OPINION: Moral Tragedy Looms In Early Chaos Of U.S. COVID-19 Vaccine Distribution

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People lined up to receive the COVID-19 vaccine at a mass vaccination site in Disneyland's parking lot in Anaheim, Calif. on Jan. 13. The state says all residents 65 or older are now eligible to receive the vaccine. / Getty Images

On April 12, 1955, a wave of public relief resonated across the United States as news arrived of a vaccine that could successfully prevent polio — one of the most feared diseases in the U.S. at the time, causing "more than 15,000 cases of paralysis a year," according to the Centers for Disease Control and Prevention. To the terror of parents, many of those paralyzed or killed by polio were children.

Jonas Salk and his research team announced that their vaccine against the virus was safe and effective; the federal government quickly gave official approval, and vaccination distribution began across the U.S. within weeks.

But collective relief soon gave way to frustration. There were simply not enough doses of the vaccine to go around at the start. Even worse, the available doses weren't going to the groups deemed most in need; instead, people who were socially well-connected and wealthy were finding ways to jump the line.

Oveta Culp Hobby, Secretary of Health, Education, and Welfare at the time, voiced her concern at a conference on April 22 of that year.

"The supply of vaccine on hand now or likely to become available during the next few months is far short of the needs and demands," she said. "The theory exists in some quarters that sizeable amounts of vaccine may appear in black markets, that prices may rise beyond reason, and that, as a consequence, many individuals in the most susceptible age groups will not receive the preventive."

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First and second graders at St. Vibiana's school in Los Angeles, Calif. were among the first inoculated against polio with the Salk vaccine in the spring of 1955. / AP

In 2021, after months of daily tragedy and unprecedented collective grief, we too have found the prospect of safe haven from the current COVID-19 pandemic in the form of safe and effective vaccines. And in an echo of 1955, we are also facing a problem of limited supply and excessive demand.

Once again, at least for right now, there are simply not enough doses of vaccine for all of us to receive it immediately. And again, there are holes in vaccine distribution strategies.

It's time for the federal government — this time under the incoming Biden administration — to take a strong leadership role in holding the line and making sure that distribution of these precious vaccine doses is fair.

Early on in the coronavirus pandemic, when the Pfizer-BioNTech, Moderna, and AstraZeneca vaccines were just glimmering promises on the scientific horizon, societal consensus and intention around vaccine allocation seemed unified. Front-line health care workers and vulnerable patient populations would be given priority for the first shots.

In its framework for the equitable allocation of the COVID-19 vaccine, the National Academies of Science, Engineering and Medicine offered a bit more detail, explicitly recommending that high-risk health care workers, first responders, people with two or more underlying medical conditions, and older adults in long-term care facilities or other overcrowded settings be prioritized. That rough framework for prioritization was subsequently adopted by the CDC's vaccine advisory group.

However, the reality of vaccine distribution thus far — at a critical moment when COVID-19 cases are surging and vaccination resources are still scarce — has been marred by a patchwork of variable vaccination strategies on the local and state level, logistical inconsistency, and the exploitation of long-standing socioeconomic power structures.

When flawed vaccine prioritization schemes altogether forgot key front-line health care providers at Stanford Medical Center, the sense of betrayal felt by some doctors — snubbed medical residents and fellows — spilled into protests, during which they lamented being "first in the room" to care for COVID-19 patients but "last in line" for a vaccine. Hospital workers in New York and Boston raised similar concerns.

On a national scale, as states have expanded their vaccination pools, prioritization groups have begun to diverge. Florida, for example, in December announced it was prioritizing all adults 65 and older in its first group to get immunized, alongside "health care personnel with direct patient contact" and residents of long-term care facilities — skipping over other essential workers, such as teachers and first responders.

And this week, as other states begin to leverage the reach of national grocery store and pharmaceutical chains to hasten distribution, some of these companies tell reporters that they have no plans to check IDs to verify that those who sign up for vaccination even qualify by age.

Some people have attributed the spotty initial rollout of COVID-19 vaccine in the U.S. to bad weather, or to a lack of funding to states for the training and hiring of workers to administer the shots — all temporary problems that should soon ease, they say. On Friday, President-elect Biden called the slow rollout "a dismal failure." His proposed $1.9 trillion economic plan for pandemic relief includes, among many other things, $20 billion in funds for vaccine distribution.

Biden says his administration will work with states to quickly move to the next phase of vaccine distribution — allowing people age 65 and older as well as front-line workers like teachers, first responders and grocery store workers to get immunized. He's pledged to also work with community-based organizations and trusted health care providers to make sure people in marginalized and medically-underserved communities quickly get access to the vaccine.

