A 3D rendering of the Omicron COVID-19 variant (Image: Adobe)

One of the striking features of this pandemic is the scale of global inequity. While differences were always expected, the extent to which rich countries have hoarded vaccines, for example, has surprised — not least because we know that it’s against our self-interest to do so.

Well the chickens may be coming home to roost — if not with Omicron (origin: sub-Saharan Africa) then with a subsequent variant that is more transmissible, more deadly and resistant to antibodies.

The strain reportedly developed in an immunocompromised patient. First of all we need to nix the argument that vaccination is irrelevant because this person may not have been eligible for the vaccine, or was vaccinated and had a “breakthrough” infection. This is wrong. The probability of infection, regardless of vaccination status, is lower the more people around them have been vaccinated. (Let’s not presume that just because it’s a developing nation infection protocols weren’t observed. African nations are, in fact, very good at this — it’s how they stamped out ebola.) 

What does Omicron mean for Australia?

At the time of writing, Omicron’s arrival here is confirmed. The best case scenario is that the mutation will be unable to displace the Delta variant — not that Delta is great (and much of what follows here will still be relevant to manage it come winter), but better the devil you know.

The worst-case scenario is troubling. While perhaps not back to square one, if Omicron is as bad as many fear it will be a major setback, especially if previous infections and vaccines offer significantly lower protection. (It isn’t yet known how the therapies like Merck’s molnupiravir — already proving to be less effective than first suggested — will perform against it.)

It doesn’t look good. Wastewater analysis from South Africa’s Gauteng province suggests that the variant is highly infectious. Hospitalisations have quadrupled in two weeks, with 18% in intensive care, and are starting to tick upwards in other parts of the country. Regarding its purportedly “mild” effect, we are better off listening to Harvard-trained epidemiologists rather than local moonlighters.

Even if symptoms are mild, letting it rip — as suggested by the leading light of the hairshirt brigade — is a bizarre idea. It’s basically inviting the virus to mutate again. Plus a more virulent, less deadly disease can ultimately cause more harm than a high-severity, less virulent one. The next two weeks will reveal how acquired immunity will go to combat it.

Given that COVID-19 is now the leading cause of death in Europe and other parts of the northern hemisphere (no worse than the flu, eh?), prospects look grim. The only upside is that we know a lot more about the virus and have an established infrastructure in place to manage it. (The speed with which the strain was detected and sequenced by South African scientists should be commended. It has bought the world a lot of time.)

Hope for the best, prepare for the worst

Preparing for the worst will require a renewed focus on public health measures. These were always going play a role, even with Delta. This means masks, ventilation, closures and (real) quarantine, tracking and tracing, and not being complacent about the little things like QR-code check-in. It may mean more targeted or general lockdowns. Renewed public messaging explaining the importance of masks, physical distancing and ventilation, and preparing people for the possibility of restrictions should start now. 

It will also mean more vaccines (oh dear God). At best, additional boosters of the existing ones (which may still offer some protection but lose potency within months anyway), or completely new versions. Thankfully mRNA versions can be tweaked relatively quickly and iterations could start rolling off production (prepared and primed from the first round) in the second quarter of 2022. 

Will getting people to front up for another round of two, three or more vaccines be easier, the same or more difficult? Hard to say. But given the purported virulence of this strain, 90% will be the bare minimum. Moreover, children as young as five will be eligible (as they already are in the US and Europe). Trials on even younger kids are likely. This will be a difficult decision for many parents.

Let’s hope decision-makers have learnt their lesson on acquisition and rollout. In terms of public information, the authorities simply must get ahead of anti-vaxxers on this. Forget silly ads. Trusted institutions like the TGA and ATAGI must play a more prominent role in communicating the benefits and risks in a clear, unambiguous way. Going on past experience, this cannot be left to our politicians (especially in an election year).

Money talks

Together with vaccine mandates and a powerful, intelligent public education campaign, financial incentives should play a role. An incremental surcharge for vaccine refusal on taxable incomes above a certain threshold caused a lot of consternation but should be entertained. Contrary to people’s understanding, this isn’t a user-pays model. It’s a risk premium for a deliberate choice that, unlike smoking or diet, puts the individual as well as other at risk. (The concept of risk reduction extending beyond the self really does seem beyond many vaccine libertarians.) Unlike behavioural habits it’s also a hell of a lot easier to monitor. Random fridge inspections by ATO officers, anyone? 

Another option is a financial reward for vaccination. This could be universal or targeted at those receiving income support. This group comprises about 27% of Australian adults, and given that hesitancy tends to skew in that direction might a prudent option. Fifty dollars can be a lot for pensioners or JobSeeker recipients. This could also be coupled with the surcharge, making it (like the original Australian carbon price) an income redistribution package with massive positive externalities — an attractive or abhorrent idea depending on your political leanings.

Are such financial transactions crass and unethical? Perhaps, but then we should start campaigning against the long list of financial nudges already embedded in our policy landscape. Let’s begin with the highly effective (but regressive) tobacco tax, the private hospital Medicare surcharge, speeding fines. Let’s not even consider junk food levies, and look at decriminalising drink-driving.

But wouldn’t payments or penalties simply harden anti-vaxxers’ resolve and feed their conspiracy narrative? It may be news to some, but these people already seem pretty convinced and determined.

The target audience is the complacent, the “soft sceptics” — the majority of refusers on whom a small (dis)incentive would likely work. A recent, well-designed Swedish study showed that even a small financial reward (US$24) increased vaccination rates by 4.2% from a baseline of 71.6%. Importantly, the effect was greater than “soft” nudges (information, discussion, reminders) and was observed at all income levels. 

If you think mandates and incentives are draconian, Israel’s domestic spy agency is reportedly planning to track Omicron patients’ phones.

Let’s be better global citizens this time

Most importantly, Omicron presents a second chance to right some wrongs on equity. Let’s contribute, rhetorically and materially, to global efforts that allocate vaccines according to need, not wealth or power.

Scarcity will not be as much of a problem this time, and there’s no reason Australia shouldn’t send the vaccines to Pacific nations at the same time as rolling them out here. Also, we need to lobby global powers to honour their pledges and vaccinate the world. We’ve recently demonstrated our influence in pushing for more timid carbon emission targets. Why not apply the same vigour here?

Let’s hope for the best. But let’s, at the very least, see this as a wake-up call and seize the opportunity to be good global citizens.