Who Gets the First COVID-19 Vaccines? The Answer is a Complex Tangle of Science and Ethics

, | September 14, 2020, 5:26 pm EDT
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This post is a part of a series on COVID-19 and the Coronavirus Pandemic

The scale of the COVID-19 pandemic has jumpstarted an unprecedented frenzy of vaccine research, and dozens of vaccines have entered clinical trials. Forecasters predict that a vaccine could be approved within the next year—a testament to the power of scientific ingenuity, especially given that vaccines usually take at least a decade to make.

In a perfect world, a newly-approved COVID-19 vaccine would be immediately available to everyone, everywhere—a tantalizing vision, but constraints in manufacturing and public health infrastructure make this vision nearly impossible to achieve. The US expects to have enough doses to cover 10-15 million people soon after a vaccine is approved. This sounds like a hefty number, but it’s only 4-6 percent of the US population.

So, who should get the first vaccines? If you stopped a few people on the street and asked them, you might expect certain answers. Hospital staff, they might say, or seniors. In fact, more than 70 percent of people in the US believe health care workers and people over the age of 55 should be vaccinated first.

But the answer is far from simple. Who, exactly, counts as a health care worker? Who is at highest risk, and why? How do you make sure people have access to a vaccine—and what if they refuse one anyway?

A National Academies of Science committee dives in

The National Academies of Science, Engineering, and Medicine (NAS) took on the challenge of answering these questions. The NAS Committee on the Equitable Allocation of Vaccine for the Novel Coronavirus—comprising nearly 20 experts in public health and policy, medicine, law, and ethics—relied on a wealth of resources to develop a framework. The committee reviewed nearly 100 studies, reports, articles, and government documents—not only on COVID-19, but also on lessons from prior pandemics and a suite of bioethical approaches to public health.

Last week, the committee released its 115-page draft report, outlining guidance for federal, state, and local governments. Their framework is summarized in the chart below.

This chart is drawn from the NAS’ “Discussion Draft of the Preliminary Framework for Equitable Allocation of COVID-19 Vaccine” (Sept. 2020). The NAS report also underscores that equity must be a consideration across these phases.

Perspectives on the NAS report

After the report’s release, dozens of people offered comments during a five-hour public listening session. From educators to firefighters, doctors to grassroots advocates, the speakers offered unique insights and perspectives. I mention a few below, but you can hear from all of them yourself at this link.

Communities of color. Adjusted for age, Black people in the US are 3.6 times more likely than white people to die from COVID-19. Indigenous people are 3.4 times more likely, Latinx people 3.2, and Pacific Islanders 3.

These frightening numbers, many commenters pointed out, highlight deep-rooted racial and ethnic inequities. Dr. Elizabeth Ofili of the Association of Black Cardiologists noted that “African-Americans have poorer outcomes of care regardless of socioeconomic status” and are underrepresented in vaccine trials. Dr. Winston Wong of the National Council of Asian Pacific Islander Physicians (NCAPIP) remarked that the report “failed to mention” the alarming infection rates among Asian Pacific Islanders.

Other speakers critiqued the report criteria’s reliance on each individual’s risk. Ellen Provost, speaking for the Alaska Native Tribal Health Consortium, urged the committee to designate Alaska Natives as a high-risk population on the basis of race, rather than individual risk. “If we are to avoid another Great Death,” Dr. Provost warned, using Alaska Natives’ term for the 1918 flu that decimated Native communities, the committee must “explicitly place this population in the highest-priority group.” Dr. Elena Rios of the National Hispanic Medical Association (NHMA) pointed out that the report’s phase criteria discussed “individuals and not families,” despite the centrality of family to Hispanic culture in the US. Stories of family resilience and survival, she noted, should be integral to vaccine education campaigns in Hispanic communities.

Older people. Other commenters underscored the vulnerability of older people. Dr. Louise Aronson, a geriatrician, noted that 80 percent of people in the US who have died from COVID-19 are older (65 and over). Dr. Timothy Farrell, vice-chair of the American Geriatrics Society, warned that some of the report’s analyses may “lean on stereotypes that potentially devalue older adults,” like using age alone to determine who gets a vaccine first. “It behooves us all to remember,” Dr. Farrell said, “that it is often the ninth inning of life that is most important.”

