As health care providers, we are very frequently put in a unique position of juggling the wholly logical and practical field of Science with the empathic nature of social justice. We know that populations that are disadvantaged - historically, socially, economically, geographically, etc. – suffer the worst outcomes from pandemics in our country, and our current battle with COVID-19 has proven no exception. Data on health disparities from social determinants of health in 2020 have shown us that Hispanic/Latino individuals are nearly three times as likely to die from COVID-19 and nearly five times more likely to be hospitalized by the virus as compared to their White, non-Hispanic peers (https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html). When it comes to the availability of a potentially life-saving, pandemic-ending vaccine, who is the most deserving? Should it just be first-come, first-serve? Should it be by objective criteria such as age? It’s nearly impossible to answer this question and be comfortable with your answer. Luckily there are experts in this exact field, and the National Academies of Science, Engineering and Medicine (NASEM) have put together an interesting and admirable framework of recommendations. And true to the mission of BMGC, the committee boasts an admirable range of perspective, comprising 18 members from across the medicine, public health, science and technology sectors. Meetings to discuss vaccine distribution were held with committee members as well as members of the general public.
The National Academy of Sciences was founded by Abraham Lincoln in the 1800s and, together with the academies of Engineering and Medicine, they work to provide objective, independent, expert advice for the country in helping to influence public policy and address relevant complex problems facing the nation. The underlying assumption in this particular assessment is that if a COVID-19 vaccine becomes available, it will be scarce during early development, and thus allocation will need to be prioritized. In contrast to many hyper-objective previous works by these sorts of independent, scientific expertise groups, this year, NASEM has acknowledged in their recommendations the paramount importance of equity in addressing pandemic public health. For those of you who don’t have time to read the 237-page document, I’ll try to break down the group’s peer-reviewed findings below. (For those of you who do have that kind of time and interest, you rock, here you go: https://www.nap.edu/catalog/25917/framework-for-equitable-allocation-of-covid-19-vaccine)
As intensive efforts to accelerate the development of safe and effective vaccines are underway, scarcity will be an issue, and vaccines will need to be allocated in a strategic way to reduce morbidity and mortality with a consideration for socioeconomic wellbeing. It must be based in science, but it must also be based in social justice and health equity. As Dr. Victor Dzau, President of the National Academy of Medicine, says, “Any vaccine allocation scheme must explicitly address the high burden of COVID-19 experienced by specific populations, given their exposure and compounding health inequities.” He also mentions that it must be independent, free from political influence, and trusted by the public. In order to meet these requirements, an allocation scheme will need to be transparent (ie. principles for allocation should be apparent to the public and the public should be involved in decision making). Of note, in its development, the document received over 1400 comments including those made during a 5 hour publicly open session, for example.
A couple of critical notes to keep in mind as we move forward: None of the trials thus far have included children. They make up a substantial portion of our population and may represent a large portion of vectors in the pandemic. How do they fit into this scheme? And as the NASEM committee also explicitly acknowledges, the groups best served by a vaccine might be the groups with the most vaccine hesitancy. This may be secondary to a long history of abuse of minority populations by the medical profession (see: Tuskeegee, etc) and really just general distrust of government. How do we reconcile this? Is a vaccine that is forced upon disadvantaged populations the image of health equity? The committee acknowledges the initial logical thought that if minorities have higher rates of infection as well as death, then we should vaccinate minorities first. But they actually decided against this, zooming in on the idea of Race vs. Racism. People have personal vulnerabilities like heart failure, obesity, etc. But people also have social vulnerabilities like living in multiple-generational households, poverty, and inability to work from home that all seem to worsen outcomes for these populations. The goal is to, “Address based on racism, not race”. Finally, it’s worth noting that uncertainty will continue. Vaccines do not replace masks, distancing, hand hygiene, etc. Imagine that a vaccine is 90% effective (which would be fantastic), there will be 10% of vaccinated people who would not be protected but wouldn’t know that. This may or may not play a major role in achieving herd immunity through the committee’s framework.
Overall, the findings have been impressively well thought-out. Typically we start with science and then think about what principles of ethics and equity should be applied, but this time they did it backwards. They thought deeply about the goals -- is it to reduce mortality, reduce transmission, reduce social disruption and open the country up sooner or something else? The committee decided that it is best to prescribe a course of action that balances all of these concerns. They truly considered multi-layered risk of infection and then risk of severe disease and also risk of passing it on and the risk to the rest of society of that person being infected. They also paid particular attention to detail, mentioning that typically “Tiers” are used in these schema which is a hierarchical term. Instead they chose to use “Phases”, which better expresses the progressive sort of nature of the proposal with increased availability of a vaccine.
Check out the summary of recommendations:
1. Adopt the framework as below:
Phase 1a- Jumpstart with a small group. High risk health care workers at risk for acquiring disease and with an important role to maintaining stability of the health system ( “People” not more important than others, however certain “positions” more important to prioritize than others)
Phase 1b- Those with severe underlying comorbidities and older adults in congregate settings like nursing homes (high consequences if infected).
Phase 2- Critical workers and teachers, those with moderate risk comorbidities, those living in homeless shelters, prison populations, older adults not living in congregate settings.
Phase 3- young adults and children, other members of the workforce.
Phase 4- all other US citizens.
*Within each population group, CDC social vulnerability scale should be used to locate geographies at highest risk
**Attention should be paid to vaccinating with consideration for the family context (more efficient and potentially more effective vaccination effort)
2. Cost should not be a barrier. Coordination is critical. We need to leverage existing systems and partnerships among government and non-governmental organizations to ensure equitable distribution of vaccine
3. Vaccine should be no cost to individual
4. Create and fund a vaccine risk communication and community engagement program to support the health authorities in ensuring there is vaccine uptake in communities
5. Develop and launch a vaccine promotion campaign to confront vaccine hesitancy
6. Develop an evidence base for effective strategies for vaccine promotion and acceptance (basically emphasizing that we are learning as we go along this process and ensuring we understand the needs of diverse communities)
7. Support equitable allocation of vaccine globally, including a recommendation to opt in to global COVAX facility and commit to allocation globally (they suggest maybe 10% of supply for global allocation and providing support to the WHO)
This document has truly set a new standard for public health and how it is expected to address crises moving forward. Although some of these findings may seem unfair at the surface, as they seemingly place different values on different lives, when you look deeper you note that the committee emphasizes how every individual has equal dignity and worth, and that the distinction is based on very narrow social roles such as provision of health care. I’ll leave you with an inspiring sentiment from a talk with the State Health Officers where Former CDC Director William Foege eloquently answers the question of how the philosophy of public health relates to the philosophy of medicine. “The philosophy of science is to break down the walls of ignorance and to try to find truth. The philosophy behind medicine is to use that truth for every individual patient, but the philosophy behind public health is to use that truth for everyone, and so the real philosophy behind public health becomes social justice”