Wednesday, May 29, 2024

Vaccine and Vaccination Quandary?

As Covid-19 continues to cut a deadly swathe of sickness, death, grief and inglorious decimation of national economies with reckless abandon one thing is becoming clear, and terribly disturbing: who will get the vaccine first, how, and why? Here is the greatest test of moral philosophy, and the most glaring illustration of the tragedy of unequal societies; are the rich willing, and ready, to quickly, and equitably, share equal access to vaccines? Our argument here is that they are not. Will Botswana manage to get an effective, perhaps even more efficacious, vaccine for its citizens? Right now nobody can tell. Why are we so pessimistic? 

First, at the outbreak of the virus the rich did not help poor nations to reorient economies towards vital medical equipment (PPE, swabs, testing kits, ventilators). Second, no fiscal tools where availed to mitigate damage, and prevent health systems failure. No technical expertise was availed to promote health transparency and data integrity. No coordinated fiscal stimulus is in place to help poor nations recover as we write, and no money is available for these countries to fight vaccine misinformation…if vaccines finally do get to countries like Botswana what kind of help can we expect to get to cover the long and difficult journey between such a vaccine arriving at the airport and getting it into the arms of 2.2 million scared, restive and beleaguered Batswana? 

Not much, and not quickly.

I listened to the 2020/2021 Budget speech yesterday. Finance minister, Honourable Dr Thapelo Matsheka, was candid about the bleak picture the world sees in Botswana. Our public finances are, for lack of a better word, in a terrible state. Covid-19, fiscal waste, low productivity, a bloated and inefficient Civil Service and antiquated tax system have bled the National Treasury dry…this at a time when we need nothing short of a war chest just to get by; to survive. 

I also listened to Cyril Ramaphosa; celebrating the arrival of a national lifeline in South Africa: a Covid-19 vaccine, and I got to wonder: just how long will it take us as a country to put our house in order?

Recently Xinhua Net reported that President Masisi had assured the Nation that ‘once available, administration of the vaccine will start with frontline workers since they are the first line of defense in treating (sic) and curbing the spread and transmission of Covid-19.’ He was speaking in Francistown. This statement is very troubling, to say the least, because it goes on to say Masisi was ‘motivating Nurses, Doctors, Police Officers and other frontline workers in Francistown.’ 

We shall return to this report later. 

In November, 2020, Reuters reported that Botswana had signed an agreement to procure a vaccine-once available-through a global distribution scheme co-led by WHO. According to this report, and subsequent ones in other news outlets, Botswana made an upfront payment to COVAX that created a pathway for the country to get roughly 940 800 vaccine doses under a two-dose regimen. This allotment guaranteed a potential vaccination of 20% of our population (to reach herd immunity/Community Immunity or Population Immunity we must vaccinate about 40-60%; these estimates vary.) 

 The COVAX  facility supports research and development, and manufacturing and negotiation of fair pricing for the entire portfolio of vaccine candidates and emergence authorized vaccines already in the world market. Regardless of national income levels, all participating countries-including Botswana-have been assured of equal access, and far allocation ( at least on paper!) , to these vaccines to protect people in all countries; low-income countries are exempt from much of the vaccine financial obligations, from contract negotiations to receipt of vaccines. 

Botswana is free to participate in its mandate through optional purchase or committed purchase arrangements. COVAX subsidizes vaccines for low-income countries like Malawi, but not better raked countries like Botswana, South Africa, and Namibia. Initially COVAX committed to cheap vaccines yet to be approved. It’s not clear what kind of vaccine Botswana will eventually get from this purchase agreement, or whether Botswana did actually pay for this potential vaccine. It is also worth noting that at the time we entered this arrangement Botswana had just engaged the World Bank, then just transitioned to offering financial capital for borrowing designed to prioritize Covid-19. Translate, Botswana had then serious financial problems, and per the Budget Speech 2020/2021, Botswana now has worse financial troubles. 

One good thing about the optional purchase model Botswana chose is the freedom to exit and consider bilateral deals directly with vaccine manufacturers. But if Botswana still has outstanding payments it would have to either borrow from the World Bank or petition development partners to help out. I don’t think COVAX can help us anyway here. Last week Reuters reported serious contractual, logistical and financial constraints that threaten to weaken its commitment to poor countries; especially difficulties circumnavigating complex supply risks. Western arguments and obfuscations now openly manifest as medical nationalism in the wake of several vaccines entering the vaccinations market…rich countries are putting their people and national security first.

Botswana really ought to be more proactive in sourcing a vaccine, and we hope this sense of urgency is not lost in the technocratic obsession with infection prevention and quarantining; the reality is that everybody is rapidly moving towards immunization. There are several urgency dictates about this pandemic that I find unavoidable. The war against Covid-19 demands; 1) prompt access to a safe and effective vaccine, 2) Botswana funding gaps undermine the fight against the disease with dire results more infections and deaths and economic ruin, 3) even if we got the vaccine we will still need more money to turn the vaccine into vaccinations that cover all Batswana. It’s not helpful to focus on just getting the vaccine: what’s going to be the cost of putting it into the arms of 2.2 million Batswana scattered throughout a country bigger than five European countries combined? 4) …to defeat Covid-19 the right people must get the right vaccine at the right time…where is the money for distribution, storage and security surveillance of the vaccine itself? 