Many speakers also emphasized the need for an expansive definition of “healthcare workforce” in a discussion of vaccine allocation for older people. Brendan Flynn, of the nonprofit LeadingAge, stressed that community-based care personnel must be considered members of this workforce. David Schless of the American Seniors Housing Association urged the committee not to overlook the diverse staff that work with long-term care residents—for example, caregivers, nurses, housekeepers, and dining staff.

People facing occupational risks. Many in the US are vulnerable to COVID-19 because of their jobs. Debbie Berkowitz, an attorney for the National Employment Law Project, noted that hundreds of low-wage workers in the meat and poultry industry have died from COVID-19, in part because of employers’ resistance to CDC guidelines. Alexis Guild of the nonprofit Farmworker Justice stressed the threat to farmworkers, the majority of whom “lack health insurance and access to regular medical care.” Mily Trevino-Sauceda, executive director of the Alianza Nacional de Campesinas, Inc., noted that agricultural workers—including the undocumented workers that make up half the nation’s crop labor force—are acutely vulnerable to COVID-19. “Even though we [agricultural workers] are called essential workers,” Trevino-Sauceda said, “we have never been treated as essential workers.”

Teachers spoke out, too. Randi Weingarten, president of the American Federation of Teachers, implored the committee to prioritize educators. “We really need to make sure we don’t pit learning [against] living,” said Weingarten, pointing to schools across the country where educators, forced to teach in-person without enough protection from COVID-19, have been infected. Scott DiMauro of the National Education Association urged the committee to use a broad definition of “school staff,” from teachers to counselors to custodians.

Diverse groups, but common themes

Many of those who spoke appealed on behalf of diverse communities and collectives, but common threads were stitched through their messages.

First, vulnerabilities compound one another. Among the populations most vulnerable to COVID-19, risks overlap and amplify. As Dr. Aronson noted, “You can actually be black [or] brown and old at the same time, and that turns out to be not good for you in this country.” Similarly, Alleanne Anderson of the nonprofit Schoolhouse Connection pointed out that people experiencing homelessness are the same people forced to work riskier jobs and less able to observe social distancing, a cocktail of compounding risks.

Second, injustice has sown mistrust in medicine. Many at-risk communities have been or still are mistreated by medical professions. “I don’t imagine I need to remind this group of the Tuskegee study,” said Dr. Oluwaferanmi Okanlami of the University of Michigan, referring to the infamous 40-year experiment in which hundreds of Black men were knowingly misled about syphilis and deprived of treatment by US government researchers. Karen Mountain of the Migrant Clinicians Network noted that, for any vaccine campaign to be successful, our society must confront this “tragic racist past” and understand its effects, including on marginalized communities’ wariness of medical research.

Third, we must ensure communities play a leading role. Many commenters stressed the importance of community leaders in a vaccine campaign. Dr. Rios of the NHMA noted that trusted community members, like “community health workers and caregivers in our homes,” must be a part of any vaccine education and rollout strategy. Dr. Marcus Plescia, Chief Medical Officer of the Association of State and Territorial Health Officers, stressed the importance of ensuring that states have the flexibility to accommodate local needs. Dr. Wong of the NCAPIP noted that community organizations are best-equipped to identify vulnerable people, such as “multi-family households that rely on a few breadwinners,” which are at heightened risk of COVID-19.

Fourth, communication is key. Misinformation about COVID-19 is rampant, and vaccine hesitancy is an enormous barrier: the NAS notes that a third of people in the US may decline a free vaccine. Many speakers stressed the necessity of open communication to combat this hesitancy. Effective public health messaging, noted Dr. Oscar Alleyne of the National Association of County and City Health Officials, “is not just about making banners or bulletin boards”—it requires enormous effort, consistency, and transparency. Amy Pisani, who leads the nonprofit Vaccinate Your Family, echoed this. Not only must vaccine allocation be equitable, she said, but “it must be perceived as equitable.”

With the draft done, the hard work must continue

Now that voices from the public have been heard, the NAS committee begins the monumental task of finalizing their recommendations. The committee should do its best to incorporate the concerns of commenters, particularly those who spoke on behalf of the vulnerable and marginalized, who too often go unheard.

The difficulty of this undertaking is nearly unimaginable. It requires not only the best available science, but a deeply nuanced consideration of ethics and history. Facts must be central to the debate—but so must compassion, and an appreciation for the enduring dignity of human life.

Once the NAS guidelines are finalized, government officials should use them to make thoughtful and equitable decisions about the COVID-19 vaccine. And as members of the public, all of us should call for transparency throughout this process, hold our leaders accountable, and demand that science leads.

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