The recent updates from Pfizer, Moderna, and now AstraZeneca about their vaccine candidates have been bright spots in what otherwise has been a terrifying past few weeks in the pandemic. But many of us won’t be lining up at a Walgreens or a CVS to get the COVID-19 jab anytime soon. Though pharmaceutical companies have already produced millions of doses, in advance of getting emergency use authorizations from the Food and Drug Administration, it’s still not enough for the whole country. Even with enough doses, vaccine distribution will take time and require Herculean efforts to reliably guarantee things like temperature control. It’s likely that shipments of doses will be arriving at hospitals, doctor’s offices, pharmacies, and state-run distribution centers well into 2021. Vaccines, in the initial rollout, will have to be rationed.
How to do that is a complicated question. Vaccine distribution plans for polio back in the 1950s, and even H1N1 in 2009, focused primarily on age, in part because of the nature of those diseases. While one idea this time around is to focus on immunizing the social butterflies to slow spread, an emerging consensus is that groups who have been hardest hit by COVID-19 should go first. In a vaccine plan laid out by the National Academies of Science, Engineering, and Medicine, which the Centers for Disease Control and Prevention and in turn most states are expected to follow, health care workers and first responders will be vaccinated as soon as possible. (This includes me, as I’m currently training as a resident physician.) Nursing home residents may also be among the first to be vaccinated. The CDC is meeting Tuesday to vote on the specifics. Next in line for the COVID-19 jab will be people with underlying risk factors. The largest of those groups, with about 140 million Americans, is folks with a body mass index greater than 30, meeting the clinical definition of obesity.
Prioritizing folks with obesity makes a lot of sense from a purely clinical perspective. Obesity in COVID patients is associated with higher death rates and higher rates of hospital admissions to the ICU. On balance, we know these patients tend to spend more time on ventilators than those with lower BMIs. This is in part because obesity is associated with a host of other diseases, like diabetes and high blood pressure, that put patients at higher risk for COVID-19. But even the biology of obesity facilitates particularly dangerous infections, through SARS-CoV-2’s ability to proliferate in fat cells armed with specific receptors. The National Academies plan isn’t the only one that recognizes the need for people with obesity to get a vaccine quickly; Great Britain’s plan puts people with morbid obesity toward the front of the line, too.
Obesity is a risk factor for so many health issues in part because it is often implicitly considered a moral failing, and not just in pop culture and judgmental social circles. Patients with obesity frequently encounter weight bias from health care providers, who may brush off their symptoms and delay diagnostic testing. This can diminish the quality of their care and, understandably, lead many to avoid getting medical care. By prioritizing patients with obesity in the line for COVID-19 vaccines, medicine is not only following the data but is also pursuing a form of equity that recognizes obesity as a disease, rather than a character flaw. It recognizes that what someone who is high risk for a deadly virus needs most is medical care—not to be marginalized.
People with obesity are hardly the only high-risk group for COVID-19. In the National Academies plan, the group slated to get the vaccine after health care workers also includes folks with diabetes, sickle cell disease, chronic kidney disease, organ transplants, serious heart conditions, and active cancer. More than 200 million Americans—as plans currently read—would fit into this second category of people to get the vaccine. Still more vulnerable groups will go in the next phase: teachers, essential workers, people with debilitating mental health diseases, senior citizens not previously covered, and people living in group settings unable to socially distance, where COVID has run rampant—like homeless individuals, people living in group homes, and incarcerated folks. Next will be young adults and children. The remainder of the general public, like healthy, middle-age folks able to work from home throughout the pandemic, will go last. But even with this structure in place, there will be tough decisions to make about whom to prioritize among those in the earlier phases.
Part of the National Academies plan is to direct a higher percentage of the vaccine to counties with large populations of marginalized people, as identified with tools like the CDC Social Vulnerability Index. The index was created to help public health officials respond to disasters—the first reference I could find is a CDC document detailing the response to Hurricane Katrina—and incorporates social factors like poverty, access to transportation, and race. In the case of the COVID vaccine, the National Academies plan suggests using the index to help states preferentially distribute vaccines to counties with large populations of Black, Latinx, American Indian, and Alaska Native communities, which have borne the most damage from the pandemic. Even if states follow the National Academies advice, and all the logistics go according to plan, obstacles remain. Vaccine hesitancy is a pressing concern among minorities who have been harmed by medical institutions in the past—and will pose a challenge to be delicately addressed throughout the vaccine rollout. But the SVI will increase the chances that someone who is both, say, Black and obese, will have access to the vaccine ahead of someone who is white and falls into one of the medically vulnerable groups, who will in turn hopefully get a chance to go ahead of someone who is white, economically secure, and not grappling with other health issues.
In following the data, the vaccine rollout would challenge medicine’s priorities and ethics in ways that are long overdue. By openly discussing the use of tools like the SVI to help distribute a vaccine, the National Academies is explicitly grappling with ideas like racial and social justice. This is long overdue. Many of these groups prioritized by the SVI, including racial minorities, have fraught histories with medicine, which makes them more likely to be at high risk for COVID-19 in the first place. Patients with sickle cell disease, for example, have had their pain crises chronically undertreated for years; ageism remains pervasive in medicine; prisoners have been unethically experimented upon in medical studies. Many are also caught within the crosshairs of systemic racism in American medicine. Black men and women have among the highest rates of obesity in the country; for American Indians, diabetes has been described as a disease of colonization. Prioritizing them undoubtedly fits an epidemiologic imperative: It will prevent death, curb morbidity, slow community spread, and reduce strain on our health care system. Yet it also could be medicine’s start to atoning for a morally stained history.
COVID-19 has fundamentally exposed us for who we are. It has targeted the marginalized and the vulnerable. In the words of city ordinances, emergency laws, and executive orders issued by governors, it has literally revealed who among us is “essential” and who gets to ride out a disaster in comfort, or even while getting richer. It has underscored the many irrational ways in which our health system already rations care and engenders bias against specific people, including folks with obesity. The vaccine rollout might offer us all some degree of redemption. For many Americans, it will mean waiting longer for a vaccine than others. However, it also presents an opportunity to start addressing those foundational flaws and to redefine our priorities. It gives us a chance to chart a better course for our post-COVID world.