Welcome to the Era of Vaccine Politics…

If recent developments around COVID vaccination has reminded us of anything, surely it’s that nothing is easy. Proof of anything is hard to come by. Weighing up a 90%-effective vaccine against a 70%-effective one might seem straightforward, but that’s without knowing if those numbers remain stable as more evidence comes in, and if so, who are the 10 and 30% and when and why a vaccine can be ineffective in a given instance. Then you’re straight on to, well what if we could have ten times as many doses of the less effective drug, or if because of storage temperature requirements, the more effective one also was ten times more expensive? What then?

Time, I think, for the standard “I’m no immunologist” disclaimer, and to highlight that most of those numbers were hypothetical. What I am is a football fan, one whose enjoyment of the most recent series of international matches was curtailed by the rising prevalence of COVID among elite players. The thought struck me while watching a phase of passing during the first of Egypt’s two victories against African Nations Cup rivals Togo: how long until these guys get vaccinated? The fixture had been robbed of its superstar Mo Salah of Liverpool and Egypt, who had registered two positive test results and returned to England. Where’s Mo on the list, I wondered.

We’re familiar with the idea that telling people “what you do”, i.e. your job, conveys more information than what your typical day consists of. It signals what you’re supposed to be good at, what your value is to the rest of us and what it’s like to be you. Prepare that for the stakes to be raised as we, as a society, face into the vexed task of determining who gets vaccinated and how soon. Jobs are already consequential for health and happiness, but what we do could yet determine which of us waits to access the vaccine because what that job we do isn’t important enough in this moment.

Footballers occupy a precarious place in cultural consciousness. Their position in society is a privileged one by dint of the huge salaries the sport’s free market awards them for their skills. But you’d be hard pressed to find anyone who thinks those salaries are ‘fair’ in the grander scheme, or who personally values what those skills add to society more than the skills of nurses, doctors, teachers or entrepreneurs.

Football has been ‘back’ almost continually since the resumption of the 2019/20 season in June, a development cheerled by Boris Johnson as far back as April, ostensibly with an eye to improving public morale. To make this work, clubs have imposed strict bubble policies, aimed at reducing the risk their employees might otherwise face in their place of work, by cutting them off from the cities they represent.

Footballers do a job where social distancing is considered poor defending. Wearing a mask throughout 10km of running and in a packed penalty box full of flailing arms would be more hazardous than protective. From a health and safety perspective, it’s not ideal. Still, players have been compelled by those manning the industry’s commercial engine-room to keep the show on the road. Now those who represent their countries have become participants in a live experiment to test what happens when bubbles mix. Preliminary results suggest that it’s probably not best practice: the number of COVID cases recorded in the league this week was higher than in any week since the June re-start.

Fast forward to a scenario where vaccinations are being rolled out. Will the court of public opinion decree that every nurse have to have been vaccinated before a single footballer does? Having worked through the pandemic and put themselves at risk for the public’s entertainment, won’t Mo Salah and his teammates in Cairo and on Merseyside have a reasonable claim to protection from further risk? Or would the parents of a nurse yet to receive his vaccination be entitled to a sense of moral outrage, having not hugged their son since March to minimise the risk to their health, should they open their paper to read about the premiership team which has successfully inoculated its starting eleven?

This example might seem trivial and, in numerical terms, the impact on the UK’s capacity to distribute vaccines to even the 25 senior squad members of the 20 premiership teams, would be miniscule. But that’s the first thing to note about the foreseeable public discourse around vaccination: it’s likely to get emotive and the emotional salience of some options may override any questions of their actual impact. Beyond that, the footballer example touches on several facets of the decisions ahead.

First, there is no one profession which will be vaccinated in its entirety before others are reached. There will be some politicians vaccinated before some doctors, some Fortune 500 CEOs vaccinated before some hospitality workers. We have already seen this with access to rapid priority testing. After a number of positive tests among the negotiation teams for the post-Brexit Free Trade Agreement, all negotiators were able to be emergency tested and receive results within hours. They’re very important people you see.

