Equitable global access to coronavirus disease 2019 vaccinesBMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4735 (Published 15 December 2020) Cite this as: BMJ 2020;371:m4735
All rapid responses
The dangers of "Values" Imperialism: how 2 opposing solutions can be both correct in their rightful place
I would like to comment on Lloyd-Sherlock et al's rapid response (ref 1) in which it appears to assert that Indonesia's approach to COVID-19 nation wide vaccination programs reflects another form of injustice, in what they termed "vaccine ageism" which will be evident in other similarly low and middle-income countries (LMICs).
Apparently the plans to prioritise COVID-19 vaccines (of which 140 million doses are firm orders for Sinovac Biotech's CoronaVax vaccine) to those aged between 18 and 59, incurred significant displeasure with the authors who consider this as evidence of " a long, problematic tradition of infantilising “grandpa and grandma” and of justifying discrimination on the basis of false claims that people aged 60 or more are by definition unproductive and younger adults universally productive".
I will not want to discuss if this assertion is indeed true or not, but I ask fellow readers to consider the following:
Much of SInovac's vaccine trial involves volunteers under 60 years and the efficacy of their vaccine above this age cut is largely unknown as Lloyd-Sherlock et al acknowledged.
In Indonesia a country of 267 million, some 9% are of 60 years and older with average life expectancy of 71 years; UK of 66 million has 16% who are at least 60 years old with average life expectancy of 81+.
A significant proportion of older persons in UK are socially and financially independent, whereas in Indonesia there are far more older people who are socially and financially reliant on their children than not. The economic impact of unrestricted travel in vaccinated people of working age therefore has far more direct impact on their older relatives dependent on their support.
UK boost multiple level of safety net including the universal healthcare system delivered by NHS (8-9% GDP), in which many are determined that the "free at point of care" service stays that way at any price, whereas in Indonesia the public healthcare system (3% GDP) strived to deliver affordable services in some form or other, but it is generally not considered in the same class as the NHS.
Hence when considering what is the "right" or "just" for the people in Indonesia as opposed to UK (or other OECD countries), it is important to remember the basic assumptions and available resources as well as outlook and shared values in the society.
Granted the Indonesian government's explanation to target younger people as they are of "productive age", and one can wonder if that is part of the government's "spin" or the brutal truth, the scientific basis to deliver these vaccine initially to these people is consistent with the fact that the SInovac trials did not have much clinical data on older persons, which therefore reflects the careful application of evidence-based medicine if this was the reason.
Furthermore there is no doubt that in a tropical country with huge population over many scattered islands with numerous small remote communities, Indonesia cannot afford alternative vaccines tested on older persons, some with difficult supply chain issues, others with expected strong competition by vaccine nationalism, and most are thought to be significantly more expensive than the Chinese vaccines in firm orders.
Commentators on the issue of vaccine distribution and availability in other countries should consider taking off their rose-tinted glasses and accept the possibilities that another country's solutions different from their own may still be correct in their own way according to their values. To shame other countries simply because their approach is not the same as UK, reeks of past imperialism, of which the British in their past has been known to use this difference in values as an excuse to start wars and invasions.
Competing interests: No competing interests
Concern about vaccine nationalism is important and well-founded, but it has overshadowed another key form of injustice: vaccine ageism.
In Indonesia, as in many low and middle-income countries (LMICs), the main form of COVID19 vaccination that will be available over the coming months will be Sinovac, produced in China.
The initial SINOVAC trials in China that led to licensing for use were only conducted on adults aged under 60 . Subsequent trials in Indonesia also exclude over 59 year-olds. The clinical trial research team leader, Kusnandi Rusmil, commented to BBC Indonesia: “"Why do we target people of a productive age? These people can work hard, so the country will not have a deficit" . As a result, there is no information about either its safety or efficacy for people at older ages. Further trials of SINOVAC for people at older ages have since begun in countries such as Brazil . Media reports suggest that SINOVAC may be effective for older people, but at a lower level than for other ages . However, related findings are yet to be published.
