Well, good afternoon, everyone. My name is Andy Wiesen. I am currently a preventive medicine physician with the United States Army. However, I am retiring at the end of this month after 30 years of service. So this will be the last time I'll be using that title in any of these presentations. I do want to make a quick apology. We have a little technical difficulty with our moderator. So I'm just going to do a quick self-introduction so that we can try and keep the track on time. And then hopefully, Dr. Costello will be able to come up a little bit later so she can monitor for questions and we can have a lively discussion. The intent of this talk was really to spur discussion because anything, anytime you talk about ethics, there's always multiple points of view and there's never one correct answer. And so my purpose in talking about this is really to get you to think, not to give you the right answer, but to give you some courses of action or potential right answers and have you think about those as you make decisions on things like, in this case, the distribution of a scarce good, in this case with the COVID vaccine, although it's not as scarce now as it was when I put this in. Let me just say up front that this is all my work and my opinion. This is not any, does not reflect an official position of the Department of Defense. And so standard disclaimer for while I'm still in the Army. All right. So I'm going to go over the objectives that I submitted for this talk. I'll talk a little bit about the background, in this case, COVID and some other similar diseases. We'll talk about a couple of the ethical theories, some of the dilemmas that arise from the conflicts between those theories. We'll look at the U.S. approach to vaccine distribution, have a discussion about pros and cons of those. We're going to talk about legal issues involved in mandating vaccination and how those could happen. I have a little summary and then questions at the end. So I'm hoping that we can have time for questions. I planned this talk so that there was plenty of time for questions and just hope we can get that discussion going as we get through these slides. So the objectives here, what we want to talk about is describing how the ethical theories and I picked these three. There are many more, but these are three that I think are relatively easy to understand. Well, I should say to begin to understand utilitarianism, deontology and justice and how you can use those to guide decision-making when you have a serious threat and you have a limited supply of available life-saving measure. Then I want to go over the, or I want you to be able to critique the prioritization plans for COVID in the United States against these theories. And then finally define the legal basis for mandating COVID vaccine use if that were to occur and list several measures that could be taken by the U.S. government to encourage uptake of the vaccine. All right, so a little bit of background here. We always hear, or we've heard comparisons, the last major pandemic typically people talk about was the 1918 influenza pandemic. Although measles was, before vaccine was introduced, it was a continuous ongoing pandemic and while largely eliminated from many countries in certainly United States, well, I should say at least endemic transmission was interrupted in many other countries, measles continues to be a worldwide problem. And so looking at that versus COVID-19. So a couple of characteristics that I wanted to talk about here, the age distribution and the flu pandemic, for whatever reason, the extremes of life were generally spared. So the elderly were spared. The thinking is that perhaps they had some previous immunity from a similar pandemic that may have occurred when they were younger. The very young children seem to be spared as well because it's thought perhaps their immune systems weren't quite fully mature and that a lot of the morbidity and mortality from the influenza pandemic had to do with immune response as opposed to the inherent lethal potential of the virus. We talk about measles. Measles, pretty much everybody is susceptible. It doesn't matter how old you are. And the same is true for COVID-19. There has been talk that there are fewer cases of COVID-19 among children, but I think that's really probably mostly because we don't test children as much and children tend to be less symptomatic. And so there are enough cases where it is likely that children are equally susceptible at least to infection. As far as morbidity and mortality in the influenza pandemic, those that were struck hardest were young adults and probably young to middle-aged adults were the bulk of what we were seeing for deaths. And so this, of course, occurring on the heels of World War I, it may have been propagated or promulgated through military movement of large numbers of people throughout the United States certainly didn't help, but the young were the ones who were dying from this disease. With measles, the childhood mortality of measles is certainly significant. Between one and three per thousand would die of measles even in the young age groups. But if you somehow didn't get measles when you were young and you got it when you're older, the death rates could be considerably higher. And so we had seen, while the death rate had fallen from the turn of the 20th century to the mid-20th century by almost a factor of 10, the rates were as high as perhaps 20 to 25 per thousand going back to around 1900. Now, with COVID-19, we see a much more linear, well, it's a log linear relationship between the morbidity and mortality where for every decade older you are, your risk of serious complications or death is about three times higher. And I'll have a chart with some of those numbers on it later that I pulled from CDC and other data, but it is very clear that the older you are with COVID-19, the more likely you are to suffer either hospitalization and or death. And then as far as countermeasures, what can we do to prevent the spread of disease? Well, the flu pandemic, it was kind of similar to early in COVID, try and keep people apart, try and reduce the amount of social gatherings that there were. Use of masks certainly did occur, but none of those measures were