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Kharel: America must globalize vaccine distribution

As the COVID-19 pandemic drags well into its second year, I see an opportunity for America to regain our status as a global leader. It’s high time that we stop domestic vaccine waste and shift our vaccination efforts to where they are needed most. Though recent promises to increase global vaccination distribution point in the right direction, a big question remains: Why are we allowing waste of these life-saving vaccines daily and why has our global response been so delayed?

This past spring, I returned to Kathmandu, Nepal, to work as an emergency medicine researcher as part of a global health project. It was my first time back in Nepal in four years and my first time as a practicing emergency medicine doctor. Despite being in the midst of the pandemic, my excitement for returning to my country of birth was immeasurable. While I had no illusions that the trip would be easy — after all, I had come to study how the rudimentary health system was (or wasn’t) coping with a global pandemic — I never expected that I would be in the global epicenter of the Delta-variant-fueled second wave. 

Within a month of my arrival, Nepal had become one of the world’s leaders in COVID cases per capita and viral transmission rates. While the world was focused on India, I watched firsthand as Nepal’s health system collapsed in a matter of days. For months, even the largest private hospitals in the country were constantly running out of oxygen. Every single ICU bed and ventilator in the country was in use, with dozens of people clamoring for every spot that became available when a patient recovered or, as happened too frequently, died.

And this was in urban areas with decent infrastructure: those best equipped to manage a surge. In rural areas lacking any advanced medical facilities, people who could not find a way out of their villages were left to die alone. Across the country, a black market quickly developed for essential equipment like oxygen cylinders, PPE and even common painkillers like paracetamol. As a researcher, I wasn’t allowed to practice medicine in Nepal. Despite this fact, my phone rang almost continually, at all hours of the day and night, for weeks. Relatives, friends of friends and people who had somehow found my number called in utter desperation, begging for help finding an ICU bed, an oxygen cylinder or even just an ambulance to take a loved one to find help. Even politicians at the highest levels of Nepal’s government couldn’t find beds for their own relatives. While my fellow Nepalis suffocated, I felt entirely helpless. Even if I could practice medicine, there was nothing I could do but watch. The resources simply didn’t exist. 

A few months later, I was in America and back to my regular medical practice. I immediately fell back into a busy routine in the E.R., strangely relieved to be seeing the usual plethora of car accidents, chest pain and back pain. But as the shifts passed in my extremely well-appointed community hospital, I couldn’t shake what I had witnessed in Nepal.

As a habit, I started asking my patients that I met if they had been vaccinated. Many patients had received the jab, but an alarming number hadn’t. When asked why, some offered concerns about vaccine safety, a lack of information or the fact that they’ve been fine without it as rationales. But as the time passed, more people refused to provide even that level of explanation. They simply didn’t want it, end of story. In the beginning, I tried to change people’s minds, as I felt that this was my duty as a care provider. I knew that every person I was successful at convincing could be a life saved. But as the months and the hundreds of conversations passed, I could only count my successes on one hand. Eventually, I just gave up. 

Speaking with my colleagues, who have had similar experiences, I realized that this was part of a larger trend — a growing sense of mistrust in government. And then I remembered Nepal. I remembered a 33-year-old Nepali mother from a rural area who was fighting for her life with an advanced case of COVID. Her family was fortunate enough to gather enough of the resources required to transport her to a nearby city in the hopes of finding an ICU bed and a ventilator to save her life. Together, they pooled their resources and spent hours on the phone calling politicians, relatives and anyone who might have an idea of how to help. Ultimately, they ran out of time. The young woman died simply because she couldn’t access the basic medical care she deserved. Meanwhile, millions of vaccines await unwilling arms in the United States.

While American exceptionalism may have taken some blows in recent months, it certainly still rings true when it comes to the COVID vaccine. The United States successfully designed and manufactured the most effective COVID vaccines on the planet, and has done an amazing job of distributing these miraculous vaccines to our entire population for free. We’ve made significant commitments to donating our vaccine supply globally, as well. Despite this fact, America’s vaccination efforts remain deeply flawed. As of early September, more than 15 million vaccine doses had been wasted for want of willing recipients. This is something that people in Nepal could only dream of. 

On average, low-income countries like Nepal show vaccine acceptance rates of over 80%, the holy grail of herd immunity. In emergency medicine, we are taught early on about the concept of triage: When resources are limited, they must be applied to the most life-threatening situations first. It’s time that we begin to triage our COVID response on a global level. By moving our efforts away from shaming the Americans who have chosen not to get vaccinated and instead find areas with dense populations and willing recipients, we will end this pandemic sooner and save more lives. Instead, we remained confined to our own borders, failing to recognize all the suffering going on beyond them. There is no ethical or economic justification for letting doses go to waste. By prioritizing vaccinations for people who don’t have access to robust medical care, we will amplify the impact of those vaccines saving even more lives per shot. 

As of September 23rd, only 20% of people in Nepal were fully vaccinated against COVID ­— despite the fact that the country has a strong system to distribute vaccines to even the most remote villages, as proven by successful campaigns against polio, measles and rubella. The only thing that is stopping Nepal from saving lives and slowing the spread of COVID is access to vaccines. And Nepal is just one example. It is time that we truly embodied the reality that we are all in this together and adopt a zero-tolerance policy for wasted vaccine doses. 

Dr. Ramu Kharel is a Global Emergency Medicine Fellow in the Department of Emergency Medicine at Brown University. He is also the founder of the grassroots nonprofit organization HAPSA Nepal. 






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