Hopeful but Cautious about COVID-19 Vaccine
MARK MOSLEY, MD, MPH
sure you’re getting the same questions I am: “Are you seeing much of the
virus?” “Do you think there will be a second wave?” “Do you really think
we should be wearing a mask everywhere?” “I’ve heard they might have a vaccine
available pretty soon. What do you think?”
You are not only a front-liner, but
everyone in your community sees you as a leader, probably for the first time in
your career. This is in your wheelhouse. A couple of times every shift, a nurse
or someone in your department, regardless of his training, says to you, “Sorry,
I don’t feel comfortable about what is happening in room X (e.g., mental
status, breathing, blood pressure, patient behavior). Can you come there?” Without
fail, you stop what you are doing, often immediately, and assess the
information you’ve been given. You doubt this will amount to much, so why do
you respond so promptly and seriously? There are at least three reasons:
assumption might be wrong, and this might be something
life-threatening that needs your immediate action. We can all think of
countless times that someone saved us by picking up on something we didn’t know
about or that we just missed.
honor the staff by taking them seriously with a prompt evaluation. You value
them by thanking them for communicating with you, even if their fears were
unjustified. And when things go bad, you sure don’t throw them under the bus by
proclaiming that they didn’t make it seem important when they told you.
You do it for the patient and the culture of the department. A good leader does
not demand leadership, he earns it. You model the behavior of service to others
by doing the hardest work and not leaving it to nurses or students. With the most
difficult patients and situations, you want the ball at the end of the game, no
matter how tired you are. You do this without hyperbole, without threat,
without blaming, without malice. You lay out enormous complexity and emotional
challenges like a cool glass of water.
Humility, respect for others with less
experience or education, honor and value of others’ efforts without blaming,
courage to take full responsibility, strength to finish a conflict with class, all
for the purpose of serving others. This is the leadership that is necessary
during the COVID-19 pandemic. You already have this.
We may be needed even more for these
leadership skills by our family, friends, and larger community as we approach a
vaccine. Like a patient with an unusual disease you’ve never seen, vaccination
may not be an area as comfortable for you as chest pain or trauma, but this may
be our time. Good leadership begins with an accurate assessment of terms and
barriers. If I may offer a quick and incomplete briefing:
When everyone begins yelling, “We have
a pulse!!” (in this case, they’ll yell, “There’s an available vaccine!”), you
will need to be the one, like you always are, who calmly steps forward, becomes
even more watchful, and says, “Good. Now, we need a blood pressure” because you
know that a pulse is not an outcome. Even a blood pressure is not an outcome.
The ultimate goal is meaningful life. A good leader needs to be thinking of the
problems that will occur and keep his eyes on the outcome.
A few problems to think about with an
Availability as discovery: There are eight
vaccines currently in phase I trials with predictions that one will be available
by late 2020 or early 2021. Vaccine development usually takes years, not
months. Even the unlikely gift of an available vaccine in 2021 means only that
we have discovered it. I would remind us that COVID-19 tests were available to
“anyone who wants a test” in mid-March, and as I write this in June, we are
still struggling to get sufficient testing, to say nothing about reliability.
Availability as large-scale manufacturing: There is a chasm
between discovery and large-scale manufacturing. After years of developing and testing
the Salk vaccine for polio, five pharmaceutical companies were left to produce
the vaccine without significant oversight. As speed took precedence over
caution, serious mistakes went unreported. Cutter Laboratories distributed a
vaccine so contaminated with live virus that it left 164 children paralyzed and
10 dead. (Paul A Offit. The Cutter Incident: How America’s First Polio
Vaccine Led to the Growing Vaccine Crisis. 2007. New Haven/London: Yale
University Press.) It is difficult to fathom the resources, materials,
planning, infrastructure, labor, and execution to manufacture billions of
COVID-19 vaccines on a scale to make it available to the entire world while
maintaining quality controls.
Availability as global distribution: To think of
distributing vaccines securely throughout a country as geographically
challenging as the United States is unimaginable. To distribute it throughout
the globe is insurmountable. And an America-first approach is a completely
ineffective strategy unless we literally close all our borders to everyone
(which we can’t do). In an America-first scenario with international commerce
and travel continued, competition kills. (“Even finding a COVID-19 vaccine
won’t be enough to end the pandemic.” Washington Post. May 11, 2020; https://wapo.st/2A0RT26.)
