Vaccine Passports

Discussions of the pros and cons of mandated lock downs to stop (or slow) the spread of Covid-19 often miss the most important point. The key factor in restraining the spread of a contagious disease (beyond vaccines, basic public health measures, etc.) is the behavior of each one of us. Given our respective risk preferences the question is whether we adjust our behavior sensibly to protect ourselves and others from infection? Our behavior may be responding to government mandates to close restaurants, theaters, and factories or it may be responding to information provided by public health experts on the nature of the risks and measures to mitigate them. In the latter case our experience and that of our neighbors will depend importantly on the quality of the information provided and our trust in its efficacy. Our individual choices allow responses that are more suited to the individual situation of each actor.  “The unnecessary fight over covid-19”

In short, if governments were to say, “do whatever you want, but these are the risks as we understand them,” people would not necessarily rush to the concert hall, or baseball game, or hop on a plane. “Sports fans live attendance poll”  Offices, factories, restaurants and entertainment venues must convince their workers and customers that they have taken reasonable steps to be safe from Covid-19 (or other risks). Thus, comparing the results (infections and economic output) of lock down with no (or mild) lock down countries is not the right test.

We need to focus attention on the quality of the information being provided to the public, the public’s trust of such information, and the efficacy of the measures being taken by those offering reasons to gather in public places to enhance its safety. Those who have had Covid-19 or who have been vaccinated for it face minimum risk of catching it (again) or of spreading it and can pretty safely attend public events. Thus, a trustworthy way of establishing that fact would be very useful. I carry my vaccine certificate wherever I go but they are relatively easy to counterfeit if it became useful to do so. Thus, the reason behind the various projects to develop so called vaccine passports (better named vaccine certificates) is obvious.

The technical design, including privacy protections, raise more issues than you might at first imagine, including establishing interoperability standards and access to public records. However, the position taken by Florida Gov. Ron DeSantis defies understanding by those of us who place our individual freedom in first place. He stated that: “We are not supporting doing any vaccine passports in the state of Florida…. It’s completely unacceptable for either the government or the private sector to impose upon you the requirement that you show proof of vaccine to just simply be able to participate in normal society.”  “Biden vaccine passports-DeSantis”  This is incredibly wrong. Restaurants now serving indoors already test our temperature before allowing us to enter. I visited my credit union in the IMF building in downtown Washington, DC today and they took my temperature as well. If gatherings are not convincingly safe, sensible people won’t attend. Countries requiring arriving passengers from other countries with a high incidence of Covid-19 infections to quarantine for two weeks would presumably wave that requirement for passengers with a credible vaccine certificate.

It is hard to imagine that the public accommodation clause of the Civil Rights Act of 1964 would require a restaurant to admit and serve a customer with a contagious disease. But there are privacy and other technical concerns with implementing a reliable certificate of a covid vaccine. “The next front in the pandemic culture wars vaccine passports” The benefits to the economy and our freedoms are significant enough to make the effort to overcome them.

Should you get vaccinated for Covid-19?

“A CBS/YouGov poll released this weekend found 33 percent of GOP voters say they will not get the vaccine when it’s available to them. Another 20 percent say they aren’t sure.” “The-daily-202”  After being thoroughly satisfied that Moderna was safe and effective, I have received both of my jabs. But I sympathize with those who are skeptical and/or distrusting of the information they have been fed over the last year. The messaging from the Trump administration was inconsistent and the CDC has now removed some earlier postings that had been more influenced by politics than by science (which, by the way, is far from having all of the answers yet).

In addition to poor messaging from the government, some badly misguided, if not deliberately evil, groups have spread false information.  So, I find it very encouraging that many of those refusing to get the vaccine say that they “want to be educated not indoctrinated.  The responses of focus group participants suggest they can be persuaded — but perhaps not by politicians, including the former president…. Be honest that scientists don’t have all the answers. Tout the number of people who got the vaccines in trials. And don’t show pro-vaccine ads with politicians — not even ones with Donald Trump.  That’s what a focus group of vaccine-hesitant Trump voters insisted to politicians and pollsters this weekend….

