I'll take the "hippie dippy wishful thinking" case for vaccinating the world

The case from human rights is the only one that really works

I think we should do whatever we need to do to vaccinate the whole world as soon as possible. I consider it an utmost priority and an obligation, and a great moral test.

But I don’t think this is the necessarily best argument for it:

Andrew Stroehlein @astroehlein

He: "As long as we get vaccinated here, it's good. If it takes a few extra years to vaccinate the developing world, too bad.” Me: “The longer the virus spreads, the greater chance for a mutation to emerge that’s more deadly & to which the vaccine you had offers no protection.”

Andrew Stroehlein @astroehlein

When we say, "we're all in this together", it's not just some hippie dippy wishful thinking. You don't escape the threat of this global pandemic until we all do.

Andrew Stroehlein @astroehlein

I'm not asking you to show empathy for others. I'm asking you to be selfish & practical for yourself and your family. The world needs to ramp up the production of approved vaccines massively. The EU, UK, US & others have to stop blocking it at the World Trade Organization.

I’ve been seeing this sentiment a lot. It comes often from my friends and people I agree with on many things. It’s certainly very well-meaning: they want to make global vaccination a priority because of the direct benefits we’ll receive here. They think that the message that being “selfish & practical for yourself and your family” will lead to more widespread global vaccination there  than if we make the case for the vaccine as a basic human right or as something we should do out of solidarity—the hippie dippy stuff.

As I see it, there are two problems here. 

First, it’s not clear to me casting the rest of the world as worth vaccinating because they pose some grave, vague threat to us is the best way to advocate for this (otherwise worthy) cause. 

Second, though, it’s not even really true.

Unfortunately, it’s perfectly possible for there to be a world in which the few hundred million people in wealthy countries are vaccinated against COVID, substantially protected against all severe outcomes, receive regular boosters that completely cover whatever new variants emerge, and are able to live and travel without worry while the rest of the world—billions of people—wait their turn for vaccinations that never arrive. 

Also, it’s not at all clear that the threat from new variants is something that has emerged solely from over there through unchecked viral propagation.

To be clear, it is certainly possible for new variants to emerge because of unchecked growth in a population, and of course pandemics require global solutions. But it’s also important to remember that, currently, a plausible scenario is that some of the variants-of-concern, at least, emerged in single individuals who had lingering, chronic infections because they were immunocompromised and were treated with remdesivir—an expensive antiviral—which created conditions for adaptive evolution through selective pressure. 

This has been documented in the UK, and thus the UK variant which may well wreak havoc in many other poorer countries may well have emerged as a result of immunopathology in an individual who was treated with advanced drugs, rather than population-wide selection pressures somewhere else. Here’s a summary of the details published in Science: 

Last summer, as the second wave of COVID-19 cases was sweeping the United Kingdom, a man in his 70s was admitted to his local hospital where he tested positive for SARS-CoV-2. He was sent home, but a month later he checked into the hospital at Cambridge University, unable to shake the virus. Like many people who develop severe COVID-19, the man was immunocompromised… Doctors gave him remdesivir, an antiviral drug used to treat COVID-19, but he showed little improvement. Two months after his illness began, as the patient continued to worsen, his medical team opted to treat him with convalescent plasma, a therapy derived from the blood of patients who have recovered from COVID-19, which contains antibodies to fight off the virus.

Sadly, he succumbed to the virus 102 days after testing positive, but what doctors learned from him and similar patients “has been transformative of our understanding of what’s going on in this disease,” says Ravindra Gupta, a member of the Cambridge Universitymedical team and senior author of a report of the man’s case published February 5 in Nature. Analysis of samples from the patient showed that the virus evolved rapidly after the plasma therapy, developing mutations that changed how it could infect cells and resist antibodies. The conditions turned out to be ripe for viral evolution. “This is a blueprint for how variants emerge,” Gupta says.

The plasma treatments did not rid the man of the virus, and in fact had little impact on the amount of virus detected. But the plasma had a remarkable effect on the genetic makeup of the viral population that the patient harbored. Seemingly in response to the antibodies contained within the plasma, the virus produced “escape mutations,” changes in the genetic code that helped it to evade detection by the sticky antibodies. Such mutations can make the virus more contagious or vaccines less effective. They are popping up in variants of SARS-CoV-2 around the world, fueling the pandemic even as vaccine shots are going into people’s arms.

