The big question: What safeguards are in place to ensure ethical distribution so that powerful groups cannot buy access before those who need it more?
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The CDC has outlined a phased approach to vaccine distribution that can be adjusted by the states. Phase 1A includes who you'd expect -- medical professionals in high-risk settings, elderly patients in long-term care facilities and dialysis patients.
That's just the first tier. The second tier will include home health care workers, public health field staff and correctional facility clinics. In the third tier will be other healthcare workers like dentists, laboratory workers and pharmacists.
Across the country, Phase 1A is comprised of about 24 million people. Once they have all received two doses (both the Pfizer and Moderna vaccines require two doses), people in Phase 1B will be eligible.
We don't yet know who will be in Phase 1B, much less, what the tiers will look like. The CDC has suggested this category will be comprised of essential workers but has not yet specified exactly who that includes.
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In California, the department of public health has set up a drafting guidelines workgroup comprised of medical professionals from across the state. They have been tasked with incorporating federal recommendations with state data to "develop California-specific guidance for the prioritization and allocation of a COVID-19 vaccine," according to a CDPH press release.
"The drafting guidelines workgroup will help us make difficult decisions and guidelines about vaccine allocation and distribution both early on when the resources are scarce, and later as supplies increase," said Dr. Erica Pan in October, as the acting state public health officer.
Dr. Louise Aronson is one of the members of the group. A professor at UCSF School of Medicine and leading geriatrician, Dr. Aronson said they have been working on creating the Phase 1B tiers for several weeks.
"The process so far seems incredibly rigorous, thoughtful and impressive," she said, unable to discuss specifics about internal discussions due to a non-disclosure agreement.
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Given the way testing for COVID-19 was rolled out and is still operating, she said she understands why people may be skeptical
"There have been inequities in this pandemic in who gets PPE and who gets testing," Aronson said. "That all happened very quickly without much planning and with, at least at the federal level, a government that didn't want to take charge across the nation."
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As groups of highly educated medical professionals weigh medical data with ethical considerations, the corporate lobby industry has been hard at work to influence the decisions.
Trade groups representing zoo workers to meat packers have been sending letters to the CDC and state governments, presenting their case for higher prioritization.
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Dr. Aronson seemed aware that industries were jockeying for position, but said. "I'm feeling confident so far based on my experience is those lobbying efforts aren't touching the part of the process in which I'm participating."
While her group offers important counsel to the CDPH, she points out that there are many other people involved.
"It's a many layered system. The process in which I am participating seems incredibly rigorous and ethical," said Aronson.
"I think it would be a mistake to pretend it's completely immune from political influence," said David Magnus, the director of Stanford's Center for Biomedical Ethics.
While he has faith in groups like the drafting guidelines workgroup, he is worried there may be some high-risk populations that may be marginalized because of political pressure.
"I don't think this will happen in California, but I will be very interested in where prisoners show up on the allocation systems. You can imagine an area where in some states it might be unpopular to vaccinate prisoners before other citizens," said Magnus.
What about wealthy people or companies paying to get higher priority? In terms of policy from the CDC or states, he sees that as unlikely, though he's already imagining loopholes.
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For example, workers in the meat and poultry industry have been hard hit, particularly in large plants in the mid-West.
While warehouse workers and meatpackers may be vulnerable, Magnus says it is the executives who will be submitting lists of employees to their county agencies.
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He worries CEOs may list themselves among the more vulnerable employees.
"If they end up putting themselves as workers in those factories, they may be able to get their own place in the cue much much higher. If that becomes invisible, that could be problematic and undermine trust," said Magnus.
On the other hand, he said that public health officials will be battling another barrier to the vaccine: Mistrust.
"It may be important that some of the leaders get vaccinated and get vaccinated in a very public way," said Magnus.
That could mean that some high profile, yet low risk people are able to access the vaccine earlier than the general public as an intentional campaign by health officials to raise awareness about the safety of the vaccine.
"Everybody is working really hard to get this right, or at least as right as we can, given that for some of these tradeoffs and dilemmas there is no one right answer," said Magnus.
In terms of companies being able to lobby the health officials directly, he said, "it helps that at the largest levels, these decisions are being made and these recommendations concretely are being made by individuals who are clearly high-minded people being motivated by decisions of equity, justice, trying to make sure it's a fairly transparent process."
Dr. Aronson also said she expects the process to be much more fair than it was for testing but cautioned, due to the limited supply, "It's not going to go the way everyone wants."
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