The immunization program has been an unprecedented challenge in recent decades because of its size and global impact on Portugal’s health, economic recovery and the need for justice, liberation and coherence. For all of us with discipline, moderation and resilience in the face of adversity and for the state for the ability to organize and mobilize the indispensable resources and skills in addition to the usual partocracy and cronyism. It is for this reason that I applaud the decision to elect an Army Officer General with an indisputable curriculum, and I wish you every success in this truly national endeavor.
Internal and external difficulties, controversy and deviations from the route, which are always undesirable, may be inevitable. It is therefore important to take into account the objectives and guiding criteria of the action so that it is not lost even in unfavorable winds.
There are clearly two goals: to save life and to control the spread of the pandemic.
The first corresponds to the humanistic vision, it is a basic assumption and an irrefutable value in our democratic and free societies, in the west and east it is a sign of civilization. The second against the SARS-CoV-2 virus means that around 60 to 70% of the adult population will receive immunity, which will only be possible with vaccination of the populations.
Vaccination as massive and as rapid as possible was the generally accepted strategy. Production and distribution restrictions and difficulties in implementing them will contribute to differences in the pace of vaccination programs in Europe and around the world and can exacerbate inequalities.
Criteria for vaccination
It has been recognized worldwide that vaccination should begin with the age group over 80, institutionalized or not, and with health professionals. The scientific basis is undeniable: higher risk of death due to age, dependencies and less autonomy, higher incidence of other diseases – comorbidities – such as diabetes, heart, arterial, respiratory diseases, kidney failure, malignant and neurological diseases. In addition, interacting with caregivers and family members will reduce the risk of spread. On the other hand, the need to ensure the functioning of health services made it necessary that doctors, nurses, technicians, operations assistants and other individuals who, by virtue of their differentiation, were essential to the functioning of health facilities should include this first group. And not just those involved in the treatment of Covid-19 patients in order to minimize the consequences of dropping out and reduce treatment for other pathologies with equal priority. The hesitation, indispensable to the security of the country, about the vaccination of the most important figures of the state, including the armed forces and others, was incomprehensible, caused confusion, and allowed incoherence and arbitration. In addition to the unacceptably pared-down saga about health professionals outside the NHS, they were an expression of the sectarian view of health politics.
The next level definition – citizens over 50 years of age with comorbidities, that is, associated diseases that have been discriminated against, sparked controversy that has now surfaced in the media. Essentially a relevant topic: vaccination according to a stricter hierarchy of potential clinical risks or acceptance of contingencies in the process. Is this desideratum compatible with the need for the most comprehensive and rapid vaccination possible? It translates conflicts between the two models of health intervention, individualized patient-centered medicine and population public health intervention in full pandemic. The first implies global knowledge of the sick person, family, environment, past and present in finding the best possible individual decision and as specific as possible for that patient’s clinical problem. The medicine of the individual! But how can we rigorously and fairly ensure this goal for all clinicians in the public, social and private sectors in a country where we do not yet have a perfect, homogeneous and compatible computer system for the registration and exchange of clinical information? How can a fair, equitable and timely selection be ensured?
The necessary intervention from a population dimension and public health perspective requires a different vision – population medicine. It leads to greater linearity in hierarchy with less commitment to justice and justice. Hence the age criterion graded after decades with two additional subgroups: with and without the identified associated diseases. Do you have any restrictions Maybe, but it seems to me that it is the most equitable, fairest, most practical and feasible, and it is uniformly applicable across the country! You should also take into account the relatively small number of young people with severe addictions and disabilities of rare diseases, who fortunately will be limited in numbers.
There will always be gaps – the holes in the cheese of some authors – through which the selection of citizens will fail, arbitrariness, opportunism, tricks, obviously unacceptable. The only way to minimize them is through discipline, determination, and effective monitoring of the intervention. That is, leadership.
It will certainly forego the permanent media obsession of political leaders, from whom perhaps greater restraint, sobriety and detachment should be expected.
May the international scientific and technological collaboration that made the unprecedented development of these vaccines possible be an inspiration for a coherent and global action plan, the ultimate legacy of a pandemic that stopped and challenged the planet and our way of life
In a recent article, I defended that wherever possible, massive vaccination efforts should be segregated from the clinical medicine sector – offices, hospitals, health centers – so as not to jeopardize other essential and urgent public health issues. Using easily customizable buildings, mobilizing retired and volunteer doctors and nurses, and medical and nursing students to properly prepare and vaccinate patients before and after vaccination would be useful. Just like the use of the community pharmacy network, which is appropriately integrated into the process and trained for the task. And this entire program, properly standardized and with a computerized record that is easy to quantify and accountable for, would be under the local supervision of the health authority and under the firm direction of a single and effective command.
The achievement of the objectives of the vaccination process can be compared in the different countries as shown in Table I, which includes the European Union and the United Kingdom.
Table I: Comparison of vaccination rates in different countries
In the European context we will take tenth place; not as bad as the hesitations and abuses that tarnish the credibility of these processes seemed to suggest. Outside Europe, the strategy followed in Israel – which has already vaccinated more than 1/3 of the population but has only now started vaccinating in the Palestinian Territories – and in the United States, led by the new president who is determined to do so Reversing consequences of an erratic policy pursued by its predecessor and will certainly be the subject of detailed assessment. In the last few days the WHO has publicly called for accelerated vaccination in Europe.
Serious restrictions on the availability of vaccines is a political, economic and strategic problem. Finding possible alternatives for your offering outside of centralized trading can be a necessity and will certainly come with conditions. As a peripheral and smaller country, Portugal, in the exercise of the rotating presidency of the European Union, should develop a proactive and visible measure to solve this problem and to ensure equality between the different states.
The world is imperfect, inequalities unfortunately persist in our societies, and effective action against the pandemic requires global planetary action. May the international scientific and technological collaboration that enabled the unprecedented development of these vaccines be the inspiration for a coherent and global action plan, the ultimate legacy of a pandemic that has stopped and challenged the planet and our way of life.
Post Scriptum: The private sector collaboration will include around 300 beds for SNS patients. A newspaper article did not contradict that the cost of buying vaccines was 85% co-financed by a consortium of companies, foundations and groups from the private sector. A lesson in the face of so much indifference and hostility. And one question: will German cooperation be limited to the chosen institution or would it not also make sense to extend it to the institutions with the highest coverage in the NHS?