particularly effective in slowing the spread of flu. Measles really had no effective countermeasures at all. There's really not much you could do for measles. And that's primarily because of the way it's transmitted is through aerosol. And so you didn't even have to be in the same place as the person who had expelled measles particles. You could enter the space maybe as much as an hour later and still acquire the infection. And so it's very difficult to combat the spread of a disease that transmits through aerosol. And then with COVID-19, we certainly had a reduction in contacts with others through use of social distancing. Masks may have provided additional protection, but then we acquired a vaccine as you're all well aware in the late 2020, early 2021. So with those in mind, we'll just talk about a couple of the ethical theories quickly. I'm not an ethicist. I do have an interest in the topic. And I've been interested since I was a medical student. And my previous program director, Dr. Jeff Gunsenhauser, introduced me to some more of these advanced concepts with social justice, with Rawls and others. And so again, I'm not presenting these theories as an expert, just as kind of a general background. And certainly there are other theories out there. There are other ways of approaching this. But I think these are the ones that I present here are ones that I think most people are at least somewhat familiar with. And so I just wanted to kind of go over them quickly. So utilitarianism, this was advocated by John Bentham. This is loosely defined as the greatest good for the greatest number. I think he defined it as actions that would ensure the most happiness for the most amount of people, something similar to that. But this is a consequentialist theory where what matters is not what actions were taken, but what the outcomes are or the consequences of the actions. And one of the issues and one of the criticisms of this theory is that you can do things that some might consider unethical and justify it by getting the right result. And so this is a it's an understandable method, but it's certainly not without its flaws. And of course, it may result in harms to individuals. And this harm principle that John Stuart Mill put forward basically said the only purpose for which power can be rightfully exercised over another member against their will is to prevent harm to others. And so this is really taking into this. When can we take some person's autonomy away? When can society exert its will against members that don't want it to happen? And we'll talk about this a little bit later in this presentation. But it's really the only justification in his mind was to prevent harm to others, a greater number of others. So deontology, this is Kant. He really put this forward. And really what it's talking about is it's your duty to do the right thing, that if you do the right thing, that's the most important thing. So this is basically action based as opposed to consequence based. And so you can do the right thing, but it may result in an unintended consequence. But if your motives were pure, then according to this theory of ethics and justice, you would be OK. The acts must be on the basis of goodwill. They can't be because you're trying to advance your own position and that you can't treat others as a means to an ends, especially if it benefits you without considering the others as ends to that, if they are harmed, that that is an end that you would weigh in your overall evaluation of whether your action was justifiable or ethical or not. And then, of course, this categorical imperative that he discussed was saying that you should act in the good nature of or for the good of others so that free will would allow any individual to say, yeah, but I don't want to do that, and so I'm not going to, which I guess at the time would say that's why there is evil in the world, because people don't look out for the will of others or for the good of others. So then John Rawls, and again, this is Dr. Gunzenhauser, introduced me to this as justice as being a concept of fairness. And this is kind of a difficult concept. There have been a lot of books since Rawls put out his original and he did a revised edition, and there have been a lot of people trying to interpret it. It's fascinating and quite too deep for me to go into in great detail here, but the things that I really liked about how he set this up was that he was looking at it in terms of a social contract theory, that a society would come together, they would all start off at a position where they needed to come to an agreement about how to move forward as a society, and they had to all agree upon what actions they were going to take and they needed to have unanimous agreement. And so one of his postulates here was that in order to do this correctly, you can't know who you are in society. And so he called this the veil of ignorance, meaning that in order for you to make a good and ethical decision, if you knew it might benefit you because you knew where you were in society, then you might make a different choice than if you didn't know who you were. And so he felt that the only way to actually do things fairly would be for no one to know their position, everyone to agree an action needed to be taken, and then everyone had to agree on the same action in order for it to go forward. Now, you might see how that could be problematic, especially in a large society, because how are you going to get every single person to agree on a single course of action? It seems like these might work in potentially in a small community, but trying to get unanimous agreement would seem to mire this process down to such a slow pace that it would never actually, nothing would ever actually get done. But anyway, he had approached this in such a way that he was trying to actually create a unifying theory of how justice could work. I'm not sure that he was completely successful in that, but I think the principles that he puts forward are really useful to think about. One of the principles that he also put in his theory were that the least advantaged member of society must benefit at least as much as the most advantaged member of society. He had built in protections for those who were least able