With the coronavirus pandemic surging and initial vaccine supplies limited, the United States faces a hard choice: Should the country's immunization program focus in the early months on the elderly and people with serious medical conditions, who are dying of the virus at the highest rates, or on essential workers, an expansive category encompassing Americans who have borne the greatest risk of infection?
Health care workers and the frailest of the elderly — residents of long-term-care facilities — will almost certainly get the first shots, under guidelines the Centers for Disease Control and Prevention issued Thursday. But with vaccination expected to start this month, the debate among federal and state health officials about who goes next, and lobbying from outside groups to be included, is growing more urgent.
Ultimately, the choice comes down to whether preventing death or curbing the spread of the virus and returning to some semblance of normalcy is the highest priority.
"If your goal is to maximize the preservation of human life, then you would bias the vaccine toward older Americans," Dr. Scott Gottlieb, the former Food and Drug Administration commissioner, said recently. "If your goal is to reduce the rate of infection, then you would prioritize essential workers. So it depends what impact you're trying to achieve."
The trade-off between the two is muddied by the fact that the definition of "essential workers" used by the CDC comprises nearly 70% of the U.S. workforce, sweeping in not just grocery store clerks and emergency responders but tugboat operators, exterminators and nuclear energy workers. Some labor economists and public health officials consider the category overly broad and say it should be narrowed to only those who interact in person with the public.
An independent committee of medical experts that advises the CDC on immunization practices will soon vote on whom to recommend for the second phase of vaccination — "Phase 1b." In a meeting last month, all voting members of the committee indicated support for putting essential workers ahead of people 65 and older and those with high-risk health conditions.
Historically, the committee relied on scientific evidence to inform its decisions. But now the members are weighing social justice concerns as well, noted Lisa Prosser, a professor of health policy and decision sciences at the University of Michigan.
"To me the issue of ethics is very significant, very important for this country," Dr. Peter Szilagyi, a committee member and a pediatrics professor at UCLA, said at the time, "and clearly favors the essential worker group because of the high proportion of minority, low-income and low-education workers among essential workers."
That position runs counter to frameworks proposed by the World Health Organization; the National Academies of Sciences, Engineering, and Medicine; and many countries, which say reducing deaths should be the unequivocal priority and that older and sicker people should thus go before the workers, a view shared by many in public health and medicine.
Dr. Robert Redfield, CDC director and the nation's top public health official, reminded the advisory committee of the importance of older people, saying in a statement Thursday that he looked forward to "future recommendations that, based on vaccine availability, demonstrate that we as a nation also prioritize the elderly."
Once the committee votes, Redfield will decide whether to accept its recommendations as the official guidance of the agency. Only rarely does a CDC director reject a recommendation from the committee, whose 14 members are selected by the Health and Human Services secretary, serve 4 ½-year terms and have never confronted a task as high-profile as this one.
But ultimately, the decision will be up to governors and state and local health officials. They are not required to follow CDC guidelines, though historically, they have done so.
Defining 'essential'
There are about 90 million essential workers nationwide, as defined by a division of the Department of Homeland Security that compiled a roster of jobs that help maintain critical infrastructure during a pandemic. That list is long, and because there won't be enough doses to reach everyone at first, states are preparing to make tough decisions. Louisiana's preliminary plan, for example, puts prison guards and food processing workers ahead of teachers and grocery employees. Nevada's prioritizes education and public transit workers over those in retail and food processing.
At this early point, many state plans put at least some people who are older and live independently, or people who have medical conditions, ahead of most essential workers, though that could change after the CDC committee makes a formal recommendation on the next phase.
One occupation whose priority is being hotly debated is teaching. The CDC includes educators as essential workers. But not everyone agrees with that designation.
Marc Lipsitch, an infectious disease public health researcher at Harvard's T.H. Chan School of Public Health, argued that teachers should not be included as essential workers if a central goal of the committee is to reduce health inequities.
"Teachers have middle-class salaries, are very often white, and they have college degrees," he said. "Of course they should be treated better, but they are not among the most mistreated of workers."
Elise Gould, a senior economist at the Economic Policy Institute, disagreed. Teachers not only ensure that children do not fall further behind in their education, she said, but are also critical to the workforce at large for child care.
In September, academic researchers analyzed the Department of Homeland Security's list of essential workers and found that it broadly mirrored the demographics of the U.S. labor force. The researchers proposed a narrower, more vulnerable category: "front-line workers," such as food deliverers, cashiers and emergency medical technicians, who must work face to face with others and are thus at greater risk of contracting the virus.
Some health policy experts said that to prioritize preventing deaths rather than reducing virus transmission is simply a pragmatic choice because there won't be enough vaccine initially available to make a meaningful dent in contagion. A more effective use of limited quantities, they say, is to save the lives of the most frail.
Some states have suggested that they will prioritize only essential workers who come face to face with the public, while others have not prioritized them at all.
Even some people whose allegiance lies with one group have made the case that others should have an earlier claim on the vaccine. Marc Perrone, president of the United Food and Commercial Workers Union, which represents 1.3 million grocery and food processing workers, said that despite the high rate of infection among his members, he thought that older adults should go first.
