Miscellaneous Thoughts on Pandemics & Immunizations

Posted by Devin Johnston on November 29th, 2009

Blogging has been somewhat slow of late, and will continue to be slow until my papers and exams are done for the term (incidentally, I'll be a law school graduate in five months.) However, I want to share a couple of thoughts about pandemics and immunizations. More to the point, I want to talk about the reasons for which governments provide (or, at least, subsidize) immunizations against infectious viruses and the public's misunderstanding of the collective benefit of such programs.

I'm writing this post mainly in reaction to three highly-publicized incidents of so-called "jumping the queue" for H1N1 vaccines:

1. some members of the Calgary Flames and their families were given H1N1 vaccine doses at a special clinic with the support of Alberta Health Services;
2. the United States government offered H1N1 immunizations to detainees in Guantanamo Bay; and,
3. New Democrat Member of Parliament Judy Wasylycia-Leis wrote to Elections Canada to what, if any, H1N1 preparedness measures would be put in place in the event of a federal election.

Leaving aside the debate about whether the H1N1 vaccines are safe and effective, I take issue with the way these stories have been portrayed in the media. The public's reaction to these stories suggests a fundamental lack of understanding about the collective social value of immunization programs. I believe that the media have exploited and perpetuated that misunderstanding in order to create sensationalist (and, hence, profitable) news coverage of what should be relatively uncontroversial events.

What is the benefit to receiving immunizations against infectious viruses (assuming, again, that they are safe and effective)? Certainly there is an individual value to getting immunized against disease: if I get an effective immunization, I am significantly less likely to be infected by the targeted virus. This means that I am less likely to get sick, miss work or school, or have complications related to the viral infection. Yipee for me.

However, the individual value of getting immunized is not the only value: there is also a collective goal. When I get immunized, I am less likely to carry the virus and transmit it to others. Therefore, my getting the immunization benefits you and your getting it benefits me. The more people who are immunized against the virus, the less it circulates and propagates. If a sufficiently large number of people (and non-human animals, in the case of influenza) are successfully immunized, the number of infections and deaths can be drastically reduced across the board (even among those who don't get immunized, because their risk of exposure is reduced). Yipee for everyone.

When the public reads about professional athletes, politicians, or terrorism suspects getting the H1N1 vaccine before other members of the public, the reaction tends to overlook the collective good served by immunizing people. The perception is that immunizing these classes of people first somehow reflects an assessment of their worth as compared to other people. This reaction is somewhat understandable: neither professional athletes, nor politicians, nor terrorism suspects should expect special treatment from the government based on their personal worth.

Yet when we examine these cases from a collective value perspective, the analysis changes. Professional athletes and politicians are, I would guess, disproportionately likely to contract and transmit viral infections due to the fact that the come into close personal contact with an unusually large number of people in the course of their work. This increases their likelihood of becoming infected. They also travel extensively throughout large geographic regions, enabling them to transmit the virus across large distances. In the case of detainees in Guantanamo Bay, they are at a disproportionately high risk of becoming infected as a result of living in a densely populated institutional setting (much like hospital patients, prisoners, and students).

It seems to me that in order to maximize our collective goal of reducing the spread of infectious viruses, immunizations against those viruses should be delivered in a targeted way to those who are disproportionately likely to become infected and transmit the virus to others. Those who receive the immunizations benefit from them, but so does everybody else. I am not a scientist or a doctor, so I am not in a position to say who those targeted groups are. However, it appears to me that a plausible case can be made that all three of groups I've identified could be included among the class of high-priority subjects of immunization. I don't have enough information or expertise to give a proper answer to that question. However, I am also disinclined to reject any them as obviously wrong or absurd. I think this is a determination to be made by experts based on sound science.

Notwithstanding that there is a collective value served by immunizing those at a high risk of transmitting the virus, we cannot disregard the individual value of immunizations. There are certain classes of people who are at a disproportionate risk of more severe reactions to infectious viruses. In the case of H1N1, these include among others elderly persons with chronic conditions, pregnant women, children under 5, and those living in remote areas. I think that there is a humanitarian case to be made to those at a higher risk of severe complications (including from secondary infections) should also be considered high-priority immunization targets. This assessment is not based on the personal worth of the individuals, but on the physiological or social factors that cause them to be at a higher risk than the general population. This potentially includes some people living in institutional settings such as prisons (the argument that prisoners or terrorism suspects should be moved to the back of the line is deeply offensive to anyone who believes in human rights.)

So, where does all of this leave us? I think there are a couple lessons to be learned here. First, the determination of which classes of people should receive higher priority in immunizations against infectious viruses should be determined by scientific experts based on objectively determinable risk factors, rather than by politicians or the public based on subjective assessments of worth. Second, the media and the public must be educated about the collective value served by immunization programs in order to avoid the confusion and controversy that arises when apparently "undeserving" people receive vaccinations earlier than other members of the public. Third, the media have an ethical responsibility to stop sensationalizing their coverage of issues relating to mass immunizations against infectious viruses.

Finally, I think there is a lesson to be learned about the relationship between industrial and developing nations. In the moder era of globalization and global transportation networks, industrial nations can no longer consider themselves insulated from viral threats emerging in other parts of the world. All of the most recent pandemic viral outbreaks have involved trans-oceanic transmission between Southeast Asia, Europe, and North America. In today's world, a viral outbreak in Hong Kong is a threat to the public in New York and vice versa. The strategy of industrial nations to horde vaccines is not only problematic from a humanitarian perspective, it is also a dumb strategy to contain infectious viruses. Immunizations should to some extent be targeted to the geographic areas in which new viruses are emerging. This means that when a virus breaks out in Southeast Asia, or Latin America, or Africa, or anywhere else on Earth, industrial nations should place a high priority on identifying those viruses, studying them, and delivering vaccinations at the source of the outbreak. I would also argue that intellectual property laws must be reformed in relation to pharmaceuticals in order to promote access to live-saving vaccinations and drugs.

And now, back to writing my paper for Advanced Public Law.

Spread the word and fan the winds of change: