As Oxford University’s vaccine entered its final trial phase, and experts noted that the vaccine could appear before the end of the year, the chair of the U.K.’s COVID-19 task force, Kate Bingham, appeared on a national morning show last week to announce preliminary recommendations from the country’s Joint Committee on Vaccination and Immunisation. She announced that the independent group had recommended to the government to prioritize four groups for a vaccine: people over 50, people with additional health conditions, front-line workers—and ethnic minorities.
The U.S. is also underway in gathering recommendations for its own decision about whom to prioritize, from a body called the Advisory Committee on Immunization Practices (ACPI). Though there are emergency structures in place for allocating and targeting pandemic influenza vaccines, they need to be adjusted for the coronavirus’s unique characteristics and the risks it poses for specific populations. And, this year, equity and race have taken new roles in discussions, amid both the higher infection rate among minorities and revitalized talks of racial injustice in society. But experts say that, no matter how well-meaning the suggestion, it’s not as clear-cut as simply placing minorities at the front of the line.
Everyone in the country will eventually need a vaccination, but the mass manufacture process will likely be gradual, so the government has to decide how to deliver the doses. The U.S. has invested in many of the candidates—giving $1.2 billion to the joint venture by Oxford and AstraZeneca, $483 million to Moderna, and $456 to Johnson & Johnson, among others. “We recognize that public health authorities . . . will play a leading role in guiding which populations should be prioritized for immunization during the emergency pandemic based on their experience and expertise,” a Johnson & Johnson representative, Jake Sargent, told Fast Company in an email.
The CDC traditionally guides the process. There’s a CDC pandemic influenza vaccine guide, which lays out suggested vaccination tiers. But the document is based on a generic flu, with lessons learned from 2009’s H1N1 virus. Most notably, that virus affected younger children and infants more (rates of hospitalization were 8.3 per 10,000 for children up to 4, compared to 3.2 for those 65 and older). So, the guide currently prioritizes children, who are in a higher tier than the over-65 population. That’s why the COVID-19 vaccine, which disproportionately threatens the elderly, needs a different template, which the recommendations from the ACIP will inform. For the first time, that group has also raised race as a possible priority factor.
The ACIP is a subcommittee within the CDC that meets regularly and develops written vaccination policy recommendations for the agency’s director, Robert Redfield. It’s composed of 15 voting members, eight representatives from other federal agencies, and 30 liaisons from medical and public health organizations. (This year, the CDC has also decided to involve a task force from the independent National Academy of Medicine, in order to include assistance on the allocation framework from a nongovernmental entity.)
“In the past, the ACPI has been very careful not to make ethnic or racial recommendations for vaccine use,” says William Schaffner, professor of medicine in the health policy division at Vanderbilt University School of Medicine, and medical director at the National Center for Infectious Diseases, where he’s the liaison to the ACIP. “Such a proposal would have been greeted with raised eyebrows. But, this time, not.” Black and Latino people have been infected by the virus at three times the rate of white people. The death rate for Black people has been 3.7 times that of white people, and 3.5 times for indigenous people.
This year, the recommendation process has been further complicated by the creation of Operation Warp Speed, set up under the Department of Health and Human Services (HHS), whose goal is “to deliver 300 million doses of a safe, effective vaccine for COVID-19 by January 2021,” and “to accelerate development while maintaining standards for safety and efficacy.” Schaffner says OWS has been “very reticent” about its involvement in deciding the rollout sequence. In an email, a senior HHS administration official told Fast Company that OWS will not play a role in distribution policy, but simply in implementing the chosen plan.
Whatever the case, it’s likely going to be a tough decision for the ACPI to handle. There’s a sense that it could become politically charged among non-minority groups. And some members of the ACIP, Schaffner says, argue that many of the minorities who need the vaccine would already be covered under elderly and front-line workers, anyway, negating the need to make a separate race category. The other sticking point is how to decide who fits into what race category, which could put individual doctors into the prickly area of defining race.
Even self-identifying race could be tricky. “You don’t want a situation where somebody walks in and says, ‘I’m African American or Latino,’ and a physician with white skin looks at them says, ‘no, you’re not,'” says Jonathan Moreno, a professor of medical ethics and health policy at the University of Pennsylvania. Instead, Moreno suggests a socioeconomic method, where priority is given geographically “by zip codes that have a high prevalence of people in poverty.” Because of decades of redlining and segregation, he says, that approach would help qualify those minorities most at risk. “That way, you will de facto pick up people that you would want to pick up under this vague notion of race,” he says.
In the past, the ACPI has been very careful not to make ethnic or racial recommendations for vaccine use.”
Bita Amani, an assistant professor at Charles Drew University and a faculty affiliate at UCLA’s Center for the Study of Racism, Social Justice and Health, also expresses concern with prioritizing for race, but because of its perception within the minority communities themselves. Becoming their own separate racial category for vaccine tests could spark fear and distrust because of a long history of “medical racism” and of Black people used as medical test subjects.
Only in 1972 did officials bring an end to The Tuskegee Study, a 40-year examination of rural Black men who had syphilis, during which the men were not told their diagnosis, and actively barred from treatment. In 1951, Johns Hopkins doctors harvested cervical cancer cells from a young Black woman named Henrietta Lacks without her consent, and went on to use them for testing for years after her death.
“We’ve made drugs and vaccines right for a very long time,” Amani says, “but the way in which we gained them has been with a disregard for human life for certain groups.” Recent Pew research shows that only 35% of Black adults have a great deal of confidence in medical scientists to act in the public’s best interests, and only 54% said they would get a COVID-19 vaccine if available today, compared to 74% of whites. Amani says authorities need to create trust and transparency first, to show that the vaccine will have been safely tested in trials before being distributed to them. They need to create a buy-in from the community, via community conversations and information sessions.
Another problem, Amani says, is that putting minorities at the front of the vaccine line ignores the reasons they’re more affected by the virus in the first place. It’s not because of biological factors, as it is with the elderly or immunocompromised, but because of structural, societal reasons. The CDC lists the “inequities in social determinants of health” that have led to this outbreak in minority communities, including: discrimination, wealth gaps, housing, healthcare access, and tendency to be essential workers. Data shows that Latinos, for instance, are twice as likely to live in crowded homes than white people, and 43% of Blacks and Latinos have jobs that can’t be done remotely, compared with about 25% of whites.
In that sense, the vaccine is a quick fix, Amani suggests, which would then allow the government to continue to practice the same policies that created the inequities in the first place. Front-line workers have been sacrificed in the interest of restarting the economy, and with little other choice due to lack of substantial stimulus, unemployment pay, or sick leave. “How is this going to go down from the perspective of somebody who’s looking at the state and saying, both historically, and in the current moment: ‘You are not making decisions that are in the best interest of my health and safety?'” she asks.
Amani says the vaccine conversation is a new opportunity to address structural racism. Prioritizing minority groups for the vaccine could be a part of the solution, but it also includes addressing deep-rooted systemic issues. Again, it comes down to transparency and communication from pharmaceutical companies, academic institutions, and the government. But, to give folks a shot in the arm and then walk away is not enough.
“It’s difficult because the government made it difficult,” she says. “It’s not because communities have a misplaced distrust.”