The bad news is an usual combination: There won’t be enough vaccine on hand to meet initial demand, yet there is also a need to urge everyone to get shots.
I have some suggestions: An unusual type of charity auction, a bit of technology and a few nudges can help.
Who goes first?
The problem that needs to be addressed very quickly is how to allocate the roughly 20 million (two-dose) vaccinations that may be available in the United States in December and January. Although states will be given the final authority, a Centers for Disease Control and Prevention panel recommends that the initial distribution go to two groups. The first are frontline health care workers; the second, residents of nursing homes, where a disproportionate number of Covid-19 deaths have occurred.
These groups are worthy, but many others deserve high priority as well. These include teachers, food workers, people with comorbidities and those over 65. The dilemma is that as many as 140 million people may be in one or more of those categories, and even if everything goes smoothly, it will take well into the spring before they can all be vaccinated. (For an idea of where you might rank in the line, check this.) Given that supply chains strained to keep up with the demand for mundane goods like flour and paper towels early in the pandemic, the distribution of vaccines won’t be easy.
All this means that demand will exceed supply for quite a while.
Economic theory offers a standard method for dealing with shortages. It is, basically: Let markets work. This would mean that those willing to pay the most would get the vaccine first.
Wisely, policymakers are not following this course. Nurses, other frontline workers and most nursing home residents could not win a bidding battle with billionaires. And, to be clear, they should not have to!
Yet there is a small but useful role that prices might play in determining who gets priority in the second round of vaccines, after the first 20 million people have gotten their shots.
At that point, perhaps sometime early this winter, suppose a small proportion of doses are sold in what would amount to a charity auction.
Who might be the winning bidders? Very wealthy individuals and high-tech companies are likely to account for some of the demand, along with businesses that employ high-profile talent like professional athletes and entertainers.
Just imagine how much the National Basketball Association, whose season will start around Christmas, would be willing to pay to ensure that none of its players or staff would be infected! The same goes for Hollywood studios and television production companies that are eager to go back to work.
The prospect of selling off precious vaccine to celebrity athletes and entertainers, hedge fund magnates and high-tech billionaires may strike you as utterly immoral, exacerbating the inequality this disease has already inflicted. But before you dismiss this idea as outrageous, let me make three points.
First, the very purpose of the charity auction would be to redistribute money from the rich to the poor. Think of it as a voluntary wealth tax. This money could be used to help people who have suffered most in the pandemic: those who have lost their jobs and face evictions, whose health has been permanently impaired, who face grievous hardship of all kinds.
Depending on the prices and quantities, billions of dollars could be raised that could be spent to help those who need it most. Robin Hood in action!
Second, be realistic. The alternative to this sort of legal market is almost certain to be a black or gray market for early vaccinations, which might be obtained by hopping on a plane to another jurisdiction, or via entrepreneurial intermediaries. As the bioethicist Arthur Caplan of New York University says: “Anything that’s seen as lifesaving, life-preserving and that’s in short supply creates black markets.”
Deep-pocketed sports leagues have already managed to conduct daily testing with quick results. If the rich and powerful are going to find a way to jump the line in any case, why not make sure that the payments made to grease the skids go to a good cause?
Third, one reason that the charity auction feels wrong is that it makes transparent what is typically opaque: Rich and powerful people in every society manage, one way or another, to obtain superior health care. Is that immoral? Perhaps it is. But it would be naïve to pretend that it doesn’t happen. And it would be a shame to let that naïveté prevent the transfer of much-needed money from the rich to the poor. Are the “facilitators” who would make the same thing happen in other ways more deserving?
Confused by the all technical terms used to describe how vaccines work and are investigated? Let us help:
- Adverse event: A health problem that crops up in volunteers in a clinical trial of a vaccine or a drug. An adverse event isn’t always caused by the treatment tested in the trial.
- Antibody: A protein produced by the immune system that can attach to a pathogen such as the coronavirus and stop it from infecting cells.
- Approval, licensure and emergency use authorization: Drugs, vaccines and medical devices cannot be sold in the United States without gaining approval from the Food and Drug Administration, also known as licensure. After a company submits the results of clinical trials to the F.D.A. for consideration, the agency decides whether the product is safe and effective, a process that generally takes many months. If the country is facing an emergency — like a pandemic — a company may apply instead for an emergency use authorization, which can be granted considerably faster.
