Getting a booster is no panacea, but not getting one may be a fatal mistake. That, at any rate, is the finding of a set of Israeli studies in the New England Journal of Medicine, one published in October, the other published just a few days ago. An excerpt from the abstract of the “Conclusions” section of the latter:

Across the age groups studied, rates of confirmed Covid-19 and severe illness were substantially lower among participants who received a booster dose of the BNT162b2 vaccine than among those who did not.

Read both articles all the way through for all of the relevant provisos and qualifications, but I think it’s fair to summarize both by saying that they jointly found that boosters reduced the incidence of both serious morbidity and mortality due to COVID-19, inclusive of all variants but Omicron (about which it’s too early to tell).

As Suleman Khawaja has suggested in a previous post here, whether or not to get a booster is not (as currently conceived by medical journals) a “scientific hypothesis.” So neither article explicitly issues such a prescription. But the intended support for such a prescription is obvious, and made obvious, by both articles.

This raises a question: what happened to all of those public health experts who, as late as September and October (and even November), were suggesting that we not get boosters? Indeed, the WHO wasn’t just suggesting that we not get them, but demanding that those countries that had them institute a “moratorium” on administering them. Should we expect recantations and apologies from these experts? Or a doubling down on their earlier demands? Or just discreet silence?

Recall that part of the rationale for the anti-booster advice was uncertainty: there was no certainty that we needed them. Of course, there was no certainty that we didn’t need them, and some good reasons to think that we did. It’s unclear to this day why the requirements of certainty were reversed in such a way as to demand that we demonstrate a priori that there be full certainty of their medical necessity before anyone was permitted access to them. As has become obvious, nothing about the efficacy of the vaccines was certain prior to administering them en masse in real-world settings. Yet that didn’t stop the same public health authorities from urging us to get “jabbed.”

The other part of the rationale against boosters was “vaccine equity“: it was, we were told, inequitable to get third doses of the vaccine when people in other parts of the world had not gotten first or second doses. I think Suleman has essentially torn this argument to pieces (here and here), but it’s worth re-visiting, if only for the gratification of shredding it just a bit more.

One of the arguments he had made was that it made no sense to demand that vaccines that could be administered here (and substitute any relevant “here” you like) ought to be sent to places where it was highly likely they either couldn’t or wouldn’t be administered. Whereas on the “vaccine equity” view, it was evidently morally more praiseworthy to waste vaccines from equitable intentions than to administer them from selfish ones.

It seems to me that Suleman’s prediction turned out to be essentially right. From a report in The New York Times about the situation in Zambia:

NGWERERE, Zambia — Four people turned up at a health clinic tucked in a sprawl of commercial maize farms on a recent morning, looking for Covid-19 vaccines. The staff had vials of the Johnson & Johnson vaccine stashed in the fridge. But the staff members apologetically declined to vaccinate the four and suggested they try another day.

A vial of the Johnson & Johnson vaccine holds five doses, and the staff was under orders not to waste a single one.

Ida Musonda, the nurse who supervises the vaccination effort, suspected that her team might have found more takers if they packed the vials in Styrofoam coolers and headed out to markets and churches. “But we have no fuel for the vehicle to take the vaccines there,” she said.

From Reuters, about Senegal:

DAKAR, Dec 13 (Reuters) – At least 200,000 COVID-19 vaccines have expired in Senegal without being used in the past two months and another 200,000 are set to expire at the end of December because demand is too slow, the head of its immunisation programme said on Monday.

And Nigeria appears to be clocking in with an expected million wasted doses.

Paradoxically, the WHO has conceptualized low demand in Africa as a response to low supply:

As vaccine supply improves, so too does demand.

It is hard to quantify the levels of demand for vaccines, but information shared by a range of African countries indicates that mistrust and misinformation are driving down demand.

“Fighting misinformation that fuels vaccine hesitancy is by no means easy,” says Dr Gilson Paluku, an Immunization Officer covering central African countries for WHO. “Low demand is contributing to low uptake.”

A few countries are struggling to administer even 50% of the available doses, yet many African countries are finding creative ways to drive up demand.

I’m afraid this just is misinformation (perhaps more obvious if you read the whole article than by reading the preceding excerpt on its own). It conflates the supply of vaccines with the supply of information about vaccines, treating an increase in the latter as equivalent to (not merely determinative of) an increase in the former. It thus treats the waste of hundreds of thousands (even millions) of vaccines as a non-existent or irrelevant issue. The logic here is: if we flood Africa with vaccines, and equate their presence in Africa with encouragement to take them, the rate of vaccination will go up, a positive result that justifies our treating the waste of hundreds of thousands, even millions of doses, as an inconsequential sunk cost.

