Who pick up the bill when who made who? Ain’t nobody told you?
On August 18th, The New York Times ran a story on the front of its feed titled “Booster Shots ‘Make a Mockery of Vaccine Equity,’ the WHO’s Africa director says.” In case that statement sounds needlessly inflammatory and emotionally manipulative, here’s the actual quote from Dr. Matshidiso Moeti:
Moves by some countries globally to introduce booster shots threaten the promise of a brighter tomorrow for Africa. As some richer countries hoard vaccines, they make a mockery of vaccine equity.
To say that the introduction of a booster program in one nation poses a near-existential threat to a continent of 1.2 billion people is a stretch. But it’s not until you drill down to the factual details of the worldwide dynamic of COVID prevalence, vaccine production, and actual vaccination that you get a sense of how misleading and irresponsible that statement is, and how shaky is Moeti’s subsequent claim that as a consequence of boosters, more dangerous variants of COVID will arise.
To review what’s already well-established, here’s a summary in list form of the epidemiological facts of vaccination against COVID:
- Vaccination protects the greatest number of people when it is targeted to those areas where disease prevalence is highest, and the existing vaccination rate is lowest.
- At this time, our best information indicates that the major pharmaceutical manufacturers of COVID vaccines have a production capacity of 13 billion doses per year, or 1.08 billion doses per month. This estimate does not include the various home-grown vaccines being produced in some countries. (For more on this issue, look at the website of the Duke Global Health Innovation Center.)
- Immunity in vaccinated individuals goes into a significant decline by 6 months after vaccination. Booster doses are demonstrated to restore immunity to levels seen after the initial vaccine series.
- In principle, the limiting factors involved in determining the success of a global vaccination campaign include, and may seem to be determined exclusively by, the supply and finances of the nations looking to acquire vaccine. But in reality, the global vaccination campaign has been limited to a far greater extent by several other factors:
- Governmental decisions about acquiring doses independent of finances.
- Issues involving supply chain.
- Issues involving storage.
- The logistics of physical distribution from the port of entry to remote locations.
- The human resources available to achieve all three of the above plus administer, trace, track, quality-control, and dispose of waste materials related to every dose of vaccine.
- People’s willingness to receive the vaccine.
So, there’s good reason to question anyone who pushes the zero-sum narrative that a dose withheld from a soccer mom in a North Jersey suburb necessarily means a dose given to an impoverished tribesman in the Masai Mara, which is what quotes like the one above are meant to evoke. The sheer existence of a surplus of vaccinations in one location has no bearing on the administration of those very vaccinations in a remote location, especially if that remote location is governed by an incompetent or hostile government, lacks an effective supply chain, lacks storage capacity, cannot handle the logistics of transportation in an effective way, lacks the personnel to transport or distribute the vaccine, and lacks a population ready to receive precisely the amount (or at least nearly equal to the amount) of vaccine shipped. There’s a lot more to fighting the pandemic globally than Dickensian hyperbole about “vaccine equity.”
In my medical practice in Ridgewood, New Jersey, I referred my first patient for a booster dose a few weeks ago, a middle-aged woman first vaccinated in February (i.e., the booster would ideally be administered six months after her initial dose). We just diagnosed her with pancreatic cancer. Based on our best understanding of the evidence, her cancer appears curable through a combination of initial chemotherapy and subsequent surgery. During her planned three months of chemotherapy, she’ll be continuously immuno-suppressed. She asks me four times a day when her booster will be given.
Even if there were no pandemic, my cancer patient would still be walking the line between life and death for months on end, and hoping to come out the other side intact. And even if there were no pandemic, there would still be people walking that same line in the various poor countries of the world due to malnutrition, inadequate sanitation, violence, and a host of other problems. Do we really need to parse and litigate the totality of all misfortunes in the world to fight a pandemic? If that’s what “vaccine equity” requires, then is it a legitimate concept in the first place? Feeling that we’ve done “the equitable thing” won’t control the pandemic. Vaccinating people according to sound epidemiological practices will.
With that in mind, I would argue that there is only a good case for shipping doses of vaccine currently held in the United States to some other nation if that nation meets the following four criteria:
(a) Higher prevalence of COVID-19 than the US.
(b) Lower current vaccination rate than the US.
(c) Poverty below a threshold that explains the country’s inability to secure its own vaccines.
