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Vincent Lam is the co-author of The Flu Pandemic and You. He is a practising physician, a faculty member at the University of Toronto and the medical director of the Coderix Medical Clinic.

If the COVID-19 pandemic were a gruelling car journey, all the passengers are exhausted. Hospitalizations and deaths are rising. The health care system is overwhelmed and understaffed. The mental health of youth and children is suffering.

Thankfully, in the face of the Omicron wave, vaccination with two or more COVID-19 jabs still provides excellent – though not perfect – protection against severe illness, hospitalization and death. In Ontario, someone 60 years or older and unvaccinated is 19 times more likely to be hospitalized with COVID-19 than someone in the same age group who has received three doses. Meanwhile, the high number of active cases means that treatment of COVID-19 infections is more important than ever.

No one wants to be in a car crash or contract COVID-19, but if this happens, the main hope is to not be seriously injured or to die. Sotrovimab, a monoclonal antibody, arguably has the strongest evidence for its ability to prevent mild illness from becoming worse. If vaccinations are like seatbelts, Sotrovimab, approved for use in Canada in July, 2021, is like an airbag. It would be better if everyone put on their seatbelts, but in a collision, the airbag might help too.

Sotrovimab has remained effective against Omicron because it targets a portion of the virus that hasn’t mutated much, while other monoclonal antibodies and existing vaccinations have targeted areas that have now mutated in new variants. In one trial, 1 per cent of those who received Sotrovimab were hospitalized or died, compared with 7 per cent in the placebo group, so it’s a pretty good airbag. All of these patients were unvaccinated and were considered at high risk for COVID-19 disease progression.

Imagine if someone told you that you should absolutely buckle up your seatbelt but that the airbags would be preferentially provided to those who did not do so. This is our current situation with Sotrovimab.

When do we admit Canada’s health care system just isn’t working?

Denying health care to the unvaccinated is one step too far

Canada has purchased 10,000 doses and entered into an agreement to purchase 20,000 more. Meanwhile, we had 269,546 new cases of COVID-19 in the past week. While details of eligibility vary by province, the broad theme is that Sotrovimab will be preferentially offered to immunocompromised persons – who we know do not mount as vigorous an immune response to vaccines – and the 19 per cent of eligible Canadians who have not yet received at least two doses of COVID-19 vaccination.

Since Sotrovimab was studied in unvaccinated patients, we don’t know how useful it is in vaccinated patients; a fair hypothesis is that it has some benefits, but they are less dramatic because fully vaccinated people are less likely to get severely ill. Given the choice of one or the other, I would take a course of vaccination before monoclonal antibodies, just as one should choose a seatbelt over an airbag. However, if all were freely available, many would take all of the above.

For an individual with a mild COVID-19 infection, their decision to forego two doses of mRNA vaccine at a cost of around $62, will improve their chance of being eligible for an injection of Sotrovimab with a price tag of $2,750.

Like airbags, which deploy only after a collision is detected and must rapidly inflate in the instant before the human passenger slams into the steering wheel, timing is crucial. Sotrovimab must be given in the first seven days of symptoms, it is not useful once illness becomes severe, and it must be infused intravenously.

This strategy is consistent with health care values in Canada. It is a rational use of scarce resources, because the unvaccinated are at far higher risk. After a car wreck, we provide trauma surgery even if someone didn’t buckle up, and we care for smokers who develop lung cancer. However, the allocation of scarce resources means that what one person receives, another does not – and herein lies a tension that has to do with our expectations from, and our obligations toward, one another.

In a poll of the vaccine hesitant, 58 per cent cited “personal freedom” as a reason for their hesitation, and people in my practice who are not vaccinated often tell me they don’t like the government telling them what to do. The underlying issues are both more varied and complex – and have to do with misinformation, trust in “the system,” and are exacerbated by systemic bias and access issues. So, as one point of information that admittedly does not remedy these imbalances, it is worth noting that this country’s health care systems still care about the unvaccinated, and will give them the airbag before the person who put on the seatbelt – even when the airbag is 44 times more expensive. This is because, just like recommending that everyone be vaccinated, it is the scientifically sound recommendation.

A notion of health as a shared public good must accept asymmetric contributions and benefits – I may contribute a lifetime of taxes and never become ill, and I hope that if I ever need a complex, expensive treatment, I will receive it. Meanwhile, this shared public good and access to its resources legitimately creates certain expectations of citizens – for instance adherence to speed and traffic regulations, and accepting vaccination against preventable and transmissible illnesses. Even if a car has an airbag, every passenger should be expected to put on their seatbelt.

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