Fear of vaccines grows with the need for medical ethics [PODCAST]

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

“While individual doctors have obligations to both the individual and public health, their first concern is their patients. And these decisions have to acknowledge fears and respect the stance. Providers must balance reassurance with acknowledgment, care, data, and the intent to ‘do no harm.’

It is undeniable that the COVID vaccination has saved countless lives and will be crucial to come out of this crisis. In particular, the OAZv has many advantages for global use. But the success of a vaccination program should not expend of public trust or we may jeopardize the future of global public health.”

Mallika Sekhar is a hematologist-oncologist.

She shares her story and discusses her KevinMD article, “Fear of vaccines grows with the need for medical ethics.”

Did you enjoy today’s episode?

Please click here to leave a review for The Podcast by KevinMD. Subscribe on your favorite podcast app to get notified when a new episode comes out!

Do you know someone who might enjoy this episode? Share this episode to anyone who wants to hear health care stories filled with information, insight, and inspiration.

Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today in the show, we have Mallika Sekhar. She is a hematologist-oncologist in the United Kingdom, and she co-wrote the KevinMD article “Fear of vaccines grows with the need for medical ethics.” Mallika, welcome to the show.

Mallika Sekhar: Thank you, Kevin. Lovely to be with you.

Kevin Pho: We’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Mallika Sekhar: Yeah. So I was born and brought up in India, in the south first and then in Bombay, now Mumbai, and I came to England, to London, in ’87. So I’ve lived there pretty much half my life. I spent a little, about a year, just short of a year, in the U.S. at NIH for a bit, and I’m now a consultant in blood diseases.

I did this essay for KevinMD really out of my interest in how people think about, especially how doctors think about and take, decisions, clinical decisions, when there’s a lot of uncertainty about an evolving medical situation. So that’s what brought it about. And then when the vaccine-related thrombosis happened, which is within my own field, I paid more attention to it, and it raised so many problems of a clinical but also an ethical nature. But I thought it resonated with a number of other issues related to COVID. That’s why I wrote that.

Kevin Pho: All right, and we’re going to certainly talk about that article a little bit. But I don’t speak to many physicians from the United Kingdom, so tell me some of the challenges that you face practicing hematology-oncology in the U.K.

Mallika Sekhar: I suppose I’d say, when I first came to this country, one of the most important statements that I remember in my first week of working is this: I took a sample down to the lab, and the nurse who was there with the patient, where I collected the sample, said, “Well, at least the system works.” And so I think that statement by that nurse has always lived with me, and I think “the system works” is something that the country takes very seriously. To an outsider, it might actually seem a very impersonal, unresponsive, uncaring system, because it’s not catered to the individual.

So that was the past, when I came in ’87. Increasingly, in the last 10 years or so, it’s become much more patient-centered, patient-focused, individual-focused, such that we’re able to pay attention not to the system working alone, but also to what an individual would actually need and would want within the constraints of what the system has. So the greatness and the shortcomings are two sides of the same coin: It’s a system, and it can fail you if you are not in the right slot, or it can be a superb asset if you fall into the right slot.

Kevin Pho: We are speaking now towards the end of November. So tell me, what’s the situation like from a hematology-oncology standpoint as it relates to the pandemic?

Mallika Sekhar: Well, during the pandemic, we had a very effective network of clinicians across the country, and so for all the blood cancers, for example, they were organized, and instructions to patients were given in a very systematic, national way. They were pretty arbitrary, because we didn’t have much in the way of evidence.

Now, coming into post-pandemic, because we’ve got a very stable situation here and the vaccine take-up is very high, we’re now in a position where we are seeing lots of patients as backlog. Patients are very unhappy, having had too many telephone consults and not enough face-to-face consults, so we’re increasing the face-to-face consults. We’ve learned a lot about treatments and how we can modify them, either by fewer visits or less intensive. So we’ve gained a lot of knowledge of the COVID months, and we’re using that in actual clinical practice to modulate treatment better. So it’s been really, really busy, and a lot of reassurance has been needed for patients and for the juniors. The juniors have been pretty hard worked through the COVID months.

Kevin Pho: So let’s talk about the KevinMD article that you co-wrote. It’s titled “Fear of vaccines grows with the need for medical ethics.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Mallika Sekhar: Well, it’s about the fact that people got thrombosis of blood clots in the veins in the head or veins in the abdomen, as an unexpected, completely unanticipated consequence of the vaccine, and particularly the AstraZeneca vaccine. So the AstraZeneca vaccine has had a very checkered career, really, but in the U.K., people were pretty pragmatic about it.

