H5N1

The COVID-19 syndemic is not global: Context matters

A letter in The Lancet: The COVID-19 syndemic is not global: context matters.

Richard Horton recently called COVID-19 a syndemic. He aptly used this concept to describe how COVID-19 clusters with pre-existing conditions, interacts with them, and is driven by larger political, economic, and social factors. 

Calling COVID-19 a global syndemic is misguided. Syndemics matter because they focus on what drives diseases to cluster and interact. What is driving coronavirus to move through the population in the USA and interact with biological and social factors, however, differs from other contexts. US political failures have driven COVID-19 morbidity and mortality, and this cannot be divorced from our historical legacy of systemic racism4 or our crisis of political leadership.  

This matters because in other contexts COVID-19 is not syndemic. New Zealand's political leadership in response to the crisis has been exemplary. COVID-19 is not syndemic there. 

In this sense, syndemics allow us to recognise how political and social factors drive, perpetuate, or worsen the emergence and clustering of diseases. Recognising contexts are different matters a great deal. For instance, contexts throughout sub-Saharan Africa are doing much better than the most burdened contexts, like the USA, Brazil, and India. Many people have questioned, why? Some have argued that this reflects a racist frame thinking that African contexts should suffer more. Yet, many African governments acted more swiftly and confidently than wealthier countries. The political leadership in these contexts, therefore, prevented the extensive death tolls, compared to contexts like the UK and the USA, where political leadership failed. 

Recognising political determinants of health is central to the syndemic construct. By calling the COVID-19 syndemic global, we miss the point of the concept entirely. 

I do not write this to dampen Horton's use of the term, as I believe COVID-19 is syndemic in my country (the USA). This is precisely because pre-existing conditions such as hypertension, diabetes, respiratory disorders, systemic racism, mistrust in science and leadership, and a fragmented health-care system have driven the spread and interacted with the virus. These synergistic failures have caused more death and devastation than many other contexts. 

Recognising failures of wealthy countries is imperative as we think about where global knowledge and power sit within fields like global health. Syndemic frames provide us with an opportunity to do this.

COVID-19 in New Zealand and the impact of the national response: A descriptive epidemiological study

Via The Lancet Public Health: COVID-19 in New Zealand and the impact of the national response: a descriptive epidemiological study. The summary:

Background 

In early 2020, during the COVID-19 pandemic, New Zealand implemented graduated, risk-informed national COVID-19 suppression measures aimed at disease elimination. We investigated their impacts on the epidemiology of the first wave of COVID-19 in the country and response performance measures. 

Methods 

We did a descriptive epidemiological study of all laboratory-confirmed and probable cases of COVID-19 and all patients tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in New Zealand from Feb 2 to May 13, 2020, after which time community transmission ceased. We extracted data from the national notifiable diseases database and the national SARS-CoV-2 test results repository. Demographic features and disease outcomes, transmission patterns (source of infection, outbreaks, household transmission), time-to-event intervals, and testing coverage were described over five phases of the response, capturing different levels of non-pharmaceutical interventions. Risk factors for severe outcomes (hospitalisation or death) were examined with multivariable logistic regression and time-to-event intervals were analysed by fitting parametric distributions using maximum likelihood estimation. 

Findings 

1503 cases were detected over the study period, including 95 (6·3%) hospital admissions and 22 (1·5%) COVID-19 deaths. The estimated case infection rate per million people per day peaked at 8·5 (95% CI 7·6–9·4) during the 10-day period of rapid response escalation, declining to 3·2 (2·8–3·7) in the start of lockdown and progressively thereafter. 1034 (69%) cases were imported or import related, tending to be younger adults, of European ethnicity, and of higher socioeconomic status. 702 (47%) cases were linked to 34 outbreaks. 

Severe outcomes were associated with locally acquired infection (crude odds ratio [OR] 2·32 [95% CI 1·40–3·82] compared with imported), older age (adjusted OR ranging from 2·72 [1·40–5·30] for 50–64 year olds to 8·25 [2·59–26·31] for people aged ≥80 years compared with 20–34 year olds), aged residential care residency (adjusted OR 3·86 [1·59–9·35]), and Pacific peoples (adjusted OR 2·76 [1·14–6·68]) and Asian (2·15 [1·10–4·20]) ethnicities relative to European or other. Times from illness onset to notification and isolation progressively decreased and testing increased over the study period, with few disparities and increasing coverage of females, Māori, Pacific peoples, and lower socioeconomic groups. 