(d) Vaccine logistics and deployment capabilities that are good enough to ensure that doses redistributed from the US do not go to waste, or at least that the rate of waste is not more than it would be if US had kept the doses.
Now, (d) may be a tall order, but it’s neither effective nor equitable to divert vaccine to a place where no one has a viable plan for what they’re going to do with it once they have it. And anyway, I thought developing such plans was the reason we have a World Health Organization. The Times article quoting Dr. Moeti is problematically silent about where we are on that project. But let’s set (d) aside for now and focus on the somewhat more objectively knowable factors related to (a), (b), and (c).
Using the NYT’s global COVID tracker, some data from the IMF (also via Statista), a few targeted internet searches to fill in a few blanks, and an Excel spreadsheet, I compiled the following chart, which consists of all countries whose COVID cases per 100,000 matches or exceeds that of the US as of 8/18/2021, the day Dr. Moeti’s quote appeared in the online version of the Times.***
|Country||Cases per 100,000||Vaccination rate||Population||Per capita GDP (PPP)**||Per capita GDP rank (of 192 nations)|
|Isle of Man||67||72%||85,000||$89,000||8|
|* Homegrown and alternative-product vaccines skew these numbers. ||**”PPP” refers to “Purchasing Power Parity,” the metric used by macroeconomists to control for differences in actual purchasing power of goods between the currencies of different countries.|
These fifteen nations are the ones that meet criterion (a). I suppose you could argue that it makes sense to include countries with less COVID than the US as candidates for diversion of vaccine held by the US. I haven’t presented these other countries partly in the interest of simplicity. But I would say if you make the claim they should be included, the burden of proof is on you, and any argument you would make has to account for the delays created in transit when vaccine is relocated from one place to another. You would also need a working definition of “at-risk groups” that discounts the importance of disease prevalence, and a justification for discounting prevalence. Another tall order.
It’s first of all striking to note that only two African nations exceed the US in disease prevalence, Botswana and Eswatini, and those two countries have a combined population comparable to the State of Connecticut, or the City of Los Angeles. The fact is, Africa, whatever its legitimate problems and hardships, has no monopoly in the world on poor, under-vaccinated countries with high COVID prevalence. The challenges of global health are indeed global.
Of the fifteen countries captured in the chart, four have higher vaccination rates than the US (Israel, Seychelles, Isle of Man, and UK), thus failing to meet criterion (b). The Isle of Man also happens to be a richer country than the US. The other fourteen are less wealthy than the US, but not all of them are fairly described as “poor”: there is no reasonable standard by which the UK, Israel (minus the Occupied Palestinian Territories), or the Seychelles would be regarded as poor countries. Malaysia, Iran, Montenegro, and Botswana all rank in the 60th percentile or above for per capita GDP. (The case of Iran is more complicated, because US sanctions impact its ability to transfer money, but more on the situation in Iran below.)
Finer points aside, a hard look at granular reality drives home an important point: the global landscape of the pandemic is not a simplistic dichotomy of healthy/rich/vaccinated nations vs. sick/poor/unvaccinated nations. Neither the rich nor the poor are served when public health officials paint it that way, so maybe they should stop. In reality, both in the US and abroad, factors other than national macroeconomic status and the number of vaccine doses in possession impact both caseload and vaccination rates. In this as in other things, the world is a complicated place. But let’s suppose for the sake of argument that we consider any nation with a per capita GDP below the top 50 as a candidate for our help in procuring vaccine. That would leave ten countries on our chart that justify consideration for diversion of US vaccine.
In those ten countries combined, there are 97 million unvaccinated people. In the US, there are 161 million unvaccinated people. Even that 97 million is massively skewed by two countries that, for important reasons, are in the chart with italics and an asterisk: Iran and Cuba. These two countries account for 84% of the unvaccinated 97 million, and it’s in part because both have home-grown vaccination programs, and also in many cases are giving “other” vaccines (e.g., SinoPharm) which “don’t count” as far as the NY Times tracker is concerned. According to a report in the British Medical Journal, “Cuba is likely to become the first country to immunize its entire population with its own vaccines.” If Iran’s 12 million SinoPharm doses are counted, then it actually has vaccinated 18 million people, or about 22%, rather than the 4% quoted by the Times.
