This post is a part of our Bioethics in the News series
By Felix Chukwuneke, MD
Avoiding the Impending Calamity: Our Ethical Responsibility
United Nations Children’s Fund (UNICEF) has warned that COVID-19 is disrupting life-saving immunization services around the world, putting millions of children in both rich and poor countries alike at risk of diseases like diphtheria, measles and polio. UNICEF, the Sabin Vaccine Institute and Gavi, the Vaccine Alliance are also worried that thousands of children could die needlessly from the diseases that were hitherto controlled through vaccination but are now being redundant because of the lockdown and compulsory quarantine by the government of the day. UNICEF Executive Director Henrietta Fore stated that there is going to be a real problem as many of these already conquered preventable diseases for children such as measles, diphtheria and cholera are in the increase across the world.
“Immunization is one of the most powerful and fundamental disease prevention tools in the history of public health,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “Disruption to immunization programmes from the COVID-19 pandemic threatens to unwind decades of progress against vaccine-preventable diseases like measles.”
[WHO News release, May 22, 2020]
There is no doubt Africa will be the worst hit by this quarantine and lockdown policy. In a place where lack of education and poverty are commonplace, the rebound of these preventable diseases as a result of improper policy and control implementation will be unprecedented in the near future after we are done with the pandemic. Most governments especially in Africa did not take into consideration the sustenance of immunization programs and were more focused on the COVID-19 pandemic – the devastating effect of the disease cannot be equated to some of these childhood preventable diseases.
The quarantine and social lockdown have resulted in a drop in vaccination rates leaving several numbers of children open to diseases that were hitherto prevented. There is a need to step up campaigning once again on the importance of sustaining immunization that has been in place before the COVID-19 pandemic.
The Philosophy of Objectivism in Public Health Emergencies Such as the Coronavirus Pandemic
The mandate from a responsible government to ensure and protect the health of the public is an inherently moral pursuit with obligation to care for the well-being of its communities. In doing so the government should refrain from immediately engaging extreme measures. Further, the widespread deployment of uniform measures should first understand the peculiarity of the environments in which they will operate. Africans across many nation states, for example, live in a diversity of settings where communicable diseases are all too common. Many individuals live in poor living conditions necessitating proper advance planning of COVID-19 pandemic management. With that management, such planning should carefully consider the sustainability of the on-going vaccinations of childhood preventable diseases. Vaccinations have had an enormous beneficial impact on population health, and the related prevention of disease has been one of the single greatest public health achievements of the last century.
The questions I pose center on an exploration of which disease should rightly be given priority based on established fact. I question why there has been so much panic and fear about COVID-19. With the introduction of this novel disease, with a mortality rate lower than that of those diseases preventable by vaccination, should we permit gains made in vaccinating children against common childhood diseases to stop? With respect to more preventable diseases, especially those that affect children, why is there such an emphasis on COVID-19? Should mothers and caregivers give precedence to the COVID-19 pandemic, deferring their children’s routine immunization? Again, in an isolation and quarantine situation with strict governmental constraints on movement, how might childhood immunizations continue, especially in rural areas (assuming that accessible immunization centers are even open and operating)?
Currently, keeping to a routine immunization regimen by parents and caregivers is a challenge, especially for those who come from remote areas. The government, through the health ministry, should ideally put procedures in place for the duration of the pandemic to encourage all women to ensure that their children get access to these vaccines. It would be tragic to view this situation as a tradeoff, thus incurring the risk of returning to the horrors of polio, diphtheria, cholera and smallpox, and in doing so, allowing many to die of already controllable diseases.
Government Needs Proper Strategizing, COVID-19 Should Not Stop Normal Existence
There is no doubt that ethical challenges abound in quarantining people compulsorily, potentially against their decisions and will because of the COVID-19 pandemic. But more challenges abound when the government fails to take the precautionary measures necessary to ensure the continuity of the vaccination program for known and preventable childhood diseases. Because some of the latter are transmitted person-to-person there is, therefore, a need to provide both individual and public protection against the disease in addition to focusing on COVID-19. Though the COVID-19 pandemic may pose a health threat to many people across the globe, I suggest that there is even greater threat to personal liberty by compulsory quarantine and economic lockdown.
There is suspicion among some that the COVID-19 pandemic has been exaggerated, and that the measures currently in place across the world are not supported by the data. This doubt is illustrated by the Tanzanian President who had samples collected from goat, pawpaw and sheep for COVID-19, assigning human names to those animal samples. Reportedly, the related test results were positive, thus feeding the concerns on the accuracy of information regarding the incidence and prevalence of the infection, influence of co-morbidities, etc.
