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We are not safe, until we are all safe

So I’ve had my first dose of vaccine. I actually consider myself, right now, knowing what we know and the circumstances we are facing, one of the luckiest people on the planet. I haven’t been given a date for that elusive 2nd dose. Before the scheduling regime was changed, it would have been last Thursday. Nothing is in sight but my Trust are making noises reassuring me that I will contacted nearer the time. For a few days, I was outraged and aggitated about this lack of certainty, but when I started to calm down, I started to think about the other people on the planet- who have lives just as precious as mine, who work just as hard as me and who might not have sight of vaccine until the end of 2021 or early 2022 even. I thought about the me, who might well have been born in Nigeria, if not for the choices my parents made in their 20’s. What would that Francesca/Bunmi be doing? When we were were growing up, in a bid for us not to forget our culture and where we were from, my dad would tell us it’s just accident of birth that you are all here. Now at the start of the 21st century, we are seeing just where that has led us. We are in the midst of a pandemic and in a country, though listed as the 5th richest nation on the planet, currently has one of the highest death tolls due to COVID-19, compared to it’s geographical neighbours. We are in a country where as somebody of BAME (Black, Asian and Minority Ethnicity) origin, I and people like me, have a higher chance of dying of this disease than some of my white counterparts. It’s terrifying. I don’t often write about it, prefering to fill my Facebook, Twitter and Instagram feed with light and jolly pictures of cake and other such delicacies but believe me, it’s on my mind, All. Of .The .Time.

While I was thinking about the scramble for vaccines, I picked up a copy of the BMJ (British Medical Journal). Almost never read by me, because I’m tired all the time and somehow would rather spend my free time baking or watching Netflix. Last week my attention was caught by an article named A fairer way to vaccinate the world. It is co-authored by Liza Herzog who is s an economist and political philosopher with a focus on economic and social justice, she is Associate Professor of Philosophy, University of Groningen, The Netherlands, Ole Norheim is a physician and medical ethicist with a focus on global health, he is Professor of Medical Ethics, University of Bergen, Norway; Ezekiel Emanuel is an oncologist and bioethicists with a focus on health policy and health justiceUniversity Professor and Vice Provost and Matthew McCoy s a political theorist and bioethicist with a focus on health policy an is the Assistant Professor of Medical Ethics Perelman School of Medicine, University of Pennsylvania, Philadephia.

Draws on literature on global and health justice, the ethics of allocating scarce resources, and medical ethic, they set out the current method for allocating COVID-19 vaccine amoung countries but argue for a model (The Fair Priority Model) that is based on limiting covid-19 harm which might have a better ethical standing.

It occured to me again that I had not thought (perhaps seflishly) about other countries that do not have the money to buy up vaccines at any cost, for their citizens. It became a further thought for me at our last Trust BAME network meeting when we were talking about reasons for reduced vaccine uptake in BAME communities. We talked about fears and anxieties about vaccine saftey which were understandable but could with information and education could at least be partially quelled. But I also pointed out that it would also be worth exploring what people of any persuasion who did not want vaccine, what they thought was the way out of this pandemic, caused by a transmitable viral disease. I also said that it was worth pointing out the supplies of vaccine were finite, and one day we would not have the luxury of refusing a precious resource. It felt harsh, even as I said it, I am a doctor, I’m meant to be compassionate and understanding of people’s health choices, but there is something about this climate that for me, means that we have to dig a little deeper into people’s thought processes. Especially when their actions have effects on other people. I also appreciate this is difficult situation. I appreciate information is changing all the time. I see that there are so many U-turns, we end up just spinning on one spot. I get it, it’s difficult.

Anyway, I digress, while these thougths were percolating through my brain, it also occured to me, that although I am a community paediatrician and immunisations are integral to what I do, I have not thought about how they get from the laboratory and into the arms of the children I see every day, much less the children in other parts of the world. I have to be fair to myself though, I am mostly thinking about other things, and my greatest concerns when reviewing files of vulnerable children are checking that they have indeed been vaccinated and that they have completed the required schedule (the irony eh).

So, so, what’s my point? Well having read this article I feel a little enlighted about what the stakes and players are going to be over the next few months. I’ve learnt a few new words and phrases that were not in my narrative this time last year. Not sure where my mind was at before, cake, probably, and work, never-ending, soul-draining work. Maybe I should count this as CPD! This is really just me making notes to myself, so that I can read this again in a few months time and think – oh!

New things that I have learnt this week

Covax Facility (Covax) : a multilateral initiative aimed at ensuring all countries have “fair and equitable access” to covid-19 vaccines. It is co-led by the Vaccine Alliance (Gavi), the Coalition for Epidemic Preparedness Innovations (CEPI), and the World Health Organisation (WHO).

It is a voluntary arrangement that enables countries to pool their resources and risk by collectively investing in vacccine candidates while developing political and logistical infrastructure needed for distribution.

