[B] Acting in the public interest: Uncertainty pervades public health crises

Reducing risk of hospitalisation and death is central to management of infectious disease. When Sars-Cov-2 was identified, it was recognised across the public health sector and by medical doctors that vaccination would be incorporated into a greater pandemic response strategy. Measures would be integrated into the response strategy, including managed interventions to slow the spread of the disease to ensure that hospitals would not be overburdened. These would include appropriate hygiene and distancing, early treatment to prevent severe disease and hospitalisation for patients with severe responses. All these measures involve considerable uncertainties. No particular measure prevents transmission of infection.

From an early stage a successful vaccine was considered unlikely, because coronaviruses are shape-shifters, picking up mutations easily. Unlike the smallpox vaccine, COVID-19 vaccines don’t produce sterilising immunity, so vaccinated people can carry viral loads and transmit the virus, resulting in continued circulation in the population. Therefore, because of the recognised difficulty in ‘pinning down’ this virus, vaccines were envisaged by doctors as a tool to protect aged and vulnerable populations, in a similar way as the flu vaccine. This tool would be part of an integrated pandemic response toolkit.

As the data has shifted claims that mandates are required appear contradicted by the scientific literature and evidence from the trials demonstrates that there was no meaningful reduction in death rate in the participants that were exposed to the mRNA treatment. Reduction of transmission was not presented as a key benefit in the approval process and the mRNA treatment appears only to reduce symptoms, while exhibiting a range of risks that appear to place a great majority of the population at more risk of an adverse effect or death from the mRNA treatment, than from hospitalisation and death from infection from Sars-Cov-2.

The clinical trials were not designed to study severe disease – and prevention of death over the longer term remains uncertain:

‘on preventing death from covid-19, there are too few data to draw conclusions—a total of three covid-19 related deaths (one on vaccine, two on placebo). There were 29 total deaths during blinded follow-up (15 in the vaccine arm; 14 in placebo).’ [i]

Dr Doshi was referring to the Six Month Safety and Efficacy of the BNT162b2 mRNA COVID-19 Vaccine[ii] [iii] trial:

‘During the blinded, controlled period, 15 BNT162b2 and 14 placebo recipients died; during the open-label period, 3 BNT162b2 and 2 original placebo recipients who received BNT162b2 after unblinding died. None of these deaths were considered related to BNT162b2 by investigators.’ [iv]

Clinical trial data for mRNA treatments remains incomplete and largely inaccessible – the scientific process is not based on open data. The approval process was swift and resulted in a relatively small group of study participants.[v] The U.S. Food and Drug Administration (FDA) filed (November 2021) to request a 55-year embargo (until 2076) on the documents supporting the FDA vaccine approval.[vi] For many in medicine, the pressure to publish can result in data fraud. There is evidence that research contractors in the trial NCT04368728[vii] may not followed correct protocols.[viii]

The Thomas paper discloses that those who were assigned to receive the placebo were offered BNT162b2. This obscured any chance the placebo group could be followed for the longer term. [ix] A U.K. based initiative has been established to enable global unvaccinated citizens to register as an unvaccinated control group, to help balance the gap in scientific knowledge.[x]

Yet the New Zealand government has continued to enact legislation at a rapid pace. For the state to justify mandates, the infection from a virus must produce a significant and severe disease burden and trust promoting measures must come first. [xi]

Norms of transparency and accountability promote trust that the machinery of government (the executive, judiciary and parliament) are acting in the best interests of citizens.

Citizens unable to contest or deliberate on emergency measures

New Zealand legislation on the management of infectious diseases has historically recognised important principles that must be taken into account by the state – the paramount consideration of which is the protection of public health. The Health Act (S.92) emphasises that paramount considerations include respect for individuals (including known special circumstances or vulnerabilities of the individual) (92C), the role of voluntary compliance (92D); the necessity for the individual to be properly informed and that individuals have a right to appeal against the exercise or performance of the functions, duties or powers and to apply for judicial review (92E). Importantly, the Health Act includes the ‘Principle of proportionality’, stating that ‘all government measures must be ‘proportionate to the public health risk sought to be prevented, minimised, or managed’ and ‘not be made or taken in an arbitrary manner’(92F). In addition to individuals being appropriately informed, ‘Individuals and communities should be encouraged to take responsibility for their own health and, to that end, to participate in decisions about how to protect and promote their own health and the health of their communities’(92D9(3)). [xii]

What has been strange is that the legislation enacted separately from the Health Act and the swift speed of the legislative process :

COVID-19 Response (Management Measures) Legislation Bill. 6 days Introduced May 5 2020 received Royal Assent 15 May 2020. Minister in Charge: Hipkins
The COVID-19 Public Health Response Bill. No public consultation 1 day. Introduced May 12, Third reading and Royal Assent May 13 2020.[xiii] Minister in Charge: Parker
COVID-19 Public Health Response Amendment Bill. No public consultation. Introduced July 29, received Royal Assent August 6 2020. Minister in Charge: Woods
COVID-19 Response (Further Management Measures) Legislation Bill (No 2) No public consultation. Introduced & passed August 4, 2020, Royal Assent August 6 2020. Minister in Charge: Hipkins
COVID-19 Response (Management Measures) Legislation Bill. No public consultation (some private consultation). 4 days. Published October 1, closing date for submissions October 5 2020.[xiv]
Inquiry into the operation of the COVID-19 Public Health Response Act 2020. One month. Published May 21, closing date for submissions June 28 2020.[xv]
COVID-19 Recovery (Fast-track Consenting) Bill. 5 days. Published 16 June, closing date for submissions 21 June 2020, Royal Assent 8 July 2020. [xvi] Minister in Charge: Parker
COVID-19 Public Health Response Amendment Bill. No public consultation. Published and passed 1 December, Royal Assent 7 December 2020. Minister in Charge: Hipkins. [xvii]
COVID-19 Public Health Response (Validation of Managed Isolation and Quarantine Charges) Amendment Bill. No public consultation. Introduced 20 May, Royal Assent 24 May 2021. Minister in Charge: Hipkins.
COVID-19 Public Health Response Amendment Bill (No 2). 11 days. Published 30 Sept closing date for submissions Oct 11 2021.[xviii] Minister in Charge: Hipkins
COVID-19 Response (Vaccinations) Legislation Bill. No public consultation. Bill introduced November 23, Royal Assent November 25 2021. Minister in Charge: Hipkins.

Legislation enacted between in November

Recent submissions to the New Zealand COVID-19 Public Health Response Amendment Bill (No 2) revealed widespread agreement across civil society that increasingly strict and coercive measures would produce a disproportionate suffering, particularly to low-income groups.[xix] However the consequent COVID-19 Public Health Response Amendment Act (No 2) 2021 was enacted on 20 November 2021, which strengthened penalties, despite heavy submissions from the public which argued against further controls and more stringent penalties. (Ministry of Health information. Link to Act ).

The following chart reveals legislation was enacted in the period 1-19 November 2021.[xx]

From 15-27 November another raft of legislation was enacted

Following rapid passing of the Covid-19 Response (Vaccinations) Legislation Bill on Wednesday 24 November, Speaker Trevor Mallard criticised the Labour government for ‘its urgent passing of Covid-19 “traffic light system” legislation though he has allowed the law to be passed.[xxi] The Human Rights Commission, Victoria University law Professor Dean Knight have all criticised the fast pace of legislation calling it a ‘constitutional disgrace’. Otago professor of law Andrew Geddis stated:

‘this is a bill that authorises the government to set constraints on who can and cannot take part in large parts of social life for the foreseeable future, that specifically permits it to require people in certain occupations to be vaccinated, and that is going to authorise other workplaces to decide if their employees have to be vaccinated or else lose their jobs……. Because, as this bill powered through all its legislative stages like a rolling maul punching over the Black Ferns forward pack, a whole bunch of pertinent information remained hidden from us. The New Zealand Council for Civil Liberties asked under the Official Information Act for a range of advice given to the government about its plans for vaccination certificates. First, the government apparently didn’t realise this request had been made, and so failed to respond to it in the time the OIA allows. Then, it refused to release the information because it will be made public “soon” … in late January, two months after the legislation authorising the use of vaccination certificates has been enacted into force.’[xxii]

There is no evidence that the government has considered the international data on hospitalisations in mRNA treated (vaccinated) populations, the increasing evidence that the treatment may have an increasingly marginal effect on reducing symptoms and preventing population transmission. Mass population mRNA treatment may enhance the potential for new variants to arise, and the latest 'Omicron' variant, appears to have been, at a very early stage, detected in vaccinated individuals in Botswana.

