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Promoting racial equity in COVID-19 resource allocation
Abstract
Due to COVID-19’s strain on health systems across the globe, triage protocols determine how to allocate scarce medical resources with the worthy goal of maximising the number of lives saved. However, due to racial biases and long-standing health inequities, the common method of ranking patients based on impersonal numeric representations of their morbidity is associated with disproportionately pronounced racial disparities. In response, policymakers have issued statements of solidarity. However, translating support into responsive COVID-19 policy is rife with complexity. Triage does not easily lend itself to race-based exceptions. Reordering triage queues based on an individual patient’s racial affiliation has been considered but may be divisive and difficult to implement. And while COVID-19 hospital policies may be presented as rigidly focused on saving the most lives, many make exceptions for those deemed worthy by policymakers such as front-line healthcare workers, older physicians, pregnant women and patients with disabilities. These exceptions demonstrate creativity and ingenuity—hallmarks of policymakers’ abilities to flexibly respond to urgent societal concerns—which should also be extended to patients of colour. This paper dismantles common arguments against the confrontation of racial inequity within COVID-19 triage protocols, highlights concerns related to existing proposals and proposes a new paradigm to increase equity when allocating scarce COVID-19 resources.
... Underrepresented communities have more difficulties in accessing healthcare compared to White groups (Bruce et al., 2021;Chinn et al., 2021). For example, during the COVID-19 pandemic, the federal government's response to the widespread disease disproportionately provided more access to healthcare barriers to minorities compared to the members of the white community (Bruce et al., 2021). ...
... Underrepresented communities have more difficulties in accessing healthcare compared to White groups (Bruce et al., 2021;Chinn et al., 2021). For example, during the COVID-19 pandemic, the federal government's response to the widespread disease disproportionately provided more access to healthcare barriers to minorities compared to the members of the white community (Bruce et al., 2021). The same can be said for Black women, though there were some improvements in access to healthcare, it is still evident that Black women still face difficulties when accessing simple things such as access to mental health or preventative health (Chinn et al., 2021). ...
... Race and disability are not separate or isolated categories; they intersect and influence one another, resulting in unique experiences and systemic disadvantages for racial minorities with disabilities (Annamma et al., 2013). People of color with disabilities face a complex web of discrimination, as they must navigate the challenges associated with racism, ableism, and other intersecting oppressions (Bruce et al., 2021;Chinn et al., 2021). The concept of intersectionality acknowledges that the experiences of disabled individuals are not homogeneous, but are shaped by the intersections of various social identities. ...
This study explores Filipina-American mothers' experiences raising children with ASD, focusing on challenges in obtaining timely diagnoses and services. Given healthcare disparities and cultural stereotypes, these mothers often face unique barriers. Using narrative inquiry, this research captures their journeys, from first recognizing symptoms to accessing essential support. Insights aim to improve early ASD detection and resource accessibility, advocating for equitable, culturally responsive autism services for children of color.
... The specialized literature has already widely discussed that public health emergencies disproportionately affect historically unprotected populations 12,21,22 . In this sense, the themes of justice and equity seem fundamental when discussing the distribution of resources for health care and actions during pandemics and epidemics. ...
... The debate on the scarcity of resources affects structural problems, especially when considering aspects related to social determinants of health and intersectionalities such as racism, class, or gender inequality 10,21 . When inequalities are ignored, responses can only escalate the harmful effects that disproportionately impact populations historically discriminated against, perpetuating those inequalities. ...
... Unintentional consequences refer to unforeseen effects -which, therefore, could not be anticipated by responses to protect and care for populations 21 . Let us consider that our country's structural inequalities are still widely debated among social actors and experts. ...
This qualitative study aimed to analyze the social actors’ perceptions of public responses during the COVID-19 pandemic. We conducted semi-structured interviews with eleven civil society representatives and social movement leaders. We also performed triangulation based on the systematization of opinion papers authored by humanitarian organizations and civil society leaders and published in large-circulation newspapers. Our analysis was inspired by the ethical principles of social justice, solidarity, and citizenship. Two main themes emerged from the thematic analysis: 1) disproportionately affected populations remain invisible to care and protection; 2) there is an intentional project to annihilate “undesirable” populations. Community movements must be incorporated as an essential part of the responses to provide care and protection and mitigate the effects during health emergencies. Care, solidarity, and social participation are central to building health protection responses within the framework of social justice. The responses to transforming the future in the aftermath of the pandemic will occur through the initiatives of civil society and community leaders within the territories.
... A literatura especializada já tem discutido amplamente o fato de as emergências em saúde pública afetarem de maneira desproporcional populações historicamente desprotegidas 12,21,22 . Nesse sentido, parece fundamental o tema da justiça e equidade quando discutimos distribuição de recursos para cuidados e ações em saúde durante pandemias e epidemias. ...
... O debate sobre escassez de recursos toca em problemas estruturais, em especial quando consideramos aspectos relacionados a determinantes socais de saúde e interseccionalidades como racismo, classe ou desigualdade de gênero 10,21 . Quando as iniquidades são ignoradas, as respostas podem apenas exacerbar os efeitos danosos que impactam desproporcionalmente as populações historicamente discriminadas, perpetuando essas iniquidades. ...
