When Hilda Bastian and I first caught up over Skype to talk about Covid-19 vaccines last autumn, she showed me the boxes and unfinished rooms in her new home in Victoria, Australia. She’d been so busy tracking the global vaccine effort, she hadn’t had time to settle in.
Bastian — an expert in analyzing clinical trial data, founding member of the Cochrane Collaboration, and a former National Institutes of Health official — has gone down rabbit holes before. There was the time she traveled the US on her own dime to research and take historical photos for a Wikipedia list of African American mathematicians.
But her obsession with vaccines in this pandemic has been especially fruitful: She’s called the race right at just about every turn.
Last July, she warned that side effects for some Covid-19 vaccines may be more severe than we’re used to with other shots. At the time, she says, “I copped flak for it.” Also last July, when the AstraZeneca/Oxford vaccine was the focal point of media coverage, she praised the rigor of clinical trials for the Pfizer/BioNTech vaccine — the first to receive emergency authorization use in the US — and said it was the one to watch.
On the AstraZeneca/Oxford vaccine, she was among the first to spot the inconsistencies and issues with the clinical trials back in June. She also supported emergency use authorization for Covid-19 vaccines last August, when it was still controversial to do so.
With all her foresight, Bastian has become something of a Zeynep Tufekci on pandemic vaccines. Like the prescient computer programmer turned sociologist, Bastian — who does this work independently and without pay — has seen the state of play more clearly than many others. Her blogs, articles, and Twitter account might also be the most comprehensive look at just about everything published on Covid-19 vaccines anywhere.
The Covid-19 vaccine project was born out of concern for her sons, one of whom is immunocompromised and at higher risk of coronavirus complications. “I wanted to do something useful, and I decided early on I thought that it was likely there would be vaccines,” Bastian told me recently.
But another motivation was frustration: The myopic focus in Western media on Europe’s and America’s vaccine development and rollout missed what was happening in most of the world — in countries like China, Russia, and Cuba, Bastian said. And so much of the coverage was “uncritical of vaccine developers’ marketing hype. … You couldn’t get an accurate perspective of what was going on, without putting a ton of time into it.”
Nearly a year into monitoring the vaccine race, I caught up with Bastian to ask where our blind spots are now and how she predicts the vaccine story — and the pandemic — will unfold. She talked about the need for health officials to acknowledge that coronavirus vaccines have potentially “big differences in efficacy and adverse events,” a time in the future when we may need Covid-19 vaccine boosters every year, and the problem of people in rich countries like the US shamelessly hogging vaccines. The transcript of our conversation has been edited for length and clarity.
Early in the pandemic, you pointed out how multiple rich countries, especially in the West, were getting their pandemic responses wrong. They were not learning from our Asian-Pacific neighbors, especially when anti-virus measures didn’t fit our preconceived notions. One example is the great mask debate of 2020. What do you think was driving that inability to learn from the experience of Asian-Pacific countries?
Somebody said that people in many rich countries have got used to thinking that they’ve conquered all infectious disease, and so there’s this hubris about that, and I think that we found that hubris was more profound than we realized. We felt far too safe, and there was really quite a great degree of arrogance in there.
I [also] started to think, “This is just racism,” an old colonialist-thinking legacy, discounting Asian science and experience, and that’s a large part of what this whole theme is. Just that assumption that you are Americans or Europeans and know best over and over again. If this pandemic has taught us anything, it should be not to think that anymore, and, yet, people keep doing it.
Where do you see that playing out now — the discounting of non-Western or lower-income countries and overestimating the wealthier, Western ones?
It’s happening with vaccines, especially thinking it’s all about the vaccines of a few big EuroAmerican multinationals galloping to the world’s rescue. One of the most fascinating stories is Cuba. I mean, there’s this really interesting juxtaposition between Cuba and Canada, ironically. In Canada [where the vaccine rollout has been slow] there’s a debate about why did they let their capacity to produce vaccines dwindle away to next to nothing.
Cuba had the exact opposite. Cuba had to become self-sufficient at pretty well everything, and that included producing drugs and producing medical teams. Cuba now exports a lot of medical care to poorer countries. The first two of their vaccines are looking really quite good. The first one’s just about to start its big phase 3 trial, and they’ve got three others coming up behind.
They’re going to have a massive amount more vaccine than they need. They’re not going to have any trouble vaccinating their population with home-grown vaccines in 2021. That just does not look remotely like it’s going to be a problem, and, then, they’re just going to be exporting masses and masses of vaccine.
One vaccine group that there was a ton of hype around — and that has under-delivered — is Oxford/AstraZeneca. It was supposed to be the vaccine that saved poor countries, but now there are manufacturing problems, and questions about the quality of their clinical trial data, including whether the vaccine even works in the highest-risk groups, like people over 65. You were, I think, first to point out the troubling signs in their clinical trials, back in June, and then followed the story in detail. Where do you think that vaccine is going?
