Who should be vaccinated first?
When hard-nosed stats meet morality
01 January 2021
I don't envy the people who are having to decide who should get the Covid vaccine first. The 'easy' part of the decision is based on statistics. The figures will tell us which people are most likely to be harmed by Covid and how much that will cost, and we can use this information to manage the risks. But there are subjective factors that make the decision-making much more complex.
I can think of at least six ways in which society could decide to prioritise treatment, and some of them are in conflict with others:
Vaccinate the people who are most likely to get seriously ill or to die if they catch Covid. This feels the most compassionate option, and is broadly the one that has been adopted in the UK. The very old and those with serious underlying health conditions are being vaccinated first. One example is Alice (not her real name) who lives near me. She's in her early 80s and is anxious about catching Covid. She's due to be vaccinated next week which will be a source of huge relief to her. When all 80+ year olds are vaccinated, the number of deaths from Covid will probably be cut by two thirds, and a lot of mental anguish will have been relieved too.
The physical health risks of Covid only apply if you actually catch it. What I didn't mention about Alice is that she lives alone. She has been scrupulous about social-distancing, and only speaks to her family via Zoom or from the end of the garden path. It is extremely unlikely she will end up in hospital with Covid for the simple reason that she almost certainly won't catch it. That's not the case for many other people. Most extreme are those who are working on the front-line dealing with Covid patients: hospital nurses, for example. But anyone who is having to spend time in enclosed spaces with other people has a significantly elevated risk of catching Covid. A 60 year old bus driver is (I suspect) far more likely to end up in hospital with Covid than Alice is. One of the most exposed groups is school teachers. Very few schools have escaped without at least one teacher catching Covid. Almost none will die from it, but many will be affected by long-Covid.
Whoever you are, catching Covid is likely to put you out of action for anything from a few days to several weeks. If you're a retired person with no real commitments, this is little more than an unpleasant inconvenience. But if you're a production line manager, a doctor, a teacher, a single-parent, a lab worker, a food-packer, a performer....or anybody else that is contributing to the economy, the loss of your services affects everyone, not just you. If the ultimate objective is a strong economy which enables us to afford more hospitals/schools/police then it makes sense to prioritise those who add the most value to the economy in its widest sense. If you're uncomfortable thinking of this as an economic decision, then instead prioritise vaccinating those who 'help' the most other people.
We've known about super-spreaders since the start of the pandemic. Some of these are easy to identify: they are the highly sociable people who are more likely to be exposed to Covid, and are also more likely to give it to other people. These include students, sports players, party-goers and also politicians (especially mask-free Republicans). Vaccinate these people and the R-rate will plunge. Taking it to an extreme, if 10% of society were super-spreaders and 90% were hermits, then you'd only have to vaccinate 10% of people and the virus would be eliminated.
The fastest way out of this pandemic will be to get tens of millions of people vaccinated in the next couple of months. We have enough vaccine to do this, so the main constraint is likely to be the logistics of injecting people. We need a vast number of people to give the vaccine, but we can't afford to take many nurses off the wards, and we can't aford to let those vaccinators get sick. There are thousands of people who have experience in giving jabs but who are themselves in vulnerable groups. My sister is one of them. Before she can help out she needs to be vaccinated. So should we be vaccinating the vaccinators before anyone else?
The idea that the vaccine should be aimed at those who most 'deserve' it is probably the most controversial of all. Thankfully, our healthcare system aims to treat all people equally, and to make no judgments about the nature of the people they are helping. But many people felt a bitter taste when Trump's legal adviser Rudy Giuliani went to hospital with Covid after deliberately flaunting guidelines about mask-wearing and social-distancing. Was it right that he should be allowed to take a hospital bed ahead of somebody who had caught Covid through no fault of their own? Vaccination could be a reward to those who have sacrificed their own wellbeing to help others. But what government could be trusted to choose the 'deserving' on our behalf.
As I say, I'm very glad that I don't have to make these decisions.