CareTalk Podcast – Who Should Get the Vaccine First?

Civil rights groups are calling for greater equity in vaccine distribution. But what are they asking for exactly? In this episode, John and David discuss equity vs. efficiency in the vaccine rollout and whether or not there is a tradeoff.

David Williams:

Hey, John, do you think we should give the vaccine out as fast and efficiently as possible? Or should we slow it down to make sure it’s more equitable?

John Driscoll:

You’re suggesting a false trade-off, David.

David Williams:

Well, let’s talk about it then.

David Williams:

Welcome to Care Talk, your weekly home for incisive debate about healthcare, business, and policy. I’m David Williams, president of Health Business Group.

John Driscoll:

And I’m John Driscoll, the CEO of CareCentrix. David, what do we have?

David Williams:

Well, John, there was a big letter signed by 151 civil rights groups and they are calling for greater equity in vaccine distribution. Why do we need that?

John Driscoll:

Well, first of all, how can you be upset about bringing more fairness and balance to vaccine distribution when the COVID virus has ravaged disproportionately poor and poor communities and individuals of color? You can’t be taking the other side of that. I mean, come on.

David Williams:

Well, John, I think it’s an important topic and the question is how we go after it. So my hypothesis,
because there’s not a lot of data to test this, is that some of the places like Massachusetts that were real slow to get started with a vaccine distribution is because it all tripped up over themselves about how are we going to do this in the most equitable way. And guess what? You know who won out? The freezers because the vaccines sat there while they could figure out how to do this in the right way. And other places like Florida just said, “Just get it out there and make it happen.” So I think there’s a … That’s the challenge, John. Equity is a great theoretical approach, but in practice you got to get it out there and focused on efficiency.

John Driscoll:

But David, we’ve got structural challenges of access, communication, and balance in our healthcare system. We’ve got a scarce supply of this stuff. You’ve got the most vulnerable populations who are not getting vaccinated at the rates of richer, whiter colleagues. There has to be a way to address some of these structural inequalities as part of distribution. Otherwise, I think we’re just going to continue to leave this virus to really harm folks of color disproportionately.

David Williams:

You’re probably right, John, but let’s just take a look at this, what do we do with a very limited supply? Right? That’s the thing. So you could say richer, whiter people are getting it. Many people are not getting it yet, it’s only a few percentage of the population that has it. The best way to save lives and actually to save the most years of life is to give the vaccine to the oldest people, even though they have a short remaining life expectancy because they tend to be hospitalized and die of COVID so much if they get it. It’s just sort of simple, just give it out, start at 120 and work it down. That’s probably the most efficient and the most equitable way to do it if you want to save the most lives, the most years of life.

John Driscoll:

I don’t know, David, I think you just made my point for me. I mean, you just said, “Okay, let’s look at who is most likely to die and get sick.” And certainly age is the first criteria, but if you look at other criteria you’ll see that being of color and living in a poor community is also a very high, disproportionately high, risk factor. So if by that calculation, we should be doing exactly what you said, getting shots into arms, but we’re not going to actually get a fair distribution of shots in arms of people of color and in poor communities because we don’t have the resources available to those populations and frankly, that’s because of all kinds of structural challenges of the distribution of healthcare. And they are by far the most vulnerable. And so both because of structural reasons and for the same criteria you just laid out, we need to have an efficient and equitable approach to this distribution.

David Williams:

So John, I’m glad I could make your points for you because someone has to do it, I guess. But listen, even this example I gave about giving it based on age, it shows how complex this problem is. So if you start with this, people are 100, 90, 80, and so on. Well guess what? The same kind of structural issues of structural racism and poverty and so on means that people of color don’t live as long, and so actually when you’re dealing with people in their nineties or their eighties, it’s actually a lot of people that are still alive are people that were privileged coming up. So it’s hard to do it, and what are we going to do? Are we going to make an adjustment for every … Based on racial groups, sex, women live longer than men, or are we going to do an individual predictive model for each one? If we do that, the freezers will all fill up and no one’s going to get a shot.

John Driscoll:

It’s not that hard. First of all, in order to address the structural and distribution inequalities that already exist, we should make sure that there are … Since all of the states seem to be using complicated websites, we should have individual volunteers going out and soliciting vaccination in poor neighborhoods and neighborhoods where people don’t … Where English is not a primary language. You could do mobile vaccination vans. You could distribute, disproportionately distribute, to those zip codes where there are poor people and people of color.

