Who should get the vaccine next? Not just seniors

There has been widespread agreement that health care workers and residents (and staff) of long-term care facilities should be at the very front of the line for the COVID-19 vaccine, and distribution to them is already underway. Now state and local officials will decide whether to adopt the recommendations of an expert panel on who goes next.

Should society aim to reduce mortality, or should we focus on the infrastructure necessary for the resumption of normalcy? The United Kingdom has prioritized people 65 years and older as the next group because they suffer the greatest risk of hospitalization and death. They then plan to work their way down, by age groups. But there is a strong case to be made for prioritizing frontline essential workers, including teachers, first responders, bus drivers, and grocery clerks, who come into direct contact with large numbers of people, are most likely to be exposed to COVID-19, and are essential to the nation’s overall wellbeing.

On Sunday, the Advisory Committee on Immunization Practices (ACIP) grappled with that question. The ACIP has recommended that after health care workers and long-term care residents receive the vaccine, next up should be frontline essential workers and those 75 years of age and older. Waiting to do the 65-74-year-olds until later provides the opportunity to begin vaccination for the oldest of the old group who are at highest risk, while at the same time reaching those workers with greatest exposure to infection.

Some on the committee were concerned about delaying the 65-74-year-old group, but in the end the vote was 13 to 1.

This was a good decision. The hardest ethical dilemmas are ones in which we must choose between equally worthy goals. Too often in such cases, we decide to pick one goal over the other. The ACIP avoided such simplistic thinking. They are explicitly valuing a return to normalcy and the importance of protecting against COVID-19 severity and death.

However, in the coming days and weeks, there may be many voices insisting on prioritizing the old over frontline workers. As recently as three weeks ago, ACIP itself had been considering putting frontline essential workers ahead of the 65+ group. This week, CDC director, Robert Redfield, encouraged priority for those over 70, and ultimately, since ACIP’s recommendations have no teeth, the exact order of vaccination will be determined at state and local levels. A more dramatic shift to a system based only, or primarily, on age would be a mistake.

There are many reasons to prioritize frontline essential workers. First is the instrumental reason that their labor is essential to the running of the country. Teachers, for example, must be prioritized because the current and future health, mental health, and wellbeing of our children — and their parents — is being damaged by school closures. A failure to bring back in-person learning stands to put a generation of children at risk.

Another instrumental reason is that protecting frontline workers could turn out to be one of the best ways to protect older people. Many frontline workers live in multi-generational housing where older family members may be exposed to younger family members’ infections. Further, targeting frontline workers is the most likely strategy for reducing overall prevalence of the virus, so it could turn out that vaccination of frontline workers could be the most effective — albeit indirect — way to reduce infection among the over 65 age group.

However, we should prioritize frontline workers for other, noninstrumental reasons as well. The ways we choose to guide allocation decisions says something about what kind of society we want to be and the values we think are most important. Frontline workers have been keeping our society running at great risk to themselves. They are owed a debt of gratitude. And since a large proportion of frontline workers are African American and LatinX, groups who have suffered disproportionately in terms of morbidity and mortality, prioritizing their vaccination would help to reduce the outsized suffering these communities have experienced from COVID-19.

Many frontline workers are low-wage earners, who cannot afford to lose the time it takes to be vaccinated, or the day or so afterwards, when they may experience some fatigue or discomfort. If the nation is serious about curtailing this pandemic — and committed to doing so justly — Congress must provide state and county public health departments with the resources they will need to deliver vaccines in hard-to-reach areas, including rural America and tribal lands, where Indigenous people are in dire straits. There will also need to be ways to compensate low-wage workers for lost time at work and novel ideas for how to deliver the vaccine to people without employment, health insurance, or access to health care.

Vaccinating America is the biggest logistical challenge since the Second World War. It is also an enormous moral challenge, requiring us to think hard about who will get the vaccine when, and how to ensure it’s just and equitable availability to all.

Mildred Z. Solomon is president of The Hastings Center, the leading bioethics research institute.