Religion, Society and the Pandemic

By Karim F Hirji

The key lessons we drew in the two earlier books in this series, Religion, Politics and Society (RPS 2022) and Religion, Eugenics, Science and Mathematics (RESM 2023), were: Historically, religions have supported and opposed injustice. No religion is more holy than any other. Conflict between religions is driven more by social, political and eco

• Language: English
• Publisher: Daraja Press
• Release date: Jan 15, 2024
• ISBN: 9781998309009

Karim F Hirji

Karim F Hirji is a retired Professor of Medical Statistics and a Fellow of the Tanzania Academy of Sciences. A recognized authority on statistical analysis of small sample discrete data, the author of the only book on the subject, he received the Snedecor Prize for Best Publication in Biometry from the American Statistical Association and International Biometrics Society for the year 1989. He has published many papers in the areas of statistical methodology, applied biomedical research, the history and practice of education in Tanzania, and written numerous essays on varied topics for the mass media and popular magazines.

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CONTENTS

PREFACE

Be safe, be smart, be kind.

Dr Tedros A Ghebreyesus

Director General, WHO

T

HE LAST DAY of December 2019 signaled a turning point in human history. On that day, a report from China about a new viral disease landed at the World Health Organization (WHO). Named Corona Virus Disease 2019 (COVID-19), it rapidly spread across the globe, killing many, causing panic, and shutting down schools, factories, offices, hotels, houses of worship and entertainment and sports venues. Within a month, the WHO declared it a global emergency. Over the next three years, the number of cases rose and fell in a wave-like pattern, nationally and internationally. The global daily new case count peaked in late January 2022 at about 3.8 million cases. By early August 2023, the virus had infected nearly 693 million and reportedly killed about 6.9 million people worldwide. And these numbers are underestimates.

This book explores the interplay between the coronavirus pandemic and religion on the theological, institutional, and societal dimensions. It focuses on Hinduism, Buddhism, Christianity, Islam and secularism, but some minor faith systems are also covered. Resting on the foundation laid in my earlier books, Religion, Politics and Society and Religion, Eugenics, Science and Mathematics, it utilizes an interdisciplinary approach and has the same foundational premise:

All humans are equal in dignity and have equal rights.

There are no chosen people; there is no chosen religion.

We all are a part of the global human family.

The coronavirus pandemic augmented the multitude of major social, economic, health, and environmental crises faced by humanity. How did people and institutions of faith and secularists react to the havoc it unleashed? Did their beliefs facilitate or hinder the efforts to resolve the calamity? Did the people of different beliefs join hands or remain divided? How did social and economic factors influence the religious and secular responses to the pandemic? These are among the queries addressed in the following pages.

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In writing this book, I have been assisted by many. Foremost, I thank the co-editors, Zarina Patel and Rosa Hirji, whose meticulous editorial corrections and insightful comments considerably enhanced its quality. Abdul Paliwala and Elizabeth Jones deserve accolades for detailed edits and valuable comments and suggestions. Zahid Rajan of Zand Press and Firoze Manji of Daraja Press deserve credit for their support and for expeditiously producing an elegantly designed book. As always, this book would not have seen the light of day without the loving support of Farida Hirji, Rosa Hirji, and Rafik Hirji.

This book uses US English spelling. The quotations at the beginning of each chapter do not necessarily reflect my views. They are meant to show the diversity of views on the subject. As they are available on many websites, the sources are not given. The images used in the book are mostly in the public domain. Their sources appear in the Credits section.

Karim F Hirji

November 2023

CHAPTER 01: INTRODUCTION

This pandemic serves as a warning

that only by coming together with a coordinated,

global response will we meet the unprecedented magnitude

of the challenges we face.

Dalai Lama

I

T WAS FOUR DAYS before Christmas Day, 2020. And it was the day when the coronavirus made its presence felt in our home. Farida had returned from her yoga class. But instead of preparing dinner, she was in bed. ʻAre you unwell? ʼ ʻI feel tiredʼ. Her muscles were aching, and she felt feverish. Mild fever persisted, and her throat was itchy the following day. The remedy: Complete rest, hot tea and soup, warm salt water gargle and sparing paracetamol use. Fever and throat irritation decreased the next day, but fatigue persisted. A home test kit revealed that the coronavirus was in her system. But she was fortunate. Apart from fatigue and headache, her other symptoms dissipated in a couple of days. It took about three weeks for her to resume her normal activities.

A few days later, I had muscle aches, an itchy throat, and fatigue, but no fever. I, too, tested positive. However, my symptoms persisted until I was prescribed an anti-viral medication. It took me nearly six weeks to return to my pre-coronavirus status. I was like a sleepy zombie. All activities apart from basic survival-related tasks ceased. As my doctor noted, given my age and compromised health status, I was lucky that my condition did not become severe at any point.

What we experienced sharply contrasted with what we had been seeing and reading on the Internet for a year: Packed hospitals with patients on ventilators served by nurses and doctors wearing spacesuit-like protective gear. COVID-19 has been like a moderate flu attack for us. Further, residents in our neighborhood were going about their lives as if nothing was afoot. We heard about COVID-19 cases in city hospitals, but it did not look like a significant outbreak. Perhaps it was a matter of time before a widespread outbreak occurred on our shores. Though the coronavirus was in the city environs, for the most part, it exhibited itself as a benign condition. Only for a small minority did it become a life-threatening hazard. Talking to local doctors, we got the same impression. And the grave images of deaths and havoc we saw on the Internet never transpired in Tanzania.

So what was the point of wearing masks, avoiding unnecessary social contact, and keeping a safe distance from people? It is not done in a flu outbreak. Why close down schools and prayer houses? After an initial period of alarm and wild rumors, most people in the city reacted to the pandemic restrictions by ignoring them unless the police or some officials were around. But a few, like Farida and I, became inordinately careful and reduced our social activities even after the health authorities relaxed the restrictions.

According to official data, over the three years up to early March 2023, about 43,000 Tanzanians had contracted COVID-19, and some 850 had died from it. In comparison, there were an estimated 8 million cases of malaria and about 26,000 deaths from malaria in Tanzania in 2021. Yet we dreaded the coronavirus more than we dreaded the malaria parasite. The COVID-19 pandemic was also a pandemic of fear.



Group Burial of Suspected COVID-19 Case.jpg Caption: Burial of Suspected COVID-19 Case… Burial of Suspected COVID-19 Case Sao Paulo, Brazil, April 2020

1.1 TANZANIA VERSUS KENYA

The coronavirus pandemic brought into the public eye a flood of information relating to medicine, viruses, and statistics. But, simultaneously, it spawned a barrage of flawed and distorted news. National and international portraits about the pandemic that were of dubious validity circulated. People were perplexed. Uncertainty catalyzed a cascade of rumors, fear and anger.

