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Should states be encouraged to require COVID-19 vaccination for public school and college students once FDA fully approves the vaccines? Members of the American Medical Association (AMA) were divided Sunday on the question.

"By the time these vaccines are fully FDA-approved, that is when we should have a mandate," Frank Dowling, MD, an Islandia, New York psychiatrist who was speaking for the New York delegation, said at a reference committee hearing during the interim meeting here of the AMA's House of Delegates. "We are still in the neighborhood of 270 to 300 people dying per day in the United States from COVID. It's way less than it was, but we are not done. At that pace, that would be 100,000 people per year -- that's still two to five times more people than die per year from the flu."

Mike Lubrano, MD, of Boston, speaking for the Young Physicians section, agreed. "COVID can be a devastating disease to the unvaccinated, and we know that vaccines are safe and they work," he said. "In order for public schools to be truly accessible to all children, including those with conditions that exclude them from vaccine eligibility, we need to ensure that all children in these spaces who can get vaccinated are vaccinated."

But Ross Goldberg, MD, of Phoenix, a delegate from the American College of Surgeons who was speaking for himself, said that now was not the right time to be pushing a vaccine mandate. "In the great state of Arizona, we actually passed a law earlier this year [making it] illegal to mandate the COVID-19 vaccine for schools," Goldberg said, noting that he has been appearing on local media to advocate in favor of vaccination. "Other states are already kind of ahead of the ball on this, and are passing these things. So the AMA now coming out and saying there needs to be a mandate -- I think the timing is off. There are some states where now we physically can't do that because laws have been passed and trust me, they're not undoing this one any time soon."

Randy Easterling, MD, an alternate delegate from Mississippi who was speaking for himself, said that while he personally was a "strong proponent" of COVID vaccinations, "If a resolution such as this passes, it will be used against us in other states that have strong vaccination laws ... to dilute our present vaccination laws."

The committee also heard positive comments on a resolution from the medical student section urging the association to encourage transplant centers to expand their criteria for potential liver transplant recipients to include patients who may not satisfy center-specific alcohol sobriety requirements. "Data show that sobriety requirements for liver transplants do not affect or influence relapse rates, and this requirement could be actively harming patients," said Kylie Rostad, of Toledo, Ohio, an alternate delegate for the Medical Student Section.

"Post-liver transplant patients with alcohol-related liver failure experience significant improvement in mortality. On the other hand, similar patients who were unable to receive a transplant have staggeringly high mortality rates," Rostad said. "While we recognize that organ transplant [involves] exceedingly complex medical management and allocation of a finite resource, we also believe that restrictive sobriety requirements should not play a significant role in the decision for receiving necessary medical treatment for end-stage disease, especially when these patients have strong interpersonal support systems."

Peter Bretan, MD, a transplant surgeon from Novato, California who spoke on behalf of the California delegation and PacWest, supported the resolution, saying that "guidelines and protocols in terms of the standard care in transplant, especially in life-or-death situations, were never meant to be so rigid to exclude patients that might benefit from these life-saving transplants ... Most importantly, they were never meant to replace overall judgment of the surgeon and transplant team."

Delegates also debated a resolution that called on the AMA to declare that "immigration status is a public health issue that requires a comprehensive public health response and solution," and that the association "support the development and implementation of public health policies and programs that aim to improve access to healthcare and minimize systemic health barriers for immigrant communities."

"We are asking immigration to be recognized as a social determinant of health," explained Kamalika Roy, MD, of Seattle, speaking on behalf of the International Medical Graduates Section, which wrote the resolution. "Research shows that immigration is a life event that is negatively linked to immigrants' health. Upon arrival to the U.S., immigrants usually have better health than their American-born peers, which is known as the 'immigrant health paradox.' However, their health declines faster the longer they live in the U.S." due to factors such as limited access to medical care, loneliness, social isolation, socioeconomic conditions, and food insecurity. "Healthcare professionals often do not recognize the complexity and interconnectedness of these issues that might affect immigrants' health," she said.

Tyler Campbell, MD, of Winchester, Ohio, who spoke on behalf of the Great Lakes Delegation, argued for the resolution to be referred to the AMA's board of trustees. "While we do agree that immigration status may indeed be a social determinant of health, we felt, as written, that this was very complex," he said. "Immigration status could include those that are undocumented immigrants, all the way to those that are very affluent ... We felt because of those complexities, and the nuances that are involved with how those factors impact those social determinants of health, we thought referral would be more appropriate."

Corliss Varnum, MD, a delegate from Oswego, New York who spoke for himself, disagreed. "Illegal, legal -- they're still people," he said. "They still need treatment and they are a source of infection -- polio that's never been vaccinated [against], and measles and other diseases that could be prevented. To protect ourselves at least, we need to treat them and protect them."

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