to protect themselves in society. Any movement forward that was going to be considered just must have met those criteria, including that the least advantaged were the most protected. There are multiple ethical dilemmas that we're talking about, vaccinations in particular, but these are general ethical dilemmas. But if we frame this towards a vaccination, there's beneficence versus autonomy, right? So I think the vaccine is going to do you good, but you don't want the vaccine. So how do I balance the two if there is also a benefit to the greater society, or perhaps in this case with vaccines and we see with mandatory vaccine programs, there are certain individuals who can't take vaccines or can't be protected by vaccines because of immune system defects or other medical issues, or perhaps they're not old enough. And so how is it that you can balance the need of society to protect those vulnerable individuals against the autonomy rights of somebody who says, but I don't want the vaccine? Similarly, have this issue of the individual versus the community. An individual wants to be able to make decisions that benefit themselves or may want to make decisions that benefit themselves the most over the general good of the community itself. Then we have issues of justice versus virtue, doing the right thing, or which is the right thing, which virtue is the one that is most important, and how you decide how to rank order those things. Other issues particular to this vaccine we've talked about is, where do you want to have the decision-making authority reside? Should it be at the federal level, a state level, a local level? How do you guarantee that the individuals who are going to be subject to this distribution plan, in this case for vaccine, were able in an agreement? And at what level can you essentially direct the distribution to occur? As you might see, how do you decide what's fair? Some people might have different viewpoints of what's fair. If your ultimate goal were, I want to save the most lives regardless of anything else, then you may have one approach. If you say, well, I want to save the most life years or the most quality life years, or I want to ensure protection of certain individuals who may otherwise have been disadvantaged, you might have different ideas of what you think fair is. And there are issues of coercion. How do I convince somebody to do something that they might not otherwise want to do, but get them to agree to it rather than forcing them to do it? And then finally, we have this issue of free riders. And this is an equal protection issue that individuals may wish to simply not take the risks of vaccine because they are going to rely on the greater society to stamp out the disease for them. So they don't have to take any risk, yet they would enjoy the benefits of the rest of society taking that risk. And so these are all real issues that you face when you're trying to determine how to distribute vaccine and whether you should or could make somebody take a vaccine. All right. So just a real quick overview here about how did the United States approach vaccine distribution? And so for the federal government, and of course, the federal government generally makes guidelines. They don't direct it, but they give guidance to the state agencies. Because generally under the 10th Amendment, the states are the ones that exercise the power of the health or police power. So the federal government put out these guidelines, and basically they defined in general risk categories. The one that's most solid that we can all agree on is age. And I'll show a little bit of data, but I know you're all well aware of this, but age clearly is the most significant risk factor. Underlying medical conditions are another risk factor that are certainly real and objective. One of the problems with the medical conditions is how broadly or narrowly do you define them? And that medical conditions in general are also associated with age. So the older you get, the more likely you are to have other medical conditions. And so how much of that is covariate overlap versus how much is an independent contribution. And then occupation, this was really defined, I think at first they were talking about individuals who are at risk because of their occupation. So healthcare workers who were taking care of COVID-infected patients. But then I think also they were talking about critical infrastructure type work where the business of the nation couldn't go on if too many individuals in certain occupations were unavailable due to illness. And so they generally put out those guidelines for the states to exercise. And then of course the states had the right to modify the federal risk categories and then decide what distribution system they were going to use. So the federal government had some, they talked about using the military, and I think they did for early distribution, but the states were really in charge of getting it to the end user, the individual. And there was a mix of public and private actors that were used to distribute the vaccine. And then some of them did it through their local health departments or other healthcare facilities. So it was done in a variety of ways. And again, I don't know that there was any single right answer, but as we talk about in the upcoming slides, there were pros and cons to each approach. All right, so just a little background here. Now, I think this data is a couple of weeks old, but it's not significantly changed from the last few weeks. And the new census data also got released. So those numbers probably got updated a little bit. But in this, I broke down by age group, the population, the total deaths in that age group, and this was for the same period that since COVID started. So it was sometime around March of 2020. So it's a little bit over a year. So the total deaths that occurred by age group, the deaths attributed to COVID, the overall death rate, the COVID death rate, and the percent of deaths in each age group that was attributed to COVID. And so what you see in this, if you look at the second to the last column here for the COVID death rate per 100,000, what you can see is that it's pretty low, of course, as we expect in the youngest age groups, the zero neonates