 All right, I think I shall begin. Good afternoon and welcome to today's session of the Ethics in the COVID-19 Pandemic lecture series who were delighted that our speaker today is Professor Govind Prasad who has trained intensely at Stanford University where he got his BA, his BS, his JD degree and his PhD degree all from Stanford. Professor Prasad research interests center on the legal and ethical dimensions of health insurance, healthcare financing for both domestic and international and markets and healthcare services as well as in professional ethics and the regulation of medical research. Professor Prasad has been selected as a 2018 to 2021 Greenwall Faculty Scholar in Bioethics and has had an ongoing research project on health insurance and protection against financial risk. Prior to joining the faculty at the University of Denver, Professor Prasad was an assistant professor of health policy and management at the Johns Hopkins University Bloomberg School of Public Health where he was affiliated closely with the Berman Institute of Bioethics and served on the school's institutional review board and was a junior faculty fellow at Georgetown University's McDonald's School of Business. You may recall some of you that just a few weeks ago, Ruth Faden, the founding director of the Berman Institute of Bioethics at Johns Hopkins spoke with us. Professor Prasad clerked for the honorary Carlos Lucero at the U.S. Court of Appeals for the 10th Circuit in Denver. He's written a series of papers with Dr. Monica Peek who is with us today and will handle the moderation after the talk. I've heard a rumor, but I don't know for sure that he and Will Parker and Zeke Emanuel have recently written the paper together on COVID-19. That may or may not be the case. Maybe Professor Prasad can tell us. The title of Govind Prasad's talk today is Implementing COVID-19 Vaccine Distribution, Legal and Equity Dimensions. It's an honor and a pleasure to welcome you, Professor Prasad. Thanks so much, Mark. And thanks to the McLean Center and University of Chicago for having me. Now these descriptions of various research interests, really what I've been doing for the past year and a lot of the other folks, I'm sure Ruth as well and many of her other speakers is working on a variety of issues in COVID-19 policy. So I would like it to be a world where I was doing all those other things but in reality that's been what it is. So I'll go ahead and share my screen to walk through the slides that I have for you today to cover, I think, some very sort of up to the minute breaking and also I hope important topics around legal and equity considerations in allocation implementation. All right, so the first thing I wanna start with is just to sort of give a little bit of the ethical framework for thinking about ways that we might prioritize access to scarce COVID-19 vaccines. So one factor that we might think about when deciding who gets vaccinated earlier is who's exposed to COVID-19 infection. And there are different ways you might be exposed. You might be exposed through your workplace, through housing, crowded or communal housing such as is the case that long-term care facilities that are prioritized early on would be exposed through caregiving activities, being a childcare worker or somebody who's staffed in a congregate facility. You might be exposed through geography, through being in an area with higher levels of COVID-19 spread. You might also prioritize people who are likely to have poor outcomes if they're infected with COVID-19. So people who are not yet immune haven't yet had COVID-19. People who are of older age, people who have certain high-risk medical conditions. So I'll talk about Down syndrome later as an example of a condition shown to be associated with much higher 10-fold in some studies risk of death. Poverties, other issues that may make it harder to obtain good medical care. And then last, might also look at harm to others if infected. So the spread of COVID-19, there's increasingly evidence that the vaccines not only prevent serious illness, hospitalization, death, but also reduced transmission. And then also, and this is an important rationale for the prioritization of healthcare workers, but I think also extends to some other groups, people who if they become infected will lead to loss of needed support for others. So as we know, when hospitals were overwhelmed, it wasn't just COVID-19 patients who suffered. It was also other patients who were unable to get care. Other caregivers, other essential workers also fall into these types of categories. So the last category here is the, what I would call sort of a Venn diagram way of thinking about the issue where to save the most lives, you wouldn't focus just on one of these sources of risk that on places where they overlap. So this is from a, I think a really interesting blog post about these issues that said, if you want to save the most lives and save the most lives as your goal, you would look at people who were at overlapping risks. So the example they give is people who are older, poor, from a minority group that have been hard hit by COVID-19, medical conditions, and they're also working in a setting with high COVID-19 spread. So the Venn diagram is old, poor, black, diabetic, grandpas working in meat packing plants are sort of the nexus of who you would prioritize for a vaccine. Now, in the title I said, talking about legal and equity adventures, I'm going to say something quickly about equity because I think it's a concept that often gets misunderstood or just goes undefined. Some people say, equity, that just means you treat everybody identically, you just use a random lottery, it gives everybody the same chance. I don't think that's the right way of thinking about equity in general or in a pandemic context. Instead, it makes sense, I would think about equity is you give priority to groups who are on the short end, the more disadvantaged end of health disparities of societal oppression, sort of in keeping for those of you who are aficionados of John Rawls's work, the his idea of giving priority to the worst off as opposed to something like a random lottery. Now, for COVID-19 vaccine allocation, benefit and equity, typically for most criteria will end up aligning. So being more equitable will also save more lives because the risk factors I talked about are highly correlated with disadvantage. So highly exposed jobs, being a meatpacking worker as opposed to working from home like I do, being in a high-risk, communal or crowded housing, instead of being, living in your own home and being able to control your level of exposure to others. And then last obviously the medical conditions as well. So conditions like diabetes, severe obesity, down syndrome, there are many conditions that have been shown to have a correlation with higher risk of hospitalization of death from COVID-19. So what I wanna talk about, we're about the first half of the talk here is a way in which I think policymakers have misaligned benefit with equity. Not all policymakers that I think the National Academies was very thoughtful about not doing this in their excellent report that they developed on, but I think you had Aldesherro come and talk about with you all. But Connecticut recently and even more so Maine have moved, I was just quoted today in a story about this, have moved to what I would call an age-only approach to vaccine allocation. Where the idea is that the only thing that matters to whether you get a vaccine is age. People who are 52 get it before everybody who's 48, regardless of their job, their exposure, what have you. I'm gonna say more about this, that it is interesting to me that this was adopted and advocated for by hospitals only after they vaccinated their own frontline workers. We can come back to this in the discussion. So to walk through both first, a couple of ways that I think this is just not good public health, not good science. And feel free to, again, in the questions, my expertise is in law and ethics, but I think the scientific problems are