Medical Examiner

Just Vaccinate People

The first weeks of vaccination have shown that we have not invested in the systems that would enable ethical ordering.

a vaccine going into an arm
Good. Arnold Jerocki/Getty Images

In the middle of the night on Monday, things at the brand-new 24/7 vaccination site in Brooklyn were pretty dead. A couple dozen temporary office buildings that had the appearance of converted shipping containers sat on a lot at the Army Terminal in Sunset Park. Nearby in a tent, 30-ish chairs sat on spaced out yellow x’s. It was one of two such new sites in New York City to be open around the clock, with three more slated to also start all-hours immunizations this week. A bit before midnight, a worker emerged to get a few boxes of treats from Dunkin Donuts. A reporter and a camera guy for a television station waited in a car nearby in case someone who had actually just been vaccinated emerged. “Get a Free COVID-19 Vaccine Here!” a colorful sign said, to almost no one.

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I loitered outside the fence for an hour with a colleague. (“APPOINTMENT NEEDED,” said the sign, barring us from going inside.) Right now, New Yorkers currently eligible to receive the vaccine include anyone over the age of 65 and set of essential workers, from those in health care to teachers to cashiers at grocery stores—rules that were expanded on Tuesday morning, after I was at the empty site. The rollout has so far gone slowly, a fact Cuomo blamed on the “drip, drip, drip from the faucet of federal dosage availability,” which is currently sending just 300,000 doses per week to the state. It’s true that that rate is low, far too low to quickly vaccinate all eligible New Yorkers. But it is also true that the state has not has not moved quickly enough to distribute the doses it has received. In New York, there have been reports of vaccines sitting in freezers, and even spoiling. Hence 24/7 vaccination sites.

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It’s hard to account for everything that is causing the slowdowns, but the overarching factor seems to be that state resources are exhausted and there isn’t enough federal investment going into getting the vaccine into people’s arms—a process that is complicated and difficult, just like the creation of the vaccine itself, if far less glamorous. The question is whether, after months of debating the proper, ethical way to distribute this vaccine, we even have the capacity to execute such a plan. Restricting eligibility is clearly well-intentioned—starting with the elderly and health care workers makes obvious sense. And as physician Vishal Kheptal explained in Slate in December, prioritizing vulnerable members of a population, like those with underlying conditions such as obesity, is a step toward reversing some of the foundation flaws in medicine. An editorial in the LA Times even went as far as to praise California Gov. Gavin Newsom for threatening sanctions to healthcare providers who give doses out of order; the editorial noted that those who cut the line should be “called out and punished in a meaningful way.” (Per the LA Times’ reporting, rich people, as you might expect, are in fact trying to cut the line.)

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empty chairs
Empty chairs at a 24/7 vaccine site. Shannon Palus

The problem is that restricting eligibility stringently is not working, as evidenced by those spoiled doses. Which is why on Tuesday, the CDC told states to open up vaccinations to more people, so that anyone over 65, or anyone under 65 with “with a co-morbidity” that places them at higher risk can get vaccinated. “You might have a sequential order in which you board people, but you don’t wait until literally every person from a group has boarded before moving onto the next,” said Alex Azar, Health and Human Services Secretary, at a briefing announcing the expanded guidelines. “You have to keep the process moving.“ Azar also blamed the slow rollout on states’ “heavy-handed micromanagement of this process.” In the Washington Post, vaccine expert Peter Hotez suggested brushing aside the strict order altogether, in addition to calling for more financial support from the federal government and setting up large stadiums for mass vaccination.

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There might be a middle-ground to tack between turning things into a vaccine-free-for-all, and trying to prevent absolutely anyone from line-jumping. States get to choose whether and how to penalize providers that give shots out of turn: In New York, providers can lose their license, while in D.C., Texas, and other places, there are anecdotes of people who do not qualify snagging a shot just before a pharmacy was set to close, with no repercussions.  “You can’t hold vaccine supply hostage to an ideal distribution system,” New York University School of Medicine bioethicist Arthur Caplan told Dana G. Smith in a piece for Elemental. “You don’t want the perfect to be the enemy of the good.” Smith’s piece is focused on the ethical question of whether you should accept a COVID-19 shot if it is randomly offered to you, even if you don’t fit the qualification requirements. The bioethicist’s answer is a pretty clear “yes.”

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All states should make it legal and even easy for providers to avoid wasting doses, or maybe even appointment slots that aren’t booked up, by allowing them to vaccinate people using their own judgment. In Connecticut for example, the Department of Health recommends clinics have a waitlist on hand in case there are doses unaccounted for. The entire point of the round-the-clock sites is to speed up the pace at which needles go into arms—24/7 vaccination sites seem like exactly the kind of ambitious and effortful response we need right now to get out of the pandemic. It was disappointing to see one so desolate. (I didn’t even try asking to get a dose, given the strict rules in New York).

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It was not clear if the vaccination site on Monday night was operating below its physical capacity on purpose; maybe this was just another piece of the rollout efforts that was taking time to boot up. I reached out to the Mayor’s office to ask about how many available appointment slots were used, but have not heard back. As of Tuesday at midnight, the city has administered 267,923 out of 793,675 doses that it has available. That works out to—counting conservatively—nearly 300,000 extra doses of vaccine available. We’re better off getting those into arms quickly, no matter whose arms they are.

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