Bioethics Meets COVID-19 Vaccine Rollout: Part 2
PublishedMarch 27, 2021
Andrew Le, MD: Do you think your Bioethics for Pandemics class would have been different if you were to teach it today during the vaccine rollout? I imagine some of the questions you would be wrestling with would be very different. As of this recording, about 10% of Americans have received a vaccination. How has your work and thinking shifted?
Tia Powell, MD: We are all on a very steep learning curve when it comes to this pandemic. In terms of the course, some of the issues are eternal and probably wouldn't change. I have to say, when putting that course together in late summer 2020, I had absolutely no faith that we would have a vaccine by this time. The timing of it all was unprecedented, and we have to remember that. It’s hard to make a vaccine—we still don't have a vaccine for AIDS. However, as a nation, we have continually been behind. We haven't been well prepared to roll it out. Now we’re thinking, OK, we've got a vaccine. We didn't expect it so soon. How do we get it to everybody?
To be fair, providing these vaccines is incredibly complicated logistically, with the deep freeze refrigeration units, etc. If you let the vaccines thaw, then you're going to waste them. It's not like handing out a pill. Obviously, a huge part of the focus is now on the vaccine. We still need better treatments. We still need to think more about prevention and protecting people. It's still infuriating that people think they don't need to wear masks. 10% of the country is vaccinated, not 90%. It's only getting easier to get infected. For young people, there's still this notion that the virus doesn't do anything bad. This is false. The death rate among 20- to 40-year-olds is way up. Ordinarily it's low, because that's a pretty healthy group of people. But there are a lot of people in that age group who are dying of COVID.
The major issues now are around the vaccine rollout. What could we be doing better? Vaccine hesitancy is a huge issue. I guess one of the big issues for the nation—I don't have an answer for this—is how to separate our incredibly divisive political situation from the issue of dealing with the public health crisis. Those things needn't ever have been overlapping and combined, but they are maybe inextricably combined now. We should look at COVID as the same as cancer. It's just a bad disease. Let's get together and figure out what to do. What do you think we’re up against?
Andrew Le, MD: I completely agree the logistical challenges are not simple relative to something like handing out a pill to people. I can't imagine watching a horror movie about a pandemic and then people politicizing the pandemic. You'd think everyone would unify behind this thing that's killing hundreds of thousands of people. We're all humans, right? We would band together and fight it. But the fact that we're working off of different versions of the truth points at a massive underlying issue with society today that is directly affecting public health and the response to the pandemic. Outside of those things that you mentioned, top of mind for me are the state-level rules in terms of who gets vaccinated first.
Then you start reading about how Black Americans are getting the vaccine at much lower rates. Then, on top of that, you're looking at Israel and the UK with higher rates of first-dose vaccinations. Israel has a higher rate of getting fully vaccinated. You start looking at their strategies relative to our strategies. You start to think a lot about equity, fairness of distribution. Is fairness more important than speed? I don't know.
Tia: That's another good question.
Andrew: Those to me are existential questions. I actually wanted to ask you that, Tia. When you think about the rules and how we are deciding to distribute, what's top of mind for you in terms of the trade-offs and dilemmas that we face?
Tia: Across the country, minority communities, particularly Black Americans, have shown a fairly high degree of vaccine hesitancy. This is incredibly complicated. I teach bioethics, which means that I teach my students about Tuskegee, about Henrietta Lacks. In speaking with them in class—and many of those students are health professionals—we talk about vaccine hesitancy.
Known officially as the Tuskegee Study of Untreated Syphilis in the Negro Male, the 40-year experiment run by Public Health Service officials followed 600 rural black men in Alabama with syphilis over the course of their lives, refusing to tell patients their diagnosis, refusing to treat them for the debilitating disease, and actively denying some of them treatment. (Left: Albretch Mueller, Right: National Archive, ARC Identifier: 956151)
Tia: They say, "You taught me about Tuskegee. Then you ask why I don't have confidence in our government’s development of a vaccine that’s being pushed on minority communities? They want me to believe they’re thinking of me and my benefit. Why would I believe that?" It's an excellent question. There is an incredible breach in trust between minority communities and the Black American community in particular, and many institutions, including the government. Mandating vaccines for people who are hesitant would be disastrous. I can't think of a worse approach to heal that breach in trust.