pretty obvious here. So I think it's absolutely right that being very old, being 80 or 90, is gonna be the strongest single predictor of COVID-19 death if you get infected. But that doesn't follow from that, that age is the only relevant basis for allocation for reasons that are really familiar. I was a great poster on Twitter and epidemiologist, her handle is Whitney Eppie that has a very nice Venn diagram about this. There's risk of exposure is also a basis for allocation. So if you're much more likely to get infected, that raises your net risk. Harm to others. So I talked about transmission, essential workers. Outcomes other than death. So long-term complications also matter to people. And then also other predictors of mortality risk in addition to age. So Down syndrome I think is part of the the clearest and most studied example. And this is especially, especially true if you're comparing not an 80 year old to a 20 year old where you have a huge age difference. But if you're comparing what Maine is actually doing, which is putting, you know, your 52 year old over your 48 year old regardless of everything else. And I think a lot of ways that this has been portrayed in papers kind of is a little bit inaccurate about the issue. So this is a headline, right? It says vaccinate is the paper in PNAS. Vaccinating the oldest against COVID-19 saves both the most lives and most years of life. If you're the governor of Maine, you know, great. You can type this headline and save the supports by policy. Turns out that it doesn't actually do that. So what they're actually saying in this paper is within an age-only framework, vaccinating the oldest group will maximize lives saved. It's not surprising, right? If you vaccinate people who are 90 to 95 as opposed to 20 to 25, that's right. But that's not what Maine is doing. Interestingly, they didn't prioritize 90-year-olds over 65-year-olds. They're prioritizing, again, within pretty close age groups in middle age. The more important point for these purposes is also vaccinating people at a given age in worse health will save more years of life and more lives than vaccinating people who are healthy at the same age. And that's also true for people who are at a slightly lower age, but in poorer health. This is the headline that I borrow from Dr. Peake, but chronological age and biological age don't always run in parallel. And that's especially true for populations that are facing overlapping disadvantage. So again, you see, I'm thinking on Maine here because I think the rationales are really unpersuasive. They say the death rate among people with COVID-19 when compared to Maine people under 50 is eight times higher for people in their fifties. This is not great use of public health statistics. Under age 50 includes kids and includes teenagers that don't have authorized vaccines. I think this is just not a good thing for public trust to use data this way. The question has to be, how does risk for people in your 50-59 bracket compare to the risk for the next bracket down? And when you think of it that way, there's a lot of problems at the Maine approach. This is from a chart that a banger daily news, the Maine newspaper did today. So here's your 80-year-olds, right? They're at huge relative increased risk. They weren't prioritized over the 60-year-olds. Here's your 70-year-olds, here's your 60-year-olds. Here are fifties versus forties. You see these little bars, there is some difference. Then you see here is organ transplant recipients. This is the pretty big change in relative risk. BMI greater than 40 or between, sorry, greater than 45 or between 40 and 45, also pretty big difference, bigger than the 50 versus 40. Down syndrome, as I said before, is gonna be up here at your 10 mark. So this is just not true, that the relative risk associated with all age differences exceeds that of having a disability. And I think disability groups are right to be frustrated about Maine, making misleading claims to justify their policy. But it gets worse, I think, for these age-only policies. So it also ignores other risks. So you have, this is a chart from a CDC piece on Native American deaths from COVID. And you have on the left side different age groups. And here I just sort of converted the table into an easier format, deaths per 100,000. And you see here that the Native American death rate in the 3039 age bracket is higher than for white Americans 50 to 59. You see a similar phenomenon if you compare 50, 59 to 60, 69, 669 to 70, 79. So if you're just focusing on age and you're ignoring other sources of risk, it's gonna be not only less equitable, but also save fewer lives. And it's gonna entrench these racial, ethnic, other forms of health disparity in a way that I think is really hard to justify from a public health perspective. I'll talk later about the sort of simple answer of just doing age times race being legally troublesome. But this I think chart should give pause to people who wanna say, well, only age matters. You're gonna be getting a lot of these folks in here with Maine's policy. And you're gonna be missing a lot of these folks here who are the 3039, 4049 Native Americans who are at higher risk. You also see that for occupational risks. So this is a paper by Kristen Bibbins Domingo and others at UCSF, it's a preprint. Find big increases in excess mortality from workplaces. So food and ag workers, transportation, sorry, we gotta have transportation workers and manufacturing workers. 59% increase, for instance, if you look at sort of occupational risk times, the risks that Latino Californians were facing. This study is a little complicated because they're looking at excess mortality, not direct deaths from COVID, but it's still relevant here in thinking about the limitations of an age-only strategy. There's also these problems of inequity. Some of them have already come up, but this is a headline from a, ProPublica's great piece about the use of age 75 as a cutoff, which Illinois actually moved this down to 65 in part for this reason and in part due to advocacy for some of the folks that hopefully are here on this Zoom. But if you set 75 as the cutoff, the average black person in many areas in the US doesn't live on average to 75. You also see this with the younger age cutoffs. So in the US, the average age, I think of minority Americans is 31, of white Americans is 44. So the main type policy is also gonna sort of again, entrench, as I said, these racial disparities. This is a more general point, right? Is that living to older age is an interesting criterion to use because it's one of the very few risk factors that doesn't align equity with benefit that doesn't reach the disadvantaged produced risk. Everybody wants to live to at least, I would say 75. People wanna live to older ages. People wanna be getting to that stage where as a side effect, you end up at higher COVID risk. Very few people wanna be working in meatpacking plants to be living in crowded housing, to be subject to structural racism, and have COPD. So that's why just using age as the only basis is really likely to grow your disparities in disadvantage. So the other issue that I think has been under discussed actually, but it's interesting because I know Dr. Slamacy came and talked about age and ventilator allocation. One thing that we learned from the way that age has approved that approach that is that states are only allowed to consider age as one factor in decision-making. So there can't be blanket exclusion, blanket exclusion of folks based solely on age. So you can consider age as one factor as a tiebreaker. A lot of states, and I think their right to do so, include age-based risk and policies. But age-only policies, there are very strict limits on those. You can only adopt those if you go through an elected general purpose legislative body. You have to have public debate and legislation. You can't just do age as a sole factor through regulation. You have to go through this process. And so I think there's a real legal problem with using age-only policies for anything. But it's