I have been keeping an eye on virus and vaccine developments in the UK, the USA where we have many friends, and Mexico, where our eldest son lives, and where we likewise have many friends. Politics, the structure of health systems and socio-economic factors have all influenced how the pandemic has affected each country.
Cases, deaths and vaccine doses per 100,000 people, and some other relevant health statistics were as follows:
|
Country |
Cases per 100,000 |
Deaths per 100,000 |
Doctors per 100,000 |
Hospital beds per 100,000 |
Total vaccine doses given |
Vaccine doses per 100,000 |
|
USA |
7,927 |
133 |
260 |
290 |
27,888,000 |
8,420 |
|
UK |
5,596 |
158 |
280 |
250 |
8,370,000 |
12,330 |
|
Mexico |
1,444 |
123 |
240 |
100 |
657,842 |
510 |
Sources: cases and deaths, Washington Post as of 29 January; doctors and hospital beds, World Bank (Mexico’s figures for doctors are for 2017; UK 2018; USA 2017. Figures for hospital beds are: Mexico 2018; UK 2019; USA 2017); vaccine doses Our World in Data as of 28 January for Mexico and UK, 29 January for USA
It should be noted that the figures for cases and deaths Mexico are most certainly a considerable underestimate. As of 24 January Mexico reported almost 150,000 deaths. A well-informed friend estimates that the real figure is closer to 250,000. Only five countries have higher case figures adjusted for population than USA: Andorra, Montenegro, Czech Republic, Luxembourg, Slovenia. Only two countries have reported higher death rates than the UK: Belgium and Slovenia.
The lesson of the statistics is simple. If deaths in Mexico really are 250,000, then the real rate per 100,000 is more like 195, much higher than UK and USA. And although we have watched horrified as the number of deaths in USA exceeded 400,000, the rate of deaths in the UK is worse.
USA: political priorities and a fragmented health system
A friend in New Jersey, a public health nurse who was transferred from her normal duties to be a vaccinator, gave me a very personal report on 16 January of her experience of vaccination in her county. The vaccine in question was the Moderna. The following is a lightly edited version of her account:
“The CDC put forth recommendations about who should get the vaccine first, and the categories started with frontline workers who are exposed to infectious material, emergency workers…then people over 75, people under 75 with chronic conditions, SMOKERS, ….until you eventually reach “everyone else.” Each state was able to form their own guidelines — New Jersey is very strict as is New York.
I got my vaccine three weeks ago, as I made it a condition of continuing work at the Health Department and being used as a vaccinator. I’m working probably 4 days a week, all day long (on my feet without a break— something I’d forgotten about. We — meaning the County Public Health Nurses, of which there are few as the pay is bad and many left when the pandemic started —work in a temporary Army Corps of Engineers hospital built for the surge last spring, and vaccinate patients allowed into the building in bunches of 10. Each of us can see a patient every 3-4 minutes, working as fast as we can, with a ton of support in terms of security, registration, education, etc. Each nurse works with five support workers. Keeping everyone socially distanced is a concern, and glitchy software is also a concern so it doesn’t go as smoothly as you always want it to. Which is code for I listen to a lot of complaints. But on the other hand, some people are actually giddy they feel so lucky to have been called up.
The problem is there is no real central administration. As a person who wants a vaccine, you can register on the county list (over 37,000 people and we’re lucky if we can see 400 a day), a hospital web site, a pharmacy website, the state website, your local health department website, ask your doctor if he has the vaccine — honestly it’s the real Wild Wild West here in terms of getting a vaccine. Although I have my husband and his 91 year old father with multiple risk factors on every list I can think of, so far all I get is an e-mail back that “we are out of vaccine” or “we will send you an e-mail when your group opens up” which it already has, but oh well. At our site we order 1,000 doses and are lucky if we get 400. And now people are starting to line up for the second dose which the Trump government had said they were holding in reserve and now say they weren’t.”