I don't have a problem with incentivizing. I don't have a problem with persuading, with saying, "Nobody knows more about how devastating COVID has been than people in minority communities." You know that's true. You protect not only yourself, but also your frail loved ones, the people you care about, everybody who's vulnerable, everybody who's sick, everybody who's old. That's part of what you're doing in taking the shot.
I'm uncomfortable that some of the public health literature talks about education, suggesting that people who are hesitant don't know much. My colleagues, who are very experienced health professionals and have been through the COVID disaster, are not uneducated. This is an evidence-based choice to say, "I don't trust these institutions anymore." It's because they are well-informed. The best pro-vaccine spokespeople have been respected minority health professionals. Talking about acknowledging their lived experience in terms of racism, both individual and structural, is important and saying, "I get it. I hear you. I don't deny that. Yet I will get the vaccine, because it's important to me to be able to work and also protect my family.” That's what I think ethically is the most appropriate thing.
I also think listening to people and doing focus groups and saying, "What would make you feel comfortable? What would it take for you to feel that this is the right step for you to take right now?" I know some people are saying, "I'm going to wait and see. Let's get a lot of other people to do it." But that's risky, because the new, easy-to-catch variants are sweeping in. The longer we take to reach herd immunity, the easier it is going to be for those new variants to take hold. It's a troubling set of issues, Andrew. I don't think there's an easy solution, but I hope we don't move toward forcing the vaccine on people, because as I say, that's disastrous.
Andrew: Right. So, to play it back, Tia, you're saying mandating would deepen already-existing wounds. It would be a disastrous strategy. Incentivizing, you're okay with. Persuading, you're even more okay with, and that's a great way to go about it. That's super helpful.
Turning a little bit to other ethical questions that I started touching on. One is fairness of distribution versus speed. Which of those wins?
Tia: Well, the fairness issue is hard to meet if you're offering it to people who say they aren't ready. It's hard to get to fairness. It may be that we can have different tracks and try and do both at the same time to increase our speed. You're saying, "Anybody who wants it, come. We're open 24/7. We're training people. We're going to roll it, roll it, roll it. I want to get to herd immunity, because that's good for everybody. Come on in." Then you also need to have a separate track for someone who was already offered the vaccine and refused it. Maybe they're a frontline worker, or in a higher tier. To them, you're saying, “You can change your mind any time. You can come in this separate batch. We're saving some for you.”
The other issue about fairness is that all these localities are putting up websites. Older people with dementia can't access those websites, yet are twice as likely as an age-matched person to get COVID. To create accessibility, we need more than just a ramp. We need to figure out how to make it incredibly easy for people with different kinds of access challenges, including internet access, to get the vaccine. In urban areas, you're going to need to get it out to the people, because not all people are able to make an online appointment and drive up to vaccine venues.
Tia: In rural areas, too. There are a lot of isolated older people who still are at risk for COVID, because the limited contact they have is in places where there's relatively little belief in the danger of COVID. You want to figure out creative strategies for getting the vaccine out to lots of people. I don't think we have to choose. You can divvy up your allotments, which will be easier as we get more and can ramp up production, which it looks like we're doing now.
Andrew: Tia, thank you for the great insight. I totally agree with you. I actually didn't have a view going into our discussion on fairness of distribution or speed, but you've convinced me. That makes a ton of sense. I appreciate you being our first interview for the CEO Corner of our Healthy Thoughts blog. This has been terrific.
About the participants:
Tia Powell, MD, bioethicist, psychiatrist and epidemiologist, Directs the Center for Bioethics and Masters' in Bioethics at Montefiore Health Systems and Albert Einstein College of Medicine Fellow at Hastings Center
Andrew Le, MD, CEO and Co-founder of Buoy Health