Economy & Business
The vaccine conundrum
To jab or not to jab, that is the question
By Mike Jewell
Three weeks into our Level-3 alert, with the prospect of another three weeks of quasi-lockdown, as the domestic outbreak of coronavirus rages on. There is no definite end in sight, but at least the case numbers are showing the first signs of hope, with daily cases decreasing and the number of unknown sources down to a mere handful. On the downside, the virus is creeping into areas beyond Taipei and New Taipei (Xinbei), finding its way into the migrant worker community and the plethora of traditional markets, with their poor ventilation, cramped spaces, and intensely close personal contact.
Taiwan can take pride in the way people have responded to the crisis, with the vast majority dutifully following central and local government recommendations and regulations regarding staying at home, wearing masks, and avoiding personal contact.
Our World In Data’s analysis shows we have settled into a new pattern of living in the past three weeks, spending 18% more time at home than before and largely avoiding public transport, as 25% fewer people go into work every day. However, there are rumblings that “work from home” (WFH) has not been as widely implemented as it should have been, due to Taiwanese management’s deep-seated mistrust of their employees.
There is broad scientific consensus that Covid-19 is spread primarily through close contact indoors and through aerosol particles. Despite official championing of flexible working hours and WFH, Taiwan’s willingness to allow white-collar workers to continue working in the office is a threat to regaining control of the virus spread.
Changes in behaviour since the beginning of May (rolling 7-day averages)
“Here there be dragons”
We are now approaching a major crunch point, Dragon Boat Festival. The last major family event, Mother’s Day on 9 May, is being highlighted as a significant catalyst in the current upsurge, with restaurants packed and extensive domestic travel, even though we knew that we already had three clusters of domestic cases simmering. Within a week, the number of Covid-19 patients took off.
In 2020, Taiwan came through all the major festivals unscathed. Big crowds at popular tourist locations during Qing Ming initially panicked the authorities, but there was no evidence of community spread in the following days, so everyone relaxed and enjoyed the rest of the year largely unconcerned and Chinese New Year this year also passed without incident.
Now though it’s completely different and there are increasingly plaintive urgings coming out from the Central Epidemic Command Center (CECC) and even from the president to stay put and enjoy a low-key Dragon Boat weekend. "I ask everyone to stay in your present location this year for the sake of your hometown and your family, considering the Covid-19 outbreak," President Tsai said in an address to the nation.
It remains to be seen whether public compliance will extend to heeding these warnings, although there are encouraging signs. Taiwan Railways Administration’s (TRA) ticket sales for the long weekend have reportedly dropped from 136,000 to 29,000 and Taiwan High Speed Rail (THSR) has also seen a decrease and has committed to keeping seat usage below 20%.
Taiwan is not alone. Thailand, Malaysia and Vietnam, other countries which had adopted a similar “zero-Covid” strategy and been widely praised for their success in combatting the pandemic, are also experiencing big surges in the number of cases. Even China, for all the ferocity of its containment measures, continues to experience periodic domestic outbreaks, the latest being in Guangzhou.
Early on, there was hope that the virus would be contained to the point where there would no longer be enough hosts for Covid to continue to spread easily – so-called “herd immunity”. Now, the virus is spreading faster than ever, infecting 750,000+ people every day, with nightmare worst-case scenarios playing out in India and Latin America.
Worse still, experts say it is changing too quickly, with new, more contagious variants appearing. Covid is well on its way to becoming endemic, an ever-present threat.
“The major factors shaping the rise and fall of the pandemic are the behaviour of governments and their responses to the pandemic.”
Few administrations have distinguished themselves in their handling of the virus. In Taiwan, for over a year, the government garnered deserved praise for the speed and decisiveness of its actions, which undoubtedly allowed us to lead relatively normal lives up until 11 May. The tumultuous events of the last month, however, have generated considerable soul-searching, with the realisation that a policy based almost entirely on stopping the disease at the border had to fail some time. The CECC admitted as much: “While we have been effective in border controls, there is indeed room for improvement in domestic prevention efforts.”
And that brings us to the thorny issue of vaccines. The ongoing Level-3 measures and even the ultimate Level-4 will not eradicate Covid from our society. Professor Wen Tzai-hung (溫在弘) from National Taiwan University (NTU) explained the situation in an interview in Commonwealth magazine:
“We shouldn’t expect the pandemic to go away just by relying on reducing or blocking contacts and increasing social distancing. People will eventually still have contacts. The true purpose of all restrictions is buying time – so that the peak [of the pandemic] can be delayed.
The experiences [with lockdowns] abroad, including in China, show that unless you are able to achieve 100%, a few loopholes will cause your entire effort to come to naught.
For us, the foreseeable end point is very clear: Vaccinations can solve the epidemic, but we need to buy time to get prepared.”
