Wayne Gretsky is the Canadian hockey legend who famously said, “you miss 100 per cent of the shots you don’t take”. It’s simultaneously a great one-liner, and one of the most universally applicable aphorisms.
It applies with particular force to the cause of vaccine sharing – and to #TheArmsRace campaign initiated by Tortoise to support that goal, and to draw much-needed attention to the crisis of vaccine inequality around the world.
In this case, the “shots” – meaning jabs – aren’t being “taken” (by patients) because the doses aren’t getting to the places where they are most desperately needed. You cannot be immunised against Covid when the vaccines simply aren’t being sent to where you live.
Why is this happening? For all the phoney talk about complex supply lines, difficult political choices, and manufacturing hold-ups, the truth is that we’re squarely in the “Scant Mystery Zone” here. The poorer nations of the world can’t get the shots because the wealthier countries have used their economic and negotiating power to put themselves first.
Naturally, the leaders of the developed world pay lip service to the principle that “nobody is safe until everybody is safe”; and to the even more basic idea that it would be preferable if the 10,000 preventable deaths a day from the virus could be – well, prevented. But when it comes to action and serious collaboration, their record to date has been pretty woeful.
Last week, Gordon Brown – a former prime minister with an unsullied reputation – pithily posed the question in a piece for the Guardian: The world is making billions of doses of Covid-19 vaccine, so why is Africa not getting them? As Brown wrote:
“About 10 million single-shot Johnson & Johnson vaccines filled and finished at the Aspen factory in South Africa will be exported to Europe, at the very time that Africa is grappling with its deadliest wave of Covid-19 infections yet…
“Of the 4.7 billion vaccines distributed globally, more than 80 per cent have gone to the richest G20 countries. The gap between rich and poor is now so wide that, while high-income countries have administered almost 100 doses for every 100 citizens, low-income countries have administered only 1.5 doses per 100”.
In this respect, Brown was echoing the point made by one of the key scientists behind the AstraZeneca vaccine, Oxford University’s Professor Sarah Gilbert, who told the i newspaper last month that “it’s more of a priority to get doses to other countries that haven’t been able to vaccinate. Because where the virus is spreading uninhibited in those countries, that’s where you’ve got a really strong risk of new variants arising and those variants will travel around the world”.
The problem is that all the fine talk about vaccine sharing is still hopelessly vague. Although the UK Government has pledged to donate 100 million surplus doses to poor countries, the timeline for delivery is conspicuous by its absence. Ministers are more fretful about third booster shots for Brits this autumn, and the vaccination of under-18s (thus nurturing a lethal false dichotomy: the idea that we must choose between the two strategies – between home and abroad, so to speak – when it is easily demonstrable that more than enough doses have been procured to achieve both objectives).
The grim prospect is that, given this political bottleneck, vaccines will go to waste – and there have been reports that this is already happening (in, for example, the Independent, the New York Times and Euractiv.)
It should be noted that, so far, the data on this are relatively thin and it is not yet possible to detect systematic patterns of failure (which is not to say that such patterns will not emerge as we aggregate more evidence). To date, the waste that is taking place seems to reflect a combination of factors: the operations of human error; the disruption of dosage schedules (as, for instance, when those newly infected with Covid are told not to get vaccinated within a month of being infected); and simple bad luck (such as equipment failure).
Rather than resorting immediately to the moral wail, it is good practice to ask why, exactly, wastage is taking place. In January, the Conversation usefully contextualised the whole question, pointing out that “the French Directorate General of Health has stated that it is operating with the cautious estimate of a 30 per cent wastage rate on Covid-19 vaccines distributed in the country. But vaccine wastage is not unusual – it’s expected. In a 2005 paper, the World Health Organization (WHO) reported vaccine wastage at over 50 per cent around the world, a number still cited by the United Nations Environment Programme today. Some waste is unavoidable. But a good understanding for [sic] where waste occurs in the vaccine supply chain – and targeted action at crucial points of that chain – can help to minimise it.
The article continued: “The WHO differentiates between ‘closed vial wastage’ (which occurs before vaccine vials are opened) and ‘open vial wastage’ (occurring after vials have been opened). Closed vial wastage occurs mostly because of errors in storage and transportation, like when vials get too warm or too cold. Open vial wastage occurs mainly because of immunisation workers’ practices, or because unused doses from multi-dose vials are thrown away”.
These distinctions are worth quoting at length because they illustrate the need for specificity in addressing the problem. Having said this, there is an obvious moral imperative to ensure that waste of vaccines in any country is as close to zero as possible. Hoarding is an all too human instinct, but in this instance, it will literally cost lives, and plenty of them.
To be fair, the UK vaccination programme has worked hard to find effective and informal ways to ensure that any vaccine likely to be surplus to immediate requirements has made its way into the arms of lucky recipients, ahead of their official appointments; and even into the arms of those walking past vaccination centres at the end of the day.
It’s basic good practice to have this sort of capacity – to keep a database of available substitutes to contact when people fail to turn up for their appointments. In the Canadian province of Alberta, a system of this kind was established to deal with no-shows and drove waste levels down to only 0.3 per cent.
So systems and procedures matter. The NHS had a policy in place to minimise the possibility of Covid-19 vaccine wastage from the very start of the programme’s rollout. Likewise, the WHO offers this helpful Standard Operating Procedure (StOP) to prevent wastage of Covid-19 vaccines.
Of course, waste is rarely an issue in the first flush of a vaccination rollout when public enthusiasm is at its highest. In the UK, the arrival of the jab prompted something like a mood of national celebration, as early recipients posted images on social media of their vaccination cards captioned with expressions of fulsome gratitude. Then, perhaps inevitably, this collective enthusiasm hit a plateau in the early summer.
