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The ethical challenges that have arisen so far in the coronavirus pandemic largely boil down to the age-old struggle between individual freedoms and the public good. Issues like restricting movement and commerce to protect community health or requiring health care workers to treat infected patients, even at the risk of getting infected themselves, are specific examples of this larger dilemma. These debates, even in the United States where rugged individualism is celebrated, have been settled for the most part in favor of the common good.

Ethical questions in the next phase of the pandemic are bound to be more fractious. They will turn from our common goal of maximizing the greater good to brokering disagreements between individual groups that may not be so easy to resolve.

The development of a vaccine is bound to raise ethical questions like these: Who should get it first? How will we judge claims to it? How will we give priority to different groups or communities?

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These issues may come up sooner than expected. The biotechnology company Moderna has tested a new vaccine on eight patients that appeared to be safe and stimulated an immune response against SARS-CoV-2, the virus that causes Covid-19. Other vaccine candidates are in the pipeline. University of Oxford scientists, for example, have announced they will begin testing of a new coronavirus vaccine in 6,000 volunteers. If the vaccine is effective, it could be available by early fall (though most experts say an effective vaccine won’t be available till next year).

But as we’ve seen with viral testing kits, manufacturing and distribution problems will almost immediately create shortages, at least in the short term. To quickly manufacture the nearly 8 billion doses required to protect everyone on the planet will be impossible.

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When a vaccine comes on the market, the U.S. Centers for Disease Control and Prevention and other advisory groups will issue guidelines on who should get first dibs. The top tier will include health care and other workers whose jobs are considered essential in the pandemic. People most likely to die if stricken may also get priority.

But these are just guidelines. The ultimate decisions on who gets vaccinated will be made by state and local health departments and community hospitals interpreting the federal guidelines.

The decisions will be fraught, as different groups jockey for their place in line. There will be disagreements.

In Texas during the 2009 H1N1 influenza pandemic, for example, some health care providers weren’t sure if they should interpret vaccination guidelines from the CDC as giving priority to police officers and firefighters. Others in the state argued that school nurses and teachers should be in the top tier. Some senior citizens were perplexed that they weren’t considered a priority.

When we eventually reach the point of having a vaccine in hand but in short supply, I worry that disadvantaged communities, which have been among the hardest hit by Covid-19, will be left out. In state after state, black and brown communities are disproportionately infected and dying.

In New York City, for example, blacks and Latinos are dying at twice the rate of the general population. In Chicago, African-Americans account for nearly 70% of coronavirus deaths but make up 30% of the city’s population. In Los Angeles, people in low-income neighborhoods are three times as likely to die as those in wealthier neighborhoods.

The reasons behind these differences aren’t fully known, but almost certainly include poor community infrastructure like lack of stable housing, lack of health insurance, and social segregation. Minorities tend to experience worse outcomes in a plethora of diseases; there was no reason to think that their outcomes in this pandemic would be any different.

Residents in these communities will need the vaccine as much as — if not more than — wealthy and connected citizens. To ensure they get their fair share, they will need representation to advocate for their interests when allocation decisions are made. They have the right to know how authorities will distribute the vaccine to their neighborhoods, as transportation problems may hinder their ability to go to hospitals or other vaccination sites.

If doctors are prioritized for getting the vaccine, will the delivery persons, grocery store clerks, and home health aides who often live in underserved communities also be given preference? Not giving due priority to these communities will only deepen their mistrust in the health care system that is already present and was worsened by debacles like the bungled rescue efforts after Hurricane Katrina.

Covid-19 does not respect borders. Rates of infection and deaths in countries in Africa have been lower than in Europe, Asia, and the United States, but there is every reason to believe they will eventually bear a disproportionate share, as they have from other infectious diseases over the past century. Poor countries have less money to buy vaccines and drugs even though they might eventually have more need for them. We must plan now to ensure they get their share of Covid-19 therapies.

Rationing antiviral drugs and other therapies has largely been absent in the U.S. during the Covid-19 pandemic, largely because no treatment has been shown to be of clear-cut benefit. That will change if and when a vaccine becomes available, and difficult choices will need to be made about allocation.

To meet that challenge head on, the CDC must develop a plan — with input from the states — to ensure that the vaccine is available wherever it is most needed and that disadvantaged communities in this country get their fair share. The plan must communicate clearly why certain groups will receive priority for early vaccination. It should also include a means to evaluate and rapidly redress grievances in the allocation process.

If we are to avoid worsening mistrust in health care and in government and possibly even social strife, we need transparent and ethical federal guidelines for distributing a Covid-19 vaccine now, before we must begin making the difficult decisions about allocating it.

Sandeep Jauhar is a cardiologist at Northwell Health in New York. His most recent book is “Heart: A History” (Farrar, Straus and Giroux, 2018).

  • The first step involves policies on applying for treatment and vaccination other than the ‘free for all’ of anyone simply walking into a facility or hospital. Given that minority communities are essentially isolated from the wider community and the elderly are are no longer employed and live alone, access will be largely determined by who has the loudest voice. There is no existing body to make decisions on distribution nor has there ever been one excepting government but government is extremely inefficient and slow as a policy maker. Furthermore, government is incapable of enforcing its policies short of extended appeals and legal actions that tend to delay decisions for years. The priority issue has already become almost totally politicized and long before any vaccine is available.

