“Can you believe it?” she asked. “In the richest country in the world.”
To account for the disparity, state officials are doing something unusual. They are taking a portion of their share of shots off the top and rushing it to places beset by poverty, poor housing and other factors most linked to the pandemic’s disproportionate toll on people of color. Explaining the move recently, Michelle D. Fiscus, who leads Tennessee’s immunization program, said, “Covid-19 has revealed that great disparity in outcomes for Black Americans.”
The approach illustrates the urgent effort by public health agencies to make sure inoculation against a virus that has ravaged communities of color — killing 1 in 1,000 Black Americans by the fall — saves the lives of the most at-risk people. The task is made more difficult by the need to reverse the inequities endangering people of color without enshrining an explicit system of racial preferences in the distribution of shots, which could prompt political blowback and legal challenges. It is harder still because of the limited initial supply of the vaccine, which is pitting essential workers, who are disproportionately people of color, against older Americans.
A Centers for Disease Control and Prevention advisory group has signaled it will recommend prioritization of certain essential workers, in part to address racial disparities exposed by the pandemic. People of color are overrepresented in industries such as food processing and transit, in jobs impossible to do from home. Some of these workers could gain access to the shots early in the new year, after health-care workers and residents and staffers at long-term care facilities.
The Advisory Committee on Immunization Practices is scheduled to vote Sunday on recommendations for the next priority groups, heightening the pressure on state officials to refine their plans. The focus on essential workers as a way to advance equity has gained support from all 14 members of the independent panel of experts. Beth Bell, a clinical professor of global health at the University of Washington who chairs the panel’s vaccine working group, bluntly expressed the calculus: “If we’re serious about valuing equity, we need to have that baked in early in the vaccination process.”
Or, as Sweet-Love put it, “These are the folks at the bottom of the totem pole.”
The limited supply of shots, as most Americans head into winter unprotected from the deadly virus, has turned allocation decisions into ethical quandaries. The pandemic, by highlighting how racial fault lines warp the body politic, “also offers a moment to address and dismantle those inequalities so that everyone has a fair and just opportunity for health,” said J. Nadine Gracia, deputy assistant secretary for minority health under President Barack Obama.
Accounting for these inequities in state vaccination plans, Gracia said, is a “moral and economic imperative.”
‘As equitable as possible’
All the places where the pandemic has disproportionately harmed people of color — not just Tennessee — are confronting dilemmas about how explicitly immunization should be aimed at rectifying racial inequality.
In California, experts are devising ways to ensure communities of color “disproportionately are benefited” from vaccine distribution, Gov. Gavin Newsom (D) vowed, “because of the impact they have felt disproportionately” during the pandemic. New York Gov. Andrew M. Cuomo (D) went as far as to threaten to sue the Trump administration over its national distribution plan, which he said failed “Black and Brown communities that were first on the list of who died.”
But it was in Tennessee, far from the made-for-TV promises of blue-state governors, that health officials put a number on their ambitions. They committed to setting aside 5 percent of their vaccine supply for areas with high scores on a CDC social vulnerability index — areas such as Haywood County, where the primary crop is still cotton and the closest emergency room is a half-hour away by car.
The index, originally developed to identify communities most in need of assistance after natural disasters, was recommended by the National Academies of Sciences, Engineering and Medicine for use in vaccine allocation because it incorporates factors “most linked to the disproportionate impact of covid-19 on people of color.” Those include minority status, crowded housing and lack of access to a vehicle — all factors that burden Haywood County, best known as the childhood home of singer Tina Turner.
The county, whose lone hospital closed in 2014, is already at a disadvantage because it cannot handle the two-dose vaccine regimen from Pfizer-BioNTech, which comes in 975-dose batches and must be stored at subarctic temperatures. Distributing shots made by Moderna based just on population would bring enough initial shots to Haywood County for not quite half of the county’s health-care workers, Fiscus said. That outcome would not be “as equitable as possible,” she said during a panel discussion this month on vaccine allocation and social justice.
The revised approach setting aside a portion of the state’s allocation to supplement the neediest areas was widely embraced in the deep-red state.
State Rep. Cameron Sexton (R), speaker of the Tennessee House, said he favored use of a clear index over “government picking winners and losers based on arbitrary facts.” Focusing on vulnerable populations, he said, “doesn’t make distribution a race issue. There’s no putting one over another. It’s based on health conditions.”
Others, meanwhile, said they were drawn to the approach precisely because it made race central to the allocation of the vaccine.
“Covid is not race-blind, and we need to act accordingly,” said Michael Caldwell, Nashville’s public health director. In meetings, he said, state health leaders have made it “crystal clear” that using social vulnerability as a guide to vaccine allocation is designed to focus attention on “inequities and disparities.”
The clashing views capture the way a National Academies committee wrestled with the issue. A race-based system of priorities would have prompted a backlash and created the appearance that “populations that already have mistrust of our health system were being told to go to the front of the line,” said Helene D. Gayle, president and chief executive of the Chicago Community Trust and a committee co-chair.
The approach is politically savvy, said Harald Schmidt, a bioethics expert at the University of Pennsylvania. By “baking metrics that grapple with race into the hardware of vaccine distribution decisions,” states can avoid the perception that they are favoring one group over another, Schmidt said.
Tennessee was the first state to commit in writing to using the CDC index to rush a set-aside share of the state’s supply to the most vulnerable areas, according to an analysis of state plans by specialists in medicine, bioethics and statistics. In draft plans, other states discuss the national index or metrics similar to it, said Schmidt, the paper’s lead author.
