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Vaccine ethics

Even with the hopeful news of successive vaccines being approved for use in various countries, a major issue confronting many societies is who should get vaccinated first. The problem exists since it will be months — and in poorer countries, perhaps years — before the supply of vaccines is actually enough to meet demand.

Even rich countries struggle with the issue. While there is a consensus that healthcare personnel ought to be among the first priorities, a good deal of debate and difference follows over who should be next. A good model of careful thinking however is set by the permanent commission on vaccination of Germany’s Robert Koch Institute.* It first lays down the social objectives, namely: to minimize death and hospitalizations; to protect people who are professionally exposed to the disease; to minimize further transmission; and to sustain public life and the continuity of government functions. (Note that if the desired objectives had been different, e.g., minimizing economic disruption, the corresponding vaccination priorities would also have differed.)

In the event, with social objectives set, vaccination priorities consistent with them can be determined. These are roughly as follows: first in line are the elderly, with diminishing priority as age declines to 60; second in line are personnel in medical institutions with priority based on the risk of exposure (e.g., frontline doctors and nurses in hospitals ahead of those in private clinical practice or administration); third, persons with underlying conditions carrying a risk of serious illness, e.g., cancer, diabetes, cardiovascular disease; fourth, teachers, school personnel, and persons doing precarious work; fifth — note only the fifth — are key government personnel at national and local levels; and finally all other persons less than 60 years old.

The science and ethics behind these priorities are clear. If the aim is to minimize deaths and hospitalization, immunizing the elderly is the most direct route, since the effects of infection are known to be most severe among the elderly. (In the Philippines, three-fourths of all infections are among the below-50 age group, but roughly 60% of hospitalizations and 80% of deaths occur in the 50 to 89-year-old age bracket.) The same logic holds for prioritizing frontline health care personnel, who must immediately be protected against the disease if they are to continue working and not infect the people they attend to. On the other hand the lower priority given to teachers is also understandable, since their risk of exposure is lower and contingent on the mode of instruction to begin with. Of course, a diabetic 60-year-old teacher might still get higher priority, not because she is a teacher but because of her age and underlying medical condition.  The fifth priority accorded to high government officials — quite apart from delicadeza — stems from their greater ability to avoid risk and their easier access to quality healthcare if they do get infected. Germany’s chancellor Angela Merkel set an example in this regard during her New Year’s address when she said: “I too will be vaccinated — when it is my turn.”

Here at home, one must wonder whether the same thoughtful science guided by ethics and local conditions has gone into the government’s own vaccine program. News reports thus far fail to give the impression of a well-thought-out plan. The public is presented instead with a hodge-podge enumeration of supposed priority groups with no detail regarding their relative importance or the sequence of the rollout. Beyond the clear case of medical frontliners, the list seems more attuned to a prioritization not of the civilian population but of government agencies and employees. Hence it first enumerates “personnel” from departments of education, social welfare, jail management, and customs (!) without distinction as to function. But seniors and the poor “will also” be among the first, and — “based on President Duterte’s wishes” — the police and the military as well. Where almost everyone is a priority, one wonders if anyone really is.

One wonders exactly how such priorities will be implemented in practice. Would an able-bodied soldier or policeman get the vaccine ahead of a 65-year-old with diabetes? Would a customs inspector be inoculated before a factory or transport worker? Or a school principal before an elderly urban poor person? More important than one or the other answer is: why or why not?

This need for a painstaking delineation of vaccine-priorities is based on an economic reality: for an extended period, the supply of vaccines will be inelastic and must be quantitatively rationed to those who are most in need. The invisible hand of the market fails to work its wonders in these cases, since even an above-normal price would do nothing to increase supply, nor is a suppression of demand acceptable on humanitarian grounds. For the same reason (i.e., one that should be taught more in Econ 11), price-controls in areas cut off by natural disasters are a justifiable departure from the otherwise reliable course of letting market forces decide the allocation of scarce resources. In such crises, the limited supply of life-preserving means must be allocated based on humanitarian need and explicit social-welfare criteria, rather than through accustomed privilege and buying power. Flouting social priorities during such times of national crisis, e.g., through hoarding or price-gouging, amounts to a crime.

