Vaccination efforts require balance between fairness and efficiency

The Yomiuri Shimbun

10:45 JST, June 4, 2021

This is the fifth installment of the series, “The Politics Behind Vaccination Program,” examining behind-the-scenes political moves concerning COVID-19 vaccines.

About 70 people, including the heads of administrative districts in Soma, Fukushima Prefecture, a city known for its traditional Soma Nomaoi festival, gathered in the main hall of a civic center in the coastal Hamadori area on Feb. 5.

All eyes were glued to a wooden box on the stage. It was a lottery device with sticks numbered from 1 to 10 inside.

Ten people in charge of administrative districts reached into the box one by one and drew lots, as if divining their fortunes. District chiefs and others, who sat at a distance wearing masks, watched the proceedings with sober faces.

Then a voice announcing the lottery results echoed in the quiet hall: “No. 1, Nakamura Tobu District. No. 2, Tamano District …”

With the lottery, they decided the order of mass vaccinations of elderly residents against the novel coronavirus, which were to be held on a date, time and place designated by the city. The lottery system was proposed by Soma Mayor Hidekiyo Tachiya and was endorsed by the district leaders’ association.

Since starting on May 1, the mass inoculation of the elderly has been going smoothly in the city of about 34,000. More than 90% of the 10,000 people who applied for the vaccination have already completed the first rounds of inoculation. Vaccinations for the non-elderly general public started Tuesday.

All city residents will be vaccinated in groups by administrative districts according to the lottery results. The lottery method has been favorably received by Soma residents as “efficient and fair.”

There was a great deal of confusion over vaccination reservations across the country. Phone lines were flooded with calls and the computer system for online bookings went down, apparently because many local governments sent out vaccination tickets to all residents at the same time.

Administrative and regulatory reform minister Taro Kono, who is also in charge of the vaccination program, apologized for the confusion.

“It was my fault. I didn’t realize that local governments were more concerned about fairness than I thought,” Kono said, defending the local governments.

Prof. Morimitsu Kurino of Keio University, who specializes in microeconomics, described the confusion as “typical of cases that occur in a first-come, first-served system.” Kurino said it is better to use a lottery system or a quota method in which administrative and other parties designate a date and time for relevant events to avoid confusion.

But many local government chiefs opted for a first-come, first-served system. A senior official of the Internal Affairs and Communications Ministry said, “The mayors, elected by voters, may have done so out of fear of receiving criticism from residents for being unfair.”

The question of who should be the given the vaccinations first is rooted in questions of what “fairness” means.

On May 13, Sogo Yamana, mayor of Kamikawa, Hyogo Prefecture, apologized over disaster-prevention community radio for having received the vaccination himself on the first day of mass vaccinations even though he was not eligible under current national regulations, which specifically allocate the inoculations to those 65 or older and medical workers first. Yamana, 62, had been criticized by locals for the inoculation. “Let me apologize for having betrayed everyone’s trust,” he said.

There have been a series of cases across the country in which local government chiefs were criticized for receiving inoculations on the grounds that they are in charge of crisis management or that they are equivalent to medical workers. Their lack of explanation on the matter beforehand further invited the public’s mistrust.

The central government has clarified that in principle the vaccinations should be given first to medical workers, and then to people aged 65 and older, followed by those with underlying medical conditions. As examples of underlying health conditions, the government cited heart and kidney disease among others.

Still, the rule contains many unclear points. A government source said: “Things actually rely on self-evaluation. Medical certificates are not required to receive a shot.”

Some countries designate essential workers as people to whom vaccinations should be given preferentially. Yusuke Inoue, associate professor of bioethics and medical ethics at the University of Tokyo, said there should be more discussion in Japan about who should be given priority for vaccinations.

At present, local governments decide who should be given priority for vaccinations within the framework set up by the national government. Fukuoka City has given priority to nursing home workers, childcare workers, teachers and staff at schools and others who have a lot of contact with the elderly and children. The Tokyo metropolitan government has also indicated that police officers and firefighters will be given priority to receive vaccinations.

There are also voices calling for shelving the issue of fairness for the time being and focusing on the prevention of infection.

In late April, Shumpei Takemori, a senior researcher at the Research Institute of Economy, Trade and Industry, said at a meeting of the government’s Council on Economic and Fiscal Policy that vaccines should be given to medical workers first in areas like Osaka where the spread of the infection is severe. The association of mayors of 20 ordinance-designated cities, chaired by Yokohama Mayor Fumiko Hayashi, has also called for a “strategic supply” of vaccines to urban areas where “population and the flow of people are concentrated.”

But local governments are opposed to such ideas. Tottori Gov. Shinji Hirai compared the matter to Ryunosuke Akutagawa’s novel “Kumo no Ito” (The Spider’s Thread), saying “The vaccine is the thread of a spider. We won’t be able to escape the quagmire if we don’t go forward, sharing the vaccine with everyone.”

In “Kumo no Ito,” the Buddha takes the silvery thread of a spider in paradise and lowers it down into hell for a sinner struggling in a pool of blood. The sinner begins to climb the thread. But as soon as he notices that others have started climbing up the thread after him, he shouts that the thread is just for himself. Thereupon, the thread breaks, causing him and the other sinners fall back into the pond.

“Is the weight of life different between big cities and rural areas?” Hirai asked.

It must be the role of politics to decide who should be given priority for vaccination based on a balance of local circumstances, fairness and efficiency, and to provide residents with sufficient explanations.