Home Ground: Ethical issues in Covid-19 vaccine roll-outs

A principled and pragmatic approach to securing and allocating Covid-19 vaccines works best

A member of the public getting their Covid-19 jab at the vaccination centre in Jalan Besar Community Club, on Feb 19, 2021.
A member of the public getting their Covid-19 jab at the vaccination centre in Jalan Besar Community Club, on Feb 19, 2021.PHOTO: ST FILE

Confession: I have been suffering a mild case of vaccine envy in recent weeks.

Among my family members, a few work in the healthcare and essential service sectors. They were called up quite quickly to get their Covid-19 vaccine jabs. About half my family members have now been vaccinated. I remain among the unjabbed half.

Early last month, I asked my company's human resources department if there were plans to vaccinate staff, especially journalists who are out covering events and interviewing people. As a columnist whose bread and butter is information and insights, I often meet people face to face. The rapport and information flow are just not the same over WhatsApp chats, a virtual meeting, or by e-mail. The HR folks said they had asked the Government and were awaiting a reply.

I hushed my vaccine envy and got on with life.

On Wednesday, I took part in a webinar organised by the Centre for Biomedical Ethics (CBME) of the Yong Loo Lin School of Medicine at the National University of Singapore. Titled Covid-19 Vaccines: Ethical Issues In Allocation, Administration And Public Acceptance, the panel featured infectious diseases experts such as Professor Paul Tambyah from the National University Hospital, Associate Professor Lim Poh Lian from the National Centre for Infectious Diseases and Assistant Professor G. Owen Schaefer from the CBME.

I was on the panel as a member of the National University Health System's Patient and Family Advisory Council, and also sharing my views as a journalist, on the public policy aspects of the ethical issues in the vaccine roll-out.

Coincidentally, an hour before the webinar began, I got a WhatsApp update from the Ministry of Health that said vaccination will be extended to those in the critical functions of "postmen, delivery staff, news reporters, bank ops".

My vaccine envy stilled, I am more chuffed that news reporters are included this round, which shows that journalism is considered a critical function in Singapore - a topic for another day.

Meanwhile, I look forward to my colleagues and me getting the vaccine at the proper time.

Moving target

Every vaccination programme carries with it ethical concerns over, among other things, safety, efficacy and how to distribute and allocate the vaccine when there are limited supplies.

A vaccine programme in the middle of a global pandemic is even trickier. On the one hand, speedy access to the vaccine can make the difference between life and death. On the other hand, the vaccines for Covid-19 are new and relatively untested: The world is learning of side effects as millions more get jabbed; and while we know the short-term efficacy, no one knows how long the protection lasts.

As Prof Lim said at the webinar, rolling out vaccination in the middle of a public health emergency is like chasing after a moving target. This requires constant monitoring and updating of rules and plans.

So while some people like me may have vaccine envy, millions around the world do not want to be jabbed. In America, one-third of military personnel offered the vaccine reportedly declined it. In Germany, so many doses are unused, they are called "shelf warmers".

Reports of some people dying or falling severely ill after vaccination have spread virally, eroding confidence in the jabs even though the cause of the deaths and complications have yet to be established.

Amid all this uncertainty, and with vaccines still in short supply worldwide, the question arises: How should vaccine programmes be rolled out and how can they be allocated equitably?


The race to get hold of supplies

The global race to get access to vaccines can be described as one based on token multilateralism, with hoarding and every-country-for-itself as the real manifestations.

Many countries have signed up to Covax, the Covid-19 Vaccine Global Access initiative under the World Health Organisation, for 92 poorer countries to get access to two billion doses by the end of this year. Singapore has given US$5 million (S$6.7 million) to this project.

Most rich countries have placed their own orders for the vaccine. The European Union did so as a bloc - and has been criticised for being slow to procure and distribute vaccines for its 27 member states. Austria and Denmark recently broke ranks to work directly with Israel on second-generation vaccines against Covid-19 variants.

EU stocks have been low as production of vaccines it ordered ran into problems. Last week, Italy, angry that its own orders had not been filled, blocked the export of 250,000 doses of the AstraZeneca vaccine to Australia, saying Australia was not on a list of "vulnerable" nations while vaccine supply was short in the EU and Italy. EU rules allow export controls of vaccines made within its bloc.

More countries are likely to either go it alone or impose export restrictions to hoard stocks for their own citizens. So much for multilateralism.

It is not only nations that jump queues - high-net-worth individuals and prominent individuals worldwide are doing so, with some companies offering "vaccination vacations" that promise holidays with vaccine jabs. The Canadian pension fund chief resigned when his trip to Dubai to get vaccinated became news.

In this scramble for vaccines, every country has had to work smart and fast to get its own supplies.

Singapore has adopted a principled and pragmatic approach. By taking part in Covax, it reinforces its commitment to multilateralism. As a responsible member of the international trading community, it did not impose export restrictions on essential medical supplies and even worked with New Zealand to get other countries to make commitments to do likewise, to ensure smooth supply chains.

At the same time, it has pragmatically made sure to place early orders for promising vaccines even in the development phase. This has led to the salutary situation where Singapore is able to vaccinate its citizens at a steady clip.

