There’s been lively discussion about whether people will be willing to take a vaccine for COVID-19 when it becomes available. It’s a question each of us will have to answer for ourselves sooner or later. But the debate obscures a more complex reality: when an effective and safe vaccine finally arrives, it will initially be in scarce supply. No country or business has the manufacturing capacity to quickly provide enough doses for an entire population.
The big question we should be considering, therefore, is who should get vaccinated first, and who should be next in line thereafter? Do certain groups within the population deserve priority over others? And if so, what considerations should influence these decisions?
This is not the first time we’ve been faced with this type of “allocation problem.” Typically, vaccine allocation decisions are made with a view toward maximizing the overall health benefit: to achieve the greatest good for the most people, such as the total number of lives saved. For reasons of epidemiology, that doesn’t always mean that people most vulnerable to a disease are the first ones to receive a vaccine. The worst-off groups are prioritized only insofar as it aligns with maximizing the benefits of the vaccine.
But COVID-19 is an exceptional disease — not just because of the rapidity and extent of its spread, but because of the way it has highlighted and heightened the inequities that exist in the United States. It has a disproportionate impact on communities who are disadvantaged by their race and ethnicity, by underlying comorbidities and lack of access to good health care, by their living conditions, or even by the kind of work they do. In the United States, rates of COVID-19 infection among Black, Latinx, and Native American people are more than two-and-a-half times as high as among white people — while hospitalization rates are approaching five times as high, and Black people are dying at twice the rate of white people. Historically, it’s precisely non-white populations that have lower coverage of vaccination for common diseases.
This is why we developed the COVID Community Vulnerability Index (CCVI) — to identify the communities impacted most negatively by the virus, so we can plan and respond accordingly. It builds on the CDC’s Social Vulnerability Index (SVI) to take into account additional vulnerability factors that come into play with a pandemic disease like COVID-19 — from minority populations and foreign languages spoken, to the amount of household crowding or limited transportation access in a community.
It’s therefore exciting to see that the National Academies of Sciences, Engineering, and Medicine (NASEM) has just launched a set of vaccine allocation recommendations for the United States that make an important departure from the traditional vaccine allocation framework. NASEM aims to achieve not only impact, but also social justice, by taking into account that ethnic minority groups are worse affected by COVID-19.
NASEM proposes a vaccine allocation framework with the goal of reducing severe illness, death, and societal consequences due to COVID-19. Its foundational principles center on maximum benefit, the mitigation of health inequities, equal concern for all, fairness, transparency, and evidence.
The NASEM framework lays out four phases for vaccine distribution: 1) first responders and high-risk health workers, and at-risk populations with underlying conditions and comorbidities; 2) essential workers in high-risk settings; 3) children and young adults; and 4) everyone not included in previous phases. Prioritization happens among the phases — phase 1 gets the vaccine first, and then phase 2, and so on — but all the groups listed within each phase have equal priority. But NASEM boldly takes things further. To ensure social equity, it proposes that in each phase, special efforts should be made to prioritize vaccination in geographic areas that are more vulnerable to the negative impact of COVID-19 because of underlying economic, social, and structural factors. Indices like the CCVI, which is COVID-19 specific, capture these vulnerabilities and can therefore be used to help ensure that populations that are most disproportionately impacted get priority in each of the allocation phases. NASEM suggests, for example, that 10 percent of vaccine stocks in each state could be reserved for the residents of areas whose score falls in the lowest quartile of the vulnerability index.
We built the CCVI early on in the pandemic, as a tool for policymakers to ensure that the geographies most vulnerable to the coronavirus could be identified and prioritized for prevention and treatment of COVID-19 and its wider-ranging impacts. With NASEM recommending the prioritization of vulnerable communities in this most important — and hopeful — phase of our fight against COVID-19, we can ensure that we don’t further exacerbate racial and ethnic disparities once a COVID-19 vaccine becomes available.
Dr. Sema Sgaier is co-founder and executive director of Surgo Foundation and adjunct assistant professor at the Harvard T.H. Chan School of Public Health.