Welcome to the era of vaccine policy …

If the recent developments surrounding COVID vaccination have reminded us of anything, it is surely that nothing is easy. Evidence of anything is hard to come by. Weighing a 90% effective vaccine against a 70% effective vaccine may seem straightforward, but without knowing if those numbers will stay stable as more evidence comes in, and if so, who the 10% and 30% are, and when and why a vaccine may be ineffective in a particular case. Then it goes straight on. What if we could have ten times as many doses of the less potent drug, or if the more effective drug was also ten times more expensive due to storage temperature requirements? So what?

I think it’s time for the standard “I’m not an immunologist” disclaimer and to highlight that most of these numbers were hypothetical. What I am is a football fan whose enjoyment of the latest series of international games has been limited by the increasing spread of COVID among elite players. The thought occurred to me as I watched a phase of passing in the first of Egypt’s two victories against rival of the African Cup of Nations, Togo: How long does it take for these guys to be vaccinated? The game had been robbed of its Liverpool and Egypt superstar Mo Salah, who had two positive test results and had returned to England. Where’s Mo on the list? I asked myself.

We’re familiar with the idea that telling people “what you do”, that is, your job, gives more information than your typical day passes. It signals what you should be good at, what value you have to the rest of us, and what it’s like to be you. Prepare for the stakes to rise when we as a society face the difficult task of determining who will be vaccinated and how quickly. Jobs are already important to health and happiness, but what we do might still determine who of us is waiting for access to the vaccine, as what we are doing isn’t important enough right now.

Footballers occupy a precarious place in cultural consciousness. Their position in society is privileged because of the enormous salaries that the free market of sport gives them for their skills. However, you find it difficult to find someone who thinks these salaries are “fairer” or who personally appreciates what these skills bring to society more than the skills of nurses, doctors, teachers or entrepreneurs.

Football has been “back” almost continuously since the 2019-2020 season resumed in June, a development Boris Johnson hailed back in April, ostensibly with the aim of improving public morale. To make this work, the clubs have put in place strict bubble policies to reduce the risk their employees would otherwise face in their workplace by cutting them off from the cities they represent.

Footballers do a job that sees social distancing as a poor defense. Wearing a mask while running 10 km and in a packed penalty area full of flapping arms would be more dangerous than protective. It is not ideal from a health and safety perspective. Even so, the players were forced to keep the show on the streets by those who occupied the industry’s commercial engine room. Now those representing their countries have taken part in a live experiment to test what happens when bubbles mix. Preliminary results suggest that this is likely not a best practice: the number of COVID cases recorded in the league this week has been higher than any other week since the restart in June.

Fast forward to a scenario where vaccinations are introduced. Will the court of public opinion rule that every nurse must be vaccinated before an individual footballer does? After working through the pandemic and putting themselves at risk for public entertainment, don’t Mo Salah and his teammates in Cairo and Merseyside have adequate entitlement to protection from further risks? Or, if the parents of a nurse who had not yet been vaccinated were entitled to moral outrage after not hugging their son since March in order to minimize the health risk, they should open their newspaper to read about the successful Premiership team vaccinated his starting XI?

This example may seem trivial, and numerically the impact on the UK’s ability to self-distribute vaccines to the 25 senior members of the 20 Premiership teams would be tiny. But that’s the first thing to note about the foreseeable public discourse about vaccination: it is likely to get emotional, and the emotional significance of some options can override any questions about their real impact. In addition, the soccer player example touches on several facets of the upcoming decisions.

First, there is no profession that is fully vaccinated before reaching others. There will be some politicians vaccinated in front of some doctors, some Fortune 500 CEOs vaccinated in front of some hospitality workers. We have already seen this with access to quick priority checks. After a series of positive tests among the negotiating teams for the free trade agreement after Brexit, all negotiators could be tested in an emergency and received results within a few hours. They are very important people that you see.

So we are not all called on the chosen day for our profession, but neither will it be random or first come, first served. Often when managing tasks, employees assess which tasks are urgent and which are important, and start with the tasks that are both urgent and important. We could implement this simplified scheme and imagine two groups: those whose health is personally most at risk from COVID (urgent), and those who, if infected, infect the most people (important). Vaccination in any of these categories will affect COVID-related illnesses and deaths.

Those who work and live in nursing homes seem to be right at the intersection of these groups. Nursing home residents and employees get extremely sick and die, while many other people get sick and quickly transmit the virus to one another. We may not have known exactly how many people are employed in nursing homes prior to COVID. But now that we’ve learned the hard way, priority vaccination in nursing homes seems like a logical place to start.

Where we should go after that is unclear. A frontline health or social services worker can be in touch on a daily basis with hundreds of people who are either at risk of transmitting the virus or who are seriously ill with the virus. But they themselves could be younger and have less risk. So in a world of scarce supplies, there can be a balance between using a vaccine to contain the spread and using it to protect the recipient’s life. Where is the best place to dam the river: upstream or downstream?

Then the question arises of who pays and how loud can the money speak. So far we have considered governments to be major customers of vaccine providers. This is a very European mindset and ignores the queue of private providers around the world who want their patient-customers to have access. Imagine the following scenario outside of medical providers as well. A tech giant is trying to order a million doses of vaccine so that they can be offered as a benefit to employees. A competing tech company sees the risk of losing to being the employer of its choice and tries to beat the first bid to stave off a rush across Silicon Valley. What should the producer do? And how do governments maintain their prime position as customers whose research infrastructure enabled the development of these vaccines?

If I were to bet, Mo Salah would be far more likely to get a vaccine from his employer at Liverpool FC (or possibly Real Madrid, depending on how long production takes) than from the NHS or his Spanish or Egyptian counterparts. Even more confusing is the fact that some football clubs are almost entirely owned by state funds. What if one of their players was given a vaccine that was supposedly given to treat the citizens of that sovereign? Are we ready for it as a society?

Then what about those who refuse to be vaccinated? A doctor I know assured me that this won’t be a problem in the short term as it will reduce the demand for a resource that will be terrifying for the foreseeable future. But while no one is panicking about anti-Vaxxers, at some point someone will get a virus they don’t want to be immunized against. Then what? Have we considered whether this person’s choices affect their right to treatment? In single payer health systems, we generally don’t consider how someone got sick in order to get access to treatment. However, could more market-driven systems lead to many people losing access to insurance if they are not vaccinated?

When we face these issues, we may know more about what we little know now, which is what proportion of the population would need to be vaccinated to stop the virus from circulating. In other words, how many unvaccinated people will we be able to take in through those who might otherwise have infected them. This, too, requires more knowledge than we currently have about the transferability of COVID in different ways, who can wear it where and for how long.

Eventually, I realize that in designing this debate as vaccination policy, I am pushing different buttons for different people. Politics is a neutral descriptive term for some people, a passion for some, and the worst force in the world for many others, enough to likely prevent anyone from reading. Anti-politics is becoming one of the most powerful mindsets floating around right now, and that is something we as a society need to grapple with if we are to maintain a sense of “we” in the future. In the meantime, if vaccination is our path back to a new normal, that of the old, maybe it’s best to return to a simple definition of politics, how groups make decisions, and accept that decisions are waiting for us at every turn better resembles. Nothing is easy.

“Vaccine with a possible cure for coronavirus and planet earth” from is licensed under CC BY

Dr. John Moriarty is a fellow in the Center for Evidence and Social Innovation and a lecturer in sociology at Queens University Belfast in the social sciences, education and social work.

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