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There's no vaccine for chaos

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Across the nation, at private hospitals and community centers and pharmacies, Americans are being vaccinated against COVID-19 at a rate of more than a million a day. Unfortunately, the ongoing chaotic rollout — governed by a patchwork of state regulations at once arbitrary and political — might also be inoculating the population against public health laws.

The logistics of vaccinating more than 300 million people are challenging, and nobody expects the implementation of any plan to be perfect. Yet it is hard to imagine an approach more Kafkaesque than the current one. Individual states set their own rules, so New Jersey vaccinates smokers, and New York vaccinates restaurant workers, and the District of Columbia will vaccinate anyone with a body mass index above 25 — in a nation where the average body mass index is roughly 29. The system favors individuals — often well-off and white — who can sit in front of their computers for hours, logging into scheduling portals repeatedly, and those who have the means to drive long distances for appointments. Multiple instances have been reported of hospital donors and their relatives receiving preferential access.

Because the system is perceived to be arbitrary, and to favor those with power, it encourages others to game the rules or lie outright. When scarce doses were earmarked for ICU physicians and nursing home patients, a case could be made for waiting one’s turn. But after healthy young members of Congress were vaccinated on the pretext of ensuring "continuity of government," and affluent Argentines began jetting into Florida for jabs, and the Department of Defense proposed vaccinating al-Qaida prisoners at Guantanamo Bay while teachers and group home residents went without, the average person could be forgiven for buying a pack of Marlboros and borrowing a friend’s address in Trenton.

If the last year has taught us anything about public health, it is that policies designed to protect us from disease are not applied consistently or enforced equitably. We watched the authorities stand down as Hasidic Jews gathered for funerals and Black Lives Matters protesters marched against racism and motorcyclists swarmed South Dakota. I do not mean to suggest that some endeavors might not justify exceptions: thousand-year-old mourning rituals and opposition to systemic racism are not comparable to tailgate parties. But to many Americans they appear analogous, a license to create one’s own rules.

Often the law is hardly enforced. Everyone knows that only a fraction of those who violate state quarantine rules are punished.

All of this matters because the odds are that there will be another public health emergency. Maybe a disease even more deadly than COVID-19. The American people cannot afford to confront that next crisis with the mindset that the system is rigged.

It is not too late to change course, to start from scratch. What is needed is an amnesty for everyone who has previously violated COVID-19 rules, followed by the rollout of a uniform national system for testing, tracing, reopening, quarantining and vaccinating. Fewer, clearer rules, but ones that are meaningfully and stringently enforced. People should be vaccinated early because they stand at greater risk of dying — not because they are savvy, or relentless, or connected. We need to get this right, not just for now, but for the next pandemic. This may be our last shot.

Jacob M. Appel, MD., is director of ethics education in psychiatry at the Icahn School of Medicine at Mount Sinai. He is the author of "Who Says You’re Dead?," a collection of ethical conundrums.

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