The situation around vaccines is a highly vexed one, blighted by nationalistic self-interest and geopolitical manoeuvring and any time politics intrudes Taiwan will inevitably lose out. President Tsai has already accused China of blocking a deal with Pfizer-BioNTech.
The imbalance between the rich nations and the poor ones is shocking. The inability or unwillingness of the rich to collaborate with the poor is both morally indefensible and myopic in the extreme. It may be a cliché, but it is also a truism – “no-one is safe until everyone is safe.”
Hedging their bets, the US and other rich countries bought many times the number of doses they needed from several manufacturers, cornering the market as if vaccines were a commodity. In the developed world, billions of doses are on hand, case numbers are coming down, economies are stirring back into life, and people are busy planning their foreign holidays. In many less developed nations, the virus is raging on, sometimes out of control, while vaccinations are happening far too slowly to protect even the most vulnerable.
In April, the Duke Global Health Innovation Center calculated that 87% of vaccine doses (4.6 billion, enough for one dose for 60% of the world’s population) were held by a handful of rich nations, while the Washington Post estimated in May that 45% of all doses had been given to 16% of the global population, in high-income countries.
For sure, there are major logistical problems in manufacturing and distributing vaccine to the entire global population. Furthermore, it is only to be expected that every country will protect its own citizens first, but the slow pace of provision of vaccines to the poorest countries shows just how far away we are from a genuinely global response.
Vaccines are also the subject of heated debate here. Professor Wen said, “we need time to get prepared.” Others counter that we should have been prepared already, and that the government started thinking seriously about vaccines too late.
Over the last month, the relationship between the government and the public, previously harmonious and defined by transparency and trust, has become muddled with political bickering, mixed messaging, and vaccine disinformation, and there has been a torrent of criticism aimed at the government as it tries to find a way forward. Trust in the CECC has dipped, and the President’s own approval rating has plummeted from an all-time high of 71% to around 40%.
The sudden turnaround in the public mood has been accompanied by a sea change in attitudes towards vaccines, as ETtoday’s opinion tracking shows quite dramatically. We have gone from being a nation of vaccine-sceptics to a nation of vaccine-believers.
The reasons for the previous scepticism and hesitancy – which was stoked by a similar lack of enthusiasm among health care professionals – stemmed from the low case count, which allowed many people to feel that there was no immediate need to get immunised. Take-up was further slowed by concerns about possible side effects, specifically the danger of potentially fatal blood clots with the AstraZeneca vaccine, which were highlighted by the government and played up in the media.
By 5 May, with 300,000 AZ doses secured and available, just shy of 74,000 had actually been administered to 0.3% of the population. And there was little effort from the centre to build momentum, even though Minister Chen Shih-chung (陳時中) had already warned of the lurking threat from the Novotel/China Airlines cluster.
Thereafter, as cases climbed, demand surged, as did impatience with the lack of available doses. People woke up to the fact that the borders were not as secure as we had all come to believe as a friend told me:
“I think now the only way to get better is to be vaccinated, we cannot lock ourselves away and pretend we are okay while the rest of the world are trying to actively fight against Covid. At first, when we were quite safe in the past year……, I wasn’t really keen on getting vaccine, because I thought we’re under control, just keep it as a safe option, but now give me vaccine, please!”
The upshot of this sudden switch in mindset has been a ten-fold jump in the number of vaccinations, but still just 3% of the population have been covered.
The government, too, has changed its tune and, it seems, is taking every possible opportunity to push the importance of vaccinations and overcome any lingering vaccine hesitancy. Previous concerns about AZ have been withdrawn.
Taiwan vs. the world
Supply remains a major problem. 400,000 doses of AZ arrived towards the end of May, followed by the first batch of 150,000 of the Moderna vaccine. There was then the gift of 1.24 million AZ doses from Japan and 750,000 more from the US. In total, about 2.8 million doses so far, enough for one dose for 12% of the population. Understandably, the government has prioritised immunising key medical personnel and others in high-risk roles.
Taiwan has signed contracts to buy nearly 20 million vaccine doses, 10 million from AZ, five million from Moderna, and 4.76 million doses of other brands through the COVAX initiative. However, timing of deliveries is unclear, and Health Minister Chen has repeatedly sought to moderate public expectations.
Some countries, such as Israel, with loud voices and deep pockets and which set about acquiring vaccines early on managed to get to the front of the queue. Taiwan waited until after vaccines were authorised by other regulators to begin striking deals but, by then, most of the first batches had already been snapped up.
The search for more supplies has taken on greater urgency and Reuters reported that the diplomatic corps have been mobilised to step up their lobbying to speed up deliveries. Hsiao Bi-khim’s representations in Washington are thought to have led to the US donation, while there are reports of ongoing negotiations between officials in Germany and BioNTech.