But there is still reason to be deeply concerned that over the next few months — as hospital systems, states, and nations begin to distribute vaccines to the wider public — the process could become even more flawed and inequitable.

In the decades before Salk's polio vaccine, the treatment of that disease was shamefully segregated — with some medical experts even falsely and outrageously asserting that African Americans were simply not as susceptible to polio as white patients. Some medical centers — including the famed polio rehabilitation center started by President Franklin D. Roosevelt in Warm Springs, Ga. — did not accept Black patients, at least not initially.

And even after the advent of Salk's vaccine, Black children were forced to wait outside and receive their polio vaccination on the lawns of white public schools. These, and many other historical injustices have inevitably led to distrust in the U.S. health care system

Already, there are early signs that the privileged and wealthy are eager to access the vaccine before others — once again trying to buy and leverage their connections to achieve a spot at the front of the line.

The scarcity of vaccines combined with the fear and desperation surrounding the pandemic is exposing a true moral tragedy: People are willing to save themselves at the expense of others.

The prioritization of certain groups for early COVID-19 vaccination is not arbitrary. When drafting guidelines about vaccine distribution, the CDC aimed to both reduce illness and deaths by helping those most at risk, and to preserve those integral to the everyday functioning of society to be able to keep doing their essential work.

Ten months of practicing medicine as emergency physicians on the front lines of this pandemic have demonstrated one clear constant to the two of us: COVID-19 is not an equal-opportunity threat. Nor is it an equal opportunity killer. We know that those with certain medical conditions are at risk of being most severely affected by the virus, and that those over the age of 65 have a significantly higher mortality rate than the rest of us.

There is also no question that COVID-19 has disproportionately affected Black, Indigenous and Latinx communities — due to the stress of structural racism, a higher burden of the chronic illnesses that place patients at higher risk for severe infection, and economic disparities in access to transportation, affordable housing and nourishing food. All those factors collectively translate to a higher risk of exposure to the coronavirus, and to getting very sick or dying from the illness. And any "essential worker" unable to work from home is also at higher risk of being exposed and infected, as evidenced by higher seroprevalence of antibodies among groups of front-line essential workers.

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A resident of the Jackson Heights neighborhood in Tampa, Fla., got immunized against COVID-19 at St. Johns Missionary Baptist Church on Jan. 10. / Getty Images

The principles of helping those most in need while maximizing benefit is not new to medicine. On the contrary, these values are central to the foundation of biomedical ethics from many cultural traditions.

When it comes to allocating scarce resources, physicians and medical ethicists have long espoused the moral principle of "distributive justice" — the distribution of benefits to individuals should be proportional to the burdens they bear. It is invoked, for example, when doctors must decide which patient should be next in line to receive organ transplantation.

Similarly, the moral principle of "utilitarianism" — doing that which maximizes the good for the greatest number of people — is applied through disaster response protocols that dictate which patients should be treated first in a mass casualty event.

Some may argue that there is sufficient moral ambiguity to provide a loophole in the COVID-19 vaccine prioritization schemes. They may point to the CEO who operates a major business as meriting prioritization for vaccination because the product the company produces is so valuable to society. It is true that what brings "good" to society can be broadly defined.

However, when we define "good" as reducing the spread and mortality of coronavirus in our midst, it seems clear that giving the vaccine to the populations at highest risk of acquiring and dying from COVID-19 will achieve the most good.

In 1956, one year after Salk's polio vaccine was introduced to great fanfare, the National Opinion Research Center published results of a national survey of public attitudes toward the U.S. polio vaccination effort, noting that there had been substantial delays and inequities.

When asked "What do you think has been chiefly responsible for this (difficulty and delay in getting the vaccine to the people)?" a significant number blamed the government or "greed, jealousy, black market, racketeering."

In 2021, to avoid those problems, and ensure the eradication of another deadly virus and a return to any semblance of normal, we all need to think of America as one unified team. Each of us has a role to play.

The responsibility for ensuring that vaccine distribution and priorities follow the CDC's broad guidance for fairness falls upon state and local officials. They are the ultimate deciders in determining how the vaccine is distributed. In turn, the federal government must hold the state and local institutions accountable for the equity of the systems they set up — and any violations that occur.

Last, but not least, as individuals desperate to get immunized and put this pandemic behind us, we all have a moral obligation to wait our turn — for the sake of our own health, our neighbor's and for the betterment of society.

Dr. Hazar Khidir and Dr. Melanie Molina are residents in Emergency Medicine at Massachusetts General Hospital in Boston.

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