Who Goes First?

The rollout of the Salk polio vaccine did not go smoothly. In April 1955, it faced critical shortages. When the vaccine was approved, the Secretary of Health, Education, and Welfare did not have a single injection available; the campaign to cure polio was to be funded by charitable donations. But the polio vaccine rollout did have one element well worked out: there was a clear priority system, a waiting line with the youngest and most vulnerable kids first. Everyone else had to wait.

The situation is different with the rollout of the Covid vaccine. We do know that children, reasonably enough given the epidemiology of the disease, are not a priority. But who is? While most states have health care workers at the front of the list, followed by those with severe health risks, it is not at all clear how we should prioritize within each group. Should people of color be offered the front of each line? Are risks additive? Should an elderly essential worker go ahead of someone who is merely elderly? Do we prioritize recent hot spots?

The reason for our greater confusion this time stems, in part, from the greater complexity of the epidemiology of Covid-19. But it also comes from the fact that we have not developed a shared comprehensive economic or moral theory that provides a methodology for weighting our different goals. Is a younger life worth more than an elderly life because the younger person has more life left and more years of work ahead? Should groups who continue to act irresponsibly (those who refuse to wear masks) paradoxically receive the benefit of the vaccine early to protect others, or should they be left with a longer wait?

Absent an agreed upon vocabulary of risk weighting, we are driven then to politics. Public health — in this case, distributing a vaccine in short supply — always demands politics, and therefore this bringing of public health and politics together is perhaps not particularly surprising. But the balance between public health and politics has been, thus far in the Covid moment, so skewed towards politics as to make public health considerations a distant second. Elected state officials have prioritized vaccine distribution based on local political exigency. In Colorado, ski industry employees living in congregate settings have been part of the early vaccine rounds. Representatives in Georgia and Arkansas have been including workers in meatpacking and food processing plants.

It is perhaps one of the central lessons of the Covid moment that we need to invest in doing the hard work of deciding how to prioritize rare and important supplies before, not during, a crisis. Absent that, we are left with little other than special interests jockeying to determine which lives are saved first.


Michael Stein & Sandro Galea

As we re-emerge from the pandemic, 2021 stands to be a turning point year for public health. In The Turning Point’s weekly essays, we reflect on what we learned during 2020, and what we are learning during 2021, that can guide us to the creation of a better, healthier world.