Editor’s Note: Megan Ranney, MD, MPH, is an associate professor of emergency medicine; co-founder of Get Us PPE; and a CNN medical analyst. The opinions expressed in this commentary are her own. View more opinion on CNN.
On Tuesday, the Department of Health and Human Services announced a change in its Covid-19 vaccine distribution plan, an effort step up the grossly insufficient number of vaccinations that have been administered to date.
Following an altered distribution protocol that President-elect Joe Biden announced last week, the administration will now release all available doses of the vaccine.
Of equal importance, the announcement also allows for immediate vaccination of individuals 65 and older and provides assistance to states in setting up administration sites. Although I see these plans as a much-needed step in getting first vaccine doses in arms, we must ask whether and how this will affect the speed and equity of vaccine administration.
Why should we ask these questions?
Well, I – in my personal capacity – have heard about well-connected friends and community members who have managed to get vaccinated against Covid-19, even though they meet no current criteria to join the front of the line. Meanwhile, many health care workers have yet to be vaccinated.
Most of us believe that there should be some element of fairness in the distribution of the Covid-19 vaccines. Aligning with guidelines advanced by the Centers for Disease Control and Prevention’s Advisory Council on Immunization Practices (ACIP) in December 2020, those at highest risk for getting sick from Covid-19, either because of their job or their underlying health status, should get first dibs.
These guidelines are supported by bioethical principles about the need to balance “priorities of minimizing societal disruption and preventing morbidity and mortality.” Justice and objectivity seem like a no-brainer. But, even with expanded distribution of the vaccine as outlined by the new plan, someone has to go first, second and last. Further complicating matters, individual states and health care facilities are under no legal obligation to follow ACIP’s recommendations.
As a result, the system is open to manipulation and some solutions as to who goes first, versus second, feel a little fairer than others.
A first distribution option is to treat vaccination like a class list. I have heard from health care workers across the country whose hospitals are offering vaccine slots according to alphabetical order. This is lovely for those whose last name is “Aguilar,” but what if the person named “Zeal” is actually at higher occupational and physical risk?
Using a list avoids any opportunity to game the system, but it also feels like something that Seinfeld’s Soup Nazi would have done.
A second, quintessentially American strategy is to treat vaccination like a Black Friday sale: first come, first served – unless you know the right people. In some counties in Florida, seniors lined up overnight to get the shot, putting their own health at risk for the chance to avert future infections. In Houston, health department call centers have been paralyzed by calls from those desperate to get protected. In NYC, there are reports of clinicians rushing to the elevator to be first in line for the vaccine.
Meanwhile, stories are already circulating about the possibility of the wealthy buying access through concierge doctors. This strategy clearly prioritizes those who are in-the-know, who have time to sit on hold, or who are willing (in the case of camping out overnight) to put their health at risk. It may also prioritize those with power and wealth. It feels haphazard and inherently wrong. A vaccine is a public health good, not the season’s hottest toy.
A third, common way to handle prioritization is to create complex algorithms that weigh risk from one’s job, underlying health problems, age and other relevant variables in order to provide a perfectly tailored list of who goes first, second and so forth.
This option sounds fair and scientific. But algorithms can also be dangerous. Predictive algorithms are notorious for being “garbage in, garbage out.” If the data that you feed into them is based on racial, gender or age-based biases, the results will simply reinforce existing structural problems.
And flawed predictive algorithms abound. One need only look at Stanford University hospital’s experience, in which, according to CNN affiliate KGO, medical residents and fellows who work in the hospital were given a lower vaccine priority than some doctors who were working from home due to missteps in the design of the algorithm.
Prioritization algorithms could also slow down distribution to new groups, by being too rigid to account for real-time distribution challenges. We cannot afford to worsen structural inequities during vaccine distribution, nor can the quest for perfection impair our speed.
Ultimately, of course, it’s the conditions of scarcity that make fairness difficult to achieve. But let’s be clear: the vaccine does not have to be as scarce as it is. Miscommunication from health officials and an underprepared vaccine distribution system can hinder vaccine administration just as much as slow vaccine production.
While some places are overwhelmed by demand, other clinics are have thrown out unused doses when individuals did not show up for their injections. As Surgeon General Jerome Adams recently said, “The problem really is that we need to continue to do a better job of matching up supply and demand at the local level.”
Whether it’s using the National Guard to assist in setting up vaccination centers, deploying mobile vans to access rural and urban populations, or working with community groups to increase uptake among at-risk populations, better is needed. In my own state of Rhode Island, we’ve both prioritized those at highest occupational and age-related risk, and have knocked on doors in our hardest-hit community to get vaccines to those who need them most. But there is always room to question our practices and aspire to do better.
So, what is the next best step for our country to achieve fairness? The new plan announced by HHS – and after January 20, the Biden administration’s plan, which will continue to prioritize using all available doses of the vaccine.
As these plans stipulate, we must release all the available doses of the Covid-19 vaccines – but we must go further by expanding the categories of who can get the vaccine to avoid wasting doses and simultaneously increasing both funding and support for getting the shot in people’s arms in ways that explicitly address considerations of equity and don’t let people use their influence or resources to cut the line. Only then we will have moved closer to our goal.
To protect our communities, we must not be paralyzed by fairness – or stop pursuing it.