Pandemic statistics from early 2020 to early March 2023 for two East African nations, Tanzania and Kenya, are illustrative. The population of the former is 64 million, and of the latter, 56 million. Yet, the former reported 43,000 cases and 850 deaths from COVID-19, and the latter reported 340,000 cases and 5,700 deaths from COVID-19. While Tanzania reported a death rate of 13 per million, for Kenya, it was 102 per million, about eight times larger.

Was this difference real? Or did it reflect varied rates of testing and reporting and diagnostic accuracy in the two nations? If it was real, was it due to some social, economic and political factors? Until June 2021, Tanzania was one of the countries with the lowest rates of reporting COVID-19 data to the WHO. At one point, it ceased reporting them altogether. Kenya, on the other hand, adhered more closely to the WHO protocols for pandemic control and reporting pandemic data. Their pandemic policy differences compounded their existing political and trade-related friction. One pandemic disparity between the two nations was the leeway granted to religious institutions.

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Somewhat over 50% of the people in Tanzania are Christians, about a third are Muslims, and the rest belong to other faiths. Irrespective of their affiliation, most people are quite religious. Attendance in churches and mosques is usually up to or above the capacity. In March 2020, when the pandemic was getting off the ground, Tanzania was still abiding by the WHO guidance on pandemic control, but with one exception. Even as schools were closed and public gatherings were banned, houses of worship could remain open as usual. President John Magufuli justified this exemption by declaring that the coronavirus was a ʻsatanicʼ entity that could not survive in holy places. The opposition parties in the nation called it a counterproductive move.

The houses of worship reacted differently to the presidential directive. Apart from placing hand washing facilities near the entrance, most churches continued with their traditional ways of worship. A few went further, limiting the number of people allowed entry and making the worshipers wear masks and sit far apart. Sunni mosques, constituting the large majority of the mosques in the nation, remained open with little change in their mode of operation. People wore masks in some mosques, yet the worshipers often stood shoulder to shoulder. However, many Shia mosques remained closed for months, and when they opened, they restricted how the prayers were conducted.

Kenya did not grant such an exemption to houses of worship. Yet, it had a higher incidence of COVID-19 and deaths from COVID-19 than Tanzania. While case numbers may not reflect reality, deaths are not easy to push under the rug. One can, with confidence, say that COVID-19 mortality in Kenya was much higher than in Tanzania. Did a divine force protect Tanzania?

The example of Kenya and Tanzania indicates that the evolution of the coronavirus pandemic is a complex process, not reducible to generalities. The experiences of my family and friends in Dar es Salaam were atypical. Further, identifying the factors behind the varied experiences of peoples, communities, and nations and discerning the role of religion therein requires careful scientific investigations. Jumping to conclusions based on apparent similarities or differences will not take us anywhere.

1.2 OBJECTIVES

The key lessons we drew in the two earlier books in this series, Religion, Politics and Society (RPS 2022) and Religion, Eugenics, Science and Mathematics (RESM 2023), were: Historically, religions have supported and opposed injustice. No religion is more holy than any other. Conflict between religions is driven more by social, political and economic factors than scriptural differences. Morality can exist without religious belief, but science or secularism does not guarantee morality. The basic philosophy and approach of religion and science differ, yet they need not be socially antagonistic forces. Religion and secularism can coexist peacefully. Religions, secularism, and science can cooperate to counter the damage wrought on our planet by profit-driven neoliberal capitalism and hyper-consumerism. RPS (2022) also presents a schema to promote joint, morally ennobling engagement between the varied faith traditions and between religions and secular forces. Its tenets are:

Declaration of spiritual equality, demarcation of common ethical principles, separation of religion and state, demarcation of the roles of religion and science in education, freedom of dress, fostering principled tolerance, acceptance of faith-based conversions, promotion of gender equality, non-discrimination over sexual preference, and regular joint celebrations and interfaith prayers. (RPS 2022).

These tenets were augmented in RESM (2023) by asserting the fundamental right of religions and science to exist and freely propagate themselves. Yet, at the same time, I suggested that scientists should be free to criticize religion and that people of faith should be free to criticize science. Religion should not intrude into public policy and education. Scientific and Aa. People of science, religion, and secularism should abide by the highest standards of morality to promote human flourishing and planetary welfare.

Only the combined force of common people, religious and secular, stretching across nations and firmly committed to social and economic justice, promises the hope of attaining a humane, tolerant social order. (RESM 2023).

The coronavirus pandemic dramatically transformed people-to-people interactions in families, communities, work, and educational places. Public social gatherings were curtailed, relatives did not visit one another, teachers kept a distance from their students, classes were held online, employees worked from home, recreational travel plummeted, supermarkets opened on a restricted entry basis, and so on. Washing hands, social distancing, and mask-wearing became the norm in public venues. International relationships and religious practices were affected drastically as well.

The main objective of this book is to examine how religions and people of faith were affected by the coronavirus pandemic and how their reactions altered its course. We also assess the validity of the above-noted conclusions drawn in RPS (2022) and RESM (2023) for the coronavirus pandemic. In particular, we ponder on the following queries:

Question 1: How did the coronavirus pandemic evolve in selected nations?

Question 2: Was religious belief an obstacle or a positive factor in understanding the scientific basis of the coronavirus pandemic?

Question 3: Did religious institutions, leaders and laity facilitate or block the implementation of the official pandemic control measures?

Question 4: Was the role played by religion in the coronavirus pandemic affected by historical, social, economic, and political factors?

Question 5: How did secularism operate in the coronavirus pandemic?

Question 6: Did the coronavirus pandemic enhance or undermine religiosity?

We explore these queries in relation to the four major faiths (Christianity, Islam, Hinduism, Buddhism), some minor religions, and secularism.

1.3 APPROACH

This book uses the same definitions of religion and science as RPS (2022) and RESM (2023):

Religion is a system of beliefs, practices and symbols shared by a community that accepts the existence of divine being(s) and/or supernatural realms and has modes of worship, rituals, stories and rules of conduct (ethical norms) that are taken to be of divine origin.

Science is a body of knowledge derived from an interacting, on- going process of observation, pattern identification, hypothesis formulation, and testing or prediction.

As in the earlier books, we use terms like faith system, belief system, faith, religious tradition and religious creed as equivalent terms for religion.

Nature and society are dynamic, interconnected, multi-faceted systems with diverse components. Both are propelled by interactions of opposing tendencies. Religion and human health are key components of society. They impinge upon the interactions of humanity with nature. Analyzing the role of religion in the coronavirus pandemic must deploy an interdisciplinary, holistic approach that considers the social, political, economic, and environmental context in which the pandemic developed.

