-19 epidemic is unfolding across the globe can potentially contribute to solving the COVID-19 puzzle. This paper tries to make sense of this variability-by exploring the important role that context plays in these different COVID-19 epidemics; by comparing COVID-19 epidemics with other respiratory diseases, including other coronaviruses that circulate continuously; and by highlighting the critical unknowns and uncertainties that remain. These unknowns and uncertainties require a deeper understanding of the variable trajectories of COVID-19. Unravelling them will be important for discerning potential future scenarios, such as the first wave in virgin territories still untouched by COVID-19 and for future waves elsewhere.