typically have higher death rates than just because of other issues surrounding birth. But once you get to the one to four, it's a pretty linear relationship. And it approximately triples every decade as you go all the way up through 85. And so a simple log linear relationship, it is very clear that the death rate from COVID is much heavily burdened on the elderly. But the interesting thing is if you look at the percentage of deaths in each age group that are from COVID, we'll note that it's pretty low until you get to 35. And then once you get to 45, the percent of all deaths in each age group attributed to COVID is pretty much the same. It's between 10 and 14%. And so even though you're less likely to die in general at age 45 as somebody who's 85, if you, of all the death causes, COVID is still causing 10 to 12%. And so it is a significant risk factor for everybody, really, clearly at 45 and over. And I think much more than people had appreciated. And really once you get into that 45 year old age group, clearly even the 35 year old is probably skewed more towards the top end of that. But you see that transition between young individuals and those who are just entering their young adult years when you're around 1% to 2%, but that pretty big jump and then it stays the same 45 and higher. All right, so now we'll do a quick calculation of years of potential life lost here. These are using the Social Security Administration, their life tables and trying to figure out. So as you, years of potential life lost is based on the age that you were, how many years you might live. And in this case, we're multiplying it by the number of deaths that occurred in that age group. And so the first column here is a repeat from the earlier table of how many total deaths we've had per age group. The next column, again, that's from the Social Security Administration for that age group, how many years of potential life do you have left on average? And so you multiply the two to get the years of potential life lost. And so the most interesting thing to me here is that the peak for years of potential life loss isn't in the oldest group, it's in the 65 to 74 year old group. And the second most years of potential life loss is in the 55 to 64 year old group. And that makes some degree of sense because 55 to 64 year olds have 23 years to live, 75 to 84 have nine years to live, there's fewer of them. So even though they're dying at a nine times higher rate than the 55 to 64 year olds, because of that factor of two and a half to three of remaining life expectancy and the smaller population, years of total potential life loss ends up being smaller. And so this gets at a utilitarian argument that one could make. I'm not making it, I'm just saying that the, I'm not personally advocating for it, but the argument would be, if you were trying to do the most good for the most people, it's not a simple age calculation anymore, that you're going to save more individuals life years by focusing on a slightly younger age group than you might have otherwise done. And even the 45 to 54 year olds have more years of potential life lost, even though their death rate is so much lower than the 85 year olds than the 85 plus year old group. And so this does make it a little bit more difficult to say it's a simple equation, let's just use age, because the just using age really then distorts the effect. It would be from a certain point of view to say all lives are equal, so it doesn't matter how old you are, I want to, if you have a higher risk, I'm going to give it to you first. And so again, this is an ethical dilemma. Now you could do similar calculations for gender and you could use underlying medical conditions. Those calculations become a little bit more complicated for anything, for certain underlying medical conditions where you don't have a single solid definition of exactly what we mean and an ability to tease out the independent contribution from age. But you could look at it from that perspective, probably in the youngest age groups to say, okay, well, this isn't adequately representing maybe say a cancer victim who's 14 years old, their rate, if they had a specific diagnosis might be much higher or combined immune deficiency or something like that. So you could use beyond just age other factors to try and help you sort this out. But the more complicated you make your models, the more difficult it would be to actually execute the distribution of the vaccine. So again, a little discussion here on the US approach. So the US approach in general, they were trying to use factors that would result in a fair distribution. They certainly considered age and age as you saw from the previous two slides is clearly a factor that is going to be involved in risk to individuals. Use of risk categories also was an attempt to allow those who didn't make it an age criteria alone, but we're still at high risk to be included. And then of course there was a local flexibility because the US federal government simply provided general guidelines and they did not direct how the vaccine would be distributed. The cons though, risk categories can get subjective as I just discussed. And the more complex you make any distribution system, the more inefficient the delivery will likely be. The simple example is if I were to say, all I need, if you're 65 or over, you can get vaccine first, I'm gonna allow you to have it first. Well, everybody should be able to show their age, age is an objective or relatively objective factor. And so if that were the only criteria that the distributors needed to use, they could say, show me an ID card, driver's license, something else, and you're okay to go. Once you add other factors in there, like you have to have an underlying medical condition or you have to have a certain occupation, now the question becomes, well, how do I interpret that that condition is adequate? Do I need to review a medical record? Do I need you to bring medical records? How do I know that your occupation, even if it's listed, you're actually at risk based on what you do? So as a personal example, I'm a healthcare provider and I am licensed to practice in the state of Virginia. Does that mean that I should be prioritized as a frontline healthcare