It has been a bit too long since the last entry having been buried by teaching and marking. The online environment is just a huge amount of work for less quality. Much has changed, and some is just the same. The vaccine announcements of recent weeks have been both staggering and disturbing. It is clear that the worst fears of a pecking order of states gaining access to the vaccine has come to be. 2021 will see at best limited access to vaccines for the majority of the world’s population, despite a great deal of signalling to the contrary. The only possible routes at present seem to be in countries, such as India, where manufacturing capacity will grant licenses and options for supply. China and the vaccines emerging there will be another route, with soft power gains aplenty, providing that quality and efficacy (the two persistent bug bears of Chinese pharmaceuticals) actually help things rather than hindering.

The range of vaccines emerging is simply a scientific triumph. It has to be recognised that the speed of development is unprecedented and comes close to being the single biggest scientific achievement of any period in history. It has been plagued by misinformation from the anti-vaxx camp flooding the internet, this abetted by the slow release of data from the firms, and publication by media release. There is also reported cyber-hacking of various nodes of the vaccine supply chains. But despite this, it all feels like the beginning of a very long end, if vaccines and supportive technologies can be made widely and freely available. This is a big if.

Not for the first time, life saving medicine revolves around the WTO. We are very much still in the two camps of access to medicine that we found ourselves in the late 1990s with HIV. It is clear that there are ethical, medical, public health and cost-benefit grounds for ensuring global access to vaccines. This is perhaps even more compelling than with ARVs, somewhat cynically the calculus of global public goods is amplified by the need for global herd immunity. While this calculus was also present for HIV transmission and the role of ARVs in progressively reaching undetectable viral loads (U=U), the highly infectious nature of SARS-COVID makes global access seem much more pressing. But we still face the same hurdles in the global patent regime and the steadfast defence of monopoly private rights.

The South African government in conjunction with India and other have made submissions to the WTO and TRIPS Council for a patent waiver on all COVID-related technologies. The South African submission was absolutely superb, a crystal clear case for the suspension of the old normal and as to why the patent waiver is needed to get the vaccines out there in conjunction with other technologies for diagnosis, prophylaxis and treatment. The alliances are familiar here, both in terms of the challenging states and the civil society players. But the opposition is still centred around the grand alliance of core states and pharmaceutical firms, nothing at all has shifted except Brazil under Bolsanaro. That country joins Australia, Japan, Canada, the USA, the EU members and UK as the countries opposing the patent waiver. All the amazing scientific effort has transparently been supported by tax dollars in this case, as it has with many of the major drug and genetic technologies over many decades. It is commodified and rights are championed still in some bizarre mixture of nationalism, comparative national advantages, and lobby and revolving door. Nothing appears to have changed, but the consequences are just as alarming as they were with HIV, before the dam broke in 2002.

We are now in a position where 80% of the foreseeable production line for the Pfizer candidate is accounted for by the USA and UK. Other of the leading candidates have the same advance purchase commitments. China has also committed to pumping out vaccines, with the caveats above still an important consideration for how that goes.

In the meantime the second, and third waves of the pandemic are in full swing in almost any region that you choose to look too. Russia and Brazil are bot reporting nearly 30,000 cases per day this week. Turkey, a model of public health response in the first six months of the pandemic, has finally seen over 30,000 cases in a single day. Belgium still has one of thee highest death rates of any country, and most of continental Europe is in various stages of seeing huge and sustained spikes. My own family is locked down in Wales, where there is only a modest respite against the recent cataclysmic surge.

But the situation in the USA is dire. While there is telling criticism of those viewing the pandemic through an American lens, it is very hard to look away from what is horrific. The CDC seems back online, having shed its simpering dependence on Trump’s threats to careers and autonomy. But the administration is AWOL and at the same time still corrosive. Leadership is long since absent having deeply failed to generate any response other than destructive messaging or retarding state level capacities and efforts. The upshot is that there are now an astounding 200,000 infections each day and 14.3 million infections, with close on 280,000 deaths. How big will be the final tally of avoidable deaths come the end of this winter. I saw one projection of a sorry 600,000 fatalities. The grisly metrics reveal carnage on the ground. The infections of November have now converted into record hospitalisations, and these to deaths.

It is reported that COVID in the USA has shaved off a one year of the life expectancy of citizens to December 4^th. At the hospital level the picture is grim, grim, grim. 38 states have seen two weeks of very steep rises in admissions. Triage, a neutral word perhaps, is increasingly the norm. Patients waiting in corridors or cars, or being sent home with oxygen. Families in some states are appealing on Facebook to hospitals out of state for ICU beds for loved ones. The Atlantic, venomous to the neglect that has produced this situation, predicts 3,000 deaths per day in just over a week – by mid-December. This will be so tough to maintain at the service level, and healthworkers will need so much support to emerge from this with any shred of mental health left intact by the carnage created by others.