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The Peril of Not Vaccinating the World

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When Gregg Gonsalves was a young AIDS activist and researcher, in the nineteen-nineties, he was struck by a pattern that kept showing up in the data: the distribution of antiviral medications fell neatly along socioeconomic and racial lines: wealthy people got them, and poor people, many of them Black or Hispanic, did not. Later, as an associate professor at the Yale School of Public Health, Gonsalves illustrated the persistence of these kinds of health disparities to his students by overlaying a map of pre-Civil War slave-holdings on a contemporary map of life expectancies, which, not surprisingly, showed that life expectancy was lowest in those regions. “It’s not rocket science that we’re seeing COVID-vaccine distribution following those same demographic patterns,” he told me. “We’re just remaining true to form.” According to a recent analysis of C.D.C. data by Kaiser Health News, only twenty-two per cent of Black Americans have been vaccinated, and Black vaccination rates are significantly lower than those of whites in almost every state. Much of what has been called vaccine hesitancy is actually a problem of vaccine access.

As it turns out, vaccine distribution follows a similar socioeconomic pattern all over the world, with most COVID vaccines going to what are called high- and middle-income countries. According to Nature, as of mid-March, those countries had secured more than six billion out of 8.6 billion doses. Less than a week later, the Times reported that “86 percent of shots” that went into arms across the globe were “administered in high- and upper-middle-income countries.” By early May, when less than eight per cent of the world’s population had received one dose, the Open Society Foundation estimated that the world’s poorest countries may not be able to vaccinate their populations until 2023. This disparity—what Gonsalves and others are calling vaccine apartheid—is a problem that will not be borne solely by the people living in those locales. It has the potential to undermine the gains made on the virus in places where vaccine adoption is high and a post-pandemic future is starting to feel possible.

There are two reasons that a person in London or Los Angeles should care about vaccination rates in Lagos or São Paulo: simple humanity and simple biology. If left unchecked, the loss of human life for families and societies worldwide will be staggering. Viruses are international travellers, and over time they mutate. Wherever vaccine coverage is patchy, there is selective pressure for the virus to evolve resistance. We’ve already seen robust virus variants from South Africa, Brazil, the U.K., and India spread around the world. So far, the first generation of COVID vaccines is holding the line against them, but that protection is not guaranteed. It’s possible that the virus, which has already infected vast numbers of people, won’t evolve in a way that fatally undermines our vaccines. On the other hand, some epidemiologists think that we have a year or less before the virus breaks through and renders them less effective. Pharmaceutical companies are working on shots that are as effective against the variants as they are against the original virus, but their efficacy hasn’t yet been proved. And, as the Oxford evolutionary virologist Aris Katzourakis told me, even if they do prove effective, “the idea that we could revaccinate the whole country or the whole world annually is not an easy challenge. That’s one of the reasons why many people, myself included, think that we should be exploiting the fact that we have vaccines that are incredibly effective right now.”

A race to vaccinate the world is not an effort to achieve herd immunity. At least in this country, that goal was a kind of marketing device, a way of inspiring people to abide by masking and social-distancing rules while waiting for a vaccine, and then to encourage everyone to do their part by getting immunized once vaccines were available. In the beginning, public-health officials, including Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, suggested that herd immunity would occur when sixty to seventy per cent of the population had been vaccinated. On the other side of that threshold, they suggested, was a magical return to the land of indoor dining, casual sex, and visits to grandparents. Later we were told that the number was more likely eighty per cent. Most recently, Fauci notched that number upward again, to ninety per cent. (When asked why he stuck with the earlier numbers when he knew them to be too low, he said that he didn’t think the country was ready to hear the truth.)

For reasons ranging from vaccine access to outright rejection by around twenty-five per cent of eligible Americans, getting to ninety per cent is not possible. Even if it were, we’d still likely have to contend with low rates of immunization elsewhere in the world, including at our northern and southern borders. (According to the latest Times tracker, less than ten per cent of Mexicans and only about six per cent of Canadians are fully vaccinated; the United States is rising from forty per cent.) A more realistic objective is to use mass vaccination to create a bulwark of resistance to prevent the virus from tearing through populations like wildfire. While there still would be flareups, they would die down once the virus lacked a sufficient number of hosts. But, without a concerted global commitment to vaccine equity, poorer regions will remain vulnerable to ferocious outbreaks, giving the SARS-CoV-2 virus the opportunity to evolve and, in a worst-case scenario, result in a chronic, never-ending pandemic.

