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Earlier this year, the UK introduced a ‘traffic light’ system in a new attempt to contain and mitigate the effects of COVID-19. The system assigned red, amber, or green status to other countries, with each color indicating different rules for a range of things, including travel conditions and quarantine requirements.
In mid-September, the British government announced an amendment to the three lists: the colors amber and green were replaced by an “OK to travel” category. The red list remains in place. The changes will take effect from October 4.
Trying to determine the rationale for lists and specific details about them is far from straightforward. The rules for which countries enter or exit are far from transparent, making it difficult to find a rationale for why a country is placed on the red list and, perhaps more importantly, how it exits.
Of the 54 Red List countries, 22 (around 41%) are from sub-Saharan Africa. In other words, of the 48 countries that make up the sub-Saharan region, 21 (around 44%) are on the UK’s red list.
Reports suggest that the UK government’s rationale for placing a country on the Red List includes: known variants of concern; known high-risk variants that are under investigation; and a very high prevalence of COVID-19 in the country or territory.
These justifications are difficult to understand on several levels. The revised rules reported on the UK government’s website are also opaque.
Let’s just take the question of variants. An important characteristic of viruses like COVID-19 is that mutations are a natural occurrence. Some mutations present additional risks, but many are inconsequential. And, of course, knowing which variants are present in any country at any given time depends entirely on the accuracy and extent of the tests performed.
This is just one of the reasons the Red List has sparked a storm, with some recommending that it be “scrapped in its entirety.” In South Africa, scientists have criticized the reasons given to justify keeping their country on the red list.
When the UK Red List is viewed at perhaps a more granular level, the difficulties immediately become apparent. Two scenarios indicate the wrong logic applied.
Sudan vs. South Sudan
Sudan is on the red list while South Sudan is not.
Still, the figures available on COVID-19 in both countries indicate that this is a ridiculous call.
Current estimates are that Sudan has a daily rate of new confirmed cases per million of 0.23. South Sudan’s rate is higher, at 1.18. On top of that, Sudan’s total immunization rate per 100 is 3.34, that of South Sudan is much lower at 0.84.
Sudan has a death rate per million of 64.15 while South Sudan’s rate is 10.36.
At the end of July, South Sudan had confirmed the presence of the Delta variant while the spread of the Delta variant in Sudan had not been confirmed.
We may wonder what these data tell us about the two countries. It is very difficult to draw firm conclusions in the absence of information on health systems and other important factors in both countries. Comparisons become difficult and somewhat arbitrary.
This is precisely the difficulty of the red list.
Is it about sorting the data? At the very least, it indicates an opacity in decision-making that should be unacceptable in an age of rigorous scientific thinking and evidence-based policy making. When difficulties arise, we must raise, rather than lower, the bar of our standards of what counts as credible evidence.
Barbados vs. Rwanda
Equally confusing and difficult to understand are the rules regarding the red list and immunization status.
The UK government website says that starting at 4 a.m. on October 4, you will be fully vaccinated according to two criteria. The first specifies a vaccination program approved by a small number of countries. The second stipulates a complete cycle of one of four vaccines named from a “competent public health body” in 18 different countries. None are in Africa.
Also, from this date
if you have stayed in a Red List country in the last 10 days, you will only be allowed to enter the UK if you are a UK or Irish national or have UK residence rights.
To illustrate how ridiculous this is, I sketched out a scenario.
I am an Australian academic currently working in Rwanda. I received both doses of the Pfizer vaccine and had numerous COVID-19 tests, all with negative results. Neither I nor any of my family has ever tested positive for COVID-19. I received my Pfizer COVID-19 vaccines in Rwanda, a country that acted swiftly and decisively with clear and transparent leadership from the first indications of the monumental importance of the virus.
Despite all this, I will not be able to visit the UK under any conditions.
Suppose I have a colleague from the UK who, before moving to Rwanda, received her two Moderna vaccines in Barbados – one of the named countries with an approved vaccination schedule – and has been living in Rwanda for six months. After being in Rwanda for two months, she hypothetically tested positive for COVID-19 even though she was asymptomatic. From 4 a.m. on October 4, she could return to the UK under certain rules such as a pre-departure test and a quarantine period once she arrives.
I do not understand how this can lead to anything other than an exacerbation of existing inequalities. What difference can it make where I got my shots? Is there a reason getting vaccinated in Rwanda or South Africa is lower than getting vaccinated in Barbados (with 360.98 new confirmed cases per day per million or Malaysia with 488.11 new confirmed cases? per day per million?
In fact, the World Health Organization recently praised Rwanda’s vaccination campaign. Yet it remains on the UK’s red list and Rwanda is not listed as a country with an approved vaccination program.
Read more: How Rwanda manages its COVID-19 vaccination deployment plans
More sophisticated footwork with numbers perhaps? Or just a biased thought.
Global health equity
The World Health Organization has made it clear that
vaccination will not end this pandemic until it is distributed to everyone in the world.
Yet some countries, mainly high-income ones, stock far more vaccines than they need and provide boosters for people who don’t need them.
COVID-19 gives us the opportunity to learn a lot about health and health systems. But perhaps the most valuable lesson is the overwhelming importance of equity for the global community. This lesson is being ignored at the risk of all of us.
Maybe rather than focusing on a Red List country club with unclear and questionable criteria, we should create a Red List of countries that are actively creating inequalities in vaccine distribution.
Timothy A. Carey does not work, consult, own stock, or receive funding from any company or organization that would benefit from this article, and has not disclosed any relevant affiliation beyond his academic appointment. .
By Timothy A. Carey, Director: Institute of Global Health Equity Research, Andrew Weiss Chair of Research in Global Health, University of Global Health Equity
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