With the increasing rate of vaccination and the lowering number of infections, it seems that the COVID-19 storm might come under control soon. But there are other concerns such as the rise of variant strains, the aftermath of the pandemic, or the upcoming pandemics that the world needs to prepare for. Are the scientific community and political leaders of the world ready to explore and understand the causes and consequences of some of the worst possible crises?
Spectra, in a quest to answer some of these questions and dive further, recently sat down with Dr Faheem Younus, also known as the ‘COVID expert’.
Dr Younus earned his Bachelors in Medicine & Bachelors in Surgery (MBBS) from the prestigious King Edward Medical University, Lahore, Pakistan and later, moved to the US for his residency in the field of Infectious Diseases. Although his supervisor was not very supportive of his decision to pursue the so-called dying field of infectious diseases, he remained determined. Today, Dr. Younus is working as the Chief of Infectious Diseases at the University of Maryland UCH in the US. During the pandemic, he has been a pre-eminent frontline physician and COVID-19 expert.
Spectra: Although you are a well-known figure in the West, we would still want you to introduce yourself to us, particularly your journey from an MBBS graduate in Pakistan to a renowned physician in the US.
Dr. Faheem: Let me start by saying that I’m an ordinary person, and I enjoy staying like one. I graduated from King Edward [Medical University] in 1995, and was fortunate enough to start my residency in 1996. It was the HIV era. Research and development in the remaining infectious diseases was minimal. So my professor, when he learned that I wanted to pursue a career in infectious diseases, discouraged me by saying: “Why do you want to pursue a dying field?” But I was excited by the prospect of actually ‘curing’ patients.
Why do you want to pursue a dying field?
Most of the common chronic diseases like hypertension, diabetes, high cholesterol are not yet curable. Instead, patients stay on pills for the rest of their lives. However, if an infection is treated with the right antibiotic, after days or weeks, you are cured.
My professor, despite all my persuasion, kept on discouraging me. but I kept requesting a reference letter. Eventually, he gave me one and mentioned in it that ‘I discourage Dr. Younus from pursuing this dying field and yet he wants to do it’.
In life, I always follow my heart and things work out. Infectious diseases were no different. First, we tamed HIV with effective cocktail treatments. I don’t remember a single of my HIV patients getting admitted to the hospital for anything related to the virus. They come to the hospital for an accident or some other health issue, but their HIV is well controlled.
The last 18 months have been the most purpose-driven part of my professional career. At the onset of the pandemic in March 2020, I started receiving text and WhatsApp messages from all over the world. Friends and family were concerned and confused. Information was rapidly evolving and no one could wrap their heads around it. One day I shared with my family as to how I felt bad, unable to get back to every message due to my immense hospital workload. My daughter suggested that if these questions were along with certain themes, that maybe I could answer them via Twitter and everyone could find their answers in one place. I posted my first thread of “top ten myths about covid” and within days it was read by 36 million people around the world. Rest is, as they say, history.
How did your research lead you to becoming a COVID-19 expert today?
No one was an expert on COVID-19. But one could retool years of experience into learning about it and become an expert. If you are an epidemiologist, this was your opportunity to figure out the spread of the pandemic. If you are a virologist, this was your opportunity to understand the viral mechanisms and vaccine development. And if you are an infectious disease doctor like me, and you had diagnosed and treated coronaviruses before, it was your opportunity to utilize your clinical acumen and adapt to the rapidly evolving pandemic. All we had to do was to come from a place of intellectual humility and get trained on the job.
On a structural level, what exactly is the coronavirus and how does it differ from the family of earlier coronaviruses?
Coronavirus is a small RNA virus, with a genome consisting of just ~30,000 nucleotides, and spike proteins protruding from its surface. The reason COVID-19 has become a big deal is that this particular coronavirus is a new type. The human body had not seen it before and no one had the immunity against it. Many details were unknown. We are still figuring out how many viral particles one has to inhale to cause the infection.
Historically, we have observed that deaths from infectious diseases like malaria and HIV follow a predictable pattern: lower-income countries are the hardest hit than higher-income countries. But the pattern for COVID-19 deaths reported per capita describes a different trend. Wealthier countries like the USare among the worst hit. Is it mostly just a demographic variable at play or is it adaptive immunity? Could it just be the sheer under-testing and underreporting of cases and deaths in these low and middle-income countries or have certain governments simply responded more effectively than others, like New Zealand?