Last summer, more than a hundred Nobel laureates, former heads of state, clerics, and business leaders urged the World Health Organization to designate COVID-19 vaccines “a global common good.” Their petition asked the W.H.O. to “set up an international committee responsible for monitoring the vaccine research and to assure equal access to the vaccine for all countries and all people within a publicly announced pre-determined time frame.” There were then around a hundred and seventy vaccine candidates, none of which had crossed the finish line; the most promising were still in the early phases of clinical trials. As those trials progressed, a movement also began to coalesce around the idea of a “people’s vaccine.” It would be patent-free, mass-produced, and available to everyone, in every country, free of charge.

That, of course, did not happen. As soon as the mRNA vaccines developed by Pfizer-BioNTech and Moderna proved to be both safe and effective, countries with deep pockets, like the United States, signed contracts to buy hundreds of millions of doses, eventually contracting for far more than they needed. The same thing happened later with the vaccines from Oxford University-AstraZeneca and Johnson & Johnson. If you were an American or an Israeli or a Brit, this kind of vaccine nationalism was, most likely, comforting. If you weren’t, well, it felt, as a senior Indian researcher put it, like staying behind as the first-class passengers board the plane and then watching them sip champagne while you shuffle back to the economy seats.

It wasn’t as if these disparities were not anticipated. As early as April of last year, Gavi, a twenty-one-year-old international vaccine alliance, partnered with the W.H.O. and the Oslo-based Coalition for Epidemic Preparedness (CEPI) to create COVAX, an initiative aimed at distributing COVID vaccines equitably around the world. Their ambition was to fund vaccine research while also creating mechanisms for any country, regardless of national income, to have access to those vaccines. Participating countries would receive vaccine doses in proportion to their population.

As of mid-May, COVAX had distributed sixty-eight million doses—a long way from the goal according to the W.H.O. of two billion by year’s end. (Most are formulations of the AstraZeneca vaccine.) Some participating countries, such as Pakistan and Bangladesh, haven’t received any doses from COVAX. The organization has received a pledge for direct donations of more than a billion doses from pharmaceutical companies and three and a half billion dollars from the U.S. When I asked Chris Elias, the president of global development at the Bill & Melinda Gates Foundation, what it will take to end the pandemic, getting COVAX fully funded was one key component. On June 2nd, that goal was reached.

But COVAX has been stymied by the very thing it was meant to circumvent: vaccine nationalism. One of COVAX’s biggest suppliers is India’s Serum Institute (S.I.I.), which is partnering with AstraZeneca to manufacture its COVID vaccine. COVAX contracted with S.I.I. to buy more than a billion doses, most of which were slated to go to low- and middle-income countries. But, when the second wave of infections began to devastate India, the Indian government halted vaccine exports. (India has a robust and well-regarded vaccine industry; in a typical year, it supplies sixty per cent of the world’s vaccines.) Though the Indian government has denied imposing an export ban, COVAX has informed a number of participant countries that their vaccine orders are currently on hold.

The United States, the biggest donor to COVAX, has also been under pressure to do more to help countries struggling to get more vaccines. At the end of April, the Biden Administration committed to releasing sixty million doses of the AstraZeneca vaccine to countries in need. “That’s showing up to a four-alarm fire with an eyedropper full of water,” Asia Russell, the executive director of Health GAP, an AIDS advocacy group, told the Times. The next week, Katherine Tai, the U.S. Trade Representative, announced that the Biden Administration supported a proposal before the World Trade Organization to waive intellectual-property rights to COVID vaccines during the pandemic. The move, which marked a policy reversal for the White House, was lauded by public-health officials, including the head of the W.H.O., Tedros Adhanom Ghebreyesus, who called it “a monumental moment in the fight against COVID-19.” (The Gates Foundation also supported the decision, although Bill Gates personally did not.) In theory, lifting the patent restrictions on COVID vaccines would uncouple the profit motive from production and enable nonprofits, as well as drug companies, to use proprietary formulas to boost manufacturing around the world. In other words, something akin to a “people’s vaccine.” But the W.T.O. works on consensus. Even if this proposal were to prevail—which seems unlikely, since most European countries oppose it—negotiations will take months, maybe longer. In the meantime, there will be more viral replication, and more COVID deaths.

