What currently determines spread? It is a combination of the virus’s virulence, and the availability of vaccines and population level immunity. Mortality will relate to outcome to therapeutics for the very sick.

Epidemiologists and virologists monitoring the strains of the virus in circulation are forever looking out for strains which are more transmissible, that cause more severe disease and that has significant immune escape, which would mean that people would really need to get revaccinated right away. Surveillance categorises them into variants of interest (VOI) Variants under Monitoring (VUM)/ Variants of Concern (VOC).

Globally, SARS-CoV-2, JN.1 is currently the most reported variant of interest (VOI, now reported by 115 countries), and accounted for 90.3% of sequences. Its parent lineage, BA.2.86, has been declining and accounted for 2.2% of sequences. The overall evaluation is that these virus strains are of low additional public health risk at the global level. The WHO is currently tracking (7) five VOIs: XBB.1.5, XBB.1.16, EG.5, BA.2.86 and JN.1; and three variants under monitoring (VUMs): XBB, XBB.1.9.1 and XBB.2.3.

Evolutionary biologists who study evolution of these viruses inform (7) us that the trend is towards viruses becoming less severe, and spreading more rapidly at times, but with less injury.  Many respiratory viruses like RSV have shown such a pattern. Seasonal flu also behaves similarly, although from time-to-time there are antigenic shifts that could lead to a dangerous epidemic affecting adults as well as children. Other influenza B type viruses do not change as much, and therefore they break out in children who have no past exposure to the virus.

Pandemics have occurred many times in the past and quarantines have been imposed. But such lock-downs are unprecedented. Even the term is new to public health, and cannot be found in any standard text-book. Lockdowns are often discussed as part of non-pharmacological interventions which is partly true but largely misleading. In a quarantine those who are suspected of having been infected are kept in isolation till the disease manifests itself. It could mean the population of a particular city if the disease is known to have spread widely there. But in a lock-down, it is the healthy population who are being quarantined from being exposed to an unknown source of disease as a form of interruption of transmission. In India, it was expressed as preventing community transmission from setting in. If that was indeed the goal, it miserably failed. If the objective was to give time for counter-measures to become pandemic-ready, or of reducing cases from peaking and preventing overwhelming of hospitals, then there could be a case for a judicious, evidence-based application of some social restrictions.

We now know a lot about the adverse impacts of the lockdowns. There are now a significant body of publications on lockdowns. Several studies that have documented the adverse impact of lockdowns on food security, on livelihoods, on the economy, on education, on mental health and on gender relations (12). Most of these studies have also pointed out huge increases in inequity on every economic and social parameter.  Not only journal publications, but there are many books as well. One example of such documentation are the case studies from India, Angola, Argentina, Ghana presented in the book Pandemic Response and the Cost of Lockdowns (13) . In particular Kunal Purohit’s chapter “How the World’s Harshes Lockdown Unleashed a Humanitarian Crisis” documents how it led to the largest and most rapid human migration seen in India since the Partition. Another detailed source material on the impact of the lockdown on the poor is the book- Covi 19, a view from the margins, edited by Yogesh and Sarah (14).

There are a number of studies and papers on the loss of lives due to disruptions in different health programmes, and this includes tuberculosis and HIV control, care in pregnancy, child immunization, non-communicable diseases, cancers and mental health. What we do not know with the same degree of certainty is whether the lockdowns helped reduce the spread of the virus and the morbidity and mortality associated with it, and whether these benefits outweighed the hardships and loss of lives the pandemic-induced lockdown caused.

But would that balance of benefits and risks apply to population groups across countries and within countries where the vaccines never reached, or reached far too late and too inadequately? Were the lockdowns worth it? We have almost no publications in this area.

The Royal Society study, examining this question for high income countries, concludes that “The effective application of NPIs ‘buys time’ to allow the development, evaluation and manufacturing of such therapies and vaccines at scale. So, there is every reason to think that the application of combinations of NPIs will be important in future pandemics, particularly at early stages with novel pathogens when there are knowledge gaps and when therapeutics and vaccines are not yet available.” Fair enough. But what about other populations like in Africa where there were stringent lockdowns, but the vaccines never reached.

A related question is about the stringency and proportionality of lockdowns and the ways used to enforce the lockdowns. A lockdown could be a universal stay at home order (or curfew) where only certain essential services were permitted, and even this was defined narrowly. It could mean closure of public transport, or of all transport including personal vehicles. It could mean shutting down of markets. It could mean closure of work-places and of schools and other educational institutions. The stay at home could be 24 hours long, or it could take the form of night curfews or weekend curfews. The boundary of the shut-down could be a block of apartments or a street, or a concentric circle of a few kilometres around a known disease incidence, or the whole town, or district, or province or country. Many of these decisions were taken by the security apparatus of the government with little reference to the public health community. But has this been subject to public health review since?