also inconsistent to say, well, we'll distribute vaccines based only on age, and there's this advantage, again, people who are below a certain age cut off, while prohibiting using age, even as a tiebreaker for ventilators, I think it's a view that Dr. Salmezzi and others have defended. I think there's a way in which this is really likely to exacerbate health disparities to take these two combined positions. Age-only allocation is also not popular. This is a poll from an organization, a public poll, looking at different bases for vaccine allocation to public endorses. The public liked, or Group 1A, healthcare workers, nursing home residents, people agreed 95% were happy with them going ahead of them. But the public also cares about teachers and childcare workers, those people with serious medical conditions, Down syndrome, COPD, care about grocery workers, communities with higher COVID-19 rates. They also care about healthy adults, age 65 or older, they care about that age-based risk. But note where your serious medical conditions your teachers are, and can I can actually kept the teachers, maybe they saw this full. Maine kicked all these folks out of line, all the medical conditions, all the teachers, grocery workers, and did nothing about prioritizing communities with these higher rates. Healthy work from home 50-year-olds who would be prioritizing the Maine policy, they're not on this public list. And I think that's the reason why the public might be sort of rightfully worried about these kinds of policies. The real rationales that I've seen out there are have to do more with kind of practicality and speculation about what you can and can't do in terms of a more equitable policy. A big argument you see the president, I think of Kaiser Foundation, Geraldman made this in the Washington Post that I just find very tiresome is, you have to use only age because everything else you might use, people will lie about that. Age can't be gained, but the lie about everything else. I don't think that's true. So really, down syndrome, people pretending that you have down syndrome is pretty challenging. On the other hand, many folks here have been under 21. They have seen cases in which people have tried to game purely age-based criteria to get something they want. So I think people are being too confident about drawing this distinction. ZIP Code is a prioritization basis that's also, I think, pretty easy if you're relying on a verification-based process. But more importantly, I'll come back to this at the end instead of relying on passive, have them come to you and then check their documents, be active and proactive, reach out to them. Maybe we'll talk about this in the Q&A, but there have been organizations including, I believe, Chicago that have used medical record info to call high-risk patients or you can bring vaccines to your meatpacking plant, to your crowded housing areas, avoiding that need for needing to have people show proof. The more general point is just that these fears about fraud, and this should be familiar from other contexts, think about voting rights, can't justify excluding people who are legitimately vulnerable. The other couple of points are, people say it will slow things down. I think it's right to try to do a lot of detailed verification at sites will slow things down. But having a hard age cut-offs also slows things down. So you have a couple who show up, one is 53, one is 47, nobody under 50 can get vaccinated. That slows things down too. So I think there are reasons to be concerned about these kinds of hard cut-offs of any kind. And I think age cut-offs are not special this way. Last, and I think this is the biggest argument, I think I just saw this from one of the other folks quoted in the Bangor News article, who I disagree with, who said, lists of, this is not quoting him, but high-risk condition lists and frontline occupations, they're too complicated, it's too Byzantine, it's too confusing. People often put this in quotes and this really bothers me. It is not a fake thing to be a meatpacking worker. It is not a fake thing to be a person of down syndrome. It is fine to recognize that it will take more work sometimes to identify these people, but it is really not great to say, to put them as care quotes. So no list is perfect. Any policy is gonna miss some high-risk people and get some low-risk ones. It's also true with age brackets. But if you combine different sources of risk, you end up saving more lives and improving equity more than focusing just on age over. Also remember the zip code-based priority are using the CDC social vulnerability index. That isn't a particularly complicated thing compared to the, I will admit, sort of more challenging tasks, say of creating your high-risk condition list. But I think overall there's much more that states could do as opposed to just going the easy way and dumping these groups out of the line. Here is my take on why this is popular in some states. Oh, I've been glad to see ACIP not adopt this approach. Glad to see the Biden administration say educators will be prioritized. I think some states like age-only policies for these reasons, which are not reasons about ethics. They are not reasons about public health. They are not reasons about the law and legality. I think these policies let states deflect blame for making hard choices, for saying, hey, you might have to wait because the meatpacking plan has an outbreak. It seems more apolitical, at least to some people. Although the point, you know, that pro-public article about the age 75 cutoff, it's really not apolitical. It really does have these disparity-increasing effects. Age-only allocation, but I said earlier, you don't have to do active outreach. So you don't have to do as much going out to meet people where they are. There's also this misleading interpretation of risk data, which is kind of fueled by some of these paper headlines. Let's main say, well, we're just following the science when we prioritize 50-year-old work-from-home guys over people with down syndrome. Last, people who are healthy, middle-aged work-from-home, they have more time to vote. They have more time to call their governors than people who have chronic diseases who work in meatpacking plans. You know, I'm gonna call my governor today to talk about my views on COVID-19 vaccine distribution policies and on who the FDA commissioner should be. If I were working in a meatpacking plant, I couldn't just go call the governor because I might get fired. Now, I think, let me turn to, so I've complained a lot about the injustice of the main approach. What are better ways? I think the long-term care policy that was adopted that made a lot of sense points to the right way forward. Those are folks who of any age were at higher risk of exposure, pardon me, and also at higher risk of death once they are exposed. Similarly, look at overlapping risk in other ways. So West Virginia is doing teachers over 50. Some other states are doing multi-generational households. You can also base some of your supply on age and other supply based on other risks. So have some of your supply go based on age, but others go to sites at schools for teachers, to medical providers to deliver vaccines to high-risk patients, to churches or other community centers in hard-to-hit high-risk communities, to mobile vaccine units. And then you can use these place-based approaches that maybe I think effectively could combine ages of other risks. So Texas and I think Chicago, DC have used approaches of prioritizing people over a given age who also are within a hard-hit zip code. And I think that makes a lot of sense compared to the age-only and is also not very hard to implement. So let me turn now, this will turn to the sort of second bit of my talks. And the first part of sort of picked out one policy that I think is really troubling from a legal and equity perspective, which is this main Connecticut, I think Nebraska is doing it to age-only based approach. I'll turn out of this question of race-based priority, which I think has been a