An African health expert summed our predicament perfectly, ‘Africa is not doing enough on the Covid-19 vaccine. We just wait for the world to do it and then hopefully we bump into it and hopefully things work out…’Joachim Osur, Technical Director of Programs, Amref Health Africa.

I have never seen my beloved country, Botswana, so vulnerable, so naked, and so helpless. Waiting, that’s what we are doing. Waiting, and hoping for a vaccine to bump into; how sad. This time things are so bad, so frightening; at all levels, amongst all classes, and in so many frightful ways, that we have, for once, failed to produce some fancy solution the way we usually do with most national disasters, emergencies and tragedies; it’s all quiet on the official front. 

And this is disturbing to us as civil society; the apparent official paralysis. 

We work with people on the ground; every day we go to work. We know what is happening in households and communities. Ordinary Batswana are free to visit us with their problems in our offices. There are so many questions that Batswana want answered. Questions ranging from vaccine post-authorization, to post-licensure, to procurement, safety, efficiency, efficacy, herd immunity, right up to the possibility of the entire world defeating Covid-19. They even want to know what a post-Covid-19 society will look like, how our Government is planning for that new world right now, and what will be their proper place in the order of things in that world. 

But nobody is giving them answers. There appears to be a mistaken consensus in the public realm that vaccines alone will defeat this disease. This attitude is wrong, and it should not be encouraged. The most important thing in the fight against the pandemic is human urgency in responding to scientific direction and negative externalities. 

What should the Botswana Government be doing right now as I am writing, while it is still waiting for a vaccine to bump into? One word: confidence. 

It’s absolutely essential to ensure confidence in government ability to do the right things. Batswana want to be assured that whatever vaccine finally arrives is safe and effective. They want to be confident that the right systems and infrastructure will be put in place to distribute and administer the vaccine into their arms. They want to be sure the right health experts will be in place to direct this whole immunization program: in other words, Government should be very busy right now preparing everybody for vaccination. What are the elements of vaccine confidence? What percentage of Batswana are willing and ready to receive the vaccine? Will the proper steps be taken to ensure our own health workers have confidence in the vaccine? That they have confidence talking about it with patients?

Botswana should be already sharing clear and accurate and complete information and messages about the vaccine instead of just reporting infection rates and deaths on BTV. Government must move from this panic mood to some rays of hope. Batswana are watching millions being vaccinated every day and they are not amused. They want information, explanations and assurances that there is movement going forward in the fight against the disease. Whatever vaccine we eventually get it will take time, resources and great public effort to build trust in the vaccine. After twenty years fighting HIV/AIDS, we still have thousands of Batswana who care not about testing, or protecting themselves against HIV infections or knowing their HIV status or taking medication if they are enrolled in antiretroviral programs…just what makes Government to think every Motswana is going to rush for a vaccination against Covid-19?

Right now government should already be addressing myths about vaccines and immunization. Already crazy stories, suspicions and conjectures are running amuck out there unacknowledged and unconfronted. Conversations about vaccines must start early precisely because this disease came far too rapidly and too destructively without notice and its impudent damaging swank has traumatized both individuals and society. These conversations must start from a place of empathy, understanding and proper apprehension of existential nightmare. This is the time to deploy the best Communicators, build a broad-based Coalition and move ahead of COVID 19.

Let’s particularly start by addressing misinformation. This we should do by educating about simple facts. No, a vaccine cannot give anyone Covid-19. Yes, if you have already been infected and recovered from the Covid-19 you can still get benefits from a vaccination. 

Here is the thing; both Covid-19 and these vaccines are new to us. More disturbing, nobody is certain how long protection lasts for those who get infected or those who are vaccinated. Start telling the people simple truths right now. There must know vaccination has side effects, some of them severe, and that these side effects are actually a good sign that your immune system is doing its job which is to build up protection against Covid-19. It would not make sense if no pain or inconvenience arose from such a complicated medico-biological process. Just talk to children about these vaccines, even some elderly people and you will get questions like: are these vaccines safe? How bad are the side effects? Is it really necessary to go to all this trouble? Just how does a vaccine protect people from such a disease? Do these vaccines really work?

More than 300 000 Batswana have preexisting conditions, many of them multiple medical conditions. These people worry about Covid-19 daily, hourly, every second. About 64% of Batswana are still young. These people need education and information, and unlike the HIV/AIDS, the Covid-19 awareness campaign, running simultaneously with mass-vaccination programs, is not going to be easily conducted through clinics and village assemblies, or radio Botswana and BTV; unless it is government intention to leave other people behind…and remember in this case you leave one or two people behind-intentional or not-you endanger the whole country, and probably the whole world again; that’s how bad this pandemic is, and how serious, and necessary, complete vaccination is.