 “’These people represent 30 million Americans. And without these people, you’re not getting herd immunity,’ said Frank Luntz, the longtime GOPpollster who convened Saturday’s focus group over Zoom.” Unfortunately Mr. Luntz is speaking nonsense as well. We would still get herd immunity even without a vaccine as people would acquire immunity as a result of being infected. The process would be slower with more deaths, but we would get there. I am sure that Mr. Luntz meant well.

Participants in these focus groups “all believed the coronavirus threat was real, with many having contracted it themselves or aware of critically ill friends and family, and they didn’t want to be condemned as “anti-vaxxers” who opposed all vaccines. Instead, they blamed their hesitation on factors like the unknown long-term effects of new vaccines, even though scientists have stressed their confidence in the products. They also accused politicians and government scientists of repeatedly misleading them this past year….

“For instance, [House Minority Leader Kevin] McCarthy said he understood the Trump voters’ hesitation because pharmaceutical companies waited until after Trump lost the election to announce their promising vaccine results — a comment that sparked participants to share their own resentments.

‘It was political stunts like that that leave doubt in our minds,’ said a man identified as David from Texas.”

In another session “a man called Chad from Minnesota,… praised [former head of the CDC Dr.] Frieden for acknowledging that the long-term risks of the vaccines aren’t yet known. “He’s just honest with us and telling us, nothing is 100 percent here, people.”

The lessons are clear. The best results are obtained by treating the public like adults. The government needs to honestly present the best information available, acknowledging what is known and what is uncertain.

“’I’ve been thinking the messaging was going to be very different for communities of color, for Democrats, for Republicans,’ said Natalie Davis, co-founder of United States of Care, a public health advocacy group working on vaccine outreach with organizations like the de Beaumont Foundation and Kaiser Family Foundation. ‘But it feels like it comes down to the basics that are shared across populations. People want full, accurate information so they can decide if this is the right thing for them and their loved ones….’

“‘The vaccines were approved quickly in part because red tape was cut, not corners,’ [Dr. Frieden said. ‘And almost all the doctors who are offered the vaccine get it.’”   “Vaccine hesitant republicans focus group”

Access to COVID-19 vaccines

In less than one year from learning of this virus, we now have two approved safe and effective covid-19 vaccines with at least one more on the way. Millions of doses have already been produced. This is a near miracle. Thank you pharmaceutical industry and the governments (and their tax payers) that are paying for it.

Getting the vaccine into our bodies is quite another thing. This has several elements. The first is distributing the vaccines to each state/county and site of vaccinations. The second (or first and a half) is staffing these sites with professions able to administer the shots with the necessary equipment (refrigeration, syringes and needles, etc.). The third is determining who can receive the shot this week and getting them to the right place. The need for these three elements has been known for as long as the need for a vaccine has been known. And officials have known the likely vaccines for at least half a year. But planning for delivering the vaccine to your arm (or the lack of it) has been totally botched.

Focusing on the United States, the federal government promised to vaccinate 20 million people by the end of the year (last week). “Of the more than 12 million doses of vaccines from Moderna Inc. and Pfizer Inc. with BioNTech SE that have been shipped, only 2.8 million have been administered, according to federal figures….  The federal government is sending vaccines to states based on their populations, and it has provided guidelines, but no rules, about how they should be distributed…. On Friday [Jan 1, 2021], Sen. Mitt Romney (R., Utah) criticized the vaccine rollout, saying in a statement that the lack of a comprehensive federal plan to be shared with states “is as incomprehensible as it is inexcusable.”  WSJ: Covid-19-vaccines-slow-rollout-could-portend-more-problems”

Priority

Beyond the above fiasco, it is necessary to determine the priority for receiving the shots and communicating that information to you and me.  As we have already seen it will take a while–many months–to vaccinate everyone even without the above mess. So, who should get them the first month and the second month etc.? I discussed this issue last May. https://wcoats.blog/2020/05/18/the-vaccine-who-gets-it-first/

One criterion for establishing inoculation priorities is to allocate the vaccines so as to maximize the lives saved. I suggest that a better criterion is to maximize the life saved. The difference between the number of lives saved and the amount of life saved can be explained with a simple example. If there is only one dose and it is given to an 85 year old woman otherwise in good health, she might live another healthy year. If given to a 40 year old nurse, he might live another 46 healthy years. In both cases only one life has been saved but in the second case much more life has been saved (46 years of life rather than only one). But this potentially understates the case for giving the jab (as the British call it) to the nurse. One nurse that has been immunized against covid-19 can safely treat more patients that have covid-19 thus saving even more lives and more life. An argument in the other direction of inoculating the elderly first is to flatten the curve (i.e., reduce the inflow of covid-19 patients into overflowing hospitals).

