Ruth Faden, an expert in biomedical ethics with Johns Hopkins University, has helped vaccine drives answer some tough questions: Who should be ahead of whom? Do we prioritize speed or equity? And once people are inoculated, should they get “vaccine passports” allowing freer movement?

She joins James Hamblin and guest host Maeve Higgins on the podcast Social Distance to assess how we’ve done so far—and what we could expect next.

Listen to their conversation here:

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What follows is a transcript of the episode, edited and condensed for clarity:

Maeve Higgins: How do you think vaccinations are going so far?

Ruth Faden: Globally, or within particular countries?

James Hamblin: Let’s start with the U.S.

Faden: Because, globally, it’s a disaster. Within the United States, it’s not so great, but it’s way better than it is globally. Right now, we are really in a bad situation. We’ve hit the horrible 400,000 death mark. And while there is some indication that the death rate and the hospitalization rate may be flattening, it’s still not clear. And if it does plateau, it’s going to plateau at a really bad place, which is the place we’re in now.

We only have about 12.5 million doses administered to people. That’s not full courses, that’s doses, because we’re still dealing with the two-dose vaccine. And that’s nowhere near the pace we need to be able to get our arms around this terrible loss of life. We need to really pick up the pace in this country.

Hamblin: In the months leading up to the actual rollout of the vaccine, there was a lot of discussion of how we created hierarchies and lists of who would get it when. How has that short supply—or less-than-expected supply—changed or put an emphasis on those difficult decisions about who should be vaccinated first?

Faden: In the summer and into the fall, an awful lot of effort was put into coming up with prioritization frameworks, with a lot of attention to the ethics justifications for which groups should go where: first phase, second phase … first half of the first phase, second half of the first phase … and so on. And, to some extent, that planning had to occur when it did, in the absence of specifics about either the particular characteristics of the vaccines, like how effective they would be or whether they would work for everybody. We didn’t know when we were doing that planning what the epidemiological context would be, that is: exactly how bad or better the pandemic would be when vaccines started to become available. And we didn’t know the pace of the supply.

A lot of that planning was done with reasonable assumptions about those three things, but knowing that the particulars would necessarily have an impact on what could be done. And I’ve been part of those efforts, so I will include myself when I raise this criticism: There was insufficient attention to matching the carefully thought-through prioritization road maps with the realities of mass vaccination programs.

Hamblin: How so?

Faden: Well, as we are learning in the U.S., it is hard to mount a massive vaccination program in a context of constrained supply with complicated criteria for who should go when. If we look to a country where things have gone well, Israel—which is totally the opposite of the U.S.: tiny population, tiny geography, and a really coordinated health-care system, so, like, nothing like the U.S. They began and continued with a very simple prioritization scheme that was age-descending. That’s a lot easier to get your hands around logistically, or so it’s argued, than the way in which we’ve sort of marched our way through in the United States.

Higgins: I wonder if there’s another example. Israel is tricky because they’re not vaccinating Palestinians, so I don’t know about them as holding them up as a great example.

Faden: Well, I think maybe you want to distinguish between two different things. They are a great example of an effective public-health program. I’m not saying whether it’s an equitable public-health program. It’s efficient. They’re doing an incredible job of getting a lot of people vaccinated in a short context.

Higgins: That’s a good distinction.

Faden: That is very different from saying whether the Israeli government has a moral obligation to Palestinians, who are not living in the territory of Israel but over which Israel has control. That is a whole separate conversation. They are linked, but you want to be careful.

Generally, there’s the question of what we sometimes call “humanitarian situations of special concern.” There are lots of places in the world where people are living where the countries that have some jurisdiction, military or political, over them, are not viewing them as citizens or residents of the country for purposes of vaccine distribution.

That’s a huge, horrible, terrible ethical morass. It’s awful. But what is going on in Israel is an example of what can be done with a really high degree of attention to detail. Within the system in which they’re operating, for people who are legal residents of Israel, whether they’re Arab or Jewish or Christian, the system is quite fair. You just have to show that you are the age at the time that that age cutoff is called up. And they also manage to largely solve the “What do we do with the doses at the end of the day?” problem.

