'Mass vaccination is a dream'
Epidemiologist Dr Larry Brilliant delves into the past and the future in an exhaustive talk about Covid-19 vaccinations
By Hari Kumar
One of the most well-known epidemiologists in the world has a stark warning for us: mass vaccination will not stop a virus, and achieving herd immunity by giving jabs to billions of people is just a dream.
Dr. Larry Brilliant should know what he is talking about. He was at the forefront waging a campaign that eradicated smallpox – the only disease that the human race has managed to eliminate so far.
“Mass vaccination never worked. Not against smallpox, not against Ebola, not against polio. It is just a dream,” he said in an exclusive interview.
Instead, Dr. Brilliant wants health authorities to change tack and try a time-tested method known as ‘ring vaccination’ to contain Covid-19 by using the available jabs more judiciously.
If there is one thing that no one will dispute about Dr Brilliant, it is his out-of-the-box thinking.
To start with, his path, after acquiring his medical degree, was different from that of the others who graduated with him. Any credit or blame for it should go to Dr. Martin Luther King Jr. For after attending a talk by Dr. King, Brilliant became enamoured with the civil rights leader’s vision that was rocking the United States in the 1960s. That is how his journey from medical school began.
While his fellow medical graduates don white coats and gravitated towards hospital wards or research laboratories, Brilliant chose to do something unusual for a medical graduate. He teamed up with a group of hippies.
Together, they raised money with a concert of Pink Floyd and Rod Stewart to go on a journey of spiritual quest in a bus painted in psychedelic colours from London to India, snaking its way through Iran, Afghanistan, and Pakistan.
But his spiritual guru whom he went to meet in India – Neem Karoli Baba (pictured below), or maharaj-ji to him – put him on a path, not towards the Himalayas, but to New Delhi – to join the battle against smallpox.
Brilliant doesn’t think that his journey was anything unusual.
“It was a typical carrier path of the 60s. I don’t know why people make such a fuss about that,” he said dismissively during an interview in September 2020.
Hippie trail
Going by his book Sometimes Brilliant, released in 2016, one could dispute his contention. But the book does give a vivid account of the trials and tribulations of the health campaign in India to root out the killer disease that had plagued the planet for thousands of years.
A vaccine for smallpox was developed in 1798. Still, India continued to see mass outbreaks for some two centuries until the World Health Organization started a campaign in the 1970s to eradicate the disease. Brilliant, who was not even trained as an epidemiologist, joined it prompted by his spiritual guru and soon became the campaign’s poster boy.
The odds were high given the lack of infrastructure, verifiable data, vaccine scepticism, and difficulty in taking the vaccine to remote areas. Nevertheless, Brilliant and his colleagues, comprising local and foreign health experts, business houses, religious leaders, and volunteers, pulled off one of the most impressive victories medical science had ever achieved.
A key aspect of the campaign was the way people were inoculated. Instead of mass vaccination, the WHO-led team adopted a method that was used effectively in Eastern Africa.
The long time it took vaccine shipments to arrive in remote rural areas with no proper storage facilities meant finding a way to administer the jabs effectively in targeted villages and contain the outbreaks there. They chose to use the vaccine they had to inoculate people who had come into contact with the infected and their contacts rather than everyone in the village. The aim was to limit the space for the virus to spread.
The credit for this procedure, which proved successful and later came to be known as ‘ring vaccination,’ goes to William Foege, who later went on to head the U.S. Centers for Disease Control and Prevention (CDC).
In his book, House of Fire: The Fight to Eradicate Smallpox, Foege says that it was a tactic that he fashioned out of experience from his days fighting forest fires. As water to douse quick-spreading flames was difficult to get, they chopped down trees on the path of the fire, and created a fire trench to block the flames from spreading.
The ring vaccination approach was later used effectively against polio and Ebola.
“But we never used the term ring vaccination; it’s a terrible name,” says Brilliant with a laugh. “We used to call it selective epidemiological control, and in India, we called it surveillance and containment. But I saw ring vaccination take out a disease that had started perhaps ten thousand years ago.”
