ML: We not only create these miracle vaccines, but the way we've distributed them creates the pressure and the opportunity for the virus to learn how to get around the vaccine before the vaccines can wipe out the virus.
RH: Yes, but the thing I want to be careful not to do is draw a causal link between vaccine inequity and the new variant—I mean, the origins of a new virus variant. It's like rolling the dice a bunch of times. It’s random, but you create conditions that create probabilities. And the conditions we've created would be the ones that would stack the deck toward new mutations emerging.
ML: If I make you God at the beginning of this pandemic, how do you distribute the vaccine to minimize the likelihood that some mutation doesn't end-run the vaccine?
RH: Theoretically, the best answer is to prevent the pandemic altogether. Once you're in a pandemic, the deck is stacked against you. The next answer is you want vaccine manufacturing everywhere, and you want to reduce that period of scarcity to the shortest possible period, and you vaccinate the world in two months, not in two years. But even before that, if I'm really God, what I want to do is this: New scary virus pops up and it's picked up by surveillance and it's sequenced and the world goes, “Oh, my God, we’ve got a scary virus,” and we clamp down in the area where the virus has emerged with non-pharmaceutical interventions to reduce transmission and spread while we rapidly develop a vaccine.
ML: And everybody knows it's only going to be 100 days, so they live with it for 100 days to avoid a pandemic.
RH: Yeah. Live with a severe clampdown in the first areas of transmission and then saturate those areas with vaccine as soon as you've got vaccines and prevent a potential pandemic from becoming a true pandemic. That’s the answer. What we were proposing to do originally was to try to share vaccines globally to protect the most vulnerable. You would have had rates of vaccination globally of approximately 20% to 30%. Everybody would have come up to that floor and protected their vulnerable and reduced deaths and reduced the pressure on health-care systems. But that approach to vaccination would still have produced pressures on the virus.
ML: If you're thinking about strategies of distribution, you can have different goals. One strategy is to minimize death. Another strategy is to minimize transmission, in which case you might vaccinate the population most likely to give Covid to people. And that might be healthy 30-year-olds.
RH: The challenge with a transmission-targeted vaccination strategy is that if you've got a virus that is differentially killing different parts of the population. It’s pretty hard—if you've got a scarce supply of vaccines—not to protect the person who's at risk of dying. You’re trapped, as long as things are driven by scarcity. The long-term solution is to create the conditions that let you eliminate scarcity as quickly as possible. Fortunately, with Covid, the period of scarcity of vaccine has basically come to the end. The supply of vaccine has ceased to be the rate limiter.
ML: So we no longer have a supply problem?
RH: Let me put it this way. The rate-limiting factor of getting people vaccinated is the ability of countries to receive and distribute and dispense the vaccine rather than the supply.