Hamblin: We were wondering about that.

Higgins: Yeah, there was a situation in Ireland, where I am at the moment, where a doctor gave out 16 extra doses to his family because he was worried they wouldn’t get used. But then members of the public found out and were very upset, understandably. But I can see it from both sides.

Faden: So, look, this is a practical problem that needs to be dealt with pragmatically, but also with some attention to concerns of ethics and equity. The worst thing is to throw away a single dose of this precious vaccine. That’s ethically unacceptable. And from a public-health point of view, it’s just dumb. So if you haven’t planned for it and you’re at the end of the day and you’re close to the end of the window where the vaccine must be administered or tossed, I don’t have any trouble with grabbing any arm you can get from anybody who wants to be vaccinated.

But stepping back, it’s possible to anticipate that you could be in that circumstance and plan for it. Even if you schedule appointments and have a very efficient system, there are going to be no-shows and there could be extra vaccine, just based on how it’s drawn out of the vial. So whether you use social media to alert people, kind of like vaccine flash mobs: It looks like we’re going to have X doses if you can show up by Y o’clock. There’s a queue.

I live in Washington, D.C., and there are a couple of pharmacies that are reputed to let people know that they’re going to stop vaccinating at 8 p.m. and people can start queuing whenever they want in case there’s any vaccine left. It’s first come, first serve. And there have been reports of people lining up at, like, 3 in the afternoon for the possibility of a vaccine-access availability at 8.

And a lot of the people who really need the vaccine right now are not positioned to be able to figure out how to check every two seconds on a website or wait forever for a phone call or navigate the system in a language they don’t know. We have a lot of equity challenges buried in the details. And then we have the equity challenges that come from the justified distrust of communities of color and poor people with respect to institutions generally and public-health programs in particular.

Hamblin: We had a question from a listener asking about if and how it’s being kept track of who’s been vaccinated and who has not. Is there any discussion about the ethics of having a registry of who has and hasn’t been vaccinated?

Faden: It’s a great question. There are two pieces to this. One: Absolutely, as a public-health matter, we have to keep track. That’s nonnegotiable. Now, the question is: What other data do you collect? Age, ethnicity, location? There’s that issue. And then there’s this issue of: Should any perks result from the fact that you’ve been fully vaccinated? And that’s the conversation about “vaccination passports” or “vaccination passes” of some kind.

Hamblin: Like that you might not have to wear a mask if you’ve been vaccinated? Or something like that that could actually incentivize people to get the vaccine?

Faden: Or maybe you have to wear a mask, but if you have been exposed and ordinarily you would be a contact and have to quarantine for two weeks, you would get a quarantine pass, for example. I don’t think anybody is going to say you don’t have to wear a mask. We don’t know enough about that yet.

Hamblin: Yeah, we don’t know yet, but just in terms of the idea of what kind of things it might eventually be …

Faden: Yeah, it could be something like that. And that’s a kind of calculated gamble too. No one is proposing that in the U.S.

Higgins: If you could prove you were vaccinated, could you travel to another country, for instance?

Faden: From a global point of view, it’s a complete structural-injustice mess. Because if we’re going to start privileging people—which makes a lot of sense, depending on what we learn about onward transmission and these vaccines, which we don’t know enough about yet … If we start basically saying that if you’ve been fully vaccinated, then you can start traveling globally. And we have a context in which a very tiny percentage of the world’s population outside of high-income countries gets access to the vaccine, who’s going to be able to travel globally?

It’s an awful picture. The director-general of the WHO gave an address [recently], and he made a stunning point. There were 39 million doses of vaccine administered in 49 high-income countries as of [a few] days ago. Can you guess how many doses have been administered so far in a lowest-income country?

Twenty-five total. Against 39 million. So I don’t think people have begun to get their heads around how wide the disparity is and how urgent it is to try to do something about this. We’re concerned about what to do because this doctor gave it to his family. I mean, there are definitely ethical issues there, and I don’t mean to dismiss them, but we have to put that in perspective as well.