California intends to use its own equity metric. Georgia’s draft includes an equity statement that suggests there will be geographical prioritization based, in part, on “race and ethnicity,” but it offers no details, and the state health department did not respond to a question about how the equity aspiration would be realized.
Federal blueprints offer only vague language. The CDC playbook sent to states listed “critical populations” at increased risk from the coronavirus, including “racial and ethnic minority groups.” Just four states — Delaware, Missouri, Montana and Nebraska — retained this language in their plans, according to Ariadne Labs, a Boston center for health system innovation run jointly by Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health.
“It could be somewhat random, but looking at those particular states, it could also reflect attention paid to tribal populations,” said Kate Miller, a senior scientist at Ariadne Labs.
Ariadne Labs found that plans in 19 states referred to a disadvantage index, among them the CDC’s vulnerability index. In some cases the aim is to guide distribution of the vaccine; in others it is to monitor its uptake in underserved areas. Tennessee makes explicit how the index determines the most basic question of all — the allocation of doses.
'A political hot potato’
When Sandra Lindsay, a Black critical-care nurse in New York, became the face of the first coronavirus vaccinations this week in the United States, she took note of the dual nature of her role. She wanted to inspire other nurses, she said in an interview, and to send a message to “minorities, people that look like me,” who may be “hesitant to take vaccines” because of mistreatment by the medical establishment.
Her words illuminated the lessons embedded in allocation plans that, on their face, say little about race. Across the country, some said justice was being done by sticking to deliberate phases putting workers, and especially health-care workers, first.
Stephen L. Williams, Houston’s health director, smiled recently as he drove past the light-rail station within the Texas Medical Center and saw that many of the waiting passengers were people of color, like him. Soon, he knew, many of the people on the platform would be vaccinated against covid-19 — not because of their skin color but because they are health-care workers.
“Look at how hospitals are staffed,” said Williams, who sits on the state panel making recommendations about vaccine allocation. “The people in their uniforms, getting on the train or bus after their shift — there are a lot of people of color in that group.”
Whether the people operating the buses go next is a more difficult question — and one even more freighted with issues of race and equity.
“The deeper you get, the more complexity there is,” said Nancy J. Cox, a virologist and former CDC official. “A lot of essential workers don’t have the same voice, they don’t have the same political pull, and those kinds of things may be coming into play here.”
Transportation is among the front-line occupations in which workers of color are most overrepresented, accounting for 56.7 percent of bus drivers and other transit workers, according to the Center for Economic and Policy Research, a D.C. think tank. More broadly, about 4 in 10 front-line workers are Black, Hispanic, Asian American or Pacific Islander, the group estimated.
Many, like Bruce Caines, also have underlying health conditions. The 61-year-old, who has diabetes, works at a Trader Joe’s on Manhattan’s Upper West Side. During his shift, from 3 to 11 p.m., he unloads deliveries, stocks shelves, rings up customers. The elderly are not the only ones at risk, said Caines, who suffered a mild case of covid-19 in February and does not want to get sick again. “In my store, we already lost one crew member, a young guy in his early 20s,” he said.
Targeting front-line workers such as Caines, who is Black, “will be taking an equity approach,” said Richard Besser, who is chief executive of the Robert Wood Johnson Foundation, the nation’s largest philanthropy focused exclusively on health, and a former top CDC official. “It would be a tragedy if communities of color that have been disproportionately affected by the pandemic are not viewed as a priority for receiving the vaccine.”
The CDC advisory group estimates there are about 87 million essential workers, and states may choose to prioritize some over others. Many states, meanwhile, are building more-granular priorities into each phase, seeking to dodge the choice between front-line workers and elderly people.
Tennessee’s draft plan makes adults with chronic conditions a priority before “critical infrastructure workers” and gives preference to people 65 and older within each phase. California’s draft puts essential workers and people 65 and over in the same phase, betting on expanded supply early in the new year, though Newsom has recently spoken about the need to give particular consideration to teachers, farmworkers and grocery workers.
Gov. Ron DeSantis (R) of Florida, a close ally of President Trump, said at a recent White House summit he would like to see the vaccine reach the “broader senior population” by the end of December, an ambitious target that would probably involve passing over many front-line workers. Participating in a panel with three other Southern governors, he was the only one not to outline how vaccine allocation would address the needs of underserved communities when that question was posed by Health and Human Services Secretary Alex Azar. Instead, he decried “shutdowns that are totally unscientific.”
“I could see how this could become a political hot potato,” said Jennifer Kates, a senior vice president at the Kaiser Family Foundation, a nonprofit health policy organization.
The pressure is heightened by constraints on the vaccine supply, driven by international demand. Some of the thorniest political differences, however, are local.
David Smith, who runs the ambulance authority in Haywood County, said nine of the unit’s workers have fallen ill with covid-19, among a staff of about 27. Still, only three of the workers who respond to calls for emergency medical service intend to be vaccinated, he said. He is not among them, he added, citing concerns about how quickly the vaccines are being developed.
Brownsville’s mayor, Bill Rawls, said he hopes many will change their minds by the time the shots arrive in the county, which could be around Christmastime. So far, only the regional hospital, a half-hour away, has received doses of the Pfizer-BioNTech vaccine.
“It will be a gift sorely needed,” Rawls said.