WHO keeps on trucking?

The Canadian Government and mainstream press seem to think that the anti-mandate movement is fringe, "unacceptable views", and against the science? Is that correct?

Trucker convoy. I don’t think I need to explain what that is.

Their primary positions are against mandatory vaccination and vaccine passports. Before hiding out in self-imposed quarantine, Prime Minister Trudeau said that they are a fringe minority, that they have “unacceptable views”, and implied that they lack the compassion for others that pro-mandate Canadians have, and the science is on his side. Let’s fact-check him on that.

On December 7, 2021, the World Health Organization (WHO) declared that vaccine mandates are an ‘absolute last resort’:

"Mandates around vaccination are an absolute last resort and only applicable when all feasible options to improve vaccination uptake have been exhausted," WHO Europe director Hans Kluge told reporters.

"The effectiveness of mandates is very context specific," Kluge said, adding that public confidence and trust in authorities needed to be considered.

They repeated this on January 13, 2022, amid the Djokovic saga.

The WHO has a 6-point policy paper on what is required for mandatory vaccination, “COVID-19 and mandatory vaccination: Ethical considerations and caveats”. It is a good read, and and notably includes:

“Mandatory vaccination should be considered only if it is necessary for, and proportionate to, the achievement of an important public health goal (including socioeconomic goals) identified by a legitimate public health authority. If such a public health goal (e.g., herd immunity, protecting the most vulnerable, protecting the capacity of the acute health care system) can be achieved with less coercive or intrusive policy interventions (e.g., public education), a mandate would not be ethically justified, as achieving public health goals with less restriction of individual liberty and autonomy yields a more favourable risk-benefit ratio (1).

As mandates represent a policy option that interferes with individual liberty and autonomy, they should be considered only if they would increase the prevention of significant risks of morbidity and mortality and/or promote significant and unequivocal public health benefits. If important public health objectives cannot be achieved without a mandate – for instance, if a substantial portion of individuals are able but unwilling to be vaccinated and this is likely to result in significant risks of harm – their concerns should be addressed, proactively if possible. If addressing such concerns is ineffective and those concerns remain a barrier to achievement of public health objectives and/or if low vaccination rates in the absence of a mandate put others at significant risk of serious harm, a mandate may be considered “necessary” to achieve public health objectives. In this case, those proposing the mandate should communicate the reasons for the mandate to the affected communities through effective channels and find ways to implement the mandate such that it accommodates the reasonable concerns of communities. Individual liberties should not be challenged for longer than necessary. Policy-makers should therefore frequently re-evaluate the mandate to ensure it remains necessary and proportionate to achieve public health goals. In addition, the necessity of a mandate to achieve public health goals should be evaluated in the context of the possibility that repeated vaccinations may be required as the virus evolves, as this may challenge the possibility of mandate to realistically achieve intended public health objectives.

This policy paper was led by Maxwell Smith, an Assistant Professor at Western University in London, Ontario, Canada, who specializes in Public health ethics/population-level bioethics, infectious disease ethics, bioethics, health equity and social justice, and health policy. You may remember Western University and bioethics from September 2021 when another ethicist, Dr. Julie Ponesse, was fired for refusing to comply with the vaccine mandate of her employer. She worked for Huron University College, part of Western University, where she taught medical ethics for 20 years.

In the quote from the WHO policy, you may note a reference with respect to better risk-benefit outcomes using less restrictive means. That reference is to Nuffield Council on Bioethics in the UK. Specifically, it refers to their 2007 report, "Public health: ethical issues". It is a substantial read, but most of the topical information can be found in Chapter 3. A key element is the evaluation of persuasion mechanisms for changing behaviour and the subsequent recommendations of the intervention ladder (Section 3.37) which addresses both the efficacy and ethics of interventions. The intervention ladder provides a series of steps of increasing governmental control over free choice as a guide toward implementing least constraints while maximizing persuasion. It proceeds are follows:

1. Do nothing and simply monitor the situation.

2. Provide information.

3. Enable choice.

4. Guide choices through changing the default policy. (E.g., approval process for face-to-face meetings, added testing)

5. Guide choices through incentives. (E.g., compensation for taking on known and unknown risks of these vaccines)

6. Guide choices through disincentives. (E.g., restrictions on work-related activities and benefits)

7. Restrict choice. (E.g., require regular testing, demonstration of antibodies/natural immunity, restrict duties and interactions with people)

8. Eliminate choice. (E.g., vaccinate or be put on indefinite unpaid leave, or fired)

Did Canada follow this ladder? Did it set time limits, address concerns, and accommodate other options? I may have missed steps 4 through 7.

Chapter 3 has many other good nuggets, including Section 3.7:

"...media stories often turn out to be based on anecdotes, unpublished reports or preliminary results, or they overstate, misrepresent or misunderstand the claims of the researcher."

Or Section 3.8:

"Perhaps only some of the literature will be cited, or explanations rely on a particular strand of scientific evidence, ignoring or excluding other evidence. All groups, politicians, the media, single interest groups and scientists are capable of this."