David Williams:

So John, basically take all the places that the previous president avoided sending the census takers and send the people into the vaccine. Is that how you would map it out?

John Driscoll:

That would be a start. Honestly, all we’re talking about is taking the system that you set up and then making sure that there is an on-ramp for people to get access. Because of the lack of access of people in those communities, to even explain how the process works, that’s a challenge. And just, I would shift more vaccines to poor communities and do exactly the same criteria that you’re saying. In a time of scarce resources, I would think you disproportionally want to get it to the people who are the most vulnerable.

David Williams:

So John, another way to look at it is to say why don’t we do it another way? Why don’t we say if we want to have the biggest impact on ending the pandemic, why don’t we reward the people with vaccines or the ones that had the worst behavior in terms of social distancing and mask wearing, because they’re the ones that are actually most likely to be spreading COVID-19. And I think you could actually go and make an argument to give it to all the social butterflies, the party people, and then over time, once the vaccine is less scarce, then focus on this, rolling it out to all these communities that you’re describing.

John Driscoll:

David, spoken like only a social butterfly. How can you take just the fact that you are the hard partying social animal that you are, and somehow justify that? We know that roughly 50% of the spread is from asymptomatic people, but we don’t know which asymptomatic people there are. I mean, come on. Let’s go with the facts. Let’s use your own criteria. Who is most vulnerable, the elderly and people of color in poor communities and disproportionately put the vaccines there. Not you and your social club.

David Williams:

Yeah John. I thought I was a wallflower all of a sudden, but it’s like the 50% of the asymptomatic spread, it’s like 50% of marketing spend. You know half is wasted, you just don’t know which one it is. I think that the point is that you got an issue about actually getting the vaccine out. So if it’s coming from Washington being directed from the feds, get them to the states and then being distributed. The issue is that you can do better with some of these mass vaccination sites like we have in Massachusetts, than you can do if you’d bring it down to community centers and going door to door where people are comfortable.

John Driscoll:

You’ve got to do both because you’re not going to reach those communities. I suppose you’re against distributing it to the third world as well.

David Williams:

Yeah.

John Driscoll:

Where there’s less access. I mean, where do you draw the line? Shouldn’t we go where people are most vulnerable?

David Williams:

John, I think you want to have your cake and eat it too, or whatever the right metaphor is going to be. There’s a trade-off here. Fact is there’s not enough vaccine, it’s not going to go everywhere first, and if you focus just on kind of reducing disparities in all your pet projects, you’re going to have the vaccination … What’s going to happen is the variants are going to spread as the vaccines are sitting around waiting to go into people’s arms and you’re just going to have to face it that there’s just not enough for everybody right now.

John Driscoll:

Don’t hide behind the fact that it’s complicated, you should build on the fact that it is complicated. If we’re going to crack this thing and we’re going to protect people, we should protect the most vulnerable. I don’t think we’re going to get to agreement on this, David. So what else would you like to talk about?

David Williams:

Yeah, so I would say with the third world [inaudible 00:08:22] withholding this from. Now, I actually
think it’s pretty darn important that we do share the vaccine wealth, such as it is, with the rest of the world, third world, second world, fourth world, whatever you want to call it. I would say I wouldn’t send it into outer space, but if you look at it, there’s a few reasons. One is that we have these variants from places like South Africa, the UK, Brazil, so we don’t want those variants because we don’t want them to come here and cause trouble. And also, you’ll note that China is using its vaccine to gain influence around the world, which I think we also don’t want. And better health is good for business, John. Better stability, not as many refugees, more exports, more tourism. So yeah, I think we should take the vaccine as soon as we have enough, then move it around the planet.

John Driscoll:

Yeah, no. I strongly agree. I think that this is also a time when we should be doubling down and
reinvesting as well as re-engaging with the World Health Organization, which can provide the
infrastructure to help us do that here and also create a global surveillance system. This won’t be the last viral attack on us, and I think that if we can create a global organization … We’re an interconnected world. We need a global organization that can really provide surveillance and support to get immunity, and frankly, containment of this and other viruses going forward.