big, it's probably generated more heat in the news than it actually has generated policies. But I think it's important to think about because it shows ways that you have to be more an understanding of the law and greater policy innovation can help advance both equity and public health goals. So here's the stat I wanted to sort of start us with. There's a big disparity by race and COVID-19 deaths. This is kind of just obvious, but if you look at a given age, suggested for age, Pacific Islander Americans, 2.7 times more likely to die of COVID-19 than white Americans. A little bit lower, but similar for Latino, indigenous, black Americans. So we see this, by the way, 2.7, right? That's a bigger disparity than you were seeing for some of those age and even disability groups. So it's not something that's just a little factor. It's a pretty big difference. And so one thing that's really tempting that I've seen from a lot of people and a lot of followers on Twitter is they say, this is a guy who wrote a book called The Wisdom of Crowds, I think it's a big, he's a major, he has a blue check, I don't. He said, you know, hey, why don't we lower the age eligibility thresholds, but only for black and Latino people? This would advance equity while also reducing risk. Now he's right, compared to age only, this from a strictly mathematical point of view would save more lives and advance equity. I will flag here, ignore for now that he leaves out the Pacific Islanders who are at the highest relative risk. I'll leave out Native Americans and some Asian Americans. We'll come back to that issue later because I think it presents a problem for individual race-based approach. So this, I think, is really tempting. I think a lot of people think this would make sense. There are legal reasons why I am very confident that this is not going to fly at the Supreme Court. So to see why, let me walk through an analogy that will explain how the Supreme Court would think about this. Here's another really big disparity in wealth. This is the median net worth of white households in the Federal Reserve just shy of 200,000, median net worth of black and Latino households under 50,000. Just in the same way that you might use race as a proxy for COVID risk, a mortgage banker might say, hey, people might lie, it's really complicated to verify income. Instead of using all this, you have to do so many forms to approve mortgages. Let's just approve white people as a proxy and not approve black and Hispanic people. They're unlikely to have enough resources to be able to reliably pay their mortgages. Now, this is obviously an unethical, illegal, horrible policy. There's no reason why you would want this to be policy. But the Supreme Court, sorry, went ahead again, the Supreme Court would think about this policy the same way as the Twitter proposal policy. So you might think if you're just a public health person or you're just a doctor, you're not a lawyer, you might think considering race to save lives to narrow disparities is different from considering it in a way that widens disparities. So different to prioritize Pacific Islanders for COVID vaccines than to deny people mortgages. Justice Stevens also thought this. So in a very important case that I have at the bottom here called interim constructors, Justice Stevens said, look, the consistency the courtest houses treating all uses of race the same, that would equate making black folks ineligible for the military with trying to recruit black people to the military. That's silly, Justice Stevens thought. But he didn't get a majority of the Supreme Court. Back in 95 in an opinion by Justice O'Connor, the Supreme Court disagreed with Justice Stevens's view. And so this is a major obstacle for public health folks who would want to use individual race to prioritize. Instead, the language focuses on this idea that the Supreme Court called consistency or symmetry. The quote above is from Justice O'Connor's opinion. And by the way, the Supreme Court has moved quite a bit more toward this what people in equal protection law call an anti-classification approach since 95. So this is O'Connor for instance, has been replaced by Justice Alito, who's a much more strong skeptic of using race and policies. So what Justice O'Connor said is anybody of whatever race has the right to demand that any governmental actor justify any racial classification under the strictest judicial scrutiny. And that goes both for the policies that are like the affirmative action to bring in more Black soldiers, Justice Stevens talked about, and the sort of more discrimination policy that I sketched out. The court's current view treats those the same for individual uses of race. Policymakers who want to use individual race and policy have to show it's the only feasible path to a compelling objective. That means they have to show that in general that they tried of what the court calls a facially race-neutral approach and it didn't work. And this is just gonna be very, very difficult to do for vaccine allocation. There are also some other reasons to be worried about this that are ethical reasons. So even if the Supreme Court had a different view, there are other reasons to think that individual race-based allocations have problems. So one is that it's likely to miss high-risk groups. So Filipino-Americans in California are lumped along with me as Asian-Americans, but we're at very different risk empirically having to do with the factor I'll talk about next. It also might include low-risk groups, people from Spain or Hispanic, but their risk is different from the Latino agricultural workers in California. Verifying self-ID race is gonna be a nightmare, much harder than any of the things people complain about verifying like Down syndrome or zip code or occupation. Race more importantly, this I think is the really important ethical point and again here I really learned from Dr. Peake and a lot of other folks is the real problem of sort of focusing on individual race is it's not the risk factor. The risk factor is being subject to racism. That's the pathway that is driving the disparities in COVID-19 risk. And there are also worries that individual race-based priority may be stigmatizing. So there's a great piece in MarketWatch that quotes Dr. Peake and George Benjamin who's the executive director of APHA. And he says, I think in talking to people in this community says it may be stigmatizing, it may be viewed really skeptically. One of the folks in the Market Budge article said, she cringes at the idea of after looking at the sort of history of racial disparities in medicine, walking up to African-American patients and saying, hey, we'll prioritize you based on individual race. It's stigmatizing George Benjamin says to prioritize saying, you're more risky because you're black as opposed to saying you're at higher risk because in occupation and housing in other ways and conditions having to do with the biological age, chronological age disparities, you're at higher risk because of those things. So the worry is that focusing on individual race is going to misidentify the source of risk we distinguish. There are better equity promoting alternatives that could be used instead of individual race. So as I talked before about this active outreach to people at high risk from place-based exposure, crowded or communal housing, occupational exposure, focusing on these things will improve benefit, improve equity and also narrow these racial disparities because the folks who are in this crowded housing who are in these exposed occupations are likely to also be, that's the reason why you're seeing the higher risks say in your Pacific Islander or indigenous communities. You could also use zip code priority. You could adjust age eligibility but not the way that was suggested by doing it by individual race which was legally problematic. Instead you could adjust it in light of local life expectancy. So the Connecticut health advocate have this great idea which Connecticut did not adopt of saying if you're in an area, I think you gave West Hartford as the example that has a low local life expectancy to avoid that age 75 problem that ProPublica pointed out and the folks in Illinois pointed out, bring the threshold down in areas where people are living less long and then are also at earlier COVID-19 risk. Another area and I can talk more about this in the questions is Native American tribal preference is not viewed by the Supreme Court the same as racial preferences. So states and in fact, this has happened in places like Alaska, states and the Federal Indian Health Service can prioritize tribes and that's actually tribes have been really effective in a lot of places, in a lot of places of getting vaccines to people quickly and addressing the really disproportionate risks that they were facing. Last thing I'll talk about and this idea again, I get from collaborations with Monica and with others is instead of looking at race at an individual level you can use it as what we call in some forthcoming work and neighborhood variable. You could consider the segregation say of a neighborhood and the CDC social vulnerability index does this to prioritize residents of all races within that neighborhood. So this is something that's been familiar and has been used effectively in educational policies. So this is a language from a case in California involving the school district in Berkeley and their school assignment policy. And what they did for school assignment is they looked at your neighborhood, your neighborhood's average household income, education level of adults in the neighborhood and the neighborhood's racial composition but it didn't classify the individual students by race. If I were living in that neighborhood in a given neighborhood and Dr. Peek were living in that neighborhood there would not be differential treatment between us and that satisfies same as if Dr. Seek were living there and that satisfies California which has very strict rules on the use of race more strict than the federal rules. So this approach of a neighborhood variable can recognize these risk disparities without presenting the sorts of legal problems that you would see from the kind of initially tempting approach of saying we'll prioritize by individual race. Now I'm gonna turn in my last couple of slides to some things that Dr. Peek, Will Parker and I have proposed in a piece of the health affairs blog. So, you know, what are better alternatives for promoting equity? So it's not enough to just criticize, you know, age only policies or people who want to say prioritized by individual race for being inequitable or for ignoring the fact that the Supreme Court will tell them they can't do it. You need to provide better alternatives. And so the thing that we suggest is first instead of just allocating doses by how many people live somewhere use measures of risk and burden. So use things like the social vulnerability index to allocate doses. The way I think Will has put it on Twitter is pour the water where the fire is. If you have a community with high burden high spread prioritize the number of doses there. Beyond that, you might instead of flying on first come first served online signups which or first come first served camp out overnight lines which are just a disaster for equity. You get healthy people with lots of time are the ones who benefit from those. Come to the people, use what we propose as auto enroll if you're a health system, all your patients in a phase and use the weighted watery that incorporates factors like SVI or high risk medical conditions to assign appointments. Last thing that we emphasize and my understanding from talking to the reporters in Maine is Maine really didn't do this is prioritize your publicized your distribution plan in detail and solicit public comment. So the National Academies was actually really good about this. They did publicize their plan. They did solicit comment. I get that when you're making decisions on the fly you cannot always go through the same process the National Academies, things evolve but to just sort of push a policy through on the basis of flimsy evidence without allowing an opportunity for the kind of legislative debate or public debate that I think would be valuable is I think not good public health, not good democratically. You saw this big pushback we talked about in the article when Stanford had that plan where all the older work from home admins got vaccine and none of the residents. And a big problem there was that they didn't sort of model what their plan would do and they didn't solicit comment. And I think, you know, in Maine say if you see your younger Somali community not getting any vaccine it will be interesting that they didn't sort of publicize that plan and get comments from various affected communities. Sorry, here I got to do the very last slide. Yeah, so this is the last point before we get to questions is because it's important to distinguish two different issues related to implementation that get confused and lead to prioritization of vulnerable people being blamed for slowing the process down keeping vaccines out of arms. I think if you do a lot of detailed verification so the governor of New York who's in a lot of trouble for a lot of other stuff I did a terrible job with the way he handled crisis standards of care. They did a lot of saying, you know if you go out of order at all, we'll find you you have to do a 40 page form to prove you have these conditions. Absolutely 100% that is gonna slow things down. If you make eligibility very narrow so you try to say, you know we're only gonna have as many people eligible as we have vaccine for the week we're gonna slow things down quite a bit. But if you prioritize among a pretty big eligibility group so among people say within a community or people over 65 you can both save more lives and improve equity as opposed to not doing that. So you could do proactive outreach communities that are high priority as Will and Monica and I recommended. Another idea that I think has been under explored is people keep talking about implementation as you know, your place in line everybody's in one line, wait in line. You could have multiple lines. So what in some collaborative work with Dr. Parag Patak and the team at MIT we've suggested what they call a reserve system that I think Massachusetts has thought about which is basically have the equivalent of a frequent flyer line devote some of your vaccines specifically to verified high priority groups but leave open eligibility for others as well. So instead of saying all the vaccine has to be allocated the same way you could set aside say, you know 10% for mobile units instead of saying we have to have the same rules for all the vaccine we have in the supply. A couple other last points one relates to some work Dr. Will Parker and I are doing. So I think this is controversial we can talk about this in the Q and A pretty strong argument to increase supply by postponing your second Pfizer Moderna dose as opposed to, you know everybody even if they got it because they showed up at a pharmacy that was going to run out has to get their second dose in three weeks. The UK's experience suggests that doesn't seem medically necessary and even Dr. Fauci in prior infection has suggested that there's good reason to think that second doses could be at the very minimum postponed. I think at the same time, you know you don't want to have vaccines going in the trash that's a really bad outcome. You don't want to have vaccines staying in freezers. That's also a bad outcome because you want to get to people more quickly but I think doing this active prioritization incorporating equity in ways that are operationalizable like the zip code or SVI based priorities can as we put it in the health affairs piece both accelerate the speed of the rollout while improving equity relative to some of the policies that states are adopting right now. So let me stop there for about 45 minutes and I'll have the rest of the time for questions. Excellent. Govind that was such a wonderful talk. I know I'm biased because you