Now zero in on recent events. A slowly-mushrooming scandal is the revelation that members of the President Duterte’s innermost circle — including some cabinet members, his own close-in Presidential Security Group (PSG), and some allege even Duterte himself — had surreptitiously secured the Chinese Sinopharm/CNBG vaccine and had themselves secretly inoculated. Various administration officials have since twisted and turned to play down the incident, seeking to limit the damage by painting it as a purely private matter, where: (a.) the drug was just “donated” (later revised to “smuggled” so its origin is presumably no longer traceable); (b.) the vaccine was “self-administered” by the soldiers themselves (so no physician or other accomplice can be called to account); (c.) the vaccination was “purely voluntary” on the part of the soldiers (to pre-empt the obvious human-rights violation of coercing subordinates to be vaccinated with an unapproved drug); and, (d.) that neither the president nor any of the PSG’s higher-ups knew anything about the matter until after the fact (which strains credulity given the president’s vaunted omniscience and ₱4.5-billion intelligence fund). This leaves the PSG head to take sole responsibility and fall on his sword. (But not to worry, there’s always a safety net and reward for the steadfast. Main thing is to stop the contagion of scandal right there.)

Much of the criticism of these actions has thus far centered on how the vaccine was still FDA-unapproved and therefore possibly unsafe or ineffective. Such criticisms miss the point however. It is precisely because the Chinese vaccine is possibly or likely to be effective that its hoarding, misappropriation, and private use — particularly by key officials — is objectionable. At a minimum, the proper action should have been to entrust the vaccine supply — approved or unapproved, donated, smuggled or otherwise — to the health department for possible future distribution. (As an aside, the Chinese government has since approved the Sinopharm vaccine for general public use; and there is little doubt it will ultimately be approved by the FDA here as well.)

The incident is a scandal because it is a big slap in the face of a government that pretends to any attempt at a fair social prioritization and orderly distribution of scarce, life-saving vaccines. It is specious to reduce the matter to a private action that harms only the participants themselves: in the midst of dire scarcity, each private action has palpable social repercussions; every act of misappropriation is a deprivation of someone more deserving. The most cogent observation that goes to the heart of the matter came from a nurse who said: “Parang inapi naman nila ‘yung health workers. Talagang ipinakita nila na hindi priority. (It is like they abused the health workers. They really showed that they are not a priority.)” To extend the metaphor of a calamity, these actions are tantamount to government workers hoarding and gorging on donated relief goods instead of distributing them to those most in need.

Unless the full truth is revealed and those truly responsible are held to account, this sordid event bodes ill for popular trust in the seriousness of the government’s vaccine distribution plan. It is cold comfort that the plan itself to date is still murky in its principles, priorities, and operational implementation. Even before these details can be sorted out, however, the plan’s credibility has already been tainted. The red flag has been raised that not only may safety protocols be breached, but that the orderly and fair vaccine distribution may be corrupted by queue-jumping, supply-diversion, patronage, deceit, and bribery, with priority given to the highest bidder — or the most connected to the center of power.

Rather than take this credibility issue dead-seriously, however, administration officials have pooh-poohed the matter and addressed it instead by: first covering up the incident and denying it even happened. Second, when that failed, disavowing any knowledge of it and shifting the responsibility entirely upon the lowly soldiers themselves. And finally, deflecting attention away from the embarrassing issue by throwing a smoke bomb regarding corrupt public engineers and congressmen (all noise, with little evidence anyway) meant to crowd out news of the matter.

Oh, well, at least now we know what “Mask, Hugas, Iwas” (Mask, Wash, Avoid) really means.

*“STIKO-Empfehlung zur COVID-19 Impfung.” Advance copy of Epidemiologisches Bulletin dated Jan. 14, 2021.

 

Emmanuel S. De Dios is professor emeritus at the University of the Philippines School of Economics.

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