I wouldn’t be surprised if the situation got worse, though I hope it will get better. [They went] about their clinical trial program in such a problematic way. [They] overlapped the early phases of their trials too much. They didn’t do early phase tests in older people as a result, leaving us struggling now with the results in a way we don’t have to with other EuroAmerican vaccines.
The publicly available details about the trial kept changing while it was in progress — and didn’t even say clearly what the dose was, for example.
The really big question about that is why on earth did the Medicines and Healthcare products Regulatory Agency [the UK’s health regulator] greenlight these plans? Maybe people ceased to be critical enough, and they went over a bit of a cliff.
Whether it turns out to be a good vaccine or not, let’s leave that to one side. The clinical trials were, the European Medicines Agency [Europe’s drug regulator] concluded, sub-optimal. That shouldn’t happen. We’re lucky the [Food and Drug Administration] insisted on a large trial. We’ll hear the results soon.
We already saw South Africa halt distribution of the Oxford/AstraZeneca vaccine because of preliminary data suggesting it didn’t work as well against the variant that emerged there. If the vaccine doesn’t end up being widely distributed in low and middle-income countries, do you think that gap will be filled maybe by the Russian and Chinese vaccines?
[The Oxford/AstraZeneca vaccine] is already being widely distributed. But China may already have supplied as much as 1 in 5 of the vaccines administered globally. And China and Russia are the ones who are there first with batches of vaccine in a lot of countries.
The role that people were ascribing to AstraZeneca, I thought always was going to be Johnson & Johnson because [they’re] a huge vaccine company. AstraZeneca is not really a vaccine company. The Johnson & Johnson vaccine is a single dose. They were also doing trials that were seriously geared at international needs. They ran the biggest trial in the most countries, and that matters a lot to people from different ethnic groups.
Even though the actual doses are a bit more expensive [for Johnson & Johnson’s vaccine], the cost of actually vaccinating people is enormously lower if you’ve only got to vaccinate everybody once. And Johnson & Johnson also committed to affordable, nonprofit vaccine for the emergency. It’s going to depend a lot on how many doses actually get delivered in the end, and what happens with variants. Now it seems likely Novavax may be as big a supplier as well — possibly more than half of the WHO-provided supply.
Another vaccine you put a lot of stock in from the start was the one developed by Pfizer/BioNTech — one that got relatively little attention in the US until the big finding of 95 percent efficacy last autumn. Why were you so impressed so early on?
That was because BioNTech was doing such thorough work early on — they were developing several versions, and testing them against each other in early trials. They didn’t have all their eggs in one basket. Then there was the partnership with Pfizer, which was going to give them an important edge in running a massive clinical trial in a pandemic. You had to have both those things — a good vaccine, and a good major trial.
Which vaccine group is the next Pfizer/BioNTech?
Novavax is an important one to watch, if the results continue to be as good as their first ones, which were similar to the mRNA vaccines. It’s a more traditional form of vaccine, so there’s more capacity to manufacture it.
There are others that could be important globally, like one from Thailand that will be cheap and both profit- and royalty-free for lower-income countries, and another that UNICEF is supporting that’s also aiming at preventing infection.
Can we talk a little more about the Russian vaccine, Sputnik V: The data published in The Lancet looked quite impressive taken at face value — but you weren’t convinced. Can you tell me why?
There wasn’t the kind of data about possible adverse reactions that have become the scientific standard, for example. Trial participants get asked to record a list of specific possible reactions in the first week — things like fever, fatigue, headaches. We know if you don’t do that systematically, you’ll end up with an underestimate and a too-rosy picture of a vaccine. Because they didn’t seem to do that, we’ll stay pretty much in the dark on how tolerable this vaccine is for a while. And there’s a lot that’s not transparent about this trial, because they played it close to the vest with critical details, like the protocol [or pre-established plan] of the trial.
When we saw the report, we could see the age spread, and it was a pretty young group — about 90 percent were under 60, so that’s not where the greatest burden of suffering from this disease is. It was done in Moscow, so there’s little diversity — 99 percent of the participants were white, so that was stark, too. There are going to be more trials outside Russia, and that’s going to help get data we can more easily compare to other vaccines.
So I guess it’s pretty fair to say at this point: The vaccine rollout is shaping up to be quite different from what many of us expected.
Yeah, we never really grappled with what we’ve got, which is, although some people don’t seem to want to face it head-on, vaccines with potentially big differences in efficacy and adverse events. So, what are the priorities, then, for the better vaccines versus the vaccines that have less protection and so on? The situation turned out to be far more complex than the experts prepared us for, I think. Communities have a lot of very tough calls to make, under very different levels of urgency.