... Consequências não-intencionais se referem a efeitos não previstos -e que por isso não poderiam ser antecipados pelas respostas para proteção e cuidado das populações 21 . Se considerarmos que as desigualdades estruturais de nosso país seguem amplamente debatidas entre atores sociais e especialistas, podemos compreender que, no cenário das respostas das autoridades públicas brasileiras à pandemia de COVID-19, há uma intencionalidade posta diante desse cenário de tragédias e mortes evitáveis. ...
This qualitative study aimed to analyze the social actors' perceptions of public responses during the COVID-19 pandemic. We conducted semi-structured interviews with eleven civil society representatives and social movement leaders. We also performed triangulation based on the systematization of opinion papers authored by humanitarian organizations and civil society leaders and published in large-circulation newspapers. Our analysis was inspired by the ethical principles of social justice, solidarity, and citizenship. Two main themes emerged from the thematic analysis: 1) disproportionately affected populations remain invisible to care and protection; 2) there is an intentional project to annihilate "undesirable" populations. Community movements must be incorporated as an essential part of the responses to provide care and protection and mitigate the effects during health emergencies. Care, solidarity, and social participation are central to building health protection responses within the framework of social justice. The responses to transforming the future in the aftermath of the pandemic will occur through the initiatives of civil society and community leaders within the territories.
... study 62,63 and acknowledge disparate minority outcomes 64 and implement evidence-based interventions makes health equity impossible. 65 Improving access to testing is a clear first step for those communities at the highest risk. Moreover, community engagement led by trusted community representatives, from strategy to implementation, should be a universal priority. ...
... 69 Lastly, as vaccinations remain the ultimate endpoint for the pandemic, the disparate outcomes warrant our emergent attention during the vaccination prioritization process. 65,70 Minority and non-English-speaking populations are clearly at high risk from multiple aspects of this health crisis, and early data already shows the maldistribution of the COVID-19 vaccine. 71,72 ...
Background
Despite past and ongoing efforts to achieve health equity in the USA, racial and ethnic disparities persist and appear to be exacerbated by COVID-19.Objective
Evaluate neighborhood-level deprivation and English language proficiency effect on disproportionate outcomes seen in racial and ethnic minorities diagnosed with COVID-19.DesignRetrospective cohort studySettingHealth records of 12 Midwest hospitals and 60 clinics in Minnesota between March 4, 2020, and August 19, 2020PatientsPolymerase chain reaction–positive COVID-19 patientsExposuresArea Deprivation Index (ADI) and primary languageMain MeasuresThe primary outcome was COVID-19 severity, using hospitalization within 45 days of diagnosis as a marker of severity. Logistic and competing-risk regression models assessed the effects of neighborhood-level deprivation (using the ADI) and primary language. Within race, effects of ADI and primary language were measured using logistic regression.ResultsA total of 5577 individuals infected with SARS-CoV-2 were included; 866 (n = 15.5%) were hospitalized within 45 days of diagnosis. Hospitalized patients were older (60.9 vs. 40.4 years, p < 0.001) and more likely to be male (n = 425 [49.1%] vs. 2049 [43.5%], p = 0.002). Of those requiring hospitalization, 43.9% (n = 381), 19.9% (n = 172), 18.6% (n = 161), and 11.8% (n = 102) were White, Black, Asian, and Hispanic, respectively. Independent of ADI, minority race/ethnicity was associated with COVID-19 severity: Hispanic patients (OR 3.8, 95% CI 2.72–5.30), Asians (OR 2.39, 95% CI 1.74–3.29), and Blacks (OR 1.50, 95% CI 1.15–1.94). ADI was not associated with hospitalization. Non-English-speaking (OR 1.91, 95% CI 1.51–2.43) significantly increased odds of hospital admission across and within minority groups.Conclusions
Minority populations have increased odds of severe COVID-19 independent of neighborhood deprivation, a commonly suspected driver of disparate outcomes. Non-English-speaking accounts for differences across and within minority populations. These results support the ongoing need to determine the mechanisms that contribute to disparities during COVID-19 while also highlighting the underappreciated role primary language plays in COVID-19 severity among minority groups.
... For example, medical practitioners and policy-makers highlighted three priority groups: healthcare workers, other essential workers and people in high-transmission settings, and people with medical vulnerabilities associated with poorer COVID-19 outcomes (Persad, Peek, & Emanuel, 2020;Truog, Mitchell, & Daley, 2020). Other concerns that have been discussed include racial equity (Bruce & Tallman, 2021). ...
The rationing of healthcare resources has emerged as an important issue, which has been discussed by medical experts, policy-makers, and the general public. We consider a rationing problem where medical units are to be allocated to patients. Each unit is reserved for one of several categories, and each category has a priority ranking over the patients. We present a class of allocation rules that respect the priorities, comply with the eligibility requirements, allocate the largest feasible number of units, and do not penalize agents for rising in the priority ranking of a category. The rules characterize all possible allocations that satisfy the first three properties and are polynomial-time computable.
