Nations need to fight issues of justice and appropriateness. They need to decide how to balance saving the lives of the most vulnerable from stopping the spread of the virus against the need to keep key workers – wherever they are defined – at work.
Tough decisions await: Who goes first, second or third?
In France, scientific advisory bodies have identified high-priority people whose age and occupation make them vulnerable. But while the doses are limited? Officials can e.g. Having to choose between the 26-year-old taxi driver in Paris, who shares an enclosed space all day with his clients, and the 69-year-old investor who works remotely from his villa in Provence, but whose age increases his chances of covid- 1
How do nations weigh other risk groups? Obesity is a comorbidity for serious complications from covid-19. Do the overweight in the richest countries jump in the queue – or just the seriously overweight? What protection does Britain or the United States owe to racial and ethnic minorities who make up an oversized proportion of those who die?
Allocation decisions can crystallize in the United States with a decision made by the Centers for Disease Control and Prevention within a few days of vaccine approval. The National Academies of Science, Technology, and Medicine called addressing racial inequalities a “moral imperative.”
Some countries also want to target groups with the greatest potential to spread the virus. Prisons have been hot spots for infection all over the world. Universities have that too. Would people at lower risk be okay, knowing that they are below those who have committed crimes or partying students who have violated public health restrictions?
As the lists begin to emerge, many nations agree that the first priority should be frontline medical workers along with first responders, such as ambulance personnel. But even within the category of heath care workers, questions arise as to which ones. The UK National Health Service, for example, employs 1.4 million workers. Not everyone interacts with patients.
Numerous task forces say the next in line should be the very elderly who are most at risk for serious illness and death from covid-19.
Japan aims to distribute vaccines in line with medical risks with the elderly right in front of the line, the health ministry announced this month.
In Europe, health officials appear likely to be leaning towards early inoculation of residents and carers in nursing homes, where the virus has taken its biggest toll – and where governments in Belgium, Britain, Spain and elsewhere have been embarrassed by their failure.
From there, the trade-offs become more complete.
“The low-hanging fruit is as it is obviously obvious, but then it becomes difficult,” said Paul Hunter, professor of medicine at the University of East Anglia. “You clearly want to protect heath care professionals and residents in nursing homes. Then extremely vulnerable. It’s easy. So important workers? It could be a very large group, ”Hunter said. “I’m glad I do not have to make those decisions, but someone does.”
Experts say decisions must be transparent and based on criteria accepted by society, not just officials or politicians. Understanding why governments favor one group over another can be crucial in getting citizens to roll up their sleeves – or wait patiently for their turn.
Germany’s vaccine commission said it would present a research – supported ranking with more details on who gets early access before the end of the year. “For evidence-based reasons, we want to make transparent why priority rankings are assigned to specific groups,” the German commission said. It added that the location would be adjusted with new scientific evidence or new vaccines.
In France, the public is actively consulted about priorities. In the UK, they are not – which has led to complaints of injustice from unions.
In the House of Lords of the British Parliament recently, Dale Campbell-Savors, a Labor gentleman, called for “the vulnerable, itinerant, homeless and residents in night shelter” to be given “absolute priority”.
“It’s the least we can do for those in need,” he said.
Colin Moynihan, the lord of a Conservative party, had his own pitch, pushing for the athletes and their entourage to follow priority, trying to represent Britain at the 2021 Olympics in Tokyo.
Japan, for its part, has promised to offer vaccines to the entire population by mid-2021 – which would be in time for the Olympics – and has pre-ordered supplies from various potential vaccine manufacturers.
Philip Clarke, a health economist at the University of Oxford, said the urgency of the priority lists will depend on how long it takes for vaccines to become widely available.
“That means if everyone has access to a shot over a period of weeks, it might not matter who goes first or last,” he said. “But if vaccines are rolled out slowly over many months, it might matter a lot who goes first or last.”
For smaller and poorer countries that could not afford to pre-order before vaccines were approved, the hierarchy will be even more critical.
Clarke said he was surprised that there has not yet been a broader public debate in most societies – as it could literally be a matter of life or death for individuals and economies.
In the UK, after vaccination of medical workers and nursing homes, the government leans towards distributing the vaccine by age group – over 80s followed by over 75s, over 70s, over 65s – before extending it to other risk groups.
Clarke said the allocation by age was “controllable and simple,” and the public might trust such an approach, “but you might prevent more covid and save more lives with better lists.”
