Which Coloradans should receive the coronavirus vaccine first? The answer depends on who you ask.

Here’s a simple question for a pandemic where nothing is ever as simple as it seems: When should college students living in dorms get the coronavirus vaccine?

In one way of looking at this question, college-age people are among the least likely Coloradans to die from COVID-19 or to need hospitalization, making them among the state’s least vulnerable. Back of the line, then.

In another way of looking at the question, people who live in dorms have no way to socially distance, making them among the state’s most vulnerable for both catching and spreading the virus. So step right up.

But, one might argue, at least some college students have been notorious social distancing scofflaws during the pandemic. Why should people who flouted public health guidance get vaccinated ahead of those who have been dutifully sequestered in their homes for 9 months?

Except, another might counter, outbreaks among college students have led to case spikes across entire communities. Why shouldn’t the vaccine be used to stop the biggest contributors to viral spread, moralizing be damned?

After months of quiet debate in Zoom meetings for committees with cumbersome acronyms, these questions have now taken on a very public urgency. The first doses of vaccine for Colorado are about to hit the mail. And the state this week is expected to release an updated plan for who will receive those first doses — right as Gov. Jared Polis signals that he disagrees with a key line of thinking in the original plan.

So, big-picture, should those precious few early doses be used to maximize benefit for the entire community? Or should they provide individual protection for those most at risk of dying from COVID-19?

There’s no one right answer, of course, but the debate reflects a consistent truth: The public health professionals who are informing the state’s response often view the pandemic differently than the state’s political leaders and much of the general public.

While the health experts think in society-wide terms, politicians and the public often focus on the individual. Epidemiologists present modeling data and talk about transmission control and viral reproductive values. And Polis talks about visiting family over Thanksgiving being like “bringing a loaded pistol for grandma’s head.”

In this context, it’s little surprise that the debate over the vaccine has split along similar lines.

“We created this monster to some extent,” said Dr. Matthew Wynia, the director of the Center for Bioethics and Humanities at the University of Colorado Anschutz Medical Campus.

He is firmly in the public health camp. But he said some of the ethical discussions surrounding vaccine allocation priorities focused on reciprocity.

“People who have to take extra risk to continue doing their job, they deserve extra consideration,” Wynia said, summing up the argument.

That shifts the conversation toward who is most deserving of getting the vaccine first, not where the vaccine can best accomplish public health goals. 

“There is value in reciprocity,” Wynia said. “But the primary goal of a vaccine allocation strategy is not payback for people who deserve consideration. It’s to stop transmission of the virus.”

Harmony, then controversy

As with the draft plan the state put forth in October, the final plan for allocating the vaccine is expected to have three phases.

Phase 1 will likely see health care workers, first responders and people living in nursing homes vaccinated first. It is not at all controversial — in part because it achieves a harmony between the differing viewpoints on the vaccine.

Health care workers, who have been risking their lives fighting the virus since spring, are individually deserving of receiving the vaccine first and also provide significant benefit to the rest of society if they are vaccinated first. Nursing home residents are both most in need of individual protection from the virus and also potential contributors to large outbreaks if they are not vaccinated.

It’s the second phase where things get messy.

The draft plan the state put forth in October splits the second phase into two subphases. Phase 2A includes essential workers whose jobs require frequent contact with the general public and also includes people living in congregate housing situations — dorms, work camps, correctional facilities, etc. The later Phase 2B includes higher-risk individuals — adults over 65 and people with underlying medical conditions like diabetes, obesity or severe heart or lung disease.

So there was the state’s initial answer to the question, as determined by groups of doctors and career public health experts who drew up the plan: College students living in dorms should be near the front of the line, along with people who are incarcerated and people experiencing homelessness who live in shelters.

At the time, it didn’t seem all that controversial, either.

“As objective as the data would allow”

The state’s plan largely follows the path plowed by a committee for The National Academies of Science, Engineering and Medicine.

That committee, which released its final report in early October, developed its allocation priorities by scoring various groups based on four criteria: The risk of catching the virus, the risk of spreading the virus, the risk of death or severe illness, and the risk that their getting sick will have an overall negative impact on society.

Dr. Ned Calonge, the president and CEO of The Colorado Trust, helped review the committee’s report prior to publication. He said the committee prized fairness and transparency in its process, so the scoring was “as objective as the data would allow.”

Health care workers and first responders ticked three of the boxes at the high-risk level. (The committee decided that those workers were at only a medium risk of death or severe illness.)

Older but otherwise healthy adults over age 65 scored as high-risk in only one category, the risk of death and severe illness. But incarcerated individuals were deemed high-risk in two categories — the risk of catching the virus and of transmitting it.

Ultimately, the committee recommended that older adults and incarcerated individuals be in the same phase, Phase 2. (The NASEM report does not split Phase 2 into subphases.) 