... For example, for vaccination, the main priority groups considered include health care workers, workers in other essential services, and people with vulnerable medical conditions [36,44]. Racial equity has been another concern [9]. Having made the priority groups, it still remains a However, the allocation of healthcare resources is an ongoing process. ...
Allocation of scarce healthcare resources under limited logistic and infrastructural facilities is a major issue in the modern society. We consider the problem of allocation of healthcare resources like vaccines to people or hospital beds to patients in an online manner. Our model takes into account the arrival of resources on a day-to-day basis, different categories of agents, the possible unavailability of agents on certain days, and the utility associated with each allotment as well as its variation over time. We propose a model where priorities for various categories are modelled in terms of utilities of agents. We give online and offline algorithms to compute an allocation that respects eligibility of agents into different categories, and incentivizes agents not to hide their eligibility for some category. The offline algorithm gives an optimal allocation while the on-line algorithm gives an approximation to the optimal allocation in terms of total utility. Our algorithms are efficient, and maintain fairness among different categories of agents. Our models have applications in other areas like refugee settlement and visa allocation. We evaluate the performance of our algorithms on real-life and synthetic datasets. The experimental results show that the online algorithm is fast and performs better than the given theoretical bound in terms of total utility. Moreover, the experimental results confirm that our utility-based model correctly captures the priorities of categories
... Compared to white individuals, racial/ethnic minority groups have differing levels of vaccination; access to medical care and COVID-19 therapeutics; baseline comorbidities; socioeconomic status; and viral exposure by virtue of their occupations and household structure-all of which may influence the risk of developing PASC. [5][6][7][8][9][10] Studies examining potential racial/ethnic differences in PASC have yielded mixed results and generally focused on a single institution or specific patient populations (e.g., U. S. veterans or Medicare Advantage beneficiaries). [11][12][13] Research examining the general adult population has focused on a limited set of potential PASC symptoms and conditions. ...
Background:
Compared to white individuals, Black and Hispanic individuals have higher rates of COVID-19 hospitalization and death. Less is known about racial/ethnic differences in post-acute sequelae of SARS-CoV-2 infection (PASC).
Objective:
Examine racial/ethnic differences in potential PASC symptoms and conditions among hospitalized and non-hospitalized COVID-19 patients.
Design:
Retrospective cohort study using data from electronic health records.
Participants:
62,339 patients with COVID-19 and 247,881 patients without COVID-19 in New York City between March 2020 and October 2021.
Main measures:
New symptoms and conditions 31-180 days after COVID-19 diagnosis.
Key results:
The final study population included 29,331 white patients (47.1%), 12,638 Black patients (20.3%), and 20,370 Hispanic patients (32.7%) diagnosed with COVID-19. After adjusting for confounders, significant racial/ethnic differences in incident symptoms and conditions existed among both hospitalized and non-hospitalized patients. For example, 31-180 days after a positive SARS-CoV-2 test, hospitalized Black patients had higher odds of being diagnosed with diabetes (adjusted odds ratio [OR]: 1.96, 95% confidence interval [CI]: 1.50-2.56, q<0.001) and headaches (OR: 1.52, 95% CI: 1.11-2.08, q=0.02), compared to hospitalized white patients. Hospitalized Hispanic patients had higher odds of headaches (OR: 1.62, 95% CI: 1.21-2.17, q=0.003) and dyspnea (OR: 1.22, 95% CI: 1.05-1.42, q=0.02), compared to hospitalized white patients. Among non-hospitalized patients, Black patients had higher odds of being diagnosed with pulmonary embolism (OR: 1.68, 95% CI: 1.20-2.36, q=0.009) and diabetes (OR: 2.13, 95% CI: 1.75-2.58, q<0.001), but lower odds of encephalopathy (OR: 0.58, 95% CI: 0.45-0.75, q<0.001), compared to white patients. Hispanic patients had higher odds of being diagnosed with headaches (OR: 1.41, 95% CI: 1.24-1.60, q<0.001) and chest pain (OR: 1.50, 95% CI: 1.35-1.67, q < 0.001), but lower odds of encephalopathy (OR: 0.64, 95% CI: 0.51-0.80, q<0.001).
Conclusions:
Compared to white patients, patients from racial/ethnic minority groups had significantly different odds of developing potential PASC symptoms and conditions. Future research should examine the reasons for these differences.
... A health equity lens to mitigate COVID-19 disparities is key. For example, enhancing access to testing in places where these groups are more likely to receive care [72], adopting more racially equitable triage in racially diverse areas [73], and addressing implicit biases in medical treatment [74] would all help address these disparities. The first six months of a pandemic appear to be critical in addressing these issues, and so learning from the COVID-19 pandemic should be applied to any future pandemics. ...
