Thinking Aloud: Who Gets the Vaccine First?

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Let’s assume that an effective vaccine for COVID-19 -- one with a level of efficacy you'll find comforting --becomes available over the next few months. Under all circumstances, demand will outstrip supply. So as we form the line, who is in the front?

I have put aside the question of how mass vaccination might work. As a child growing up in the ‘50s, I remember lining up in the school auditorium for my polio shot and a few years later for my polio “sugar cube.” With so many urgent care centers and pharmacies turn “primary” care, I am optimistic enough not to be concerned about those logistics. 

And I have mixed feelings about the survey by YahooNews/YouGov, showing only 42% would get vaccinated for COVID-19. (19-25 say they won’t get treated, the remaining 26-33 are unsure). It does move me up in the line, but I worry that those not getting vaccinated will be a pox upon my house. 

It is easy to say that priority should go to essential workers and those at risk, but those terms are a bit too vague when it actually comes to forming the line. Let’s begin with essential workers, where I make my first distinction. While first-responders, those that run towards the problem, are indeed essential workers, they are, to my mind, different. They are the most critical; they provide us with a crucial measure of safety in our daily lives, from disease, crime, and fire. I am not sure I would extend that same priority to the first-responders’ administrators, no offense intended, but the billing office and service line administrators of hospitals, who face no higher risk than other workers, maybe they can wait. Dispatchers for police, fire, and EMS might be considered “administrators,” but without them, first-responders cannot work, so in my current thinking, they are a priority.

Are there other levels of “essential” I should consider? After all, doesn’t everyone consider themselves or their work essential? Now I am beginning to think about supply chains. Can we all agree that those supplying our food, in the supermarket/bodega sense, not the GrubHub sense, are an essential supply chain? And if they are in the mix, we would need to include other supply chains of necessities, paper goods like toilet paper and diapers come to mind. What about grapes? Do they fall under food, or if I prefer them fermented, which I do, do winegrowers make the cut? Of course, whichever of these supply chains would determine to be essential; we will have to include the transporters, the big rigs, the trains, the warehouse distribution systems, Amazon, UPS, and USPS. And like the first-responders, we have to include the support services for these supply and transport chains, mechanics, oil and gas workers, tire makers. With so many interconnections, the rabbit hole of choosing runs deep.

Perhaps identifying those at “heighten risk” might be an easier task. Our current understanding of the epidemiology of COVID-19 can inform our decision; we know that age, and specific co-morbidities and ethnicities are at more significant mortality and morbidity risk than others. Hypertension, diabetes, and cardiovascular disease are the most commonly associated with COVID-19 infections, but not with dying. I am not sure that the last part, about the association with mortality matters – being infected with COVID-19 is sufficient to represent a heightened risk for me. By the numbers, these diseases affect half of our population, so that is over 160 million vaccinations right there. Nursing homes need to be a priority, but is there an ethical minefield if the quality of life is considered – that question is so individualized that no general policy can be evenly applied.  

Where do teachers fit in? As a product of public schools and having experience distance learning as an adult, I believe that nothing is better than face-to-face instruction, and the smaller the group, the better. Given these underlying assumptions, I am concerned about virtual learning, especially for those already educationally disadvantaged. With an MD degree, I could only help my children with their homework until 10th grade. How well has it gone for parents over the last few months, most seem to drop to their knees to thank teachers. Education is an essential service to me, but teachers did not sign up to possibly get ill and die at work, so they are not acting as if they are essential; important yes, essential not so much. That said, certainly, a vaccine would entice reticent teachers to return, so they need to be in the queue.

Finally, there are our elected leaders. It will be fascinating to see if vaccination becomes like other measures, a political statement. Will the vaccine-hesitant shift their view when they see the President, whomever that is in that moment, get vaccinated? Will the President not get treated? Congress, of course, will consider themselves essential, but their actions in not working around the clock for their constituents in a time of crisis speaks volumes. Remember, it was Congress that secretly built a bomb shelter for themselves at the Greenbrier in West Virginia when nuclear war was a more prominent concern. The Greenbrier holds two additional lessons. First, Congressional leadership, the Speaker of the House, majority and minority leaders and whips, all had private rooms in the bunker; the rest of Congress were put up in army-style dorms. Why is that George Orwell line in my head, “All animals are equal, but some animals are more equal than others.”

The second lesson of the Greenbrier is the media room which featured images of the Capital, a sized and proportioned for a television camera’s vision to make it appear that our Congress was not buried in a bunker for safety, but there at the front lines just outside the Capital, suffering and surviving just like the rest of us. The powerful still are disingenuous, and by the way, do you think the rich and powerful will cut the line?

 

Thinking Aloud are my lightly edited thoughts, neither fully formed nor subjected to rigorous analysis. They do not necessarily reflect the public positions of the American Council of Science and Health, which are based upon discussion with our Board of Scientific Advisors.