Interpretation 

New Zealand's response resulted in low relative burden of disease, low levels of population disease disparities, and the initial achievement of COVID-19 elimination.

Richard Horton: Reasons for hope

In The Lancet, its editor Richard Horton writes: Offline: Reasons for hope.

Fatigue. Despair. Misery. Cracks are beginning to appear in our mental resilience. 10 months of this calamity. How much more can we bear? It was always so. When the Bishop of Winchester died of plague in 1626, John Milton issued a searing cry of anguish in his Elegia Tertia. The great poet was just 17 years old, “sad...with no companion, and many sorrows clung to my soul”. He sought to commemorate this “grim killing” of a revered literary figure, a “dreadful death, fearsome with her sepulchral torch”. “Why does it please you”, Milton asked, “to stain your hands with human slaughter, and to have sharpened sure arrows against a noble breast, and to have driven a half-divine soul from its home?” 

It would be easy to sink into despondency. Governments are struggling. The public is restless. We need hope. There was one buoyant piece of news last week. The UK's National Health Service (NHS) committed itself to becoming the world's first carbon net zero health system by 2040. WHO's Director-General, Tedros Adhanom Ghebreyesus, welcomed the news, noting that “Health is leading the way to a greener, safer planet.” The NHS has appointed Nick Watts, who has blazingly led The Lancet's Countdown on Health and Climate Change, as its first Chief Sustainability Officer. This news is certainly one reason for hope.

As Laura Spinney pointed out in her history of the 1918 influenza pandemic, Pale Rider (2017), humanity was left transformed once the infection ebbed. Out of tragedy came regeneration. “The 1918 pandemic accelerated the pace of change in the first half of the twentieth century, and helped shape our modern world.” Societies bounced back. The 1920s ushered in a new era of intellectual and artistic creativity. Governments embraced health and made it an explicit political priority—“The state of a nation's health came to be seen as an index of its modernity or civilisation.” The conditions for universal health care were created. There was a “psychological shift” across the world. Although we are still in the midst of a dreadful coronavirus syndemic, if we lift our gaze we can see a better future ahead, a future that is up to us to define. Our societies can revive, stronger, smarter, and kinder. The first step is to reinvigorate our conversation about what tomorrow should look like. That conversation has started.  

Fran Baum and Sharon Friel recently proposed the need for a social as well as a biological vaccine to solve the challenge of COVID-19. They argued in the Medical Journal of Australia that we need to go beyond a biomedical vision for solving this syndemic. By a social vaccine, they mean “a metaphor designed to shift the dominant biomedical orientation of the health sector towards the underlying distal factors that cause disease and suffering”. 

They set our four foundational requirements for health—a life with security, opportunities that are fair, a planet that is habitable and supports biodiversity, and governance that is just. Each of these requirements determines the components of a social vaccine. A life with security demands a universal system to guarantee social protection, employment, and shelter; progressive taxation; and international treaties to ensure peace and security. 

Opportunities that are fair include (at a minimum) universal and free education; racial, sex, and disability discrimination laws; decent jobs; and environments that enable healthy choices. A planet that is habitable requires a zero carbon future; protection of biodiversity; and elimination of fossil fuel subsidies. Finally, governance that is just means a universal franchise; robust systems of political accountability; and strong civil society organisations, protected by legislation. 

They write, inspiringly, that, “A global social vaccine will enable a new way of living that is healthy, just, convivial, and sustainable, and will inoculate future society against a return to a world growing increasingly less healthy, sustainable, and equal.” 

Or turn to Rene Loewenson and colleagues who wrote a powerful call to reclaim a comprehensive public health in BMJ Global Health last month—“Biosecurity is not equal to public health”, they insisted. 

Something is stirring in the heart of our society. In health, the debate about our future is intensifying. Old assumptions are being questioned. New directions are being proposed. Amid the carnage of COVID-19, a renaissance of hope is emerging. It's time to join the conversation about the world to come.

My own thoughts on the world to come are here.

Measuring equity from the start: Disparities in the health development of US kindergartners

Via Health Affairs: Measuring Equity From The Start: Disparities In The Health Development Of US Kindergartners. The abstract:

Racialized disparities in health and well-being begin early in life and influence lifelong health outcomes. Using the Early Development Instrument—a population-level early childhood health measure—this article examines potential health inequities with regard to neighborhood income and race/ethnicity in a convenience sample of 183,717 kindergartners in ninety-eight US school districts from 2010 to 2017. 