Most of the trials haven’t had enough severely ill people to give us a clear picture on how much the vaccines will prevent severe disease, and the differences there might not be as big as other differences. If you’re in a community that’s very vulnerable to major outbreaks, with a limited supply of vaccines, the differences between them are small compared to the risks to ourselves and our communities of being unvaccinated.
Doesn’t this raise questions about health officials who are telling the public all vaccines are equal?
Trying to convince people that the vaccines are all equal isn’t going to work. People are making claims that go beyond the solid data we have, and that’s a risky proposition. We’re going to see the differences in rates of adverse events, for example, pretty quickly for ourselves once we know lots of people getting vaccinated.
Especially when the fear of major outbreaks subsides — prematurely — and we’re trying to get younger people to accept vaccination, adverse reactions are going to matter to people.
“The story of the pandemic”
Moving forward, what’s the big vaccine issue you’re going to be tracking?
It’s still early days for clinical trials, so I’ll be tracking those and new boosters against variants, as well as what happens in vaccinated communities. [I’m] also watching how the rich countries are cornering vaccines, and those advancing their geopolitics to fill in the gaps — it’s actually quite a horrifying thing.
Very rarely do you see people from one of the rich countries expressing concern that their country may be fully vaccinated within a few months. I’m not utopian and that idealistic about it. It was never 100 percent going to happen that way [that the high priority groups in rich and poor countries got vaccinated at the same levels at the same time, per WHO advice], but I hoped at least for something roughly close, and I’m really quite shocked how comfortable people are with what’s happening.
Some are promoting personal donations to WHO now for vaccines, which just underscores the lack of awareness that the problem is rich countries taking all the doses for ourselves. You can’t buy what’s already gone from the shelves. There are severe limits to what can be produced this year. Even with recent promises of more money for WHO from rich countries, 2021 looks pretty grim.
In a way, for me, that’s the story of the pandemic. We had too many people more concerned about their individual rights or about wearing masks or flying for a vacation, or complaining about the restrictions that they faced, than the consequences of those actions for people more vulnerable than themselves. Now, it’s playing out [with] vaccines, too.
From a health perspective, why is hoarding so concerning?
We need to reduce the chances of the virus morphing into more dangerous variants — vaccines might not protect communities enough from new variants sweeping through. And many of the rich countries will have trouble getting enough people vaccinated anyway. The notion that there can be countries where there’s going to be 40-year-olds and 30-year-olds vaccinated while there are terrible outbreaks in other parts of the world, and even the health care practitioners are unprotected, isn’t okay on any level.
Even rich countries, though, are having manufacturing and supply issues — like Canada, as you mentioned. Will the world be able to maintain a sustained production capacity for vaccines, or will it see spikes and drops for the next while?
It could settle down, particularly if some of the more traditional forms of vaccine, like the one from Novavax, make it into use and are popular and effective. Vaccines that can tap into more of the existing widespread technical capacity should help. And I guess there’ll be more movement from the big companies that don’t yet have a vaccine of their own.
How does this end?
Okay, so now we have multiple effective vaccines on the market, and more coming online soon. But we also have this emerging variant problem and questions about how to use the vaccines we’ve got. Do we know how this pandemic ends?
No, I don’t think we [do]. I don’t think there’s been a pandemic quite like this because they were either that the thing went through and did its worst and left horrific death in its wake, or the smaller ones in more contained areas that are recent.
But this thing on this scale, while there’s this level of antibody-based treatments out there, and vaccines of different efficacy, and all of this stuff that could play in the favor of variants, this situation has never existed before.
I don’t think that the past tells us where this is going. [But] I believe the people who are saying that we appear to be on a course to eventually get to the point where we get vaccinated against this each year. The path to global eradication — through very high levels of vaccination with a high level of other suppression efforts — seems narrow. That could change, though, and I hope it does.
Do you have any predictions for long-lasting effects of the pandemic, how it changes society?
For me, one of the things that is a really huge unknown is what happens with long Covid. When I lived in Germany, I was trying to understand why issues for people with disabilities were so much better in Germany than any place I’d ever spent time in, and on a scale that was really quite extraordinary.
Then, I started to read about the history of the disability movement after World War I, that you had such a huge proportion of young men with major disabilities, whether it was sight, limbs missing — and to have such a massive proportion of your population suddenly with disabilities, changed societies. It happened again after World War II. So, I’m thinking about that again, now.
To some extent, it’s going to depend on how disabling long Covid turns out to be, and for how many people? Are we looking at a really serious big wave of decades-long disability? Because if we are, that is a really profound, sudden change in societies.