On 8 July 2021, the world’s known COVID-19 death toll passed 4 million [1]. While the official numbers are likely to be underreported, the pandemic’s remarkable acceleration is not. It took 9 months for the virus to claim 1 million lives, the second million were lost in 3.5 months, the third in 3 months, and the fourth in about 2.5 months. The upcoming fourth wave confirms that the coronavirus is here to stay and find its own niche among seasonal respiratory infections. The anticipated emergence of new variants of the virus and rising inequity in access to COVID vaccines are forcing the world to recognize the potential for “a catastrophic moral failure.”

On 21 July 2021, the World Trade Organization and the World Health Organization held a high-level dialog to identify obstacles and propose solutions to inequitable access to vaccines. The Directors General of the World Trade Organization, the World Health Organization, and the World Intellectual Property Organization participated in the discussion. At this forum, Ellen ‘t Hoen, our Editorial Member, stated that vaccines should be treated as ‘global public goods.’ Here are some of her remarks [2].

The Covid-19 outbreak led to unprecedented scientific collaboration and vast amounts of public financing – at least 93 billion Euros – to develop products to respond to the outbreak. The first Covid vaccines went to market 9 months after the pandemic was declared. Never before have vaccines come to market at such a rapid speed.

But the pandemic has also laid bare the lack of an effective mechanism for the sharing of intellectual property (IP), knowledge, know-how, data and technology required to produce at scale the diagnostics, therapeutics and vaccines needed to fight the pandemic. We have seen hoarding of vaccines by wealthy nations and hoarding of knowledge required to produce these vaccines by their pharmaceutical companies.

So far, pharmaceutical companies have refused to collaborate with C-TAP and the WHO technology transfer hubs, as recommended also by the Independent Panel on Pandemic Preparedness and Response (IPPPR) but have not offered any convincing reasons as to why this is so.

Public funding significantly de-risked companies endeavours to bring vaccines to market rapidly, but failed to ensure, in exchange for this de-risking, the sharing of the knowhow. The lack of conditionalities in these publicly funded contracts is a tangible example of policy failure.

To be better prepared for future outbreaks, the world needs new rules to assure access to technologies needed to respond to an outbreak as well as access to the knowhow to be able to produce at scale. The pandemic treaty negotiations tentatively scheduled to start in the fall of 2021 offer an opportunity to regulate this. Key elements for a better multilateral pandemic response framework should include:

  • Commitments to public financing for R&D of vaccines and treatments which should be abundant, predictable, and provided upon the conditions that (a) the know-how is open sourced for others to use in further research and to produce at-scale and (b) that resulting products are priced fairly.

  • Vaccine production capacity should be created and funded in the regions of the world that currently are underserved.

  • Sharing of know-how and technology that is needed to build new manufacturing capacity should be assured and not subject to controversy during a pandemic.

The preparedness for the next season of coronavirus, next outbreak, and next pandemic should start now. While the governmental agencies and private companies are inventing incentives for vaccination where vaccines are available, the rest of the world is observing the madness of offering 1 million USD for a shot [3]—the amount that can keep a mid-size town protected from a deadly infection.

The global pandemic of COVID-19 exposed many flaws in public health systems, infrastructure, and the abilities of socio-political systems to interact, communicate, and act together to protect human health. For public health professionals, the crisis pointed out where our priorities should be and what we should be able to do. These priorities encapsulate the design, implementation, and assessment of practical solutions for emerging problems and communication strategies. These priorities dictate the need for basic research on the effectiveness of public health policies and their short- and long-term consequences.

In the current issue of the JPHP, we highlight several aspects of COVID-19 vaccine distribution. Recognizing numerous logistical barriers of rapid mass immunization, public health professionals are in search of a fair framework [4] and exploring the ethics of mass vaccination given the current vaccine approval process [5]. Debates on the ethics of mandated vaccination at the workplace and professional responsibility are also on the rise. By examining the key ethical dimensions of a public health issue as endorsed by the American Public Health Association (APHA) and applied to mandated vaccination against hepatitis A among food workers, several recommendations have been proposed [6]. Considering ongoing methodology development in risk assessment and the growing discussion of both actual and perceived risks, it is time to explore the multifaceted aspects of hazards, risks, and risk communication for common and emerging infections.