There’s terrible anxiety out there in society and it is folly to delay education and sharing of vital information until the last minute before a mass-vaccination campaign is rolled out. 

We see what is happening in Europe and America: fumbled, disorganized, confused, and therefore frighteningly costly vaccine rollouts; especially in America where trillions upon trillions of dollars have gone in to fight this disease, and at every level there is horrifying wastage and mounting rates of human suffering and death. Can penniless Botswana afford the luxury of such complacence? I don’t think so. We must safe every penny, every resource, and every life.

Planning in advance eliminates conflicting priorities. If we are to reach every bush, every valley, every hut, every village and every town in Botswana, emergency critical decisions will have to be evolved to local communities, clinics and primary hospitals. Continued sole direction from the top will just not do. Botswana must get its priorities right. Who gets the vaccine first? How? Why? Who will be directly involved in vaccine distribution? Can they be trust to do a good job? Who really is better placed and qualified to do this; health experts, military logisticians or Government authorities? 

There are serious logistical entanglements involved in building such an unprecedented health campaign from scratch. Botswana vaccination program will be badly affected by lack of funds. We also don’t have a competent professional health workforce strategically deployable throughout the country; health facilities just aren’t available or fit for purpose. The entire heath system is already overwhelmed with disease burden, and professional fatigue is already telling. Pandemic control measures of 2020 have already knocked the air out of just about everyone, a situation compounded, and sharply accentuated, by economic urgency and personal grief and losses. 

We truly are no longer a healthy nation but vaccinate we must, and vaccinate we will. Government must start involving every citizen in the fight against Covid-19 beyond just lockdowns and other restrictions. Prepare citizens and the nation for vaccination now. Figure out and explain to us right now who is going to be vaccinated first and why. Statements like the one allegedly made by President Masisi, in Francistown, referred to above are not helpful. Is Government really serious they are going to vaccinate police officers ahead of hundreds of thousands of Batswana with vulnerabilities arising from preexisting conditions or old age?

How is Government going to ensure distribution and vaccination are quick and geared to purpose in such a way that weaker population-level protection is enhanced to prevent more deaths? I am aware of the shrinking budget and the overwhelming burden of 2020 pandemic costly battles. The new obligation to get, distribute and administer a vaccine is likely to be more daunting, perhaps even marked with disturbing professional and political fatigue, but it would not help if government just opted for an easy way out like heavy reliance on existing childhood immunization programs, or copying what other countries are doing. 

Botswana is a big country. We have a small population. We cannot afford to sacrifice a few lives, like America, or ignore the uniqueness of vaccinating large masses of people in a few months…which is what this vaccination campaign is all about. Existing childhood immunization facilities are just not robust enough for Covid-19 vaccination.

We call upon Botswana government to immediately rollout a Covid-19 vaccination plan that is open to collaboration and public commitment all levels of society. The country might not have a sustainable infrastructure to manage the overwhelming demands of a desperate and impatient public but it does have strong enough institutional capacity to think out a more effective and efficient way forward.

As citizens we have moral obligations to each other. To beat Covid-19 politicians and technocrats must think like philosophers, and behave like economists. This is necessary because we are facing a test of survival as humans and society, and the moral dimensions on crisis will endure for years. We feel government has banished us from the republic when it comes to fighting for our own survival, and the protection of our public goods. For, example, Batswana must be involved in issues at the centre of impending vaccination campaign: Do we need a mandatory policy for Covid-19 vaccination? Is it unethical for my neighbor to refuse a Covid-19 vaccine? Why are Batswana not allowed, or encouraged to buy their own vaccines? Is it ethical to allow Botswana insurance companies to procure vaccines for their subscribers? There are so many things Batswana want talk about, but the Presidential Task Force has become the only voice allowed in the fight against Covid-19.

It is our hope that vaccine programs are in place that cover the entire population. We hope once the vaccine gets here there will be rapid and fair deployment of the vaccine, and that there will be proper alignment of Covid-19 diagnostics, vaccines and therapeutics. We take it that the Presidential Task Force has already accumulated sufficient baseline knowledge to identify and rectify gaps in vaccination preparedness plans, including medical countermeasures plans for receipt, storage and staging of the vaccine, and solidified delivery plans based on rational and fair prioritization guidelines. 

In conclusion we call on Government to never lose sight of our commitment to the UN SDGs. These are the foundation for our future as country. This mass-vaccination campaign must be enhanced their public health objectives; including the principles of prioritization of target populations, especially during vaccine supply constraints. Government must also design and ground in place effective and efficient principles of distribution that ensure human well-being for us all, national equity equal respect and democratic legitimacy of our republican principles. 


Read this week's paper