Tim Hoff: Welcome to Ethics Talk, the American Medical Association Journal of Ethics podcast on ethics in health and health care. I'm your host, Tim Hoff. This episode is an audio version of a video interview conducted by the Journal's editor in chief, Dr Audiey Kao, with Dr Ruth Faden. Dr Faden is a Professor of Biomedical Ethics at the Johns Hopkins Berman Institute of Bioethics. She joined us to talk about how to fairly distribute any potential SARS-CoV-2 vaccine when supply is limited. To watch the full video interview, head to our site, JournalOfEthics.org, or visit our YouTube channel.
Dr Audiey Kao: Dr Faden, thanks for being a guest on Ethics Talk today. [music fades out]
Dr Ruth Faden: Totally my pleasure. Thank you for inviting me.
Kao: So, the COVID-19 pandemic is the first pandemic experienced by individuals and nations in our lifetimes. Given the global nature of this public health threat, many believe that any SARS-CoV-2 vaccine needs to be a global public health good. United Nations Secretary General António Guterres has said that a vaccine or vaccines must be treated as global public health goods available and affordable for all. What has been done, and maybe more importantly, what more needs to be done to ensure that so-called vaccine nationalism, where each nation prioritizes its own interests, does not undercut our global response to end this pandemic?
Faden: I think it's the challenge, frankly, of this phase of the pandemic: that is how to get this right from a global equity or a global justice standpoint. So first, in terms of what's going on right now, there is an entity called the COVAX facility, which has been stood up as part of the ACT Accelerator. And I apologize to the listeners because it's just so much alphabet soup. But it is basically an entity that was established expressly in the case of the COVAX facility to accomplish a couple of things, one of which was to put a floor beneath low- and middle-income countries so that there would be some amount of vaccine that would be guaranteed to lower-income countries if they cooperate in this collaborative effort. This effort, this COVAX facility arrangement is inviting high-income countries, as well as low- and middle-income countries to join in a kind of buying collective where, with a great deal of internal expertise, companies and vaccines are being vetted, a portfolio of vaccines is being established, and then an arrangement for how to distribute vaccine as it comes in to the COVAX facility is put into place that ensures that low- and middle-income countries get some vaccine with the cost for low- and middle-income countries being largely supported from various donor sources.
Faden: For the COVAX facility to be maximally effective, so it's a sort of first-line defense against profound global inequity or profound global injustice, it's really important that paying countries contribute to and participate in the COVAX facility. So, that's one structure that's already in place.
In addition, wealthy countries—wealthy countries in terms of economic resources, scientific talent, production capacity, all countries that fit that description—are well on their own paths to secure a vaccine for their own population. So, in the U.S., we talk about Operation Warp Speed, which is our instantiation of that effort. And for a complex of reasons that if we had more time I would talk about from the standpoint of global justice argument, a plausible case can be made that countries do have a first-line priority to the residents, to their own populations. I'm avoiding saying “citizens” intentionally because I want to include everyone who lives within the territory of a nation state. So, that's a reasonable first-line priority.
But the fact that countries as nation states with obligations under human rights covenants and other sorts of structures, constitutional covenants, have an obligation to their own populations first, it doesn't absolve those countries of responsibility at the global level.
Faden: So, somewhere between a realistic recognition that countries are going to commit, and arguably should commit, to securing vaccine for their whole populations and icing out low- and middle-income countries from being able to have access to vaccine is a kind of global ethics sweet spot where countries are going to have to take seriously, wealthy countries, that they do have obligations outside of their own population and establish their own tipping points. At what point, right, are they going to move from let's call it a stockpiling to a sharing model of vaccine that's separate from obligations to contribute to global efforts, global cooperative efforts, like the COVAX facility.
Let me just say one other thing. There are good prudential reasons, national self-interested reasons for contributing to a global vaccine equity mission. We know in public health the standard line is if there's infection anywhere, if there are outbreaks anywhere, there are outbreaks everywhere. So, simply from the standpoint of self-interest, we want to really contain this pandemic, we need to think globally about the distribution of vaccine and also economically. It's critical from an economic perspective that we have reliable global pipelines and reliable global markets. Otherwise our economic recovery cannot be fulsome. And so, that, too, depends on the containment of the pandemic everywhere.
Kao: Yeah I think you make some excellent points about the obligations in the global health equity standpoint that we in healthy, in wealthy nations need to step up. But beyond just equity arguments, there's a self-interested argument as well.
Faden: Correct. Very healthy self-interested argument.
Kao: Yeah. So, if we move from the global to the U.S. domestic context, currently the U.S. Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices and the National Academy of Medicine Committee are examining how to fairly distribute a SARS-CoV-2 vaccine when the supply is limited.
Kao: And there's general consensus that front-line health care workers should receive priority for vaccines because they may be at higher occupational risk for exposure, and that these jobs are necessary for the rest of society to function. While that may sound straightforward, how should we go about deciding who is quote-unquote an “essential worker” in this situation?
