Health experts want to prioritize people of color for a Covid-19 vaccine. But how should it be done?

As the U.S. edges closer to approving a vaccine for Covid-19, a difficult decision is emerging as a central issue: Should people in hard-hit communities of color receive priority access to it, and if so, how should that be done?

Frontline health workers, elderly people, and those with chronic conditions that make them especially vulnerable to Covid-19 are likely to be at the head of the line, but there is also support among public health experts for making special efforts to deliver the vaccine early on to Black, Latino, Native Hawaiian and Pacific Islander, and Native American people — who have experienced higher rates of serious illness and death from the coronavirus.

“Having a racial preference for a Covid-19 vaccine is not only ethically permissible, but I think it’s an ethical imperative,” said Lawrence Gostin, a professor of global health law at Georgetown University. “The reason is both because of historic structural racism that’s resulted in grossly unequal health outcomes for all kinds of diseases, and because Covid-19 has so disproportionately impacted the lives of people of color.”

There are concerns, however, about legal objections to any framework that uses race and ethnicity when determining vaccine allocation and the way it might be interpreted in court. For instance, judicial scrutiny would not allow health care workers to skip a white person in line for a vaccine in favor of a person of color, as Gostin wrote recently in the Journal of the American Medical Association. He also noted that legally, a public health agency could probably not distribute vaccines to geographic locations based solely on race.

“My worry is that if there was explicit racial priority given to the Covid-19 vaccine, we could be embroiled in litigation that would really undermine implementation of the vaccine process, and also be at great risk of being overturned by the Supreme Court, particularly with its new conservative majority,” Gostin told STAT.

There is also concern that some groups, especially Black people, might be hesitant to be among the first to get a vaccine, given the history of mistreatment of Black patients in medical research.

“The other challenge you have with saying, ‘We want African Americans to step up first,’  is that we don’t want people to feel that they’re being guinea pigs,” said Georges Benjamin, executive director of the American Public Health Association. “We need to be very careful. We don’t want to give people the perception that they’re being experimented upon.”

The Advisory Committee on Immunization Practices, which gives vaccination guidance to the director of the Centers for Disease Control and Prevention, won’t make a decision on who should get a vaccine, and whether to give preference to communities of color, until a vaccine is approved.

The group will be guided in part by a framework released last month by the National Academies of Sciences, Engineering, and Medicine, which advocates taking an equitable approach to vaccine allocation. (Other frameworks that are informing ACIP’s discussion on vaccine distribution were created by the Johns Hopkins Bloomberg School of Public Health and the World Health Organization Strategic Advisory Group of Experts.)

The National Academies’ recommendations are broken down into four phases and set a goal to ensure that every step of the process takes into account the disproportionate public health and economic impact the virus has had on the elderly and communities of color.

“We’re making sure that we’re prioritizing those communities who have borne the largest burden of this pandemic,” said Helene Gayle, president and CEO of the Chicago Community Trust and a co-chair of the National Academies report.

Across all phases, the National Academies says geographic priority should be given to communities that are high on what the CDC calls the Social Vulnerability Index, which identifies communities most endangered and in need of aid during disasters like hurricanes. The index takes into account poverty, unemployment, and health insurance rates, among other socioeconomic, demographic, housing, and transportation vulnerabilities.

“We wanted to make sure that there was real consideration given to getting it to people who are at the highest risk, particularly communities of color, who oftentimes are higher on that social vulnerability scale,” said Gayle.

The first phase outlined by the National Academies would include frontline health workers like those at hospitals or nursing homes and first responders who are at high risk of contracting the virus. Vaccination of these workers would allow them to continue providing essential care, especially to the elderly who are at the greatest risk of contracting or dying from Covid-19, the report said. Nursing homes have seen 63,600 deaths among their residents — more than one-fourth of U.S. deaths — according to the Centers for Medicare & Medicaid Services, and some 800 nursing home staff have died from Covid-19, according to the report.

“An equity lens has to make sure even within those categories that we’re focused on the types of workers that oftentimes are neglected and fall through the cracks in our system,” said Kirsten Bibbins-Domingo, an epidemiologist at the University of California, San Francisco, who was a reviewer for the report. “Those workers are disproportionately low-wage workers. They’re disproportionately workers from communities of color.”

Bibbins-Domingo said taking an equitable approach to that first phase would mean making sure it’s not just doctors who receive the vaccine.

“It’s the health care worker, the public health aide, the home health aide who’s going to come in to take care of my mother and then go work in a nursing home and then go work somewhere else who I worry about won’t get prioritized for the vaccination and absolutely should be,” she said. The report said 27.8% of nursing home workers are Black, while among home health aides, 29.7% are Black and 17.5% are Latino.

But she said it would be a challenge to ensure equitable distribution. It will be up to state, local, and tribal health agencies to determine who falls into each priority group and how to deliver it to them.

“It’s likely going to be enforced through the way we distribute vaccinations to health care organizations to give to their employees,” said Bibbins-Domingo. “And the question will be whether those low-wage health care workers, the contracted employees, will actually get their vaccinations that they need.”

The CDC issued a revised version of its Covid-19 vaccination playbook in October, which was influenced by the National Academies report and designed to help states, territories, and local health officials develop plans for distributing vaccines. The playbook suggests jurisdictions make plans that “ensure equitable access to vaccination” and lists underrepresented racial and ethnic groups as critical populations that may be at an increased risk of acquiring Covid-19.

But Howard Koh, a professor at the Harvard T.H. Chan School of Public Health and a former assistant secretary of health in the Department of Health and Human Services during the Obama administration, noted that the National Academies and ACIP guidelines were just that, guidelines.

“Once all that advice and insight and analysis is put in, it’s ultimately up to government officials to lead and coordinate the distribution,” Koh said. He pointed out that national guidelines and principles aren’t necessarily followed through at the state and local level, pointing to what happened following the shutdown in the spring. “Every state reopened by using its own standards. Even though the CDC put out some guidelines, they weren’t enforced, and no one was held accountable,” he said.

Another challenge is that some of the vaccines require being held in extreme cold conditions, including the Pfizer one that’s likely to be the first approved and needs to be kept at minus 94 degrees Fahrenheit. That would limit where they can be stored and what communities, such as Native American populations in rural areas, have access to them.

While the National Academies panel prioritized people at highest risk, Benjamin cautioned that its plan could be misunderstood if the public messaging isn’t correct.

“If you only say, ‘We want to go to this ZIP code, or that ZIP code or communities of color’ without doing it on risk, then you run the risk of stigmatizing those populations and giving people a vaccine that don’t need them,” he said.

“If you’re healthy, just the fact you’re African American doesn’t mean that you ought to get to the front of the line,” Benjamin said. “If you’re African American, and you’re a bus driver, and you have chronic diseases. Absolutely.”