The answer is all of the above, plus other unknown factors that we are unaware of to date. The reasons why it has hit the developed world more are:
Number one, the mortality or hospitalization of the coronavirus increases proportionately with age. The median age in Pakistan, for example, is 23 years, whereas, in Italy, it is 47 years. Moreover, if you look at the over-65 population in Italy it is 23%, and surprisingly in Pakistan, it is only around 4%. You can change Italy with any other western country and Pakistan with any other developing country, you will see the same pattern. So, if your susceptible pool is small then you are going to have fewer deaths.
Number two, the more you test, the more you diagnose. And it is also contingent on the cultural expression in the region. For example, in Pakistan, we generally tend to avoid bad news. If somebody in the family has cancer, people prefer to hush it down or use vague words to talk about it. We feel that the patient will not be able to withstand the news and might die of shock. In the US, on the other hand, people are quite honest with patients. So, I think we may have downplayed the risks and mortality of COVID in certain countries just for the same reason. Some people were never diagnosed with COVID but might have died because of it.
Number three is travel and recreation. This virus has spread from one city to another, one country to another via travel. Western societies are highly mobile and this virus may have infected more people due to business and leisure travel. Indoor conferences, concerts, etc. were all breeding grounds for this virus.
Lastly, in some societies, individuals have incentives to get tested while in others, there are risks of getting ostracised if found positive. In two to three years we will be able to better understand these nuances—we are not going to understand them all today.
It gives me goosebumps to imagine that the scientists successfully created a vaccine from merely a genetic sequence.
While in 2020, the primary focus was around understanding COVID as a pandemic, this year, our concerns have shifted to COVID vaccines. According to you, how has the global performance been so far in terms of manufacturing and administering the vaccines? What are the positive and negative effects of it that have come to the surface?
It is fantastic that the scientific community has created a vaccine at such a short notice. Years were saved in developing the vaccine candidate as research on SARS and MERS over the past decade had already solved the mystery. It has been a collective effort starting from Dr. Zhang, the Chinese scientist who publicly shared the genetic sequence of Coronavirus on the 11th of January 2020. Can you imagine that vaccine manufacturers did not need the actual virus to begin their work? It gives me goosebumps to imagine that the scientists successfully created a vaccine from merely a genetic sequence. There was so much disease around that enrolling thousands of patients in phase 3 trials happened within months instead of years. And then, the governments poured in the funds to expedite manufacturing and FDA gave fast-track approvals. All in all, the way all the nations came together to fight the virus is commendable.
However, there are some concerns too. Vaccine nationalism is gaining momentum. Vaccine inequality is a critical issue. The rich countries are hoarding vaccines while developing countries are struggling to even vaccinate their frontline providers.
How would you rate Pakistan’s performance in terms of policies, health care facilities, and controlling misinformation?
Let’s start with America. For the COVID crisis in 2020, the US was a disaster. It has the best scientists, the best infrastructure, and the highest number of ICU beds. There was no reason for it to be so vulnerable.
I empathize with the individuals who have to choose between paying the school fees for their child versus paying for Remdesivir.
Pakistan has been a mixed bag. The positive is its balanced approach. Not relying on perpetual lockdowns and also not being dismissive of the virus. The negatives seem to be low testing, not fighting disinformation aggressively, not creating a guiding coalition of experts and politicians to unify the message, and being a little slow to vaccination. However, the lack of resources must be a major challenge for Pakistan. And I empathize with the Pakistani government and all governments that may not have resources. I empathize with the individuals who have to choose between paying the school fees for their child versus paying for Remdesivir. I think it is a very difficult choice on an individual level, which eventually magnifies to the national level.
Having said that, there were also several opportunities that did not require massive investment or infrastructure but could have been useful against COVID. Effective communication is one such example. Politicians are smart but it is not in their best interest to talk about something as nuanced as a virus. Instead, top physicians and infectious disease epidemiologists who are working on the ground should have led the communication right from the beginning. If you ask me, Pakistan should have had an hour-long question and answer show every night on prime time on most [TV] channels, where people could submit their questions and get answers. To my limited understanding, there is no excuse for the country to not do it other than human discord.
