Now that covid-19 vaccines are increasingly becoming available to people beyond health-care workers and those in long-term care, the question turns to who should be immunized next. For many people, the answer is essential workers. But while many workers face an elevated risk and should receive a vaccine soon, we believe the most ethically justified path forward is to focus on individuals 65 and older.
The primary reason to prioritize people in this age group is simple: They account for more than 80 percent of covid-19 deaths, even though they are only about 16 percent of the population. This disproportionate toll is why the Biden administration’s vaccine plan encourages states to expand vaccine eligibility to those who are 65 and older.
But while many places — such as D.C., New York and Florida — are converging on a 65-and-older strategy, whether seniors qualify for vaccination largely depends on where they live. In New Mexico and Connecticut, you need to be at least 75 years old. In Colorado and Nevada, 70 is old enough. And in Hawaii and Virginia, older adults must compete with many other people for the same limited vaccine supply, including essential workers.
Prioritizing people 65 and older is the most efficient route to reduce the dying, but that is not the only reason it is the most ethically defensible way to proceed. The age cutoff also directly addresses disproportionate mortality in structurally disadvantaged groups. The differences in mortality rates by race are arguably the most morally egregious of the covid-19 disparities. The Centers for Disease Control and Prevention report that Black and Latinx people have experienced death at 2.8 times the rate of White people. Indigenous Americans have only a slightly lower ratio, at 2.6 times.
For many of the same structurally unjust reasons that people of color are dying of covid-19 at higher rates than White people, they are also dying at earlier ages. While nearly three-quarters of White people who die of covid-19 are 75 or older, that is true for only 45 percent of deaths among Black people and 33 percent of deaths among indigenous Americans. By contrast, almost 70 percent of covid-19 deaths among Black and Latinx people and 60 percent of deaths among Native people were among people 65 and older.
There is substantial variation among the states in terms of both percentage of the population over 65 and the percentage who are members of disadvantaged minority groups. But within each state, the relative distribution of mortality by age and the relative impact of disadvantage on mortality remains effectively the same. Thus, by simplifying vaccine prioritization to focus on people 65 and older across the nation, we can more effectively protect most Americans at the highest risk of dying in each ethnic and racial demographic in a way that focusing on essential workers would not.
While a national age cutoff of 65 would go a long way to address equity concerns, it would not, by itself, be sufficient. We must also make intensive efforts to overcome barriers in vaccinating older people in communities of color. For many months now, there have been pleas to address the justified distrust many people of color have in government programs and public health, and to reduce barriers to registration for and access to vaccine administration. Any vaccine strategy, whether it prioritizes essential workers or older adults, will be inequitable without addressing these challenges. The considerable differential uptake of vaccines among health-care workers of color proves this point.
Massive efforts must be initiated, now, to narrow this differential among older Americans. The National Academies of Sciences, Engineering, and Medicine recommended ensuring access in areas of social vulnerability. Different jurisdictions are applying metrics to do so. For example, D.C., which began offering vaccines to people over 65 on Jan. 11, is differentially reserving some vaccine appointments for residents of sections of the city that have been hit hardest by covid-19 hospitalizations and deaths.
With thousands of Americans succumbing to covid-19 daily, it is imperative we get our vaccine strategy right. The use of a nationally coordinated age cutoff of 65 may seem deceptively simple, but in conjunction with intensive equity efforts, it is also our best opportunity to save lives with the fierce urgency of now.