Give the vaccine to the elderly

It's simple, it's fair, and it saves the most lives

Everybody seems to agree that the absolute first batch of vaccine doses should go to health care workers in direct contact with patients, nursing home staff, and nursing home residents.

The thinking here is very clear. According to Kaiser Family Foundation data, nursing home residents account for less than 0.5 percent of America’s adult population but over one-third of the Covid-19 deaths. And when hospital staff get sick with Covid, the hospitals have less capacity to treat Covid patients and people die. So if you can vaccinate those two groups, then you have taken a huge bite out of the pandemic.

Beyond that, things get a bit complicated. The CDC’s Advisory Committee on Immunization Practices describes a triad of scientific, ethical, and implementation considerations. Since each of those issues is complicated, it leads to an underlying set of recommendations that are complicated. And then because states rather than ACIP are actually in charge of making these decisions, practice will vary considerably from jurisdiction to jurisdiction, even though everyone is working in the same broad framework.

I want to suggest that authorities consider the complexity to itself be a problem for both implementation and ethics. We should aim for a simple solution, and if you look at the science while insisting on a simple solution, I think it clearly supports vaccinating the oldest people first and then going down the chain.

But the CDC itself seems to disagree, saying that racial equity considerations militate against prioritizing the elderly even though they concede that doing so would save the most lives of people of all races.

We’re on track for a complicated situation

The current guidance seems to say that senior citizens and essential workers outside the health care field and people with relevant preexisting conditions should all be prioritized.

Again, turning things over to Kaiser:

While [the Advisory Committee on Immunization Practices] has yet to finalize recommendations on subsequent prioritization (expected soon), according to presentations and materials provided in recent ACIP meetings, the committee is likely to recommend that (non-healthcare) essential workers be the next priority group (“Phase 1b”), followed by persons age 65 and older and those with conditions that place them at high risk for severe illness from COVID-19 (“Phase 1c”).  These groups are much larger, which will likely make the next stages of prioritization much more difficult given that supply will still be limited (according to ACIP, there are an estimated 87 million essential workers, 53+ million seniors and more than 100 million individuals with high-risk medical conditions).

The obvious problem with this is that it’s way too many people to say something like “okay Phase 1b you’re up!” And these are also not independent categories.

  • Most people over 65 are retired but some are working, including in essential occupations.

  • Many of the people with comorbidities are elderly.

  • Many other people with comorbidities are essential workers.

There is also ambiguity regarding which workers are the essential ones. Grocery store employees are the paradigmatic case of essential workers — they are in the businesses that were kept open even during the Maximum Lockdown period. But today the vast majority of businesses are open just because we don’t think it makes sense to order them closed. The florist across the street from me isn’t “essential,” but its staff are “essential workers” in the ACIP sense that they are not doing their job remotely.

Now, if you could make sure that vaccination priority within the essential category would be done based on a sound technical understanding of who is most likely to spread the virus, that would be great. But as Judd Legum writes, this is in practice a political decision that is being made under a cloud of heavy lobbying.

Then there are the co-morbities. And, yes, obviously a person who is 64 and in poor cardiovascular should in principle get priority over a person who is 66 and in perfect health. But as Olivia Goldhill and Nicholas St. Fleur write, this in a practical sense is going to come down to what you can get a doctor to agree to:

Another opening that could be exploited to skip the line involves high-risk medical conditions that warrant early access to the vaccine. Smokers are within this group, according to ACIP, and people with conditions such as moderate-to-severe asthma and high blood pressure could also be included.

This leaves room for a doctor to, for example, portray a patient’s mild asthma as severe enough to justify early access to a vaccine, said Jonathan Cushing, head of major projects of the health initiative at Transparency International, a nonprofit focused on global corruption. The profit motives within U.S. health care make it particularly susceptible to such distortions, he said: “It’s a market-based economy. You as a doctor want to keep your clients coming back.”

This is going to create a lot of problems.

Expert advice in the real world

There is a segment of the population that is reluctant to take the vaccine, and there’s been a lot of discussion of that. But there is also a segment of the population that’s been following public health guidelines and is desperate to take the vaccine. And while people are capable of being patient, nobody wants to be a sucker. If employers feel that other employers are gaming the system, then they’ll want to do it too. If people hear rumors about doctors helping patients cut the line, they’ll want to cut the line, too. That whole process will further erode Americans’ trust in each other and in America’s institutions.

Rather than go down that cycle of distrust, authorities really ought to consider that the present-day United States is already a fairly low-trust society.

Politicians are not highly inclined to cooperate with one another, neither citizens nor politicians are highly deferential to experts, the experts themselves are clearly not outside of the political disputes in our society, the wealthy do not behave in a highly solidaristic manner, and public officials don’t follow their own rules.

It’s important to husband the public trust we have and hopefully bolster it. As long as vaccines are in short supply, I am not super worried about anti-vaccine sentiment. But over time we do want people to take the vaccine! The best way to do that is to distribute the vaccines to those who want them in an orderly, transparent, and clearly fair way with rules that everyone understands and that are easily enforced.

Age is an objective criterion. And dividing the population on the basis of age is also “fair” in the sense that oldness occurs among all major social categories in the United States.

  • Are police officers more essential than people working at McDonalds? It doesn’t matter, you just go in order of age.