What struck us as co-writers was the fact that people were so worried about this unexpected consequence that in their actions they expressed their fear: They went to casualty departments, and they declined to take a vaccine. But at the same time, there was a reluctance to accept this being spoken about publicly. So my colleague, who would speak about it to say, “Oh, five patients have been admitted with this kind of a problem. Should we be questioning the vaccine?” got a stony silence facing her.

So that became a matter not just of clinical management but of ethics, of how we deal with the public interest as opposed to a private need, and how people can be shoehorned into categories just on the basis of how they communicate and what they communicate. And a corollary to that might be now the need to vaccinate children. So I’ll be vaccinating children to protect the adults, and that might be completely valid, but it’s a question that needs to be asked, and to ask that question is no bad thing. So the nuance is, therefore, how do we ask a question? Is it permissible to ask the question? And how do we deal with the aftermath?

Kevin Pho: So give us a sense of the background of the Oxford-AstraZeneca vaccine. As you know, this vaccine isn’t even approved in the United States, so give us a snapshot of how often that vaccine is used in the U.K.

Mallika Sekhar: So I’m no expert on vaccines, but what I have in practice, for example, is that a lot of us health care workers started off as the first round of vaccine receivers, recipients, and a lot of us got the Pfizer vaccine at the outset. The AstraZeneca vaccine was rolled out to the wider community, so lots of people got the AstraZeneca vaccine. Once the thrombosis issue became known, then there was an age cutoff that was defined, such that below this age, people will only receive the Pfizer vaccine. And that age cutoff varied in different countries. In some countries it was 50, in some it was 30, and so that has also changed over time. So now, in the booster program, most of us are now getting a Pfizer vaccine for the booster program.

The other politics about AstraZeneca: America hasn’t endorsed it. The FDA hasn’t approved it because of the nature of the data, which was not entirely clear. But it’s also interesting that people have used the variance in data and the unexpected findings, which you never planned for when you design the study; they’ve actually used it to develop science as a goal. It’s a very pragmatic approach to science. So in that way, I think the U.K. approach to developing vaccine science based on the failures of AstraZeneca has been tremendous.

Politically speaking, India manufactures AstraZeneca vaccine, but actually it was not recognized even by the U.K., nor by the WHO. The WHO has only recently recognized it, and the U.K. only recently recognized it. So there are lots of connotations, not least that it’s still not FDA-endorsed.

Kevin Pho: What’s the prevalence of thrombotic events from the AstraZeneca vaccine?

Mallika Sekhar: Very rare, vanishingly rare. How vanishingly rare seems to be changing. One in a million, but then some say that it is more frequent, but it is along those lines. As we’ve gone along since the original publications, more and more reports have been made, but also, equally, fewer people are receiving AstraZeneca. Then there were some reports with the Moderna vaccine, so it doesn’t seem to be confined to these.

Kevin Pho: Giving out the vaccine, you talk about the ethical quandaries that physicians face. So give me some specific examples of some of these decision points as they consider which vaccine to give out.

Mallika Sekhar: Well, the vaccine issue itself is full of quandaries because of vaccine nationalism. So who has the right and the privilege to receive a vaccine? How should it be equitably distributed? Should a booster vaccine in a country be prioritized over primary vaccination in another country, because it is about availability? And how much should people be allowed to travel for vaccine tourism? So these are all questions that are coming up.

I think, practically speaking, youngsters, especially teenagers and increasingly older children, are becoming more vocal to say, “You know, why should I take the vaccine? Because it’s not something that’s going to affect me in a fundamentally significant way.” And so there are a lot of voices that are now being heard from the younger people, and we have to pay heed to that, as to who is the beneficiary from these vaccines.

But I think, to me, perhaps the most important point is that through HIV in the ’80s, the one thing that the world learned is how to deliver equity of treatment across the world. That was the one useful, really important global outcome of the HIV pandemic, such that people across the world could access HIV treatment, and successfully so, without having to sell their house or whatever. So having had that infrastructure, and the intellectual knowledge of how to deliver it, and society’s capital of how to deal with delivery, to implement this, it seems really perverse that we haven’t been able to translate those lessons into vaccine equity for COVID. Because it’s such a rapidly evolving pandemic, vaccine equity was considered, actually, and is considered, a really top priority. So that’s something, a conundrum, that I haven’t quite understood.