mentioned my name several times but I'm super excited about that. We already have a number of questions in the Q&A and so I think we'll just get started. One of them is a little step back and just ask sort of bigger picture questions about like basically are we there yet? So the question is actually in the U.S. are people actually fighting figuratively over vaccines or are more people in the skeptical wait and see type? That's a great. And then some of this is a scientific question where I'd be really interested to have if you're willing Dr. Peake to have your thoughts as well. I think that one of the problems is that the U.S. is such a big diverse country compared to some of the other countries that have been talked about in the rollout that there are places where people really are demand is hugely exceeding supply. People are struggling to get appointments because of lack of supply. At the same time, there have been other places and in other settings and they may not always be the settings that you would expect where there have been more people who have been skeptical wait and sees. So I've seen reports about first responders like police departments being really hesitant, certain health workers in some settings being hesitant. So I don't think there's one answer to the question. I think there are both places where people are really, really high in demand. And one of the challenges is that if you don't have active approaches, potentially the people who may have the very highest demand may not be the people who you would get the most population level benefit from vaccinating them. And so I think when you say somebody's a skeptical wait and see type, let me just see if I can get Dr. Peake to a pint on this. They may be a skeptical wait and see type because of failures in the way that we've messaged. And that it's not a sort of fixed fact about who's fighting for vaccines and who's skeptical. Yeah, I would, it's so interesting. If you could talk a little bit more about the, which you sort of alluded to the speed for speed sake, like we were mentioning when we were had the panel the other week, I think that's sort of an important part of the equation too. Like who are we rushing to vaccinate in the impact of sort of speedy vaccination? And then I'll sort of weigh in and then move to the next question. Do you know? Great, should we go to the next question or do you have more sort of thoughts on? Oh, okay. So what I was going to say is that one of the points you had made the other day was that with this sort of rush to vaccinate that we were getting the most bang for the buck if we're rushing to vaccinate those who are highest risk. And when we're just saying, we're in a hurry to vaccinate and get to herd immunity that we're not as effectively getting to goal if we're rushing to vaccinate all the lower risk people. And it is frequently that the lower risk people that are fighting literally and figuratively to get vaccinated. I would say also that your point is well taken about the vaccine hesitancy, that there's a reason that people may be more wait and see and that is part of the challenge that we have to try and make sure that everyone's vaccinated equitably. But the last thing I'll say is that here in Chicago and in many other places, the number of people who are hesitant is greatly outweighed by the people who want the vaccine. And so right now we can't get enough vaccine for our patients who are eager to have it. And we are actively advocating for more vaccine every day. And so we're vaccinating at a certain place in the hospital that I walk past on my way home every day to get to my car and there's always people waiting and we're prioritizing high risk zip codes and the people who really need it the most. And many of my people have been vaccinated and they're like, I can't wait. And so I think that we do have both kinds of people in this country, but right now, even those who are high risk still want to be vaccinated in large numbers. It's great and I guess another point I would make and forgive me Dr. Pink for using the example here, but I think we often overlook that hesitancy or people being skeptical isn't something that's the kind of fixed factor that we have no way of coming to people and sort of talking to them, especially doing it early before they may become into being in a priority group. So vaccines are scarce. Physician time is also scarce, but there are ways in which a lot of our scarcity around that is artificial and not something that we really should be so willing to accept as an excuse. I think there, you know, I've seen, Monica, I've seen you sort of tweet about this. Having effective communication with people before they become a prioritized group as opposed to not having that effective communication can change the extent to which you have either overall hesitancy or disparities in hesitancy once you get to the point of actual prioritization. So I think it's important to recognize that, you know, there are people who you're gonna have to come back to who may not be ready the first go round, but I don't know that like getting vaccines and arms while that is a very important thing to be speedy is intention with at the same time having that outreach and messaging of the kind that I know you've been doing to your patients. And I think the question is how can we scale up? Some of that messaging to people effectively in a variety of communities. The next question is about sort of weighing the pros and cons of a simple strategy versus some of the complexities of equity. So this is from an anonymous person who says, given the issues and unknowns, especially at the beginning of vaccine rollout, such as hesitancy, rejection of vaccine storage and administration complexities, et cetera, what do you think about the argument of that simplifying the access rules to maximize vaccinating anyone is overall better than trying for perfect allocation strategy? This is a great question. I think it really sort of fits with a lot of what, you know, you see policymakers talking about. I would argue is that you don't want an allocation strategy. And this is where I'm hard on New York that leads to vaccines sitting in freezers. But at the same time, I think you can maximize, there are policies that I think can do just as well when you're in a situation like what Monica is talking about where you have much more demand than you have supply. There are access rules that will vaccinate just as many people every day while doing a better job at matching the vaccines that are delivered to the risk levels of the recipients than just saying, you know, vaccinate anyone. And so I think it's important to, this is why I think there's a good reason to be worried about onerous verification processes, especially ones that put the burden of verification on the vaccine recipient as opposed to the health system to do that pretty easily in advance for the medical record. I think this is a really important point. But I also think that there are, it's not so much for me about the access rule being quote simple as in terms of like having only one variable. I think what you wanna have as an access rule that doesn't slow things down. And I think that there are access rules that don't sort of appreciably or seriously slow things down and do a better job at benefit by matching early vaccine to higher risk and also a better job at equity at not sort of leading to the people who are slower to click on the first come first serve website or are under 75 getting shut out in ways that kind of worsen equity divide. So I think policymakers often get, I think to, first come first served, I think is a great example because it's very simple to explain, but even more than my complaints about the age only stuff, first come first served if anything is like a worse, these online websites, the worst disaster or just as bad from the equity point of view. So I think it's important to really push policymakers, they'll say, oh, this will take too long, this is too complex. And when you see localities that actually have done some of this