Last week we had a little “accident” at my university. Due to a misstep somewhere, some biology graduate students got their Covid-19 vaccinations before healthcare workers at the hospital. These students had nothing to do with clinical research, but apparently got their jab tickets because they are, like me, part of the Biological Science Division, which includes the University hospital that is currently scheduling shots for its own workers. I suspect that someone messed up the scheduling.
This distressed me quite a bit, as I’m waiting patiently in line for my jab, and feel that healthcare workers should certainly get the first shots (they haven’t finished yet). But some of the students, surely knowing this was an error, ran over immediately and got their shots. (Others realized the potential error and made inquiries.) That, of course, means that a second dose had to be reserved for their second shot, and that some essential healthcare workers had to wait. I’ve let the powers-that-be know about the error so this won’t happen again. (It was surely a mistake, and these things will happen.)
In fact, this kind of error happened in another U.S. hospital last week (it was on the news; I can’t remember where), and caused a huge furor. Those people who want the shots—and thankfully their numbers are growing—are rightfully incensed by “line jumping”. I suspect that if rich people could pay to get vaccinated early, it would create huge turmoil, and rightly so. After all, is a rich person’s life worth more than a poor one’s? Not in my book. But according to LA Magazine, the wealthy are already angling to get early jabs.
But regardless of existing ordering, the question of whose lives are worth more is the real topic of this discussion, moderated by the New York Times‘s Emily Bazelon with a good lineup of participants. As I discussed the other day, the CDC originally wanted to vaccinate essential non-healthcare workers before older people—even though their models showed that this ordering would lead to more deaths than the reverse ordering—because the second group was “whiter”. That’s been changed, but race is also a central issue in this discussion. Click on the screenshot to read it:
Here’s the lineup, which is a good group:
Ngozi Ezike, an internist and pediatrician, is the director of the Illinois Department of Public Health. She previously worked for 15 years in the Cook County health system, where she delivered inpatient and outpatient care and directed medical services at the Cook County Juvenile Detention Center.
Gregg Gonsalves is a professor of epidemiology at the Yale School of Public Health and an AIDS and global health activist. He is also a 2018 MacArthur Fellow.
Juliette Kayyem is a professor at the Harvard Kennedy School, where she is the faculty chairwoman of the Security and Global Health program, and a former assistant secretary at the Department of Homeland Security. She is advising a number of public and private entities on pandemic response and vaccine distribution.
Siddhartha Mukherjee is a professor of medicine at Columbia University and a cancer physician and researcher. He is the author of “The Emperor of All Maladies: A Biography of Cancer,” which was the winner of the 2011 Pulitzer Prize in general nonfiction. He is a founder of a vaccine-delivery platform called Othena.
Peter Singer is a bioethics professor at Princeton, author of “The Life You Can Save” and founder of the charity of the same name. His most recent book is “Why Vegan?”
Emily Bazelon, a staff writer for The New York Times Magazine, moderated the discussion, which has been edited and condensed for clarity, with material added from follow-up interviews.
I’m not going to reprise the whole long exchange, but just mention a few high points.
What surprised me is that race, though the first thing Bazelon brought up (this is, of course, the NYT), wasn’t an element of dissent. Everyone agreed that since people of color have a higher risk of dying from the virus, they should, as Singer said get the first jabs, though he notes the unethicality of the CDC’s original recommendation:
Peter Singer: It makes sense to protect those who are most vulnerable, whether the vulnerability is social or health-related. So if the evidence indicates that Black, Latino or Native American people have a higher risk of dying from the virus, they should be offered the vaccine ahead of others of the same age who are at lower risk because they are white or Asian. But a document that was circulated in November to A.C.I.P., the C.D.C. panel, suggested that the fact that racial and ethnic minorities are underrepresented among those older than 65 is a reason for giving lower priority to that age group as a whole and instead vaccinating more than 100 million “essential workers” ahead of them. The effect would be that more people over all would die — and also that more members of racial and ethnic minorities would die, because the higher fatality rate in older people would outweigh their lower share of representation in that age group. That’s absurd. Equity for disadvantaged minorities can’t tell us to distribute vaccines in a manner that will mean more deaths in those communities themselves.