We focus on three Hindu-majority nations (India, Nepal and Mauritius), two Buddhist-majority nations (Myanmar and Sri Lanka), five Christian-majority nations (Brazil, the Philippines, USA, South Africa and Tanzania), four Muslim-majority nations (Indonesia, Bangladesh, Tunisia and Iran), and three nations where secularism has a significant presence (Cuba, Singapore and China). Some nations like Peru and New Zealand are covered tangentially. The relevant social, economic, political, cultural, and historical information for some of these nations was provided in RPS (2022). Hence, it is not repeated here.

Like its predecessors, this book is based on secondary sources. Though it can be read independently, we advise the reader to familiarize herself with the issues covered in RPS (2022) and RESM (2023). These two books also explain the basic terminology encountered in religion-related discussions.

This book shares a fundamental premise with RPS (2022) and RESM (2023):

All humans are equal in dignity, and all faith systems and secular creeds deserve equal respect and freedom to operate. Yet, that freedom does not include the freedom to harm others. It favors open-minded discussion of religion, secularism, science and health with the proviso that it be a respectful dialogue that does not compromise on history and evidence.

The ultimate objective of this book is to promote peace and harmony between different faiths, secularism, and science so that they can be optimally harnessed in the endeavor to tackle global health problems like the coronavirus pandemic and other major social, economic, political, and environmental issues facing the human race today.

Unless otherwise stated, in this book, the terms ‘virus’ and ‘coronavirus virusʼ mean SARS-Cov-2, and the term's ʻcoronavirus pandemic’ and the ʻpandemicʼ mean the COVID-19 pandemic. SARS-Cov-2 is sometimes abbreviated as SARS-2, which is not done in this book.

CHAPTER 02: EPIDEMIOLOGY

Outbreaks are inevitable.

But pandemics are optional.

Larry Brilliant

Epidemiologist

V

IRUSES ARE MICROSCOPIC particles made of genetic material, DNA or RNA, a protein coat, and perhaps a fatty envelope. Viruses coexist symbiotically with humans, animals, and plants, but some cause mild to serious diseases. Human viral infections include the common cold, influenza, chicken pox, measles, rubella, shingles, rabies, smallpox, yellow fever, AIDS and Ebola. Viruses also benefit humans through their impact on physiological equilibrium, the ecosystem and other life forms.

Viruses are everywhere: in the air, oceans, rivers, and soil, as well as in plants and animals. Their numbers exceed the number of bacteria and other organisms on Earth. That is surprising because a typical virus cannot survive, but for a short time, on its own. Viruses occupy the nebulous zone between life and non-life. A virus cannot reproduce by itself. To procreate, it must enter a living cell and usurp the cellular machinery for its own ends.

Viruses are efficient reproducers. Once in a cell, they deploy the cellular DNA and other molecules to rapidly make copies of themselves. As the viral load becomes large, the virions extricate themselves from the cell or cause it to burst. Viral copies released into the bloodstream go on to infect other cells. Detecting a foreign entity, the immune system mounts a defensive cascade to contain or destroy it. In some cases, the virus is contained before any symptoms are seen. But in other cases, an illness ensues depending upon the organs involved. Some people survive; others do not. Survivors of a viral infection usually have antibodies circulating in their blood that give them protection from reinfection. Some survivors become asymptomatic carriers of the virus.

Viruses mutate as they propagate themselves. The new variant may be more transmissible, cause more severe symptoms, or be less susceptible to existing vaccines or anti-viral drugs. Or, it may be less lethal. Human viruses spread via air droplets, water, food, feces, blood, mosquito bites, etc. They may jump from humans to humans and from animals to humans. Plant viruses can cause devastating food shortages.

Coronaviruses are a class of widely prevalent viruses that infect the human respiratory system. SARS-Cov-2 is a new coronavirus that was first identified in China in December 2019. COVID-19, the disease it causes, can seriously disable or kill the afflicted person. The prevailing consensus is that SARS-Cov-2 jumped from bats to humans via another host sometime in the past (Chapter 9). (Such an event is known as a spillover event.) But now, the main mode of transmission is from person to person. Corona viral particles can remain airborne for up to three hours. Touching surfaces where virus droplets have landed within a short time and then touching one's mouth or nose with the same fingers risk an infection.

[The] corona virus is spread through droplets and virus particles released into the air when an infected person breathes, talks, laughs, sings, coughs or sneezes. (Sauer 2021).

Group SARS-CoV-2 Virion Caption: SARS-CoV-2 Virion SARS-CoV-2 Virion

Observing basic hygiene is the key to controlling the spread of the coronavirus. The risk of infection is significantly reduced by adhering to a series of non-pharmaceutical interventions (NPIs). They include:

physical distancing, community use of well-fitting masks (e.g., barrier face coverings, procedure/surgical masks), adequate ventilation, and avoidance of crowded indoor spaces. These methods will reduce transmission both from inhalation of virus and deposition of virus on exposed mucous membranes. Transmission through soiled hands and surfaces can be prevented by practicing good hand hygiene and by environmental cleaning. (CDC 2021).

The first case of COVID-19 was reported in Wuhan, China, in December 2019, and the first death from the infection was reported in the same locality on 9 January 2020. With the ultra-globalization of manufacturing, commercial services, trade, tourist and business travel, and cultural exchanges, it rapidly spread to all continents within a couple of months. The WHO responded to the rapid spread of the virus by declaring it a Public Health Emergency of International Concern on 30 January 2020 and designating it as a pandemic on 11 March 2020.

As the pandemic unfolded, the authorities in many countries mandated mask-wearing and social distancing, imposed strict curfews and quarantines, banned local and international travel, and closed schools, businesses, entertainment venues, and houses of worship. Only a few essential services and activities were allowed to operate. Special arrangements were made for the delivery of food and medicines. The poor and most vulnerable segments of the population everywhere were the most adversely affected by the COVID-19 restrictions.

Group Masked Nurse Caption: Masked Nurse Masked Nurse

The pandemic unfolded in waves, and the restrictions were modified accordingly. At the same time, improved tests, vaccines and treatments were developed. To date, hundreds of millions have been vaccinated, and case numbers and deaths have declined significantly from what they were during the peak periods. Yet, the day COVID-19 no longer poses a significant threat is not here.

2.1 BASIC STATISTICS

There are three types of tests for coronavirus infection: the polymerase chain reaction (PCR) test, the antigen test, and the antibody (serology) test. The first two tests need a nasal or throat swab and detect a current infection. The antibody test requires a blood sample and picks up a past infection. The PCR test is the most accurate, but it is more costly and needs special swabs. Since the antigen test can give false negative results, a negative result needs validation by a PCR test. The antibody test, the least accurate test, is helpful for community surveillance. (DCU 2020).