stuff effectively, I think there are real reasons to be, take with several grains of salt when policymakers come to you and say, all we can do is a first come first serve website. It is too hard to do anything else because I think the facts show it is not actually that it is impossible to do anything else. It is that your political constraints or political fears about people complaining that they had to wait behind somebody in a high risk zip code or your understaffed department and you're sort of not reaching out to volunteers or being more creative, that's the obstacle. It's not necessarily that like it's impossible to have ways of prioritizing people at overlapping risk. This might be polemical, but I guess my suspicion about this is that if something like first come first served or age only turned out to be disadvantaged, people who are wealthier and work from home and vote reliably, there would be a change of tune from the policymakers I've been hard on. And this is why I think it is important not to think that we should leave vaccine and freezers to get to the perfect person in a week later, but it's also important to view policymakers' resistance to some of these ideas like zip code priority with I think healthy skepticism. I think you just answered probably fully Will Parker's question about why do you think first come first serve is so appealing to politicians? If you had any other comments, I'll. Yeah, I think this is really, I would love it actually if there are any people on here who have worked with policymakers. I think it's appealing because it's easier to explain. It fits into a certain myth about people who have the wherewithal, especially with these awful camp out overnight lines, having the wherewithal, having the, or the first come first served signup, it sort of creates an artificial idea of who deserves vaccine that legitimates some of these inequalities. There are also, I think just inefficient inequalities and like they don't save as many lives even if you were like purely a mathematical maximizer of why it's saved. So I think it appeals to politicians because it's simple to explain and you don't have to do a lot of work implementing it. But, and it also has this, I didn't say before this veneer of creating a dessert basis for getting a vaccine where if you did the hard work of getting up early to get your vaccine appointment or camping out all night, overlooking obviously the fact that if you have to watch your grandkids all day or because their parents are working and they don't have access to childcare, or if you are, have medical conditions you can't camp out all night, you're, I think this is probably okay as an acronym, your SOL on the first come first served set up. So yeah, there are a couple of other great questions I wanna make sure we get to. I think the Pamela Gonzalez question I thought was really interesting. I didn't realize you could see these. Yeah, yeah, knock yourself out. Yeah, so the one of the ones I see here now. So the first question I see here I think is really interesting and I think is really complex. So that's, you know, incarcerated citizens haven't been prioritized in any state given communal living outbreaks, the way in which people who are minority Americans have been disproportionately imprisoned this group should be priority. So what I wanna say about that is I think this is a complicated issue for a couple of reasons. There are some states, I think Massachusetts has done this that have given some priority to people in communal living including prison. And I think that makes a lot of sense public health wise. I think that the challenges for that are, I think there's a bigger political challenge and in particular sort of, I would suspect and I think there's some, I hope to have some data soon to back this up. People in disadvantaged communities may not be happy if you have incarcerated citizens in say group one A when people who are made vulnerable in communal settings or by place-based risk or job risk in other ways, if they feel like those risks are being ignored but only prison-based communal risks are being identified. So I think that any proposal to prioritize folks who are incarcerated to make sort of public health sense and to be politically tenable would make sense to do it alongside other groups that are facing the same kinds of congregate housing-based risks. But at the same time, I do think the political realities and we hope to have more pulling about this out soon for that particular policy make it more understandable, not more justifiable ethically, but more understandable why you've, I am much more puzzled about why you haven't seen why people are throwing the teachers who folks love in the polls out of line than folks throwing the prisoners out of line, even though I think ethically the arguments that you identify in the question about outbreaks communal living are absolutely right. I thought I had seen some place that Illinois was vaccinating prisoners or inmates earlier in the process. Anyone who has access to speak, is that not accurate as of a recent? Oh, wait, here's someone in the chat. Someone posted about the Kansas doing that for state prisons. I know New Jersey did something really interesting where basically they, for doses that were available at the end of the day in the 1A group, they brought those doses over to a prison, which I think is an innovative idea because that's a group that you know is high risk and you know that they're gonna be there when you have additional doses. So I think that is also an idea that maybe makes some sense. I can see, you know, the optics of that, people might say, oh, you know, they're at the end of the line but they're still far ahead of where they would be in most states under that New Jersey approach. So there have been states, I don't know if anyone else is speaking on the chat about Illinois, but there have been states who have done it. They've also been, you know, my state of Colorado has been really bad about this. They have not shown an interest in giving any priority, I think, for this group. And they basically overruled the advisory committee on allocation, which recommended prioritizing those groups. So states are really different on this, I think. I'd like for you to answer this next question or this question that I'm looking at. With states like Texas and Florida rolling back mask mandates with ongoing high case numbers, knowing this will likely cost some large spikes in cases and deaths, should sending vaccines to these states be increasingly prioritized or should vaccines be rerouted to other states where there's more hope of controlling spread? Yes, this is something I really wrestle with. And I think, you know, some people have the line that, you know, this would be unethical. And I tend to probably go that way that it's tough because you basically don't want to reward or encourage governors for adopting bad policy. And I'm sort of treated by this. This is going to lead to a lot of basically waste of vaccines because people are going to be vaccinated, be waiting for their immunity to develop and get COVID. At the same time, like, you know, 40 plus percent of people in Texas didn't vote for the Texas governor. Rerunning vaccines away from them, I grew up in Texas, I have a lot of family there, also seems troubling. It would be interesting, and I don't know whether you could, you know, there are sort of, you know, something that I would actually like to see honestly is, you know, could some of the federal sites try to step in in ways that try to correct for this inequity at the state level. So some of the FEMA sites and federalists talked about prioritizing teachers, you know, are there ways that federal leverage could be used effectively to try to discourage some of this mask mandate rollback? I think this is challenging for me because people will differ on this. I do think it is legitimate for states to have different policies about vaccine allocation from each other. I think it's legitimate to have different policies about what you have open in some