COVID vaccine

The state’s vaccine distribution plan allots residents to one of six phases: teachers are in phase 2a, adults 75 and older are in phase 1b, those moderately medically vulnerable to the virus are in phase 3a, and so on.

While age and profession can be sorted into categories, medical vulnerabilities are not so easily classified. In an attempt to operationalize “medical vulnerability,” the state lists 12 medical conditions on its website, including obesity, pregnancy and cancer. If you have one of the listed conditions, you’re in phase 3a. Two conditions? Phase 1b.

Medicine, the state says, is much more complicated than that.

To account for the seemingly infinite combination of conditions that could make someone vulnerable to COVID-19, the state is giving doctors latitude to move people between phases.

“Every patient has a different medical history,” Gov. Chris Sununu said at Tuesday’s press conference. “You could have folks not just with asthma but severe asthma. You could have stage II cancer, stage IV cancer. You can have a lot of different factors in there.”

What this exception process might look like in practice is still fuzzy.

Asked about how the state would ensure doctors are consistent in their exceptions, Sununu said the state hasn’t come up with a way to standardize the program, nor do they necessarily plan to. He said decision-making will be left to the “best and the brightest,” which he expects to lead to some inconsistency.

“There is a lot of gray area, frankly,” he said. “Physicians can make determinations based on what they see with their patient’s history.”

Michael McLeod, the Associate Chief Clinical Officer at Concord Hospital, said few details have been provided to hospitals about the logistics of this program. How vaccines will be allocated to those given an exception, whether the state will oversee the process, or how many exceptions doctors are allowed to grant, is still unknown.

He said the hospital will likely try to implement a system of checks and balances to standardize the process to the best of their ability, but overseeing decisions that involve weighing a variety of complex medical conditions will be extremely difficult.

“The textbooks are really helpful to provide you with general guidance but part of the reason they call it the art of medicine is because nobody ever has one condition,” he said.

As the next stage of vaccinations nears, the hospital will have to iron out the details, hopefully with more guidance from the N.H Department of Health, McLeod said. Whatever the process for exceptions ends up being, McLeod said he doubts patients will have to call their doctors to plead their case. He said the hospital will likely use their database of medical records to determine who meets the state’s definition of phase 1b. From there, physicians will be able to advocate for patients who don’t necessarily fit the exact requirements of phase 1b.

Stephanie Patrick, executive director of the Disability Rights Center of New Hampshire, said this flexibility is essential to ensure vaccines are going to the most vulnerable Granite Staters, even if they don’t fit neatly into one of the state’s phases.

Researchers may not have studied the effect of COVID-19 on individuals with rare disabilities, but that doesn’t mean they’re not vulnerable to the virus, she said. Giving room for doctors to use their own discretion gives much-needed nuance to the distribution process, she said.

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