People of different racial/ethnic backgrounds, demographics, health, and socioeconomic characteristics have experienced disproportionate rates of infection and death due to COVID-19. This study tests if and how county-level rates of infection and death have changed in relation to societal county characteristics through time as the pandemic progressed. This longitudinal study sampled monthly county-level COVID-19 case and death data per 100,000 residents from April 2020 to March 2022, and studied the relationships of these variables with racial/ethnic, demographic, health, and socioeconomic characteristics for 3125 or 97.0% of U.S. counties, accounting for 96.4% of the U.S. population. The association of all county-level characteristics with COVID-19 case and death rates changed significantly through time, and showed different patterns. For example, counties with higher population proportions of Black, Native American, foreign-born non-citizen, elderly residents, households in poverty, or higher income inequality suffered disproportionately higher COVID-19 case and death rates at the beginning of the pandemic, followed by reversed, attenuated or fluctuating patterns, depending on the variable. Patterns for counties with higher White versus Black population proportions showed somewhat inverse patterns. Counties with higher female population proportions initially had lower case rates but higher death rates, and case and death rates become more coupled and fluctuated later in the pandemic. Counties with higher population densities had fluctuating case and death rates, with peaks coinciding with new variants of COVID-19. Counties with a greater proportion of university-educated residents had lower case and death rates throughout the pandemic, although the strength of this relationship fluctuated through time. This research clearly shows that how different segments of society are affected by a pandemic changes through time. Therefore, targeted policies and interventions that change as a pandemic unfolds are necessary to mitigate its disproportionate effects on vulnerable populations, particularly during the first six months of a pandemic.
... An example is in triage of critical care resources in COVID: should we ensure that racialized minorities have the same access to critical care resources as others, 21 or should we prioritize access for patients whose COVID status is derived from their social determinants of health? 22 For example, consider that racialized minorities disproportionately work in the public-facing service economy, with precarious employment conditions and minimal provision for sick leave, while their families and communities take on their risk of exposure to COVID in turn due to high-occupancy housing and a lack of outdoor public spaces for safe recreation. In addition, they may serve a public that resists social distancing measures, placing them in unnecessary danger. ...
... 11,26,27 This last point is especially pertinent because health-care emergencies often exacerbate existing health disparities, 28,29 and while the triage process is unlikely to effectively correct for the many inequities in the health-care system, it should at a minimum seek to avoid worsening inequities. 11,13,28,30,31 The question of whether to include age as a factor in triage team decision-making generated substantial debate among Delphi participants, which is also reflected in the broader literature. 32 Age is a strong predictor of mortality for critically ill patients, including for patients with COVID-19, 25 and because older adults, on average, have a lower expected longevity, consideration of age in triage would result in a disproportionate number of older adults being denied treatment. ...
Objective
Plans for allocation of scarce life-sustaining resources during the coronavirus disease 2019 (COVID-19) pandemic often include triage teams, but operational details are lacking, including what patient information is needed to make triage decisions.
Methods
A Delphi study among Washington state disaster preparedness experts was performed to develop a list of patient information items needed for triage team decision-making during the COVID-19 pandemic. Experts proposed and rated their agreement with candidate information items during asynchronous Delphi rounds. Consensus was defined as ≥80% agreement. Qualitative analysis was used to describe considerations arising in this deliberation. A timed simulation was performed to evaluate feasibility of data collection from the electronic health record.
Results
Over 3 asynchronous Delphi rounds, 50 experts reached consensus on 24 patient information items, including patients’ age, severe or end-stage comorbidities, the reason for and timing of admission, measures of acute respiratory failure, and clinical trajectory. Experts weighed complex considerations around how information items could support effective prognostication, consistency, accuracy, minimizing bias, and operationalizability of the triage process. Data collection took a median of 227 seconds (interquartile range = 205, 298) per patient.
Conclusions
Experts achieved consensus on patient information items that were necessary and appropriate for informing triage teams during the COVID-19 pandemic.
... While "most lives saved" (MLS) approaches for vaccine distribution may have some merit, they may fail to adequately help underserved minority groups which suffer from increased risk of COVID-19 hospitalization. 37 Health equity issues leading to "long COVID" may also lead to under-enrollment of EBC patients to trials in areas with low vaccine acceptance and in underserved minority communities where vaccine access may be limited. ...
While COVID-19 vaccine distribution has addressed vulnerabilities related to age and co-morbidities, there is a need to ensure vaccination of cancer patients receiving experimental and routine treatment, where interruption of treatment by infection is likely to result in inferior outcomes. Among cancer patients, those undergoing neoadjuvant chemotherapy (NAC) or adjuvant chemotherapy (Adj chemo) for early breast cancer (EBC) are at particularly high risk for inferior outcomes, in part because optimal timing of chemotherapy is essential for promoting distant disease-free survival (DDFS). COVID-19 data from the ongoing multicenter I-SPY 2 trial of NAC for EBC provides a window into the magnitude of the problem of treatment interruption, not only for the trial itself but also for routine Adj chemo. In the I-SPY 2 trial 4.5% of patients had disruption of therapy by COVID-19 prior to wide vaccine availability, suggesting that nationally up to 5,700 EBC patients were at risk for adverse outcomes from COVID-19 infection in 2020. To address this problem, vaccine education and public engagement are essential to overcome hesitancy, while equity of distribution is needed to address access. To accomplish these goals, health care organizations (HCOs) need to not only call out disinformation but engage the public with vaccine education and find common ground for vaccine acceptance, while partnering with state/local governments to improve efficiency of vaccine distribution. These approaches are important to improving trial access and to reducing susceptibility to COVID-19, as the pandemic could continue to impact access to clinical trials and routine cancer treatment.
