I rang my mother last week to apply the “mum test”, as recommended by Professor Jonathan Van-Tam. Asked at a press briefing whether he had any safety concerns about imminent Covid-19 vaccines, England’s deputy chief medical officer replied that he would love to be first in line but was too young. Instead, he would urge his 78-year-old mum to be ready and waiting.
My own mother, a retired nurse in her eighties who never misses her flu jab, was having none of it: “Why should I get the vaccine first? I never go out! It should go to someone younger so the economy can reopen.” She accepted that her diabetes and South Asian heritage might pile on extra risk but hers, she insisted, was a life well lived and she was happy to wait a little longer if her sacrifice could deliver a greater social good.
Our exchange revealed that even the most rationally calculated vaccination strategy can falter on contact with reality. While some priorities will depend on the nature of the vaccines that make the cut, such as whether they dial down disease in older people, we are overdue a thoughtful open conversation on how an initially scarce and valuable commodity should be allocated in a way that the public understands and supports.
The dilemma over who to inoculate first is being thrashed out by the UK’s Joint Committee on Vaccination and Immunisation, which issued provisional advice in September.
The advice is likely to change in the coming weeks as readouts from multiple vaccine trials build up a picture of effectiveness, safety and logistical considerations, such as the need for boosters or a cold chain (the Pfizer-BioNTech vaccine requires both).
It will also depend on where the transmission rate is high. The committee’s stated priorities are to prevent death and disease, and to keep the NHS running.
Care home residents and staff are, naturally, top of the list. Healthcare and frontline workers are also a priority, to ensure resilience in what could be a challenging winter.
Beyond that, the plan is to vaccinate according to age, oldest first and working downwards to those aged 50 and over.
It is logistically straightforward and should mop up individuals with age-related risk factors, such as diabetes and heart disease.
Younger age groups, who suffer markedly lower rates of hospitalisation and death, will be folded in as more stocks become available. Whether children are eventually immunised may depend on their role in transmission.
Hugo Slim, a senior research fellow at the Blavatnik School of Government at the University of Oxford, is disappointed at the lack of open discussion about how lives are being prioritised. While he agrees it seems sensible to first vaccinate those most likely to fall gravely ill, he argues that age-based ethics is being ignored.
“I know it’s an unpopular thing to say, especially as a humanitarian scholar, but I don’t think we should be valuing every life equally,” he says.
“We have not heard the voice of older people on this, and consent is important. Many, including me, share your mother’s sentiment of prioritising the young over the old.”
The 59-year-old insists he is no lockdown sceptic. Rather, he feels the distinction between biology and biography has been lost. Current pandemic policy overplays the former and underplays the latter: “As older people, we have lived our biographical lives. The young are having their biographical trajectory dramatically changed by reduced education, socialising and employment.”
To vaccinate older people merely to reduce the NHS burden, he says, does not assign intrinsic value to their lives but instead amounts to pricing the inconvenience of their falling sick.
The role of ethnicity also requires renewed scrutiny from those setting vaccine priorities, with more confirmation last week that people from black, Asian and minority ethnic communities are being hit exceptionally hard by Covid-19. Black people are twice as likely to be infected as white people, and Asian people 1.5 times as likely, according to research from Leicester and Nottingham universities published in The Lancet’s EClinicalMedicine.
The systematic review and meta-analysis, covering nearly 19m people in the UK and US, also found that people of Asian ethnicities were more likely to end up in intensive care. I asked Manish Pareek, a co-author at Leicester university, whether ethnic background should be factored into the national vaccination strategy. “Given our work, I suspect JCVI will come back and look at this again,” was his diplomatic response.
However, to single out high-risk individuals on the basis of ethnicity carries hazards of its own. Pauline Paterson of the London School of Hygiene & Tropical Medicine warns that targeting minority communities for early jabs risks stigmatising them — while one survey suggests they may be three times more likely than white people to reject a Covid-19 vaccine.
There may be another way. Ethnicity is too often aligned with deprivation, which reveals itself in ways that heighten transmission risk: multigenerational households, cramped housing, a reliance on public transport, key worker roles, particularly in health and social care, and less opportunity to work from home. Critically, scientists think that factors like these, not genetics, mostly explain the disparity.
If deprivation is the common thread for risk, then vaccinating by postcode might help to catch the most vulnerable without stigmatising communities that are already under strain. That would be some irony, if the fairest and least divisive way to roll out a pandemic-ending vaccine rested on a postcode lottery.
Written by: Anjana Ahuja
© Financial Times
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