Hurdles ahead
Recently, Brilliant co-wrote an article in the Foreign Affairs magazine calling on health authorities to consider ring vaccination, saying the delay in distributing the jabs to all corners of the world is granting the coronavirus a free ride in many countries and thereby increasing the chances of more variants emerging and putting the vaccination immunity at risk.
Health experts see a major problem with this argument. Their concern is that the Sars-Cov-2 virus is different from smallpox and Ebola viruses. People infected with smallpox or Ebola showed visible symptoms that made easy to identify and isolate the infected. In the case of Covid-19, around 40 percent who get the bug are asymptomatic, making it difficult to employ the ring vaccination method.
Clinical microbiologist, Dr. Siddharth Sreedhar of Hong Kong University is doubtful if ring vaccination approach will work. “The incubation period of the infection is too short, the vaccines take time to mount an effective response,” he said in an email interview. So, the only way out of this crisis is equitable distribution of vaccines, he said. [Email interview]
Brilliant is aware of these difficulties. He says that untill some three months ago he thought the asymptomatic nature of some Covid cases was an unsurmountable problem. However, studies and reports of different methods of surveillance used in various countries have convinced him that ring vaccination can be used effectively in conjunction with other methods.
Not all surveillance methods work in all places, he admits. For example, making house calls in places where a lot of guns are in circulation is not going to work. “You may know, one of the countries [is where] I am calling you from. You can’t make house calls in the United States.”
Digital help
As a person who struck up a friendship with Steve Jobs when both of them were roaming around bare footed in India in search of spiritual guidance and relationship that flourished till the death of the Apple founder in 2011, and as a former vice-president of Google, Brilliant sees modern technology as a critical factor in keeping track of the Covid-19 outbreaks.
He says there is no one-size-fits-all solution for surveillance. From sewage testing, mobile alert systems, and even using satellites to monitor traffic to hospitals, there are several modern tools that can be used in combination with traditional methods to map out an effective strategy and keep an eye out for flare ups in different areas.
Methods like sewage testing can detect the virus, whether from a symptomatic case or an asymptomatic case, says Brilliant. And there are other approaches he feels need to be sniffed out. Like the idea of using dogs to detect Covid infections.
“It’s not just the dogs. It is the idea that there is an odour, aromatic means created when someone has Covid. I remain sceptical, but you know we have to try everything,” says Brilliant.
The epidemiologist who chairs Pandefense Advisory, a firm that helps organizations respond to Covid-19, says researchers at The London School of Hygiene & Tropical Medicine were excited about developing a digital sniffer that can be used to detect such odours.
Unlike some other Silicon Valley heavyweights who fantasise about reaching for the moon, Brilliant sees the obstacles ahead clearly and is not saying there is only one way forward.
Asymptomatic cases
The number of asymptomatic cases and difficulties in quickly detecting infections are huge problems, he admits. It may be even more than what the experts usually say, he adds.
“To buttress the argument against ring vaccinations, I think they’re even more asymptomatics than we thought before … I think the ratio might be not fifty-fifty, but it may be four times as many asymptomatics,” he warns.
“But if we do better contact tracing – normal, human, analogue contact tracing – you will automatically find asymptomatics as you will find symptomatics. So, you are finding anyone who has been in contact with someone who is a case. So, I am not as frightened of the fact that Covid has as many asymptomatic cases.”
The sensitivity of tests to detect cases could also be a problem. But he points out that none of the screenings invented by human beings have had a 100 percent success rate.
“We just don’t have a test that is completely perfect. As the great saying goes, you don’t go into a battle with weapons you wish you had; you go in with what you have.”
“So, what I’m saying is, there are other ways. If we’re serious about this, and we have to be, about trying to stop Covid, we have to not pretend that we’re going to be able to do it through mass vaccination. It’s never worked against smallpox, didn’t work against Ebola, and didn’t work against polio. Mass vaccination is a dream.
“You can’t get to herd immunity when you have got a disease like the delta variant, which is probably double or triple as transmissible as the original Covid.”
Better vaccines
Brilliant also says the pressure on manufacturers to churn out vast quantities of vaccine is coming at the expense of not having time to fine tune their product. Nobody is going to the vaccine makers and saying we need a vaccine that will immunise the people faster rather than the current 10 to 12 days.