Biden’s reversal was widely panned by the pharmaceutical industry. Pfizer, which spent two billion dollars to develop its messenger-RNA platform—without knowing whether it would prove safe and effective—expects to make fifteen billion dollars from its COVID vaccine this year. Industry representatives point to such gambles when they argue that lifting patent restrictions will discourage companies from investing in research and development. In a letter, obtained by The New Yorker, in response to calls from a group of Democratic senators, including Elizabeth Warren, of Massachusetts, and Jeff Merkley, of Oregon, for vaccine developers to share their intellectual property, Jennifer Walton, Pfizer’s vice-president for U.S. government relations, wrote, “Without a strong IP framework, we would not have mRNA vaccine technology, a breakthrough discovery that is helping to address the global pandemic. We believe the IP system is an essential facilitator to the availability of the vaccine, not an impediment or risk and remains a critical enabler of the future research that will be necessary to end the pandemic.” Walton also argued that opening up the Pfizer vaccine to other manufacturers ran the risk of shutting down the company’s own production, which is now on schedule to deliver a hundred million doses a month. “Manufacturing of our vaccine involves the use of over 280 materials,” she wrote. “These materials come from 86 suppliers in 19 different countries. If any one of the 280 different components from suppliers, however trivial, is not provided, we cannot manufacture or release the vaccine.”

The C.E.O. of Moderna, Stéphane Bancel, took a different tack. In an earnings call shortly after the Biden Administration’s I.P. announcement, he told a group of analysts and investors that he “didn’t lose a minute of sleep” over the news. In fact, in October, the company, which, unlike Pfizer, received billions of dollars from the government to develop its vaccine, had announced that it would not enforce its COVID-related patents. Having the recipe for making the vaccine, Bancel explained, was not the same as having the ability to make the vaccine. “There is no mRNA in manufacturing capacity in the world,” he told the group. “This is a new technology. You cannot go hire people who know how to make the mRNA. Those people don’t exist. And then, even if all those things were available, whoever wants to do mRNA vaccines will have to buy the machine, invent the manufacturing process, invest in verification processes, analytical processes. And then they will have to go run a clinical trial, get the data, get the product approved, and scale the manufacturing. This doesn’t happen in six or twelve or eighteen months.”

Still, some degree of technology transfer is happening already. AstraZeneca is working with the Serum Institute, as is Novavax, whose vaccine looks to be ninety-six-per-cent effective. Johnson & Johnson is collaborating with Aspen Pharmaceuticals in South Africa. The French pharmaceutical giant Sanofi has agreed to fill and pack the Pfizer-BioNTech vaccine at its Frankfurt plant. And a group from the University of Pennsylvania, which pioneered some of the earliest and most consequential work on mRNA, is working with Chulalongkorn University, in Bangkok, to build a vaccine-manufacturing facility.

Increasing vaccine production through technology transfers, although crucial, is insufficient for ending the pandemic. Elias pointed to research that shows that, without equitable global distribution, we are likely to be dealing with COVID for a very long time. Those of us in the United States and other wealthy countries may imagine that to mean living with SARS-CoV-2 the way we live with the flu. But, as Katzourakis, the Oxford virologist, told me, “The analogy we choose to draw now may paint a picture of the future we want to live in. The flu future is one possibility, but it’s a reactive one that condemns us to a perpetual race of trying to keep up with the virus, and we may find that things aren’t so simple. We’ve been blessed with vaccines whose effectiveness against this virus is absolutely remarkable. They give us a shot at potentially eliminating the virus right now in very large parts of the world. If we resign ourselves to perennially trying to keep up with the virus, we could have wasted a remarkable opportunity to rid ourselves of this disease.”


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Sunday Reading: Commemorating Juneteenth

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Juneteenth, the commemoration of emancipation, is a moment of reflection for this country. Last year, the Harvard professor and historian Annette Gordon-Reed published a piece in The New Yorker about her childhood in Texas and the meaning of the holiday for her family and community. Juneteenth and the Fourth of July were inextricably linked during those years, she notes, in part because the Declaration of Independence carried a promise yet to be fulfilled for Black Americans. “I also did not know, as a child,” she writes, “how intensely African-Americans had fought to keep alive the memory of Juneteenth—to commemorate our ancestors’ struggles and their hopes, and to link them to our own.”

