The world has spent a long time collectively holding its breath waiting for a COVID vaccine to end lockdowns and reduce death rates. When it finally became available there were long queues and pricing had to be imposed. It was by no means exceptional. Whenever a scarce medical resource meets high demand, rationing ensues. For example, this was also the case when a new medical treatment for hepatitis C became available in 2014, when this disease was the leading cause of infectious death in the United States.
Who should be vaccinated and who should wait? The rationing of scarce medical resources is in the realm of medicine ethics, which aims to identify ethical principles that we should hopefully all agree on. Alas, the rationing procedures that have been used for COVID vaccines around the world have flagrantly violated these principles. Not on purpose, beware. There was no “bad hand” at work. The reason was simply that political realities clashed with common sense, and common sense gave way.
Ethical principles: priority and equality
Medical ethics has more or less agreed on a few principles. The two most important, in the case of COVID vaccines are priority and equality.
Priority simply means that certain people must come first. For example, medical personnel should be vaccinated first, otherwise the whole system could collapse, but, after them, the elderly and those particularly at risk should be given priority over young and healthy people. You end up with a few priority classes and it is expected that no one in a lower priority class will receive vaccines until those with a higher priority are vaccinated.
Equality means that two people belonging to the same priority class should be treated equally, regardless, for example, of where they live.
COVID vaccines have been purchased and distributed by a number of large organizations. The European Union has distributed vaccines to its member countries. The United States has done the same for its Member States. The World Health Organization has sponsored a multi-country initiative called COVAX. All have implemented rationing between their member territories (states or countries).
What did these organizations do? In the face of local political pressure, they settled for a rapid rationing rule that treated territories according to size. Essentially, they were shipping vaccines in proportion to the territories’ population, asking them to vaccinate according to priority classes. Quick and easy. And ethically wrong.
Not bad as intentionally bad, but rather bad as naively deceived. My new article in Frontiers in public health“Ethical allocation of rare vaccine doses: the Priority-Equality protocol(in collaboration with J. García-Segarra and M. Ginés-Vilar) shows that the allocation of COVID vaccines violated the ethical principles of priority and equality, and explains how we could have done better.
Pixabay/Gerd Altmann
Albertville and Barryland
How we could have improved the system can be demonstrated with a simple example. Suppose we have two different hypothetical territories, Albertville and Barryland. Both have the same number of inhabitants. Albertville has a lot of elderly people and medical personnel, that is 400,000 people. Barryland is much younger, with only 100,000 elderly people and medical staff. Together, the two territories have half a million elderly people and medical personnel. In the first batch available, there are only a quarter of a million vaccines.
Respect priority, it is clear that only healthcare workers and the elderly should receive vaccines. Respect equality, the same should be vaccinated in Albertville and Barryland: more precisely, half of them. It would be 200,000 in Albertville and 50,000 in Barryland. Easy, right?
This is not what happened with the COVID vaccines. In this example, allocating vaccines in proportion to population means that Albertville and Barryland each receive 125,000 doses of vaccine. This means that all An elderly person or healthcare worker in Barryland is vaccinated, while much less than half those of Albertville are.
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This violates equality, since people in the same priority class are treated differently depending on where they live. Worse, Barryland is left with 25,000 extra doses that are used to vaccinate young, healthy people, while the elderly inhabitants of Albertville risk death. This of course violates priority. We let the old and the infirm die to vaccinate the young and healthy.
This is not just a theoretical example. These problems have become painfully evident in Europe. As of week 12 of 2021, the percentage of healthcare workers vaccinated was 72% in Romania and 67% in Estonia, which contrasts sharply with the corresponding rates of 37% in Denmark and 22% in Iceland. Hungary actually broke the agreement and obtained additional vaccines itself. around 22n/a week, some European countries, such as Spain and Belgium, had received enough vaccines for all healthcare workers and all people aged 70 or over, while other EU members, such as the Denmark, France and Greece had barely received enough to vaccinate those over 80. The imbalance was so obvious that some people engaged in “vaccine tourism”, crossing national borders to receive their vaccines earlier.
How to allocate rare vaccines
What politicians have forgotten is that there is an entire branch of the social sciences (mathematics) devoted to the allocation of scarce resources. Ethical principles or socially desirable properties can be translated into formal principles, and then mathematics can be applied to find out if there are methods that satisfy them, and exactly how those methods work. That’s what we did.
In our article, we show that there is one (and, indeed, only one) method of rationalization that will always ensure that priority and equality are met, regardless of the number and size of priority territories and classes. .
It goes like this: add up the size of priority classes across territories and assign vaccines to those cross-territorial classes. Then divide them in proportion to the size of the classes in the territories.
In the example above, Albertville and Barryland together have half a million senior citizens and healthcare workers, and there are only a quarter of a million vaccines. Thus, only people in these classes will be vaccinated. Albertville has 400,000 and Barryland 100,000, so a fifth of the vaccines will go to Barryland and the rest to Albertville. Each of the territories will vaccinate half of its highest priority populations.
Looking back, the story of the allocation of COVID vaccines is a sad one. We knew what ethics dictated. For once, a solution existed and could have been easily found, if the right scientists had been called upon. Policy otherwise dictated. Thus, young and healthy individuals were vaccinated while elsewhere, elderly and sick people died while waiting for a vaccine.
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