Some weeks ago, on the same day an elderly American friend despaired at the prospect of driving through the snow for hours to get a vaccine, I received an invitation for mine.
Although staff didn’t have a choice, rumours were already dubbing the Pfizer shot as the Ferrari and AstraZeneca the Camry of vaccines. The comparison felt uncomfortable and unwarranted, prompting me to say to a colleague that we must watch our words.
Three weeks later, I received my second dose followed by mild symptoms that I faithfully reported. Feeling somewhat guilty, I reassured others that their vaccine would come soon.
But as my American friend expressed delight and relief at being spoilt for choice, things took an unexpected turn in Australia.
Gaps in communication had already frustrated doctors even before it became evident that the Astra Zeneca vaccine was going to be a hard sell. I didn’t realise just how hard until a GP lamented that after heightened anticipation, he received 50 AstraZeneca vaccines but when the staff called the first 50 elderly people and braced for protest from the rest, only eight agreed to come.
Then, an expert committee recommended Pfizer as the preferred vaccine for those aged under 50 due to the risk of a rare but potentially fatal clotting disorder associated with the Astra Zeneca vaccine.
The announcement was described as a “highly precautionary position” against a “very, very rare event”, but it had sceptical elders asking, “If it’s not good enough for the young, is it good enough for me?”
Next, the drug regulator (Therapeutic Goods Administration) linked the death of a 48-year-old diabetic woman to the AstraZeneca vaccine.
This week, attempting to balance competing risks, the Victorian government lifted its pause on the AstraZeneca vaccine for those under 50 and moved to establish mass vaccination hubs.
Now, it is the young wondering, “If it wasn’t good enough last week, will it be good enough next week?”
Australia is heavily reliant on the AstraZeneca vaccine after other candidates either failed or their supply was delayed. In truth, this vaccine is more than ‘“good enough” at a population level. It is highly effective against severe illness and death from Covid, and the risk of dying without the vaccine outweighs the risk of death from the vaccine. Swimming, drinking and driving are all more dangerous than being vaccinated.
Patients all over are being urged to talk to their doctor about the vaccine, with the implicit hope that the reassurance of doctors will encourage vaccination. But more scientific facts have never filled a gap in confidence.
As an oncologist, I often see bewildered patients looking for a neat explanation.
Would an earlier diagnosis have saved my life? Did the stress cause my cancer? What if I had had another treatment? No single explanation can fit the myriad things that affect an individual, but it helps to have a framework for approaching the problem. Mine comes from an unexpected source, in the form of the three questions posed by the philosopher Immanuel Kant in his study of reason.
What can I know? What ought I do? What may I hope?
In terms of what we know, the quoted clotting rate of the AstraZeneca vaccine is about four per million. The immune-mediated clots tend to affect the young and are different from those associated with the contraceptive pill. The fatality rate of vaccine-related clotting is 25% versus 3% for the pill. In other words, while the chance of getting a vaccine-related clot is rare, if you do get it, there is a one in four chance of dying. Several European countries have paused the AstraZeneca vaccine but others such as Papua New Guinea are entirely dependent on it, warning that there is no time to lose.
Australia risks becoming a victim of its own success because it is difficult for a country that has avoided mass devastation to persuade its citizens to use a vaccine with a perception problem when there is no community transmission and the borders are closed.
On the question of what to do, doctors face a tricky challenge because advising the person in front of you is not the same as a panel discussion (or writing an article). Based on the same evidence, some patients will decline the vaccine, others will wait, and some will promptly roll up their sleeves.
Even in an era of patient autonomy, patients are asking their doctor, “If you were me, what would you do?” Some doctors refuse to answer, casting this as a personal choice, but this seems unfair, which is why most thoughtful doctors strive to do better. The Australian Technical Advisory Group on Immunisation advisory board (Atagi ) admitted how hard it was to wrap its head around the AstraZeneca risks. Doctors caught in the same bind will feel ethically obliged to tell their patient.
In a long career, every doctor gives advice that is a cause for later remorse. Doctors and nurses concerned about assuming moral responsibility are not being unhelpful or irresponsible; on the contrary, their reaction reflects a commitment to provider-patient trust. Similarly, people who request extra time to decide are not ignorant or irrational; their reaction reveals the limits of scientific argument in conveying personal meaning. Eventually, we will turn the tide but expect a slow start.
So, what may we hope for?
Our immediate hopes revolve around improved vaccine availability and community confidence. As America has belatedly shown, clear, empathetic communication must be paired with ongoing decisive action. We must have sympathy that vaccine supply is globally constrained, and with the death toll surpassing three million, our fellow human beings are far more desperate for vaccines, oxygen and beds.
Our greatest hope should be that this never happens again.
Australia, with its recognised excellence in immunology and related fields, can build stronger domestic capability to produce its own vaccine. National spending on research and development (1.8% of GDP) lags behind the OECD average (2.4%) and far below world leaders like South Korea and Israel (about 5%). Basic science researchers face an unnecessarily hostile funding environment when by definition, their research is meant to be advanced by others. We can expect governments to properly and securely fund universities and national science organisations to undertake directed research such as recent efforts exploring drought-resistant agriculture and antibiotic resistance. Not every investment will deliver but some will yield important dividends and importantly, fuel imagination and keep our brightest scientists at home.
There is a palpable change in the mood of everyday Americans, a happy reminder of the resilience of the human spirit and our ability to self-correct. One day, Australians too will look back at this prolonged challenge.
When we do, we must say that we learned our lesson.