states versus others. So I'm sympathetic to what in law people would call federalism. But at the same time, there are certain things that you would do at the state level that I think go sort of beyond what is reasonable from a federalism point of view. And mask mandate rollbacks, which are, mask mandates are not a sort of high burden thing compared to closures and the benefit is pretty big. It would be interesting to see federal leverage be used to try to discourage that. And I think the question is whether it would be ethical to consider that in vaccine allocation as one form of leverage. And I think there are reasons to be ethically worried about that obviously, but at the same time, you know, for the same reason that you don't want, at least in my view, to be giving second doses right away. And the CDC also doesn't think that, even for first doses actually, the people who had COVID in the last 90 days, there are reasons to be worried about sending a lot of vaccines to a place where, you know, on the other hand, if you're sending vaccines, maybe you're getting spread down so there are trade-offs there. But there are reasons basically, I'll just say this, to think that the mask mandate rollbacks are really bad because they will lead to vaccines being unable to protect people successfully. And the question is, you know, how can we try to get states not to do that? There are reasons, I think, because of the fact that vaccines also reduce spread to think that just saying they can't get vaccines is not either ethical or efficient as a way of doing that. But what are the avenues that the state has to, you know, you, pardon me, the federal government has to use some of this leverage the way they've required mask mandates in federal settings to try to push back on some of these state mask mandate removals. Yeah. So Pringle Miller wants to get back to the idea of extending access and supply of vaccines across populations by giving one of the Pfizer or Moderna vaccines instead of two. She has to, we know enough about immunity after one vaccine to advocate for that. And wouldn't that change the efficacy statistics that we know about and perhaps endanger people with respect to more risk because of liberalizing their exposure? And so can you talk to her? Well, a lot of people have the view that the questioner asks. That's why the policy is the way it is. The reason why I, and there are other folks who feel this way who are immunologists who I'm not is basically it does not make sense to think about vaccine distribution strategies and a public health emergency through the lens of maximizing efficacy for each individual who gets vaccinated. We know that not being vaccinated at all is much more risky than having received only one dose. And especially if you have a setting which is I think in the US is true where supply is gonna increase over time. I think ethically it's really troubling especially given some of the failures of equity early on in the rollout to be devoting so much supply right now say to second doses for work from home, hospital admins who got it in 1A or people who got it because they luckily showed up at a pharmacy when we know that you have right there 65 year old people who are still in the workforce who are not vaccinated. So I do think obviously there are uncertainties about the duration of improvements in protection after one dose but it's not true that we don't know anything. I think the question is how do you weigh the uncertainty against the fact that I think there are really decent arguments that it would be better. There was a study in animals that sort of modeled this better both for efficiency and equity they modeled the efficiency part to extend the dosing interval beyond the kind of three week follow up. And that I think is especially would be true for people who are low risk because they have prior infection or they were in groups that were not actually high risk when they caught it. So possibly and it's hard to say because we have five minutes we might get a second question but this broader concept of equity and right now we know that we don't have equity. And so the idea that right now we're playing catch up with communities as far as vaccine allocation but how do we try and shift the paradigm from even if we had high risk communities getting equal amounts of vaccines as low risk communities that we actually need to do more than that in order to try to get to true equity in outcomes and that we actually need to disproportionately to flip that and to getting that your idea of treating people identically that that is actually not the right thing to do in this case when you have disproportionate risk and disproportionate outcomes. And so how do we translate that message? I feel like I'm hoarse trying to say this every day like what do we do? Yeah, so I think a big challenge for that has been that I think equity has been misframed as being in tension with saving more lives. I think there hasn't been sufficient attention to just make some great I think work in progress and I'm gonna follow on Twitter at Epidemiologists in Minnesota named Elizabeth Brigley-Field who's written about this where there's really strong empirical evidence that if you include geographic risk and occupational risk, geographic risk is a great example for your question that will save more lives than ignoring it. But I think and people I think are willing to accept you'll give more vaccine to people in nursing homes or people over 75 or 65 than to people who are in their 30s. I don't think people think that you have to treat me identically to somebody in those groups but I don't think people get that some of the forms of occupational risk or of place-based risk are also ways that if you give more doses to those folks it will improve lives saved. I don't know, I think part of it has to do with framing part of it has to do with politics but I think that emphasizing the ways in which including place-based risk through say zip code or something and giving them more doses looks very similar to sensible policies like giving the earliest doses to overlapping risk folks in nursing homes would be the way to go. It's not that equity is some sort of thing here that's showing up by magic or that conflicts with efficiency for vaccine allocation. It's something that's consistent with public health principles of addressing risk I think is one way that I would think about it. I think often people have not been as good as they could be in identifying that alignment. Thank you so much. I'll just end on one note with a shout out to September Williams who's a big hero of mine just reminding us all about the importance of work that people of color do in this movement to change the narrative around disparities and equity about what it means to be vaccine hesitant about how to reach and empower communities of color and to sort of shift the paradigms and how we're going to ultimately get through this pandemic. And so thank you, Govind Prasad for all of the work that you're doing. Thank you so much, Monica. And just in one last note relating to that point to maybe the point of the chat about the Choctaw Reservation I would also add the work would say Black Doctors Consortium that they're doing in Philadelphia, groups in Illinois as well. Some of these local groups that I think often led as Monica said by folks of color have done really, really important work because they're sort of aware of their local environment and are being really innovative. And I would love to see, everybody's seen the headlines about the way Philly messed up by not going to the Black Doctors Consortium first and going with the sort of glitzy group that didn't end up doing anything. That is what this sort of local informed, it's an evidence-based approach that's informed by actually knowing the evidence as I think is what we need more of in the vaccine rollout. So I think Choctaw Reservation is a great example of that too. Thank you so much. It's been such a pleasure. What a delightful time. Thank you everyone for joining. Thank you. All right.