Debate over vaccine priority is growing
With the coronavirus pandemic surging and initial vaccine supplies limited, the U.S. faces a hard choice: Should the country’s immunization program focus in the early months on the elderly and people with serious medical conditions, who are dying of the virus at the highest rates, or on essential workers, an expansive category encompassing Americans who have borne the greatest risk of infection?
Health care workers and the frailest of the elderly — residents of long-term care facilities — will almost certainly get the first shots, under guidelines the Centers for Disease Control and Prevention issued Thursday. But with vaccination expected to start this month, the debate among federal and state health officials aboutwho goes next, and lobbying from outside groups to be included, is growing more urgent.
Ultimately, the choice comes down to whether preventing death or curbing the spread of the virus and returning to some semblance of normalcy is the highest priority.
“If your goal is to maximize the preservation of human life, then youwould bias the vaccine toward older Americans,” Dr. Scott Gottlieb, a former Food and Drug Administration commissioner, said recently. “If your goal is to reduce the rate of infection, then you would prioritize essential workers. So it depends what impact you’re trying to achieve.”
The trade-off between the two is muddied by the definition of “essential workers” used by the CDC making up nearly 70 percent of the U.S. workforce, sweeping in not just grocery store clerks and emergency responders but tugboat operators, exterminators and nuclear energy workers. Some labor economists and public health officials consider the category overly broad and say it should be narrowed to only those who interact in person with the public.
An independent committee of medical experts that advises the CDC on immunization practices will soon vote on whom to recommend for the second phase of vaccination — “Phase1b.” In ameeting last month, all voting members of the committee indicated support for putting essential workers ahead of people 65 and older and those with high-risk health conditions.
Historically, the committee relied on scientific evidence to inform its decisions. But now the members are weighing social justice concerns as well, noted Lisa Prosser, a professor of health policy and decision sciences at the University of Michigan.
Differing views
“To me, the issue of ethics is very significant, very important for this country,” Dr. Peter Szilagyi, a committee member and a pediatrics professor at the University of California, Los Angeles, said at the time of the vote, “and clearly favors the essentialworker group because of the high proportion of minority, low-income and low-education workers among essential workers.”
That position runs counter to frameworks proposed by the World Health Organization; the National Academies of Sciences, Engineering, and Medicine; and many countries, which say reducing deaths should be the unequivocal priority and that older and sicker people should go before the workers, a view shared by many in public health and medicine.
Dr. Robert Redfield, CDC director and the nation’s top public health official, reminded the advisory committee of the importance of older people, saying in a statement Thursday that he looked forward to “future recommendations that, based on vaccine availability, demonstrate thatwe as a nationalso prioritize the elderly.”
Once the committee votes, Redfield will decide whether to accept its recommendations as the official guidance of the agency. Only rarely does a CDC director reject a recommendation from the committee, whose 14 members are selected by the Health and Human Services secretary, serve 4½-year terms and have never confronted a task as high in profile as this one.
But ultimately, the decision will be up to governors and state and local health officials. They are not required to followCDC guidelines, though historically, they have done so.
There are about 90 million essential workers nationwide, as defined by a division of the Homeland Security Department that compiled a roster of jobs that help maintain critical infrastructure during a pandemic. That list is long, and because therewon’t be enough doses to reach everyone at first, states are preparing to make tough decisions. Louisiana’s preliminary plan, for example, puts prison guards and food processing workers ahead of teachers and grocery employees. Nevada’s prioritizes education and public transit workers over those in retail and food processing.
Status of teachers
At this early point, many state plans put at least some people who are older and live independently, or people who have medical conditions, ahead of most essential workers, though that could change after the CDC committee makes a formal recommendation on the next phase.
One occupation whose priority is being hotly debated is teaching. The CDC includes educators as essential workers. But not everyone agrees with that designation.
Marc Lipsitch, an infectious disease public health researcher at Harvard’s T.H. Chan School of Public Health, argued that teachers should not be included as essential workers if a central goal of the committee is to reduce health inequities.
“Teachers have middleclass salaries, are very often white, and they have college degrees,” he said. “Of course they should be treated better, but they are not among the most mistreated of workers.”
Elise Gould, a senior economist at the Economic Policy Institute, disagreed. Teachers not only ensure that children do not fall further behind in their education, she said, but are also critical to the workforce at large.
“When you talk about disproportionate impact and you’re concerned about people getting back into the labor force, many are mothers, and they will have a harder time if their children don’t have a reliable place to go,” she said. “And if you think generally about people who have jobs where they can’t telework, they are disproportionately Black and brown. They’ll have more of a challenge when child care is an issue.”
In September, academic researchers analyzed the Homeland Security Department’s list of essential workers and found that it broadly mirrored the demographics of the U.S. labor force. The researchers proposed a narrower, more vulnerable category: “front-line workers,” such as food deliverers, cashiers and emergency medical technicians, who must work face to face with others and are thus at greater risk of contracting the virus.
By this definition, said Francine Blau, a labor economist at Cornell University and an author of the study, teachers belong in the larger category of essential workers. However, only when they work in classrooms rather than remotely, she said, would they fit into the “front-line” group. Individual states categorize teachers differently.
The essential workers on the federal list make up nearly 70 percent of the U.S. labor force, the researchers said, compared with 42 percent for the front-line workers. Women made up 39 percent of front-line workers and, in certain occupations, far more. Front-line workers’ education levels are lower, as are their wages — on average, just under $22 an hour. The proportion of Black and Hispanic workers is higher than in the broader category of essential workers.
Some health policy experts said that to prioritize preventing deaths rather than reducing virus transmission was simply a pragmatic choice because there won’t be enough vaccine initially available to make a meaningful dent in contagion. A more effective use of limited quantities, they say, is to save the lives of the most frail.
Vulnerability factors
Vaccine trial results so far showonly that the shots can protect the individuals who receive them. The trials have not yet demonstrated that a vaccinated person would not infect others. Although scientists believe that is likely to be the case, it has yet to be proved.
Harald Schmidt, an expert in ethics and health policy at the University of Pennsylvania, said it is reasonable to put essential workers ahead of older adults, given their risks and that they are disproportionately minorities. “Older populations arewhiter, ” Schmidt said. “Society is structured in away that enables them to live longer. Instead of giving additional health benefits to those who already had more of them, we can start to level the playing field a bit.”
But to protect older people more at risk, he called on the CDC committee to also integrate the agency’s own “social vulnerability index.”
The index includes 15 measures derived from the census — such as overcrowded housing, lack of vehicle access and poverty — to determine howurgently a community needs health support, with the goal of reducing inequities.
In a new analysis of the states’ preliminary vaccine plans, Schmidt found that at least 18 states intended to apply the index. Tennessee, for one, has indicated that it will reserve some of its early allotments for disadvantaged communities.
Further complicating matters, the different priority groups discussed by the CDC committee are overlapping; many essential workers have high-risk conditions, and some are older than 65. Some states have suggested that they will prioritize only essential workers who come face to face with the public, while others have not prioritized them at all.
Even some people whose allegiance lies with one group have made the case that others should have an earlier claim on the vaccine. Marc Perrone, president of the United Food and Commercial Workers Union, which represents 1.3million grocery and food processing workers, said that despite the high rate of infection among his members, he thought that older adults should go first.
One uncertainty: Given the high rates of apprehension swirling around this vaccine, how many people in the early groups will actually line up for it?
“If a high proportion of essential workers decline to get the vaccine, states will have to quickly move on to the next group anyway,” said Prosser, the University of Michigan health policy professor. “Because once the vaccines arrive, they will have to be used in a certain amount of time before they degrade.”