... COVID-19 outcomes . Other concerns that have been discussed include racial equity (Bruce and Tallman, 2021). ...
As the COVID-19 pandemic shows no clear signs of subsiding, fair and efficient rationing of healthcare resources has emerged as an important issue that has been discussed by medical experts, policy-makers, and the general public. We consider a healthcare rationing problem where medical units are to be allocated to patients. Each unit is reserved for one of several categories and the patients have different priorities for the categories. We present an allocation rule that respects the priorities, complies with the eligibility requirements, allocates the largest feasible number of units, and does not incentivize agents to hide that they qualify through a category. Moreover, the rule is polynomial-time computable. To the best of our knowledge, it is the first known rule with the aforementioned properties.
This paper explores resource allocation complexities during health emergencies, focusing on pervasive racial disparities, notably affecting black communities. It aims to investigate alternatives to the Most Lives Saved approach, particularly its potential to exacerbate disparities. To analyse resource allocation strategies, the essay reviews the Dual-Principled System proposed by Bruce and Tallman (B+T) in 2021. B+T’s proposal critiques previous methods like the Area Deprivation Index and First Come First Serve while seeking to balance equity and utility by adjusting triage scores based on diseases displaying racial disparities. However, the study identifies inherent challenges in subjectivity, complexity and fairness, necessitating a careful examination and potential innovative solutions. The examination of the Dual-Principled System uncovers challenges, leading to the identification of three main issues and potential solutions. Furthermore, to address subjectivity concerns, it is necessary to adopt objective disease selection criteria through data analysis. Moreover, proposed solutions for complexity include real-time data updates, adaptability and regional considerations. Fairness concerns can be mitigated through educational campaigns and a lottery system integrated with triage score adjustments. The study emphasises nuanced resource allocation with objective disease selection, adaptable strategies and educational initiatives, including a lottery system, aligning with fairness, equity and practicality. As healthcare evolves, resource allocation must align with justice, fostering inclusivity and responsiveness for all.
Importance
COVID-19 prompted rapid development of scarce resource allocation (SRA) policies to be implemented if demand eclipsed health systems’ ability to provide critical care. While SRA policies follow general ethical frameworks, understanding priorities of those affected by policies and/or tasked with implementing them is critical.
Objective
To evaluate whether community members and health care profesionals (HCP) agree with SRA protocols at the University of California (UC).
Design, Setting, and Participants
This survey study used social media and community-partnered engagement to recruit participants to a web-based survey open to all participants aged older than 18 years who wished to enroll. This study was fielded between May and September 2020 and queried participants’ values and preferences on draft SRA policy tenets. Participants were also encouraged to forward the survey to their networks for snowball sampling. Data were analyzed from July 2020 to January 2024.
Main Outcomes and Measures
Survey items assessed values and preferences, graded on Likert scales. Agreement was tabulated as difference in Likert points between expressed opinion and policy tenets. Descriptive statistics were tested for significance by HCP status. Free text responses were analyzed using applied rapid qualitative analysis.
Results
A total of 1545 participants aged older than 18 years (mean [SD] age 49 [16] years; 1149 female participants [74%], 478 health care practitioners [30%]) provided data on SRA values and preferences. Agreement with UC SRA policy as drafted was moderately high among respondents, ranging from 67% to 83% across domains. Higher agreement with the interim policy was observed for laypersons across all domains except health-related factors. HCPs agreed more strongly on average that resources should not be allocated to those less likely to survive (HCP mean, 3.70; 95% CI, 3.16-3.59; vs layperson mean, 3.38; 95% CI, 3.17-3.59; P = .002), and were more in favor of reallocating life support from patients less likely to those more likely to survive (HCP mean, 6.41; 95% CI, 6.15-6.67; vs layperson mean, 5.40; 95% CI, 5.23-5.58; P < .001). Transparency and trust building themes were common in free text responses and highly rated on scaled items.
Conclusions and Relevance
This survey of SRA policy values found moderate agreement with fundamental principles of such policies. Engagement with communities affected by SRA policy should continue in iterative refinement in preparation for future crises.
Socially responsible publishers, such as the BMJ, have demonstrated a commitment to health equity and working toward rectifying the structural racism that exists both in health care and in medical publishing.(1) The commitment of academic publishers to collecting information relevant to promoting equity and diversity is important and commendable where it leads to that result.(2) But collecting sensitive demographic data is not a morally neutral activity. Rather, it carries with it both known and potential risks. Among these are issues around privacy or data misuse, as well as more basic concerns about how, when, or why people should be categorized in certain ways and/or made to conceive of themselves or their identities in certain terms.(3) If such data are to be collected, therefore, their effectiveness in achieving the stated ends must have a sufficiently compelling evidence base so as to justify the various risks involved. And where possible, these risks must also be identified and minimised.