An ongoing emergency approach is not viable

Ongoing legislative measures have provided the platform for the New Zealand governments’ COVID-19 response. The speed of legislative action left citizens ‘on the back foot’ and struggling to reconcile the speed and pace of emergency measures with the evidence in the literature on infectivity and risk for hospitalisation and death; historically accepted normative public health measures for infectious disease; and the implication of a novel medical treatment. The list of legislation enacted between November 1-21 was undertaken at a time when only 38 members of the population had died from COVID-19[xxiii]; while over 100 people had died following mRNA treatment/vaccination, with many suffering from adverse effects following treatment.[xxiv] It is difficult to access a data-base showing death from COVID-19 by age group. As of November 2021, there may have been no deaths under age 55. However, this is not transparently declared on the Ministry of Health information page[xxv] and the media are not reporting deaths by age group.

New Zealand’s production of legislation which continues to promote emergency-based restrictive measures, continuing to emphasise case rates, rather than adopting an integrated public health approach that is both evidence-based and mitigation based. A positive PCR test does not automatically imply that a person ‘has the virus’. However it is well known that the PCR test generates false positives, and most ‘cases’ are not subject to confirmatory testing.[xxvi]

While many have argued that the speed and pace of enforcement measures have been necessary, these have been undertaken in the absence of public testing to identify levels of endemic natural immunity in the population, and the off-target harms, including job losses. Recently, measures were strengthened despite a significant protestation from civil society, and with public ignorance of population level immunity, despite the presence of Sars-Cov-2 in the country for nearly two years.

The benefit of restrictive non-pharmaceutical measures which include mandatory stay-at-home and business closure orders (lockdowns) continue to be contested due to the potential for the potential stress of lockdown to exacerbate other (cascading) harms, including to mental health, to those with pre-existing conditions, and to small businesses. Mandatory stay at home orders have increased risk of economic, hunger, delayed medical treatment, domestic abuse, mental illness and non-compliance with routine immunisations.[xxvii] [xxviii] [xxix] There is evidence that investment in healthcare and in treatment modalities reduce the need for lockdowns, which proactively decreases the rate of death in the population from COVID-19 and lockdown-related measures.[xxx]

Public health scientists have recently proposed recommendations relating to 10 key policy areas.[xxxi]

Revisiting COVID-19 policies: 10 evidence-based recommendations for where to go from here

1: Prioritise vulnerable populations for vaccines and ensure that vaccines for vulnerable populations and essential workers are directed to those without prior immunity. Enable those with prior immunity to defer vaccination, and then limit their vaccination to one dose. Refrain from giving boosters to the immunocompetent general population. Only impose mandates in high-risk settings.

2: Gradually ease restrictions as vaccination expands. Once vaccination made widely available, and rates of hospitalisation and mortality fall, there is no need to expect the vaccinated to follow all current restrictions imposed mainly to protect those who decline vaccination. The same can be said regarding immunity following infection. Given the rarity of reinfection and the duration of immunity post-infection (at least 6–12 months ) those with evidence of prior infection appear to be as immune as those who have been vaccinated.

3: Emphasize education and harm reduction approaches over coercive and punitive measures. Harm reduction involves informing people how to assess and mitigate risk, while acknowledging the real-world conditions that may lead some persons to take calculated risks. Accordingly, any restrictions and mandates, including vaccinations passports should focus on high-risk situations and consider a number of scientific and ethical questions. Mandates must take account of prior infection.

4: Encourage outdoor activities – the risk of transmission outdoors is vastly lower than indoors.

5: Don’t close schools. Schools have not been shown to be major drivers of SARS-CoV-2 transmission, However, their prolonged closure have had disastrous academic, psychosocial, and other harmful consequences on children, including access to essential services, especially in lower-income populations.