An update on 26 January reports that my friend’s centres has featured in the news as a great success, administering about 500 shots a day between 09:00-14:30. The biggest problem is getting an appointment, especially for older people with no smartphone or internet. A person who is eligible to be vaccinated has to scan a code for dates which is supposed to be available only those eligible and when an appointment is available. However, codes have been posted on Facebook, shared at church or among teachers. People who are entitled to be registered remain at the end of the queue, while others who are not eligible take their place.
Two other problems are the lack of vaccinators and the supply of vaccines. The county announced a vaccine “mega site” to deliver thousands of doses per day. The opening was delayed for a week because insufficient staff could be found. Then it opened and closed after two days for lack of vaccine. Similarly, a vaccination centre at the Meadowlands racetrack in northern Jersey, and another in the south of the state, had all their appointments booked, but closed because the vaccine ran out. New Jersey (population 8,882,000) was allocated 500,000 doses by the federal government. The governor says that to vaccinate 70% of the population the state needs 4.7 million shots.
My friend’s account touches on a number of reasons for the USA’s relatively poor management of the pandemic, despite its wealth of medical/scientific expertise and economic resources. The country’s response has been handicapped by a fragmented health system, ill-designed to handle a nationwide logistical challenge. The result is, as my friend points outs, a system of everyman/woman for him/herself. Public health is not well funded. The system is beset with legal requirements that translate into a substantial bureaucratic burden for such a large-scale vaccination programme.
Political decisions, or rather avoidance of decisions, have been the most important reason for the inadequate response to the disease. At the centre, the federal government prioritized the President’s political fortunes over public health. Inconvenient voices of medical and epidemiological experts were silenced or side-lined. The political strategy was to dismiss Covid-19 as a not terribly serious condition. Supporters of the president were encouraged to show their disdain for the virus and public health advice by refusing to wear a mask. Thus, protecting one’s fellow citizens by wearing face coverings was turned into a symbol of individual freedom, much like carrying high-powered firearms. Not because it benefits you or society, simply because you can and it makes you feel empowered.
The response to the pandemic was left to the states. This resulted in competition for protective equipment, ventilators etc, which increased their price since states bid against one another. A national, coordinated strategy to suppress the virus has been impossible. In Republican states, the political imperative was to show loyalty to President Trump by aping his nonchalant attitude to the virus. In Florida, a data scientist responsible for compiling Covid-19 statistics was dismissed in May 2020 for refusing to manipulate data to justify easing restrictions. The scientist was later arrested, accused of illegally accessing her state computer, an allegation she denies. In November, Governor DeSantis appointed a new data analyst to provide Covid-19 data. He selected for this post an Uber driver/sports blogger, who cheerfully acknowledged that “Fact is, I’m not an ‘expert.’ I’m not a doctor, epidemiologist, virologist or scientist. I also don’t need to be. Experts don’t have all the answers, and we’ve learned that the hard way.” This non-expert is of the opinion that masks do not inhibit the transmission of Covd-19, that hydroxychloroquine, a drug favoured by Mr Trump, is an effective treatment, that Covid-19 might be a weapon of a Chinese bio-war, and that Covid-19 is no more serious than the flu. Quite why the Chinese would launch a biological attack with an ineffective virus he does not explain.
Mexico: political priorities, an underfunded health system and extreme social/economic inequalities
In Mexico, President Andrés Manuel López Obrador (AMLO) has, like Mr Trump, dismissed or downplayed the seriousness of the virus, and has been dismissive of wearing masks and social distancing. He has continued to meet members of the public, dispensing abrazos (hugs) which he considers an indispensable feature of Mexican identity, and not wearing a mask. He has told the public that Mexico’s cultural traditions will protect them and has displayed the amulets which he carries to ward off infection. The amulets may have lost their power to protect, since it has just been announced that AMLO has contracted the virus.
