YELLOW PAD

By Filomeno S. Sta. Ana III

BENZOIX/FREEPIK

An otherwise comedic story if not for its disastrous effect could have well happened in the Philippines.  

A clinic in West Virginia blundered and injected 42 people not with a COVID-19 vaccine but with an experimental antibody cocktail. (Also, the procedure for the use of the antibody treatment was wrong. It is administered through infusion, not inoculation.)  This tragedy was attributed to a “breakdown in the process” and to “human errors.” 

And across the United States, the vaccine distribution is plagued by the lack of resources and logistical complications.  A typical story is that the vaccines are available but are stored in hospitals and not given to the most vulnerable people.  Worse are accounts of health workers who have refused vaccination. 

As a consequence of all this, the US government sorely missed the goal of having 20 million people vaccinated by end-2020. By yearend, the Centers for Disease Control and Prevention reported that 2.8 million people received the first dose of the vaccine.  Even assuming that this was a conservative report, we would still conclude that the performance was way below the target.

It goes without saying that such problems pertaining to disorganization, inefficiency and incompetence are more pronounced in the Philippines.

So is it a blessing in disguise that Philippine vaccination is not right out of the gate?  Not really.  The point though is that we must learn the lessons from the front-runners.  But more importantly, we need to internalize lessons from our own experiences in fighting COVID-19, especially our failings.

Many lessons have to be learned in rolling out our vaccination program.  I emphasize a few, namely:

First, do not treat the first-generation vaccines as silver bullets.  The efficacy of the first vaccines has been established in clinical trials, but the real world is different.   By all means, have the approved vaccines, but be prepared for twists and turns.  The ultimate success of the vaccine depends on factors that we cannot predict like the actual and long-term effectiveness of the vaccines. 

A fine difference exists between efficacy and effectiveness.  Here’s a relevant passage from Carl Zimmer, “2 Companies Say Their Vaccines are 95% Effective. What Does That Mean?” This was published in The New York Times on 20 November 2020 and updated on 4 December 2020:

“Efficacy is just a measurement made during a clinical trial. ‘Effectiveness is how well the vaccine works out in the real world,’ said Naor Bar-Zeev, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health.

“It’s possible that the effectiveness of coronavirus vaccines will match their impressive efficacy in clinical trials.  But if previous vaccines are any guide, effectiveness may prove somewhat lower.”

The second lesson, which follows from avoiding the temptation to devote all efforts and resources to the vaccination program, is to do well in previous tasks.   The truth is, much still has to be done to improve the Philippine capacity for case finding, testing, screening, quarantining the infected and those with symptoms, and contact tracing. The vaccination program must go hand in hand with the above interventions.

The Philippines has been able to reduce the number of cases from a peak of more than 6,000 cases in August 2020 to around 1,250 cases on average in the last two weeks (although the number is under-reported).  But this is no consolation.  It just means that cases have remained high despite the lockdown measures.  The lockdown is effective when complemented by effective measures on case finding, testing, quarantining, contact tracing, etc. 

For comparison, Thailand hit a daily high of 745 cases on 4 January 2020, leading to the imposition of new far-ranging restrictions. In Korea, a resurgence of infection is happening, with an average of around 750 cases in the past two weeks.  It goes without saying that the total population in Thailand or South Korea is far less than that of the Philippines.

The third lesson is to have effective strategic communication.  Strategic communication—one that is clear, accurate, transparent, and persuasive—is in fact the strategy.

Again, the Philippines is wanting in this area.  Different authorities contradict one another.  Worse, some officials are the carriers of fake news. Remember the statement of President Rodrigo Duterte that gasoline can be used as a disinfectant against COVID-19?  He was probably joking, but it was a bad joke. Some folks take his every utterance seriously.

Moreover, good communication is built on trust.  Trust gets eroded when authorities themselves break the rules (more on this later). The unauthorized, nay, illegal, use of a vaccine to supposedly protect the Presidential Security Group (PSG) and the subsequent cover-up are a blow to the credibility and integrity of the administration.