I would add that, to the extent that the poor require special consideration on the global health landscape, it’s not fair simply to describe the US as a “rich country” and call it a day. One of the reasons the US is so troublesome from a public health standpoint is that it is geographically large, has a large and widely mobile population, and is plagued by an extraordinary degree of economic inequality. The US has 40 million people living in poverty. We have more people living in poverty than most African countries have people. That doesn’t make the United States a global charity case in a macroeconomic sense, but it does impact meaningfully on the proposition of diverting vaccine supplies currently in our reach in the supposed interests of “equity.”
The fact of waning immunity makes the advent of booster doses a necessity not only for Americans, but for every nation. It now makes more sense to look at COVID vaccination as a three-dose protocol, not the two-dose protocol it was originally conceived of as being. It makes no more sense to withhold the third dose than it would have made to withhold the second. A great number of Americans were (double) vaccinated in the early days of Pfizer and Moderna availability, from December 2020 through February 2021. We now know that those people don’t own immunity; they just had a 6-month lease on life that is now in the process of running out. We don’t know for sure where the next COVID variant will be bred, but it’s just disingenuous and wrong to say in defiance of all we know, that the US isn’t one of the prime breeding grounds.
If we’re having a discussion about vaccine distribution, it’s also important to go back to that number: 1.08 billion vaccine doses per month manufactured by the major suppliers (the ones who “count”). That’s 36 million doses per day. To raise all 10 countries from their current aggregate vaccination rate of 8% (again, heavily skewed by the Iran lowball) to our current vaccination rate of 51% would require about 90 million doses. For the factories, that’s only 3 days’ work. This raises the question of why people at the WHO are talking in terms of zero-sum supply scarcity when there is enough for everyone. It also raises the question of how the WHO is performing at its job.
Unfortunately, for Americans, the biggest liability remains the self-inflicted one of vaccine refusal at the individual level. If there’s one persuasive counterargument to all I’ve presented above, it’s that no one knows how to squander a good resource like Americans. If there’s a real mockery here, it’s the one we’ve made of ourselves. Ultimately, in the eyes of the world, if all we’re going to do is sit on hundreds of millions of shots while we commit genocide on ourselves, then other people, if they are ready and willing, should not have to wait on us. That said, if we can make use of shots ready to hand, maybe we should put aside vague qualms about “equity,” and do just that.
***The data for the information in this chart exists only in very fragmented form, and is bound to be imperfect if presented in any form. I relied most heavily on The New York Times tracker and on Statista, but there were holes in their data that required a tedious series of patchwork Google searches that I haven’t cited here in full detail. One or two very small countries or territories may have fallen out of my presentation. But such issues of detail don’t affect my main point: the more imperfect the information regarding vaccination abroad, the weaker the case for re-distributing American vaccines to places about which data is imperfect. The data is imperfect in the US as well, but generally superior to that for developing countries.
(Suleman Khawaja is a hospitalist at Valley Hospital in Ridgewood, New Jersey. The views expressed here are solely those of the author in his personal capacity, and are not intended to represent the views of Valley Hospital. All formatting errors in this post are the editor’s fault, as are almost all gratuitous references to AC/DC.)
Excellent analysis! I hate when I read how the WHO said giving boosters (or a 3 shot series of vaccines) is like giving a life jacket to those who already have one while others are drowning. Your imagery (“lease on life that is now expiring”) is accurate. It also annoys me when writers state the breakthroughs are rarer than being “hit by a meteor” or “struck by lightning.” I checked the statistics for these comparisons, and they are not accurate either. Breakthroughs are not as rare as these anymore. I am also tired of the simile that the vaccine is like a raincoat and Delta is a hurricane, but at least it makes some sense. The imagery matters.
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For comparison’s case, here is a brief statement of the case against boosters, in a recent issue of Nature:
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This piece in Nature rightfully points out that there are ways in which nations like ours can be more involved in promoting increased vaccination in other under vaccinated countries. My piece isn’t intended as a defense of the United States across the board on global health. But a critique of our degree of engagement in the global vaccination project is not a justification of halting a booster program. Nothing in the Nature piece gives specific justification for the assertion, made over and over again, that increasing global vaccination rates and deploying boosters in the US are mutually exclusive objectives. Frankly, the Nature piece is a recitation of the same double standards and selectively vague assertions I’ve seen everywhere on this issue. It demands a level of certainty around the empiric effectiveness of boosters that is beyond what is currently attainable without time travel, and at the same time glosses over all of the specific challenges related to vaccine deployment in remote and infrastructure-poor places.
Everyone keeps saying that vaccines are scarce, but no one seems to be explaining what exactly is the disconnect between the data we have in hand on global production capacity (>30 million doses a day) and the supposedly scarcity-driven under- vaccination of the world. Either the estimate of production capacity is somehow wrong or misleading, or else we’re being misled by the claim that the number of vaccines available is a limiting factor. I’m not on the inside of the production and logistics. I’m just looking at the data that are available to the public, and what they tell me is that the case for halting actual vaccinations to shunt supply is not self-evident. If global health experts really know so much about how vaccine resources should be allocated, and for all the ink being spilled and fingers being pointed on this, it’s not too much to ask for a simple explanation of what exactly accounts for the apparent scarcity where the rubber meets the road, and exactly how this can be remedied by our stopping the progress of our domestic booster vaccination program.
This is exactly the same kind of illogic that bred distrust of our own public health establishment around the issue of mask scarcity in the Spring of 2020. When the public health establishment was shown to have pontificated to the nation in bad faith, somehow they felt entitled to just turn the page and never cop to what they did. The subsequent waves of COVID have been in large part those chickens coming home to roost. In my opinion, distrust wasn’t the only thing the CDC bred in that moment. I don’t understand how agencies whose core competency is supposed to be advising the public on facts relevant to an epidemic can fail so badly to explain scarcity when they’re so committed to scarcity limiting access to some valued thing. It’s not a hard explanation to make: “There are x number of doses available. There are y number of people who need them. y – x = z, the number that represents the gap between what we need and what we have. We need to triage doses in a manner that reduces z to the lowest number attainable. The virus is most likely to strike people in large numbers next in these locations. Hence we have to ensure that these places are given highest priority to increase vaccination levels to a degree that confers adequate protection to that population.”
It remains disturbing to me that people who are claiming expertise in epidemiology never touch the issue of how disease prevalence should impact vaccination priorities. They paint a picture of COVID ravaging other countries as if things are fine in the US and UK, and never give an apples-to-apples comparison of how much COVID there is in one place vs. the other. Going back to the very questionable way in which opponents of our booster program are disputing the efficacy of boosters: The statement made in the Nature piece that “some studies” found waning antibody levels is largely semantic posturing; those “some studies” represent the best evidence we currently have, not some selected subset of a larger body of data that contradicts them. Yes, it’s true that we don’t know yet how well restoring antibody levels will translate into a reduction in breakthrough cases. Again, we don’t have a time machine. Are we really in a position to wait 6 more months to complete a controlled trial? The delta variant is blowing up in the US at levels that are measurably higher than levels of COVID across pretty much any contiguous territory that contains 320 million people.
The WHO and its apologists are making three connected, very loaded, and each very disputable assertions:
1. Vaccine supplies are too scarce to support both booster programs and first-dose vaccination programs globally.
2. Constraining vaccination use in countries planning booster programs will necessarily lead to a justifiably proportionate increase in actual immunization elsewhere.
3. Booster vaccines do not confer enough immunity to justify their use.
They haven’t made a satisfactory case that any one of these three premises is true, let alone that halting the US booster program is a valid conclusion. And worse yet, they communicate their assertion with an attitude of contempt and disdain toward anyone who would question them, as if to say “We don’t have to make arguments, we’re the WHO, and we’re doing God’s work.”
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Very well said. We’ve been ill-served by a lot of scientists, a lot of science journalists, a lot of ideologues, and a lot of regulatory-administrator types who seem to believe that the invocation of Science is a substitute both for ethics and for thought. They’re under the misapprehension that epidemiology has the inside track on questions of fair distribution, and also under the worse misapprehension that Science for the Masses consists in putting blind faith in the scientists who get the most coverage in mainstream publications. I’ve run into some of these people, and argued with them, and their thought-processes are sometimes hard to distinguish from anti-vaxxers.