Some have asked why Singapore has not rushed to vaccinate its population - it has a vaccination rate of 10.7 per cent  as at Wednesday, lagging behind Israel (100 per cent) and the United Kingdom (36 per cent). (This rate is based on  the number of doses given per 100 population, and includes those with first doses.) Its pace is similar to that of small European countries such as Norway, Finland, Switzerland (11.6 per cent, 10.9 per cent and 11.1 per cent).  

The answer is that a phased approach allows more time for the vaccine's side effects to be uncovered. It also buys time for the infrastructure that delivers millions of doses rapidly and safely to be scaled up. After all, getting access to ready stocks is no easy task. As supplies are more assured, the country can step up the pace. Meanwhile, Singapore's low community transmission also reduces the urgency to vaccinate its population.

The Government has said that Singapore can get all its population vaccinated by the third quarter of this year, although interruptions in supply or the need for public education to persuade more people to get vaccinated may delay the schedule.

Who gets jabbed first and why

Once supplies of the vaccine are secured, planners have to decide how to allocate them.

One simple rule is to distribute based on medical need. Jab those most exposed to the virus first - that would be healthcare workers at the front line caring for Covid-19 patients.

Next, protect the vulnerable - the elderly who are prone to becoming severely ill if infected, including those staying in nursing homes where close living proximity aids transmission.

Giving the vaccine to healthcare workers also meets reciprocity rules. This says that those who contributed to something (the fight against Covid-19 in this case) should be rewarded (with Covid-19 vaccination). It is the same principle that gives those on clinical trials faster access to trial medication proven to be effective.

Prioritising healthcare workers also meets instrumentality criteria that we vaccinate those who contribute most to society first. So we vaccinate those without whose work society will become unbearable - apart from healthcare workers, this includes essential services workers in public transport, cleaners, garbage collectors, and food and beverage workers.

Applying the rule of instrumentality means we should also prioritise vaccination for politicians and leaders of institutions fighting Covid-19.

Cabinet ministers here were among the first to get vaccinated. Although they pitched the event as one of showing confidence in the vaccine and encouraging Singaporeans to get vaccinated, there are also good ethical grounds to vaccinate political office-holders first: preserving the health of the officials leading the fight against Covid-19 helps protect the entire nation. This is similar to the principle in airplanes where you are advised to don the oxygen mask first before attending to your dependants.

Allocation also needs to be risk-adjusted: giving to the more susceptible first to protect them early and reduce their chance of getting infected. This is why Singapore vaccinated those in their 70s first and is working down the age groups.

Why giving a choice of vaccine is not a good idea

So far, with a rational and sensible allocation plan, there have been few public reports of queue-jumping, although anecdotally I hear of people who are not in front-line work who got vaccinated ahead of their age cohorts by piggy-backing on their company's vaccination programme. Examples might include the head of administration or corporate services of, say, a healthcare institution. But with the general ethos of Singaporeans against queue-jumping and undeserved priority access, there is societal disapproval that should keep such behaviours in check.

The Government's decision not to make vaccination compulsory, but to offer it free and to use public education to encourage the take-up rate, has drawn various responses, but I for one think its stand is reasonable.

Whether it is the Pfizer-BioNTech, AstraZeneca, Moderna or Sinovac vaccine, all are experimental in nature, with unprecedented fast-tracked approval processes, and still-evolving results on efficacy and side-effects. When the medical risk is unknown, it would be unconscionable for the state to compel citizens into vaccination.

Offering it free nudges people to take it up - which is good given the prosocial effects of vaccination - a vaccinated person not only protects herself from severe diseases, but she also reduces the chance of getting infected and hence the chance of transmitting it to others.

Many have asked why Singaporeans are not allowed a choice of vaccine. One answer is that choice delays the roll-out of the vaccination programme and increases the risk of infections spreading. Modelling studies show that compared with waiting for vaccines of higher efficacy, getting more people vaccinated early, even with vaccines of lower efficacy, saves the number of infections, severe hospitalisations, and deaths across the population.

Prof Lim adds that offering a choice means the Government needs to have ready stocks of the available vaccines to cater to their choices, which will result in wastage at a time when there are not enough supplies worldwide.

She uses this vivid example: "It's like being on a flight and the menu has a choice of chicken or fish. There are 100 passengers, and they stock 70 chicken and 70 fish entrees, but 90 people choose chicken. Well, for the 20 passengers who want chicken after it has run out, they don't have a choice; it's fish or nothing.

"The only way to have a real choice would be to stock 100 chicken and 100 fish entrees. But that means throwing out 100 unused meals at the end of the flight. Can we justify this wastage from a public health or ethical perspective? In some situations, having a choice is valid, but in other situations, such as a global public health emergency, with complicated and rapidly changing data on vaccines and variants, insisting on choice may not be the wisest approach.

As the production capacity of vaccines ramps up, there will invariably be stocks available in the private-sector market. Private hospitals in Malaysia, for example, want to be able to buy the vaccines for their fee-paying patients who do not want to wait their turn for the government roll-out.

Will Singapore permit similar access based on willingness to pay? I think it is unlikely, because it will spawn equity concerns. Also, the steady pace of state-sponsored vaccination here should dampen such demand.

As I told the webinar participants, given the scramble to get hold of vaccines worldwide, I am happy to live in a country that has a principled and pragmatic approach to securing and allocating Covid-19 vaccines.

The article has been edited for clarity.