But the equation is nonsensical, and the cost both consequential and avoidable. The supply of vaccines is not equivalent to the supply of information about them, and not by itself a prediction of demand for them. The cost of more than a million vaccines wasted is not easily dismissed. And nothing obliged or forced us to engage in the folly that led to this level of waste–nothing except the misguided belief that we “had to.”

The WHO’s policy prescription requires us to treat the lives of the First World people who might have gotten those wasted doses, or even some small fraction of them, as morally irrelevant, as long as we get an increase in the rate of vaccination in Africa–no matter how many doses we waste in the process, no matter how much time, effort, and money it takes, and no matter how low or high the prevalence of COVID in the relevant country. What argument generates that conclusion? It’d be nice to see it laid out in print.*

The booster shot was a Christmas present that our “public health authorities” decided to re-gift to people who either didn’t want it or didn’t have the infrastructure to give it. It’s as though we stopped manufacturing seatbelts out of “fabric equity,” on the grounds that the fabric used to make seatbelts only benefits the privileged people who have clothes and drive cars. What about the unclad who can’t afford cars or plane tickets? Why not declare a global moratorium on the manufacture of seatbelts so as to clothe them?

The reductio involved here might be iterated ad nauseam. Why hydrate, bathe, or flush the toilet when some people lack clean water? Why turn on the heat when some people lack heat or cooking oil? Why permit yourself a spare room in your house when some people altogether lack a place to live? Why choose an expensive specialist for your medical care when some people lack access even to the most rudimentary health clinic? Why get treatment for cancer when some people don’t live long enough to get cancer? It all sounds absurd, but it’s no less absurd than foregoing a booster shot in New Jersey because that booster shot might, with greater equity, have been shipped to Zambia, Senegal, or Nigeria–where someone who hasn’t been vaccinated can decline to show up to take it.

I don’t mean to “praise” the horrors of this pandemic, but one salutary effect it’s had is to lay bare the weaknesses of many aspects of our enormously over-confident society. One source of weakness is the theory and practice of contemporary bioethics. The concept of “vaccine equity” is one born of the professional culture of bioethics, a culture which, despite its immersion in the world of clinical and public health practice, is systematically prone to generating wild claims that flout obvious practical realities.

No reasonable person could dispute the need, in the abstract, for something like vaccine equity: vaccines are and have been administered in inequitable ways. But no reasonable person would, in the middle of a global pandemic, have demanded a moratorium on booster shots when it was becoming obvious that the pre-booster protocol provided inadequate protection against the disease. And yet this is exactly what our public experts did, invoking the prestige of “bioethics” to do so, with little or no objection from any organized group of academic bioethicists–on the contrary, with their apparent approval.

Had the WHO declared a moratorium on abortions, or third-trimester abortions, or sex-selected abortions, I doubt that that would have gone by without objection. Likewise a moratorium on gender re-assignment surgery, or the over-prescription of anti-depressants, or a lifting of the moratorium on conversion therapy for sexual orientation.** But somehow, a moratorium on booster shots in the middle of a pandemic didn’t seem like much of a big deal. But it was a big deal, and is a big deal, and will remain one, as this winter will likely prove. I’m gratified that governments, at least, have gotten out in front of their “public health experts” on this: most people in the First World should be able to get booster shots for the asking. But after the confusion spread on the subject, you can almost forgive them for failing to ask. Whether we can forgive the people who confused them is another matter.

*For one attempt, see Nancy Jecker et al, “Vaccine ethics: an ethical framework for global distribution of COVID-19 vaccines,” Journal of Medical Ethics 47:5 (2021). Though it would take a separate post to respond to this article, I don’t think the authors deal adequately with the logistical objections Suleman raises in the post I linked to above. Nothing in the relevant section of the paper (Section II) deals frontally with what would appear an obvious logistical problem: how do we justify the waste of hundreds of thousands of doses in cases where nations lack either the infrastructure or demand to use them? And as an economic matter, why conceptualize the issue of vaccine distribution as a zero sum game in the first place? Do we in fact face a production-level trade-off between demand for vaccines in First World countries versus demand elsewhere?

**A garbled version of this sentence was edited after posting.

Thanks to Suleman Khawaja for helpful discussion on this issue. I’ve filched some of his ideas and formulations, but responsibility for everything in this post is mine.