Why the Distribution of COVID Vaccines Was Unethical

The world spent a long time holding its collective breath waiting for a COVID vaccine to end lockdowns and curtail mortality rates. When it finally became available, there were long waiting lines, and rationing had to be imposed. This was by no means exceptional. Whenever a scarce medical resource meets a large demand, rationing follows. For instance, this was also the case when a new medical treatment for hepatitis C became available in 2014, when this disease was the single greatest cause of infectious death in the United States.

Who should be vaccinated, and who should wait? The rationing of scarce medical resources is the domain of medical ethics, which aims to identify ethical principles we should, hopefully, all agree on. Alas, the rationing procedures which were used for COVID vaccines around the world blatantly violated those principles. Not on purpose, mind you. There was no “evil hand” at work. The reason was simply that political realities clashed with common sense, and the latter gave way.

Ethical Principles: Priority and Equality

Medical ethics has roughly agreed on a few principles. The two most important ones, in the case of COVID vaccines are priority and equality.

Priority just means that some people should come first. For instance, medical personnel should be immunized first, because the whole system might collapse otherwise, but, following them, the elderly and those especially at-risk should be given priority over the young and healthy. One ends up with a few priority classes and expects that no one in a lower-priority class receives vaccines until those with higher priority are vaccinated.

Equality means that any two people within the same priority class should be treated equally, independently of, say, where they live.

COVID vaccines were bought and distributed by a number of large organizations. The European Union distributed vaccines to its member countries. The U.S. did the same for its member states. The World Health Organization sponsored a multi-country initiative called COVAX. All of them implemented rationing among their member territories (states or countries).

What did those organizations do? Faced with local political pressure, they settled for a quick rationing rule which treated territories according to their size. Essentially, they shipped vaccines proportionally to the population of the territories, asking those to vaccinate according to priority classes. Fast and easy. And ethically wrong.

Not wrong as purposefully evil, but rather wrong as naively mistaken. My new article in Frontiers in Public Health, “Ethical allocation of scarce vaccine doses: The Priority-Equality protocol” (joint with J. García-Segarra and M. Ginés-Vilar) shows that the allocation of COVID vaccines violated the ethical principles of priority and equality, and explains how we could have done it better.

Pixabay/Gerd Altmann

Albertville and Barryland

How we could have improved on the system can be demonstrated with a simple example. Suppose we have two different, hypothetical territories, Albertville and Barryland. Both of them have the same number of inhabitants. Albertville has a lot of elderly people and medical personnel, adding up to 400,000. Barryland is far younger, it only has 100,000 elderly people and medical personnel. Together, both territories have half a million elder people and medical personnel. In the first available batch, there are only a quarter million vaccines.

To respect priority, it is clear that only healthcare workers and the elderly should receive vaccines. To respect equality, the same proportion of those should be immunized in both Albertville and Barryland: specifically, half of them. That would be 200,000 in Albertville and 50,000 in Barryland. Easy, right?

That is not what happened with COVID vaccines. In this example, allocating vaccines proportionally by population, means Albertville and Barryland receive 125,000 vaccine doses each. That means that every elderly person or healthcare worker in Barryland is vaccinated, while far less than half of those in Albertville are.

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This violates equality, since people in the same priority class are treated differently depending on where they live. Worse, Barryland is left with 25,000 extra doses which are used to vaccinate young, healthy people, while the elderly inhabitants of Albertville risk death. This of course violates priority. We are letting the old and infirm die to vaccinate the young and healthy.

This is not just a theoretical example. These problems became painfully obvious in Europe. By the 12th week of 2021, the percentage of vaccinated healthcare workers was 72 percent in Romania and 67 percent in Estonia, in stark contrast with the corresponding rates of 37 percent in Denmark and 22 percent in Iceland. Hungary actually broke the agreement and secured additional vaccines on its own. By the 22^nd week, some European countries, like Spain and Belgium, had received enough vaccines for all healthcare workers and all those aged 70 or older, while other EU members, such as Denmark, France, and Greece had barely received enough to immunize those older than 80. The imbalance was so evident that some people engaged in “vaccine tourism,” crossing national boundaries to receive their vaccines earlier.

How to Allocate Scarce Vaccines

What politicians forgot is that there is an entire branch of the (mathematical) social sciences dedicated to the allocation of scarce resources. Ethical principles or socially desirable properties can be translated into formal principles, and then one can apply mathematics to find out whether there are methods that fulfill them, and exactly how those methods work. This is what we did.

In our article, we show that there is one (and, actually, only one) rationing method that will always guarantee that priority and equality are fulfilled, no matter what the number and size of the territories and priority classes might be.

It goes as follows: add up the size of the priority classes across territories, and allocate vaccines to those cross-territory classes. Then divide them proportionally to the sizes of the classes in the territories.

In the example above, Albertville and Barryland together have half a million elderly people and healthcare workers, and there are only a quarter million vaccines. So only people in those classes will receive vaccines. Albertville has 400,000 of them, and Barryland 100,000, so one-fifth of the vaccines will go to Barryland and the rest to Albertville. Each of the territories will vaccinate half of their highest-priority people.

In hindsight, the story of the allocation of COVID vaccines is a sad one. We knew what ethics dictated. For once, a solution existed and could have been easily found, if the right scientists had been asked. Politics dictated otherwise. And so some young and healthy individuals were vaccinated while elsewhere the elder and the sick died waiting for a vaccine.