The COVID-19 pandemic is raging in the US, with almost 3000 deaths per day. But both the Pfizer COVID-19 vaccine and the Moderna COVID-19 vaccine have been approved in the US. I congratulate the scientists who worked on this impressive achievement. It reminds me of those old Western movies in which the cavalry would arrive "just in the nick of time" to "save the day."
Millions of doses of the vaccines are being distributed, but not on a "first come, first served" basis. There is only a limited supply of vaccine doses at this time, with many more doses to be available in 2021. The vaccine shots are being distributed in accordance with vaccine distribution policies that have been decided on by various expert committees. Below is the plan for New York state as declared on page 29 of this document.
The author points out the plan is to give 4 million vaccine doses of the first 20 million vaccine doses to nursing home residents and nursing home personnel, and then states this:
"Giving the next 15 million doses to health care workers does not compute by any calculus valuing lives saved. I know the arguments. They put themselves at risk. They are needed, healthy, for hospitals to function smoothly. They tend to roll up their sleeves more willingly than average Americans. The problem: they don’t die very often. Approximately 0.5% of US deaths from Covid-19 have been health care workers. Approximately 80% of US deaths from Covid-19 have been from those over 65. 80%. Versus 0.5%. How is this even a question?"
The author seems to have adopted a simple "save the most lives" principle. But is that the best principle to be following? There is an alternate moral calculation: one that uses a principle of "save the most life years."
Let's imagine how such a principle might be used. Imagine you are the captain of a small boat, and you come across the aftermath of a shipwreck. Looking through your binoculars, you see two small groups of frigid passengers treading water. Over to the east is a group of three very old people treading water. Over to the west is a group of two young adults treading water. Which do you save first?
According to a "save the most lives" principle, the answer is easy: go to the east, because there are three people over there, not just two. But imagine if the captain uses a different principle, a "save the most life years" principle. He then may try to calculate the number of life years saved by going east and going west. The three very old people have a rather small number of life years ahead of them. Each one will be expected to live an average of only about 10 years. So if the captain goes east, he will be saving a total of about 30 years of human life. But the two young adults to the west will have many years ahead of them if they are saved. Each will live perhaps 50 additional years. So the captain can save a total of about 100 years of life if he goes to the west.
In this case, the "save the most life years" principle results in a different decision that the "save the most lives" principle. If the sea captain acted according to the "save the most lives" principle, he would go to the east to save the three very old people. But if the captain acted according to the "save the most life years" principle, he will go to the west, thinking that it is more important to save about 100 life-years than to save only about 30 life-years.
Similarly, for certain types of viruses, a "save the most life years" principle might result in different vaccine distribution plans than a "save the most lives" principle. Let us imagine a Virus X that kills both young adults and old people, but causes deaths at a rate 200% greater in people over 70, compared to young adults. If we followed a "save the most lives" policy, we might recommend that people over 70 get the first doses of a newly available vaccine for Virus X. But since a young adult has maybe a 400% greater life expectancy than a 70-year-old, if we were following a "save the most life years" policy, it seems we would give the first vaccine doses to the young adults.
However, in the case of COVID-19, a different mathematics is involved. According to the chart below (made using the data on this CDC page), the death rate for people with an age between 65 and 74 is not just 200% greater than for young adults, but actually more than 50 times greater.
So it turns out even if we use a "save the most life years" principle rather than a "save the most lives" principle, we come to the same recommendation, that an average person over 65 should get the vaccine before an average young adult should get the vaccine (not taking into consideration occupations). Such a policy will result in both more lives saved, and also more years-of-life saved.
Now let's consider a very questionable aspect of the New York state plan for a COVID-19 vaccine rollout. The plan is that in a Phase 2 "other essential frontline workers" (including "grocery store workers" and "transit workers" and "teacher/school staff") will get the vaccine before people 65 and older, who will not get the vaccine until a Phase 3. Does this make sense, under either a "save the most lives" principle or a "save the most life years" principle?
To address that question intelligently, we must get some statistics regarding the incidence of COVID-19 deaths by occupation. A British study released in May 2020 claimed the following:
"Healthcare workers, including doctors and nurses, were not found to have statistically higher rates of death involving covid-19 when compared with the rate among those of the same age and sex in the general population....Male security guards had one of the highest death rates at 45.7 deaths per 100 000 (63 deaths). Other jobs with raised rates of covid-19 death included taxi drivers and chauffeurs (36.4 deaths per 100 000), bus and coach drivers (26.4 deaths per 100 000), chefs (35.9 deaths per 100 000), and sales and retail staff (19.8 per 100 000). Men and women working in social care both had significantly raised rates of death involving covid-19 with rates of 23.4 deaths per 100 000 in men (45 deaths) and 9.6 deaths per 100 000 women (86 deaths)...The rate of death among healthcare workers was 10.2 deaths per 100 000 males and 4.8 deaths (43 deaths) per 100 000 females (63 deaths). The category included doctors, nurses, midwives, nurse assistants, paramedics and ambulance staff, and hospital porters."
The chart here compares COVID-19 rates for various occupations, and tells us that "teaching professionals" and "healthcare workers" have a rate of COVID-19 death less than 10 per 100,000, while people such as police, firemen, shop workers and printers have a rate of COVID-19 up to about 20 per 100,000 or as high as about 30 per 100,000.
We can compare these relatively low death rates to the vastly higher deaths of people over 65. Below is a chart from a Connecticut state web site, showing COVID-19 death rates per 100,000 in that state, by age (choose "Total Number of Deaths" in the "Age Group Chart" to see the latest version of such a graph).
COVID-19 death rates per 100,000 in Connecticut, by age
If we limit ourselves to a "save the most lives" principle we should complain about this, just as did the doctor I earlier mentioned, who evokes such a "save the most lives" principle to complain about the COVID-19 vaccine rollout plans. But if we use a "save the most life years" principle, there will be less to complain about. Let's imagine you are a health care worker who is a young adult. Even though your COVID-19 death risk is much lower than that of a 65-year-old, the number of life years that will be saved if your death is prevented is maybe four times greater than if a 65-year-old dies from COVID-19.
Did those who created the COVID-19 vaccine rollout plans use a "save the most life years" principle rather than a "save the most lives" principle? We don't know. But it's rather clear the rollout plans are not right under a "save the most lives" principle. The plans are less objectionable under a "save the most life years" principle. But such a principle by itself fails to justify the COVID-19 vaccine rollout plans.
Let's consider 40-year-old healthcare workers. According to the statistics above, their risk of getting COVID-19 is many times lower than the rate of someone over 65 (which is about 600 per 100,000, according to the graph above). Even if we take into account that the "years lost" for the person in his sixties would be only about 50%-30% of the "years lost" for someone dying at the age of 40, it still seems that a mere "save the most life years" policy would lead us to give the vaccine first to people over 65 before it is given to most healthcare workers. Instead, the healthcare worker gets the vaccine in Phase 1 of the New York state rollout, while a 65-year-old gets the vaccine only in Phase 3 of the rollout.
Clearly even if we use the less common "save the most life years" principle, it fails to justify the COVID-19 rollout plans such as the New York state plan. Are there other principles that can be appealed to? There are. There is a "keep society running smoothly" principle or "cultural convenience" principle, under which "essential workers" are valued far more highly than retired people. And there is a "reward the recent achievers" principle under which people who previously saved lives or did hard work recently may be given the vaccine earlier, as a kind of bonus.
So after appealing to three different principles ("save the most life years," "avoid cultural inconveniences and keep society running smoothly" and "reward the recent achievers"), we might be able to end up justifying the current COVID-19 vaccine rollout plans. But they sure cannot be justified by appealing to a single simple principle such as "save the most lives" or "save the most life years" or "prioritize the most endangered."
On page 10 of the document for the New York State vaccine rollout plan, there is this claim: "New York State’s COVID-19 vaccine distribution approach will be based solely on clinical and equitable standards that prioritize access to persons at higher risk of exposure, illness and/or poor outcome, regardless of other unrelated factors, such as wealth or social status, that might confer unwarranted preferential treatment." This statement is very false. If the plan had been "based solely on clinical and equitable standards that prioritize access to persons at higher risk of exposure, illness and/or poor outcome," the people 65 or older would not be put in a phase 3 of the rollout, behind teachers, transit employees and grocery workers put in a phase 2 of the rollout. The COVID-19 death rate of people over 65 is more than 20 times greater than the COVID-19 death rate of teachers, transit employees and grocery workers.
I can imagine the thoughts of someone creating a COVID-19 rollout plan like the New York state plan. He might be someone who put a high value on convenience. So he might be thinking like this:
"Look, we've got to keep the trains running on time. No one likes late mail, and when you order from Amazon, you don't want to wait too long for your package. And everyone likes clean streets. Think of all those empty office buildings. They have to be protected. We can't let homeless people camp out inside them. And we have to keep all our grocery workers at their stations. No one likes having to walk too far to buy food, and no one likes having to wait too long in food store lines. When you go buy food, you want everything neatly organized on the shelves, so you can find things very fast. And we can't let teachers be out under quarantine, for then we might have to teach many of our kids how to learn on their own."