According to the WHO, a confirmed case of SARS-CoV-2 virus infection is a person who is either positive on a PCR test with or without any relevant clinical symptoms for COVID-19 or is positive on an antigen test and has either the relevant clinical symptoms for COVID-19 and/or has been in close proximity with confirmed or probable COVID-19 case(s). Confirmed cases are recorded in regional or national COVID-19 registries, and the totals are reported to the WHO regularly. In this book, the term ‘COVID-19 cases’ refers to confirmed COVID-19 cases. Another important aspect of the impact of the pandemic is people who develop severe symptoms of another disease or die from ailments arising from the conditions created by the pandemic or an ailment exacerbated by COVID-19 infection. For example, an elderly woman living alone and with pneumonia may die because she was not able to reach a hospital under a total lockdown. A man with mild COVID-19 may die from exacerbation of existing heart disease or diabetes. A child may die from measles because of the diversion of resources from the measles immunization program to the COVID-19 vaccination effort. Some deaths are accelerated by the societal changes brought on by the pandemic. Such deaths are known as COVID-19-related fatalities.

Counts and Rates

The impact of the coronavirus pandemic on a nation is gauged by several indicators. One is the number of people infected by the coronavirus to date (the Cumulative Case Count (CCC)). Two, the number of deaths from COVID-19 to date (the Cumulative Death Count (CDC)). Three, the COVID-19 related death count (the Cumulative COVID-19 Related Death Count (CCRDC)) to date. The ongoing impact of the pandemic is gauged by daily or weekly case and death counts. The impact of the pandemic on the quality of life, including income, living conditions, and mental health, is a key consideration as well.

The total numbers of cases and deaths, in themselves, do not give a fair picture of the impact of a pandemic, especially for international comparisons. We must also consider the size of the population. For, 100,000 cases in a nation of 10 million represents a picture similar to that of 10,000 cases in a nation of 1 million. Hence, we also need to compute case rates and death rates. For a particular point in time, we define:

CCR = Cumulative Case Rate per 1 Million People

= (CCC × 1,000,000) / Population

CDR = Cumulative Death Rate per 1 Million People

= (CDC × 1,000,000) / Population

Since population size changes, we use the population size at the mid-point of the period. For example, up to 8 August 2023, the CDR for China was 71 per million, but for Brazil, it was 3290 per million, and for the USA, it was 3411 per million. (CRC 2023).

Nations differ widely in terms of their health facilities, health manpower, laboratories and testing capability. The accuracy and comprehensiveness of their recording system for health outcomes and death varies, too. Due to a lack of resources or other reasons, some COVID-19-infected persons, especially the asymptomatic ones, were not tested in many nations. Some symptomatic persons opted not to or could not visit a test center. Door-to-door community testing is costly and onerous. It was rarely done. Some confirmed cases were not entered into the database. At times, it was done intentionally in order to create a positive image. Some untested or tested people died from COVID-19 at home and were not included in the official count. Some people tested positive with a home test kit but did not go to a health center. Some self-medicated. Coding and entry errors further compromised data accuracy. Hence, for a variety of reasons, the official or reported COVID-19 cases and death counts often were undercounted. At times, they were gross undercounts.

Most nations have a register of births and deaths, though its accuracy may vary from place to place. From this register, we get the total death count (TDC), say during 2021. We classify these deaths into four groups: (i) Reported COVID-19 deaths (RCD); (ii) Unreported COVID-19 deaths (URCD); (iii) COVID-19-related deaths (CRD); and (iv) Deaths due to other (normal) causes (DOC). Then,

TDC = RCD + URCD + CRD + DOC

Two components of this formula, TDC and RCD, are generally known. The sum of the recorded and unrecorded COVID-19 deaths plus COVID-19-related deaths is called Excess Mortality (EM).

EM = TDC - DOC = RCD + URCD + CRD

Excess mortality is the difference in the total number of deaths in a crisis compared to those expected under normal conditions. (Msemburi et al. 2023).

Several statistical techniques to estimate excess mortality exist. EM gives a more valid picture of the death toll of COVID-19 in a society. In part, it adjusts for the deficiencies in the testing and data collection system.

A prudent portrait of the death toll of the coronavirus pandemic in a region, nation or the world requires the following statistics:

RCD = Reported COVID-19 Deaths

RCMR = Reported COVID-19 Mortality Rate (per million people)

EM = Excess Mortality (estimate)

EMR = Excess Mortality Rate (per million people)

Several studies and COVID-19 monitoring websites reported COVID-19 deaths (RCD) and estimates of EM globally and nationally for the different years of the pandemic. According to one study, 5.4 million deaths from COVID-19 were reported to the WHO up to December 31, 2021. Statistical modeling indicated that COVID-19 had directly or indirectly caused 14.9 million excess deaths during this period. Some 9.5 million or about 64% of COVID-19 deaths or COVID-19-related deaths were not reported. Males constituted 57% of the excess deaths, and females 43%. Another study put the reported COVID-19 deaths at 5.9 million and the EM at 18.2 million for the same period. The global EMR was 1203 deaths per million. (CDC 2022d; CEMC 2022; Msemburi et al. 2023; OWID 2023; WHO 2023d).

The COVID-19 excess mortality rate (EMR) up to 31 December 2021 per million people was 2000 for South Africa, 1710 for India, and 1600 for Brazil. The global figure was 960 per million. But for China, it was -20 per million. A negative EM or EMR indicates that the number of people who died during the pandemic was less than expected. The pandemic control measures reduced deaths from other causes to a degree that neutralized the extra deaths due to COVID-19. The zero-COVID policy pursued by China was a key factor behind its negative EM. (Msemburi et al. 2023). Many nations do not have an accurate register of deaths. In that case, the actual death toll of COVID-19 is difficult to gauge.

The reporting accuracy ratio (RAC) is the ratio of reported deaths (RCD) to expected deaths (EM). It is an indicator of the comprehensiveness of the COVID-19 reporting system. In many nations, it may be as low as 50%. Thus, the reported figures give us a ballpark view. And at times, they provide a significantly erroneous view.

Two other indicators of the gravity of COVID-19 are also used. One is the ratio of confirmed deaths to confirmed infected persons (Infection Fatality Rate or IFR), and the other is the ratio of documented deaths to confirmed symptomatic COVID-19 cases (Case Fatality Rate or CFR), denoting the chance of an infected asymptomatic or symptomatic person dying. IFR and CFR denote the ability of the health system to save the lives of COVID-19 victims. A nation may have a low case count but lack the facilities to treat them adequately.