Faden: Well, you listed one, health care, one class of essential workers: health care workers. Within health care workers, there are distinctions that potentially may need to be made, especially initially. The question of how to determine the broad categories of occupations or jobs in the United States that should qualify as essential workers, there are a number of estimates that are out there in terms of the numbers of people because the sort of elastic nature of who counts as an essential worker in some states. For example, the categories of workers that qualify as essential or as permitted to return to work early during shutdowns are always being allowed to work with incredibly big. In other states, it was very narrow. And any number of think tanks have come up with recommendations for a list of essential workers. I think the key thing, right, as we start sorting out by essential workers is to be, first of all, not biased or constrained by the notion that essential means highly-skilled, well-trained, or professional.
Faden: There's a kind of elitist bias that operates that makes us focus first on people who would fit that description. So, in the health care context, we're talking about the custodial staff and the food preparers, as well as the ICU clinicians, nurses, doctors, respiratory therapists. We have to be thinking that way. When we go outside, we have to remember that the kinds of people who are critical to our food supply, are critical to our transportation system, are critical to the maintenance of the power grid, are not all of them highly-trained, highly-paid professional people. Now, if we end up, so first, we've got to figure out who counts by worker category, right? And that's part of the process that we're underway right now.
And there's a lot that's normatively charged here. One of the most normatively charged territories for us, I think right now, in this moment as a nation, are K through 12 teachers. Are they essential workers or not? I would make a big plug for K through 12 workers being essential workers. Someone else might want to throw in university professors into that category as well. We're going to have a conversation about that. Let's just put it that way.
Faden: Beyond that, if we are in an initial situation in which vaccine supply is constrained, there are going to have to be sort of priorities within priorities. And here, a series of factors are morally relevant to think about. And they are sort of the same categories that matter in the first place. One is the level of risk, additional risk, that comes with the occupation. And you're going to see, for example, in health care a big difference between people in health care who are directly involved in providing care to COVID patients or supporting COVID patients versus people who are offering care in facilities in which no COVID patients, that are known to be infected anyway, are present. So, it's the level of risk, the extent to which risk can be mitigated by PPE in the worker category, the availability and quality of the PPE. The extent to which social distancing is possible in that worksite is another way to reduce risk.
Faden: The likelihood that severe disease will follow from infection by occupational category. And also ultimately, the concerns about the extent to which workers in this category may be in a position to be epicenters for outbreaks. You might think about meatpacking plant workers or farm workers depending on where they live elsewhere.
And finally, and this is a category or a criterion that runs against what I said earlier, workers who could be replaced by other people easily at some point, if things get tough enough, have to be differentiated from people who have skill sets. And these are not necessarily only professional skill sets. Not everybody can slaughter meat in a meatpacking plant. It's a skill set, right? Whereas other kinds of jobs are different. So, a whole bunch of questions that need to be answered around what I would call morally relevant criteria for making a fine cut within essential workers.
Kao: So, if I can follow up on what you've just said. So far, the U.S. federal government has committed over $9 billion to speed vaccine development and to ramp up vaccine manufacturing. So, for example, Pfizer has been awarded nearly $2 billion to deliver 100 million doses of its COVID mRNA vaccine currently being tested. But despite these efforts, there's always a ramp up to vaccine production and distribution.
Kao: So, initial supply of any FDA-approved vaccine may not permit all quote-unquote “essential workers” to be vaccinated. And some have advocated a use of a lottery. What do you think of that idea?
Faden: I think it doesn't make any sense at all. I mean, if we had a super, super, super constrained supply, and we were down to a very finite description of a group of people, right, then yes. But before we get to that point, we're going to have to be doing a lot of very careful sort of ethics analysis linked very tightly to epi data, right, about whether, if we have a short supply, it makes sense to, for example, pick a whole class of essential workers and move them forward first, or take 50 percent of different worker classes and go that way. It will depend a lot on what we're facing in terms of vaccine supply and where the state is of the epi knowledge and the pandemic at the point when vaccine becomes available. So, there may be a role for a lottery. But before we get to where a lottery would make sense, there's a lot more careful thinking that needs to be done and that requires very careful justification for landing on this.
I hope that the period in which supply is that constrained is limited, is really limited. And within the health care context, it is also important to recognize that we're not only concerned about minimizing risk, we're also concerned, and this is true for all essential workers, is essentially to express a national debt of gratitude to people who have been putting themselves at elevated risk. It's a kind of reciprocity concept. People have been putting themselves on the line, either voluntarily or not, because of their life circumstances—it's hard to say—and making it possible for the rest of us to live with less risk and less fear and with more normality in the case of food and transportation and the delivery of packages and so on. So, there's a debt owed there. And we also need to incentivize people to continue to do those jobs, to make them feel not only acknowledged and that expression of national gratitude, but also okay, I can keep doing this because I'm going to be protected.
Kao: Yeah. So, if we can move beyond the vaccination of prioritization of essential workers, giving priority to those at greater risk of physical harm if they were to get COVID-19 is also widely endorsed. Hardly surprising in this pandemic, those among us who have been disproportionately affected by COVID-19 are people of color and those who are poor. And past vaccine allocation guidelines such as CDC's 2018 guidance on pandemic influenza vaccine distribution prioritized individuals based on age, pregnancy status, and underlying medical conditions that can place individuals at higher risk of morbidity and mortality from influenza infections. However, neither race nor class has been used in prioritizing individuals. So, how should such socioeconomic attributes be applied in deciding who gets priority access to vaccines during this pandemic?