worker? How does Virginia decide whether I'm actually doing, even though I'm not doing direct patient care? So should I be allowed to be prioritized just because of the fact that I am a healthcare worker? Now, of course, from that perspective, you could say that my own internal ethical duty is to make that determination for myself. But as I pointed out, it just makes the distribution plans a little bit harder. And then finally, a con here is that the action-based versus outcome-based ends up being a little bit complicated. If you're trying to make it fair, then did you actually accomplish the greatest good for the greatest number? Of course, that's not a requirement, but from the utilitarian standpoint, it would be preferable. All right, so I wanted to talk a little bit about mandatory vaccination. I had given a similar talk to this a couple of years ago, but I'm just gonna touch on the highlights of the mandatory vaccination. So the first, the underlying ethical dilemma here is the respect for persons to be able to choose. And so, of course, the underlying factor here is that people have a right to choose for themselves and control their own bodies. And then of course, our utilitarian side and then of course, our utilitarian good, preserve life, do good, avoid evil, and greatest good for the greatest number. And so what we have here with vaccination is this classical problem of how do I balance the needs of the society itself to protect itself from a communicable disease and allow individuals to choose not to avail themselves of that protection? Because if enough people say, I'm not going to do it, then the society cannot be protected. So the society needs a certain percentage of individuals to participate in the program, but how do you get the individuals to do so? And we're seeing some of this right now in the United States with the COVID vaccine that we are at a level where we're not at a high enough level to enjoy the benefits of herd immunity. Herd immunity is a little bit of a difficult concept with COVID anyway, because like measles, you can't really stop or interrupt transmission based on herd immunity. You really have to get to extraordinarily high levels of vaccination. But there is already significant vaccine reluctance that we achieved a level where those who wanted it were able to get it. They were up around 40 to 50% of the US individuals who were eligible over the age of, at the time, 15, now I guess now 12, were able to avail themselves of the vaccine, but the distribution rate has slowed significantly. And so the question is, it's not enough. We're not at a high enough level to protect society. And so what steps be necessary to take in order to get to that societal level of protection? And how much do we need to know and how much justification do we need to have before we might take steps to mandate vaccination? So the legal basis for vaccination, mandatory vaccine programs, this has been ruled on by the Supreme Court a few times. So first of all, it's police power. And so this is a 10th Amendment issue that I briefly mentioned earlier that the power to mandate vaccination is reserved to the states under the 10th Amendment. But a Supreme Court ruling in 1905 was about smallpox and smallpox was an interesting case that this individual didn't wanna get smallpox vaccine because he said, you know, I just don't believe in it. And the state of Massachusetts ensued saying, we can force him to because there is a societal need to protect society from smallpox. Now, smallpox was a disease where the consequences of getting smallpox could be very severe. The death rates and disfigurement rates were extraordinarily high among smallpox. And so from that standpoint, society was at risk of harm. And so the justification for vaccinating contacts of smallpox was to prevent spread and you could recognize the disease. You knew who the contacts were. You at least had a pretty good idea because smallpox required a fairly high degree of contact in order to spread. It was relatively inefficient spreader. And so at the time, the Supreme Court said, yes, this is a valid use of the police power and they upheld that. Now, the federal government doesn't really have the authority to mandate vaccination programs except in the District of Columbia because that's under federal control and military installations, a few other areas, but they can't do it because it's a power reserved to the states. And so most or many of the determinations about how you can do vaccinations or mandate vaccinations were either decided in state courts or initially decided in state courts and then elevated Supreme Court if there was a dispute. But a couple of them of significance, 1922 ruling Zunk versus King upheld that you could require vaccination to attend school, that it didn't violate the 14th Amendment of Equal Protection because the other individuals attending school had the right to be protected from communicable diseases, including those who could not be vaccinated for medical or other reasons. In 1944, there was another ruling that said the state can substitute its judgment for child welfare, overriding wishes of parents. And then a 1987 decision said that, again, another educational question that said, an individual's right to education doesn't trump the state's needs to protect against spread of disease. So the basis for mandatory vaccination is has been settled in case law. That's not to say it couldn't be subject to challenge again, but the established precedents are that the states can require it if they wish to. Again, the federal government can't force it, but the federal government can encourage it. And so the question is how, and you've seen this already with some initial discussions from the administration of offering incentives to be vaccinated. I know I'd heard about sports tickets. I know one state itself was gonna give a lottery, entry in a lottery if you had gotten vaccinated. Non-governmental agencies can do it. Krispy Kreme was giving out free donuts for a while. I don't know if they're still doing it. But the federal government, what can they do? Well, of course, they can use educational programs, primarily through at least the spokesperson would be the CBC. The CBC would put out information that