College students living in dorms were placed in Phase 3, though the report did acknowledge that “infections in college-aged adults can threaten the health of faculty and other university staff, many of whom are older or have underlying illnesses that put them at risk of severe COVID-19.”

To many public health experts in Colorado, prioritizing the vaccine to quash outbreaks seemed like a no-brainer — and the draft report mentions that it may be changed on the fly to target emerging hotspots.

As of last week, 14 of the state’s 15 largest COVID-19 outbreaks have been in correctional facilities or on university campuses. Combined, those two settings are responsible for more than 10,000 cases, according to data from the Colorado Department of Public Health and Environment. At least 11 inmates in Colorado prisons have died from COVID-19.

(Outbreaks at nursing homes and other skilled nursing facilities have contributed more than 8,600 cases to the state’s totals but have also, by far, been responsible for the most deaths — more than 930, according to the state’s data.)

When students returned to the University of Colorado at Boulder campus in late summer, it spurred an outbreak that spread cases across the county. Informed by that experience, Boulder County Public Health spokesperson Chana Goussetis voiced some support for placing college students in a higher-priority tier.

“Preventing spread in groups susceptible to widespread transmission and large outbreaks is beneficial to the community for containing the pandemic, particularly when the group is likely to gather and be asymptomatic,” she wrote in an email to The Sun.

Wynia, the CU bioethicist, said this can be thought of as a “harm reduction” approach. While many college students will likely act responsibly, he said, some won’t. And you’re not going to stop that from happening.

There is a similar truth for inmates in a prison. They simply can’t make the choice to socially distance. So outbreaks that can spread outside the prison’s walls are likely to happen without intervention.

“You get the biggest bang for your buck by targeting people who spread the disease once they catch it,” Wynia said. “If you can prevent one superspreader, you’re going to get a lot more than if you give the vaccine to one person who is mostly able to shelter at home.”

Calonge put it more directly: “If you eliminate the congregate settings, you interrupt transmission.”

Focus on medical vulnerability

But, as the vaccine’s arrival has neared, there are new doubts about whether the state will place as great of an emphasis on this approach.

In interviews, Polis has repeatedly suggested that he does not think healthy, younger people should be given priority just because they live in congregate housing situations. His comments first came in response to questions about people who are incarcerated, saying that, “There’s no way it’s going to go to prisoners before it goes to people who haven’t committed any crime.”

He has since walked those comments back, saying that he will not discriminate against inmates. But, in an interview Friday on Colorado Public Radio’s “Colorado Matters,” Polis again suggested that he believes vaccinating people at individual risk of severe infection is more important than vaccinating people who live in outbreak-prone settings.

Polis told host Ryan Warner that vulnerable inmates should be vaccinated at the same time similarly vulnerable Coloradans are. But he sidestepped a question about whether all inmates should be considered vulnerable because of the circumstances in which they live. Instead, he talked in terms of medical vulnerability.

Mentioning his own 76-year-old parents, whom he said have hardly left their house in the last 9 months, Polis said: “If we’re focused on not overwhelming our hospitals, we really need to focus on who would most likely not only need to be hospitalized but frankly who could also be at greater risk of death from this virus.”

In this sense, his comments have begun to tack toward those of his fiercest critic on the subject — 18th Judicial District Attorney George Brauchler, a Republican who once ran for governor, writes a regular opinion column for The Denver Post and hosts a radio show on the conservative station 710 KNUS.

In a column late last month, Brauchler wrote that Polis and state health officials “intend to prioritize the health of incarcerated murderers, rapists, and child molesters over the lives of law-abiding Coloradans 65 years and older and immunocompromised adults.”

“Almost there” — but how?

Polis and Brauchler are not alone in wanting to focus more on protecting the lives of the most medically vulnerable, even if it means perhaps letting the virus continue to run in other outbreak-prone places.

A World Health Organization committee last month released a “roadmap” suggesting that older adults should be among the first vaccinated.

Last week, a federal Centers for Disease Control and Prevention committee made its first recommendations on prioritization for a coronavirus vaccine. Health care workers and nursing home residents were at the top, in a mostly noncontroversial decision.

But a bigger debate looms over the committee’s next votes, when it will have to grapple with the same decision that Colorado is facing. Who goes first in Phase 2? There is an increasing push among some federal officials to see the community-wide public health focus replaced with a more specific focus on those most likely to die if they get infected.

The state still has some time to figure this out. Colorado’s first shipment of coronavirus vaccine will only include about 46,000 doses, and there are more than 300,000 people estimated to be eligible for vaccination in the state’s Phase 1. It could be a couple months before there is enough vaccine available to begin Phase 2. That leaves an awful lot of time for debate on a question that is literally about life and death.

“There is hope,” Polis said in a briefing last week, urging Coloradans to hang in there a little longer. “We are very close.

“We’re almost there,” he said. “We’re almost there.”

But what it will look like to get there remains unclear.