In the middle of January, as 300 people a day died from COVID-19 in Los Angeles County and an additional 15,000 became newly infected, a friend of mine posted a photo of himself to Instagram. “Bye COVID,” the caption read, with a image of him getting a shot in his arm. But wait—my friend is young and healthy and doesn’t work in healthcare, so how did he get the vaccine?
When I asked the friend—who requested I not use his name for this story, so let’s call him Peter—how he got the vaccine, he told me “Strings, brother.” When I asked if it was ethical that he, a relatively low-risk individual, get the shot before high-risk individuals in desperate need, he told me, “Either it’s thrown away or someone uses it. I’ll vote for using it.”
Peter is not alone. There are many like him skipping the vaccine line to get their shot early, including 49-year-old non-medical worker Eric Garcetti. In fact, I’ve had several friends in the weeks since find ways to get vaccinated early. Some post about it, some just mention it in passing, yet the refrain is always the same: Better that I get the dose than it go to waste.
But that response is starting to feel more like a deflection than a justification. It says, hey, I’m just taking care of myself; don’t blame me, blame the system. So, is taking advantage of a flaw in the system ethical, especially when it won’t necessarily save your life but could hurt someone else?
“The core ethical mistake here is thinking you’re special and making an exception of yourself,” says Pamela Hieronymi, a professor of philosophy at UCLA who studies ethics and moral responsibility. As she explains, human beings always need to feel like the good guy, and we are excellent at creating justifications for our actions because we “care a ton about how we think other people should think about us.” As for the line-skipper’s refrain, Hieronymi says, “It would be a good justification if it were true.”
To Hieronymi’s point, take this example: another one of my friends who found a way to skip the line and get vaccinated early did so by spending multiple days driving out to a pop-up clinic at the Antelope Valley Public Health Center in Lancaster and waiting in the standby line until finally given a shot. Look up this health center on Google Maps, though, and you’ll see that it sits just a few miles down the street from a California State Prison facility that, as of last December, had the highest COVID case load of any facility in the state.
Should we accept that my young, healthy friend’s arm was the only place those unused doses from the Lancaster clinic could have gone, and could not instead have been loaded up into a car and taken to the inmates down the road who are trapped with the virus and in imminent danger of infection?
“The idea that an organization has extra doses and just does whatever they feel like with it demonstrates how, as a community, we have not done a great job in terms of ensuring who they are getting allocated to,” says Dr. Alyssa Burgart, a clinical physician and bioethicist with the Stanford Center for Biomedical Ethics. “Should it go in the garbage instead of vaccinating whoever’s available? No, but that shouldn’t be the only option.”
Yet, so far, it seems those have been the only two options. Last week, five vaccination sites around L.A. county (including Dodgers Stadium, one of the nation’s largest vaccination centers) closed due to a lack of available vaccine supply. This week, supply was low due to winter weather elsewhere in the country. While there is very little official data on whom the 46.4 million doses of vaccine have been administered to nationwide (a problem in itself), the CDC reports that upward of 63 percent of those doses have gone to white Americans, while about 8.7 percent have gone to Hispanic Americans. However, Hispanics make up over 20 percent of COVID cases, while whites make up about 56 percent.
“Should it go in the garbage instead of vaccinating whoever’s available? No, but that shouldn’t be the only option.” —Dr. Alyssa Burgart
It’s this systemic inequality that is the real concern for medical ethicists like Anne Sosin, program director at the Center for Global Health Equity at Dartmouth. “If we vaccinate a bunch of people who are unlikely to ever get exposed, we will do nothing to prevent death,” Sosin warns. “We have to slow this down urgently” and focus our efforts in a targeted and equitable manner. She adds that vaccinating retirees over 65 who haven’t left home in months and who have their groceries safely delivered to their doorstep are not the priority over the person delivering those groceries. “L.A. is the best argument for prioritizing the essential workforce.”
In August, UCSF epidemiologist Dr. Kirsten Bibbins-Domingo pleaded for a vaccine rollout that built on what was learned from past failures. “We simply cannot afford to bear witness to yet another manifestation of health inequities,” Bibbins-Domingo, wrote. She continued that “for our public health efforts at mitigation and containment to be most effective, resources must be invested in the communities hardest hit by COVID-19 to redress past underinvestment and the ongoing impact of the economic crisis.”
Two months into the vaccine rollout, we continue to repeat old models of inequality and have yet to redress our past (and current) underinvestment. A major obstacle to this, Burgart suggests, is the poor design of the vaccine program itself. As she explains, “It doesn’t matter that you came up with this great ethical system if people can just jump the line because the allocation strategy is so complicated that it leaves all this room for kind of rogue behavior.”
This “rogue behavior” is largely aided and amplified by technology. Local vaccine line-skippers have been using social media to navigate the system on their own, and have even created a “mega thread” on the Reddit subcommunity r/LosAngeles where Redditors discuss volunteering for the day as a way to get vaccinated early, have suggested Kaiser Permanente members have an easier time getting leftover doses, and post tips about open availability. It’s helpful advice—for those who can access it.
Our current outreach model “is very geared towards the users of Twitter—higher income, generally Anglo communities,” says Dr. Stefan Baral, a physician and associate professor in the Department of Epidemiology at the Johns Hopkins School of Public Health. It’s no wonder that a vaccination program that relies almost exclusively on technology for both communication and appointment scheduling will create disparities that favor the tech-literate and those with the intellectual and financial resources necessary to navigate the system—or, said another way, that excludes the most vulnerable among us.
But it’s not just outreach that’s a problem. Even if modified messaging campaigns are successful with high-risk communities, Baral questions the feasibility of large vaccination centers like Dodgers Stadium and the Forum that presume you not only have a car but can take the time off from work. “I know it looks like a wonderful operation,” says Baral, “but it’s not set up to where risk really is.” A gig worker who cannot afford a break certainly cannot afford to take a few hours off to wait in line for their shot.
The best ways to target, message, and distribute care within individual communities is something public health officials have learned how to do from past crises, like the HIV/AIDS epidemic of the ’80s and ’90s. Not implementing these methods now could cause unnecessary harm and death. Across L.A. County, community organizations are already contracted with the city, county, and state to provide various healthcare services to these specific populations. Leveraging these organizations to help distribution would be an easy fix, according to Baral. “They’re just more aligned with the communities they serve, and they know those communities to actually be the ones to deliver the vaccine,” says Baral. The solution to these inequities exist, but why don’t public health officials and politicians implement them?
The California Department of Public Health was contacted multiple times for this story but didn’t respond. L.A. County Department of Public Health responded to a request for comment with an email response directing us to the department’s allocation guidance document.
While individuals may not be able to fix the flawed system, they can control how they do or don’t utilize—or exploit—it. As UCLA’s Hieronymi explains, think of a subway system. The system is set up in a way that requires public cooperation (paying the fare), yet if a few people jump the turnstiles that’s OK—the system won’t collapse. “The argument here is similar: ‘Why can’t I [get a spare dose] then, if it hurts no one but helps me?,’” Hieronymi continues. The answer: because we have a system in place, and everyone wants to ride for free, meaning no one can. “There will always be slack in the system,” she says, “but it doesn’t mean you’re special.”
For those low-risk individuals finding ways to get vaccinated early, there is a simple miscalculation: helping themselves achieves little in the grand scheme of things, and even if they do get vaccinated, restaurants, gyms, businesses, and large social gatherings will still be off-limits. If those same people instead helped higher-risk individuals receive their vaccinations, they’d arguably help speed up a return to relative normalcy.
“We’re never going to get out of the pandemic without a team spirit,” says Hieronymi. “That’s a crass way to put it in terms of the team,” she says with a laugh, but “it’s just not OK to push yourself to the front of the line when there are people that you know who need it more than you, and that are more at-risk doing things to keep the rest of us getting our Uber Eats and our stuff from Amazon.”
If you’re lucky enough to work a remote job, and have high tech literacy and the spare time, “put your brain and internet skills to work to help those in need” get vaccinated, stresses Hieronymi.
For Baral, it’s an urgent plea. “What we’re talking about here is about saving lives, and that we can do this better,” he says. Baral cautions that the Biden Administration’s goal of vaccinating 100 million people within the President’s first 100 days in office is meaningless “unless we vaccinate the right 100 million people, or we’ll see basically the natural history of how many people were going to die.” In other words, if we don’t vaccinate the most at-risk people, and the ones most likely to spread COVID, we’ll reach about the same death tolls as if we vaccinated no one. There couldn’t be higher stakes for doing the most ethical thing.