Vaccine cakeism and moral dilemmas.

Cakeism def. The wish to have or do two good things at the same time when this is impossible. From the phrase “to have your cake and eat it too”. (https://dictionary.cambridge.org/)

Over the past months, a lot has been said about vaccine nationalism. Much less has been said about vaccine ageism (the decision of some countries to prioritise lower risk groups over those at the oldest ages). And almost nothing has been said about vaccine cakeism.

In a world of finite resources, policymaking is about managing trade-offs between different needs, interests and entitlements. This has never been truer than during the pandemic. There is a tendency in global policy and agenda-setting for different voices to promote the specific interests of their own groups without considering what that may mean for the rest.

For example, globally there is only a finite amount of COVID-19 vaccine doses. This resource is not being distributed equitably, due to both vaccine nationalism and, in some cases, vaccine ageism. But in more recent months, the main driver of global vaccination inequality has arguably been vaccine cakeism. Almost all vaccinations being provided in high-income countries have been for younger people with relatively limited risk. At the same time, many high-risk groups in low and middle-income countries, including frontline health and care workers, the oldest old and people with specific health conditions are yet to receive a single dose.

There is a brutal equation here. Each dose given to a younger person in a rich country means one less dose for a vulnerable person in a poor one. Back in May, the Director General of WHO made this point very directly:

“In January, I spoke about the potential unfolding of a moral catastrophe. Unfortunately, we’re now witnessing this play out. In a handful of rich countries, which bought up the majority of the supply, lower-risk groups are now being vaccinated…I understand why some countries want to vaccinate their children and adolescents, but right now I urge them to reconsider and to instead donate vaccines to Covax.” https://www.theguardian.com/world/2021/may/14/vaccinate-vulnerable-global-poor-before-rich-children-who-says

By way of example: in the USA over the past 14 days, around 4.5 million people aged under 40 received either a first or second dose of COVID-19 vaccination. https://covid.cdc.gov/covid-data-tracker/#vaccination-demographic That’s roughly equivalent to the total number of people aged 70 or more living in Vietnam.

How can this be reconciled with the calls from high-income country public health experts to prioritise the COVID-19 of younger people? https://www.theguardian.com/world/2021/sep/13/vaccinating-teenagers-against-covid-is-priority-says-uk-epidemiologist?CMP=Share_iOSApp_Other

This is a very uncomfortable issue for people like me with adolescent children trying to navigate the risks and uncertainties of our own family “pandemic worlds”.

It also poses a dilemma for organisations with a mandate for representing the interests of younger people. According to UNICEF:

“A recent analysis showed it is possible for well-supplied countries to donate vaccine doses without having a significant impact on their commitments to vaccinate their own adult population”. https://www.unicef.org/coronavirus/covax

UNICEF quite rightly does not refer to vaccinating children against COVID-19, either in rich or in poor countries. By referring to “adult populations”, it implies that COVID-19 vaccine should not go into the arms of children anywhere until governments have met their commitments to COVAX. But, understandably, UNICEF doesn’t go so far as to state this explicitly.

We can see other example of cakeism in COVID-19 policies. In this week’s Lancet, we discuss vaccine ageism, but (with reference to acute COVID-19 care) we also recognise that in a context of resource scarcity and a need for brutal pragmatism

“All things being equal, people at older ages are less likely to respond positively to treatment and therefore some age rationing might have maximised years of life saved.” https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01689-5/fulltext

As someone who works on older people’s rights, it sticks in the craw to say that denying older people acute COVID-19 care may have sometimes been justifiable. But, of course, every older person on a ventilator meant somebody else wasn’t.

The easy, perhaps glib answer is we need more of everything: more vaccine doses, more ventilators, more compassion. But, until that time comes, advocacy networks should be mindful that trade-offs exist and should try to find ways to resolve them. This is much more easily said than done and it goes against the grain for people and organisations focussed on specific interest groups, be they older people, children or others.

And on a personal level, the dilemmas of vaccine cakeism are real and acute. What happens when my own child is offered a jab? I really don’t know.