Our findings demonstrate a distinct income-related outcome gradient. Thirty percent of children in the lowest-income neighborhoods were vulnerable in one or more domains of health development, compared with 17 percent of children in higher-income settings. Significantly higher rates of income-related Early Development Instrument vulnerability—defined as children falling below the tenth-percentile cutoff on any Early Development Instrument domain—were demonstrated for Black/African American and Hispanic/Latinx children. 

These findings underscore the utility of the Early Development Instrument as a way for communities to measure child health equity gaps and inform the design, implementation, and performance of multisector place-based child health initiatives. 

More broadly, results indicate that for the US to make significant headway in decreasing lifelong health inequities, it is important to achieve health equity by early childhood.

Intersectionality and inequalities in medical risk for severe COVID-19 in the Canadian Longitudinal Study on Aging

Via The Gerontologist: Intersectionality and inequalities in medical risk for severe COVID-19 in the Canadian Longitudinal Study on Aging. Excerpt:

Background and Objectives 

Older populations with underlying medical conditions are at higher risk of COVID-19 severity and mortality once infected. Intersectional gerontology considers the compounding effects of multiple forms of social inequity. This study explores how racial-nativity status, family income, education level and the intersecting profile of these three social standings stratify differential patterns of chronic conditions among Canadians aged 45 years and older.  

Research Design and Methods 

Using the baseline Canadian Longitudinal Study on Aging (n = 29,748), multinomial logistic regression analyses were conducted to estimate multivariable-adjusted odds of having one and/or two (≤ 2) or multiple (≥3) medical conditions (i.e., diabetes, asthma, cancer, previous heart attack, cardiovascular disease, kidney disease, hypertension, chronic obstructive pulmonary disease, and obesity) based on socio-demographic characteristics.  

Results 

There were significant racial-nativity disparities and social-class gradients in multimorbidity. The odds of having ≥3 medical conditions were greater for Black immigrants (OR=1.79, 95% CI=1.13, 2.82), South Asian immigrants (OR=1.49, 95% CI=1.02, 2.19) and close to double for Aboriginal Canadians (OR=1.96, 95% CI=1.37, 2.80) relative to Canadian-born Whites. Black, South Asian and Aboriginal populations from disadvantaged socioeconomic backgrounds had the highest odds of having ≥3 medical conditions (OR=3.50, 95% CI=1.41, 8.70).  

Discussion and Implications 

Despite a universal health system, marginalized older Canadians who are racialized foreign-born, less educated, and/or low-income have a higher prevalence of multimorbidity that are associated with COVID-19 severe illness and mortality. Upstream health policy and social care tackling intersecting structural inequities should be undertaken to prevent increasing multimorbidity among underserved aging populations.

Horton: COVID-19 is not a pandemic

In The Lancet, editor Richard Horton makes an important point: Offline: COVID-19 is not a pandemic.

As the world approaches 1 million deaths from COVID-19, we must confront the fact that we are taking a far too narrow approach to managing this outbreak of a new coronavirus. We have viewed the cause of this crisis as an infectious disease. All of our interventions have focused on cutting lines of viral transmission, thereby controlling the spread of the pathogen. The “science” that has guided governments has been driven mostly by epidemic modellers and infectious disease specialists, who understandably frame the present health emergency in centuries-old terms of plague. 

But what we have learned so far tells us that the story of COVID-19 is not so simple. Two categories of disease are interacting within specific populations—infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and an array of non-communicable diseases (NCDs). These conditions are clustering within social groups according to patterns of inequality deeply embedded in our societies. The aggregation of these diseases on a background of social and economic disparity exacerbates the adverse effects of each separate disease. 

COVID-19 is not a pandemic. It is a syndemic. The syndemic nature of the threat we face means that a more nuanced approach is needed if we are to protect the health of our communities. 

The notion of a syndemic was first conceived by Merrill Singer, an American medical anthropologist, in the 1990s. Writing in The Lancet in 2017, together with Emily Mendenhall and colleagues, Singer argued that a syndemic approach reveals biological and social interactions that are important for prognosis, treatment, and health policy. Limiting the harm caused by SARS-CoV-2 will demand far greater attention to NCDs and socioeconomic inequality than has hitherto been admitted. 

