Photo: Elaine Cromie/Getty Images
As the federal government haphazardly distributed remdesivir, Gilead Sciences’ repurposed antiviral drug, to some of the states hit hardest by COVID-19, policymakers scrambled to develop criteria to allocate the drug to their hospitals. Our state, Michigan, was among these states. The disparities in the burden of suffering from COVID-19 in the state are striking. Detroit’s death rate from the infection are more than four times the state average. So you might think that Detroit would have been high on the list for getting remdesivir. It wasn’t on it at all. According to the initial federal guidance on allocating remdesivir, which we were able to view, Kent County, home of the city of Grand Rapids, Secretary of Education Betsy DeVos, and at the time 85 people dead from COVID-19, was intended to receive the supply of remdesivir given to the state. Meanwhile, the city of Detroit, where 1,374 people had died, was intended to get none. The populations of Kent County and the city of Detroit are similar, both between 650,000-700,000 people.
There are no morally justifiable criteria that would give Kent County priority access to remdesivir over Detroit. Thankfully, the state was able to develop alternative criteria, which resulted in the distribution of the drug to the areas suffering most, such as Detroit. But the fact that the federal government’s intended allocation completely ignored those communities — without an explanation — shows why transparent and thoughtful criteria are necessary for ethical allocation of scarce resources like treatments and vaccines.
Although there are many different ethically justifiable approaches to allocating scarce resources like new treatments or vaccines, states should give priority — meaning first dibs on the resource — to the communities that bear a disproportionate burden of suffering. For states with significant health disparities, such as Michigan, this approach could help improve those disparities. In fact, any other allocation scheme may make them worse.
Whether an allocation is fair is a matter of whether that resource is available to all. But when resources are scarce, as in the case of remdesivir, any inequalities in its distribution must end up benefiting those who are worst off. Otherwise, the distribution is unfair, unjust. The allocation that prioritizes Detroit gives the advantage to those worst off and is therefore fairer than allocating it to Kent County or any other community in the state. And unless one is indifferent to whether a person lives or dies, we are all better off when there are fewer preventable deaths.
Prioritizing communities with the highest rates of death increases the odds that the drug will prevent death, the worst harm that can come from COVID-19. It’s certainly much more important than recovering in 11 days rather than 15.
But there are other benefits to allocating scarce medicines or supplies to communities that bear a disproportionate burden of illness. These are often communities that have long histories of being underserved or abused by governments and health care services. Giving them priority access can help repair trust with the community which, in turn, may help improve healthy behaviors. If a second wave of COVID-19 is coming, increased trust may help people better follow public health interventions. Giving priority to communities populated by people who already trust policymakers and the health care system is unlikely to achieve this additional benefit.
In states where there are great disparities in the burden of illness, the only morally justifiable allocation of remdesivir is to prioritize communities that are hardest hit. Michigan ultimately did this, as did Illinois. But what about states without great disparities? In these states, it may be justifiable to allocate remdesivir or ventilators to communities in ways that do not explicitly consider health care disparities, such as by case count or even by randomization.
The introduction of remdesivir as a potential treatment for COVID-19 presents states with a real opportunity to address inequity in health care. Another opportunity may be looming, as Moderna and others are racing to develop vaccines to prevent COVID-19.
If states become responsible for allocating a vaccine to their residents, it is likely they will give priority access to health care workers and other first responders. But at some point, states will have to decide who in the larger community should get it. We argue that communities long beset by heavier disease burdens and those with health disparities should be given access to the vaccine before less affected communities. That would not fully repair health disparities, but it shouldn’t make them worse.
Failing to prioritize these communities in the allocation of remdesivir, ventilators, vaccines, or any other treatments may do just that.
Parker Crutchfield is a philosopher and associate professor in medical ethics, humanities, and law at Western Michigan University Homer Stryker M.D. School of Medicine, where Tyler S. Gibb is a lawyer and philosopher in the program in medical ethics, humanities, and law, and Michael Redinger is a physician and assistant professor in psychiatry and medical ethics, humanities, and law. The opinions expressed here do not necessarily reflect those of their employer.