The government has taken a number of steps to downplay the significance of the virus. Mexico carries out a very small number of tests for a country of almost 128 million people. Cases and deaths are certainly under-reported. Under-reporting is also the consequence of social stigma attached to contracting the virus, which causes many to avoid being tested. Doctors are encouraged to attribute deaths to other causes on death certificates.
Mexico entered the pandemic with a disadvantage in terms of hospital capacity. Mexican doctors are well-qualified and the number of physicians per capita is not substantially less than in the USA or the UK. However, hospital provision is much less. Moreover, while the private hospitals are excellent, the public hospitals and clinics are too few and poorly funded. Waits for treatment are long, medicines sometimes out of stock, and technology and treatments behind the times. One government response to the pandemic has been to encourage families to treat infected relatives at home, even to the extent of relatives administering (and paying for) oxygen at home. Reports have described desperate people queueing for hard-to-obtain cylinders of oxygen.
AMLO’s rather hands-off approach has left the state governments to manage the pandemic. The approach generally has been to apply a traffic light system (red indicating tighter restrictions, green a more relaxed regime, and amber a middling level of restrictions), according to the level of infections. As in the USA delegating strategy to the states has resulted in a very disjointed response. For example, our son lives in the small state of Nayarit, but only a few miles from the border of Jalisco, a much larger state. At times one state has applied more severe restrictions than the other, even though people regularly move from one to the other. Some restrictions have been quite radical, while others have not. Nayarit has shut its schools since last Spring, while bars and restaurants have been closed for much shorter periods, if at all. This in a state where the public school system provides only half a day of education under normal conditions. Lessons are sent to parents by Whatsapp and some lessons are aired on TV, but are often scheduled at hours unsuitable for the children’s age.
States run by governors of AMLO’s MORENA party have generally followed the President’s relaxed line. However, recently, as hospitals in Mexico City became full, and patients were turned away as infections increased, the MORENA governor has imposed a number of restrictions, such as the closure of most shops, allowing restaurants to open only for takeaway and so on.
Nevertheless, the extent of social contact and movement of people would astound residents on the UK. Internal flights now require passengers to wear masks, but are full and operating as normal, as are the thousands of buses that connect Mexico’s cities, although, again, passengers wear masks. In many areas there are elements of restriction, such as allowing only one shopper per trolley in supermarkets, but restaurants, hotels, bars, gyms and other business remain open. Many businesses take measures to encourage social distancing, sanitization of equipment and so on, but this depends on how conscientious the business is. Enforcement is minimal.
Reports from friends and our son suggest that behaviour varies considerably by social class and location. There are few if any effective restrictions on social gatherings. Our son was invited to a 15 year party for a girl who receives therapy from his charity. The gathering was held in an open air venue and numbers restricted – to 50! Reports from a town in the State of Mexico, about two hours from Mexico City, over the Christmas period, told me that most people wear a mask in the street. However, family gatherings of 20 or more people indoors with no ventilation (at that altitude December is very cold) were common. A few of those at the party might wear a mask, but most not. A senior doctor and his wife travelled from Mexico City to one party on a rancho just outside town – family ties and good food it seems exerted a stronger pull than social distancing, even in the case of a medical professional.
Here people earn their living in ways that expose them to the risk of infection or encourage transmission. One family, for example, has a son who buys goods in Tepito, a working class district of Mexico City, transports them home and then sells them on to towns where such goods are not obtainable. His parents rent part of their home to a couple that uses the space to prepare chickens for sale. In short, this family has contact with numerous people in a number of locations. If these contacts were to cease their income would disappear. They are by no means one of the poorest families: they own their home, their son owns an apartment, they have cars and eat well, provided they are earning. But self-isolation is not an option.