Further, effective communication must convince the population to have the COVID-19 vaccine.  We have to contend with the sad reality that a significant number of our people fear vaccination, borne out of experience.  Thousands of families, especially their schoolchildren, suffered from what is known as the Dengvaxia controversy. 

Despite the advance warning of some quarters from the scientific and health community, the Department of Health in the previous administration swiftly introduced the questionable Sanofi Pasteur’s Dengvaxia vaccine against dengue. Eventually, but with the damage already done, Sanofi withdrew Dengvaxia, admitting that the vaccine posed a higher risk of a severe case of dengue for previously uninfected persons.

Worse, a recent Pulse Asia survey shows that a plurality of the population (47 percent) of the population does not want to be vaccinated against COVID-19.  (A third or 32 percent agrees to being vaccinated.)

Fourth, recognizing that the virus cannot be annihilated soon despite the vaccine introduction, we have to continue adhering to the protocols of self-protection, especially physical distancing. But social compliance depends to a significant extent on how leaders themselves follow the rules. 

A survey and study done by the University College London showed a decrease in social compliance (and Brits typically abide by rules!) when the public found out that their leaders avoided or violated the rules. Having excuses and using loopholes make things worse in gaining trust.  Pinoys also follow their leaders’ example.

The administration thus should no longer tolerate and should condemn actions such as the Chief of the Philippine National Police having a mañanita and the President’s Spokesperson enjoying the company of dolphins during the strict lockdown or singing loudly in a bar during the community quarantine. Those who violated the law for illegally vaccinating PSG soldiers (narrated above) must likewise be made accountable.

Fifth, the vaccination program is an opportunity to accelerate the implementation of Universal Health Care (UHC), particularly primary care. The vaccination program is favorable to setting up the UHC’s service delivery networks with the city or the province as unit. 

For the vaccination also entails the gathering and monitoring of information in real time, it is absolutely necessary to have in place the system for electronic medical records, which the UHC law mandates.  The main obstacle to having electronic medical records is being addressed.  The administration has made the pronouncement and a credible commitment to have an Executive Order soon, which will liberalize the entry of satellite internet providers.  This contributes towards achieving universal connectivity.

A crucial component of the UHC is the health technology assessment (HTA).  The HTA has the mandate to assess and recommend the vaccines that are efficacious and cost-effective.

Last but not least, we must recognize that the vaccination program must be a whole-of-society approach.  The government, the private sector, and the civil society organizations must coordinate efforts and unite in common strategies for the transparent acquisition and equitable distribution of the vaccine. 

It must be emphasized that priority for vaccination should be the front-line health workers and the elderly, the most vulnerable to being infected by COVID-19.

Up to now, apart from receiving general pronouncements, the public is not fully informed about the framework, goals and strategies for vaccine allocation and distribution. 

As a result of the lack of a unified national plan, various entities have taken their own initiatives.  But kanya-kanya in this situation, particularly when vaccines are scarce, leads to sub-optimal outcomes.  Independent actions arising from a murky or confused national plan abet waste, inefficiency, scarcity, corruption, and inequity. 

Several rich local government units (LGUs) in Metro Manila are planning their own vaccination programs. Such initiative is understandable.  Makati just announced that it would allocate PhP 1 billion to procure vaccines.  Good for Makati citizens but the unintended consequences for the whole of society are adverse.  The residents of Forbes Park, Dasmariñas, and other exclusive villages will be ahead of the line.  But science, reason and ethics dictate that health front-liners and the elderly be first vaccinated.

The pronouncement of LGUs to procure the vaccines independent of the central government is politically difficult to reverse. 

The problem of kanya-kanya is not limited to LGUs.  Even among national agencies, including within the Inter-Agency Task Force for the Management of Emerging Inectious Diseases (IATF), contradictions exist.   We may have to accept the fact of kanya-kanya as a given constraint, and settle for second-best or third-best approach.

We nevertheless need a bi-partisan effort and a broad coalition that will rally around transparency, accountability, equity, and efficiency in the formulation and implementation of the vaccination program. Let us learn the lessons, and embark on new strategies towards a better new normal.