Whenever a vaccine for the coronavirus becomes available, one thing is virtually certain: There won't be enough to go around. That means there will be rationing.
Someone will have to decide which of the world's 7.8 billion people gets first crack at returning to a more normal life. Infectious disease experts and medical ethicists say this exceptionally complex decision must weigh not only who is most at risk from the virus and who is most likely to spread it, but also who is most important for maintaining the medical and financial health of a nation as well as its safety.
This pandemic has also added a new quandary: how to address the fact that people of color have suffered higher rates of serious illness and death than white people.
"It's going to be very, very hard," Harald Schmidt, a University of Pennsylvania bioethicist, said of the priority-setting process. There will likely be more than one type of vaccine. One may work better in certain groups, say, older adults, than another.
"We don't only have to make this decision once, but multiple times for multiple vaccines," Schmidt said. "They won't all be there at the same time, and they will have different profiles."
Arthur Caplan, a bioethicist at New York University, said the rush to bring vaccines to market likely will leave many questions unanswered at first about how well they work in different groups. He sees the first public doses as an extension of clinical trials. That will require careful tracking of recipients. "We keep acting as if the race to get FDA approval is the end of things," he said. "I would say it's just the start."
Vaccine development has been moving at lightning speed, and a handful of candidates have had promising results. Experts say the best-case scenario is that a vaccine could be available to the public by the first quarter of 2021.
Traditionally, the U.S. Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) recommends who should get vaccines, and it has been discussing since April how to divvy up a new coronavirus shot. It is unclear whether officials from the Trump administration's Operation Warp Speed on vaccine development will want in on the decision as well. "It's a black box," said Paul Offit, a vaccine expert at Children's Hospital of Philadelphia. He thinks Warp Speed will probably focus on distribution. The National Academy of Medicine, at the behest of the National Institutes of Health, has also created an expert panel to study the issue.
At the panel's first meeting on Friday, Victor Dzau, the academy's president, said he expected final recommendations by late September to early October. CDC Director Robert Redfield stressed that it was important for Americans to see vaccine allocation as "equitable, fair, and transparent."
National Institutes of Health Director Francis Collins, who has faced some criticism for potentially adding to decision-making confusion, said this issue is so thorny, we can benefit from extra "deep thinkers."