In my view there is a strong case for maximizing the life saved rather than the number of lives saved. We older people should not crowed out younger people who as a result of the vaccination might enjoy much longer lives, something we have already enjoyed. The case, in my view, is overwhelming for critical workers (healthcare workers, grocery store workers, delivery people, etc.) of all ages to receive priority. “Many states are following CDC guidelines to start with front-line medical workers and people in long-term care facilities, but not all. Florida Gov. Ron DeSantis on Dec. 23 extended eligibility to people aged 65 and older.  Because each county and hospital in the state implemented its own approach, many people didn’t know whether to call, log on or show up in person to secure a spot.” [Same WSJ article] 

 A single dose of Moderna and Pfizer’s vaccines “appears to provide strong protection against the coronavirus…. With supplies of the vaccines limited — and hundreds of millions of people waiting for inoculation — this leaves epidemiologists grappling with a complicated question. Should the nation vaccinate fewer people with the best protection possible, or provide twice the number of people with a single shot, covering more of the population but with slightly weaker protection?”  “Coronavirus-vaccine-single-dose-debate”

But if the government can get itself organized (I know that that asks a lot) the existing and rapidly expanding supply of vaccines can be administered in a relatively modest number of months after which the priority issue vanishes.

Information

Whatever your priority turns out to be, how do you know where and when to show up? Do you need a prescription or approval and if so where do you get it? My insurance company is sending regular updates on what I should do. My Maryland county (Montgomery) website has information on the priority phase they are in (phase 1 at the moment) and that is about all (probably because every dispensary–hospitals, doctor’s offices, CVS–sets its own rules). I plan to contact my Primary Care Physician (PCP) for instructions next month when the situation might be a bit clearer.  What should people without medical insurance or a PCP do?  I have visited Kenya many times with the IMF and suspect that they are doing a better job with this than we are. How and why is this such a mess?

The Vaccine: Who gets it first?

For context, the common cold is caused by coronaviruses (with rhinoviruses being the most common virus) and there are no vaccines for colds. More seriously, because colds are rarely more than annoying, HIV, the virus that causes AIDS, has no vaccine despite almost 40 years of trying to develop one.  While AIDS was fatal for many years there are now treatments that hold it in check, but the vaccine remains elusive.

There is hope that an effective vaccine will be found soon for SARS-CoV-2, the virus that causes covid-19. In fact, six potential vaccines have entered phase one of human trails (the first of three required testing phases). Once a potential vaccine has been developed it must be tested first for its safety (side effects and who is at greatest risk of these side effects) and then for its effectiveness. On average it takes five to ten years to pass these hurdles and be approved for general use. Coronavirus-vaccine-here-are-the-steps-it-will-need-to-go-through-during-development

But the science has gotten better and the authorities have put great urgency on the development of a vaccine for this virus and seem willing to cut a few corners to speed up the testing and approval, though there are risks in doing so. Still “some of Mr. Trump’s top public health advisers have repeatedly cautioned that an effective vaccine might not be ready for widespread distribution for 18 months, and perhaps even longer. Mr. Trump ordered the creation of the Warp Speed program to try to speed that timeline.” Coronavirus-Trump-operation-warp-speed

Trump says the U.S. will have a vaccine by the end of the year (this year, 2020!!), which would indeed be a miracle. But even with a crash program to produce and administer it, it will take several years from approval before enough can be produced and distributed for everyone to be vaccinated. Thus, one important question is who gets it first. Lets-say-theres-a-covid-19-vaccine-who-gets-it-first

Answering that difficult question can be approached in several ways. One is to ask what would be fair. Is it fair to give everyone an equal chance at being first, second and third….? That would require a lottery and would mean that some who would benefit more and thus have a greater need for the vaccine (health care workers being an obvious example) would often be well down the line from say children less likely to get, or at least suffer from, covid-19 in the first place. So, an ethically more defensible criteria would be to establish medically which hierarchy of priorities would save the most lives in the long run.  Perhaps after healthcare workers and first defenders, children should be next so they can get on with their life-altering educations and avoid infecting their parents and grandparents, etc.