A syndemic is not merely a comorbidity. Syndemics are characterised by biological and social interactions between conditions and states, interactions that increase a person's susceptibility to harm or worsen their health outcomes. In the case of COVID-19, attacking NCDs will be a prerequisite for successful containment. As our recently published NCD Countdown 2030 showed, although premature mortality from NCDs is falling, the pace of change is too slow. The total number of people living with chronic diseases is growing. Addressing COVID-19 means addressing hypertension, obesity, diabetes, cardiovascular and chronic respiratory diseases, and cancer. 

Paying greater attention to NCDs is not an agenda only for richer nations. NCDs are a neglected cause of ill-health in poorer countries too. In their Lancet Commission, published last week, Gene Bukhman and Ana Mocumbi described an entity they called NCDI Poverty, adding injuries to a range of NCDs—conditions such as snake bites, epilepsy, renal disease, and sickle cell disease. For the poorest billion people in the world today, NCDIs make up over a third of their burden of disease. The Commission described how the availability of affordable, cost-effective interventions over the next decade could avert almost 5 million deaths among the world's poorest people. And that is without considering the reduced risks of dying from COVID-19.

The most important consequence of seeing COVID-19 as a syndemic is to underline its social origins. The vulnerability of older citizens; Black, Asian, and minority ethnic communities; and key workers who are commonly poorly paid with fewer welfare protections points to a truth so far barely acknowledged—namely, that no matter how effective a treatment or protective a vaccine, the pursuit of a purely biomedical solution to COVID-19 will fail. 

Unless governments devise policies and programmes to reverse profound disparities, our societies will never be truly COVID-19 secure. As Singer and colleagues wrote in 2017, “A syndemic approach provides a very different orientation to clinical medicine and public health by showing how an integrated approach to understanding and treating diseases can be far more successful than simply controlling epidemic disease or treating individual patients.” 

I would add one further advantage. Our societies need hope. The economic crisis that is advancing towards us will not be solved by a drug or a vaccine. Nothing less than national revival is needed. 

Approaching COVID-19 as a syndemic will invite a larger vision, one encompassing education, employment, housing, food, and environment. Viewing COVID-19 only as a pandemic excludes such a broader but necessary prospectus.

Madrid orders partial lockdown after surge in Covid-19 infections

Via France24: Madrid orders partial lockdown after surge in Covid-19 infections.

The regional government of the Spanish capital Madrid ordered a lockdown from Monday in some of the poorer areas of the city and its outskirts that are home to about 850,000 people, after a surge in coronavirus infections there. 

Regional leader Isabel Diaz Ayuso said on Friday movement between and within areas in six districts would be restricted, but people would be able to go to work in Spain's hardest-hit region. 

Residents in Madrid's poorer districts had said earlier they felt abandoned, stigmatised and feared new restrictions would deprive them of income. 

After the announcement, a few hundred protestors gathered in front of the offices of Madrid's regional government to demand Ayuso quit. 

"The health centres are saturated in the south of the city and they have not done anything about it," said protester Rosa Baras, 65. 

Ayuso, who attracted criticism for saying this week "the way of life of immigrants" was partly to blame for the rise in cases, said the areas had been chosen because contagion levels there exceeded 1,000 per 100,000 people. 

"We need to avoid lockdown, we need to avoid economic disaster," Ayuso told a news conference. "We don't think it's time to restrict all citizens, but rather to apply measures in areas we have perfectly identified."  

Access to parks and public areas will be restricted, gatherings will be limited to six people and commercial establishments will have to close by 10 p.m. in the areas. 

Inequality gap  

The gap between poorer and richer areas is at the heart of a debate over how to curb an increase in new cases.  

Restrictions will affect Vallecas, a southern district with a lower average income and higher immigrant population, which has one of the highest infection rates in Madrid. It is almost six times higher than in Chamberi, one of the wealthier, northern districts.  

The health system "is more paralysed here, they have us out here waiting, crowded, queues everywhere," retiree Mari Paz Gonzalez said. "We are abandoned... They left us in the hands of God."

Bill Gates on COVID-19, vaccines and global health

Via The New York Times: Bill Gates on Coronavirus, Vaccines and Global Health. Excerpt:

On Monday, the Bill and Melinda Gates Foundation released the fourth of its annual Goalkeeper reports, which track the slow but steady progress the world has made toward more than a dozen health-related goals set forth by the United Nations in 2015.

This year’s was unrelentingly grim. The coronavirus pandemic has scorched away years of work: More families are in dire poverty, malnutrition is increasing, far fewer children are getting immunized. 

The assessment comes as the United States, stung harder by the virus than any other country, is retreating from the global health stage and seems focused primarily on saving itself. Could it ever return to its role as the world’s leader in both competence and generosity? In an interview with The New York Times, Mr. Gates devoted a half-hour to explaining why he was optimistic that it would. 

“It’s my disposition,” he said. “Plus, I’ve got to call these people up and make the pitch to them that this really makes sense — and I totally, totally believe it makes sense.”

By “these people,” he was referring to leading figures in the White House and Congress, whom he has personally lobbied to do “this”: namely, add an extra $4 billion to the fiscal stimulus package now under debate in Congress so that poor countries can get Covid-19 vaccines.  

Ultimately his goal is far more ambitious: to double American foreign aid from less than 0.25 percent of gross domestic product to 0.5 percent or more. He sees the pandemic as an opportunity to do that. 

“As they say,” he added cheerily, “the U.S. government — after it’s tried every other thing — does the right thing.” 

As he did in Silicon Valley while battling competitors and antitrust regulators, Mr. Gates can calculate his chances of success with a ruthless logic. That has rarely been as true as it is now, as a once-in-a-century pandemic devastates the impoverished countries where he focuses his giving.  

The damage has been wrought less by the virus — so far it has killed much smaller percentages of the populations of Asia and Africa than of the Americas and Western Europe — than by the economic impact, which has been far greater in countries where people and governments “have no spare reserves to draw on,” Mr. Gates said. 

The collapse of tourism, declines in remittances from relatives working abroad, the shutdown of ports, mines and oil wells, school closings and new stresses on fragile health care systems have all created enormous suffering. 

Not since 1870 have so many countries been in recession at once, according to the Goalkeeper report. Between 1990 and 2020, the percentage of the world’s population living in extreme poverty, which is now defined as living on less than $2 a day, shrank to less than 7 percent from 37 percent. In just the past few months, 37 million people have fallen back below the line, the report estimated.  

“The longer the pandemic lasts, the worse its economic scars will be,” it added.

Assessment of COVID-19 hospitalizations by race/ethnicity in 12 states

Via JAMA, a research letter: Assessment of COVID-19 Hospitalizations by Race/Ethnicity in 12 States.

Given the reported health disparities in coronavirus disease 2019 (COVID-19) infection and mortality by race/ethnicity, there is an immediate need for increased assessment of the prevalence of COVID-19 across racial/ethnic subgroups of the population in the US. We examined the racial/ethnic prevalence of cumulative COVID-19 hospitalizations in the 12 states that report such data and compared how this prevalence differs from the racial/ethnic composition of each state’s population. 

Methods 

Using data extracted from the University of Minnesota COVID-19 Hospitalization Tracking Project, we identified the 12 states that reported the race/ethnicity of individuals hospitalized with COVID-19 between April 30 and June 24, 2020. We calculated the percentage of cumulative hospitalizations by racial/ethnic categories averaged over the study period and then calculated the difference between the percentage of cumulative hospitalizations for each subgroup and the corresponding percentage of the state’s population for each racial/ethnic subgroup as reported in the US Census. 

The race/ethnicity categories included were White, Black, American Indian and/or Alaskan Native, Asian, and Hispanic. Descriptive statistical analyses were conducted using Stata/MP, version 14 (Stata Corp). The University of Minnesota Institutional Review Board reviewed the study data and deemed it exempt from review and informed consent requirements because the study was not human subjects research. 

Results 

This analysis of COVID-19 hospitalizations in 12 US states during nearly a 2-month period represented a total of 48 788 cumulative hospitalizations among a total population of 66 796 666 individuals in 12 US states by the end of the study period on June 24, 2020. The share of the hospitalizations of White patients was substantially smaller vs their share of state population in all 12 states (Table and Figure). For example, in Minnesota, the share of hospitalizations of White patients was 52.9%, whereas their share of the state population was 84.1%. 

Conversely, the percentage of hospitalizations among Black patients exceeded the percentage of their representative proportion of the state population in all 12 states. Differences between the cumulative percentage of hospitalizations and the state population of Black individuals were greatest in Ohio (31.8% vs 13.0%), Minnesota (24.9% vs 6.8%), Indiana (28.1% vs 9.8%), and Kansas (22.0% vs 6.1%). 

