Covid-19 vaccine distribution has a fairness problem

Figuring out how to combine science with fairness in Covid-19 vaccine distribution is a tricky puzzle. Science can help predict how to distribute limited doses to minimize overall deaths, but that means acting fast, which might compromise fairness. That's how we end up with outrage when hospital administrators get shots ahead of nursing home residents, or, as The Atlantic reports, offspring ahead of their elderly parents.

Perfection is impossible. But there's a way to do justice to both science and ethics: Focus vaccines on geographic hot spots and the elderly. Experts say both are important — and getting the vaccines to the hard-hit areas could correct racial disparities that are already appearing in the early rollout.

Focusing on geographic hot spots can help minimize spread of the disease, which will also minimize the risk of new vaccine-evading variants cropping up. The more people get infected, the greater the number of viral particles out there, and the greater number of mutant versions will arise. And that means the greater the odds a dangerous variant will spread.

Yale epidemiologist Robert Hecht has been studying Covid-19 in Massachusetts and found the virus is vastly more prevalent in some areas than others. "We're not just talking about a marginal difference of five or ten percent," he says. "We are talking about two hundred, three hundred percent differences."

He likens vaccinating these hot spots to firefighters starting where flames are burning hottest. And the hot spots are hot for a reason, he says — it's where people have in-person jobs, can't afford not to work, and live in multi-generational housing sometimes taking in extra tenants to make ends meet.

The hot spots are also places recent immigrants come to live, and many don't have any connection to the health care system. They may be reluctant to seek testing or medical help because of their immigration status, he says.

Dousing the flames in these hot spots will prevent them spreading elsewhere. "You can get multiple benefits out of this," he says. It's the right thing to do from an epidemic control standpoint, he says. And it could bring some relief to communities that have not had good access to healthcare through the pandemic.

Sending vaccines to hot spots is also the fair thing to do, since many people in places with high rates of disease live in crowded housing and do high-risk jobs, often not by choice. Many are members of minority groups who have been disproportionately hurt by the virus and its economic fallout. 

Demographic data collected by the CDC suggests that too few vaccines have gotten to high-risk people who are Black, American Indian, Alaska Native or Hispanic.

Dorit Reiss, a professor at the University of California's Hastings College of the Law, says it's important to separate problems with vaccine allocation plans from what happens in reality. The CDC and the National Academy of Sciences have created thoughtful plans that give the most vulnerable people priority, she says, but inadequate funding has made it hard to carry out those plans. And some states are creating plans on their own.

With poor funding for distributing vaccines, she says, it's been cheaper to send doses to big hospitals, even though that's led to hospital administrative staff getting the shots before many people who are more at risk.

What she says would make the most sense ethically would be to get vaccine doses to regions where people have been underserved throughout the pandemic. "I am really concerned we are seeing racial imbalance in vaccine distribution," she says, adding that the way to improve fairness to minorities is to bring the vaccines to them.

Reiss says it's also important to avoid judging people who have behavior-related health problems. While social media has fueled some outrage against people with smoking-related illnesses getting the vaccine early, she says such judgment is ethically dubious.

We don't deny people care for skin cancer because they went out in the sun, she says. "The fact that someone got addicted to cigarettes and did not manage to quit … does not seem a reason to let them die from Covid," she says. Beyond that, smoking addiction is more common in socioeconomic groups that are more likely to be at risk from the virus.

And it's a waste of energy getting outraged at "selfish" people getting vaccinated "out of turn." As some infectious disease experts are arguing, the vaccines likely do have some effect on reducing transmission, so getting one is not all selfish — it's part of a civic duty and could help protect others and end the pandemic. 

Above all, we shouldn't let the perfect be the enemy of the good. Getting too rigid with allocation standards could mean throwing away doses — and that's the worst of all possible worlds.

Faye Flam, Journalist .

Disclaimer: This opinion first appeared on Bloomberg, and is published by special syndication arrangement.