According to one set of global estimates, and looking at the nations examined in this book, the CFR up to 8 August 2023 ranged from 0.1 percent for Singapore to 2.5% for Sri Lanka, South Africa and Tunisia. (CRC 2023). If unreported COVID-19 deaths are taken into account, possibly 10% of the COVID-19 cases died. Use of CFR for assessing the COVID-19 death toll should bear in mind that reported deaths do not usually represent an accurate picture and that the criteria for assigning the primary and secondary causes of death differ from nation to nation.

IFR and CFR depend on the population's age structure and the nation's health system. They are also dynamic quantities that vary by the stage of the pandemic wave, the viral variant and the vaccination rate. The Omicron variant, the variant prevailing in late 2023, is more infectious but much less lethal than the Delta variant that had prevailed earlier.

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Unless noted otherwise, all COVID-19 reported case and death data in this book are extracted from the website www.worldometers.info/coronavirus. The WHO is a valued information source as well. Two cutoff dates, 20 September 2021 and 6 April 2023 are used for primary between-nations comparisons.

International comparisons of COVID-19 data have to consider the differences in age structure, economic conditions and health status between nations. No single statistical measure adequately captures these differences. Nonetheless, health experts regard the Infant Mortality Rate (IMR), the risk of a child dying before reaching the age of one year, as a key index of the health status of a population. The IMR data we use are the year 2019 data from the World Bank website: https://data.worldbank.org/indicator/SP.DYN.IMRT.IN.

In 1990, with the global population at 5.3 billion, a total of 8.7 million infants (children under the age of one year) died worldwide. By 2018, the population of the globe had increased to 7.6 billion, but the annual number of infant deaths had gone down to 4.0 million. In 2018, in the WHO African Region, the IMR was 52 per 1,000 live births, but in the WHO European Region, it was 7 per 1,000 live births. By a critical measure, the general health status in the African Region is worse than that in the European region.

Since COVID-19 data have multiple uncertainties, using exact numbers gives a misleading impression. Thus, we round the pandemic case and death numbers to three or four significant digits. An official count of 1,231,362 cases is thus rounded to 1,231,000 cases.

2.2 A GLOBAL PICTURE

The coronavirus pandemic surged, plateaued, and ebbed in waves of varying duration and intensity. The pattern of variation differed from nation to nation. A nation with a high cumulative case count at one point had a low number of active cases, while a nation with a low cumulative case count experienced a dramatic surge.

From January 2020 to early August 2023, 681 million cases and 6.8 million global deaths were attributed to COVID-19. The actual figures were possibly three times higher. Morbidity and mortality are but a first step in assessing the impact of a multi-faceted pandemic. Hundreds of millions saw a decline in their quality of life. Tens of millions endured long hospital stays. More than 10% of the recovered cases suffered from debilitating long-term aftereffects (Long COVID).

The pandemic drastically altered most nations' daily life, education, health systems, travel, cultural activities and the economy. To stave off a major economic catastrophe, governments provided relief packages to individuals and businesses. However, the wealthy and the major corporations benefited more than the ordinary people. Inequality expanded almost everywhere. While considerable sums were expended to control the pandemic, the funds allocated for prevention, monitoring and treatment for many serious ailments declined. The coverage of normal childhood vaccinations went down. Children died. People feared visiting health facilities. Morbidity and mortality from diseases like malaria, tuberculosis and HIV rose or was expected to grow in the poorer nations.

The five nations with the highest number of reported cases by early August 2023 were the US (107,700,000), India (45,000,000), France (40,140,000), Germany (38,430,000) and Brazil (37,740,000). The reported COVID-19 deaths in these nations for the same period were: in the US (1,172,000), India (532,000), France (168,000), Germany (174,000) and Brazil (705,000)., The US, Brazil and India, in that order, had the highest total COVID-19 deaths in the world. At 0.4% and 0.5%, France and Germany had the lowest infection fatality rates among these five nations, followed by the US (1.1%), India (1.2%), and Brazil (1.9%).

A disturbing aspect of the coronavirus pandemic was its impact on health staff—doctors, nurses, auxiliary staff, and emergency responders. At peak periods of the pandemic waves, health systems in many nations were stretched to capacity, and the health staff were exhausted. In the first eighteen months of the pandemic, the health staff contracted the coronavirus in large numbers. According to the WHO, from January 2020 to May 2021, between 80,000 and 180,000 health workers across the globe succumbed to COVID-19. In the US, more than 3,600 health staff died from COVID-19 during the first 12 months of the pandemic. Nurses and support staff were at a higher risk of death from COVID-19 than doctors. In the WHO-designated Region of the Americas, an estimated 570,000 health workers contracted COVID-19 from early January 2020 to the end of August 2020. Of them, 2,500 died. A study done in nine European nations compared the COVID-19 risk for health workers and non-health workers for 12 months starting from the end of January 2020. Health workers were three times at a higher risk for infection, 1.8 times for hospitalization, 1.9 times for ICU admission, and 0.9 times for death than non-health workers.

In many nations, masks were in short supply, mask quality was substandard, and masks were overused at the outset. As the pandemic progressed, the supply of protective gear and the handling of patients improved. And especially after vaccines became available, the incidence and fatality rates from COVID-19 among health workers declined. But stress, burnout and depression continued. Deaths among health staff enhanced public fear and anxiety. People trusted nurses and doctors but feared the hospital environment.

In many places, the public lauded the dedication of health staff. Called heroes, the front-line workers were heralded in public events. However, public support did not persuade governments to undo the damage neoliberal cutbacks inflicted on national health systems.

2.3 VACCINATION

Humans are constantly threatened by microorganisms (viruses, bacteria, fungi and parasites) and toxins from the environment and other living entities. But they possess a complex system―the immune system―consisting of protective barriers, specialized organs, and blood-borne B cells, T cells and macrophages to contain and eliminate the threats. When the system detects a foreign substance in the body, say a protein on the coat of a virus (an antigen), it sets off a cascade of events that isolate and eventually destroy the invading organism. Yet, as the body mounts a counteroffensive, the virus may infect many cells, spread and cause unpleasant symptoms. The afflicted suffer until her immune system manages to contain the virus. Some people need an antiviral medicine. In some infections, the immune system releases chemicals that raise the body's temperature. This reduces the rate at which the virus multiplies.

The immune system possesses memory. After an initial attack, it generates proteins (antibodies) specific to the virus circulating in the blood. When the virus reinfects the person, these antibodies enable the immune system to mount a rapid and more effective response and ward it off before it can produce severe symptoms or cause organ damage.