people can read and try to understand and communicate the idea of why they might want to be vaccinated. Federal government can restrict travel by commercial means too, through their various agencies. So they could require a vaccination or travel by air, rail, or bus. As of this point, there's not the appetite to do that, but that's not to say it couldn't happen in the future. Those of you who are older, like me, might remember yellow shot cards and yellow fever stamps that you would get in the cards. These were used for international travel, of course, but the idea would be similar that you have to show proof of vaccination to enter certain countries. Within travel, within country travel is a little bit more difficult, but the idea is they could do that if they wanted to. And of course, federal government can always withhold resources. And this is one of the ways that they often influence state policy. And so they could tell states, hey, look, you gotta implement school vaccine requirements whenever vaccine's available for school-aged children, or we're gonna withhold resources. They can withhold, I suppose, highway funds or Medicare funds. They can withhold just about anything if the Congress passed it to say, I'm gonna encourage these states to encourage their citizenry to get vaccinated. And of course, they could pass labor laws that might require an offer of vaccine for selected occupations, but it would be up to the employers themselves to require it. Of course, the federal government's employer can require it for their own employees, should they wish to. And of course, right now, as you're all aware, the vaccine is approved as under an emergency use authorization as opposed to a full approval. If you wanted to use some of these more coercive means, like say a vaccine passport, it would have to be fully approved. Trying the inherent nature of an emergency use authorization is the individual gives their consent in order to take the vaccine or take the medical product, in this case, a vaccine. And so it would not really be fair to then say, well, you can't do things that the normal society would offer you unless you have given up your right to choose to decline a vaccine. So these are the main options that are available. And I'm sure there are more, but I just wanted to cover a few of the ones that I've seen or at least were discussed. So the summary here, I want to leave time for questions or discussion at the end. And I'm sorry, I keep looking side to side because my moderator may be coming up on the other computers, sending me some messages. There isn't one right answer to how you distribute the vaccination, but I did want people to think about some of the considerations that might be involved there. Eventually, when we look back at this in a few years to say, well, was this a good and fair program? The evaluation of success is really dependent on what your ultimate goal was going, well, what it was, how you define it. And then finally, they said the legal basis to mandate vaccination is reserved to the state. Federal government can incur vaccination, but they cannot mandate it, so. Excellent. Okay, all right. So I think that concludes my prepared, I did a little suggested reading here for you. For those of you who are ethicists in the audience, you probably already read all of these, but I found these books to at least be useful to take a look at. So I am going to open it up at this point to questions through the moderator on the chat or however else they're going to come across. Thank you, Andrew. This is Lauren. We have quite a few questions in the chat. The first one is, how do you build vaccine confidence considering varying public health messaging about vaccine prioritization? Yeah, it's an excellent question. Building vaccine confidence is a communication skill, right? I think when you talk about, how do I convince somebody to do something they might not otherwise want to do? It's understanding why it is that they're reluctant. And I've talked to a few people, I can't say I've done any kind of a formal survey, but talking to a few people, what I perceive is they don't believe they're at risk. And they resent being told they have to do something. And this is kind of a general, this is this individual rights versus societal rights where the United States was kind of founded on this concept of individual liberty and it is highly ingrained in society. They are resistant, individuals are resistant to being directed as to what to do. And so to try and overcome vaccine hesitancy, I think really is, it requires us to do a better job of really explaining to individuals what their risk might be. And to say, the alternative to not getting vaccinated is you're gonna get natural disease. There is not, this COVID-19 is infectious enough. And we've seen several articles have come out that says it probably is being primarily transmitted through aerosols. And aerosols are almost impossible to slow, I mean, you can slow it to some degree, but you can't stop. And so if you don't get vaccinated, you're gonna get natural disease. So if you're worried about the effects of the downside, the risks of the vaccine, you need to consider what are the risks of natural infection. In general, the risks of natural infection are higher. One of the things I tell people who are younger is, well, you might only lose smell and taste for six months or a year or the rest of your life. Now, that may only occur one in a thousand and one in 10,000, but if it happened to you, that would be pretty bad, right? I mean, most people don't want to not be able to taste anything. I mean, that's a big quality of life issue. So yeah, you might not die or go to the hospital, but maybe you can't taste anymore. Why do you wanna take that risk if the vaccine has no such risk, right? I mean, the vaccine has roughly the same risk as other vaccines in terms of one in a hundred thousand, anaphylaxis, et cetera. We haven't seen specific. We did see some questions about this thromboembolic disease, but at a very, very low rate among a select group of individuals. So again, I think it's really about risk communication packages, and I'm not sure that the administration has been particularly affected at getting the vaccine sold, except