Who should be first in line?
Bioethicists warn distribution should address systemic racism
When a vaccine is made available, some experts say certain groups should be given priority in order to address the inequities of the pandemic,
When a COVID-19 vaccine is available, who should get it first?
It’s a question bioethicists, epidemiologists and public health experts are wrestling with now, even as a safe and effective vaccine remains an uncertain goal.
Dr. Theresa Tam, Canada’s chief public health officer, has said she is “cautiously optimistic” a safe and effective vaccine will be available in the “first quarter of 2021.” Prime Minister Justin Trudeau reiterated that timeline on Monday amid promising early results from pharmaceutical giant Pfizer Inc.’s potential vaccine.
Whenever it arrives, there is a presumption that demand for the vaccine will initially outstrip supply, so governments will have to develop a clear plan for who should be prioritized.
Canada’s National Advisory Committee on Immunization released preliminary guidelines recently identifying four key groups for prioritization: 1) those at high risk of severe illness or death, including older people and people with high-risk conditions; 2) people most likely to transmit the virus to those who are high risk, including front-line health-care workers; 3) essential workers who can’t do their jobs from home; and 4) others whose living and working conditions put them at elevated risk of infection and where infection could have “disproportionate” consequences.
The guidelines, which are non-binding and meant to advise regional public health officials, are necessarily vague given the uncertainty around a potential vaccine and how scarce initial doses might be.
But in light of the clear disproportionate impact of COVID-19 on racialized and lower-income people, some experts are calling for a more explicit approach to reducing the inequities revealed by the coronavirus by ensuring those who have borne the heaviest burden are prioritized.
In a report released last month, the U.S. National Academy of Sciences said addressing systemic racism and the underlying causes of health inequities should be a priority for COVID-19 vaccine allocation.
“Mitigating these inequities by explicitly addressing the higher burden of COVID-19 experienced by these populations is a moral imperative of any equitable vaccine allocation framework,” reads the report.
The academy identifies high-risk groups similar to the Canadian guidelines, but also recommends applying a vulnerability index — some composite measure of socioeconomic indicators — to prioritize certain communities and geographic areas within those high-risk groups.
“They’re basically saying do this riskbased approach to start with, but in addition, within each of the phases prioritize worse-off communities within those phases,” said Harald Schmidt, an assistant professor of medical ethics and health policy at the University of Pennsylvania. “If you’re a neurosurgeon who lives in a wealthy suburb and drives to work and has very minimal exposure during their work, you have a very different need for a vaccine than if you’re a nurse who takes public transport and lives with multiple generations in a small apartment.”
The discussion comes in the midst of
COVID-19’s second wave with Ontario this past week reporting an average of almost 1,300 new cases per day.
The disparities in infection rates by race, income and geography are stark. In Toronto, racialized people account for 82 per cent of infections, although they comprise just 52 per cent of the overall population. People with a household income of less than $50,000 account for 51 per cent, while making up just 29 per cent of the population. Neighbourhoods in the city’s northwest corner have case rates that are 10 times higher than in the least-affected parts of the city.
Schmidt, who was not involved in the academy’s report, said their recommendations mark a significant shift from the standard utilitarian approach to health resource allocation, which often translates to maximizing the total life years saved and tends to favour populations that are already better off.
Schmidt has written that vaccine rationing strategies should give priority to groups that have been “structurally and historically disadvantaged, even if this means that overall life years gained may be lower.”
If we don’t do that, he said, we will “replicate patterns of disadvantage” and “just repeat everything that led to the differences in life expectancy being what they are at the moment.”
Although the call to address systemic racism is not as explicit in the Canadian guidelines, equity is included as a “guiding principle” and the report concludes with a warning: “Existing inequities magnified by this pandemic may be exacerbated with the inequitable allocation of vaccines.”
A spokesperson for Ontario’s Ministry of Health said they are reviewing the guidelines released by the National Advisory Committee on Immunization and “working closely” with the federal government “to plan for the delivery of a COVID-19 vaccine when one becomes available.”
Maxwell Smith, a bioethicist and assistant professor at Western University, said it’s important for policy-makers to be clear about the goals of any vaccine strategy, transparent about the underlying principles guiding their decisions and explicit in their value judgments to ensure public trust in the process.
Which groups should be prioritized to receive the vaccine will differ if the goal is to reduce the total number of deaths, rather than end the spread of the virus as quickly as possible, he said.
“The evidence alone won’t tell us what the right aim is. So we have to come up with an answer for what the right aim is.”
Alison Thompson, a University of Toronto professor and public health ethicist, said groups that are disproportionately affected by COVID-19 tend to be groups that also have low trust in the health system, and identifying them to be early recipients of a new vaccine could create the impression that they’re being used as guinea pigs.
“So there’s a real need for consultation with groups like that to talk about if they want to be prioritized and what kind of monitoring for adverse events is available to them,” she said.
Thompson, who is a member of Ontario’s Bioethics Table, an advisory body to the Ministry of Health, said there have been “late-in-the-game efforts” to consult with Black, Indigenous and other racialized communities, but there needs to be “much more robust conversation with those groups” and also with the public at large, she said. “Some of the questions around this are empirical and science can answer them, but a lot of this has to do with our values.”