He said in the UK that some professions were clearly more risky than others. “The first wave of the pandemic showed that security guards and delivery drivers had worse mortality rates than health workers.”
The German Vaccine Commission said shots should be given to people whose work in society fulfills “particularly relevant functions and which cannot be easily replaced.” Although many people think they are irreplaceable, Germany suggests that these workers are public health officers, police, firefighters and teachers.
In China, officials want to include dockworkers who provide the vital service of loading and unloading cargo ships operating their trade.
In Indonesia, the government is focusing on protecting younger workers to keep the economy going.
What about political leaders? Should members of the House and Senate – or members of the German Bundestag, the British Parliament and the National People’s Congress of China – be given priority access regardless of age and health?
In its early guidelines, the World Health Organization said yes, early access for government leaders makes sense, but it warned that the beneficiaries should include “a very small number of individuals.”
Russia – where President Vladimir Putin’s daughter has been vaccinated – may have already exceeded these limits.
Russia has administered thousands of doses of its Sputnik V vaccine. Health workers at covid-19 wards were among the first recipients. More than 45,000 of them have been shot, according to Alexander Gintsburg, director of the Gamaleya National Center for Epidemiology and Microbiology, which developed Russia’s vaccine.
Bloomberg News reported in July that Russian politicians, officials and oligarchs gained access to the vaccine beginning in April before it was registered.
Health officials reject this claim. But many senior Russian officials have now been vaccinated, including Defense Minister Sergei Shoigu and Moscow Mayor Sergei Sobyanin. Sobyanin said it would have been difficult for him to fight for the vaccine if he did not get it.
In China, the calculation of who is vaccinated first has been different than in the West, as the greatest risk is imported cases. China has largely eliminated the domestic spread of the virus through exhaustive measures, such as testing all residents of a city when a new cluster emerges.
China has put citizens with overseas travel plans among the groups prioritized for emergency vaccines. Aside from preventing its citizens from bringing the virus home again, it also reduces the risk of Chinese nationals becoming carriers of the virus abroad, at a time when anti-Chinese sentiment is high in many places due to the pandemic’s origins in China.
China’s vaccine allocation has also been affected by the fact that emergency use began long before the experimental vaccines proved to be safe and effective. They still have not been – at least not in any medical record.
So the first groups to gain access in China were those who could be trusted to accept personal risks on behalf of their nation: soldiers, diplomats, workers in state-owned enterprises, and employees of the vaccine manufacturers themselves.
Sinovac Biotech’s CEO said in September that 90 percent of his company’s employees and their families had taken their experimental vaccine.
Zheng Zhongwei, an official with China’s National Health Commission, said last month that the population in general had been classified for vaccine access at three levels: those in high-risk environments, vulnerable groups and the general public. Vulnerable groups include children in China.
“Whatever region they are in, if they meet these characteristics, they should be prioritized for the vaccine,” he said.
Another alternative might be to focus less on people’s characteristics but regions. In some countries, governments may first target hot spots or focus on dense urban populations versus those who are more isolated in the countryside.
Penny Ward, visiting professor of pharmaceutical medicine at King’s College London, said the allocation of vaccines in different countries may depend on what the vaccines prove to work best.
Ward said the UK’s focus on inoculating the elderly is based on the presumption that the vaccine will predominantly protect against disease rather than prevent infection altogether. And then British officials are targeting people who are most likely to suffer from serious illness that requires hospitalization and death.
“This approach also requires that a lower proportion of the population be vaccinated than would be necessary if the strategy were to be to prevent infection and reduce short-term outbreaks in society, which would require vaccination of a high proportion of the entire population,” she said. .
Yet another approach would be to go random. In the movie “Contagion” from 2011, the world is saved by a vaccine, made from an attenuated virus, which is distributed to the public by a lottery based on birthdays, not age.
It is not a far-fetched idea. Randomization or a weighted lottery has previously been used to distribute scarce, life-saving drugs – most recently the allocation of remdesivir for the treatment of seriously ill covid-19 patients.
Dou reported from Seoul, Dixon reported from Moscow and Beck reported from Berlin. Simon Denyer in Tokyo, Liu Yang in Beijing, Joanna Slater in New Delhi, Gabriela Martinez in Mexico City and Terrence McCoy in Rio de Janeiro contributed to this report.