David Williams:

John, I hesitate to agree with you since you’ve been so disagreeable to me. However, however, I do
agree that we need a robust and a non politicized World Health Organization, because you need to
actually identify and stop these pathogens early to avoid them spreading in the first place. Yeah, there’s going to be more pandemics, it would also be good to prevent the ones from happening because these viruses are … They’re coming up and with some things like Ebola, you saw … I remember thinking, okay wow, it’s in Africa and it could come over here and we’re going to be in difficult shape, but they basically contained it and it didn’t happen. Now we’re talking about okay, well, we’re going to close the borders, but you’re closing the borders after the variants have already come in and new viruses have come in. So we really do need a whole new approach to this, otherwise, there’s no reason to think that this particular pandemic, as bad as it’s been, is the big one, so to speak.

John Driscoll:

The interesting thing that Bill Gates said the other day is this isn’t the big one. That if you look at … And how remarkable is it, David, that with a global pandemic, we were actually able to shut down pretty much the entire economies to slow this virus without creating mass starvation. Yes, there’s been … It’s disproportionately hit poor people and people of color, and yes, the essential workers are disproportionately poor and of color, and they’ve been really … And women have been really … Their employment prospects have been hammered, but it could be much worse.

John Driscoll:

Normally it takes eight years to develop a vaccine. We did it in months. We leveraged new technology and old technology. We spun up, maybe not as efficient as you’d like it, a distribution capability, but it’s pretty amazing that we’ve got tens of millions of Americans already vaccinated in a lot of vaccination arms so quickly after a pandemic. And this pandemic, while horribly nasty, was not nearly, at least the old, the current variant of COVID-19, that was predominant in the U.S., was not as mortal a risk as the Spanish Flu.

John Driscoll:

And I think in an interconnected world where you’re seeing viruses jump from host to host, from
animals to humans, where we’re encroaching upon wild spaces where we don’t have natural viral
defenses, it’s really critical to think bigger here. And that’s why that investment in the World Health Organization and pandemic protection, we just have to … And I’m hoping this administration will make a real investment in this kind of bio-surveillance and bio-support. So as we’re thinking through and arguing about how to optimize our current vaccines, that we’re thinking about how we can make these kinds of viruses, like Ebola, containable and defeatable.

David Williams:

John, when I hear about these things about the hosts, the wild animal hosts and the human hosts, I’m thinking about some of your wild parties. You’ve been able to throw those for a while. When the pandemic first started, we were talking about how we’re all in this together, which quickly became almost a joke because a lot of people are able to insulate themselves from the pandemic while others are just facing it day to day. And I think we’ve seen those kinds of disparities, and that’s a lot of what we’re talking about here with the distribution of the vaccine.

David Williams:

But if you look about what is the actual possible way out of these future pandemics and a more
enlightened view that actually realizes that we are connected, that vaccine nationalism, COVID
nationalism, doesn’t make sense. That we actually want to have equitable distribution, not just of
vaccines, but prevention, treatment, and testing, and so on. I would like to be optimistic that we’re actually going to take that path into a more interconnected world where we do take a more enlightened view, but I’m not so optimistic that just because it’s logical it’s going to happen. What do you think?

John Driscoll:

I think we’re a more mature country. I think we’ve suffered enough economically. I think that separate in a way from the national election, I think people, regardless of what party, understand that this has been pretty devastating. I’m more optimistic. I actually think America can and will get its act together on this, and I think the world will. We have to, otherwise, I think we’re going to be in the same ways that we are starting to find that we have to endure erratic climate volatility and climate change. I think we’re going to … And we have the ability to contain and defeat these viruses, but if we don’t build that infrastructure, we’re going to have the same result on people and the economics as we’re seeing on cities with floods and droughts.

David Williams:

Well, John, I know you started off saying you’re optimistic, but I don’t know. That’s a pretty pessimistic form of optimism.

John Driscoll:

You can’t … If you’re honest about threats and vulnerabilities, you can defeat them. If you’re not, they’ll defeat you.

David Williams:

All right, John. Well, I feel defeated by the rest of this conversation. So I’m going to say, let’s wrap it up here and say that’s it for yet another edition of Care Talk. I’m David Williams, president of Health Business Group.

John Driscoll:

And I’m John Driscoll, the CEO of CareCentrix still fighting for equity. We’ve told you what we think, we want to hear what you think. Please leave us a comment or review and make sure to subscribe on your favorite service.