Those who agreed with more stringent lockdowns were generally those with good social security, and living conditions and where work-from-home possibility existed. For them the precautionary principle was everything. An example “We do not want to send our children to school since we are afraid they would get covid. We know that covid has no serious adverse effect in most children, but we have to be cautious since it may have a long-term effect. And even if it is only one or two children why take the risk.” Or the argument may go “we know that covid 19 does not spread much in an open environment. The probability of catching the virus from someone going past in a scooter or walking past you on the road is very low. But it is possible. So why not insist on mandatory enforced masking even in such circumstances.”

But for those with no social security, or who need to go to work daily, or where living conditions are poor, it is proportionality that is the main issue. Is the suffering and risks that a specific population faces due to restrictions outweigh those faced due to the disease? Would not the principle of Common but Differentiated Responsibilities and Respective Capacities, which has been applied to medical counter-measures, equally apply to the issue of social restrictions?

The reality is that we really do not know the answers to any of these questions, and there is little ongoing research or expert committees at work trying to answer them either. The chances are that if we have another pandemic, we may experience the same madness all over again, with little learnings even in finetuning decisions and processes of social restrictions better than we did before. Several chapters in the book (13), “Pandemic Response and the Cost of Lockdowns”, looks at some of the determinants of this silence.. It has some chapters that reflect on why such an enquiry did not take place.  One of these is the way the boundary of what could be debated got drawn within the policy community and in the public discourse, with some considerations a priori being labelled as inconsistent with a scientific outlook. In high income countries, right-wing politics, made an uneasy alliance with science sceptics and industry interests to deny the seriousness of the pandemic and this made democratic discussion on these issues within the scientific community difficult, with sceptics of the lockdown having to subscribe to the group-think on the issue. Second, was the systematic ignoring of proportionality and equity concerns, in favour of an overly precautionary approach. And third, was the difficulty of challenging any opinion which was considered as “rooted in science” as identified by whoever were declared the authority figures within science.  One author (of the chapter on proportionality of response) concludes: “To be fair, the respective ideas whose far-reaching absence in the public discourse I bemoan in this chapter- thinking more about the costs of lockdowns to freedom, questioning the relevance of average age of the people dying of covid 19, questioning the preference given to the protection of life over other considerations- were all at one point considered and discussed. But they were rejected too quickly and eradicated from the realm of respectability too fiercely, leaving the lockdown endorsing strategy as the only acceptable one and pushing the discussion of alternatives into the public sphere.” (page no 167)(13).

The issue of innovation, manufacture and access for the future dominates discussions at the global stage. One recent development was that closure on Dec 31, 2023, of COVAX, the multilateral mechanism established to accelerate the development and manufacture of  Covid 19 vaccines and support equitable access to vaccines. This mechanism had been launched in 2020 by the Coalition for Epidemic Preparedness Innovations (CEPI), GAVI, the Vaccine Alliance, UNICEF, and WHO. In an article in Lancet (17) , marking the closure, the achievements of COVAX are described as “delivered almost 2 billion doses of COVID-19 vaccines and safe injection devices and nearly US $2 billion to support vaccination campaigns…. enabled by agreements with 190 economies across all income levels, making it one of the largest multilateral partnerships in modern history.” It further states “To maximise support to countries, the mechanism provided end-to-end assistance across research and development (R&D), manufacturing, policy development, regulatory systems, supply and country readiness assessments, transportation and logistics, storage, and administration, as well as monitoring and evaluation.” This narrative would be contested by most in low- and middle-income countries as the negotiations at the Pandemic Agreement show. It does not do justice to the tremendous challenges developing countries faced in getting timely access to vaccines they needed, even when excessive stocks were crossing expiry dates in high income countries.

Most independent commentaries on COVAX are far more critical. In one important comment on this issue David Legge writes (18) : “In March global cooperation around diagnostics, medicines and vaccines moved from WHO to the ‘Access to COVID-19 Tools Accelerator’, a new ‘multi-stakeholder public private partnership. The “vaccine arm” of the Accelerator was the Covax Facility which would mobilise donor funds to pay for vaccines for the 20% priority populations in low and lower middle income countries. By July however, it was clear that massive bilateral advanced purchase agreements by the high income countries would reserve most of the early supply of effective vaccines and jeopardise the fund-raising for Covax. The rise of ‘vaccine nationalism’ looks set to cause long delays in access to vaccination in many L&MICs, and significant morbidity and mortality as a consequence.” (2021). The paper recommends that solutions lie in full public funding of Covax and expansion of local production of vaccines supported by technology transfer and an immediate waiver of key provisions of the TRIPS Agreement. This was the narrative that was supported not only by wide sections of civil society, but also by most L&MICs. And this is one of the frontiers of contestation between high income nations and L&MICs in the ongoing negotiations on the Pandemic Agreement.