27says, would ensure that doctors, who have the most informa-
tion about their individual patients, would be able to broadly
stratify people in terms of their COVID-19 risk. That risk boils
down to two vulnerabilities: first, how much risk their patients
have for getting infected in the first place, which takes into ac-
count where they live and the infection rates there, and their
exposure to high-risk settings such as hospitals or public ven-
ues; and second, their risk for getting
severely ill and potentially dying from
COVID-19 if they were to be infected.
Doctors will increasingly be faced
with balancing these risks, and for
them, the simplest strategies might
be the most efficient. Wolfe says a
starting point to avoid the ethical and
medical tangle of comparing people
with different conditions might be
to use age as the determining factor.
Older people tend to have more
health issues, and when they do, their
conditions are generally more severe
than those experienced by younger
people. And that’s especially the case with COVID-19, which
hits elderly people harder. “If I can’t medically stand in front
of two patients and separate their arguments, how do I break
the tie in cases where there is a scarce resource?” he says.
“Sometimes age is the easy delineator. If someone is hyper-
tensive with a BMI of 30, but only 25, their risk is less than
someone’s who is hypertensive with a BMI of 30 but age 64.”
And if age isn’t a tiebreaker, practicality may rule the day—
whoever is available and can be vaccinated sooner should get
the shot. But that layers the sticky question of access on top of
sensitive triage issues. So far, doses have been funneled to hos-
pitals, clinics and other health care centers in order to reach the
first priority group of health care workers. Yet around 25% of
the U.S. population doesn’t see a doc-
tor regularly, according to a 2020 JAMA
Internal Medicine study, much less have
access to a hospital or clinic. As a result,
many of these people have chronic con-
ditions that aren’t treated at all or, if they
are, aren’t well controlled. Reaching
this group of people, and making them
comfortable with getting vaccinated, is
a black box that public-health officials
haven’t quite decoded yet.For now, hospitals and health systems
are focusing on the lowest- hanging
fruit: their own patients. At least they
have electronic medical records for these people and can con-
tact them to let them know when they become eligible for vacci-
nation. Plus, if necessary, they can mine their health records to
triage them by COVID-19 risk and therefore vaccination prior-
ity. Between two patients with diabetes, for example, they can
determine who has less-controlled blood-sugar levels and place‘No one wants to
be on the committee
that makes these
allocations.’
DR. CAMERON WOLFE,
DUKE UNIVERSITY, PROFESSOR
AND INFECTIOUS-DISEASE EXPERT