The reality, however, is that whoever owns the vaccine will have the largest say in the determination of the priorities of who gets it. Without that incentive only government labs would be working to develop a vaccine and how dreadful that would be. Private pharmaceutical companies are spending multiple millions of dollars in the race to develop “the” vaccine first. Their profit reward will come not only in initial dollars and cents but in the boost to their reputations, which will also reflect how the public sees their pricing and allocation of their product. We are quite used to the fact that hot new products–think of the first iPhones–are relatively expensive and go to those willing to pay the most. As production expands and demand is more widely met, prices come down. Governments are major funders of the research and development going into the search for a vaccine and they will rightly consider themselves entitled to an owner’s reward (first priority). Coronavirus-vaccine-frontrunners-emerge-rollouts-weighed

Policy is further complicated by whether exclusive ownership or more social collaboration (the equivalent of open source code) will produce the best vaccine the quickest.  Governments might give large financial prizes to the best two or three vaccine ideas to those developing them rather than patents to encourage information sharing.  Moreover, there can be more than one winner. The first vaccine approved will not necessarily be the best in the long run. There is a strong case for going forward with several vaccines. This view is put forth in an article by Larry Corey of the Vaccine and Infectious Disease Division at Fred Hutchinson Cancer Center, John Mascola and Anthony Fauci of the National Institute of Allergy and Infectious Diseases, and Francis Collins, head of the National Institutes of Health. Science mag.org/content/early/2020/05/12/science.abc5312

But who gets it first is an unavoidable and potentially very contentious issue.  “After controversial comments by the CEO of a French pharmaceutical company, French Prime Minister Édouard Philippe took the opportunity on Thursday to say that equal access to any vaccine that is developed is “non-negotiable.” Paul Hudson, the head of Sanofi, told Bloomberg on Wednesday that the United States would get the “largest pre-order” of a successful vaccine because it was the first to fund the firm’s research—a statement he later walked back.” Coronavirus-pandemic-vaccine-Sanofi-France-United-States.  But to say that “equal access” is non-negotiable is both ignorant and meaningless, ignoring the obvious fact that production for hundreds of millions of people will take months if not years to distribute.

It would be best if all countries agreed in advance (in a philosophical veil of ignorance) on the principles that would guide the priority of distributing vaccines. The company and country of the winner(s) should get a significant share of the initial (and subsequent) supply and within all countries those most in need for the protection of the broader society should get first priority.

“Secretary of State Mike Pompeo told an Israeli journalist on Wednesday that, ‘We’ll figure out the model for distribution when the time comes.’” Nations-jockey-to-see-who-gets-coronavirus-vaccine-first  As is so often the case these days Secretary Pompeo is wrong. Or as the Economist magazine put it this week: “For a man acknowledged to be highly intelligent, Mike Pompeo has a long history of talking nonsense.”   Mike-Pompeos-politicisation-of-foreign-policy-is-unworthy-of-him

 

 

Beating covid-19: Compulsion or Persuasion and Guidance

March 31, 2020

The number of deaths in the U.S. from covid-19 have doubled every three days over the last 22 days amounting to 3,141 by the end of March 30. At that point there were 163,788 confirmed cases (those testing positive for the virus).  https://www.ft.com/coronavirus-latest  The actual number of cases is thought to be considerably larger but remains undetected because of limited viral testing.  America’s overall strategy for containing the virus is to isolate those infected in order to stop or slow its spread until a vaccine can be developed, tested for safety and effectiveness, manufactured and administered (one to two years after the discovery of the vaccine, with luck) or until enough of the population has acquired immunity as the result of surviving from the disease (herd immunization), i.e., almost everyone who gets it. The details of the approach vary from community to community.