it's the right thing to do. Altruism only goes so far. I think people need to understand why they themselves may benefit too, and they really would. It's just, they perceive their individual risk to be so low that they don't need to worry about it. But I think that's a mistake. I mean, it'd be like, well, why do you wear a seatbelt? It's like, you're probably not gonna get in an accident, but you can reduce your risk by doing something pretty simple. Why wouldn't you do it? But I think that's what we really need to work on. It's not, out of the Army, it won't be my job anymore. Maybe it will be my next position, but I think this is something that the administration needs to focus on, and local and state public health leaders as well. Should I go to the next question, Lauren? Are you gonna read them to me? How am I doing this now? I see the questions up on the board. Yeah, so the next question is, where is the United States in regards to achieving herd immunity, and should vaccine be mandatory for school, employment, et cetera? Well, it's a good question. All right, so the problem with determining herd immunity, I mean, the term itself came from herds of cattle, which were small, defined groups of which you knew what the turnover rate was, and you knew what the mixing was. The United States, with 330 million people who are spread heterogeneously throughout the country, isn't actually a herd. And so we see this, even though we saw last year with measles, that even at extremely high levels of vaccination, you can have continuous transmission of disease. So the question right now for the United States is, first of all, we don't know how many people have had natural infection. We know how many were reported, which is in the 30 million range. And we know that the best estimates are that there's at least four to five unreported cases for every reported case. And so if we take that, and let's just say it's four, so let's say there were 120 million natural cases of COVID. And we will then say, because we have not screened when we get vaccination for previous infection, we have to determine, well, how many total percent of the United States has either been infected or vaccinated, or both, right? You don't wanna count them separately. My calculations are it's around 68%, somewhere in that range. Now, if the R value of COVID were at four, which is a little higher than we originally thought, the requirement would be 75%, if I'm saying this, 75% would have to be immune in order to achieve this herd immunity threshold. But the problem is herd immunity doesn't actually end transmission. It just creates a steady state where the number of introduced new susceptibles equals the number of individuals who've already had the disease who die in society on a daily basis. So we have approximately 10,000 new births in the United States every single day, 70,000 new births per week. And we have immigration, other people transiting. And so there's gonna be disease introduced until we're at a much higher level of protection than we are right now. Now, we were on track when, earlier on, we were given vaccines at the rate of new individuals receiving vaccine of over a million a day, but that's fallen down to about half or 400,000, perhaps it's fallen by about 60% since the end of April. And that'll likely continue to decline because now you have to get to the point of convincing people to get the vaccine. In addition to that, the natural case rate has fallen substantially too. So if we're reporting 30,000 cases a day, we may actually have 120,000 cases a day. But at that level, it would take a very, very long time in order for everybody to acquire disease, especially when you consider we have 70,000 new births every single day. So to actually get to herd immunity, if that concept means anything, I think what most people wanna know is when am I gonna interrupt endemic transmission? When will it be like measles, where the only cases we see are those that are imported from other countries, and we don't have it in the United States. It took us 37 years for the introduction of effective measles vaccine in 1963 until we interrupted endemic transmission. And we started at a level where 98% of the United States or maybe it was 95% were already infected because all the adults had already had it. And so we didn't have that with COVID. So it could take quite a long time. The problem we have with vaccine hesitancy is that the more people who acquire natural infection, the greater there is a risk for a mutation in the wild type virus that will allow it to defeat vaccine. And that's really what we don't want because then we would have to start over. All right, I'm probably talking too long on each question. No, that's fine. We've got time. What success stories in distributing and administrating vaccines in populations facing challenges with healthcare access? All right, I have to think about this for a second here. I'm reading the question here. So, I mean, I think the success stories should probably be measured in terms of how well was vaccine accepted in community and what were your overall vaccine rates? And if you, I mean, I think it's a success story too to figure out if I'm not successful at getting the vaccine to people, did I try and implement something different, right? So if there's a particular community that is not accepting a vaccine, then a success story is, well, how do I turn that around? How do I get there? How do I get into that community and make that happen? I myself have not looked at individual community level distribution like that. I mean, from where I'm working at the DOD, we've had relatively, the uptake of the DOD has been similar to that of the general United States. I mean, part of the issue for the DOD is service members are young and healthy and they're targeted in the population now because of readiness issues. They have a critical mission for the country, but they're not at a particularly high risk of getting hospitalized or dying from disease because they're in their 20s and they don't have underlying medical conditions. And so even with that as a hesitancy, I think our rates among that age group is probably a little bit higher. And I think that that for us in the DOD has simply been making it