Age, Race, Equity the Problem of Prioritization
Thank you for this format of different points of view regarding deeply involved subjects. We see so little of this kind of informed discussion and it can, at the very least, make one less apt to jump to a conclusion in situations where there are not clear paths to solutions. Especially when so well written it also helps to battle TLDR syndrome :-)
Appreciate the thoughtful and informative write ups.
My fear/guess is that our “famously fractured and decentralized” healthcare system combined with our new found dysfunctional planning capabilities, will put us into a free-for-all system very soon after we run through the cohort that’s highly prioritized, easily identifiable, and readily physically accessible
Most informative. Thank you to both you and Dr Robinson — and to all those working on this problem.
I really love the Counter series and how much it opens up my own thinking (unlike falsely structured "debates," which don't ever seem to dig below the surface level). Thank you to Dr. Robinson for so clearly laying out the knowns/unknowns and reminding us how much it matters to gather date, to consider it carefully, and to use it well.
I really appreciate this kind of science reporting/writing. Clearly outlining the complexities, challenges, and unknowns we are facing is exactly what's needed at the moment.
It seems to me this discussion is more appropriate for a world where we can depend on logistical institutions to reliably follow the rules authorities set, and where people will reliably line up in the priority order authorities determine to take every available dose, than for the world we live in.
In the world we live in, vaccine doses are in danger of expiring because they can't get it together logistically to give them all out and/or not enough people are lining up for them. In the world we live in, the difference between the Israeli vaccination approach's speed and the US approach's speed seems very likely to matter far, far more than any prioritization rule tweaks we can make.
In that world, isn't the right course of advocacy and emphasis to shout from the rooftops and to every level of government official: treat this like a hurricane or an earthquake, deploy the National Guard, enlist paramedics and combat medics and veterinarians and so forth, get ALL the parallel vaccine administration capacity you can out there and get it running 24/7? Fretting over whether essential workers are going to get in line ahead of old people or whatever just seems penny wise and pound foolish compared to the imperative of treating this like a logistical emergency, which most of the West other than Israel is just not doing.
Thank you Dr. Tufekci and Dr. Robinson for this thoughtful discussion. The various approaches in administering the vaccine reminds me of a morbid version of boarding airplanes, because no matter what factors go into the protocol, those with elite classification get to go first. I’d also done a 360 degree swing from pessimism -> optimism -> pessimism re: vaccines, as the seemingly feverish vaccine production from Pfizer and Moderna pre-authorization is unmatched by planning guidance and support from the Feds. We already see the debacle that ensues at the well-resourced Stanford Hospital, so it’ll be difficult for under resourced local health departments to lead vaccination drives for non-healthcare worker groups. The way I see this actually happening is provisioning by health insurance groups (e.g., Kaiser Permanente) to their members, with LHD targeting high-risk groups not covered by the employer-based health insurance companies, with help from community-based organizations.
Thank you for this discussion. I was fully on board with age as the simplest and most direct determinant of vaccine eligibility, and probably still am, but I do understand these other factors. My main fear is that the introduction of any level of complexity will open up loopholes that ensure those who control the levels of power will be first in line to receive the vaccine. Age is a simple, immutable factor. Of course, then we get into the complexities brought up in the article regarding finding and classifying the elderly, ordering those within these strata, and engaging with vaccine hesitancies.
Thank you for the very informative pieces. How worried are you right now about rate of vaccinations and actual distribution in states? CNN and others are running pieces on how 11.4 million have been distributed and only 2.1 million have been administered (data lag; other caveats withstanding) which both are less than 20 million number govt wanted. On top of figuring out how to prioritize vaccine, states and localities are are running their own logistics, and I am wondering how this will affect underserved and rural areas.
I am not a professional in any healthcare/public health fields, but I think Texas DSHS has said that after vaccinating the first tier of voluntary healthcare workers, do not wait to vaccinate 2nd tier (in TX it's 65+ or 16+ with comorbidities), and under circumstances vaccinate anyone available to not waste any extra dosages (guessing since vials go bad after a few hours once you start drawing). It sounds like TX is afraid of not vaccinating fast enough, but it is not as if locations are getting a list of people to vaccinate in multiples of 5 or 10 on any given day. Hoping that manufacturing problem will not be compounded by waste.
I have participated in the Florida free-for-all on behalf of 85-year-old in-laws, who are not very internet-capable, and find themselves competing with 65-year olds for a limited supply of vaccine. After a couple of rounds of failures, we went into full-on attack mode - 12 computers and iPads with a total of 15 browsers across three locations launched at 6am to hunt two doses of vaccine. This finally, after 45 minutes of watching available vaccine numbers dwindle, produced success. I know we are far from being the only people who have resorted to this overkill. The authorities have created an arms-race almost perfectly designed to favor people with relatives with computers, high-speed internet and time available to engage in the battle - and to ensure that many of the neediest cases get vaccinated last, or simply give up.
Looking at the racial disparity charts, I see something else. The tallest spikes for black and Hispanic death rates are in March / April 2020, when the epidemic in the US was basically confined to a few densely-populated cities with large black and Hispanic populations. Those areas hold a ledger proportion of the nation's black and Hispanic populations than of its white population. How do these charts look if you confine the denominator to the population of the regions affected by the pandemic.
@zeynep would love your reaction/opinion to this art intervention (and how to make it better, more impactful). (Bitly link is a screenrecording of the experience - can also share the app experience too, if interested.) This is regarding Covid mortality numbers and how the public seems to be getting normalized/numb to the scope of the epidemic: https://bit.ly/CoronaBears_b3
Fantastic piece, Whitney, I won't say a word against it. I was especially moved by the description of the NHS and it's extensive contact list, and am jealous that we do not have those here. But we don't. And so, the debate over who gets vaccinated first has become an intellectual parlor game, where we play the role of a room full of Chidi Adagonyes, agonizing over inherently equal and un-equal choices.
Stepping out of the parlor and into the news, two stories are simultaneously developing: that the wrong people are getting the first shots; and that the shots are not going out fast enough. Which makes sense, because the more you try to control and prioritize the rollout, the slower it will go.
Back when I used to study, I came across a set of six criteria for measuring quality of a given theory. I forget most of them, but empirical validity and parsimony have stuck with me. Prioritizing those >75 is simple and valid. Prioritizing all hospital staff is simple and valid. Prioritizing from multiple groups and multiple variables is valid, but not simple. If saving lives and SARS CoV-2 eradication are the goals, an orderly, efficient, trackable system to administer shots as quickly as they become available is what we need.
Considering that all their hospital workers are at the front of a very long line, Stanford might have been better off trying a different prioritizing algorithm: alphabetical order.
Wow. I am loving these Counter Point articles! Learning so much. I do believe prisons have a relatively low death rate (among inmates) very unlike nursing homes. But of course one has to consider the staff as well, and potential superspreading events. Dr Robinson's Venn diagram was brilliant!
I don't understand her comments on known unknown #6 - it seems like driver's licenses, etc all have information on ages, so that appears to me to be an easy gate to validate.
Finally, I like her very humble finish on unknown unknowns, reminds me of what Dr Osterholm constantly says about what he thinks is next. Again -- THANKS so much for these!