So we won’t all be called upon on the chosen day for our occupation, but nor will it be a random or first-come-first-served process. When managing tasks, people often assess which tasks are urgent and which are important and start with those which are both urgent and important. We could transpose this simplified scheme and imagine two groups: those whose health is most at risk personally from COVID (urgent) and those who, should they become infected, will infect the most people (important). Vaccination in either of these categories will make an impact on COVID-related illness and death.

Those working and residing in care homes appear to be at the exact intersection of these groups. Care home residents and staff are becoming extremely ill and dying, while also making a lot of other people ill and passing the virus rapidly among one another. Possibly we didn’t realise just what a sizable section of the workforce are employed in care homes prior to COVID. But now that we’ve learned the hard way, priority vaccination in care homes would seem like a logical starting point.

Where to go after that is unclear. A frontline health or social service worker may be in daily contact with hundreds of people either at risk of transmitting the virus or becoming seriously ill from the virus. But they themselves might be younger and at reduced risk. So in a world of scarce supply, there may be a balance to be struck between using a vaccine to curb spread versus using it to protect the life of the recipient. Where best to dam the river: upstream or downstream?

Then there’s the question of who pays and how loudly money will be allowed to talk. So far we’ve been thinking of governments as the main customer of vaccine providers. That’s a very European-style mode of thought and ignores the queue of private providers around the globe who will want their patient-clients to have access. Even beyond medical providers, imagine the following scenario. A tech giant tries to place an order for a million vaccine doses so they can offer those as a benefit to employees. A rival tech company sees a risk of losing out in an effort to be the employer of choice and tries to outdo the first bid to avert a stampede across Silicon Valley. What is the producer to do? And how do governments assert their priority place as the customers whose research infrastructures have allowed these vaccines to be developed?

If I were to bet, Mo Salah seems much more likely to be given a vaccine by his employer at Liverpool FC (or possibly Real Madrid depending how long production takes) than by the NHS or their Spanish or Egyptian counterparts. Confusing this picture even further is the fact that some football clubs are owned almost wholly by sovereign wealth funds. What if one of their players is found to have received a vaccine which was obtained ostensibly to treat the citizens of that sovereign? Are we up for that as society?

What then of those who refuse to be vaccinated? A doctor of my acquaintance assured me that, in the short term, this won’t be a concern as it will curtail demand on what will be a scare resource for the foreseeable future. But while nobody may be panicking just yet about anti-vaxxers, eventually someone will fall ill with a virus they chose not to be immunised from. Then what? Will we have we thought through whether that person’s decisions affect their entitlement to treatment? In single payer healthcare systems, we generally don’t factor how someone got sick into their ability to access treatment. But could more market-oriented systems see large numbers losing access to insurance through non-uptake of vaccination.

By the time we are confronted by these issues, we may know more about what we know little of now, namely what proportion of the population would need to be vaccinated for the virus to stop circulating. In other words, how many unvaccinated people will we be able to carry through uptake by those who might otherwise have infected them. Again deferring to my doctor friend, this will require more knowledge than we currently have about transmissibility of COVID through various routes, who can carry it where and for how long.

Finally, I realise that by framing this debate as the politics of vaccination, I’m pressing different buttons for different people. Politics is a neutral descriptive term for some people, it’s a passion for some and for many many others it’s the worst force that exists in the world, enough to probably turn someone off reading on. Anti-politics is becoming one of the most potent modes of thought currently in circulation and that’s something we as a society need to confront if we want to maintain any sense of ‘we’ into the future. In the meantime, perhaps we’re best returning to a simple definition of politics, namely how groups make decisions, and accept that if vaccination is our route back to a new normal which better resembles the old one, decisions await us at every turn. Nothing is easy.

Vaccine with a possible cure for Coronavirus and Planet Earth” by focusonmore.com is licensed under CC BY