With a Covid-19 vaccine in hand, who should get it first? – STAT

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?


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. Oxford University 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.


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).

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