Demystifying the COVID-19 Pandemic While Achieving Health for All
Conflicting data notwithstanding, there are those who hold the opinion that measures taken by governments around the world are based on fear and speculations, and ultimately, might prove ineffective. It is argued here, that denying people their right to personal movement has a preventable impact on established vaccination programs, programs with known effectiveness in the reduction of mortality among children. High numbers of people are still being infected by those preventable diseases. It might also be argued that at present the imposition of a uniform isolation strategy is premature, especially with conflicting reports on its mode of transmission and degree of virulence. Perhaps it would be prudent to lay emphasis on practicing safe habits, building and supporting one’s immune system, maintaining proper hygiene, social distancing, and taking care of those most vulnerable ones among us such as the children and the elderly.
Felix Nzube Chukwuneke, is a Fogarty Trained Bioethicist and Professor of Oral & Maxillofacial Surgery and Dean of Dentistry in the College of Medicine, University of Nigeria Nsukka (UNN) Enugu Campus. He is Chair of the UNESCO Bioethics Unit at the College of Medicine, University of Nigeria; Chair of the College of Medicine Research Ethics Committee (COMREC) and Chair of the Eastern Nigeria Research Ethics Forum (ENREF).
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References
- World Health Organization. At least 80 million children under one at risk of diseases such as diphtheria, measles and polio as COVID-19 disrupts routine vaccination efforts, warn Gavi, WHO and UNICEF. May 22, 2020. https://www.who.int/news-room/detail/22-05-2020-at-least-80-million-children-under-one-at-risk-of-diseases-such-as-diphtheria-measles-and-polio-as-covid-19-disrupts-routine-vaccination-efforts-warn-gavi-who-and-unicef.
- Mazumdar T. Stalled vaccine programmes ‘putting children’s lives at risk’. BBC News. June 4, 2020. https://www.bbc.com/news/health-52911972.
- WTX News. Vaccination programmes disruption causes risk to children’s lives. June 4, 2020. https://wtxnews.com/2020/06/04/vaccination-programmes-disruption-causes-risk-to-childrens-lives/.
- Schwartz JL. New media, old messages: themes in the history of vaccine hesitancy and refusal. Virtual Mentor. 2012;14(1):50-55. 10.1001/virtualmentor.2012.14.1.mhst1-1201. https://journalofethics.ama-assn.org/article/new-media-old-messages-themes-history-vaccine-hesitancy-and-refusal/2012-01.
- World Health Organization. (2017). Vaccination in acute humanitarian emergencies: a framework for decision making. World Health Organization. https://apps.who.int/iris/handle/10665/255575.
- Global Polio Eradication Initiative. Polio eradication programme continuity: implementation in the context of the COVID-19 pandemic; Interim guide: May 2020 update v2.0. http://polioeradication.org/wp-content/uploads/2020/03/COVID-POL-programme-continuity-planning-20200325.pdf.
- Di Pasquale A, Bonanni P, Garçon N, Stanberry LR, El-Hodhod M, Da Silva FT. Vaccine safety evaluation: Practical aspects in assessing benefits and risks. Vaccine. 2016 Dec 20;34(52):6672-6680. doi: 10.1016/j.vaccine.2016.10.039. https://pubmed.ncbi.nlm.nih.gov/27836435/.
- Vondrak K, Bishop S. Global Public Health Threats: The Role of Vaccinations. Health Progress: Journal of The Catholic Health Association of the United States. January-February 2017. https://www.chausa.org/publications/health-progress/article/january-february-2017/global-public-health-threats-the-role-of-vaccinations.
- Beaumont P. Tanzania’s president shrugs off Covid-19 risk after sending fruit for ‘tests’. The Guardian. May 19, 2020. https://www.theguardian.com/global-development/2020/may/19/tanzanias-president-shrugs-off-covid-19-risk-after-sending-fruit-for-tests.
- Obulutsa G. Tanzania suspends laboratory head after president questions coronavirus tests. Reuters. May 4, 2020. https://www.reuters.com/article/us-health-coronavirus-tanzania-idUSKBN22G295.
- World Health Organization. Coronavirus disease (COVID-19) technical guidance: Essential resource planning. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items.
- Salmon DA, Omer SB. Individual freedoms versus collective responsibility: immunization decision-making in the face of occasionally competing values. Emerging Themes in Epidemiology. 2006;3(13). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1592474/.
- World Health Organization Africa. Africa Vaccination Week 2020 kicks off as COVID-19 threatens immunization gains. April 24, 2020. https://www.afro.who.int/news/africa-vaccination-week-2020-kicks-covid-19-threatens-immunization-gains.
- World Health Organization Regional Office for the Western Pacific. The COVID-19 risk communication package for healthcare facilities. 2020. https://iris.wpro.who.int/handle/10665.1/14482.
MSU Bioethics 
We operated as if other diseases were on vacations…..Nigeria did not take into consideration their local circumstances in its containment and management efforts. Great perspective
This is great…….! Very insightful and helpful. It’s high time we refrain from stereotypical perception or mindset towards covid-19 pandemic and see how we can holistically contain/accommodate it in public health exercise. Especially now that the Pandemic has advanced into communual transmission.
…..Let this publication continue to go viral until the attention of our Policy markers are drawn on it.