Kevin Pho: So you mentioned vaccine nationalism as a potential cause for the problems that we face with vaccine equity. Are there any other reasons why we’re having problems with vaccine equity today?

Mallika Sekhar: There are a lot of anti-vaxxers, or vaccine deniers, you know, deniers, vaccine refusers. So even within the low-income countries, where people have made a lot of effort to deliver vaccines to a community, there’s been a poor take-up. And within Africa, for example, there’s a big South-to-South collaboration, so if country A has excess stocks, they would send it to country B. And so this transfer of surplus stocks has been useful to deflate some of the wastage, but poor take-up has spread very widely, and that has complicated matters when it comes to poor equity of delivery.

It’s very hard to trace all of these things, but it probably began as a financial, political, financial kind of deal, where people wanted to stock vaccines and charge other people, and raw materials were not sent. These are all fundamentally financial deals. But then that soon translated into society’s suspicion of everything, and that suspicion soon translated into poor acceptance of the vaccine. So I think we’re probably getting past that third stage into something better than where we were, say, four months ago, I feel.

Kevin Pho: We’re talking to Mallika Sekhar. She is a hematology-oncology physician in the United Kingdom, and she co-wrote the KevinMD article “Fear of vaccines grows with the need for medical ethics.” Mallika, as we hopefully transition into a post-pandemic period, what do you feel are the remaining challenges when it comes to vaccine equity?

Mallika Sekhar: I think it’s about the nudge factor, being able to persuade people, using the right language and vocabulary, that this is actually something useful, but then going beyond. And the second is, of course, to be able to distribute the vaccine effectively and not waste, as we are at present.

But I think, going forward, this is a model. So we had a big crisis with Ebola. Luckily, Ebola virus has never spread as widely as this virus has spread. But how we deal with a disease in a community, how the community deals with the dead, how we reconfigured our ecosystems, I think these are major questions, and the world has got to address these really, really carefully, because we’ve got a climate crisis, and we’ve got a huge inflation in so many countries, perhaps not in the U.S., but practically everywhere else. The inflation is huge, and so combining these with further pandemics, I think, needs a very self-aware solution from politicians.

Kevin Pho: So you mentioned vaccine hesitancy, which, of course, is a problem in the United States. Can you comment on the scope of vaccine hesitancy in the United Kingdom?

Mallika Sekhar: Well, we have less vaccine hesitancy than many other countries. The delivery was very smooth, and one of the biggest things that happened with the vaccine delivery, as opposed to a lot of the COVID testing delivery, is that the NHS took it upon itself to deliver the vaccine program. And like I said at the outset, the NHS does some things really, really well, and the vaccine delivery was a successful rollout. It was done really slickly; people could just go get it done.

So for a variety of reasons, we haven’t had much, but we did have a huge hesitancy in certain sections of the population, some of which were ethnic minority populations, some of which were people who were young, young women, young men, and so on, even health care workers. Many doctors declined; 25 percent of doctors at one time declined to have a vaccine.

So the government, I think, has, and there’s been a lot in the media, and in religious groups, where people have gone out of their way to dispel myths and have spoken to their own kin and networks. So it’s not as if I’m being spoken to by you as an American, but I’m being spoken to as by my friend in the street, or whatever, you know, somebody who considers my welfare as important. And so I think that’s really struck a chord, and it persuaded many people of the middle ages and the older ages to change their practice.

For the youngsters, I think the fact that you could go clubbing, you could go to the pubs more easily if you had a vaccine, I think that’s changed that dynamic. For the health care workers, it’s going to become mandated that people have to be vaccinated; otherwise, they would have to move from their jobs. And so I think that’s going to change it.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Mallika Sekhar: Well, I think the main message is, how do we deal when the science is uncertain? How do we deal with diseases as doctors when the science is uncertain? That’s always been my research interest. I’ve made some podcasts around HIV and hemophilia. So in the ’80s, people with hemophilia got HIV and AIDS because of their treatment. So how do the doctors think? For four years, people didn’t understand what was going on. So how do you take treatment decisions? How did you counsel your patients? What do you tell your patients? And how do you feel about it now? So those are the questions that are the subject of my podcast, which is on Spotify and Apple and so on. It’s called The Bitter Pill podcast.

Kevin Pho: Mallika, thank you so much for sharing your time and insight, and thanks again for being on the show.

Mallika Sekhar: Thank you, Kevin.

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes