Is Vaccine Prioritization by Health Status a Losing Proposition?

It cannot be entirely coincidental that Disneyland has been designated as a COVID vaccination site because the vaccine rollout has been a Mickey Mouse operation by any measure.  It would take hours to describe the chaos we've seen so far. But things could very well get even more chaotic if individuals' health status is figured into an already unsolvable equation. 

Although it may intuitively (and perhaps ethically) make medical sense to inoculate people who are most likely to become seriously ill if infected, the nearly-impossible logistics of doing so will almost certainly cause more damage than it will prevent. One need look no further than the CDC's "People With Certain Medical Conditions" publication to see one reason why such a protocol is a bad idea.

1. Medical Problems

Medically, some of the CDC classifications border on ridiculous. For example:

• As I previously wrote, people who smoke, along with 11 other conditions "are at increased risk of severe illness from the virus that causes COVID-19."
• On the other hand, severe asthma, cystic fibrosis, and an immunocompromised state are relegated to "second place"; "conditions [that] might be at an increased risk for severe illness from the virus that causes COVID-19."
• Regardless of the data CDC used to establish this pecking order, it does not pass the "common sense test." There can be no sane explanation for deciding to put smokers ahead of severe asthmatics or people with high blood pressure.

2. Bureaucratic Problems

If the medical side of this prioritization plan is bad, the logistics of implementing it are far worse. Adding this layer on top of an already dysfunctional system will no doubt, further hamper the goal of vaccinating as many people as possible.

• How can health status be factored into a system that is so broken that people spend hours online trying to schedule their vaccination only to find that appointments may become available in three months, provided that there is a supply of vaccine, while in other places leftover doses are thrown away?
• Even with an adequate supply, it will be impossible to apply CDC criteria. Will the workers who are vaccinating thousands of people really be able to check to see whether a 55-year old man who wants the vaccine actually has any of the conditions listed by the CDC? Of course not.
• Many of the criteria are subjective. How high is high blood pressure? Is someone with a BMI of 31 (highest risk) be distinguishable from someone with a BMI of 29 (lower risk)? Will there be someone present with a scale to measure height and weight and calculate the number? Of course not.
• How can someone prove that they actually belong in a group that will be given higher priority? Will a letter from the doctor suffice? Who will read and interpret that letter? The answer, of course, is no one.
• Application of the CDC guidance guarantees that there will be line jumping. People will exaggerate (or simply make up) the severity of their asthma, heart disease, obesity, or COPD and there will be no way to challenge these claims. It is impossible.

3. Exacerbation of Healthcare Inequities

• If some type of documentation is required for people to receive the vaccine before their age group qualifies, this can only serve to amplify the disparity in vaccinations of those who are already being medically underserved.
• People who are poor, live in underserved communities, or disabled, that already have substandard medical care, will be less likely to even know about conditions that will put them at high risk let alone be able to call their long-time PCP for documentation of their condition.
• And people in this group are more likely to have these conditions.

In a perfect world where an ample supply of vaccine is available and some (any) kind of coherent policy is in place, it would be sensible to provide vaccines to those who have specific medical needs that would get them to the front of the line. But we have nothing of the sort.

Right now the best thing we can do is use simple determinants like age, job/career, and being in an assisted living facility or nursing home to push people to the head of the line. Anything more will only make a dysfunctional system even more so. People with the greatest need will be lost in the mad rush – exactly what this flawed policy was supposed to prevent.