As the article concludes, the viral colony in the patient in question developed the particular mutation that’s the defining feature of the UK B.1.1.7. lineage:

The post-plasma virus strain carried two particular mutations: one, called D796H, has been only rarely documented before. The other, resulting in the deletion of two amino acids, called ∆H69/∆V70, “has gained notoriety, because it’s one of the defining mutations in the B.1.1.7 lineage,” says Gupta, referring to a strain originally found in the U.K., which has been shown to be more transmissible. (Gupta believes that the B.1.1.7 strain likely emerged from an immunocompromised patient, but the data show it did not originate in this specific patient.)

This is not the only known example of accelerated viral evolution in an immunocompromised individual treated with antivirals or with convalescent plasma.  Here’s the case study in another unfortunate patient—who also lost his life, eventually—from Boston:

A 45-year-old man with severe antiphospholipid syndrome complicated by diffuse alveolar hemorrhage,1 who was receiving anticoagulation therapy, glucocorticoids, cyclophosphamide, and intermittent rituximab and eculizumab, was admitted to the hospital with fever... On day 0, Covid-19 was diagnosed by SARS-CoV-2.. and the patient received a 5-day course of remdesivir (Fig. S2)... On day 72 (4 days into another hospital admission for hypoxemia), RT-PCR assay of a nasopharyngeal swab was positive, with a Ct value of 27.6, causing concern for a recurrence of Covid-19. The patient again received remdesivir (a 10-day course), and subsequent RT-PCR assays were negative… On day 105, the patient was admitted for cellulitis. On day 111, hypoxemia developed, ultimately requiring treatment with high-flow oxygen. Given the concern for recurrent diffuse alveolar hemorrhage, the patient’s immunosuppression was escalated (Figs. S1 through S3). On day 128, the RT-PCR Ct value was 32.7, which caused concern for a second Covid-19 recurrence, and the patient was given another 5-day course of remdesivir… On day 143, the RT-PCR Ct value was 15.6, which caused concern for a third recurrence of Covid-19. The patient received a SARS-CoV-2 antibody cocktail against the SARS-CoV-2 spike protein (Regeneron).4 On day 150, he underwent endotracheal intubation because of hypoxemia. A bronchoalveolar-lavage specimen on day 151 revealed an RT-PCR Ct value of 15.8 and grew Aspergillus fumigatus. The patient received remdesivir and antifungal agents. On day 154, he died from shock and respiratory failure.

Here, too, the virus underwent significant and accelerated viral evolution:

Phylogenetic analysis was consistent with persistent infection and accelerated viral evolution (Figures 1A and S6). Amino acid changes were predominantly in the spike gene and the receptor-binding domain, which make up 13% and 2% of the viral genome, respectively, but harbored 57% and 38% of the observed changes (Figure 1B). Viral infectivity studies confirmed infectious virus in nasopharyngeal samples from days 75 and 143 (Fig. S7). Immunophenotyping and SARS-CoV-2–specific B-cell and T-cell responses are shown in Table S2 and Figures S8 through S11.

So, to recap, it’s completely possible that at least some of the variants we’re worried about have risen not through unchecked growth in poorer countries, but through persistent, chronic infections in patients treated with potent, expensive antivirals or convalescent plasma—acquired from patients that had COVID-19 but recovered and authorized by the FDA for use on COVID-19 patients. 

Perhaps we can and we should argue that the many billions of people in the world are worth vaccinating simply because they are fellow human-beings whose lives are as worthy as anyone else’s—including ours. Casting them as threats may seem like a short-term nudge, but I doubt it’s very convincing to people who do not see them as worthy. Worse, it can potentially  further the vision of a segregated world where we protect ourselves from the dangerous masses out there. A lot of such periods in history have come with casting immigration and other people over there as dangerous disease vectors.

During the 20th century the united states witnessed sweeping social, political, and economic transformations as well as far-reaching advancements in medical diagnosis and care. Despite the dramatic changes in demography, the meaning of citizenship, and the ability to treat and cure acute and chronic diseases, foreigners were consistently associated with germs and contagion. In this article we explore why, at critical junctures in American history, immigrants have been stigmatized as the etiology of a wide variety of physical and societal ills. Anti-immigrant rhetoric and policy have often been framed by an explicitly medical language, one in which the line between perceived and actual threat is slippery and prone to hysteria and hyperbole.

Plus, even if there were some completely rational but coldly calculating individuals who might be suspect to such reasoning, they will probably notice that the vaccines we have—or the boosters we are developing—will indeed provide significant protection against the variants, and it is indeed rationally possible not to care that much at a selfish level.

Photo source: https://iaphs.org/racism-in-the-time-of-covid-19/

Maybe we don’t need to cast billions of people as if they were vague threats to us, or exaggerate the risk of vaccine failure because of them. 

How about simply this: we should vaccinate the world because every human being deserves being protected against a disease for which we have safe and efficacious vaccines. 

Maybe the hippie dippy argument is just fine.