Harald Schmidt is an assistant professor of medical ethics and health policy at the University of Pennsylvania. Lawrence O. Gostin is a professor and director of the O’Neill Institute for National and Global Health Law at Georgetown University Law Center. Michelle Williams is dean of the Harvard T.H. Chan School of Public Health.
President Biden’s announcement that all U.S. adults will be eligible for coronavirus vaccines by May 1 is, in many ways, good news. But opening the gates does not mean that the debate about equitable and fair allocation is over. Far from it.
To ensure equitable allocation and mitigate the pandemic’s disproportionate impact on disadvantaged communities, three things are central: prioritizing more vulnerable communities; conveying that doing so is good for both public health and equity; and making clear that equity is not the enemy of efficiency. These steps will matter as much once we open up vaccine eligibility to the general population as they do now.
State policies on who gets the vaccine have been the subject of much controversy over the past few months. Kitchen tables across the country have featured a recurrent question: "When is it my turn?”
By May 1, these questions will end. At least 50 million people who were not included in any of the previous priority groups will qualify. But they will be competing for doses against those who were eligible for vaccines earlier, and who, for one reason or another, remained unvaccinated. This includes people who wanted a vaccine but weren’t able to get one, as well as those with reservations about the injection. Surveys suggest this group includes at least 30 percent of those in all priority groups, or about 70 million people.
In other words, at least 100 million people will likely still not be vaccinated on May 1. Getting shots into those arms will take time, and although we will no longer have priority groups based on age or profession, it is imperative to still prioritize those for whom vaccines matter the most.
For many who have not yet been vaccinated, waiting another month or longer will be an inconvenience that can be handled safely. But others will continue to be at greater risk of the virus and may no longer be able to withstand the pandemic’s economic impact. We also know that because of structural racism, that latter group will include much larger shares of people of color, who not only lag behind in vaccination coverage but also have suffered far higher rates of unemployment, infections and deaths, as well as structurally curtailed economic opportunities.
Data bear out that the worse-off people are, the more dramatic the consequences of covid-19. A recent study using the Social Vulnerability Index — a measure developed by the Centers of Disease Control and Prevention that compiles a bunch of factors (such as income, quality of housing and education) into a single score for a region’s overall vulnerability — found that an increase of 0.1 point in the SVI score was associated with a 14.3 percent increase in covid-19 incidence and a 13.7 percent increase in mortality rate.
Such disadvantage indices can and should be used to guide allocations within and across states. Encouragingly, in a review we conducted with colleagues in November 2020, we found that 19 states used an index such as the SVI. By late January 2021, this number had increased to 29, allowing state planners to identify where to place vaccination sites; to tailor communication and outreach strategies so that they are responsive to the specific communities; and to monitor and adjust allocations as needed to make sure disadvantaged groups are not left out.
Such data prove that promoting equity and protecting public health are flip sides of the same coin: Meaningful herd immunity is not achieved by simply vaccinating the largest number of people, but by vaccinating more of those people who are most likely to get and spread the infection. The increasing uptake by states is promising, and hopefully will become universal.
It also demonstrates the false dichotomy that equity comes at the expense of efficiency. For example, adjusting allocation quotas in a spreadsheet so that disadvantaged areas receive larger amounts of vaccine doses can be done in an instant. All it takes is intentionality and attention to details.
It is understandable that most people take a first-person approach to the pandemic. But the pandemic is not just about us as individuals; rather, it is about all of us as an interconnected collective.
Twenty-eight states have already expanded their eligibility to all adults, or will do so before the second week of April. Yet 17 of these states are below average in terms of the population share that has received vaccines. And in general, vaccination rates are lower in counties that have been hit harder by covid-19 and have higher poverty rates or larger shares of Black and Hispanic populations. We all stand to benefit if those states and regional health departments use data to ensure, at minimum, that vaccination rates among the nation’s most vulnerable are not lower than among the more privileged groups — both for public health reasons and for social justice.