I've been thinking about vaccine distribution lately. In a worldwide pandemic with multiple competing interests, the best way to vaccinate isn't entirely obvious. What we're seeing now in the United States with a haphazard and slow rollout is a failure of planning. We spent so many resources on developing this vaccine yet little on distribution and actualizing the immunizations. 

At the most basic level, vaccines need to be given. We may debate about who gets priority and how to do it, but more doses need to be given, and soon. The pandemic is a raging fire, and we need to sap the fuel. Those logistics are not easy. In our fractured health care system with many providers, insurers, and systems, capturing everyone is going to be a nightmare. We need strong leadership and foresight to tackle that problem.

But even from a more theoretical standpoint, we should define our goals for vaccination. I think three important but competing goals are: (1) preventing unnecessary deaths, (2) getting the pandemic under control, and (3) maintaining our health care system. Strangely enough, these goals can be at odds with each other.

In the short term, to prevent unnecessary deaths, we ought to vaccinate those for whom contracting the disease could be fatal. Here we would immunize high-risk people, the elderly, those living in nursing homes, and those with medical comorbidities. Each person vaccinated could be a potential life saved.

Yet, to prevent deaths in the long term, we need to get the crisis under control faster. To stop spread effectively, we could immunize those who are likely superspreaders. One of my friends suggested that we stand outside bars and vaccinate everyone who comes out. Although this was said in jest, it's not a bad idea. There are modeling studies that show if you immunize the most likely spreaders in a population, you can get herd immunity quicker. In one such model, researchers asked college students who their most popular friend was and gave that person a flu shot. They found less community spread of flu with that plan compared to vaccinating a random sample of students.

Realistically, that type of plan wouldn't pan out. These days, we struggle to enforce mask wearing and social distancing. If we started vaccinating those who didn't follow the rules, there would be backlash. Even worse, people might stop following guidelines in order to get immunized.

But ultimately, our current vaccination scheme prioritizes one other important goal: the preservation of our health care system. First responders, nurses, respiratory therapists, physicians, hospital workers, and nursing home staff are at high risk for exposure. As our health care system reaches and exceeds capacity, risks to health care workers increase. This makes us vulnerable to a catastrophic spiral: our health care workers fall ill and can no longer work, our hospital system becomes even more strained, remaining staff are exposed to more risk, and more workers contract COVID. If our health care falls apart, we will have unnecessary deaths both from COVID and non-COVID causes.

Of course, as an intensive care physician, I am biased regarding vaccine prioritization. In general, health care workers are not at the highest risk for dying if they get COVID. Vaccinating me may not prevent me from dying. But if it prevents me from falling ill and quarantining for two weeks, that may translate into lives saved. I think the initial goal of protecting health care workers and nursing home residents makes a lot of sense.

Who do we vaccinate next? I don't know. I turn to the experts who can outline our objectives and weigh the risks and benefits. I see arguments for vaccinating other front-line workers, the elderly, those with comorbidities, and pockets of society with rapid spread. I'm not sure about the best approach. But I do think we should not let other factors, namely wealth, affect our vaccinations. In the last few months, I've had several instances of wealthy families trying to use their resources to get specific care. This is ethically indefensible. COVID vaccinations are in short supply. Taking them away from those who need it may mean the difference between life and death or another outbreak or a hospital forced to ration care. I hope our government and health policy experts are working on improving our vaccination plan.