After a summer of corporate statements pledging that Black Lives Matter, America’s vaccine rollout is creating inequities stemming from a ruling class making rules to favor themselves. In the first two weeks after the FDA authorized the life-saving vaccine, hospital board members, spouses of physicians, cosmetic surgery receptionists, and young firefighters have been getting the vaccine ahead of our society’s most vulnerable. Low-risk Americans with access and power are cutting in the vaccine line and, by doing so, are essentially telling our society’s most vulnerable members “your life matters less.”
Part of the inequality stems from the late and flawed guidance from the CDC Advisory Committee on Immunization Practices (ACIP) which did distinguish frontline COVID-19 workers from all healthcare workers. Among healthcare professionals, a 61-year-old ICU nurse should be getting the vaccine right now, but a young healthy clinician who injects Botox for a living and had the infection in the past should step aside.
Tragically, because of poor CDC guidance, we are vaccinating people already immune to COVID-19. The CDC guidance failed to deprioritize those who already had the infection unless they had it in the last 90 days. Natural immunity may last as long or nearly as long as vaccinated immunity — a question that will be answered over time. But so far, after one year, re-infections are observed to be rare and when they do occur they are mild infections. Keep in mind that COVID-19 infection occurs in approximately 5% of vaccinated individuals. Those who have had the infection should be stepping aside in the vaccine line as long as we are severely supply-constrained.
Here’s the bottom line: Just because you can get the vaccine doesn’t mean you should. Those with access should pause and assess their own individual risk as we are supply constrained and vulnerable Americans are told to wait.
High-risk Americans have gotten clobbered. We have lost nearly 10% of the U.S. nursing home population from COVID-19 and 80% of all deaths have been in people over 65. Another 15% of the deaths are among those with known co-morbidity. So why not vaccinate these vulnerable Americans before we vaccinate the young and healthy who are not on the frontlines of COVID-19?
The problem with allocating vaccines by profession is that the CDC guidance did not prioritize those who carry a high case fatality risk within each profession. Europe is using age and risk of mortality as the leading criteria in their vaccine allocation. Prioritizing the vaccine by risk of mortality maximizes the number of lives saved and optimally reduces the influx of infected COVID-19 patients presenting to a hospital.
The formal guidance from the medical establishment has been hard to watch. First, the National Academy of Medicine guidance was only a framework, in classic academic, ivory-tower fashion. It was too broad and failed to commit to a prioritization order. Then the CDC came late to the party. After having 9 months to develop guidance, ACIP voted just 5 days before Christmas on their recommendations on vaccine prioritization — 2 weeks after the FDA authorized the first vaccine. The CDC guidance was so late that states were literally sitting on vaccine surpluses while the CDC was pondering their guidance. The CDC was like a college student handing in a term paper 2 weeks after the deadline, despite having 9 months to work on it.
The CDC guidance was also flawed. It failed to distinguish the healthy 25-year-old cosmetic proceduralist from the 64-year-old emergency medicine physician with multiple comorbidities. As a result, hospitals scrambled to develop their own tiered allocation systems. Some hospitals did it well and others did it poorly, magnifying inequities in our healthcare system. Some facilities also received more vaccine doses than they have patients and staff, fostering cronyism in who gets the vaccine.
In my opinion, a 74-year-old Black resident of Baltimore who has renal disease has a right to ask why a 25-year-old healthy person is getting the vaccine right now, not to mention the many connected wealthy low-risk Americans who received it through their networks. Through the lens of minority communities, such as that of my 74-year-old Baltimore friend, the ruling class is again writing their own rules to favor themselves.
I don’t believe ACIP members intended to exclude any minority group; in fact, they rigorously debated how to ensure minority groups would have access to the vaccine. The committee and the career staff at the CDC simply failed to recognize how prioritizing Americans by profession would result in so many low-risk people getting vaccinated before high-risk people, who are disproportionately comprised of Black, Hispanic, and Asian Americans. That’s why the CDC’s own director took issue with the ACIP recommendations, urging use of case fatality risk as a leading criterion. He supported a recommendation more like Europe’s.
Some states are choosing not to use the ACIP guidance, and instead are using age and comorbidity as the leading criteria. Florida is one state that has followed the European prioritization model. The CDC guidance is only advisory and ultimately states make their own decisions.
Florida’s governor has said, “it makes no sense for someone that’s 42 to jump ahead of somebody that’s 70 years old.” Despite the state’s checkered history responding to the pandemic, the governor is aligned with a growing group of physicians arguing for a more equitable allocation that maximizes the preservation of life.
On a personal note, I can’t justify getting the vaccine myself before my 74-year-old Baltimore friend who is high-risk. My personal case fatality rate is very low and I have an extremely low exposure risk to COVID-19 since I do not work on the front lines of COVID-19 and the limited clinical work I do is among surgical patients who are tested before surgery. We also have superb COVID protocols in my line of work.
I’m not criticizing clinicians who get the vaccine — my personal decision might be different if I spent more time in the ICU, took more ER calls, or was high risk of being a silent carrier of the virus, putting my patients at risk. But that’s not me. Given my very low personal risk of mortality and my very low risk of getting the virus in my clinical work, I have joined a growing chorus of healthcare workers who have taken a pledge to not get the vaccine until every high-risk American has been offered it first.
Flight attendants and airline pilots have had a lower risk of infection than the general population. That’s because they are using excellent protocols including universal masking, sanitizing, and the use of fresh air on planes with air filtration comparable to that of an operating room. My hospital and clinic work is even safer. Now that COVID-19 prevention protocols have matured to markedly reduce transmission and now that PPE is widely available, we should be putting vulnerable members of our community first, prioritizing them over low-risk people who work in low-risk settings, like myself. After all, putting others first is central to our great medical heritage.
Marty Makary MD, MPH, is editor-in-chief of MedPage Today as well as professor of surgery and health policy at the Johns Hopkins University School of Medicine and author of The Price We Pay: What Broke American Health Care — and How to Fix It.