In public health emergencies that warrant mass vaccination, vaccine mandates are sometimes imposed. There is historical evidence of the effectiveness of vaccination mandates, but varying strategies in policy implementation. The COVID-19 vaccine mandate presents an ethical imbroglio that poses these bioethical questions, “Is there ethical justification for a vaccine mandate?”, and “Whose responsibility is it to ensure the equitability of a vaccine mandate in a pandemic?” Using ethical principles and theories, this paper focuses on the health equity of vaccine mandates, considering both the global and local implications. Vaccination mandate, in a pandemic, is driven by the need to accelerate the achievement of public health goals of herd immunity, protecting the most vulnerable in terms of case fatality and hospitalization rates, protecting the capacity of the acute health care system, as well as circumventing the economic impact. These mandates must still be guided by appropriate stakeholder involvement and bioethical considerations, to assess their validity and equitability, as vaccine mandates may impose restrictions on the freedoms and rights of an individual. Using COVID-19 as a case study, we argued the equitability of vaccine mandates based on the WHO framework of ethical considerations and caveats for mandatory vaccination. Necessity and proportionality of the vaccine, sufficient evidence of safety, efficacy, and effectiveness, sufficient supply, and public trust are key during ethical processes of decision-making. We conclude that vaccine mandates are more equitable as population-specific mandates, as opposed to global or universal mandates, even in pandemics. This is due to varying geographic, socio-cultural, and economic characteristics. Bioethicists should be actively engaged in discussions on the vaccine mandate, as its equitability is a function of critically analyzing the proposed mandate based on ethical recommendations prior to being issued. Retrospective bioethical analysis is warranted to identify shortfalls and make recommendations for future decision-making.
Background: Leisure time physical activity is an essential part of taking care of the body and the mind. It assists in keeping our bodies healthy and functioning. However, COVID-19 challenged the community's ability to engage in leisure time physical activity. Aim: The aim of this study was to explore and describe the perceptions of leisure-time physical activity amidst the COVID-19 pandemic in the City of Cape Town for people with disabilities. Methods: The study was conducted using a descriptive qualitative research design, making use of semi-structured interviews with open-ended questions. The study used a purposive sampling technique to recruit participants from NGOs' in the City of Cape Town townships, which caters to people with disabilities. Eight participants were recruited and interviewed for this study. The participants were free and voluntarily to participate in the study, were able to withdraw from the study at any time, and were made aware of their rights. Results: The study reported two themes which are leisure time physical activity during and post COVID-19 and leisure time physical activity support to advance participation. Results have shown that the participants had different perceptions of leisure time physical activity and they engaged in different leisure time physical activities of their own understanding. The challenges people with disabilities experienced were similar during and post the COVID-19 pandemic and they included a lack of facilities and financial support. Conclusion: The COVID-19 pandemic had a psychological and physical impact on the participants and more resources need to be made available to advance leisure time physical activity for people with disabilities.
Allocation of scarce healthcare resources under limited logistic and infrastructural facilities is a major issue in the modern society. We consider the problem of allocation of healthcare resources like vaccines to people or hospital beds to patients in an online manner. Our model takes into account the arrival of resources on a day-to-day basis, different categories of agents, the possible unavailability of agents on certain days, and the utility associated with each allotment as well as its variation over time.We propose a model where priorities for various categories are modelled in terms of utilities of agents. We give online and offline algorithms to compute an allocation that respects eligibility of agents into different categories, and incentivizes agents not to hide their eligibility for some category. The offline algorithm gives an optimal allocation while the online algorithm gives an approximation to the optimal allocation in terms of total utility. Our algorithms are efficient, and maintain fairness among different categories of agents. Our models have applications in other areas like refugee settlement and visa allocation. We evaluate the performance of our algorithms on real-life and synthetic datasets. The experimental results show that the online algorithm is fast and performs better than the given theoretical bound in terms of total utility. Moreover, the experimental results confirm that our utility-based model correctly captures the priorities of categories.
Background
COVID-19 remains a complex disease in terms of its trajectory and the diversity of outcomes rendering disease management and clinical resource allocation challenging. Varying symptomatology in older patients as well as limitation of clinical scoring systems have created the need for more objective and consistent methods to aid clinical decision making. In this regard, machine learning methods have been shown to enhance prognostication, while improving consistency. However, current machine learning approaches have been limited by lack of generalisation to diverse patient populations, between patients admitted at different waves and small sample sizes.
Objectives
We sought to investigate whether machine learning models, derived on routinely collected clinical data, can generalise well i) between European countries, ii) between European patients admitted at different COVID-19 waves, and iii) between geographically diverse patients, namely whether a model derived on the European patient cohort can be used to predict outcomes of patients admitted to Asian, African and American ICUs.
Methods
We compare Logistic Regression, Feed Forward Neural Network and XGBoost algorithms to analyse data from 3,933 older patients with a confirmed COVID-19 diagnosis in predicting three outcomes, namely: ICU mortality, 30-day mortality and patients at low risk of deterioration. The patients were admitted to ICUs located in 37 countries, between January 11, 2020, and April 27, 2021.
Results
The XGBoost model derived on the European cohort and externally validated in cohorts of Asian, African, and American patients, achieved AUC of 0.89 (95% CI 0.89–0.89) in predicting ICU mortality, AUC of 0.86 (95% CI 0.86–0.86) for 30-day mortality prediction and AUC of 0.86 (95% CI 0.86–0.86) in predicting low-risk patients. Similar AUC performance was achieved also when predicting outcomes between European countries and between pandemic waves, while the models showed high calibration quality. Furthermore, saliency analysis showed that FiO2 values of up to 40% do not appear to increase the predicted risk of ICU and 30-day mortality, while PaO2 values of 75 mmHg or lower are associated with a sharp increase in the predicted risk of ICU and 30-day mortality. Lastly, increase in SOFA scores also increase the predicted risk, but only up to a value of 8. Beyond these scores the predicted risk remains consistently high.
Conclusion
The models captured both the dynamic course of the disease as well as similarities and differences between the diverse patient cohorts, enabling prediction of disease severity, identification of low-risk patients and potentially supporting effective planning of essential clinical resources.
Trial registration number
NCT04321265.
In Ländern, die von der Corona-Pandemie besonders hart betroffen waren und in denen nicht genügend intensivmedizinische Ressourcen und Kapazitäten zur Verfügung standen, konnten Ärzte nur die Covid-19-Patienten mit guten Heilungschancen behandeln und mussten andere Patienten sterben lassen. Im Folgenden sollen die ethischen Grundlagen und Kriterien solcher Triage-Entscheidungen untersucht werden und verschiedene von medizinischen Fachverbänden herausgegebene Triage-Richtlinien verglichen werden. Es stellt sich insbesondere die Frage, ob es erlaubt ist, Leben gegen Leben abzuwägen.
The chapter begins by characterizing the COVID-19 disparities affecting BIPOC populations and summarizing research putting these disparities in historical context. It then presents a model explaining why these disparities arise. This background information grounds a discussion of why these disparities constitute inequities, and what justice requires in these circumstances. The analysis focuses primarily on obligations during pandemic but acknowledges that obligations do not end when pandemic does. It considers alternative conceptions of justice, focusing on questions about whether it is permissible to take race and ethnicity into account in pandemic response initiatives.KeywordsJusticeHealth equityRacial and ethnic health disparitiesPandemic ethicsFair processEqual opportunity
The SARS-CoV-2 (COVID-19) pandemic continues to expose underlying inequities in healthcare for black, indigenous and Latinx communities in the USA. The gaps in equitable care for communities of colour transcend the diagnosis, treatment and vaccinations related to COVID-19. We are experiencing a continued gap across racial and socioeconomic lines for those who suffer prolonged effects of COVID-19, also known as ‘Long COVID-19’. What we know about the treatment for Long COVID-19 so far is that it is complex, requires a multidisciplinary approach and there is still much research needed to fully understand the effects. In this paper, we discuss pragmatic considerations for including affected communities, relevant stakeholders, and leaders from communities of colour in the planning and implementation of Long COVID-19 research.
Shortages of life-saving medical resources caused by COVID-19 have prompted hospitals, healthcare systems, and governmentsto develop crisis standards of care, including 'triage protocols' to potentially ration medical supplies during the public health emergency. At the same time, the pandemic has highlighted and exacerbated racial, ethnic, and socioeconomic health disparities that together constitute a form of structural racism. These disparities pose a critical ethical challenge in developing fair triage systems that will maximize lives saved without perpetuating systemic inequities. Here we review alternatives to 'utilitarian' triage, including first-come first-served, egalitarian, and prioritarian systems of allocating scarce medical resources. We assess the comparative advantages and disadvantages of these allocation schemes. Ultimately, we argue that while triage protocols should not exacerbate disparities, they are not an adequate mechanism for redressing systemic health inequities. Entrenched health disparities must be addressed through broader social change.
Demands to address the health inequalities facing ethnic minorities date back at least two decades. Yet it has taken a global pandemic for those demands to be taken seriously. The question now is what can be done and how quickly?
Some ethicists assert that there is a consensus that maximising medical outcomes takes precedence as a principle of resource allocation in emergency triage of absolutely scarce resources. But the nature of the current severe acute respiratory syndrome-related coronavirus 2 pandemic and the history of debate about balancing equity and efficiency in resource allocation do not support this assertion. I distinguish a number of concerns with justice and balancing considerations that should play a role in critical care triage policy, focusing on discrimination and on fundamental egalitarian and social justice concerns.
