The headline said, “Vaccination plan puts health care workers first,” but you had to read the article to find out who goes next: the military. This according to the Guidance on allocating and targeting pandemic influenza vaccine released yesterday by the US Department of Health and Human Services (DHHS). The guidance is premised on the assumption that in the early phases of a pandemic, any vaccine will be in short supply and will need to be rationed. The document gives “strong advice” on how DHHS thinks this rationing should take place, although much is left unexplained. Since the allocation to states will come from a national stockpile, the strong advice will have some weight. Moreover, some of the vaccine will be taken “off the top” for federal government use and this will not be subject to any decisions downstream. And some of the federal allocations appear to us to be highly questionable:
The plan puts a million health care workers, such as emergency room staff and nurses, at the top. Next are military and “mission critical” personnel, public health workers and hospital and nursing home staff.
All of these play a “critical role in providing care for the sickest persons; highest risk of exposure and occupational infection,” the plan reads.
“This guidance is the result of a deliberative democratic process,” HHS Secretary Mike Leavitt said in a statement. “This document represents the best of shared responsibility and decision-making.” (Maggie Fox, Reuters)
Putting frontline health care workers at the top makes sense (NB: I am a health care worker but as a researcher-physician would not be considered “front line,” so this isn’t special pleading). But why is the military at the top along with them, ahead of many other “mission critical” workers like police, fire and communications? Reading the document provides no obvious answers. The document is replete with claims that the guidance was developed by an open and transparent process with ample opportunity for the public and other stakeholders to comment to the Working Group that drafted the document:
“This guidance is the result of a deliberative democratic process,” HHS Secretary Mike Leavitt said in a statement. “This document represents the best of shared responsibility and decision-making.” (Reuters)
But we also read that in meeting after meeting the same objectives were identified:
• Protect persons critical to the pandemic response and who provide care for persons with pandemic illness
• Protect persons who provide essential community services
• Protect persons who are at high risk of infection because of their occupation, and
• Protect children. (Guidance document, Appendix A)
There is no mention of putting the military up at the top. In fact there is no mention of the military at all. In the “rigorous” decision process they apparently didn’t score very high:
Groups with the highest overall scores, regardless of pandemic severity, included front-line public health responders, essential health care workers, emergency medical service providers, and law enforcement personnel. Among the general population groups, infants and toddlers ranked highest. (Guidance document, Appendix A)
So how did they get up to the highest Tier and within the highest Tier the second highest priority after front line health care workers? The document doesn’t tell us, but the game seems to have been rigged at the outset by its structure. The entire population was divided into four categories: homeland and national security, health care and community support services, critical infrastructures, and the general population (Guidance Document, p. 5). Each category was then divided into five Tiers or priority levels, with everyone in a Tier initially receiving equal priority regardless of category. Thus by including homeland and national security as a category, the military was guaranteed a top Tier (since each category had a top Tier). Moreover each Tier has its own priorities in the event there isn’t enough vaccine to cover the Tier. At the top of Tier 1 are frontline inpatient and hospital-based health care workers (estimated to be about 1,000,000) and right after them comes the military (700,000), before five other Tier 1 categories, i.e., ahead of:
- Front-line Emergency Medical Service personnel (those providing patient assessment, triage, and transport)
- Front-line outpatient health care providers (physicians, nurses, respiratory therapy; includes public health personnel who provide outpatient care for underserved groups)
- Front-line fire and law enforcement personnel
- Pregnant women and infants 6-11 months old
- Others in Tier 1 (includes Tier 1 health care workers not vaccinated previously in hospitals, outpatient settings, home health, long-term care facilities, and public health; emergency service providers; manufacturers of pandemic vaccine, antiviral drugs, and other key pandemic response materials; and children 12-35 months old) [p.10]
I don’t know how the military got a category of their own and then a spot almost at the top despite the fact they never scored high in the “open and transparent” process touted by DHHS, but there you have it. The reasoning doesn’t make much sense. Do we need the military to be ready to fight a war in the midst of a pandemic? If the whole world is sick (and much of it sicker than the rich nations), do we think we are going to be attacked? If the problem is the living conditions of the military, then change their living conditions. That’s called a non-pharmaceutical intervention and it will be urged on the rest of us.
And not everyone with expertise thinks they have the rest of it right, either:
Mike Osterholm, an infectious disease expert at the University of Minnesota’s Centers for Infectious Disease Research and Policy, said the plan did not do enough to protect critical workers.
While it designates people involved in making vaccines and drugs for flu, it does not account for other drugs such as insulin and antibiotics, he said.
“It does nothing to help support the manufacturing and transportation system for moving these drugs from offshore to the United States,” Osterholm, who advised the government on the guidelines, said in a telephone interview. (Reuters)
DHHS has it right that it is critically important to discuss this with the public in an open and transparent manner. It sounds, though, that someone shot an arrow and the Working Group complied by painting the target around it.