Levelling Up Our Vaccine Game

The pandemic may be viewed as a battle between efficiencies: humanity’s ability to allocate our rich resources versus the virus’ transmissibility. Can we allocate everything from supplies to health human resources to scientific discoveries faster and more effectively than the virus can continue to find targets and claim lives. The arrival of new variants, that are more transmissible and potentially more deadly, represent the virus’ levelling up. Can we do the same?

In Canada, we have had opportunities to level-up our pandemic response since it began. We have taken advantage of some and let others pass by. For example, we could have chosen to pursue nation-wide credentialing for healthcare workers like physicians, nurses and personal support workers, which could allow these workers to move between provincial jurisdictions to help those regional systems harder hit by the virus. In 2019, when Alberta faced severe threat from forest fires, Ontario deployed firefighters from its service to assist when our season was relatively quiet. Just recently, the Biden Administration announced broadening use of its Public Readiness and Emergency Preparedness (PREP) Act to expand the vaccination workforce quickly with additional qualified healthcare professionals, including any healthcare provider who is licensed or certified in a state to prescribe, dispense, and/or administer COVID-19 vaccines in any other state or U.S. territory, as well as authorizing any physician, registered nurse, or practical nurse whose license or certification expired within the past five years to prescribe, dispense and/or administer COVID-19 vaccines in any state or U.S. territory so long as the license or certification was active and in good standing prior to the date it went inactive. We should consider doing something similar in Canada because it’s a good idea in and of itself but also because if we were to grow the vaccination workforce, new opportunities for further leveling up our response could be unlocked.

Canada wisely leveled up when it came time to procure vaccines. Instead of leaving it up to provinces to purchase vaccines for their populations, with the difficulties of acquiring personal protective equipment and all of the lessons learned from that experience fresh on their minds, the Canadian government took the lead and entered into contracts with various vaccine manufacturers up to a volume of nearly nine doses per Canadian in order to spur discovery, scale manufacture even before winners were identified and to hedge its effective vaccine bets. This strategy also has the added benefit of aggregating our supply needs to optimize purchase price. While we experience delays in the delivery of approved vaccines under contract, one wonders if it might be time to consider levelling up the distribution of vaccines by adopting a more risk-based approach?

Traditionally, Canadian federal governments strive for regional equity. While in many cases this is the right approach to preserve the bonds of the federation, it sometimes favours peace and order over good government. In the context of vaccine distribution, Canada could consider prioritizing vaccinating all Canadians over 65 regardless of where they live, for example, versus distributing vaccines on an equitable per capita basis to provinces and territories. Would it really be so outrageous to allocate vaccines with a view to optimizing lives saved? We would not for instance distribute funds to support hard hit industries, like the tourism sector, on a per capita basis; rather, we would allocate those funds based on need with a view to preserving and supporting as many eligible businesses as possible. Nobody would ever suggest that we were picking winners and losers, just being evidence based and guided by need.

At the end of the day, there will be no normal until a sufficient percentage of Canadians are fully vaccinated. The greatest COVID threat to those provinces who are experiencing low levels of transmission are those provinces that are experiencing high levels of community transmission. Provincial economies will not return to pre-pandemic levels of robustness until we all see the country turning the corner on this pandemic. In my view, a more risk-based approach to vaccine distribution is a better one (an approach that will leave me at the end of the line, which is right and fine) for all these reasons. In gratitude, we could even send some of those willing nationally credentialed health care workers mentioned above to help with their vaccine roll-out. Canada is full of neighborly people but I appreciate this is likely a bridge too far for many, even for the host country in Come From Away. This is not the only opportunity to level up our vaccine game in any event.

