I’m a much better person than my wife. When I have an unconscionable thought I immediately suppress it. When she does she puts it on the table and toys with it like a cat does a mouse. Her latest is this:
If all we’re trying to do is save the most vulnerable, then by all means prioritize the elderly in long-term care homes and their staff. But from a purely utilitarian years-of-life perspective, the elderly should be sent to the very back of the line. They’ve long since made whatever contribution they were going to, and they have much less time remaining to enjoy life in any case. And the same holds true for those in the infant acute cardiac unit.
A sick argument and an irrefutable one are not incompatible. But it’s the next one that’s not so much sick as it is quirky. If what we’re trying to do is minimize the spread, then shouldn’t the first round of vaccinations go to the people who’ve been refusing to wear a mask? That we find this argument repugnant would seem to suggest that we’re not, at least not exclusively, concerned to minimize the spread. We’re also concerned about merit. Those maskless people, dammit, have Covid coming, in just the way the rest of us do not. Wouldn’t it be the height of moral irony if people refused to mask up precisely because they could then anticipate going to the front of the line to be vaccinated?
These are the things my wife thinks of that I’m too decent to. It’s a wonder I can sleep at night without an eye open. The clock radio is on her side of the bed, and it’s a heavy one.
Categories: Everything You Wanted to Know About What's Going On in the World But Were Afraid to Ask, Humour
In 2019 about 13,000 Albertans over the age of 70 died from similar comorbidities to what this age group is dying with now – only now they have been tested and found to have Covid too. 591 people over the age of 70 have died ‘with’ Covid, 92% of all Covid deaths have 2 or more health problems. My doctor seems to think we are trying to save a vulnerable population that in previous years were just dying because their time was up… I’ll have to ask him who he thinks should be vaccinated first. I think he will say all those poor souls who can’t work from home and are not considered to be ‘essential’. Those are the people he is busy trying to save. My hairdresser comes to mind…
Paul, just a word in defence of the children in “the infant acute cardiac unit.” Used as I understand it, this would mean children having surgery to correct congenital heart defects. These kids often do well with modern surgical techniques and have good prognosis for reasonably long (sometimes very long) and happy lives. If you are in fact referring to infants in the neonatal ICU weighing < 500 g and born at < 26 weeks gestation whose care costs millions of dollars for often heart-breaking outcomes I would not argue with your point. I don’t want to be churlish about sick children. Still, clarity of terms is important.
The quirky arguments about vaccine allocation are thought-provoking. The fear I want to put into all of your hearts is that voluntary acceptance of vaccine might not be high enough to confer the herd immunity that it will take to end the pandemic. Experts have validated my educated guess that 70% uptake will be necessary, perhaps even 80%. (That’s more than the number who vote in federal elections, and for the vaccine they’ll have to make two trips to the polling station.). If the folks at high risk of dying, plus motivated healthcare workers, plus the worried well, get vaccinated eagerly but only 10-20% of the rest of us submit, the epidemic will continue on as now. Fewer old people will die (because vaccinated) but transmission will continue briskly enough to nail the folks who couldn’t or wouldn’t be vaccinated but turned out to be high-risk after all. (Half the men in Alberta over 50 have high blood pressure. Blacks and Hispanics in the U.S. are telling pollsters they will refuse vaccine wholesale, yet are dying now at three times the rate of whites, despite being much younger.) And while almost all the deaths in Canada occur in residents of nursing homes, the beds in our ICUs are being occupied by Covid patients in their 50s-60s. But if you are young, white, and healthy, what incentive do you have to take any vaccine risk at all, when your self-perceived risk of getting seriously ill from Covid is already so close to zero? What care you for the plight of the ICU director who has no beds? Or that of the 70-year-old whose cancer surgery is cancelled yet again?
The vaccines represent a historic scientific achievement but their success in solving this collective action problem (success defined as getting us back to “normal”) rests on a historically unprecedented effort to immunize an entire adult population in a short period of time. If this effort fails to deliver herd immunity, the achievement will have come to naught. Indeed, if herd immunity is not achieved, it will have been wasteful to have immunized any low-risk people at all, since they will derive no individual benefit, nor will their inadequate numbers help stop the epidemic. But the authorities won’t want to end epidemic controls while cases continue to mushroom and visible minorities are visibly dying. So “Shock and awe” will fizzle into an unwinnable but ruinously expensive war of attrition. Every year a large number of newly vaccinated people will die — of Alzheimer’s, not Covid — and a fresh cohort of maturing unvaccinated children will enlarge the pool of susceptibles for reinvigorated transmission. (And that’s assuming that vaccine immunity lasts a long time. If it wanes, you have to go back and do it all over again. Don’t even go there, …yet.)
Then what do we do? What form of argument would a philosopher apply to the task of making a principled policy choice this time next year when vaccine has trickled out into Canada as far as it’s going to?
Leslie MacMillan offers one correction and one worry. My thanks for both. As to the first point, I misspoke. I have a friend working in the neonatal ICU who reports just how heartbreaking that assignment is, and what I MEANT to refer to was THAT unit, not, as I did, the infant acute cardiac unit. I thank Leslie for the correction. As to his worry that there may be enough vaccine hesitancy to render all our efforts as naught, I suspect his powers of prognosis are better than mine, except to say that if he’s right – and now he’s got me worried that he might be – abandon all hope ye who enter here. I can only hope – as I’m sure Leslie does too – that he’s awfulizing. One of those cases where he probably doesn’t want to crow that, “I told you so!”
Estimates of herd immunity vary wildly. I’ve seen numbers from about 20% to 80%. The most naive and obvious calculation gives 66% but this assumes an entirely homogeneous population. The more heterogeneous you assume the population is, the lower the threshold gets. But I would argue thinking about it as a threshold is wrong, because it’s not. The more people immune (either because they got the disease or the vaccine), the lower the R value will be because there will be which means less spread overall, which means we can get away with fewer restrictions for the same result (restrictions also lower the R value).
Also, I don’t think the point is to eliminate the disease and that shouldn’t be the goal. Pockets of the virus will remain, even if it’s only in our pets, no matter how wide spread the vaccine is distributed. It will likely become endemic, but the harm it causes will be much less seeing most people’s immune system will have seen it, or will see it as a child where the negative effects are minimal. This is really the case of many of the common cold coronoviruses that have been pandemics in the past.
To Pam’s point about us trying to minimize the spread: I don’t think that’s the goal at all. That’s just the means to our real goal which is to limit death and the strain on our health care system. Given that more than 95% of fatalities are over the age of 60, as are the majority of hospitalizations, vaccinating the old will have the largest effect toward better outcomes. Vaccinating people who aren’t wearing a mask will have only minimal indirect effects on the severe outcomes, so it does not actually make any sense.
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Agree with Anon that eradication of Covid is not necessary, given its trivial consequences in most people infected. Vaccination of people over 60, who are likely motivated customers anyway, will indeed take the steam out of the potential to wreck the hospitals. The supply of vaccine is likely to be too low in Canada for many months for any more ambitious vaccination effort in any case — that is still a very large number of people. And heterogeneity and clustering, the degree to which every person in your geographical area is not equally randomly likely to come in contact with you, is important in estimating the impact of control measures, including vaccine. All true.
But policy makers will still have to wrestle with their obligations to people who aren’t vaccinated, or who are vaccinated but perhaps not protected. (Volunteers in randomized trials are always healthier than the population you’d like to give the intervention to. We can’t assume that frail elderly in care homes, for instance, will be 90-95% protected even if all are vaccinated.). If we aren’t aiming for eradication through herd immunity, the unprotected will be left vulnerable to bad luck.
So a year from now, Canada is still seeing 5000 cases a day (guess), reported in the media every day. These will, as now, be in younger people, who aren’t vaccinated (by refusal or, more likely, by rationing policy.). Deaths and ICU use are way down but there are enough “leakers” down the risk ladder that deaths are a daily occurrence in big provinces and crowded, “diverse” cities. What philosophical principles ought governments apply in deciding about ending lockdowns and travel restrictions in the face of these “preventable” deaths?
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At least one expert agrees with Paul’s wife about vaccinating according to the risk of spreading and not entirely according to risk of dying. Chris Bauch at U of Waterloo is a professor of applied math who worked on models used iin vaccine policy development. He is quoted by CBC News this morning that reducing spread in low-risk-of-dying young adults—the ones not wearing masks, right? —is a worthy goal in itself because it will reduce cases in the vulnerable. The people currently getting critically ill caught it from a contact chain that originated in the young, since that’s where most of the new cases are occurring. Of course this approach, to be successful, requires high vaccine acceptance by those unconcerned young people. If our reach exceeds our grasp the goal will elude us — there are threshold effects, pace Anon.