available and reducing barriers to distribution and encouraging people to do it, not maybe for themselves, but for others around them. But I can't say that it was hugely successful. It's at least been reasonably successful. Wonderful, thank you. Next question is, should vaccine passports be required for travel, school, work, doctor's offices, consumer locations like stores, restaurants, movies, or other social events? Well, I mean, I guess the first question is, if you did do that, if you said, I want a vaccine passport, we have a couple of issues of, you have a privacy issue. You would have an issue of, how do I get these passports to individuals? How difficult is it to obtain? What if people don't want to show it? What about counterfeiting? I mean, if you know from the old, the old shot record, it'd be really easy to counterfeit with Photoshop. I think you could pretty straightforwardly make a vaccine card. And so I guess the real question is, what are you trying to accomplish by requiring a passport? And again, this gets into what can the federal or state or local government do? Federal government says right now, they're not going to do vaccine passports, but federal government can only control things under federal jurisdiction, like plane, air, bus travel. If individual states or localities wanted to require a passport, I think it would be subject to multiple legal challenges. And I think it would probably fail in the courts. And I think it would fail in the courts because it's hard to show that once you've given the vaccine to all those who want it, the remainder who chosen not to take it are making their own choice to say, I will accept the consequence of the disease. And unless you can show a true burden to society, like they are really going to hurt someone else. And that would be someone who needs the vaccine, but can't take it for a medical condition. They just can't take this kind of vaccine. That would be the only real justification. And because COVID is not in terms of, it's not as dangerous as say smallpox or measles. I think that the argument would be much more difficult to make. We never were able to make it for flu. And flu certainly circulates every year and many people just decline it. So I don't know that you could make that work. I think it's an idea worthy of exploration, but I think it would be very difficult to implement. Thank you. I think we have time for one more question. Do you think there's momentum to work on further pandemic preparedness? Or have we exhausted our political will panic momentum? I do think that there is some interest now. Of course, the DoD has always interested in vaccines that are of military concern or diseases of military concern. But interestingly enough, the push to get a universal flu vaccine predated, of course, COVID. And DoD has been a participant in that. I think you're right though, it comes down to nothing spurs action like a crisis. And it's difficult to get people to wanna then prepare in between crises for the next one. I think it is important, but the sheer number of potential threats that are out there would say, I can't develop a vaccine for any everything, can I at least develop the base of a vaccine so that it might be adaptable? And that's really what happened with these mRNA vaccines is that there was a lot of research that was done to be able to create a vaccine that might be adaptable to multiple infectious threats. And they were able to really rapidly in what eight months when the previous record was four years in the mumps vaccine, come out with a new one. So I do think in the pharmaceutical community, there is a significant interest because that's how things are changing in medicine and prevention is going to custom designer interventions. I mean, you look at biologics and cancer treatment and has revolutionized many different disease treatments. So I do think there is still momentum. I'm not sure how much it'll stay in the mind of the average American, but I do think that there is momentum behind it. Thank you. I think we do have time for one more. So would it help increase vaccination rates if employers were required to give a day of PTO to employees after each dose? It could, again, there's a cost obviously to an employer to do that because the worker isn't there. It probably would increase rates, but I think it really helps to understand the reluctance on whatever group it is you're talking about. Because there isn't typically a single solution to anything. So as I said, my discussions with individuals about why they don't want the vaccine, it's not the barrier to getting the vaccine. It's that they just don't think they're at risk. And so they just don't want to do it. And so I think that is something where we really need to expend more effort. We can try and use enticements and I think there's nothing wrong with that so long as the employer can afford it or they're somehow otherwise compensated, but then it's the taxpayers, I guess, who are affording it. But yes, I think incentives are important, but I think the most important thing in getting somebody to do something is not ordering them to do it, but getting them to want to do it. And in order to get them to want to do it, you have to figure out why they don't want to do it now and objectively listen and try and convince. And I think that is a difficult task. It's my discussion with relatives and friends. It's like, why don't you have the vaccine again? It's like, because I'm not at risk. I don't need it. Nobody's gonna tell me what to do. That is just a steep hill to climb. Well, thank you so much. We really appreciate your time and expertise on this topic and can't thank you enough for joining us for PM21. With that, I think we will wrap the session. Any last words you want to leave us with? Well, it was really an honor to be able to present to you all again. I think this would have been easier if there was a live audience, but I hope at least people got, I got people to think. Well, thank you so much. We will look forward to seeing everybody in our next session and have a great afternoon. Thank you.

COVID-19 vaccine

ethical considerations

distribution

utilitarianism

deontology

justice

decision-making

scarce good

U.S. approach

risk categories