Due to the lack of published evidence, the government of Indonesia has decided to exclude people aged 60 and over from their vaccine roll-out . In the (ageist) words of Minister of Health Terawan Agus Putranto, the target is to vaccinate 107,206,544 people aged between 18 and 59, as they are of “productive age”. An article in the national media concludes: “Isn't it strange that if we want to vaccinate them, we will have to fly our children or grandma and grandpa to England?” . This age-targeted vaccination policy will lead to reservoirs of Covid-19 among children and older people, resulting in continuing viral transmission, more hospital admissions and avoidable deaths. The aim of vaccination programmes is not simply to protect individuals, but to achieve herd immunity in order to protect whole populations, including vaccine non-responders and non-compliers .
Not all candidate COVID-19 vaccine trials have excluded older people, and it is welcome that ongoing trials of SINOVAC will include them . Whether this will lead to vaccine policy change in countries like Indonesia remains to be seen. There is a long and problematic history of excluding older people from trials of vaccines or treatments for conditions that affect them greatly . There is a long, problematic tradition of infantilising “grandpa and grandma” and of justifying discrimination on the basis of false claims that people aged 60 or more are by definition unproductive and younger adults universally productive. Nationalist self-interest will mean that most LMICs will be at the back of the global vaccine queue; and vaccine ageism will mean that older people will be at the back of the queue in many LMICs.
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Competing interests: No competing interests
Many vaccines against coronavirus disease 2019 (covid-19) are being developed, and some of them have already shown promising results with 70%-95% efficacy in their pivotal Phase III trials . Some developed countries have been approved to use covid-19 vaccines developed by Pfizer/BioNTech .
The situation has become more dreadful in the second/third wave of COVID-19. Since herd immunity is far away, effective vaccines are highly desired to save life and unwanted deaths . Vaccines' production and distribution process need plenty of time and may need some years to fulfill global needs. Moreover, vaccines might be a big-budget for under-developed countries. Although the fair distribution of vaccines is already a concern of world leaders, equitable access to the covid-19 vaccines throughout the world is a challenging issue . However, to achieve an effective global vaccination program, global cooperation is required .
Secondly, who should get the vaccine in the first stage? Front-line workers like hospital staff need to be considered first. Then older people (60 years or above) should be prioritized as they are the most vulnerable group for COVID-19 and shared the highest percentages of deaths . People with diabetes, cardiovascular diseases, respiratory problems, hypertension, and cancer showed that they suffer from severe COVID-19 . Therefore, people with comorbid conditions (any age) should be listed for the third stage to get the vaccines, followed by the age group 50-59. In the fifth stage, people aged 40-49 years should be vaccinated, followed by 30-39 years.
The vaccine should not be mandatory for all, and consent matters. The vaccines have many unanswered questions and need some years to get answers, such as the vaccine's effectiveness in different ages and races, the vaccines' adverse outcomes in the long-run, and whether the vaccine will affect the next generation, transparency about the results of clinical trials and so on. As the children are at lower risk of dying from COVID-19 [4-5], they should not be vaccinated at such an early stage of vaccines to avoid unnecessary risk in the future.
1. Corum J, Grady D, Wee SL, Zimmer C. Coronavirus vaccine tracker. The New York Times. 2020. https://www.nytimes.com/interactive/2020/science/coronavirus-vaccine-tra... (Accessed on Dec 17, 2020)
2. Schwartz JL. Equitable global access to coronavirus disease 2019 vaccines. BMJ 2020;371:m4735. doi: 10.1136/bmj.m4735
3. Randolph HE, Barreiro LB. Herd Immunity: Understanding COVID-19. Immunity 2020; 52:737-41.
4. Jordan RE, Adab P, Cheng KK. Covid-19: risk factors for severe disease and death. BMJ 2020;368:m1198. doi: 10.1136/bmj.m1198
5. Omori R, Matsuyama R, Nakata Y. The age distribution of mortality from novel coronavirus disease (COVID-19) suggests no large difference of susceptibility by age. Scientific Reports 2020; 10:1-9. doi: 10.1038/s41598-020-73777-8.
Competing interests: No competing interests