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This week, as we prepare to honor the holiday and those sacrifices, on June 19th, we’re bringing you a selection of pieces about racial injustice and the abiding legacy of slavery. In “The Prophecies of George Floyd,” Michael Eric Dyson explores how Floyd’s killing sparked some of the largest protests in American history, and considers the inescapable threat of violence by police officers against Black Americans. In “The Long War Against Slavery,” Casey Cep writes about the protracted struggle of abolitionists and civil-rights activists across the country. In “Black Bodies in Motion and in Pain,” Edwidge Danticat reflects on the massacre at the Emanuel African Methodist Episcopal Church, in Charleston, and asks whether the nation will ever confront the devastating repercussions of white supremacy. (“Black bodies are increasingly becoming battlefields upon which horrors are routinely executed, each one so close to the last that we barely have the time to fully grieve and mourn.”) Finally, in “The Matter of Black Lives,” from 2016, Jelani Cobb profiles Alicia Garza, a co-founder of Black Lives Matter, and examines the powerful appeal of the movement that is helping to change America.

—David Remnick


A family at a Juneteenth celebration

A mural of George Floyd with candles, flowers, and protest signs.

An illustration of Tacky's Revolt

A painting from Jacob Lawrence's “Migration Series”

Alicia Garza
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Running: A Success Story

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Proust and the Sex Rats

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Many people have asked me, since the publication of my long review of new books on Proust, about what seemed a perhaps too-casual reference to Proust’s paraphilia—a fancy but fashionable word for a sexual fetish—somehow involving the use, or rather abuse, of caged rats. I had danced past this quickly in the essay, not out of delicacy but out of an unwillingness to linger too long on a controversial point in the Proust biographical literature, and also because to go into it in depth would have required not merely a parenthesis but something more like a relentless footnote, or what used to be called, in the heyday of glossy magazines, a sidebar. Herewith though, in response, is that sidebar, with an attempt to make sense of the anecdote, true or false.

The story of Proust and the sex rats comes in several distinct versions, in itself a marker either of multiple confirmation or of the processes of fable-making. It seems to have made its first public appearance, at least in the English-speaking world, in George Painter’s once “definitive” biography. It occurs in this form: “The wretched creatures were pierced with hatpins or beaten with sticks, while Proust looked on,” according to André Gide, because of his “desire to conjoin the most disparate sensations and emotions for the purposes of orgasm.” Painter sources the story to several different, though not necessarily independent, informants, including, in addition to Gide, the writer Maurice Sachs, who was said to have heard it from Albert Le Cuziat, the owner of a brothel Proust was known to frequent.

In the newer biography by William C. Carter, and then in greater detail in Carter’s 2006 book, “Proust in Love,” the story is repeated in more gruesome form, starting again with Proust in a brothel: “If Proust failed to achieve orgasm [from gazing at a male sex worker] ‘he would make a gesture for me to leave’ and Albert would bring in two cages,’ each of which contained a famished rat. Le Cuziat would set the cages together and open the door. The two starving beasts would attack each other, making piercing squeaks as they clawed and bit each other, a spectacle that allowed Proust to achieve orgasm.”

This version of the story is sourced to Henri Bonnet’s 1985 volume, “Les amours et la sexualité de Marcel Proust,” in which it is said to be reaffirmed by an anonymous prostitute—the quoted speaker in the passage—whose memories were recorded by the writer Marcel Jouhandeau. The, uh, tale, is further confirmed by Carter with an item in Jean Cocteau’s diaries—though Cocteau’s version, in turn, is complicated by an accompanying and not terribly clear account that Proust also somehow, within this ritual, profaned a photograph of his mother.

The story then seems to have entered the cultural mainstream when it was significantly amplified in two improbable places—stranger bedfellows in the dissemination of literary gossip are hard to imagine. The first is Nabokov’s immense, bizarre 1969 novel, “Ada, or Ardor,” in which, among much other material, there is a reference to Proust decapitating rats: “crusty Proust who liked to decapitate rats when he did not feel like sleeping”—the decapitation being a neat, Nabokovian twist not previously encountered in the literature.