In fact, I found the whole discussion much less engaging than I thought it would be—except for Singer’s comments. He’s always provocative, and though I’m initially shocked by some of his views about ethics, like recommending euthanasia for terminally deformed or sick newborns, I usually come around to his way of thinking. And so he makes a statement that may shock people, but has some merit:
Singer: The objective that we should aim for is to reduce years of life lost. I know a lot of people are talking just about saving lives. But I do think that it’s different whether somebody dies at 90 or 50 or a younger age still. So, in my view, that’s what we should be looking at.
. . . The basis for the British government’s plan is, of course, to treat those who are at the highest risk of dying and thus to minimize the number of deaths. But it is also important to consider what your life would be like if you don’t die.
It might still be that we should protect 90-year-olds first, based on data suggesting that 90-plus are at eight times the risk of dying from the virus as people around 70, whereas their life-expectancy difference is roughly something like four and a half years as against 15 years for 70-year-olds. If that’s correct, then the higher risk to the 90-year-olds outweighs the difference in life expectancy.
He also suggests that older people without the ability to give consent, like those with dementia, might not be vaccinated, arguing that “many doctors tell me that when patients have severe dementia, they do not treat conditions like pneumonia. Even though you could treat it with antibiotics relatively simply, they say, there’s a time to let a patient go.” (He also says that families should of course be consulted.)
Mukherjee seems to spend a fair amount of his discussion promoting his vaccine-delivery platform (see description above). If he doesn’t profit from the platform, that’s fine, but if he does (and the platform’s website and this interview suggest that it’s part of his own company, Cura), statements like the following seem self-promoting:
Mukherjee: When you talk about trucks breaking down, that’s one problem. There’s a second, equally important but I think neglected logistical problem, which a company I co-founded, Othena, is trying to solve. The Pfizer and the Moderna vaccines require booster shots. They need to be tracked, and they need monitoring and auditing. What’s the reminder system for telling you to come back for your second dose and for tracking which populations are getting the vaccine? This is a data-management challenge. We are piloting Othena software to address this issue in Orange County and other places in the country.
Current software systems are not patient-based, and vaccination will only be scalable if patients can manage their own vaccination.
He repeats this emphasis, but I’ll move on.
Two other matters in the exchange are worth considering. First, there’s the fact that areas like the U.S., Australia, New Zealand, and Europe are clearly getting priority for the vaccines, even though places like Brazil are severely afflicted, and African countries might soon be in the same situation. (I heard on the news last night that New Zealand has ordered enough vaccine to do its entire population more than four times over!) Is that ethical? Why should any countries get priority over others, much less reserve excess vaccine? I haven’t thought much about this, but offer it for your consideration.
And there’s the issue of patent-breaking—of poorer countries stealing the patents on vaccines to help their residents, as (says Mukherjee) India did with anti-retroviral drugs during the AIDS crisis. To me, if it saves lives, it’s worth considering, and perhaps companies shouldn’t go after patent-breakers so long as the stolen vaccines are good ones.
As for the ordering, I’m happy with where it is, and if they decide to vaccinate bartenders or truck drivers before me, well, so be it. This is a complicated process, and different states will have different priorities. It turns out that American states do have considerable leeway about the order of vaccination, and I haven’t paid much attention to the variation: I just watch the news and have registered at the hospital here to be informed when my number is up.
And about jumping the queue with money, here’s part of that discussion:
Mukherjee: Peter, what if you could jump the queue, and get 10 doses of vaccine for your friends and family, if you contribute 5,000 or 10,000 or 500,000 doses for the Global South. Would you be open to such an option?
Singer: Yes, I would be, I think. Clearly, for a utilitarian like me, the benefits greatly outweigh the costs.
Gonsalves: It won’t happen. But there will be huge numbers of rich people who will jump the line for the vaccine and not give anything back.
I don’t see how rich people can jump the line given the guidelines, but Gonsalves is sure that will happen. If it does, it will really piss people off. After all, this isn’t a queue to get into the movies or buy toilet paper, but one that can affect your chance of dying.