6: Avoid Lockdowns. ‘Sledge-hammer’ lockdown approaches should be avoided in favour of carefully target ‘scalpel’ public health approaches. Indiscriminate lockdowns have had far-reaching unintended consequences, disproportionately affecting socioeconomically disadvantaged and vulnerable populations.

7: De-emphasize excessive surface disinfection and other ineffective measures. Indirect contact transmission is not a significant driver of Sars-Cov-2 spread. Excessive cleaning rituals divert important resources, time, and energy from much more useful forms of prevention.

8: Reassess testing practices and policies. As Sars-Cov-2 becomes an endemic virus, it is vital to deemphasize identification of new cases as the key outcome metric of mitigation measures and rather to assess mortality and hospitalization rates.

9: Expand access to outpatient therapies and prophylactics. Some vaccinated individuals will still contract Sars-Cov-2 and some persons will remain unvaccinated. As evidence on treatment options evolves, policymakers should prioritize quick access to effective outpatient therapies in patients with risk factors for severe disease and to prophylactics for unvaccinated persons at high risk.

10: Prevent and prepare for future pandemics. Effective mechanisms must also be established to address equity in access to treatments and vaccines, prioritizing those at highest risk.

Halperin et al. Revisiting COVID-19 policies: 10 evidence-based recommendations for where to go from here. BMC Public Health (2021) 21:2084 https://doi.org/10.1186/s12889-021-12082-z

New Zealand court cases

Three court cases protesting mandates had been undertaken, in each case, the judge failed to find in favour of the applicants:

24 September 2021. An application for judicial review. Between GF (applicant, a Customs Service worker) and Minister for COVID-19 Response, Associate Minister of Health and the Attorney-General. CIV-2021-485-474 [2021] NZHC 2526. (Link)
22 October 2021. An application for judicial review. Between four aviation security service employees (applicants) and the Minister for COVID-19 Response, Associate Minister of Health and the Attorney-General. CIV-2021-485-509 [2021] NZHC 3012. (Link)
12 November 2021. An application for judicial review. Between (applicants) four midwives and the Minister for COVID-19 Response and the Attorney General (respondents). CIV-2021-485-584 [2021] NZHC 3064 (Link)

In the judgements, the presiding judges appeared unaware of the substantial difference between the effectiveness of the novel mRNA treatment and historic childhood vaccines. This included familiarity with the short-life of the mRNA treatment including unexpected waning; knowledge concerning the absence of any meaningful difference between vaccinated and unvaccinated in preventing transmission of infection; of the potential role of natural immunity; and of the potential for other (economically viable) treatments to play an important role in preventing hospitalisation and death.

Wide differences in risk across the population

These issues have been overlaid with complexities relating to varying risk relating to age group and the implications of measures for healthy individuals versus those with multiple conditions that place them at greater risk for hospitalisation and death. The tightly controlled pandemic response has discouraged expert scientific quorums that might deepen policy and improve health equity.

Human bodies have different vulnerabilities and strengths, based on income status, environmental stress, age and to a much lesser extent, inherited characteristics.

New Zealand’s testing rate in October 2021 was similar to Germany and the Netherlands at around 730 tests per 1000 people. The USA, Australia and Canada have tested at a higher rate.[xxxii] New Zealand’s level of obesity, a major determinant for health risk, is similar to Canada and less than the USA and United Kingdom. New Zealand’s median age, 37 is on par with the USA, Australia and China, while Canada and the UK have an older median age, 40. However, this is important to emphasise, New Zealand’s obesity is disproportionately represented in Māori and Pasifika and their health status is dramatically poorer[xxxiii], and their average age groups is roughly ten years younger than the average population age, around 25.[xxxiv]

The infection fatality rate (IFR), identifies the number of deaths divided by the number of infections. Estimates of the IFR indicate that globally, the outcome has been better (the rate has been lower) than expected. [xxxv] The IFR may be a better estimate than the case fatality rate (CFR), as many cases go unrecognised because no symptoms are identified. IFR can be estimated from surveillance and seroprevalence data. This differs significantly by age. [xxxvi] [xxxvii] The risk increases for younger groups who have associated chronic health conditions.[xxxviii]

Axfors and Ioannidis analysed 23 seroprevalence surveys across 14 countries, to calculate the infection fatality rate – noting particularly that very low IFRs were confirmed in the youngest populations.: [xxxix]

Across all countries, the median IFR in community-dwelling elderly and elderly overall was 2.4% (range 0.3%-7.2%) and 5.5% (range 0.3%-12.1%). IFR was higher with larger proportions of people >85 years. Younger age strata had low IFR values (median 0.0027%, 0.014%, 0.031%, 0.082%, 0.27%, and 0.59%, at 0-19, 20-29, 30-39, 40-49, 50-59, and 60-69 years).