Meanwhile, in Albert Goldman’s best-selling, and once notorious, 1981 biography of Elvis Presley, the story occurs again, as a thing widely known, in the course of Goldman’s discussion of Elvis’s paraphilia—reported presumably by Elvis’s own André Gide, his assistant Lamar Fike, who seems to have been Goldman’s informant on Elvis’s erotic life—which allegedly tended toward movies showing “cat fights,” i.e., half-dressed women wrestling. Goldman—a former professor at Columbia, whose descent into gossipy pop bios should not detract from the intelligence or the excellence of his biography of Lenny Bruce—used the Proust story to make the point that “mama’s boys,” as they were then known (a class that included both Proust and Elvis), might work out their ambivalent feelings about their beloved mothers in sexual play-acting. Proust’s rats were an oddly recherché literary reference for a mass-market pop biography—but that, of course, was rather the point.

From this spillover, the story can be found everywhere, with variants. So, to the core issue: Is it true? As with so many stories of the kind, it is hard to be certain. In doing the spadework a decade ago on the controversy about whether Edwin Stanton said, at Abraham Lincoln’s deathbed, “Now he belongs to the ages” or “Now he belongs to the angels,” I followed the trail of this widely circulated and poorly sourced story back to a single disseminating source—and a very dubious one, Otto Eisenschiml, a conspiracy theorist. (He believed that Stanton had conspired to have Lincoln killed.)

The source of the Proust story seems as specific, and to be primarily Gide, along with the prostitute whom Jouhandeau quotes (discounting Cocteau’s reference, perhaps unfairly but cautiously, as likely derivative of Gide). Gide certainly knew Proust, but he also had reasons to gossip maliciously about a writer whom he had, at first, patronized from a height and ignored—and then had to watch become more revered than he himself had been. And Gide presumably had a reason to bring Proust into his own orbit of ostentatious sexual experimentation, involving what we would now characterize as sex tourism and open pedophilia. (Cocteau’s diary, again, is thirty years after Proust’s death, and the anonymous prostitute’s recollection, secondhand, is not by itself definitive.)

And, then, though the fighting rats do not sound like the kind of thing one just makes up, Proust’s supposed paraphilia does seem suspiciously singular, inasmuch as it is not one that, at least to the perhaps too innocent-minded search of this writer, has any other participants. (The famous fetishes, even though odd, tend to be surprisingly widespread; Elvis had no trouble getting movies devoted to his predilection.) There are certainly sexual fetishes horribly associated with animal torture—Google, or rather, don’t, “crush videos.” But that such things exist now does not, of course, prove that they did then, and they tend now, apparently, to be associated with highly theatricalized bondage rituals.

It seems unlikely that the rat scene could quite have taken place as described. Who would keep starved rats on the premises in case a client so disposed came in? (Even a favored one, as Proust presumably would have been.) Who cared for the rats while waiting for Proust, or some other rat fetishist, to show up? Though finding rats in Paris then was no more difficult than it is now, the idea of caging fierce and starving rats for an indefinite period in anticipation of a client with this brutal taste seems improbable. The improbability of the enterprise does not make it impossible, of course—but it does remind one of how easily we suspend normal skepticism about events when they touch on venomous gossip about the well known. (And, as Benjamin Taylor suggests in his Proust book, one’s sympathies must extend first to the rats who would surely have wanted to be excluded from this narrative.)

One need hardly mention here—yet one will—the once famous and not entirely dissimilar rumor that had a movie star going to a Los Angeles hospital to have a gerbil removed from his anatomy, where it had been lodged for erotic pleasure. The inherent absurdity of this story did not keep it from becoming surprisingly widespread and, if not universally credited, then, at least, as the Web site Snopes tells us, leading “countless doctors and nurses [to] claim to have participated in, been on hand during, or heard from a reliable colleague about, the procedure.” Not only is the story false but the entire “practice” of gerbil stuffing seems wholly invented, a deliberate attempt to suggest the most improbable possible activity in order to shock and titillate readers. Indeed, the rodent-sex nexus is itself a telltale sign of fabrication: What’s the most shocking thing you can imagine someone doing? Make sure it includes a hamster.

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