Taiwan Foreign Ministry spokesperson Joanne Ou said, "we are making great efforts and trying through all means to get the qualified vaccines for our people and residents."
China has “generously” offered several million doses from its own stockpile, but that ain’t going to happen! And Terry Guo (郭台銘) has taken the initiative to try to acquire supplies through his YongLin Charity Foundation, but quite when Taiwan will have the stocks to be able to achieve its goal of vaccinating 1.7 million people each week is unknown.
With so much desire for the safety of inoculation but such limited supplies, it is hardly surprising that frustration is building. Thousands are heading to the US to take advantage of the immediate availability there, so much so that airlines are already adding extra capacity on their West Coast routes. One intending traveller told me:
“We booked flights yesterday to the States, to get the jabs we want. I already made the appointments for Pfizer jabs for the next morning after we arrive in LA. You can walk into pharmacies, Target, Walmart, Costco to get Moderna straight away!”
Interestingly, while there has been savage criticism of the government in some quarters, as I was canvassing opinions for this article, I also found plenty of counterbalancing support, and a belief that the authorities are in fact doing their best while odds are heavily stacked against us.
“I hope we can get some more vaccine soon and indeed the government is already trying very hard. However, not everyone thinks so. Many blame the government for not preparing more stocks, while they forget the fact that people were reluctant to get vaccinated just a month ago.”
Irrespective of whether the government acted too slowly, Taiwan certainly recognised that there would be all kinds of obstacles to overcome in obtaining a timely supply of vaccines and looked to try to mitigate these by challenging the local pharma industry to develop vaccines domestically.
"We have tried our best to purchase vaccines from international companies, but we didn't get much. The only way to sustain our supply is to manufacture ourselves, this is very important for Taiwan," said Minister Chen.
The results of those efforts are now being realised, the authorities expecting to approve vaccines from Medigen (高端疫苗) and United Biomedical (聯亞生技) “for emergency use” in July, albeit only on the basis of phase II clinical trials. Other local companies are also developing vaccines.
While local production may make up for the deficiencies in the global supply chain, the whole subject is generating heated debate. There are passionate supporters of the initiative who trust the local industry implicitly and those who are vehemently opposed, wary of the lack of rigorous safety testing and suspicious that dark forces are at work, aiming to line the pockets of a few, with little regard for the health of the public.
In ETtoday’s recent survey, 50% said they were willing to take a Taiwanese vaccine, although, when given a free choice, 66% came down in favour of an imported dose. My own conversations around this topic revealed a relatively high degree of confidence in the four international brands – Pfizer-BioNTech, Moderna, AZ and Janssen – but still with lingering concerns over possible side effects, especially with AZ, but there were opposing views about the Chinese vaccines. While many of my contacts were firmly against them, doubting the quality, others were more positive, even favouring them over Taiwanese products
“A lot of people are against the China ones, but I think they are probably better than our local ones. At least they have already been used on a lot of people in China and what’s the sample pool for the local ones? 2,000 or 3,000? I don’t know, but I’m not that confident.”
One critical point the government must address around local vaccines is international approval. Chen Shih-chung has already sounded a warning note that this may be slow to achieve, but it will be vital for anyone who has a local jab and then wants to travel. If the Taiwanese vaccines are not recognised by foreign authorities, then entry to those countries is likely to be prohibited.
And there is one further question linked to all vaccines – what about children? Authorities around the world have been hesitant to inoculate anyone under the age of 18, but that seems to be changing, despite the fact that little testing has been done on the young. An open letter from a large number of eminent UK medical professionals to the Medicines and Healthcare Products Regulatory Agency argued strongly against proceeding with a vaccination campaign for the young:
The letter states that the signatories have “grave concerns regarding all proposals to administer Covid-19 vaccines to children…with a product still at the research stage and about which no medium- or long-term effects are known, against a disease which presents no material risk to them.”
The counter argument is that, though children are generally not affected by SARS-COV-2, they nevertheless can spread the disease, so they present a threat to global containment of the pandemic, but the lack of knowledge about the effects of any of the vaccines on children must be a cause of concern for any parent.
In Taiwan, our days of innocence are over, and we are caught up in the pandemic as much as the rest of the world. Our case numbers remain low compared with the majority of nations and there are realistic hopes that this outbreak can be brought under control reasonably quickly. However, the experience of the last few weeks has brought to light the need for far more depth and clarity in the messaging from the centre. There is so much uncertainty and a litany of unanswered questions. In the words of one of my contacts:
“I don’t want to get vaccinated, as there’s not enough information about vaccines. Why do we need to get it? What are the pros and cons of getting it? I think this is government’s responsibility to educate people.”
This is a familiar plea from countries around the world from a year ago, the desire for complete, clear, consistent messaging. Taiwan 2021 seems like the rest of the world 2020. Let’s just hope we learn from the mistakes of others.