Thank you so much my Dean and able Chair.
A good point Rev. Okoye. Well, we have to keep reminding them of their responsibility because issues like this needs political will power. Our own responsibility is to bring it to their knowledge through any means of communication and hope they will act accordingly.
Thank you Borke. You made a very good point. The philosophy of objectivism and distributive justice concerning sustenance of childhood immunization in Nigeria and indeed other African Countries is better served by Government of the day properly strategizing and putting in place essential services to maintain the vaccination process while protecting the public against COVID-19 to avoid collateral damage of millions of Children dying from preventable Disease because of severe disruptions to Vaccination Programs. I think that should be an ethical thing to do by a responsible government whose obligation is to care for the well-being of its citizens.
Great write up with great insight with regards to the peculiar situations in Nigeria and probably Africa as a whole.
To the best of my knowledge, childhood immunisation was not put on hold in the UK. Thus the writer is correct in pointing out this dangerous omission in the fight against covid-19 pandemic in Nigeria and Africa.
While covid-19 may have received appropriate attention given the rate of spread and recorded deaths, I agree that Nigeria and Africa should plan their fight strategy based on the peculiar conditions on ground in their environment. Emphasis should be on hygiene, social distancing and education.
Dr Akonobi thanks for your comment. This has often been the problem with Nigeria when dealing with a pandemic such as COVID-19. We tend to ignore other diseases that are more prevalent in our environment not minding that we live in very poor setting where other diseases eradicated by vaccine may rebound and cause more deaths. UK and other western countries are always proactive in issues of public health.
This is really informative and have a lot of insights….
Nigeria Government have never really been serious with Public health programs and prevention of diseases except in the face of pandemic or when matters knocks at their doors and stares at their faces….
I think they should even provide money and hire experts that will always go down to the Rurals within each state to educate the people there that have little or no access to education ….. A little light can actually go a long way…. And not just controlling a disease but preventing it….
I think Nigeria Center for Disease Control (NCDC) should add Prevention to its name too…it goes a long way to create a mark and a good narrative to the essence of prevention….
You’re very correct wisdom. Government need more work after this pandemic if they do not put adequate measures in place now to boost the morale of the parents and facilitate their means of ensuring the continuation of vaccination of their children in this pandemic period. The Expanded Programme on Immunization (EPI), introduced in 1979 with the aim of providing routine immunization to children less than the age of two years, recorded initial success but later declined especially in the Northern part of Nigeria. Immunization has always been a very difficult health project in Nigeria because many families do not always allow their family members including children to be immunized mostly due to cultural and religious beliefs. Some studies have shown Nigeria as the worst immunization defaulter in the West African subregion, only better than Sierra Leone. So, one can imagine what happens with the lockdown
A very rich and thought provoking article.
It analysed the effect of covid scare on immunisation and the way forward.
Excellent article, my Prof.
Dr Ajuba Thank you. We will keep reminding the government of their moral and statutory obligation to ensuring the health of their citizen by being holistic in public health issues and not focusing on COVID-19 alone as the pandemic will end with devastating effects of other diseases.
I agree with the conclusions reached. The data suggests that COVID-19 is not going anywhere soon. The government especially in African countries with various health needs and underserved populations needs to come up with a response plan that will ensure access to basic healthcare and economic development. While Imposing lockdown might be an effective strategy for controlling the present Pandemic. It also limits access to healthcare and can have devastating consequences in the future.
Thank you Johnbaptist. The mandate to ensure and protect the health of the public is an inherent moral pursuit of any responsible government whose obligation is to care for the well-being of its citizens. Through a well planned prevention of ill health, individuals can spend more of their years in good health and contribute meaningfully to the development of the society. Government should therefore not focus on COVID-19 alone and forget about other communicable and preventable diseases that were hitherto controlled before the pandemic especially in children that are most vulnerable. .
This is a very valid point. The society cannot afford to lose all we gained with childhood immunization. Thanks for pointing this out, Prof.
Exactly Ijeoma. Thats the argument. We hope our government and other Africans will listen. Thank you.
A well considered article. Nigeria like most of the global South watched a poorly managed response to the Covid-19 pandemic unfold in well resourced OECD nations. It was politicized and characterized by incoherent haphazard public health interventions in what are otherwise robust healthcare systems. The ‘over-reaction’in Nigeria was not entirely irrational since its system in the best of times is stretched. The choice between an immediate response to a highly contagious novel virus and childhood immunization ( which has a sustained pushback in many parts of Northern Nigeria was inevitably going to be fraught with ethical and logistical challenges .
We needn’t choose one over the other but expectations must be realistic . The world hasn’t dealt with a public health crisis of this magnitude since the Spanish Flu of the early 1900s.
The ‘drop’ in Expanded Programme on Immunization-EPI coverage should and will be addressed with sustained evidence based and targeted Health Promotion interventions as morbidity and mortality associated with the Covid-19 pandemic wanes.
Very apt and crystal. Thank you Ezenwugo.