Availability as a most
effective prioritized distribution: As we know, triage is not
first come, first served, and you don’t move to the front of the line if you
have better insurance. The most effective distribution is often not equitable.
The triage of a COVID-19 vaccine in the United States should not be prioritized
to the wealthy and famous who have the power to get them but strictly from a
scientific evidenced-based perspective to the poor, African Americans, Latinos,
and indigenous people. (JAMA. 2020;323:1891; https://bit.ly/2U4BaC7.)
The politics of this rational scientific-based decision would be a racial
cauldron, not to mention the reluctance of communities that have endured U.S.
government experimentation, like African Americans with syphilis. (Susan M.
Reverby. Examining Tuskegee: The Infamous
Syphilis Study and Its Legacy. 2013. Chapel Hill: University of
North Carolina Press.) A vaccine provided to poor people of color will more
likely be a vaccine reasonably refused.
Availability as an effective and safe vaccine:
of a vaccine that is sufficiently immunogenic with minimal adverse effects in
vaccine trials is not the same as a vaccine in the community that is effective
and safe. Efficacy and safety require large numbers over a fair period of time,
even under the best of conditions. Concerns of a new swine flu in 1976 led to a
government-backed mass vaccine program that was rushed. Some who received the
vaccine had no immune response at all, and a few individuals came down with
Guillian-Barré syndrome. (Emerg Infect Dis. 2006;12:29.)
Availability as a vaccine actually used (not
A miracle will be needed to produce a vaccine at warp speed that has better
efficacy than the influenza vaccine with fewer side effects than any other
vaccine we have produced. More than ever, it’s all about trust. (JAMA. May 26, 2020; https://bit.ly/3gPvg1u.) The COVID-19 vaccine
will have one shot to be nothing less than perfect in our current cultural
climate. Any failure will be fuel to anti-vaxxers.
But many others are also hesitant. Mistrust of
the government as a rule and of this administration in particular runs high,
making the adoption of an effective and safe vaccine challenging. Currently,
only three of four people would be willing to take the vaccine, and only 30
percent would take it soon after it is available. And this is in the
heat of the pandemic when people are more accepting of trying anything. (JAMA.
May 18, 2020; https://bit.ly/3gSqiRg.) If the vaccine arrives
next year without an alarming second wave, the desire to take a vaccine will
diminish further. This does not account for internet conspiracy stories and
fake, inaccurate claims (e.g., autism).
Availability as meeting the outcome of herd
The outcome is herd immunity, not discovery, manufacturing, distribution,
prioritized distribution, efficacy and safety, or even public health
salesmanship. Many people cannot or will not take the vaccine—children on
chemotherapy, pregnant women, the immunocompromised, the underprivileged, the mentally
disabled, or even the vaccine-hesitant whose socioeconomic conditions mean they
cannot get a vaccine. These are the American citizens who must have herd
immunity to survive.
It is true that getting a good vaccine to one
person will protect him, and one goal is to prevent infection in the
individual. But a larger goal is to prevent transmission of the virus to others,
and the ultimate outcome is herd immunity. Experts say this will require 55 to 82
percent of a population being immunized with an adequate vaccine. (The New
York Times. May 28, 2020; https://nyti.ms/370Stt4.) If herd immunity
requires that kind of response, we might want to consider putting ourselves on
the endangered species list.
In a world that says, “I am the only
science I need,” “I am the only government I need,” and even “I am the only
race I need,” many people have migrated into a mental habitat that has quit
thinking about a “we” world. It is immunologically lethal to live in an open
society with that kind of closed mind. Opinion no longer even cares to look at
the complexity of truth. We like or dislike something in a hot minute.
Unfortunately, it is not enough to say, “You must do it for the village even if
it impedes your personal choice.” It is still sadly uncertain if this current
cultural climate can change.
This challenge will not be easy and
probably will not be over for a while. When the media and everyone around you
begin yelling, “We have an available vaccine,” we need to be the ones who
step calmly closer, watch even more carefully, encourage hope but be
exquisitely cautious, and say, “Good. Now we need a blood pressure.”
Mosley is an emergency physician in Wichita, KS.