The data has often obfuscated risk. Scientists assert that the predicted number of deaths following the early trials appear incorrectly skewed to attribute risk. The elderly have to date suffered the greatest death rate, however the early trials were not appropriately weighted towards this age range. While 58% of the deaths occurred in the age range 75+, only 4.4% of the participants in the clinical trial were 75+. The age range most impacted were under-represented. The trials also under-represented the population level comorbid conditions, as they were excluded from the clinical trials. [xl]

The question for many health practitioners, is: how do they differently recognise risk in the individual sitting before them? This is enshrined in the medical principle of ‘first do no harm’, in the Bill of Rights Act and the Health Act, which recognises that responses in infectious disease management must be proportionate and must take account of individual needs. However, previously non-controversial scientific and medical norms are now controversial. The ordinary practices of general practitioners are now critiqued and questioned in such a way that is unprecedented. Informed consent, a principle that is employed to ensure patient autonomy, and to ensure that treatment decisions are made in such a way that ensures patients are fully informed and treated in accordance with patients beliefs and values[xli], is now contested by state institutions.

From the commencement of the pandemic, certain assumptions have been built-in to analysis and modelling which have produced barriers to identified risk by age and health status from dually Sars-Cov-2 infection and from vaccination/inoculation. The initial clinical trials that produced fundamental assumptions relating to risk from which governments then based risk modelling scenarios on, under-represented young people and conflated the 17-64 age group into one demographic. [xlii] When large cohort studies do not evaluate risk for different brackets of the 18-59 year-old, they make fundamental underlying assumptions that conflate risk across generations. [xliii]

Why is the vaccine the only game in town?

The current situation, where only a very small group of therapies are recommended by the Ministry of Health,[xliv] [xlv] [xlvi] carries with it grave potential to result in unnecessary deaths, as doctor responses are stymied from anticipating and responding to broader health needs in the New Zealand population. Current policy measures direct doctors to recommend the vaccine over other measures. Yet COVID-19 pathologies are complex and vaccine failure, including waning and breakthrough is relatively common. While many people will present with reduced symptoms, this will not be the case for all groups. Yet the treatment protocols markedly deviate from medical and therapeutic custom in prescribing a narrow treatment range. Current recommendations ignore the fact that the most at-risk populations have pervasive and long-term nutrient deficiencies. This is a form of discrimination, and it must be addressed.

Repurposing of drugs with a long history of safe use to prescribe them for specific symptom profiles is common practice and conventionally uncontroversial. Repurposed drugs carry with them a long history of use and have a low level of reported adverse side effects, whereas new therapies can often be released onto the market, and only after some time do doctors, pharmacists and agencies recognise and report patterns of side effects. Often repurposed drugs will be used alongside other treatments in order to improve overall systemic health, but neither the doctor nor patient will understand where the benefits from one drug ceases, and another commences. Medical groups have developed treatment protocols and are convening conferences[xlvii], to assist colleagues to recognise that COVID-19 can be prevented and treated, and transition the population to a situation where the Sars-Cov-2 virus has achieved endemic status and herd immunity has been established. A recent paper released by the Nebraskan Attorney General, considered the potential for patients to receive repurposed drugs. The Attorney General considered that as long as physicians practiced informed consent, prescribed reasonable doses and checked for contraindications, physicians would not violate their obligations in law.[xlviii] The letter of the Attorney General recognised that uncertainty is prevalent in both prescribing early treatment or in approving use of the mRNA vaccine.

Yes to natural immunity

Naturally acquired - natural immunity confers equal or better protection than available estimates on vaccine efficacy. [xlix] [l] [li] [lii] [liii] Individuals with natural immunity are less likely to be reinfected [liv] [lv] [lvi] [lvii] [lviii] and lower rates of hospitalisation and death in reinfected individuals.[lix] A November meta-analysis stated:

‘Given the evidence of immunity from previous SARS-CoV-2 infection, however, policy makers should consider recovery from previous SARS-CoV-2 infection equal to immunity from vaccination for purposes related to entry to public events, businesses, and the workplace, or travel requirements.’[lx]

Coronaviruses are large RNA viruses. The vaccine is based on a segment of the virus that codes for the spike protein of the virus. Variants can arise as breakthrough cases, i.e. cases which aren’t recognised by the immune system of vaccinated people. This means that variants can arise as breakthrough cases, that aren’t recognised by the immune system of vaccinated people. Recently, a study demonstrated that naturally infected people produce a broad range of antibody responses which produce an overarching structural response that is effective against emerging variants of concern. Their antibodies cross-neutralising emerging variants ‘with high potency’.[lxi]

Conventionally, viral pathogens become endemic in the population, such as influenza, presenting a risk to only those with weak immune systems. It is accepted that viruses become endemic, and most of the population achieve natural immunity. Yet such discussion relating to the trajectory of Sars-Cov2 remains controversial – the stuff of conspiracy theorists. The recognition that children are at low risk of harm, and that natural immunity would confer increased protection against future unknown variants, is all but incendiary.

The Variant cycle

There is profound uncertainty relating to the risk profile of future variants. Delta is highly contagious. Studies differ, however there may be only a weak association of the variant with clinical severity such as pneumonia or death, and the scientific literature is yet to reveal a distinct increase in risk from the original 2019 strain. A recent study in Singapore of 838 people infected with newer variants of concern showed that the Delta variant was associated with an increased viral load and longer shedding time. Of this group older patients with comorbidities were likely to be admitted with severe infection. While Delta was associated with higher odds of pneumonia it was not statistically significant. Of the 67 individuals with Delta, only one death occurred which was consistent with the original Sars-Cov-2 virus. The age of death was not reported. High risk patients were treated exclusively with remdesivir and dexamethasone (as per national guidelines).[lxii]

An October paper[lxiii] looking at 212,326 Sars-Cov-2 infected people in Ontario, Canada measured increased risk of hospitalisation, intensive care (ICU) admission and death from new variants of concern. The 212,326 people had tested positive for Covid-19. Of this group a total of 2324 were admitted to the ICU – 1% of total cases. Of the 5989 who had probable Delta, 90 were admitted to ICU – 1.5% of Delta cases. Of the total 212,326 tested positive, a total of 1820 died – 0.8% of total cases. Of the 5989 of this group who had probable Delta, 40 died – 0.67% of Delta cases.

Fisman DN & Tuite AR. Evaluation of the relative virulence of novel SARS-CoV-2 variants: a retrospective cohort study in Ontario, Canada. CMAJ (2021) October doi: 10.1503/cmaj.211248;

The paper stated ‘hospitalization, ICU admission and death were relatively rare among cases’. The authors claimed that having a non-Delta variant of concern increased the risk of hospitalisation, intensive care (ICU) admission and death by 50%, while Delta doubled the risk. Average age of death was not declared, nor comorbidity status. However the overall likelihood of death is extremely low in the cases that were identified. [lxiv]

The case fatality rate (CFR) (the number of deaths divided by the number of cases) is strongly associated with median age of the population and the level of obesity.[lxv] The global Public Health England data in July, 2021, shows that the CFR is somewhere between 0.2% and 2.8%. with the Delta case fatality rate is 0.2%.[lxvi] New Zealand’s CFR, based on official WHO figures cautiously may be observed to be .7%.[lxvii] As of October 9, 28 people were reported to have died from COVID-19 and 4169 cases have been recorded. There appears to be a declining trend in the global CFR.[lxviii] [lxix] When case fatality rate is adjusted for age, radical differences appear. A review of the case fatality rate for hospitalised adult patients demonstrated that once hospitalised, patients under 50 had a 3% chance of death, while patients over 50 had a 19% chance of morbidity.[lxx]

Nutrition New Zealand’s obesity rates are among the highest in the developed world.

Obesity is a risk factor for hospitalisation and death from COVID-19.

1.3 million New Zealanders are obese. [lxxi] Obesity has tripled since 1975 and is a recognised pandemic. [lxxii] No policy to prevent obesity and increase access to non-obesogenic food has been produced to prevent the disease or assist to reverse obesity and its related diseases, since the COVID-19 pandemic commenced. Obesity is a disease that is strongly associated with income status[lxxiii] and absence of adequate nutrition.

‘The 2016/17 New Zealand Health Survey found that one in three children aged 2–14 years was either overweight (21.0%) or obese (12.3%). Pacific (29.1%) and Māori (18.1%) children had higher rates of obesity than non-Pacific and non-Māori children. Children living in the most socioeconomically deprived areas were 2.5 times more likely to be obese than those living in the least deprived areas, after adjusting for age, sex and ethnicity.’[lxxiv]

Vulnerability to infectious disease for sufferers, occurs in many ways. Low-grade chronic inflammation is driven by excess adipose tissue excretes inflammatory products that erodes immune health, making those with the disease of obesity vulnerable to ongoing chronic disease, including cancer and depression. Hormones such as leptin and insulin are impacted by obesity, and impact immune function. The ACE-2 enzyme is over-expressed in obese individuals and increased ACE-2 expression appears connected to severity of COVID-19. Obese individuals appear more susceptible to thrombotic events, such as clotting.[lxxv] These factors combine to increase risk of death and hospitalisation in COVID-19. Malnutrition is the primary cause of immunodeficiency – a cause and consequence of immune system dysfunction. [lxxvi] Childhood undernutrition (growth failure and/or micronutrient deficiencies) and overnutrition (of low nutrient foodstuffs leading to obesity) produces a double burden that increases risk for severe outcome in Covid-19.[lxxvii] [lxxviii] [lxxix] [lxxx]

Obesity effectively places young people in an equivalent age bracket to older people for chronic and infectious disease health risk. The most important risk factor for hospitalisation and death after age is the presence of comorbidities – particularly those comorbidities associated with poverty and structural racism, obesity, diabetes and the accompanying suite of metabolic diseases that combine to increase vulnerability to cancer, depression, influenza and Sars-Cov-2. Therefore, when a younger than 65-year-old individual presents with these health conditions – their body is effectively prematurely ageing. These young people join the risk bracket of the older cohort. Younger people with obesity, diabetes and other comorbidities are at high risk of adverse outcomes.[lxxxi] [lxxxii]

As the Ministry of Health has discussed, children living in low-income areas are 2.5x likely to be obese. Cheap ultraprocessed, calorie-dense food is obesogenic. The ‘per calorie’ cost of nutrient dense foods is higher than calorie-dense junk foods.[lxxxiii]

There has been no advocacy relating to nutrition throughout the pandemic, no nutrition directive to ensure low-income groups could access basic immune-related supplements through Pharmac. A recent Official Information Act request directed to the Ministry of Health[lxxxiv] reveals that no discussion on dietary protective policy has been developed to improve access for these groups. One of the queries in the request was whether there had been discussion on ‘New Zealand's chronic disease epidemic (including diabetes) and SARS-CoV-2/COVID-19 risk’. This was refused because the ‘information is not held by the Ministry.’

As authors have noted ‘The voice of nutrition in New Zealand is alarmingly quiet’.[lxxxv] Governments have resisted and ignored policies that can reduce pervasive inequities relating to the social determinants of health.[lxxxvi] [lxxxvii]

Māori & Pasifika – socially structured case rates

At highest risk in New Zealand for an adverse outcome from COVID-19 are elderly populations, followed by Māori and Pasifika communities. For ‘ordinarily’ healthy people, risk is structured by age, as a recent paper stated: ‘Age is the largest risk factor for severe or fatal COVID-19. Compared to a 20-year-old, a 65-year-old individual in the United States has a 90x higher risk of death from COVID-19, and an individual 75 years old has a 200x higher risk of death’.[lxxxviii]