Or Section 3.9:

"A related issue is the status of views that are not considered to be ‘mainstream’ or typical of the scientific community. Such heterodox views sometimes turn out to be correct, so it is important that they are not ignored."

Or Section 3.11:

"Although scientific experts may sometimes be tempted, or pressured, in these circumstances into offering precise answers to policy makers, the honest answer will often be “we don’t know” or “we can only estimate the risk to within certain, sometimes wide, limits”. It follows that claims of absolute safety or certainty should be treated with great caution."

One of my favorites is Section 3.46:

"Political interests can also have significant impact on public health matters when politicians are motivated by the need to be seen to be ‘doing something’. They may have to choose between an intervention that would be popular straight away but ineffective, and another having less immediate appeal but more likely to be successful in public health terms."

Those nuggets of wisdom were produced back in 2007, but of course they are all based on historical reviews of social behaviours around public healthcare. These are not protest tweets. It almost pre-dates the existence of Twitter.

The Nuffield Council on Bioethics does have several contemporary statements specific to COVID-19. In September 2021, they made specific statements about vaccination polies:

“The idea of vaccine passports raises ethical questions concerning respect for individual rights and interests, public health responsibilities and social justice. We are concerned that bringing in passports in relatively uncontroversial areas (e.g. for entry to large events and clubs) could pave the way to passports being required in other areas of life. This, we believe, could lead to discrimination against and a loss of opportunity those who cannot provide proof of vaccine status. It could also exacerbate distrust by marginalised people and increase vaccine hesitancy, particularly if this is seen as introducing mandatory vaccination by the back door or building surveillance apparatus for communities that are already disproportionately monitored.”

In October 2021 they made specific statements about mandatory vaccination for health and social care workers:

"the Government has not provided adequate evidence of the proposed policy’s effectiveness, nor an evaluation of less intrusive measures, to justify mandating vaccination."

It is interesting that their concern for mandatory vaccinations and vaccine passports is because of individual rights, public health responsibility, social justice, and marginalized people. I’ve seen these concerns elsewhere. The WHO opposition to boosters seems to have similar sentiments:

In accordance with the Roadmap and WHO’s Strategy to Achieve Global COVID-19 Vaccination by mid-2022, the first priority of a vaccination programme is to reduce mortality and severe disease and to protect health systems. The most important measure to achieve this goal is to maximize coverage among those most likely to become seriously ill and those most likely to become infected especially those who are critical for health system functioning. In order to do this, primary series coverage and selective booster options must be weighed and prioritized carefully. This priority also contributes to socioeconomic recovery, as the severity of COVID-19 and its potential to overwhelm health systems constitute a primary rationale for public health and social measures that restrict social and economic activity. To use vaccines first for those at lower risk of severe disease before achieving high primary series coverage and sustained protection through selective booster doses for those most likely to become seriously ill will reduce the impact that could be secured with the ongoing limited vaccine supply, and runs counter to the National Equity and Equal Respect principles of the Values Framework.

Perhaps you also noticed the following statement:

WHO is currently not recommending the general vaccination of children and adolescents as the burden of severe disease in these age groups is low and high coverage has not yet been achieved in all countries among those groups who are at highest risk of severe disease.

That’s right. The WHO doesn’t recommend boosters or vaccinating children and adolescents, except in higher risk categories, because it is of marginal additional value to the individual recipient compared to putting the vaccine to much better use in places where people are in greater need of the vaccines. One might rephrase this more bluntly as suggesting boosters and vaccinating children is greedy, selfish, and self-serving. That doesn’t quite sounds as friendly and neighbourly as Trudeau has suggested.

To be fair, the WHO and Nuffield Council are foreign, despite the Canadian lead on the WHO policy. Maybe inside of Canada, bioethics and concern for social justice, human rights, equity, and equal respect are considered fringe “unacceptable views”. Perhaps we can look to the medical science itself then, and keep it within Canada.

Canadian federal vaccine advisory comes from the National Advisory Committee on Immunization (NACI). After the September 2021 federal election in Canada, while the government was implementing Trudeau’s mandatory vaccination policies, NACI released an Advisory Committee Statement (ACS) on October 22, 2021. It focused mainly on value of the vaccines to the recipients, but did investigate secondary transmission, stating in the summary:

"There is currently limited evidence on the duration of protection and on the efficacy of these vaccines in reducing transmission of SARS-CoV-2, although studies are ongoing. Evidence of protection against asymptomatic SARS-CoV-2 infection is emerging for the mRNA and Janssen vaccines."

There’s a section in the main statement on this topic as well, titled "Efficacy and effectiveness against asymptomatic infection and transmission", which states that "the current data is insufficient to draw conclusions" and AstroZeneca "has not demonstrated efficacy against confirmed SARS-CoV-2 asymptomatic infection".

This seems odd, because two months before this Trudeau was talking about how unvaccinated people were “putting their kids at risk, and our kids at risk”, and he implemented his mandatory vaccination policy in the federal public service on October 6, 2021. The justification for requiring it, without violating Section 7 of the Charter of Rights and Freedoms, is that the risk to other employees supersedes the rights of individual worker. This comes into play in Section 3.1.1 where it is claimed that an unvaccinated remote worker who is required to come on site ad hoc is a greater risk to colleageus and clients than a vaccinated worker who is normally onsite.

This is particularly odd given that provincial mandates, even at that time, kept unvaccinated people out of restaurants, gyms, and bars. The relative risk of secondary transmission is the product of three components: the relative risk of exposure, the relative risk of infection if exposed, and the relative risk of transmission given infection. According to Health Canada,:

We know that the virus is most frequently transmitted when people are in close contact with others who are infected with the virus (either with or without symptoms). We also know that most transmission occurs indoors.

Reports of outbreaks in settings with poor ventilation suggest that infectious aerosols were suspended in the air and that people inhaled the virus at distances beyond 2 metres. Such settings have included choir practice, fitness classes, and restaurants, as well as other settings.

Given the NACI statement, and the much lower risk of exposure and uncertain value in asymptomatic infection and transmission, it seems the science isn’t so sure and Trudeau’s statements are more aligned with the Nuffield report’s Section 3.11 and 3.46.

Maybe NACI is just too conservative. Perhaps the vaccine manufacturers know better. They have to produce monthly product monographs submitted to Health Canada. The Pfizer-BioNTech COMIRNATY vaccine monograph was last updated Nov 19. Section 7 says

"It is unknown whether COMIRNATY has an impact on fertility."

"The safety and efficacy of COMIRNATY in pregnant women have not yet been established. It is unknown whether COMIRNATY is excreted in human milk. A risk to the newborns/infants cannot be excluded. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for immunization against COVID-19."

The other vaccines suggest similar:

• Moderna's SPIKEVAX, updated Dec. 23

• AstroZenica's VAXZEVRIA, from Nov 19.

• J&J JANSSEN, updated Nov 23.

On that note, these vaccines themselves were approved in a process with a risk management plan. For example, for the COMIRNATY approval:

"An important limitation of the data is the lack of information on the long-term safety and effectiveness of the vaccine. The identified limitations are managed through labelling and the Risk Management Plan RMP).

The RMP is designed to describe known and potential safety issues, to present the monitoring plan and when needed, to describe measures that will be put in place to minimize risks associated with the product.”

This is an excellent risk management plan because both the labelling and monographs diversify risk via one-on-one informed decision-making between patient and doctor. The monographs themselves describe balancing considerations between patient and healthcare provider for informed consent. Come to think of it, the NACI report also is filled with recommendation about balancing considerations for informed consent. Coercive measures eliminate this risk diversification and undermine Health Canada's own risk mitigation strategy.

Maybe Trudeau considers NACI, vaccine manufacturers, and Health Canada as “fringe” with “unacceptable views”. Maybe it isn’t national vs international, but politicians who get it right and only health-based organizations in general that are the fringe problem, including WHO, Nuffield, NACI, vaccine manufacturers, and Health Canada. Except that many U.S. states are fully re-opened, the UK, Denmark, and soon Sweden and Norway. Canada seems to be one of the most restrictive.

Some U.S. states have long been anti-mandates, most famously Florida and, to a lesser degree, Texas. Florida ranks 18th in COVID-19 deaths per 100,000 population, at 300, well behind restriction-heavy New York in 7th with 329. Texas is a distant 29th with 271. In fact, there doesn’t seem to be much structure in the order compared to restriction rules, suggesting these restrictions don’t have much effect.

Given all of this information, it looks to me that these truckers represent the mainstream science, bioethics, and risk management, along with fairly common international sociopolitical positions. That doesn’t sound very fringe to me, or “unacceptable views”. It seems perhaps what is going on here is what is highlighted in the Nuffield report, Section 3.7, 3.8., 3.9, 3.11, and 3.46, that these restrictions, mandates, and passports are politically driven, not science.

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Cover image by Bob Moran.

Addendum

As a follow-up to this article, I came across the Financial Times COVID-19 tracker, which notes:

As the vaccine rollout began in January 2021, WHO officials warned of a “catastrophic moral failure” as poor countries struggle to gain access to vaccines, creating the risk that new strains of coronavirus impervious to the existing vaccines would emerge in their unprotected populations.

But the inequity in vaccine distribution has continued throughout 2021, with more Covid boosters having been administered in high-income countries than all vaccine doses combined in the world’s lowest-income countries.

(Article also here.)

Yet, domestically we are told that getting vaccinated is helping others and not getting vaccinated is selfish. My experience is quite the opposite. In addition the WHO’s condemnation of greedy boostering, and unnecessary child vaccination, what I experience in the faces and words of those people condemning the unvaccinated is a personal fear for themselves; they have taken all of the vaccine and boosters as quickly as allowed, and want their neighbours vaccinated to protect themselves, not their neighbours. The fact that their neighbours get protects is ancillary, particularly when they’ve already dehumanized them for being unvaccinated, and some even wishing their death.