What we learn from ‘ race blind’ vaccine threshold

Disparity shows how U. S. must prioritize equity

Last summer, the United States seemingly woke up to how systems and policies drive widespread racial disparities. With the killings of George Floyd and Breonna Taylor, it was painfully clear that Black people were not only more likely to be killed by police than white people – Black people were also more likely to die of COVID- 19, more likely to lose work during the pandemic, and more likely to face food and housing insecurity.

People poured onto the streets to demand change. As former Minneapolis police officer Derek Chauvin was found guilty in Floyd’s death, policies continue to exacerbate disparities.

The recommendation to distribute vaccines based on age thresholds was “race blind” and profoundly inequitable. About 12% of Black people and 8% of Latinx people in the United States are over the age of 65, relative to 21% of white people. Black and Latinx people then were about half as likely as white people to be eligible for vaccination based on a 65- year- age threshold.

Such an inequitable policy decision was particularly striking in light of findings from Dr. Mary Bassett and colleagues, that Black and Latinx people under 65 were five to nine times more likely to have died of COVID- 19 than white people under 65.

Undelivered vaccines

Now, hospitalization data indicates it is Black people who bore the brunt of the pandemic’s fourth wave in April. Like disparities in so many other aspects of health, racial disparities in COVID- 19 vaccinations and hospitalizations were driven by a policy decision about vaccine priorities. Vaccine priorities highlight how hard we must work to center equity in future policies.

Equitable and ethical vaccine delivery was arguably the best planned aspect of the U. S. pandemic response, as the Trump administration primarily downplayed the pandemic and put the onus on states to respond. When it came to vaccine priorities, the scientists on the Centers for Disease Control and Prevention’s existing Advisory Committee on Immunization Practices ( ACIP) met monthly to carefully consider evidence and ethics to develop recommendations. But the first month of vaccine delivery was slow.

Amid a clear lack of federal leadership or financial support for the state and local governments tasked with leading vaccine implementation, it was not these forces but equitable and ethical vaccine priorities that took the blame for undelivered vaccines.

Commentators called to dismiss the vaccine priorities in favor of simpler age thresholds, and the Trump administration followed suit. Health and Human Services Secretary Alex Azar recommended states make all those 65 and older eligible for the vaccine.

The incoming Biden- Harris administration chose to continue with that recommendation. As our research team tracked state vaccine priorities, we watched state after state shift to prioritizing retirees who could comfortably stay home over essential workers who have been more likely to die young throughout the pandemic, leaving an estimated 40,000 children without their parents.

The data for Native American people shows what could have been for Black and Latinx communities. The federal government supplied the Indian Health Service with high numbers of vaccines, tribal leaders organized to deliver to their communities and there was high uptake. The Navajo Nation recently reported no new cases. Native American hospitalizations went from being highest throughout the pandemic to among the lowest.

There was similarly high vaccine uptake in Riverside, California, and Central Falls, Rhode Island, when their governments delivered vaccines to workplaces and housing complexes where COVID- 19 rates were high. These strategies should not be exceptions that make headlines; they should be our default approach of getting vaccines to people who need them most.

Historical and modern policies

The Biden- Harris administration has heard the call to address racism. On his first day in office, President Joe Biden issued an executive order to prioritize racial equity across the functions of the federal government. He appointed a historically diverse Cabinet. The March American Rescue Plan makes historic inroads into addressing economic precarity that has disproportionately affected Black, Latinx and Native American people during the pandemic.

Even so, policymakers and experts who care deeply about equity can make inequitable decisions if the equity implications of policy decisions are not made explicit.

Racial and ethnic disparities in COVID- 19 are a result of centuries of racist health and social policies that shape disparities in wealth, education, income and housing. Historical and modern policies will continue to drive widespread disparities in deaths and disease by race and ethnicity, from police killings and COVID- 19, to HIV and homicide, to heart disease and diabetes – unless we center and measure equity in all policy decisions.

Good place to start

The Biden- Harris administration laid the groundwork to do so with its executive order – now it is time to center equity in all policy responses to COVID- 19 and the unemployment crisis.

The health and social policies that we put in place to address the pandemic and its economic consequences have the power to erase or to grow already large disparities. Shaping a more equitable future requires leading in a way that makes equity a central part of every policy decision.

Immediately having the White House COVID- 19 Response Team begin reporting on racial and ethnic disparities in vaccinations every time it reports on overall vaccinations in America – and delivering vaccines to Black and Latinx communities in workplaces, homes and through federally qualified health centers – is a good place to start.

Julia Raifman, ScD, is an assistant professor at the Boston University School of Public Health, where she leads the COVID- 19 US State Policy Database. Lorraine Dean, ScD, is an associate professor at the Johns Hopkins Bloomberg School of Public Health.