The virus that causes covid-19 is spread from person to person. It can be picked up from surfaces touched by a sick person, coughed or sneezed into the air within six or so feet or by direct contact, but it can only enter one’s body via the month, nose or eyes.  “Prevent-getting-sick/how-covid-spreads”  “Protecting-yourself-from-coronavirus”  Thus those who test positive for the virus should be isolated from the rest of us (quarantined) and the rest of us should self-isolate if we experience symptoms of the disease. To protect ourselves from picking up the virus and bringing it to our faces we can reduce our social interactions (work from home, avoid public gatherings such as religious services, and restaurants, bars and public entertainment). Two measures are more important than any others: test as many people as possible in order to detect and isolate those with the virus and wash our hands with soap frequently.  The President’s coronavirus-guidelines for American

These measures can be imposed by government decree and enforcement by the state or can be urged by public education and voluntary individual actions. On March 17 the Governor of Virginia explained why he had not ordered restaurants and bars to close. “Northam said too many Virginia residents rely on restaurants for their meals to justify ordering they shut down.”  “Northam-adopts-10-person-standard-opposes-closing-restaurants”  For the United States as a whole and for most communities (public health services are administered by cities and states) the restrictions on our activities are voluntary. The specific guidance or rules are determined locally, thus providing useful data on which approaches work best.

As in Singapore, S. Korea, Japan, Hong Kong, Sweden and a few other countries, business closures in the U.S. have generally been voluntary until March 30. But unlike these countries, which have successfully kept death rates relatively low, the U.S. failed to undertake significant testing for the virus for more than two months after the outbreak of the disease in Wuhan, China. After the tenth death, the death rate from covid-19 in the U.S. has doubled every three days and passed the number of 9/11 deaths on March 30. On March 30, the Governor of Maryland, followed by the Governor of Virginia and the Mayor of the District of Columbia, made shelter in place mandatory: “We Are No Longer Asking Or Suggesting That Marylanders Stay Home, We Are Directing Them To Do So.” “As-covid-19-crisis-escalates-in-capital-region-governor-hogan-issues-stay-at-home-order-effective-tonight”

There is general agreement that testing should be pursued vigorously and those testing positive should be quarantined and their contacts tested, etc. This buys time to better prepare for the increased demand for medical care that will be needed and to develop treatments and vaccines. Though many will die needlessly in the U.S. because of a several months late start with such a program, the question remains which policy to follow for everyone else going forward.  Should it be government mandates to shut most things down and keep everyone home (or at least try to), or should we rely on the choices of each individual for how best to protect themselves and their loved ones while carrying on with their lives? What are the matrixes by which that choice should be judged? “This-pro-trump-coastal-community-in-florida-hit-early-by-virus-sits-at-emotional-nexus-of-national-debate-over-reopening-economy-amid-health-crisis”

In my opinion maximizing individual choices about how to respond to the epidemic is both more effective and more in keeping with America’s freedom loving culture. By more effective I mean that it will best slow the spread of the disease with minimal damage to the economy and the quality of our lives. We each have a strong incentive to protect ourselves from contracting the virus. We also care about protecting others from exposure (most strongly our families and loved ones) but can be deterred from that goal by the loss of income if we stay home. The CARES Acted signed into law a few days ago is meant to compensate firms that shut down temporarily and workers who stay home temporarily and thus to better align the incentives to protect others with the financial consequences.

We protect ourselves and others by diligently adhering to enhanced hygiene practices (frequent hand washing) and by reducing unnecessary social contacts (no hand shaking etc.). As with most everything else in life we are each better able to determine how best to balance the risks of social interactions (whether to work from home or in the office) with safer isolation, than are government officials making general rules for everyone.  The countries that have adopted this approach have left their citizens free to go to work or restaurants but undertaken extensive educational programs on the best practices to protect against transmission of the virus. “South-korea-keeps-covid-19-at-bay-without-a-total-lockdown”

South Korea, Singapore, Taiwan and other countries taking this approach provide their citizens with honest information needed by them to evaluate the risks of different choices. This includes information on who is infected and identifying infection hot spots. In the U.S. a person’s health status is private. But when a person carries a contagious disease into the public, his/her condition should be made known to those who risk exposure.  “Coronavirus-data-privacy”

Government mandates to shelter in place or cease many business activity will become increasingly difficult to enforce (have you watched the “Steven Soderbergh movie Contagion”). Persuading the public to adjust their behavior in ways that slow the virus’s spread and providing helpful guidance on how best to do so until a vaccine is found or most of the population becomes immune would be both more effective and more politically popular.