A well-known objection to prioritarianism, famously levelled by Mike Otsuka and Alex Voorhoeve, is that it wrongly ignores the unity of the individual in treating intra-personal cases like inter-personal cases. In this paper we accept that there should be a moral shift between these cases, but argue that this is because autonomy is a relevant consideration in intra-personal but not inter-personal cases, and one to which pluralist prioritarians ought to attend. To avoid this response, Otsuka and Voorhoeve must (and do) assume we know nothing about the subjective information of the person being chosen for. But we show that this commits them to two controversial assumptions: that welfare consists in an objective list of goods, and – if one accepts an unorthodox but plausible account of the relationship between risk aversion and rationality – that there is only a narrow range of rational risk aversions. Only prioritarians who accept both these assumptions are on the hook of Otsuka and Voorhoeve’s objection; for all others, the examples have insufficient information, and so lose their sting.
People who are decisionally incapacitated but haven't provided advance directives and have no health care surrogates are often powerless and marginalized. Yet medical decision making for these patients often lacks minimally sufficient safeguards and protections. People who are decisionally incapacitated but haven't provided advance directives for their health care and have no health care surrogates sometimes called the unbefriended or unrepresented are some of the most powerless and marginalized members of society. Most of the unrepresented are elderly, homeless, mentally disabled, or socially alienated. Yet medical decision making for these vulnerable patients often lacks even minimally sufficient safeguards and protections. Consequently, health care decisions made on their behalf are at risk of being biased, arbitrary, corrupt, or careless. Most U.S. states have similar processes for making treatment decisions on behalf of patients without ...
Over the past fifteen years, a majority of states have enacted medical futility statutes that permit a health care provider to refuse a patient’s request for life-sustaining medical treatment. These statutes typically permit the provider to unilaterally stop LSMT where it would not provide “significant benefit” or would be contrary to “generally accepted health care standards.” But these safe harbors are vague and imprecise. Consequently, providers have been reluctant to utilize these medical futility statutes. This uncertainty probably cannot be reduced. Consensus on substantive measures of medical inappropriateness has proven unachievable. Only a purely process-based approach like that outlined in the Texas Advance Directives Act, has proven effective in inducing the conduct that medical futility statutes intended. Therefore, while the specific contours of TADA must be refined, policymakers in other states should look to the TADA as a model.
The COVID-19 pandemic has disproportionately affected racial and ethnic minority groups, with high rates of death in African American, Native American, and LatinX communities. While the mechanisms of these disparities are being investigated, they can be conceived as arising from biomedical factors as well as social determinants of health. Minority groups are disproportionately affected by chronic medical conditions and lower access to healthcare that may portend worse COVID-19 outcomes. Furthermore, minority communities are more likely to experience living and working conditions that predispose them to worse outcomes. Underpinning these disparities are long-standing structural and societal factors that the COVID-19 pandemic has exposed. Clinicians can partner with patients and communities to reduce the short-term impact of COVID-19 disparities while advocating for structural change.
Background:
During a catastrophe, health care providers may face difficult questions regarding who will receive limited life-saving resources. The ethical principles that should guide decision-making have been considered by expert panels but have not been well explored with the public or front line clinicians. The objective of this study was to characterize the public's values regarding how scarce mechanical ventilators should be allocated during an influenza pandemic, with the ultimate goal of informing a statewide scare resource allocation framework.
Methods:
Adopting Deliberative Democracy practices, we conducted 15 half-day community engagement forums with the general public and health-related professionals. Small group discussions of 6 potential guiding ethical principles were led by trained facilitators. The forums consisted exclusively of either members of the general public or health-related or disaster professionals and were convened in a variety of meeting places across the State of Maryland. Primary data sources were pre- and post- deliberation surveys and notes of small group deliberations compiled by trained note takers.
Results:
324 individuals participated in 15 forums. Participants indicated a preference for prioritizing short and long-term survival, but they indicated that these should not be the only factors driving decision-making during a crisis. Qualitative analysis identified 10 major themes that emerged. Many, but not all, themes were consistent with previously issued recommendations. The most important difference related to withholding versus withdrawing ventilator support.
Conclusions:
The values expressed by the public and front-line clinicians sometimes diverge from expert guidance in important ways. Awareness of these differences should inform policy-making.
This article seeks to defend prioritarianism against a pair of challenges from Michael Otsuka and Alex Voorhoeve. Otsuka and Voorhoeve first argue that prioritarianism makes implausible recommendations in one-person cases under conditions of risk, as it fails to allow that it is reasonable to act to maximize expected utility, rather than expected weighted benefits, in such cases. I show that, in response, prioritarians can either reject Otsuka and Voorhoeve's claim, by means of appealing to a distinction between personal and impersonal value, or alternatively they can harmlessly accommodate it, by means of appealing to the status of prioritarianism as a view about the moral value of outcomes, rather than as an account of all-things-considered reasonable action. Otsuka and Voorhoeve secondly claim that prioritarianism fails to explain a divergence in our considered moral judgement between one-person and many-person cases. I show that the prioritarian has two alternative, and independently plausible, lines of response to this charge, one more concessive and the other more unyielding. Hence, neither of Otsuka and Voorhoeve's challenges need seriously trouble the prioritarian.
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