COVID-19’s Honor System

It is four o’clock in the morning and we are online looking at all the possible vaccine appointments available in our county.

We try the hospital we normally go to, and then we try another hospital.

We move on to the pharmacy chains. We try one after another. We try pharmacies in our zip code, we try other zip codes, we try other states.

We keep going until we hit refresh so many times the website browser itself tells us to stop. Dropping a perfectly timed delay on the computer screen, arriving just in time to aggravate our growing frustrations into outright angst and concerns.

“What if we miss the vaccine?”

“Should we just say we are healthcare workers?”

“Should we just pretend we are essential workers?”

The thoughts begin. With the growing angst and concerns come the tendencies to bend the rules a bit, to interpret the questions just a bit more leniently.

As we are starting to realize, we all have this particular tendency to think about healthcare along familiar patterns of thought.

In the internal surveys conducted over the months of December 2020 and January 2021, we found two interesting trends.

Those who responded in January responded more frequently that the vaccine appears safe compared to those who responded in December. A shift likely coming from the early data showing few reactions among those who received the vaccine, and even fewer allergic complications like anaphylaxis from taking the vaccine.

But perhaps more relevant, when asked about the willingness to take the vaccine, the responses indicated that people are swayed more by their peers than by the published data.

As a greater percent of people became more confident in getting the vaccine based on whether their peers already got it.

Revealing a fascinating trend towards consumerism in healthcare. In which we compare our health and access to health relative to our peers. And make comparisons regarding to our health as we would a car or house purchase.

Explaining why the failures of the COVID-19 vaccination program have given rise to a sense of class warfare among different populations – segregating society into those who can get the vaccine and those who are not able to get the vaccine.

Experts have spent months developing a complex prioritization system and debating the medical ethics of choosing one population group over another.

But the actual process will rely heavily on the tried-and-true honor system.

Now that the first round of COVID vaccines have already been administered, state and local officials likely will not be able to ensure that the rest of the process will put high-risk people first. The infrastructure to enforce prioritization simply does not exist.

Reducing what has been touted as a complex prioritization schedule into nothing more than a house of cards. Held together by our basic sense of honest and trust worthiness.

But when we see others getting the vaccine, those who we believe may be less at risk than us, these basic sensibilities quickly become liabilities that we readily discard every time we go online to see if a new vaccine appointment has become available.

It is easy to ensure that the highest-priority groups, like health care workers and nursing-home residents, receive the first vaccine doses. Large, integrated healthcare delivery systems like hospitals and long-term care facilities can go through the staff and resident rosters to identify out who should be offered a vaccine.

After that, prioritization becomes more murky, and more subjective. Different experts have said the next round of doses should focus on either people who are most at risk to catch or spread the virus, or those most at risk for COVID-19 related complications. Which would include either essential service workers or people with underlying health conditions.

Regardless of who we prioritize, we do not have any structure or single database to verify who is who.

“It’s going to be harder and harder to ensure you adhere strictly to these priority groups. I’m sure there will be a point where we see line-jumping”, said Josh Michaud, associate director of global health policy at the Kaiser Family Foundation.

Something we are not giving enough importance to, at our own peril. Given the vaccine skepticism in the U.S., some experts have stated publicly that they would be thrilled if line-skipping ends up being the biggest problem.

We could not disagree more.

Line-skipping is not the innocuous, white lie many policy experts presume it to be. In fact, it will be the last thing many people remember about this pandemic.

We remember events by the lasts experiences of that event. If something ends well, no matter how terrible, we perceive it to be less terrible. And if something ends poorly, no matter how good, we perceive it to be worse than it was.

This is human nature, as any behavioral economist will tell you. Last impressions matter as much as first impressions.

If the last impression people get of the pandemic is line-skipping, and hook-or-crook, by-any-means-necessary healthcare policy-making, then the long term impression of the pandemic will be worse than if people felt confident that the vaccine prioritization was administered in a fair and equitable manner.

The pandemic has already made manifestly apparent the healthcare inequities that exist in this country. We know Hispanics and African Americans have been affected more by the pandemic than other ethnic group. Hispanics and African Americans have responded by increasing the number of applications to medical schools.

They are responding to a perceived inequity by addressing that inequity.

If people feel that the vaccine distribution model represents an unfair, unjust model – people will respond accordingly.

Some may respond by detaching themselves even further from the healthcare system. After enduring the government abuses rampant during the opioid epidemic, and the rising costs of healthcare, many became disillusioned with healthcare.

That disillusionment can quickly become overt disdain if the lasting impression of COVID-19 is the poorly administered vaccine distribution program.

Some may respond by putting healthcare inequity square into the public forum alongside issues of race inequality. A tactic that has done much to raise awareness of the social injustices continuing against African Americans. We have seen physicians and nurses protesting for healthcare injustices, but no consistent movement has been developed or sustained over a period of time.

Which may change as we start to learn more about the socioeconomic disparities perpetuated by healthcare disparities that appeared in the pandemic. We may soon realize that there can be no civil justice without healthcare justice.

No matter what the response will come to be, we know there will be a response to the COVID-19 pandemic. And the most influential factor in that response will be the last impression, which will dictate the overall impression of the pandemic.

Let us try to make it is a good one.

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