At the beginning of June, as ministers grew concerned that the rollout might be losing its early momentum, a series of one-off, large-scale events were mounted to make vaccines generally available on a first-come-first-served basis for younger people. But this burst of activity – in football stadiums and similar venues – did not last long.
This is a shame, because – in fact – the behavioural character of the rollout has changed fundamentally, and predictably. In the first phase, as the top nine categories identified by the Joint Committee on Vaccination and Immunisation received their jabs, the “pull factor” was in the ascendant. Older and more vulnerable people were naturally more enthusiastic about jabs that would protect them from hospitalisation and death.
Then the target demographic changed. Younger people, even in the face of the aggressive Delta variant, are temperamentally less inclined to regard themselves as being at risk from any disease. There are also demographic groups who tend towards vaccine hesitancy for historic reasons, or because of online misinformation.
There have been admirable initiatives undertaken to address the latter problem – notably by mosques that have turned their premises into vaccine clinics. This fine letter by Dr Karthikeyan Iyengar and colleagues to the British Medical Journal’s Postgraduate Medical Journal about minority ethnic communities’ relative reluctance to be vaccinated concludes with an excellent statement of principle: “the quote by H. Jackson Brown Jr. – ‘Nothing is more expensive than a missed opportunity’ most aptly applies to the Covid-19 vaccination”.
As for younger people: there is still a failure of messaging at work here, the absence of a slogan or image or core theme that captures the idea of vaccination as a civic matter, rather than a narrow question of individual choice. The young may be less at risk than their elders (though Delta is less merciful in this respect than its predecessors). But – even for a 25-year-old triathlete in peak condition – getting the jab still minimises the risk of infection and reduces the potential burden upon the NHS. Vaccination needs to be presented more forcefully as what it is: a fundamentally social treatment.
Herein lies the thorny heart of the matter: the more successful a national vaccine rollout programme is, the greater the risk becomes of dosage waste. By definition, every society that has sufficient supply reaches the point where those who are keen to be vaccinated have been vaccinated.
The next trick is to make those who, for whatever reason, are reluctant, feel less reluctant. And the key word here is feel. Inertia and hesitancy will not be conquered by statistics and bar-charts. Cultural sensitivity and imagination are much more important.
Some of this is about taking the vaccines where the vaccine-reluctant people are, and making jabs as easy to get as possible. It’s not about bullying, and it’s not (please note) about bribery. It probably is about making sure that, alongside the gradual and reasonable introduction of restrictions for people who don’t have full proof vaccination (as has worked in France), it is made as easy as possible for people to get vaccinated in the course of their daily lives. Inconvenience is a powerful incentive to action, especially when the solution is straightforwardly accessible.
So much for minimising wastage within nations. What about the question that naturally follows, and is also true to Gretsky’s Law: how to maximise the sharing of spare doses, to ensure that surplus vaccines in wealthy countries get to the poorer nations that so desperately need them? How, as the hashtag has it, to #ShareTheSpare?
Thus far, the emphasis has fallen upon institutional structures: notably the mechanism of Covax, the worldwide vaccine initiative overseen by Gavi, the Vaccine Alliance, the Coalition for Epidemic Preparedness Innovations, and the WHO. And this is natural enough. Such a body was always going to be essential to vaccine-sharing in this pandemic.
But – again – it is important to mobilise feelings, broaden horizons, match emotional incentives with rational needs. In this case, we badly need to stop talking about some nebulous “international community” – waiting for this or that supranational organisation to act like a superhero – and start thinking of hard-headed ways of utilising the power of self-regard and competition.
What do I mean by this? I mean treating nations as though they were communities of people and not just sovereign legal entities. So, for instance: we should have a “buddy list” which matches countries of comparable population but different levels of national wealth. The rich help the poor. The relationship is real, rather than abstract. It bonds two peoples, probably on different sides of the planet.
And such a system would, of course, lend itself to the creation of a league table of “helper” nations. A media organisation – why not Tortoise? – could collaborate with other news platforms to create a ranking of countries that are doing most to help vaccinate the world, and those that are indefensibly hoarding their surplus doses.
Think of how much attention people (including politicians) pay to the medal table during an Olympic Games. Now import that competitive spirit to the presently technocratic world of vaccine-sharing. Would the UK really want to lag behind, say, France or Germany? How would the US feel about its position relative to China and Russia? Which nation is the Usain Bolt of #TheArmsRace?
Again, we come back to the combination of push and pull. The buddying scheme is the carrot, the feel-good factor in vaccine equality. The league table is the stick for those who lag behind and fail to prioritise the sharing of doses. The psychology of virtue is complex and multi-layered. Pure goodness is all too rare in human affairs; it is always important to incentivise ethical action, rather than to rely purely on innately moral conduct.
“Nation shall speak peace unto nation” was the founding concept of the BBC. It remains a fine maxim today, and has a powerful resonance in this particular endeavour. Waiting for a purely technocratic solution to vaccine sharing is as profitable as waiting for Hell to freeze over.
What is badly missing in the race to vaccinate the world is a spirit of competition; a sense, frankly, that this is a race at all. We need the great nations of the world to feel that their honour and status is wrapped up in the successful accomplishment of this task; that vaccinating domestic populations is only the first part of the challenge, and that the second – to get jabs to the rest of the world – is only just beginning. We need them, in short, to think like Wayne Gretsky.
Photograph by Michael Ciaglo/Getty Images
Andy Cowper is the Editor of Health Policy Insight
We need to act urgently
Head to The Arms Race page for links so you can donate vaccine doses, and write to your MP, ahead of the G20 summit in October. Please share these pieces with your friends and ask them to help. The clock is ticking. Thank you.