Vaccines don’t save lives, vaccination does.
Moreover, Pakistan needs to attack disinformation, and implement the use of masks and social distancing seriously. It has to tenaciously work on vaccine hesitancy so that people don’t believe conspiracy theories. Vaccines don’t save lives, vaccination does. If millions of vaccines are sitting in the refrigerator while people are reluctant to roll up their sleeves, it is of no use.
Like many other countries, anti-vaccine drives are gaining impetus in Pakistan as well. People are reluctant to vaccinate themselves against COVID, for unusual reasons, such as infertility — a stigma attached to polio vaccines as well. What measures do you suggest to the authorities to battle such beliefs? And why do you think people are harboring such beliefs?
That’s a tough one. I believe there is mistrust in most communities, including America and Pakistan. And it could be a repercussion of polarised media. We love to use and misuse information for political purposes and we hate it when it bites us.
We need a multi-pronged approach to tackle the issue. First of all, when people make an absurd claim, the burden of proof lies with them. If I claim I have seen a flying horse, you will ask me to prove it. You don’t have to prove that horses don’t fly. Similarly, in civil societies, if someone makes an absurd claim about vaccines, the question should be thrown back at the person, asking them for the proof? And if there is none, well then it is a joke and shouldn’t be entertained.
Secondly, there is an extensive vaccine track record. If you count all the billions of childhood vaccines that have been administered over the past 20-30 years, the question is, how many of those children are infertile today? If infertility was an issue, it must have surfaced on a grand scale. Instead what we see is a population explosion, not an infertility problem.
Lastly, you can lead by example. For example, Jonas Salk, the researcher who worked on the polio vaccine in the 1950s, vaccinated himself first. He then vaccinated his wife and his two sons publicly, followed by the people who were working in the lab. This generated core trust between scientists and the public. Similarly, vaccine campaigns can target the famous in the country to affirm vaccination drives. It is extremely important to have experts on board. It is called deference to expertise.
In Pakistan, the two widely available vaccines are: Sinopharm and Sinovac. What do you think about these vaccines and which one should people opt for?
Sinopharm and Sinovac are both traditional vaccines that use inactive viruses. With their extensive track record, these are the safer options. By observing their reported efficacy rate from different countries, including UAE or South America, one can see that these vaccines are effective. if they are the main options available in the country, people should get vaccinated.
efficacy can be a misleading marker; we need vaccines that prevent COVID hospitalizations and deaths.
However, I’m not saying that Sinopharm and Sinovac are as effective as Moderna, Johnson and Johnson, or Pfizer. We don’t know it yet. There have been no head-to-head trials so one can’t make that scientific statement. In fact, there is a good chance that it may not be as good, and that’s because the efficacy rate for other vaccines is very high. I was quite pleasantly shocked to learn about Pfizer and Moderna’s 94% – 95% efficacy. But even if Sinopharm and Sinovac have a 70% – 75% efficacy rate, the key point is how many hospitalizations and deaths they can prevent, not how many infections. This means even if people vaccinated by Sinopharm end up getting COVID, their condition won’t be very critical for hospitalization. And that is a triumph. Right now, efficacy can be a misleading marker; we need vaccines that prevent COVID hospitalizations and deaths.
So far, AstraZeneca, Johnson and Johnson, Pfizer, and Moderna, all four have different efficacy numbers — ranging from 95% to perhaps 70%, or 65%. But all of them are nearly 100% effective in preventing deaths and hospitalization during clinical trials. In real life, such numbers have been over 90%. How much of that will change due to variants is yet to be seen.
Although more and more people are getting vaccinated every day, there is always the chance of a new strain emerging that the vaccine might not be effective against. So, how is it all going to end? Is there ever an end for COVID-19?
There is absolutely no doubt in my mind that the pandemic will end. With every passing day, two things are happening. First, the virus’ window of opportunity is closing because of the vaccine. Second, since millions of people have been infected and recovered, their bodies have developed a certain level of immunity. As both these numbers continue to increase, the possibility for the virus to survive decreases. The novelty of this virus is ending. But the pandemic will end asymmetrically; sooner in some countries, later in others. WHO declared COVID to be a pandemic on March 11th, 2020 but we will not have a precise date in 2021 when WHO announces the end of this pandemic.