Eleven states reported the number of COVID-19 hospitalizations for Hispanic individuals, and in 10 states, the percentage of hospitalizations for Hispanic individuals was higher than their representative proportion of the state population. The disparity among Hispanic individuals was most pronounced in Virginia (36.2% of hospitalizations vs 9.6% of population), Utah (35.3% of hospitalizations vs 14.2% of population), and Rhode Island (33.0% of hospitalizations vs 15.9% of population).  

The pattern was largely reversed for the Asian population. In 6 of 10 states that reported data for this subgroup, the proportion of hospitalizations was lower compared with their population representation. In Massachusetts, for example, the Asian population comprised 7.0% of the population but only 4.0% of the COVID-19 hospitalizations. 

Hospitalization data for American Indian and Alaskan Native populations were only reported by 8 states. However, the disparity was substantial in select states. In Arizona, the American Indian and Alaskan Native population accounted for 15.7% of the hospitalizations but only 4.0% of the state’s population. Similarly, in Utah, this subgroup accounted for 5.0% of the hospitalizations in contrast with 0.9% representation of the state population.  

Discussion 

This analysis identified considerable disparities in the prevalence of COVID-19 across racial/ethnic subgroups of the population in 12 US states. These findings are consistent with an earlier Centers for Disease Control and Prevention analysis of 580 hospitalizations between March 1 and March 30, 2020, that found disproportionately high COVID-19 hospitalizations for the Black population. 

Similarly, a study of 1052 confirmed COVID-19 cases between January 1 and April 8, 2020, at a California health system reported higher odds of hospitalization in non-Hispanic Black individuals compared with non-Hispanic White individuals. In addition, we observed high hospitalization rates for Hispanic individuals in most of the states analyzed and high hospitalization rates for American Indian and Alaskan Native populations in select states.  

These findings highlight the need for increased data reporting and consistency within and across all states. Only 12 of 50 US states have consistently reported hospitalizations by race/ethnicity during our study period. New Jersey and Florida recently started reporting data on COVID-19 hospitalizations by race/ethnicity. The present study is limited in that there was no adjustment for age, sex, comorbidities, and socioeconomic factors within each racial/ethnic group that are likely to be associated with COVID-19 hospitalizations. 

A large body of research has identified racial/ethnic health disparities in the risk of infection associated with a higher prevalence of comorbidities, less access to health care, adverse economic conditions, and service-related occupations. The unique clinical, financial, and social implications of COVID-19 for racial/ethnic populations that are often systematically marginalized in society must be well understood to design and establish effective and equitable infrastructure solutions.

New report: An Interim Framework for COVID-19 Vaccine Allocation and Distribution in the US

A news release from Johns Hopkins Bloomberg School of Public Health: New Report: An Interim Framework for COVID-19 Vaccine Allocation and Distribution in the U.S.

Today (Wednesday, August 19, 2020), the Center for Health Security at Johns Hopkins Bloomberg School of Public Health released a new report providing an ethical framework for making decisions about allocation and distribution of a COVID-19 vaccine during the initial period when such a vaccine has first been authorized for use and is still in limited supply.   

The report, Interim Framework for COVID-19 Vaccine Allocation and Distribution in the United States, proposes specific tiers of high-priority candidates for receiving a first vaccine based on this framework, including recognizing the contributions of essential workers who have been overlooked in previous allocation schemes:  

Tier 1 includes those: 

• Most essential in sustaining the ongoing COVID-19 response. 

• At greatest risk of severe illness and death, and their caregivers. 

• Most essential to maintaining core societal functions. 

Tier 2 includes those: 

• Involved in broader health provision. 

• Facing greater barriers to access care if they become seriously ill. 

• Contributing to maintenance of core societal functions. 

• Whose living or working conditions give them elevated risk of infection, even if they have lesser or unknown risk of severe illness and death. 

The framework is guided by the following ethical principles, which the report authors believe should guide COVID-19 vaccine allocation and help identify more specific policy goals and objectives around vaccine policies: 

• Promotion of the common good, by promoting public health while enabling social and economic activity. 

• The importance of treating individuals fairly and promoting social equity, for example by addressing racial and ethnic disparities in COVID-19 mortality, and by recognizing the contributions of essential workers who have been overlooked in previous allocation schemes.  

• The promotion of legitimacy, trust and a sense of community ownership over vaccine policy, while respecting the diversity of values and beliefs in our pluralist society.