Vaccination is a highly effective method of preventing nearly twenty serious diseases caused by viruses and other microorganisms. As the duration for which vaccines protect from infection varies, some vaccines need more frequent booster shots. Traditionally, vaccines have come in two forms: those that contain parts of the infecting organism and those that contain the whole infecting organism but in such a weakened (attenuated) form that it cannot cause the disease. The former, called inactivated vaccines, generally provide less protection and may need more booster doses than the latter. Their principal advantage is that they cannot cause the disease. The live virus vaccines, though often more effective and with longer-lasting protection, pose a risk for immune-compromised persons. The safe organism in the live vaccine may mutate and generate a variant that may induce a dangerous form of the disease. But such risks are usually exceedingly low. To retain potency, live virus vaccines usually require elaborate ways of storage and transportation, an issue of particular concern in poor nations. On the other hand, inactivated vaccines have a high manufacturing cost. Of recent, a new gene-based approach for vaccines has been developed.

The WHO and UNICEF are two principal organizations that establish global standards and programs for vaccinating children and adults. Many low-income countries use their programs. But some nations have their own schemes. In many nations, vaccines are mandated by law and compulsory for school attendance. Exemptions based on medical and religious grounds are also granted. Presently, vaccines for more than 20 diseases exist. Globally, they prevent more than 3.5 million deaths annually.

Immunization is a key component of primary health care and an indisputable human right. It’s also one of the best health investments money can buy. (WHO 2023a).

Take the Diphtheria, Pertussis and Tetanus (DPT) vaccine. Three doses are administered during the first year of life. According to the World Bank, 86% of eligible children worldwide had full DPT vaccine coverage in 2019. However, coverage levels varied across nations. In high-income countries, it was 95%; in middle-income countries, 87%; and in low-income countries, 74%. The coverage level for sub-Saharan Africa was 77%.

In the three Hindu-majority nations and two Buddhist-majority nations studied in this book, the DPT vaccine coverage was 90% or higher. In Sri Lanka, it was 99%. In the five Christian-majority nations, it ranged from 65% in the Philippines to 94% in the USA. Among the four Muslim-majority nations, it ranged from 85% in Indonesia to 99% in Iran. The coverage level in Bangladesh reached 98%. Singapore and Cuba had vaccinated, respectively, 96% and 99% of the eligible children with the DPT vaccine.

The factors inducing varying levels of coverage are complex and intertwined and have not been fully elucidated. They include poor official communication, lower per-person income, adverse outcomes of the vaccine seen in the initial rollout program, political conflict, and cultural or religious factors. In many places, a group of strident opponents of vaccination, known as anti-vaxxers, is often allied with right-wing political movements. Their presence lowers the vaccination rate.

Vaccines have side effects. They include soreness at the vaccine site, muscle aches, chills and fever, and fatigue. Generally, these effects are mild. Some people have severe allergic reactions. Unwillingness to take medicines due to perceived side effects affects health care in general. But vaccines stand out. In many parts of the world, vaccines have elicited notably high levels of reluctance and even opposition. Called vaccine hesitancy:

[it] refers to delay in acceptance or refusal of vaccination despite availability of vaccination services. (MacDonald 2015).

Despite strong recommendations by health authorities and availability, people refuse to vaccinate themselves and their families. Often, such a stand is more prevalent in particular communities. Vaccine hesitancy is as high in some affluent American locales as in distant Afghani villages. The WHO attributes increasing deaths from some infectious diseases to lower vaccination rates. Some health authorities assert that religious belief strongly influences vaccine acceptance. Islam is a prime focus of attention because some vaccines use pork gelatin as a stabilizing agent, and pork consumption is proscribed in Islam (and Judaism). Porcine gelatin is cheaper, readily available, and gives longer shelf life to vaccines. Vaccines free from porcine gelatin exist. In affluent nations like the UK, hardly any vaccine has porcine gelatin, and for the couple that do, there are alternatives. But, in some countries, the issue has been critical:

In 2018, vaccination rates fell to as low as 8% in some provinces in Indonesia after a fresh wave of confusion erupted over whether vaccines were acceptable under Islamic law. In one district, an outbreak of 800 cases of measles resulted in the deaths of 72 children. (Proto 2019).

Inclusive communication with the public and religious authorities can reduce misunderstandings about the vaccine and its acceptability on religious grounds. In Nigeria, especially in the predominantly Muslim northern provinces, polio vaccination stalled for a long time due to misinformation and religious concerns. But a sustained campaign to build trust turned it around. After marking three years since the report of the last case of polio, Nigeria was at last certified as polio-free on 21 August 2019. Resistance to measles vaccination on religious and other grounds remains an important issue in many nations, primarily Muslim but in some other nations as well.

Politics affects vaccination rates. Pakistan and Afghanistan are the only two nations where wild-type polio remains endemic. The Taliban has promoted polio vaccination in Afghanistan. Still, the effort has been stalled by the humanitarian crisis caused by Western imperial intrusion and the vindictive policy towards that country adopted by Western nations after they withdrew their armies. In Pakistan, a major drive to extend vaccine coverage into remote villages has been underway for a while. It reached a crescendo in late 2020.

Despite heavy rain and flooding in several provinces, Pakistan’s national polio immunization campaign reached over 39 million under-five children with the polio vaccine. More than 260,000 trained front line workers went door to door and, in the context of COVID-19, were equipped with personal protective gear, to ensure the safety of children, caregivers and polio workers. (Mansoor 2020).

Yet, a fundamentalist Islamist faction was determined to halt the vaccine drive. Its militants assassinated health workers involved in the vaccination effort and their guards. In the latest drive, in August 2022, a vaccination team and their two police guards were attacked by gunmen. The guards were killed, but the health staff escaped injury. The militants claim that the vaccine contains pork, and the vaccine drive is a Western plot to sterilize the Pakistani population. These false claims received a significant boost in 2011 when the US CIA launched a fake polio vaccine drive to locate and assassinate Osama Bin Laden, the Al-Qaeda leader. It took a while before the general public's faith in the polio vaccine was restored.

Does inordinate attention to vaccination divert attention from the key social and economic factors affecting health and diseases? Neoliberal policies of relying on private healthcare pursued in almost all nations constitute a significant barrier to improved health for everyone except the wealthy. Vaccines are vital, but so is the improvement of people's living standards.

COVID-19 Vaccination

The COVID-19 pandemic prompted a concerted global effort by scientists, health agencies and pharmaceutical companies to produce safe and effective vaccines against the virus. By December 2020, nearly 200 potential vaccines were under investigation, and 52 candidate vaccines were being evaluated in Phase III human clinical trials. The first vaccine to gain official approval was the Convidecia vaccine from China. Tested on 40,000 subjects in Argentina, Chile, Mexico, Pakistan, Russia, and Saudi Arabia, it was approved for use in China and some other countries in June 2020, just eight months after the onset of the pandemic. In the US, the first FDA approval for a COVID-19 vaccine was granted in August 2021 to the Pfizer–BioNTech COVID-19 vaccine. Usually, it takes several years for a vaccine to obtain official approval. However, the acute pandemic situation necessitated approvals on an accelerated basis. Monitoring the safety and efficacy of COVID-19 vaccines continues.