The most important leveling up opportunity in the context of vaccines relates to Canada’s approach to pharmaceutical policy more broadly. Legislative momentum has been building towards a national pharmacare program, starting with the revision of the reference countries used for pricing determinations and other changes to the Patented Medicine Prices Review Board (PMPRB). Implementation of those new regulations were delayed for a second time in December 2020 due to the pandemic and two court decisions that impact the regulations. Enter vaccine shortages, now we are wincing over our nation’s lack of capacity for vaccine manufacture — a problem that we originally understood as an economic problem we were willing to bear which we now see as a matter of domestic security. The government recently added $123-million for the National Research Council to not only expand the Royalmount facility in Montreal, but also build an entirely new production site beside it capable of pumping out two million doses of vaccine a month and has entered into a (unfinalized) deal with Novavax to domestically produce its vaccine once approved. Canada also invested another $173 million to Quebec’s Medicago to push research on its vaccine and build a new production plant in Quebec. The level up opportunity here is not to extend the period during which affordability of prescription medicines remains a concern for too many Canadians, nor is it to view pharmacare policy in isolation from our newly realized security concerns over lack of domestic vaccine manufacture.

In my view, the big opportunity is to reconsider our relationship with the pharmaceutical sector as a whole. What I’m suggesting is not so different than the approach adopted for the renegotiation of NAFTA: a centralized coordinating effort that looks at all aspects of pharma policy (from pricing and sourcing to clinical trial hosting to jobs to innovation and domestic security), including wide spread outreach across party lines to our negotiating partners and rapid response when necessary. The NAFTA approach recognized that fundamentally what was at stake was a relationship, as much as a trade agreement, and that effective management and building up of the relationship would lead to a better agreement outcome. We are but one rather small country negotiating with global companies; it will take a coordinated and concerted effort to punch above our weight. It will also take time that we don’t feel we have but that doesn’t change the fact that the current state of the relationship was many years in the making and improving it will not happen overnight. Nevertheless, separating the issues of domestic vaccine production (and clinical trial hosting, research investment etc.) from pharmacare, economic and innovation policies may just lead to suboptimal outcomes for all. It’s better to rebuild the whole relationship as intensively as possible to lift all of our pharma policy boats.

This speaks to the next opportunity, this time on the policy front. As we build out a renewed framework for pharmaceutical policy in Canada (for which drug pricing is but one element), we should endeavour to build one that is harmonizable with other country’s approaches. This is not an opportunity for a made-in-Canada solution because, to my mind, we will not achieve better drug pricing in negotiation with global companies until we aggregate our spend with other like-minded countries. Adopting a policy approach that down the road can allow us to work and ally with other countries is key to capitalizing on our renewed understanding of the strategic significance of pharma policy, as well as to achieving more sustainable pricing and a better more balanced relationship with pharma. That partner will never be the United States because of the differences in our health systems. But we could look to partner with the United Kingdom, the European Union (appreciating our relationship is strained at the moment), or New Zealand. Aggregating spend is the most tried and true method of lowering price by fair means. At this stage, all that is required of policy makers is to refrain from pursuing anything too unique in our approach that might make allying impossible at a later date. A national pharmacare program is exciting; a pharmacare alliance moreso.

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I sometimes feel like I’m watching a disappointing version of the movie Independence Day. One of those intimidating saucers is over Canada. There’s a saucer over Brazil as well and it’s producing new faster and more deadly saucers and the same is happening in the United Kingdom and South Africa. Some countries have figured out how to disable the saucers. Others are rapidly deploying protective shields. And instead of there being a final scene of cheering crowds from all over the world when each country defeats the invading alien species in parallel, each country instead spends excess energy on small improvements to our own national situations, inefficiently competing against one another for resources, all the while the alien gets stronger and better adapted to our planet.

I’ve shared a few ideas as to how we can level up our vaccine response in Canada to the COVID-19 threat. There are certainly other and perhaps even better opportunities than the ones proposed here, including ones that extend beyond our borders. Let me say as well that I appreciate no politician wakes up in the morning looking to be mediocre or to phone it in. I’m grateful for all of their service and sacrifice. Joe Rotman once shared with me that when business growth is not going in the direction you want it go in or at the preferred pace, doing more of the same things or doing them faster is almost never the solution; you need to change your strategy. Rather than a prescription for our challenges, this is a call to ask how we can do things differently in order to be more effective? Should we be thinking bigger than we are today? The virus is winning. I’m worried more of the same will not change that.