It ensures that vaccines financed through the initiative will be allocated in a transparent and coordianted manner.

In September the WHO delineated its plan for allocating vaccines through Covax

World Health Organization.Fair allocation mechanism for covid-19 vaccines through the Covax Facility. 2020

In this plan vaccine doses would initially be allocated to participating countries in proportion to their population size.

Only after each country receives vaccine doses for 20% of its population would countries’ covid risk profiles be considered in a subsequent phase of vaccine distribution.

Countries participating in Covax are permitted to pursue bilateral contracts with vaccine manufacturers like the one between the UK and Pfizer-BioNTech. Many countries, high income and even low-middle income countries, such as Indonesia and Vietnam, have secured vaccine through bilateral agreements.

Proportional allocation of vaccines through Covax is fairer and more efficient than an uncoordinated approach in which countries compete in the market to secure as much vaccine as possible for their own citizens.

The other term that I have heard being thrown around in the past few weeks is vaccine nationalism

Vaccine nationalism: rich countries bid against each other to secure bilateral contracts with vaccine manufacturers and stockpile vaccine doses for their own citizens.

https://www.sciencemag.org/news/2020/07/vaccine-nationalism-threatens-global-plan-distribute-covid-19-shots-fairly

This is –

Unfair vaccine hoarding by high income countries profoundly disadvantages people living in low income countries that lack the resource to procure vaccines for their citizens.

Inefficient it fails to allocate vaccines to countries with the greatest need and greatest potential for harm reduction, unnecessarily prolonging the pandemic and causing many preventable deaths.

So, I waded deeper into the article, admittingly falling asleep on the sofa, resting my eyes for a while. However when I was more alert, I read a bit more about vaccine allocation

WHO plan for proportional allocation

It would ensure that each of the more than 170 countries participating in Covax would receive some vaccine in the initial phase of distribution

first for 3% of their population, with priority to health personnel,

then for 20% of their population, with priority to high risk groups

Regardless of their ability to pay, thus it would thus prevent a deeply unethical scenario in which large stores of vaccine are retained by high income countries while poorer countries, including those hit hardest by the pandemic such as Peru, have no or limited access to vaccines.

Modelling suggests that proportional allocation would be more efficient than an unregulated market and likely to reduce preventable deaths due to covid-19.

Modellers recently compared a scenario in which:

the first two billion doses of covid-19 vaccine (assumed to be 80% effective two weeks after administration) are hoarded by the 50 wealthiest countries VERSUS

one in which vaccines are distributed to all countries proportional to their population.

They concluded that proportional allocation would avert nearly twice as many preventable deaths as hoarding by rich countries.

Although there are substantial uncertainties about the effectiveness in real life circumstances of the vaccines that will eventually be produced

I.e

  1. whether they will reduce the risk of transmission or death, in which groups, and

2. how long immunity will last

these results support the comparative efficiency of the Covax model.

Good news right? We are sorted. Seems not. At this point I’m pouring myself another cup of tea because there is more learning to come. Turns out there is more sage and it does not come with onions…

The WHO have a Strategic Advisory Group of Experts’ (SAGE) who have an ethical framework fo covid-19 vaccine allocation.

World Health Organization.WHO SAGE values framework for the allocation and prioritization of covid-19 vaccination. 2020.

The authors of this paper argue that despite the fairness and efficiency of proportional allocation (compared to vaccine hoarding) it, does, in the context on covid-19 fall short of its own ethical principles.

What?

If we assume that the most likely function of covid vaccine is to reduce death and serious economic and social harms then it is argued that in the context of covid-19 distributing vaccine in proportion to a country’s population might well be unjust.

OK…

The SAGE framework incorporates six fundamental values and the authors argue that proportional allocation is poorly aligned with at least three of these ethical principles, namely human well being, equal respect and global equity.

HUMAN WELL BEING

Protect and promote human well-being including health, social and economic security, human rights and civil liberties, and child development.

Herzog et al argue that in this context, human wellbeing aims to “reduce deaths and disease burden” and “societal and economic disruption” due to covid-19.WHO’s proportional allocation would require sending substantial quantities of vaccine to countries that have relatively low risk of death, disease, and social and economic disruption due to covid-19, such as New Zealand, Kenya, Senegal, South Korea, and Thailand instead of prioritising countries most affected by the pandemic, where the potential for harm reduction from a vaccine would be far greater, such as Mexico, Brazil, Iran, and Ecuador.

EQUAL RESPECT

Recognize and treat all human beings as having equal moral status and their interests as deserving of equal moral consideration

Equal respect, aims at treating “the interests of all individuals and groups with equal consideration.” Treating people identically regardless of their circumstances is not equal respect. Herzog et al argue that, this principle requires responding to people’s different needs with equal consideration. Those living in countries hardest hit by the pandemic have greater need for vaccines, in terms of both health and the economy, than those living in less severely affected countries. Proportional allocation fails to account for these differences in need and thus fails to treat people with equal respect.

