It is not just about age or vulnerability – those most disenfranchised by Covid should get the vaccine first

So we have a vaccine. Maybe. Though let’s be honest, nothing has actually changed. Yet.

While the news has been greeted by many as a sign of an imminent return to normal (especially in the stock market), the vaccine is still several months from being routinely available to the general public in Britain – if it passes all of the regulatory requirements needed to bring the vaccine to market. Pfizer will not have the data to know if it can proceed to this next stage until the third week of November. It will then apply for emergency approval of the vaccine to the public.

Forgive me if I’m a bit flat about it all, but we’re going to be in and out of lockdowns, and sticking to social distancing measures, for several months yet.

And that’s when the real trouble begins, because it should come as no surprise that there has been little transparency around who and how the vaccine will be distributed and administered, and who will get the vaccine first. These are not inconsequential questions or small details.

The administration of the vaccine is done in two stages, roughly three weeks apart, meaning every person who gets a vaccine requires two doses for it to be effective. Pfizer has agreed to sell 10 million doses to the UK in the first instance, which translates into 5 million people vaccinated sometime in the next few months. That’s only 7.5 per cent of the UK population. Even the more optimistic promise of a further 30 million doses would only allow for about a third of the population to be vaccinated, and there has been no discussion at all about how the further 103.33 million or so doses needed to fully vaccinate the entire population will be procured.

The UK government has said the “NHS stands ready to begin a vaccination programme for those most at risk”, but to whom do they refer? The Joint Committee on Vaccination and Immunisation (JCVI) have largely identified these categories of risk by age, though even they say they cannot “come to a firm position on priority groups at this time”. 

They suggest, and many agree, the obvious choices are the clinically vulnerable and the staff who care for them. There are roughly 400,000 care home residents in the UK and around 1.4 million NHS staff. That doesn’t seem too bad, but when you add the 2.2 million people identified as clinically vulnerable in the first wave and the seven million people who care for them, the numbers simply do not add up. Not to mention once you move down to the “final” priority group, which is everyone under 50, all the JCVI can offer is a vague “rest of the population (priority to be determined)”. The question may be settled on who gets the very first doses, but how will subsequent doses be distributed?

As an ethicist, this is where I take issue. Ethicists saw the writing on the wall as soon as it became clear that a vaccine would be a coveted and limited resource. There have been several attempts in my field to decide how a vaccine should be distributed, and to whom. Like with most other areas of the pandemic, the focus has been on fairness, reimagined in a number of different ways, normally with a focus on doing what will ultimately help the most people possible. There has been a suggestion to inoculate healthcare staff first, so they are safe to care for the sick. Others have suggested we vaccinate the sick, so they cannot infect others and are less likely to die from the disease. Some have argued the opposite, that we should forget the old and ill, and use the vaccine for those who will be left behind to rebuild. To my mind this last one feels a bit too apocalyptic compared to the reality of the situation, but every one of these is based on being “fair” or “balanced” in some way.

But this continued focus on fairness ignores how the pandemic is distinctly unfair. In fact, we know several months in now, that the pandemic has cruelly exposed and exploited the imbalances in our society, leaving the deprived, the disabled and those from ethnic minority backgrounds with more long-term illness, more poor health outcomes and more dead to bury than any other group. 

Fairness as conceived in so much of the guidance, in so many of the blogs, articles and work that has come out of the pandemic, fails to account for how this version of fairness does not mean “equity”, and that we are blundering through this pandemic in a way that will, at best, leave the marginalised permanently on their knees and, at worst, wipe them from our society in one distinctly unfair swoop.

The discovery of the Pfizer vaccine is a moment of celebration, but also an opportunity to pause and consider how we can develop and implement policy and guidance on administration of the vaccine in a way that is actually fair. Guidance that advocates for the vaccine to be distributed, such that it protects those most in need, and by this, I mean including those most likely to have been, or will be disenfranchised the most by the pandemic.

To start, we must heed the research of the past several months that “vulnerability” to the virus is not just about existing clinical illnesses and age. Socio-economic background, to pick just a single example, is also an important factor, and those in deprivation are just as at risk of poor outcomes and death.

To my detractors perhaps I can soften the blow by saying there is significant overlap between these groups. Further, it is possible to integrate this approach with the recommendations of the JCVI, by allowing within the priority categories those who have borne the brunt of the pandemic, and explicitly placing them among the first groups to receive the vaccine, in recognition that they share an equal risk to already identified priority groups. 

Now is the time to think about what kind of society Britain is and how we value, or do not value, certain members of it. To do otherwise is to be complicit in decisions and actions that explicitly say to members of our country that they have no value at all. Now is an opportunity to really, truly, be fair.

Dr Alexis Paton is a lecturer in social epidemiology and the sociology of health at Aston University, chair of the Committee on Ethical Issues in Medicine at the Royal College of Physicians, and a trustee of the Institute of Medical Ethics