  • Should clergy be considered eligible so they can minister to their flocks in person? It doesn’t matter, you just go in order of age.

  • Is an admiral a more important government official than the Secretary of Agriculture? It doesn’t matter you just go in order of age.

First, they say everyone over 85 can get the vaccine. Then they expand to everyone over 80. Then 75. Then 70. Then 65. And on and on down the list. There’s no concierge doctor who can get you to cut the line. There’s no sleight of hand whereby the CEO of JP Morgan gets a vaccine on the grounds that bank tellers are essential workers. It will let us end this pandemic on a happy note of things working the way they are supposed to. And while it’s not totally optimal from a science standpoint, it’s honestly pretty close for such a crude measure.

Covid risk is highly correlated with age

Saying that the risk of dying of Covid-19 is strongly correlated with age has become politically contentious, because a lot of pandemic denialists have seized on it to suggest that the non-elderly have basically nothing to fear from the virus.

That’s just not true across any number of dimensions.

What is true, as this chart illustrates, is that Covid death risk rises exponentially with age (this is a log scale) and seems to do so basically all throughout the age distribution.

What this means is if you start with the oldest people and just work your way down, you can eliminate the majority of the mortality risk way before you’ve vaccinated half the population.

Compared to a completely idealized plan where you simultaneously consider age risk, occupational risk, and prior health diagnoses, this is a bit worse. But the age correlation alone really is very strong. Considering how much more transparent and harder to game a pure age criteria is, I think it has a lot of advantages. And the arguments for prioritizing essential workers don’t seem to me to hold a lot of water.

Illusions of equity

The best reason to prioritize essential workers would be if we had clear reason to believe that lots of people were catching the virus through commerce and that the vaccine halts transmission of the virus. That way, vaccinating store clerks and restaurant cooks could — even if the cooks and clerks are not necessarily at high risk themselves — greatly slow the spread of the virus throughout society.

But experts keep saying that the clinical trials the Pfizer and Moderna vaccines have been through can’t really establish whether or not vaccinated people could be asymptomatically spreading the virus.

And the evidence on where people are catching it is all over the map.

Whatever the occupation-specific risk is, it’s almost certainly not uniform across “essential” occupations, and it’s also not going to be strongly correlated with how “essential” the work really is. Making policy decisions based on this murky evidence about transmission seems like a mistake when we have very solid evidence about actual vulnerability.

As Helen Branswell at Stat has reported, a key motive for prioritizing essential workers is that this is supposed to promote racial equity:

The intention is to bring many people of color closer to the front of the vaccine priority line — should they want to be vaccinated — in recognition of the fact that the pandemic has disproportionately hit Black and Latino communities.

And later:

Though people from racial and ethnic minorities make up 40% of the American population, they account for nearly 60% of Covid cases and 50% of the Covid deaths in this country, according to CDC data. Agency data also show that Black people make up about 38% of essential workers, compared to 27% for both white and Hispanic people. Black people also more commonly work in jobs that expose them to SARS-CoV-2, the virus that causes Covid-19.

The logic of this argument is genuinely hard to follow.

David Algonquin has a twitter thread dissecting the CDC’s analysis of why racial justice requires prioritizing essential workers over the elderly, but it basically comes down to the observation that the oldest cohort in America is whiter than the general population.

This is true as far as it goes. But the actual magnitude of the gap is not particularly large compared to the age-based mortality gradient.

Basically, if you take 1,000 prime-age Americans you’d expect to have 150 African-Americans in the pool versus about 100 if you take 1,000 senior citizens. So in that sense, vaccinating essential workers promotes racial equity because you’re giving shots to more Black people. But since the infection fatality rate for senior citizens is at least 10 times the rate for non-seniors, you’re not actually saving Black people’s lives this way. You’re opting for a strategy that leads to more Black deaths and more white deaths than the “vaccinate seniors first” strategy, but deciding that it’s better for equity and this is what ethics requires.

I was a philosophy major in college so I’m biased, but I often feel that medical ethics people should run their ideas by a normal ethicist, because to me that doesn’t make a lot of sense.

Last but by no means least, note the weird racecraft here. We know the people who’ve been dying the most from Covid are Black senior citizens. The decision here is to not prioritize vaccinating them, but to instead vaccinate a different, less vulnerable group of people and then assert that this creates some kind of abstract collective racial benefit. There have been a lot of takes lately about woke liberals prioritizing symbolic racial issues over the concrete needs of non-white people, but this idea really takes the cake.

Keep it simple, stupid

American society seems in so many ways to be at a kind of breaking point, with institutions failing and trust collapsing. But while vaccine distribution logistics are inherently complicated, we have an opportunity to make the rules for who is eligible to get the vaccine very simple.

It’s common for diseases to impact people of different ages in different ways. But this one has an incredibly uniform pattern where it’s worse and worse the older you get. People of all races seem about equally vulnerable, but across ethnicities, the elderly are much more vulnerable than the middle-aged and the young much less so.

This lends itself to a really simple scheme where we start vaccinating the oldest people and then just move on down over time. Checking people’s ages is simple and routinely done, and the wealthy and powerful don’t have a good way to game this. The elderly are most vulnerable. Let’s just take care of them first.