I know Paul was being thoughtfully provocative in citing his wife’s proposal to put mask refuseniks at the head of the line and the nursing-home residents at the back. The question of social merit is not morally irrelevant when scarce resources have to be allocated and the problem can’t be eliminated merely with more money. It is precisely because vaccinating young spreaders first (and letting the old die in their beds) does make operational sense that it needs to be confronted on moral grounds.
We are not done with philosophy.
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Paul, one of your old posts, The Real cost of Covid 19, seems relevant to this discussion,
Indonesia’s government agrees with Paul’s wife, who I gather is also known as Pammentations..
This might be behind a paywall. If so, the Coles Notes version is that they are going to vaccinate *only* people under 60, starting with essential workers with much face-to-face contact with the public and broadening coverage to all the population under 60 as more vaccine comes in. Their rationale is much like Paul’s and Pam’s. They hope to protect old people, many of whom live in multi-generational family households, by preventing transmission in high-spreading young people (irrespective of mask-wearing — I get that Pam was just testing our “social-worth” reflexes there.) From the story: ‘Health Minister Budi Gunadi Sadikin has said the government wants to target “those who are likely to get it and spread it.”’ A wrinkle in Indonesia is that their Chinese vaccine was tested only in people under 60 — so there is no scientific information about benefit or safety in the elderly anyway. Conveniently. There may be some compulsion involved, but they can handle that. There will be compulsion (by employers, if not by government) in Canada, too.
I will point out that the vaccines currently pouring into nursing homes in other countries (or trickling in, in Canada’s case) have not been tested in nursing home residents. You have to read between the lines but it is clear that both published vaccine trials enrolled almost exclusively adults who were living independently in the community, from 16 or 18 and up. (The oldest in both trials was 91.) Only a small handful, 1559 in Pfizer, were over 75. We know that frail elderly in long-term care don’t make good immune responses to other vaccines (or to infections) and there is no evidence that the Covid vaccines are any different here. It is really a leap of faith that somehow things will be different this time….and that vaccinating staff will protect the residents in the same way that vaccination of young people in Indonesia will protect the elderly there. I think that the latter bet s a good one but again we don’t know yet.
Both trials did include a good diversity of racial minorities, people over 65, and people with serious health conditions so there is excellent reason to think the vaccines will reduce severe illness in people, even elderly, outside nursing homes. (Most ICU use is by the 50-80 year-olds with health problems, and not nursing home residents.) It is every bit a scientific triumph, bigger than polio vaccine I think. So get vaccinated as soon as you are offered it. But the vaccines may not solve the political problem faced by provincial governments who have “failed” (again) to “protect our precious seniors” from dying a month or two sooner than God intended. ..so we are in our second state of emergency-lite in Ontario. The floggings will escalate until morale improves, as the T-shirt will say.
On social worth, I want to credit my wife with this insight about the recent dust-up around vaccinating prison inmates. She says: Vaccinate every single one of them. Keep them in jail where they belong and out of my ICU. Guards, manacles, attitude, drug addiction, and hostile visitors we can do without. (well, no visitors any more but you can see how smart and quirky she is. The clock radio is on her side of our bed, too.)
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If mask refusers were to be vaccinated as a priority, as Pam suggests, we would soon know if vaccination truly prevents spread, which is at the moment an unanswered question. If you wear a mask after vaccination as you are told to do, you can’t tell what is preventing disease in your contacts, the mask or the vaccine. But if you refuse to wear a mask, then your contacts are testing the effect purely of the vaccine. If they don’t get sick then the vaccine prevented you from spreading it to them. Bingo. Case closed.
Not quite, because it will take thousands of observations to trace the impact of vaccine only vs. vaccine + mask as we follow infections through the population. There are only 94,000 active cases in the whole country, so 99.7% of the population is not infected anyway. You would have to observe many thousands of mask refuseniks to find one that actually gets infected, and if vaccinated he probably won’t become infected anyway. And one’s contacts are not just one’s own, they are the contacts of many other people, too. (Although not so much any more.) And we need some way for the mask-refusers to be protected from punishment (or even worse, changing their minds) while we are following them, like a Get-out-of-jail-free card.
But in principle, Pam is right: People who refuse to wear masks can tell us a lot about how the disease is, and isn’t, spread. We should treasure them.
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