Some COVID-19 vaccines utilize the conventional inactivated virus or viral subunits approach. But others use gene-based technology to develop what are known as messenger RNA (mRNA) and DNA vaccines. Compared to traditional vaccines, these vaccines generate a more robust and long-lasting immune response, are more cost-effective, can be readily adapted to large-scale production and have a built-in flexibility to deal with new viral variants. While mRNA vaccines need special storage methods to retain their potency, DNA vaccines carry the risk of inducing a permanent change in the host genome.

Global health inequalities impacted the delivery of COVID-19 vaccines to the world population. People in the wealthier nations stood first in the line. However, the gap was partly closed with resources obtained under the WHO-led multinational, multi-agency COVAX facility.

By the end of 2021, nearly all countries had introduced COVID-19 vaccination, and by early 2022 one billion doses of COVID-19 vaccine had been delivered through COVAX. (WHO 2023a).

Yet, the strong influence of the Western vaccine manufacturers and the policies of their governments undermined the goal of global equity. Further, the COVID-19 pandemic diverted resources away from other major health issues. It raised the global count of children not getting the traditional vaccines from 6 million in 2019 to 25 million in 2021. Poor children in poor nations were particularly affected. Such an outcome was not inevitable. It was primarily caused by the priorities of dependent, neoliberal governments (Chapter 9).

Vaccination Rate

Suppose the health authorities in a community of N = 1,200,000 people require all people to be vaccinated against a disease X. Assume three types of vaccines, V1, V2 and V3, are available. V1 is a single-dose vaccine, V2 is a two-dose vaccine, and V3 is a three-dose vaccine.

For a particular time point, we define N1V1 as the number of people who have received one (and the only) dose of V1, N1V2 as the number of people who have received one dose of V2, N2V2 as the number of people who have received both doses of V2, N1V3 as the number of people who have received one dose of V3, N2V3 as the number of people who have received two doses of V3, N3V3 as the number of people who have received all three doses of V3.

The number fully vaccinated (NFV) as of this date comprises people who have got all the required doses of their particular vaccine:

NFV = N1V1 + N2V2 + N3V3

and the number of partly vaccinated (NPV) is

NPV = N1V2 + N1V3 + N2V3

and the number not at all vaccinated (NNV) is

NNV = N - (NFV + NPV)

And the full vaccination rate (FVR) as of this date is:

FVR = (NFV / N) x 100

Assume that by 1 May 2023, N1V1 = 300,000, N1V2 = 200,000, N2V2 = 150,000, N1V3 = 200,000, N2V3 = 150,000, N3V3 = 100,000. Then

NFV = 300,000 + 150,000 + 100,000 = 550,000

NPV = 200,000 + 200,000 + 150,000 = 550,000

NNV = 1,200.000 - (550,000 + 550,000) = 100,000

FVR = (550,000/1,200,000) x 100 = 46%

Now, consider a somewhat different scenario. Let us assume that in a population of size N = 3,000,000, vaccination against X is required only for those aged 18 and over, who form about 50% of the total population. The target population (NTP) for the vaccine is 0.5x3,000,000 = 1,500,000. Suppose we are again dealing with three vaccine types and vaccinated numbers are as above.

Then NFV = 550,000; NPV = 550,000 and NNV = 1,500,000 - 1,100,000 = 400,000. Here, the full vaccination rate for the target population is

FVR = (NFV / NTP) x 100 = (550,000/1,500,000) x 100 = 37%

Nations use different combinations of vaccination types and varied schedules for the second or third dose, where needed. Further, many report COVID-19 vaccine program results regarding total vaccine doses administered. If only a single dose of vaccine is used, then vaccine doses administered (NVD) equals the NFV.

Consider a community with a target population N = 1,200,000 where only a two-dose vaccine (V2) is used. The official report says that NVD = 1,000,000 doses have been administered. The conventional estimate of the total vaccination rate is obtained by assuming that half of the number of doses equals the number fully vaccinated and using the formula:

FVR = (NVD / 2N) x 100 = (1,000,000/(2x1,200,000)) x 100 = 42%

Suppose a detailed computerized examination of the vaccine record reveals that 400,000 (NPV) people had received only the first dose and 300,000 (NFV) had received both doses. Then, the true full vaccination rate is

FVR = (NFV / 2N) x 100 = (300,000/1,200,000) x 100 = 25%

Hence, the commonly used method to estimate FVR gives an exaggerated picture of the success of the vaccination program. When it is used in conjunction with an inaccurate estimate of the target population and other data errors, it can give a total vaccination rate of more than 100%.

Consider the official COVID-19 vaccination data from Indonesia as shown in Wikipedia (2023 - COVID-19 Vaccination in Indonesia). In a table giving data up to 8 January 2023 by province, the target population for Jakarta province is given as 8,395,427, the number of people who have received the first dose is given as 12,636,915, the number who have received two doses is 10,927,844. The full vaccination rate is given as 103.46%. In another table showing the breakdown of vaccination data up to 5 February 2023 by societal group, the target population size for Health Professionals is given as 1,468,746, the number of health professionals who have received the first dose is given as 2,049,957, and the first-dose vaccination rate for this group is declared as 139.57% which is the same as (2,049,957)/(1,468,746).

How can the size of a vaccinated group exceed the target population? How can the vaccination rate for a defined population exceed 100%? This problem is also seen in COVID-19 vaccination reports from other nations.

Another concern is with data accuracy, especially in a large population. Large numbers of sites for vaccine administration, errors in data entry and compilation, variations in data submission times, and improper conduct at some vaccine sites may render the totals at the center somewhat inaccurate. Minor errors can add up. As the Wikipedia page on COVID-19 vaccinations in Indonesia cautions:

Vaccination numbers may not be accurate due to different calculations, cut-off times, and sources from the government. (Wikipedia 2023 - COVID-19 Vaccination in Indonesia).

When data are error-prone, reporting them with a high level of accuracy is, as noted earlier, not advisable. Consider vaccination results over two years in a population of about 315,000,000 people. Declaring that the target population is 315,151,397 and the fully vaccinated group is 209,007,451 reflects spurious accuracy. Populations change over time, and population counts are never that accurate. It is better to use a rounded mid-period estimate, say 314,000,000 for the population count and state the full vaccination count as 209,000,000. And instead of stating that the FVR is 66.32%, it should be declared as 67%. Under uncertainty, rounding is prudent, a practice often lacking in reports of COVID-19 statistics.