Faden: Yeah. So, it's an incredibly important question. And if I think from the global perspective that the biggest challenge is—and whether we will face it as a global community, I don't know yet—is how to come up with some way of ensuring that people in low- and middle-income countries receive sizable amounts of vaccine. I'll put it that way. The greatest challenge, I think, within the U.S. and also within many countries is to meet the moment with respect to the recognition that structural racism and structural disadvantage generally has is playing a very acute role in the way in which the burdens of this pandemic are being distributed across populations. So, it's not as if these structural disadvantages, the structural racism and the structural bias in terms of questions of fairness and power, are new. They've been around for hundreds of years. And in countries older than ours for many, many hundreds of years, in some cases, very entrenched social practices and laws that have kept some people systematically down and other groups of people systematically elevated. The fact is that all of those unjust fault lines have been not only exposed during this pandemic, but widened by the pandemic.
Faden: So, the comment you just made about how disproportionately the mortality and morbidity rates are traveling with disadvantage in terms of color or in terms of race. So, step back to ignore that fact, right, at this moment is to me an enormous moral failure. We have to recognize that the question of how to distribute vaccine fairly in our country right now has to be addressed from the standpoint of this whole national reckoning that we are having on racial injustice and systematic injustice more broadly. Okay. Full stop there. What exactly does that mean? How hard is it going to be to address this in a way that is normatively acceptable, culturally acceptable, and politically viable?
So, one strategy is to recognize that if you go with a traditional list of priority groups for vaccine, you will hit a significant number of poor people and a significant number of people of color. Being at elevated risk because of comorbidities will capture it. If you move to another priority grouping that would, for example, focus on people living in a context in which it is difficult to socially distance because of density, you then pick up and therefore have elevated risk of not only acquisition of the infection, but becoming ill from it. As a consequence, you would pick up sizable members of poor people living in urban areas and so on. So, you see how that goes. And that's good. That's all good. The real challenging part will be to say, okay, is that enough? And there is epi data that pretty much suggests that when it comes to people of color, you can't kind of account for all of the differential in this way and for good reasons we don't have the time to go into.
So, it seems to me that we have now a challenge, which is we need to respond to this recognition of profound background injustice which is carrying through to this disproportionate burdening of the pandemic on some groups who are already disadvantaged now even more so. And also acknowledge that many of the people in these very same communities have a justified reason to feel distrustful about being singled out to be first for a new vaccine or a new anything in health or medicine.
Faden: Especially in a context in which we keep using words like “Operation Warp Speed,” and “this is the fastest we've ever had” and blah blah blah blah blah. All that language, which has its function, but also tends to reinforce a view that the products will be released, the vaccine will be released, before there's this normal level of confidence about safety. And we've been reassured that will not be the case. But nevertheless, it's a confusing message that is landing against this historical distrust.
So, my own view about this is that we can't proceed from the top down here. That however this prioritization process proceeds, it will fail. It will fail generally, and it will fail specifically with respect to this moral obligation in this moment to confront racial injustice and structural injustice generally, perhaps for the first time in a vaccine context. I'm not sure it is the very first time, but first time of this magnitude. It has to go on in parallel, in conversation and engagement with the people who would fall into these groups, who do fall into these groups, to say, okay, look. Here's the dilemma, right? And let's discuss how to proceed.
And let me say one other thing too. It's also not only a question of engaging with communities to understand and to discuss, not to lay down, but to try to develop together, appropriate responses, but also recognizing that as we're doing this, we need to have our delivery system in place.
Faden: It's not a simple matter to deliver vaccine to very poor people in rural areas, for example. Whether they want it or not is a separate issue. It's not a simple matter to make vaccine available through vehicles in locations where people feel comfortable, where they have a level of trust, where they don't have to travel distances, where they can walk, and where they can reduce exposure to additional risk. So, there's a lot of effort and energy that has to go into that as well.
Kao: Yeah, no. I appreciate your last points. I think the challenge is how do we practically implement our moral obligation here, given what we're seeing, which are not new injustices that affect people's health and well-being? And I read recently, people have suggested using measures such as the Area Deprivation Index to assess communities that have been economically disenfranchised for decades as a possible way of practically implementing and reaching those communities that are, again, disproportionately impacted by COVID-19.
Faden: Exactly. We need a lot of creative thinking. We need a lot of engaged activity. And we have to get this out of the experts, right?
Kao: Right. So, on that note, I want to thank Dr Ruth Faden for sharing her expertise and insights with our audience. Ruth, thank you for being a guest on Ethics Talk.
Faden: My pleasure. Thank you.
Kao: For more COVID ethics resources, please visit the AMA Journal of Ethics at JournalOfEthics.org. And finally, to our viewing audience, be safe and be well. We'll see you next time on Ethics Talk. [bright theme music plays]
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