GLOBAL EQUITY

Ensure equity in vaccine access and benefit globally among people living in all countries, particularly those living in low and middle income countries.

In their final point, Herzog et al express that: global equity requires ensuring “that vaccine allocation takes into account the special epidemic risks and needs of all countries, particularly low and middle income countries.” Ironically, proportional allocation disregards countries’ special risks and needs. It pays no particular attention to the situation of individuals in low and middle income countries, who may have greater need for a vaccine than those living in other countries that are able to mitigate the most serious risks of the pandemic through effective public health measures.

I did think about the UK when I got to this paragraph…

NATIONAL EQUITY

Ensure equity in vaccine access and benefit within countries for groups experiencing greater burdens from the COVID-19 pandemic.

RECIPROCITY

Honor obligations of reciprocity to those individuals and groups within countries who bear significant additional risks and burdens of COVID-19 response for the benefit of society.

LEGITIMACY

Make global decisions about vaccine allocation and national decisions about vaccine prioritization through transparent processes that are based on shared values, best avaialable scientific evidence, and appropriate representation and input by affected parties.

After all that , my head was spinning and I really did lie down just think about this and try to digest it.

So your’re saying it’s not quite as would like to fair as we have believed?

Do you have an alternative proposal?

Well – funny you should ask…?

So half-way through the article, we get to the premise of the article. And not being a professor of anything, and thinking that the time I was really forced to think about epidemiology and related things was probbaby during my MSc studies, I’ll freely admit that I will have to go away and read a bit more about these concepts. But I’ll just present them here straight from the article, really for me to read and reflect upon another day. Totally trashing the principle of “don’t put anything on your slides, that you can’t explain…”. Thinking that in 2 weeks time, by the time I’ve listened to more podcasts, read more articles and doom-scrolled through my Twitter and Facebook feed, this will be as normal to me as face covering and ‘stay safe!’.

Let’s get to it…

The Fair Priority Model

This is based on 3 widely shared ethical values

  • benefitting people and limiting harm
  • prioritising those who are disadvantaged
  • equal moral concern

The Fair Priority Model allocates vaccines between countries in 3 phases.

The assumption is that approved vaccines will be safe and can reduce the risk of severe complications and death from COVID-19.

At each phase the model gives priority to reducing the most harm to health and the economy with extra prority to those in the most disadvantage countries, using well established metrics that can be applied on the basis of available data.

Phase 1

Aims at minimising premature deaths, based on the reduction of standard expected years of life lost (SEYLL) averted per dose.

The aim of the first stage, assuming that vaccines will reduce mortality risk, is to reduce premature deaths caused directly or indirectly by covid-19 using standard expected years of life lost (SEYLL) averted per dose as a metric. SEYLL is commonly used in global burden of disease estimates. It calculates life years lost compared with a standardised global reference life table. Allocating vaccine on the basis of SYELL averted promotes the principle of human wellbeing by directing vaccine to the countries where it will save the most life years. It promotes the principle of equal respect by valuing a life saved at a given age identically, regardless of the country in which it occurs. Finally, because SEYLL’s are standardised to the world’s highest life expectancy, the lower life expectancy in many poorer countries is not taken as a reason to deprioritise those countries, which would violate the principle of global equity. Instead, by saving more life years, using SEYLLs would prioritise those living in the most disadvantaged countries.

Phase 2

Adds socioeconomic factors, measured in SEYLL, loss of gross national income (GNI), and reduction in the poverty gap.

In the second phase of distribution, the model takes serious economic and social harm caused by covid-19 into account by adding two socioeconomic metrics to SEYLL: improvements in gross national income (GNI) per dose and reduction in absolute poverty gap per dose. These indicators ensure that even after covid related deaths are brought relatively under control, vaccine will continue to be allocated in a way that prevents serious economic and social harms due to the pandemic while prioritising disadvantaged people by focusing on narrowing the poverty gap. Earlier vaccination can, for example, allow a poor country to relax lockdown measures that often hit the poorest part of the population who work in service sectors hardest.

Phase 3

Aims at returning countries to their pre-COVID-19 situation.

In the third phase of distribution, the model aims to end community spread of covid-19 by prioritising countries with the highest transmission rates, ensuring that even as the pandemic begins to abate, priority is given to preventing harm and to people in countries most affected by the pandemic.

Phew...

Now I think to myself, having some public health knowledge would take me a long way. But it’s OK, I know different things for different reasons at different times. Perhaps now is my time to think about this a bit more. Our job is to learn, think and analyse, so that will come in the next few weeks I’m guessing. I’d be very interested to see what the wider response to this will be.

In the mean time, I might stay away from journals and read some Harry Potter, my brain aches…

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