I haven’t read this book, but it’s been very well reviewed, and its thesis strikes me (from the blurb) as exactly on target:
Though it’s not mentioned in the blurb, I think it’s also been extremely harmful to outsource normative questions to scientists, not because they don’t have the right to sound off on them, but because it’s a gigantic mistake to substitute scientific expertise for normative knowledge. A huge number of scientists regard “normative knowledge” as a contradiction in terms, then express befuddlement when no one takes their moral judgments seriously–or better yet, as stating facts.
What’s sad is that so many of the issues facing us are the kind of thing that come up in an upper-division undergraduate course in the philosophy of science or even one of those 200-level “Philosophical Issues in Science” courses I used to teach as an adjunct at The College of New Jersey. I’d like to think that some of my better students are doing a better job than half of the people I’m reading nowadays.
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So here is the report from the New York Times we all could have guessed we’d find ourselves reading one of these mornings. While it is premature to conclude that the pause and retrenchment on government approval of booster vaccines will prove to be a permanent one, I’d be remiss if I didn’t point out the following:
In the time since I first ran numbers on COVID prevalence, vaccination rates, and national economic standing, the US has had both absolute increases in COVID infections (now above 50 per 100,000) and has risen in relative prevalence compared to other countries in the world. There are now 154 million unvaccinated Americans (down from 161M), and the sum total of all unvaccinated individuals in all countries meeting criteria A, B, and C is 30 million (down from over 90 million). This number still includes Cuba. In the time since mid-August, the US has passed Iran.
In the attached NYT article, it’s worth noting the not-so-subtle shift in terms between the last sentence of the third paragraph and the first sentence of the fourth paragraph: In the former, you have a White House official saying the administration would follow “the advice of government scientists,” in the latter another official says they would follow “the science,” with the two being used interchangeably. The advice of scientists is not the same as science. By the same token, there is no such thing as a scientific study whose hypothesis is whether or not a government should approve a vaccine. The way the administration is using the buzz phrase “follow the science” for political cover effectively removes all meaning from the phrase.
For each day the administration pauses on the approval of boosters, it has decided to not deploy boosters to the population, and needs to be held accountable for that as an affirmative decision. There are currently 1,500 COVID deaths a day in the US with cases and deaths both on a rising trend. The data that officials are claiming they need to review before deciding are not all new in the last week or two, before which their position was the opposite. In that much time, schools throughout the country have returned to session. In as much time as it takes the officials to review the data they now say they need to review, more data will have rolled in. No one has given a straight answer about how much science we will need to have before we get to call it science, and what the relationship between having scientific data and making a policy decision are/will be. As of right now, I would say that the administration has a moral obligation to make an affirmative argument identifying and quantifying the actual harm that would be caused by proceeding with boosters without further delay. Failing that, they need to make an affirmative argument that identifies the specific more beneficial action that will be taken involving every single US vaccine dose compared to use in a booster program, starting right now.
For a country that is supposedly sitting on billions of doses of unused vaccine, and which promised to proceed at a pace of 2 million vaccinations per day until herd immunity, our actual vaccine progress in the last 16 days (since I last ran numbers) is about 400,000 doses per day. In that same time, we’ve been seeing 160,000 reported COVID cases per day. Biden has continued to escalate promises to fund global vaccination. Each time Biden pledges something, he’s criticized by global health officials for not having pledged something else that they’ve decided they want more. No one seems to be giving a straightforward accounting of how many doses the US has made, has in storage, has on order, or are being manufactured either domestically or globally, at the present time. (If I reported my income to the IRS the way public health officials report on vaccine supply, I’d be in jail.) The press has been quoting for months his donation of 600 million doses to countries in need. No one as far as I can tell has reported on where those doses are, what has happened to them, or if they are even real, manufactured, stockpiled vaccines in vials, as opposed to a “pledge” of vaccine in the abstract.
None of this seems to make a compelling case against mobilizing current supply to provide boosters, but if such a compelling case exists, then let’s get busy mobilizing that supply to vaccinate someone else without delay. At this point no one is saying it out loud, but it is impossible to imagine that most doses held back from use as a boosters are doing much else but sitting idle. That’s just me looking at the dots, with no one in the official global health community bothered enough to connect them. To me, the worst crime global health crime possible is to have vaccine and not use it as days pass and the virus tears through unvaccinated populations. Compared to that, a dose given that is later proved to have marginally less than optimal efficacy in the individual who received it, or a marginal uptick in adverse reactions to vaccine, or a dose given amid a shifting data field, does not rate as a real global threat.
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