Herd Immunity

The spread of the virus in a community may be controlled by the imposition of barriers that block or reduce the chances of a person-to-person jump of the virus. Masking, social distancing, travel restrictions, closure of public spaces, and lockdowns are the commonly used non-pharmaceutical methods to control the spread of the coronavirus. But they cannot be continued indefinitely. If complete eradication of the virus is not possible, long-term control requires the development of herd immunity.

Herd (community) immunity is a central concept in viral epidemiology. It indicates how a viral epidemic is controlled by immunity spread through the natural spread of the virus or by vaccination. Consider a simple example. A large square hall of 100 meters by 100 meters is divided into four square rooms of equal size, designated A, B, C & D, divided by temporary but impenetrable wooden walls.

Room A has people afflicted with an air-borne viral disease (the infected), Room B and Room C have people who do not have this infection and are not vaccinated against it (the susceptible), and Room D has people who have taken the full dose of an effective vaccine and are not carrying the virus (the immune). When the barriers are removed, the people can intermingle, and the virus may jump from the infected to the susceptible.

Consider the four different settings given below:

Setting 1: A = 380, B = C = 300, D = 20

Setting 2: A = 200, B = C = 300, D = 200

Setting 3: A = 20, B = C = 300, D = 380

Setting 4: A = 2, B = C = 200, D = 598

The full vaccination rates for settings 1 to 4 are 2%, 20%, 38% and 59.8%, respectively. The proportions infected for settings 1 to 4 are 38%, 20%, 2% and 0.2%, respectively. It is apparent that the possibility for the virus to jump from the infected to the susceptible is reduced as we progressively move from settings 1 to 4. The vaccinated constitute a barrier between the infected and the susceptible. This phenomenon is known as herd immunity. To stamp out the virus, it is not necessary to attain a 100% immunization rate, particularly if other public health measures are being widely observed.

The natural spread of a mostly non-fatal virus through a community also results in herd immunity. The infected develop antibodies that enable them to ward off another infection. As their number increases, they form a barrier against the further spread of the virus. Whether attained through natural spread or vaccination, the minimal proportion of immune individuals required to halt the pandemic effectively is called the threshold level for herd immunity.

The herd immunity threshold for measles, one of the most infectious diseases, is about 94%. For SARS-CoV-2 variants of concern, such as B.1.1.7 (Alpha), the threshold is about 80% and it may be higher for newly emerging variants like B.1.617.2 (Delta). (Bolotin et al. 2021).

Some governments initially did not accept the strict control measures set by the WHO and focused on the natural attainment of herd immunity for controlling the pandemic. For example, the UK government under Prime Minister Boris Johnson initially allowed workplaces, bars, entertainment venues, restaurants, schools, universities, and churches to operate normally. It was felt that the ensuing spread of the virus would rapidly generate herd immunity. Broad-based testing was halted, and, critically, no special steps were taken to protect the elderly in care homes, a high-risk group for serious COVID-19. Protecting the economy was the underlying rationale. Though his scientific advisors backed him, the death toll mounted, and the policy was abandoned. A subsequent evaluation of the policy indicated:

The U.K.'s initial response to the corona virus pandemic ranks among the worst public health failures in the country's history, causing many thousands of avoidable deaths… (Neuman 2021).

The natural herd immunity approach contrasts sharply with the Chinese policy on pandemic control. From the time of emergence of a few cases and deaths, China instituted complete lockdowns in affected areas and instituted a community-wise testing and contact tracing protocol. It was known as the zero-COVID policy. Most governments opted for a compromise between the natural herd immunity policy and the zero-COVID policy, modulating control measures as warranted. But the implementation of their policies differed widely, producing, in some cases, avoidable disasters and, in other cases, laudable outcomes. Note that the WHO recommends gradually easing lockdowns after two weeks of successive decline in daily detected cases.

‘Flatten the curve’, a phrase often encountered in discussions of the coronavirus pandemic, refers to the graphs of either the cumulative number of cases or the cumulative number of deaths from COVID-19 shown over time. The flatter the curve, the more successful the pandemic control policy.

Virus Reproductive Rate

Viruses block efforts to control them through random mutation and selection. The coronavirus is adept at spawning more transmissible variants and sub-variants. In less than three years, from the index Alpha variant, it generated the Beta, Gamma and Delta variants, and now the Omicron variant. The new variants may further inhibit control efforts and reduce the efficacy of the existing vaccines.

The rate at which a new virus spreads across a community depends on its biological features, including the mode of transmission, the prevailing social and economic conditions, and the behavioral characteristics of the people. The average number of uninfected persons an infected person infects under these conditions is known as the Basic Reproductive Rate and is denoted by R0. If R0 is greater than 1, the virus will progressively spread throughout the community, and if it is less than one, it will gradually be eliminated. The R0 for influenza is about 1.5.

According to the WHO, the R0 value for the Alpha variant of the coronavirus was around 2. Thus, at the inception of the pandemic, an infected person infected two persons on average. By the time the Delta variant emerged, the R0 value went up to about 5, and the Omicron variant is estimated to be about 8. A new variant does not necessarily have a higher case fatality rate. Thus, R0 represents the ability to spread, not the seriousness of the impact, of the virus variant.

Pandemic control measures affect the viral transmission rate. If they work, the virus reproductive rate is lower. The rate under the new conditions is called the Effective Reproductive Rate and is denoted by Re. The Re value for the Omicron variant is about 4, which is more than twice the Re value of the Delta variant.

Herd immunity implies that for viral spread to be contained, not everyone has to be vaccinated. Epidemiological modeling shows that the threshold or minimal vaccination level, TVL, is related to the virus reproduction rate (R) and vaccine efficacy (VE) by the formula:

TVL = (1 - (1/R)) × (1/VE)

Where vaccine efficacy is the relative proportion of vaccinated people protected from acquiring the disease (or another outcome) as compared to non-vaccinated people. VE varies from zero for a useless vaccine to 1 for a perfect vaccine. No vaccine is perfect. Depending on the outcome (symptomatic disease, severe disease, or death), vaccines tested for coronavirus vaccines have efficacy levels ranging from below 50% to over 90%.

Assume that a viral variant has the reproductive number R = 4 and vaccine efficacy for symptomatic disease VE = 0.90. Then, the proportion of people who need to be vaccinated to prevent this outcome in the community

TVR = (1 - (1/4)) x (1/0.9) = 0.83

Hence, vaccinating 83% of the population would enable the attainment of effective herd immunity.

For COVID-19 vaccines, lower than desired vaccination levels are not just due to practical and technical reasons. Vaccine hesitancy is a