“There is no incentive for that innovation. There is no market for that,” he says. “If you had a programme that would be the only vaccine you buy, then they would optimise their manufacturing techniques for speedy immunisation.”
“If you have a programme, then you have something to persuade the vaccine manufacturers to make a vaccine that would make that program successful.”
Brilliant points out, the idea that firms can pump out billions of vaccines on time and get into the arms of everyone is the only policy now. But what the world needs is a combination of every tool available, including ring vaccination, to derive maximum results instead of depending on just one approach.
Every health campaign had its difficulty. Eradication of smallpox in India was done much before communication systems became as robust as now. “But we managed to make two billion house calls,” he points out. The campaign against Ebola was undertaken in areas where a civil war was raging.
Brilliant says those who dismiss ring vaccination as not suited are comparing it with an easily defined solution like mass vaccination. The genial philanthropist gets vocal when the long list of hurdles confronting a ring vaccination approach is brought up.
“It’s so easy to be sceptical. But then you have to say what are you offering instead,” he asks. “That Covid will kill 50 million people? Are you offering instead to manufacture 50 billion doses of vaccine? You seriously think the Greek alphabet ends with Delta?”
With some drug companies now saying, those who got two jabs would get protection with booster shot is going to put equitable distribution of vaccines at further risk as richer countries would now be looking at a third shot for the inoculated.
Ring vaccination [“I hate that term,” he says again] was not all about jabs, says Brilliant.
“It’s funny that people have named this process ring vaccination. I think the vaccination was less than 15% of what we did. The 80% was surveillance.”
The Indian smallpox eradication campaign used 20 different surveillance systems, including investigating every rumour of outbreaks from remote villages that often involved white-knuckle drives and hostile receptions.
Modelling study
Brilliant knows that citing the mere history of earlier campaigns will not work as Covid-19 is one of the most challenging diseases health experts have faced. So, he has raised half a million dollars to help conduct modelling studies by roping in one of the topmost experts in the world, Professor Ira Longini from the University of Florida.
In a separate interview, Longini said that a modelling study on ring vaccination has already been done in a major Asian city. It was conducted with actual inputs from the field. Initial data gathered from this study hold out a lot of promise. The result of this study is to be published soon, while more studies in other parts of the world are in the pipeline.
But whether a few such studies will change the way nations tackle Covid-19 is a moot question as politics has been the driving force in such a decision. The biggest problem that worries Brilliant is the lack of a coordinated global approach to tackle Covid-19.
He points out that different countries have come up with their own methods to fight the disease, and there is no effort to collate all the policies that were effective and come up with a common basket of measures.
He wants a global approach that taps into effective policies adopted anywhere in the world. China and East Asia did well to control the situation in the early stage of the pandemic, but as time wore on, things have gone pear shaped in many of these countries.
“No country has managed to come up with a comprehensive plan to tackle Covid-19,” says Brilliant, stressing the urgent need for a unified approach.
Contagion warning
The 2011 film, Contagion, was much talked about in the early days of the pandemic as it seemed to predict almost a decade before the Covid-19 outbreak, the emergence of a killer virus that spreads through the air and leads to millions of deaths.
The screenwriter Scott Burns got the idea about that movie after he came across a Ted Talk presentation by Brilliant, who later worked as an expert consultant for the movie. CNN classified that movie as “part fantasy, part reality and totally possible”.
The one thing that the movie failed to factor in was the geopolitical tug of war over the pandemic and economy that has made any unified response look like a remote possibility now.
History as guide
Brilliant is not particularly perturbed about the odds stacked against his push for a change in policies. He has seen such impediments before, including objections from experts in the medical field. Almost everyone had told him their team would never get rid of smallpox in India.
He recalls a top WHO official was completely unconvinced about the campaign and even challenged them by saying he will eat the tyre of a Land Rover if the disease was fully rooted out.
“The happiest day in my life during my ten years in India was when we shipped a Land Rover tyre to him and asked whether he wants mustard or ketchup with it,” Brilliant recalls with a hearty laugh.
He had the last laugh then. Only time will tell if history will repeat itself as the world races to contain yet another killer virus.