However, this distressingly changes in the face of poverty and the diseases experienced in populations who are food insecure. At a population level, this is demonstrated by the extreme vulnerability of Māori and Pasifika, and the failure of the state to produce policy structures that promote health equity. Dr Rawiri Taonui has outlined how in New Zealand, new cases are disproportionately reflected in the Māori population, placing Māori disproportionately at risk of hospitalisation and death. Dr Taonui has argued that the age focus in the rollout was discriminatory as it ignored Māori’s disproportionate risk. [lxxxix] [xc] Māori lag behind other vaccination rates and it is likely that there are multiple overlapping reasons for this. New Zealand has a long history of failing to provide the same level of medical care for Māori and Pasifika compared to other groups. Entrenched racism can diminish trust in health providers. Other issues can increase skepticism around the benefits of medical treatment, higher metabolic diseases result in higher medication rates – polypharmacy – and there is a chance side effects from medication have been experienced at higher rates in these populations. As a result, they might consider claims by the state with a more critical, or jaded eye. These issues are not exclusive, and they may overlap.

A recent study drew attention to ethnic disparities in health, reporting that the risk of hospitalisation with COVID-19 in the 80-year-old European group (without reported health conditions) had the same predicted risk of hospitalisation of the 59-year-old Māori group.[xci] The study did not include obesity as an underlying health condition and did not consider nutritional biomarkers. Because of the risk to Māori, an earlier study had estimated the infection fatality rate in Māori to be 50% higher than that of non-Māori. [xcii]

Pervasive Dilemmas

Continued increases in COVID-19 appear unrelated to levels of vaccination.[xciii] It appears that even when countries follow an aggressive vaccination policy, such as Israel, that vaccination does not ‘stamp out’ transmission. This may be from vaccine becoming less effective and waning, or from breakthrough infection from new variants. Breakthrough cases are increasingly recorded in the scientific literature.[xciv] It may be because some immune systems only poorly respond to vaccination – some people are non-responders. Much remains unclear. Yet other breakthrough cases demonstrate that the Israel situation is not an isolated situation.[xcv] [xcvi] [xcvii] [xcviii] The evidence suggests that patients with associated health conditions, may be at greatest risk of breakthrough infections.[xcix]

The implications of a vaccine not preventing transmission create two dilemmas. The first draws attention to the fact that if a vaccine does not prevent transmission, it can’t technically be described as a vaccine – it’s an inoculant. Legally, a vaccine must prevent disease, and in many cases scientists observe a protective effect as symptoms are reduced.[c] However, as Kostoff and colleagues have noted, the U.S. Patent Office has previously rejected patent applications for vaccines which have been merely protective, requiring that infection is prevented.[ci] The second relates to the increasingly shaky moral economy of state pressure to require all citizens to be vaccinated, when the states assertion of risk is inconsistent with the scientific literature and the public interest.

For many doctors and scientists, the absence of public testing to assess the degree to which populations have been natural infected by Sars-Cov-2 and acquired natural immunity has been perplexing. Historically, the evaluation of population-level natural immunity has been a critical platform of public health efforts in times of infectious disease pandemics. Instead, governments have focussed on ‘case numbers’ which are obtained from the PCR test (polymerase chain reaction (RT–PCR)). The PCR test remains controversial as a Sars-Cov-2 diagnostic tool. PCR tests have a fast turnaround time, but the test cannot differentiate between old (non-infectious) viral RNA and currently infectious viral RNA. Scientists have queried the potential for high amplification rates beyond a cycle threshold of 35 to increase the potential for false positives and queried the potential for altered cycle threshold rates to dial up or dial down claimed case numbers.[cii] [ciii] The PCR test methodology remains controversial as it appears to have been developed from an insilico (computer generated) model of theoretical sequences, as at the time neither control material of infectious (“live”) or inactivated SARS-CoV-2 nor isolated genomic RNA of the virus was available to the authors’. [civ] [cv] [cvi] It remains unclear (and controversial) as to whether this insilico sequence used in the PCR tests has been validated against an isolated Sars-Cov-2 virus, nor whether the New Zealand government has a sample of the Sars-Cov-2 virus in an isolated and purified form.

NEXT: [C] Risk to children and young adults

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