In early December, a friend in a smallish provincial town told me that the government’s vaccination plan was as follows:
1. Health workers
2. People aged 80 and above
3. 70-70 age group
4. 60-69 age group
5. 50-60 age group
6. 40-49 age group
7. Under 40 age group
The stages would be:
-First, December 2020-February 2021... frontline health personnel
-Second, February-April 2021... other health personnel and 60+ age group
-Third, April-May... 50-59 age group
-Fourth, May-June... 40-49 age group
-Fifth, June 2021-March 2022... rest of the population
“According to this, my wife and I would receive it sometime between February and April, so I guess we'll have to keep observing the restrictions for a good while yet.” My friend reported this month that he has little information about the progress of the vaccination programme, beyond anecdotal evidence of doctors who have, or have not, been vaccinated.
Mexico lacks the extent of the infrastructure and a national health system equivalent to the USA. It also faces particular infrastructure challenges. Mexico is large and predominantly mountainous. Many population centres are a considerable distance from places likely to have the refrigeration and other logistics required by the Pfizer vaccine. Nevertheless, the country possesses considerable logistic capacity. An article sent to me by a friend points out that Grupo Bimbo, manufactures of a low cost bread and other food products, distributes is bread in 30 countries to 1.8 million outlets. There can be few places in Mexico where you cannot buy a pack of Pan Bimbo.
The Mexican government already operates the Programa de Vacunación Universal (Universal Vaccine Programme). This programme begins with new-borns (BCG and hepatitis B). Before a child is one year old the following are available: Pentavalent (diphtheria, tetanus, whooping cough, hepatitis B and haemophilus influenza) or Hexavalent (diphtheria, tetanus, whooping cough, haemophilus influenza, hepatitis B and polio); the second and third doses of hepatitis B vaccine; a rotavirus (a stomach infection) vaccine; and two doses against influenza. At one year children are vaccinated against pneumonia, measles, mumps and rubella, and receive a top up dose of Pentavalent or Hexavalent. Further anti-bacterial and anti-viral vaccinations are given at ages four and six. Although I wonder whether this programme reaches some remote or crime-ridden parts of the country effectively, there is an existing vaccine expertise and logistics, but directed to young children. Reaching an adult population, especially, those working in the informal economy or in very remote areas, will be a different challenge.
The vaccination programme is run from the offices of the presidency in the National Palace in Mexico City. Health workers and the army manage the vaccinations. Apparently, a representative of the government’s social programmes is usually present, possibly to ensure that the government and MORENA get the credit. AMLO deserves credit for agreeing to a UN request to defer a delivery of the Pfizer vaccine so that it could be diverted to a poorer country. I doubt that our Mr Johnson would have had the moral courage to do this.
UK: the voices of scientists heard, cronyism, fluctuating decision-making, a National Health System, an effective vaccination programme … so far
On 8 January we heard from two friends who live in Reading, not far from us, that they had received the first dose of the Pfizer vaccine. Both felt fatigued for a day or two, but otherwise reported no side effects. They are a year or two older than us, which puts them in priority group 4, while we are in Group 5. Fortunately, the vaccination programme in the UK seems to be, more efficient and more rationally organized than in USA and Mexico so far.
From the start of the pandemic UK government ministers have uttered the phrase “we are guided by the science” with metronomic regularity. Scientists have been seen and heard in government press campaigns. There have been a few occasions when government scientific and medical advisers have been prevented from commenting on matters that question government actions. However, scientific information and the voices of numerous epidemiologists, virologists, vaccinologists, data modellers, statisticians, clinicians and public health specialists have been regularly and frequently heard. There has been no effort to suppress scientific opinion and advice comparable to the actions of the Trump or AMLO administrations.
However, being “guided by the science”, is in part a device to avoid criticism of faulty political decisions. For example, as the pandemic picked up speed last year, it became apparent that the national stock of protective equipment for medical staff was insufficient, and a substantial portion of it so old that it may not have been safe to use. The government responded with emergency efforts to buy large quantities of equipment. It later emerged that civil servants were instructed to give preferential access to the government programme to potential suppliers whose executives/owners were known to government ministers. In effect, a VIP channel of contracts awarded to personal contacts and political acquaintances was created. In normal circumstances, this would have been in breach of government rules. Emergency powers given to the government under pandemic legislation were used to justify this practice. However, some suppliers proved not to be qualified to fulfil their contracts to an adequate standard, and some simply failed to meet their obligations despite being paid in advance. A number of middlemen with no obvious qualifications received sizeable commissions.
