Scarcity and Ethics

In December, the data wonk Nate Silver sparked controversy when he not only critiqued the preliminary vaccination prioritization guidelines from the U.S. Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) but managed to do it in a way that disparaged the entire public health profession. Silver, criticizing the guidelines for not prioritizing vaccination of adults 65 and older over people with high-risk health conditions, argued that "scientific evidence" should have made the prioritization simple, straightforward, and obvious. Public health officials and experts responded on Twitter to explain some of the ways in which the decision was more complex than Silver believed.

As it happened, Silver's comments came out before the ACIP had released its final prioritization, which ended up being closer to what Silver wanted anyway. Meanwhile, since the ACIP list was only a guide, each state has created its own rollout strategy, which has then been filtered through the vicissitudes of implementation. In mid-February, California changed its approach to make disabled people and those with high-risk conditions eligible after outcry against an initial plan to prioritize age first. And so the controversy over who should be vaccinated and when continues as individuals, advocacy groups, and experts in a wide range of fields argue about the ethics involved.

These types of discussions are familiar to me from my research of disaster response. Disasters breed scarcity. They cut supply chains, spur sudden increases in demand, and complicate transportation. And scarcity is something that people in wealthy countries—particularly their leaders—are bad at talking about. There's a tendency to believe that enough money can buy anything, immediately, but in a large enough disaster, money becomes imperfectly fungible. The planes cannot land until the airstrip is cleared; there are not enough heavy-lift helicopters to carry bulldozers to the sites where they're needed; paying more money does not magically train additional doctors and nurses; the vaccine cannot be developed or tested any faster.

Scarcity, in turn, requires making difficult decisions: Who gets food first? Which roads are cleared first? Do you give the 300 blankets to the evacuation center with 250 people or the hospital with 600 people? There are no correct answers to these questions and no way to maximize efficiency without first defining what efficiency means in context. The decision also depends on what values or principles are important to the population in question.

Most often, such decisions are made in ad hoc, inefficient, and seemingly valueless ways like "first come, first served," which was used for distributing aid goods after Hurricane Katrina and has been the method for distributing vaccines in some Florida counties. But that strategy is anything but valueless: It prioritizes the physically able, those who own cars, people without responsibilities they can't set aside, or those people with telephones or internet connections if that's how appointments are made

To create a more explicit, equitable, and controlled distribution requires making value-laden choices. Do we want to prioritize saving lives above all? Saving potential life years (that is, valuing younger people with, hypothetically, more years remaining)? It requires deciding whether to make population categories large and easy to triage or narrower and more manageable once criteria are proven. In the case of COVID-19 vaccinations, it means deciding whether it is more important to vaccinate as many people as possible quickly or to deter people from trying to jump the line.

There are always going to be exceptions and special cases, but having a general principle or two, an explicit value statement for everyone involved, makes the decisions easier for the individuals who have to make them, more consistent throughout the organization, and more explicable—and cogently debatable—for the people affected by them.

But if there's anything governments like talking about less than scarcity, it is values. To be sure, they love spouting value-laden buzzwords like "liberty" and "family values," which are essentially meaningless. But values guiding irrevocable decisions that will make some people angry and resentful? Not so much.

And so what we end up with are disaster plans that do not consider scarcity because that would require admitting that procurement and transportation operations might fail and being explicit about the ethical framework for making difficult decisions. Without guidance, the decisions fall to stressed, overworked, and often untrained people on the front lines. The daily calls may be different in different jurisdictions; after Hurricane Katrina, some counties in Mississippi gave relief goods to anyone who showed up, while others would only give items to people living in the county. In one city in Japan, after the 2011 earthquake and tsunami, the person in charge of distributions decided to wait until there were enough items for everyone before distributing anything: no bicycles or lanterns or towels for anyone until everyone could have one.

None of this is necessarily wrong. One could argue that counties need to take care of their own first or that they have a responsibility to help people who might be stranded far from home or otherwise fall through the cracks. You can argue that fairness is more important than speed, especially considering the relations of people living in close quarters for months, or you can say items shouldn't be left in a warehouse when people need them. The only way to decide is based on priorities and principles; if there are clear statements on these, then recipients and staff alike have some guidance.

Guidance and clarity are helpful for both the recipients—like those in Iowa complaining that no one knows how decisions about the vaccination plan were made—and the front-line workers themselves. The journalist Sheri Fink has written about how disasters force doctors and nurses to make impossible choices in exhausted moments of strain. Many of the disaster managers, volunteers, and other government staff I talked to during my research were still caught up in wondering whether they had done the right thing years earlier.

Of course, even with a framework, there will always be people unhappy with the result. But a consistent principle, and transparency about how it is applied, is both easier to defend and easier for opponents to mount a substantive debate against. And, of course, thinking in advance about scarcity and values helps for better planning. Yes, it's scary to admit that there might not always be enough of everything we want or need. But we'd be better off holding national and local conversations about that before it happens.

Malka Older

And we better do it soon. As environmental pressures mount, the world is going to face more instances of scarcity and urgency, more difficult choices, and more threats to the legitimacy of the people making them. Organization and planning are the most important tools against disaster—and dealing with collective values is key to unlocking those.

Disclaimer: This article first appeared on Foreign Policy, and is published by special syndication arrangement