Hazards brought by COVID-19 to the workplace are widespread. For workers everywhere: from hospitals to schools, from public commute to construction sites, from places of worship to places of entertainment—the main question remains: is my workplace safe? The individual risks for exposure and subsequent infection may vary drastically and, although reduced by vaccination, are still non-zero. The perceived and tolerated risks also varies, even for those with identical actual risks. Some may see their own risk of being exposed and infected as high when the actual risk is low. And the reverse scenario—when the perceived risk is low, and the actual risk is high—is also possible. As an example, let us say, two adults live a community with the ongoing high rate of infection, work at a local pharmacy, and are frequently in contact with seemingly healthy individuals. By nature of their occupation, they are positioned in a potentially high-risk environment, yet one may perceive it as low-risk and the other sees a high-risk situation. This perception is shaped by their personal belief system, trust in official and non-official information, and past experiences that have shaped their knowledge and attitudes. Likewise, their actions will also be influenced by their perceptions of the actual risk involved in their profession. The individual who perceives high risk could be duly cautious and take steps to limit own exposure and the downstream exposure of their social network. However, the individual who sees this environment as low-risk might not exercise the same caution and therefore may be more likely to contract the virus and pass it to their network as well as co-workers and customers. Personal losses often drastically modify both actual and perceived risks as people are changing opinions, behaviors, and attitudes. This perception and the resultant spread, or lack of, is entirely influenced by their individual experience and perception of the messaging and the messenger.

The interplay of the actual and perceived risks could change rapidly. Thus, risk communication for people who face hazards to their survival, health, economic or social wellbeing, should be tailored to fit the broad range of ever-changing actual and perceived risks. With this range of perceptions and communication styles, a ‘one size’ message is likely to fit none. Of course, the logical follow-up question is, how many messages should public health professionals develop to satisfy every possible attitude: from a denier to a worrier? How often should the messaging be updated to keep up with the changing opinions and point of views?

To be effective the public health messaging should evolve and appeal to the core human virtues—courage, altruism, and solidarity. Risk communication should be evidence-based and rooted in the local context. Effective communication is the key in building successful health emergency preparedness, response, and recovery efforts for public health emergencies such as COVID-19. It requires to know more, faster, and deeper. It means that the public health community needs actionable data of high-fidelity, resolution, and quality on all aspects of the pandemic. It calls for collaborative and transparent research in a timely fashion. It demands to present information clearly and comprehensively for all audiences. How realistic is it to accomplish these hefty tasks in times of crisis, when trust in governments is low, misinformation is on the rise, and the whole human ecosystem is disrupted?

Over the last 50 years, developmental biologists had established the concept of a keystone species as an organism that helps define an entire ecosystem. A keystone species has a disproportionately large effect on its natural environment, not by its abundance but by its impact. Without its keystone species, the ecosystem might cease to exist. As by reintegrating of keystone species, we help to hold the ecosystem, and build resilience and diversity. I believe that among humans an altruist—an unselfish person whose actions show concern for the welfare of others—is a keystone species. By reintroducing them in society, we will be able to restore the human ecosystem and heal it from greed and mistrust. We need to strengthen the altruistic nature of the public health profession and nurture their goals and aspirations. In fact, altruism as the promotion of another's self-interest is the core of health profession tracing its roots all the way back to the Hippocratic Oath. We need to reaffirm our support for public health professionals as well as investments in public health infrastructure to provide proper training, compensation, and protection. The society must see and recognize the value of public health and be part of designing, implementing, and assessing public health policies.

Elena N. Naumova, Editor-in-Chief