The largest such decision was the issuing of contracts to create a national test, track and trace system. Now, every local government in the country has a Public Health department, with experience of tracking the spread of infections, understanding the local community, and taking effective action to limit the spread of infection. It is true that funding of these departments had been reduced substantially by successive Conservative governments, but their knowledge and expertise had survived the budget cuts. If properly funded, they could have played an important role in the early stages of the pandemic. Instead, the government awarded contracts to outsourcing companies with no experience or knowledge of public health. They were, however, familiar to government ministers because they have been awarded contracts across many functions of government, including running prisons and detention centres for immigrants, recruitment to the military (a signal failure), and, at a local level, rubbish collection for the Royal Borough of Windsor and Maidenhead where we live. Many of the executives are also familiar to Conservative ministers (e.g. one is a grandson of Winston Churchill). These companies, in turn, subcontracted the tracing of contacts of infected people to other outsourcers. Call centres staffed by people with a script but no knowledge of disease control were established. The person appointed to manage the programme is the former chief executive of a mobile phone company (who presumably knows a lot about call centres) and an important figure in the Jockey Club. And, married to a Conservative MP, and a friend of government ministers. Test and Trace has not so far succeeded in reaching the standards of performance that “the science” tells us is required. Belated efforts have been made to involve local Public Health Departments, but the enormous budget is still spent principally on paying outsourcing companies to outsource work to other outsourcing companies.
The quality, timing and decisiveness (or rather indecisiveness and sudden changes of tack) of government decisions have been open to question on a number of occasions. The opening and closing of schools, whether to hold national exams and how to mark/evaluate them or their replacement, have suffered from a particularly hapless lack of contingency planning. The minister in question has defended himself by stating the obvious, that the pandemic is unprecedented. The implication is that he cannot be held responsible for uncertainty and the unpredictable. The problem is that he has announced decisions, only to withdraw them within days, because he makes no provision for unexpected turns of events.
The National Health Service, much derided in the past by US Republicans as “socialized medicine” in which “death panels” make clinical judgements, and regularly underfunded by Conservative governments, has demonstrated the benefits of a unified national health network that supports local provision across the country. The positives have been particularly evident in the vaccination programme. We all have a general practitioner whose practice has our medical records and contact details. We do not have to go looking for a vaccination appointment as people do in New Jersey. Indeed, we cannot: we wait for an appointment to be offered. For example, our 75-year old neighbour called us excitedly Sunday 24 January to tell us that she had received a text to call her GP practice. She was given a vaccination appointment. In our area vaccinations are given in the sports complex of a large local business. Because it had snowed quite heavily that day our neighbour’s son drove her to the vaccination centre.
The vaccination programme has been the bright spot in the government’s very uncertain handling of the pandemic. The Prime Minister is reported to be indecisive by disposition, a trait which has resulted in delay and temporizing when critical decisions have been required. Undoubtedly, his best decision was the appointment of the wife of another Conservative MP as head vaccine task force was the wife. No doubt, this was an example of cronyism similar to the appointment of the head of the test and trace system. However, this crony turned out to be just the right person. She had a clear and convincing plan and led a team which executed it with great precision and decisiveness.
The structures of the health system and the extent and nature of social inequalities vary from country to country. In a pandemic these have proved critical factors for success or failure. A key question will be whether our political leaders have the vision and courage to invest in stronger health systems and to address inequalities, or whether, once the pandemic is over, health will be seen once again as a substantial cost ripe for cutting and social inequality too politically difficult.