  • Vaccines ercate go away covid 19
    Go away virus so I can play with my friends outside and so I can play chalk balll park and figet spinner soccer football Halloween ball baseball basketball
    Playing at little park playing on bounce pony mocile ladder and slide and monkey bar is fun and interesting thing to do at thr little park and so I can go insect hunting is fun and interesting

  • Since there are many companies developing vaccines, I assume that not all the vaccines will have the same exact effect in recipients. And since it is critical to reduce the number of positive cases of COVID 19, is it possible to administer more than one vaccine preparation to individuals? That is, would multiple vaccines interact with each other in dangerous or problematic ways, or could this be a way of hedging bets about the fastest way to quash the pandemic?

  • This is silly. Anyone getting a vaccination vaccinates everyone else to some extent. So we would allocate vaccinations first to the most vulnerable populations and those that are most likely to spread the virus, to help everyone else. Where is the controversy?

  • Why does 7 go before ten? You interested in foreign lands but can’t service foreigners in your own land first.I smell propaganda folded in this piece. Just like how they had a vaccine to test on Africa months ago before being exposed.

    • hi, i’m assuming this is a comment on my ’10cent’ list. I was placing the priorities based on
      a) potential threat to opening up society with the next numbered step, and
      b) ramp-ups in the economy/supply chain that happens after vaccination in the next steps

      so the 7th step, giving assistance to foreign hospitals (obviously i think only a partial token effort) gives the next steps of meat packing workers, etc a high amount of transparent good will, allowing greater vaccination levels from trust, and can medically reduce the high likelyhood of second-wave immigrant influx hotspots as the economy restarts. There will be many transient workers in a Depression II economy, giving assistance to nearby medical facilities helps to get trustworthy visas back in place as border supply chains reopen.

    • i’m looking at logistics and reducing likeliest 2nd wave mis-steps. I am not an expert, either — just a ’10cent’ guess… so what’s your own list ?

  • my 10cent priority list for vaccination (i’m not on it)
    1 hospital sanitation workers
    2 hospital workers
    3 police and firemen
    4 sanitation workers
    5 nursing homes, workers and elderly
    6 government workers, soc sec
    7 support to foreign hospitals
    8 meat workers
    9 resturaunt workers
    10 immigrant workers in tight quarters
    11 truckers and supply warehouses
    12 farmers
    13 factory workers

    • i would hasten to add that along with the CoViD-2 vaccine, a minimal number of other vaccines should be mandated to go along with it, such as measles.
      No measles vaccination, no CoViD-2 vaccination.

    • oops missed a few. need more coffee..
      6a Prisons, staff and inmates
      14 schools, teachers and kids

    • urgh. missed:
      5a home health aides
      7a delivery persons
      11a grocery store clerks

    • i now think i’m wrong about the antivaxers. Its better to ‘pull on a string rather than push it’. If a particular enticement or endorsement will attract them, its maybe an acceptable bargain. Maybe a way to attract them would be an allowance for no measles vaccination if the CoV-2 vaccination is done, or a cash payout. I’d think that might work as participation starts to decline later in the effort.

  • Not a bad article, but some definite mistakes. 1. It’s not a struggle between individual freedoms and the “public good“. That makes it sound like we’re all monsters if we choose individual freedoms. We’re all in favor of public good, which includes individual freedoms. It’s a struggle between the free choice and government intervention. Got to get that one straight. 2. Eight billion doses are not required. Not even close. Easily half of the 8 billion will elect not to be vaccinated. Of the 4 billion left over, those under the age of 30 have very little need for the vaccination. The initial supply will go to the most vulnerable. 3. You “worry“ about disadvantaged communities and immediately refer to black and brown. That’s pretty sad and improper inference, and something makes me think you’re not really that worried. 4. Nothing is ever going to be transparent. Simple fact.

    • It’s the new racism, which is considered a required token of right thinking among those who loudly denounce 19th century racism.

    • You’re so off base it is like reading the twilight zone.

      Without a societal purpose, there is no reason for a vaccine. The societal purpose of a vaccine is herd immunity. Herd immunity will protect all including those that don’t want to participate, not just the vulnerable. Herd immunity is achieved at different levels of vaccination depending on many factors.

      The vaccination availability should be targeted at optimizing every factor possible to achieve herd immunity with as few doses as possible. In general, targeting the most likely spreaders regardless of their vulnerability would achieve that. Many of the groups the article mentions would be among those in that group. They would include groups with high public contact like first responders, anyone working in retail, anyone in schools, etc. They would also include many of the most vulnerable, but not because of their vulnerability but because the close confinement and health problems provide for rapid spread. For similar reasons, prison populations should be vaccinated early. If you let it run rampant through prison populations, the staff and visitors will ultimately bring it into the main population. Prison populations have driven many of the outbreaks we have in the main population when you look under the hood of the outbreaks.

      Avoiding the young would definitely be very counter to achieving herd immunity. In fact, it would be so counter to the goal that it might be impossible without them. They have high mobility across regions and survive with the least symptoms and thus are more likely to spread to large numbers.

    • interesting points, all.
      it makes me realize that the ‘deplorables’, least likely to wear a mask, actually should be shoved (ungraciously) to the front of the vaccination line for my own good. maybe offer vaccinations at cannabis locations..

    • What @delphia means is “until I can get someone to euthanize all those people I look down on, I can at least use them for medical beta tests”

    • on the contrary, for myself, i realize in an epidemic the groups i might most disagree with, who i forsee as personal contagion threats as they push into public spaces with no masks, are the ones i would give vaccinations to *before* myself. I am afterwards on that prioirty list ! So i find that a wee bit interestingly ironic, since not helping others not in your own ‘tribe’ is a thing for many currently…

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