It is reasonable to ask whether the authors of such a COVID-19 rollout plan have valued "cultural convenience factors" such as "maintain critical infrastructure" far above saving the lives of people over 65. It is somewhat as if the authors of such a plan tended to regard senior citizens as being rather expendable. Similarly, I can imagine a rescue boat approaching shipwreck survivors treading in icy water, and the captain shouting out to the swimmers, "Raise your hand if you're usefully employed."
Don't get me wrong. I'm a fan of the COVID-19 vaccines and the brilliant minds who developed them. I'm just not a fan of most of the rollout plans for such vaccines.
Postscript: An expert panel of the CDC (Center for Disease Control) has released today a recommendation regarding COVID-19 vaccine distribution. It partially corrects the appalling shortcomings of the New York state plan discussed above, but still jeopardizes those in the very high-risk age group of 65-74.
Don't be fooled by its designations of 1a, 1b and 1c. "1a" is phase 1, "1b" is phase 2, and "1c" is phase 3. The panel recommends that phase 2 of the COVID-19 vaccine distribution (euphemistically called "phase 1b") should be a group of 49 million people including about 14 million who are 75 and older and some huge group of about 35 million called (not really accurately) "frontline essential workers," a group that includes basically any worker at all who cannot work from home. The vast majority of these workers will have a COVID-19 death risk many times smaller than those age 65-74, but such workers will get their vaccines ahead of such seniors, who are consigned to a phase 3 (euphemistically called "1c").
The article here quotes one of the panel members who mentions some reasons for his vote, none of which is "save the most lives."
Anyone impressed by the CDC imprimatur here should remember that both the CDC and the World Health Organization made gigantic COVID-19 blunders earlier this year, by telling people during the critical first months of the pandemic that they did not need to wear face masks, before recanting their foolish advice on this topic (as discussed here and here).
Post-postscript: On television December 21 a Professor Anne Rimoin commented on the new CDC guideline. I can't remember her saying anything about any "save the most lives" rationale or any "prioritize the most endangered" rationale. Instead, she repeatedly stated that the specially favored workers (given vaccines before those at vastly higher risk) are "very important people." I guess we can call this guideline a "VIPs first " policy.
“ 'I will be eternally perplexed if the US doesn’t choose to vaccinate the elderly first and foremost, along with those who take care of them directly,' wrote Zeynep Tufekci, a University of North Carolina professor of sociology who has emerged as one of the country’s sharpest coronavirus policy commentators. 'Everyone deserves protection, but if we do not prioritize vaccination by actual risk, which basically means prioritizing by age and vaccinating the elderly first, it may well be the greatest, most consequential mistake [the] United States does in a year full of very very bad ones.' She cited a preprint of a paper on vaccine prioritization, which makes the case that vaccinating older adults first will save the most lives. It would also save the most 'life-years' — a measure of lives saved that considers how many more years of life that person has (and so values saving a 20-year-old much more than saving an 80-year-old)."
Besides the paper mentioned above, there is the paper here, which finds that "for a range of assumptions on the action and efficacy of the vaccine, targeting older age groups first is optimal and can avoid a second wave if the vaccine prevents transmission as well as disease." Then there is the paper here which says, "Our model suggests a vaccine distribution that emphasizes age-based mortality risk more than occupation-based exposure risk." Then there is the paper here which says, "Vaccinating 60+ year-olds first prevents more deaths (up to 8% more) than transmission-interrupting strategies for January [2021] vaccine availability across most parameter regimes."
A COVID-19 vaccine strategy of "prioritize the most endangered" would also distribute first to neighborhoods with the highest infection rate. If this were done in New York City, priority would be given to neighborhoods with the highest infection rates, as listed on the current map of New York City zip codes and their infection rates. Under such a policy, some minority-rich neighborhoods would get vaccines first, not because ethnicity was considered, but simply because the COVID-19 infection rate happened to be higher in such neighborhoods.
Post-post-post-postscript: On January 12, 2021, the CDC announced that it was changing its guidelines, recommending the immediate COVID-19 vaccination of anyone 65 or older. So the policy I complained about was changed in the way I recommended much earlier (around December 20, 2020).
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