COVID’s eradication is not the goal here
But more importantly, COVID’s eradication is not the goal here. The goal is to make it irrelevant. Despite influenza killing a quarter million to half million people every year, life goes on. Influenza doesn’t shut down schools and businesses. It does not curtail international travel. But COVID did that. It brought the world to a halt. Initially, COVID’s comparison with Influenza was absurd as one was a novel virus. But as COVID’s novelty wears off, this comparison will become appropriate at some stage. People shouldn’t be hopeless. COVID is already irrelevant in many countries like Singapore, South Korea, Taiwan, China, Vietnam, or New Zealand. In many developing countries, it may become irrelevant by the end of 2021.
It is better, however, to act and make it irrelevant instead of passively hoping for things to happen. Hope is not a strategy.
Hope is not a strategy.
After facing the catastrophic crisis of COVID-19, can we say that we are now prepared for any coming pandemic? What are the major loopholes in the world’s public health policies that have surfaced during the COVID situation and what lessons do we need to learn?
No, I don’t think we are prepared. If we look at Pakistan, its medical infrastructure is frail. The number of hospital beds, especially ICU beds in the country, is 20 times less than most developed countries. Age-old public health infectious diseases like polio and rabies are still not fully under control. Politics precludes us from thoughtful investments in primary care and public health. Lack of education and influential people peddling conspiracy theory is yet another toxicity we have to deal with. How can we expect an extensive transformation in the system to prepare for a future pandemic?
Many of these challenges are true for the USA as well. Our public health systems have abysmal funding. They didn’t have enough funds to provide tests or perform contact tracings. Millions don’t have access to healthcare. Special populations like undocumented immigrants or prison populations remain vulnerable and the divisive politics are all impediments.
However, there are exceptions. Taiwan, China, Hong Kong, and Singapore were able to control COVID sooner because they learned their lessons when SARS-CoV-1 hit in 2003. They learned their lesson in 2009 during the H1N1 influenza pandemic. These countries think from a communal standpoint.
America is great for individuals to “put a dent in the universe”, as Steve Jobs said. But Steve Jobs and Bill Gates working together is a very difficult thing. America is not optimized for collective action.
I would love to paint a more optimistic picture. But unless one sees the fundamental levers of how a society operates and cares for its people, it’s hard to visualize.
How can organizations like the WHO improve their messaging? For example, there was a famous incident where the WHO said that asymptomatic transmission of COVID is ‘very rare’, and then later they had to retract that claim. The WHO explained that there had been a misunderstanding. So how do we improve these kinds of messaging fiascos?
It is a great example of how the media can amplify human errors without realizing how such reporting risks human lives. WHO was making a nuanced point at a time of uncertainty. You are bound to make some errors when the terrain ahead is unknown. For WHO, this virus was as novel as it was for others. They were constantly updating their information, issuing corrections and clarifications where needed. Their message was not confusing to me but when the media only picks a four-second sound bite out of a 40-minute media briefing without understanding the larger context, of course, it breeds confusion. To me, the WHO did a reasonably good job with inadequate funding, under adequate international pressure.
Has the entire COVID situation, in any way, helped bridge the gap between scientists/researchers and policymakers/politicians?
Yes, it has brought us all together and made us realize that none of us can win by ourselves. So, if I talk for myself, I have contributed as an educator and a frontline clinician. I have not spent hours in the lab working with the virus. I have not developed the vaccine. But I have shared my technical knowledge with patients and the world at large. Scientists have realized the opportunities to develop new vaccines and treatments quickly. The governments have realized the power of supporting scientists and politicians have (hopefully) understood that there is no way to get re-elected without keeping their citizens safe.
The pandemic has brought us together in strange ways.
Moreover, there has been a significant improvement in the public’s understanding of science. They have learned that science is not static but ever-evolving. Before this pandemic, the general public had little idea about terms like phase 3 trials, variants, false positives, or false negatives. Now my children use such words. The pandemic has brought us together in strange ways.
This interview has been edited for length and clarity.