- Background rate: How often a health problem, known as an adverse event, arises in the general population. To determine if a vaccine or a drug is safe, researchers compare the rate of adverse events in a trial to the background rate.
- Efficacy: The benefit that a vaccine provides compared to a placebo, as measured in a clinical trial. To test a coronavirus vaccine, for instance, researchers compare how many people in the vaccinated and placebo groups get Covid-19. Effectiveness, by contrast, is the benefit that a vaccine or a drug provides out in the real world. A vaccine’s effectiveness may turn out to be lower or higher than its efficacy.
- Phase 1, 2, and 3 trials: Clinical trials typically take place in three stages. Phase 1 trials usually involve a few dozen people and are designed to observe whether a vaccine or drug is safe. Phase 2 trials, involving hundreds of people, allow researchers to try out different doses and gather more measurements about the vaccine’s effects on the immune system. Phase 3 trials, involving thousands or tens of thousands of volunteers, determine the safety and efficacy of the vaccine or drug by waiting to see how many people are protected from the disease it’s designed to fight.
- Placebo: A substance that has no therapeutic effect, often used in a clinical trial. To see if a vaccine can prevent Covid-19, for example, researchers may inject the vaccine into half of their volunteers, while the other half get a placebo of salt water. They can then compare how many people in each group get infected.
- Post-market surveillance: The monitoring that takes place after a vaccine or drug has been approved and is regularly prescribed by doctors. This surveillance typically confirms that the treatment is safe. On rare occasions, it detects side effects in certain groups of people that were missed during clinical trials.
- Preclinical research: Studies that take place before the start of a clinical trial, typically involving experiments where a treatment is tested on cells or in animals.
- Viral vector vaccines: A type of vaccine that uses a harmless virus to chauffeur immune-system-stimulating ingredients into the human body. Viral vectors are used in several experimental Covid-19 vaccines, including those developed by AstraZeneca and Johnson & Johnson. Both of these companies are using a common cold virus called an adenovirus as their vector. The adenovirus carries coronavirus genes.
- Trial protocol: A series of procedures to be carried out during a clinical trial.
What’s more, celebrities are public influencers, by definition. If they make eye-popping payments for access to a vaccine, they could persuade thousands of others to seek inoculations.
Nudges can bring herd immunity closer.
At some point the main policy attention will shift from deciding who goes first to figuring out how to nudge reluctant people to go and get their shots — and not one shot but two, which will be necessary for the vaccines to work properly.
What can be done to get the widest participation possible? Three words: Make it easy!
That means making the process for the first shot smooth. No long lines! Then, at the time people are vaccinated, immediately schedule their second shot and urge them to make specific plans to come. Next, send them electronic reminders. These methods are well proven.
To promote coronavirus vaccinations generally, I also suggest offering a perk to those who have been inoculated, one that could also help accelerate the economic recovery.
At an appropriate time, give people who have taken both shots a Covid-19 “health passport” that certifies complete vaccination. Ideally, it would be electronic, stored on phones or on cards that can be swiped.
In addition to the vaccine confirmation, it would need to include contact information and a photo ID so that it could reliably be used to gain admission to airplane flights, restaurants, bars, concerts, schools and college campuses. (The contact information is crucial for tracking people down in the case of possible health issues, and if booster shots are necessary. It must be national, because people move around.)
This concept is recommended in a report issued by the Tony Blair Institute, which the former British prime minister leads. The report says the English Premier League is already in discussions to require such a passport for admission to soccer stadiums next season.
Unfortunately, though, the existing federal plans in the United States call for providing those vaccinated merely with a paper document, a decidedly 20th-century approach that would not meet public health needs and that would be easy to counterfeit.
There is a better alternative. Making a health passport work reliably and safely, with privacy issues resolved, would require some technology, legal expertise and political good will, but all of this is possible. After all, many states already were planning to upgrade driver’s licenses in the United States into so-called Real ID employing similar technology, but Covid-19 delayed that initiative. Unlike Real ID, the health passport needs to be made available to everyone, including undocumented immigrants and children, because everyone needs to be vaccinated.
The states and federal agencies should cooperate to make this happen. Maybe at warp speed?
Richard H. Thaler, a professor of economics and behavioral science at the Booth School of Business at the University of Chicago, is an author of “Nudge.” He won the 2017 Nobel Memorial Prize in Economic Sciences. Follow him on Twitter: @R_Thaler