A New Zealand doctor at the centre of efforts to combat Covid-19, Ebola and other viruses in developing countries is calling for richer nations not to hoard the vaccines. By Clare de Lore.
Ask Dr Clair Mills if one Covid-19 vaccine is better than another and her response betrays the frustration of someone who would just love to get supplies of any of them.
"Everyone wants Pfizer. And the Johnson & Johnson one, it requires only one jab. But we should be bloody grateful to scientists and manufacturers that we have all these vaccines. They're all good."
For the past four months, on a "break" from her Paris base, Mills has been running a global operation for Médecins Sans Frontières (MSF – Doctors Without Borders) from her bach near Matapouri, in Northland. In some ways, it was a holiday –hot, sunny days with twice-daily dips in the sea – but every evening, Mills turned her attention to some of the world's Covid hotspots, some in Europe but mostly in Africa.
She worked from mid-evening until the wee small hours of the following day, liaising with her teams around the world. She spoke to the Listener before returning to the French capital late last month, just before Auckland returned to Level 3 and the rest of New Zealand to Level 2 restrictions.
Mills has spent three decades in international emergency medicine. In 2015, she was recruited to help sort out the international response to the Ebola outbreak in Sierra Leone that took 3600 lives over 18 months. She's worked in conflict zones including Sri Lanka, South Sudan, Mozambique and Papua New Guinea.
A former GP and medical officer of health for Northland, Mills is well placed to compare New Zealand's pandemic experience with the broader international picture. Now the medical director for MSF, she sends teams of doctors and nurses to places where health facilities are in crisis, or virtually non-existent. But unlike challenges such as Ebola, which was largely geographically contained, Covid 19 is a one-in-100-years pandemic.
"It's pretty grim in Paris still. And in the field, there has been lots to do, not just for Covid but all the usual other problems. We're quite concerned about Covid in West Africa. There's been a surge in Senegal and we've seen more cases again in Burkina Faso.
"There was a big surge of the South African variant in December and January and into February. Our teams in Malawi were pretty busy there."
MSF finds it hard to get good data on how many have died from Covid and is using aerial surveillance of gravesites. "We've access to a University of London study comparing satellite images of grave sites with their size in the past. In Congo, and similar countries, there is pretty poor on-the-ground reporting. We are about to do a mortality and seroprevalence survey in Lubumbashi, in the Democratic Republic of the Congo. There's been a big wave there."
Seroprevalence tests measure antibodies to Covid and MSF is employing them among not only patients, but also its own staff.
"You're looking at measuring the antibodies that people have developed against Covid and that gives you an idea of past infection rates. In Yemen, we've been testing our staff and we think that probably two thirds of our staff there became infected, so that shows you the size of the first wave there.
"We're also testing blood donors in Mali, and it looks like about 25 per cent are positive. And these are healthy young people. It's not passed on through blood, but we did this because there isn't a lot of access to other testing, certainly not PCR [nose swab testing]. Now there are more rapid tests available, mostly still pharyngeal [throat swabs], but you do a rapid test rather than PCR."
About 30,000 MSF staff are working around the world, most of them volunteers. Most frontline staff are not yet vaccinated against Covid-19, Mills says.
"In Yemen, there isn't any vaccine. And we have taken the position that we want all healthcare workers to be vaccinated – the people who drive, those who do our logistics, the people who do the community work in high-risk populations.
"That makes it tricky to say MSF workers should be vaccinated ahead of people in the health ministries, for example.
"Another problem is you cannot actually buy the vaccines, although the numbers we need are small, while countries are buying millions of doses."
Mills wants as many countries as possible to get behind the World Health Organisation-linked Covax effort to provide equitable access to vaccines for all countries.
The New Zealand Government has just secured 8.5 million doses of the two-shot Pfizer/BioNTech vaccine on top of the 1.5 million it had already ordered – enough to vaccinate almost the entire population of 5.1 million. It also has orders in place with Janssen, Novavax and Astra Zeneca, sufficient to inoculate a further 14 million people if all orders are fulfilled.
The over-ordering of vaccine isn't uncommon, especially among richer countries, but it has been a source of irritation for crisis-response doctors in less-developed nations. "At the beginning, no one knew which vaccine would work; people hedged their bets and put in orders for three or four different ones, and that's understandable," says Mills. "But now they all look pretty good. Obviously, there will be some concerns about the variants and future variants but, in principle, if you want to prevent severe disease and reduce transmission, they will all be reasonably effective. Now it's time to get rational and release those orders for others who need it."
The Government says it is developing plans to ensure other countries in need benefit from any surplus supplies here.
As for Covid testing, Mills agrees that the PCR nasal swab test is the gold standard, but she is also an advocate for faster, cheaper and less-invasive tests, including saliva tests, which are not favoured for general use by our Ministry of Health.
"Any test will give you a better predictive value if you've got lots of Covid going on. The 'problem' in New Zealand is there's not much Covid. And if your test is not very sensitive or specific, then your predictive value is not going to be great.
"On the other hand, you can do saliva testing every day and you're going to have a better chance of picking something up. It's much more comfortable than having something stuck up the back of your nose. Anything that is quick, rapid and painless has got to be an improvement on the nose swab."
She adds that laboratories are making good money from PCR testing and are unlikely to support a move away from it.
Mills knows the frustrations of lockdowns and restrictions – she spent half of the last year in various states of lockdown in Paris, then two weeks in managed isolation in New Zealand. But overall, New Zealand's approach compares favourably with the countries her teams are working in.
"I admit, I didn't initially think an elimination strategy was possible. But it has been a very good strategy for New Zealand and economically we are doing better than a lot of countries. The rest of the world is such a mess. Some are having a terrible time. The next issue, for me, is how we look after the people that are most affected – whether by Covid or the lockdowns."
She is concerned about the effect of lockdowns and isolation on mental health, and for people who have had diagnosis and treatment for other medical conditions delayed. But she is cautiously optimistic for the future.
"Coming out of this, if people think we're going to get back to normal, they're wrong. And if they think getting vaccinated is going to be the cure, that's also not right.
"I think there will still be some limitations on travel for at least another year. But we have some answers in terms of both public-health measures and vaccinations. There's still a lot to understand but we know so much more about Covid than we did this time last year."
Want to help? To learn more or to donate to MSF, visit msf.org.nz