By Megan J. Shen
How COVID-19 vaccines roll out in the U.S. will highlight the nation’s priorities, and potentially also its persistent disparities.
Top of the list to receive the vaccine are frontline healthcare workers, who were the first to receive Pfizer’s new vaccine this week.
But there is still a long winter ahead where many will not yet have access to the vaccine. And it remains unclear how the next round of vaccine recipients will be allocated to serve the most vulnerable populations.
Targeting underserved communities — specifically low-income communities, which are disproportionately Black and Latino — is the key to addressing this issue.
But whether this will happen is still unclear. The wider vaccine rollout is likely to be very messy and inequitable, like much of America’s healthcare system has been throughout this entire pandemic.
It is, of course, a tricky formula to determine who should be prioritized for vaccine distribution.
Age, particularly for those over 65 years old, is a huge risk factor. Obesity, which plagues well over 40% of Americans, is another risk factor that increases the severity of disease. Other comorbidities including kidney disease, diabetes, asthma, and underlying heart conditions also increase the risk of severe COVID-19. There has already been much discussion as to how to best roll out the vaccine to these next high need groups, but no clear determinations have been made as to next steps.
And what about communities of color and those from low-income communities? The virus has taken a disproportionate and devastating toll on these groups; rates of COVID-19 cases and mortality continue to remain alarmingly higher for Black and Latino Americans than their white counterparts. Individuals from low-income communities are also at higher risk.
When considering COVID-19 vaccine distribution after health care and long-term care facility residents and staff are immunized, it may be tempting to focus on the clear biological drivers of increased risk, such as pre-existing comorbidities. But this individual-level approach may be difficult to implement at the population level.
Taking a broader systems-level approach rather than an individual-level approach to the distribution of incoming COVID-19 vaccines, focusing allocation efforts first on underserved and high need communities, may not only drive health equity, but also create a simpler formula for effective distribution to the most vulnerable.
Underserved minorities, particularly Black and Latino individuals, suffer from higher rates of obesity and obesity-related comorbidities, such as diabetes and hypertension. This, in turn, makes these racial and ethnic minority groups at higher risk of severe COVID-19 related complications, hospitalizations, and mortality. Under-insured or uninsured individuals such as those from low-income communities may be less likely to seek needed medical help to manage COVID-19, putting them at higher risk of complications or mortality.
Prioritizing underserved communities — particularly Black, Latino, and low income communities — also targets those most at risk of virus exposure and least able to comply with the recommended guidelines to help slow the spread of the virus. For instance, individuals from low-income communities are more likely to live in crowded dwellings where quarantining if sick is not an option. They are also more likely to live in multi-generational homes, putting older adults at risk.
Targeting underserved communities also prioritizes those most at risk of being exposed to COVID-19 over the next few months as vaccines are distributed. Individuals from low-income communities face some of the highest risks of exposure. They are more likely to rely on public transportation, live in crowded urban areas, and be low-wage frontline workers. This, of course, also puts them at a higher risk of not having paid sick leave, further exacerbating the problem of exposure risk. Black and Latino workers are more likely to live in low-income communities and work in lower-paying occupations. This further highlights the extreme systemic inequities present in the U.S. healthcare system for racial and ethnic minorities.
So yes, we could come up with a formula to decide which specific pre-existing condition makes an individual most at risk and thus next on the list to get vaccinated against COVID-19. But such a formula would be complicated, challenging to implement at a population level, and would overlook transmission and exposure risks, such as the degree to which individuals have the option to practice social distancing until a vaccine is widely available.
Thus, a population-level approach that focuses on underserved communities, and specifically low-income communities, which are disproportionately Black and Latino, should guide the distribution of COVID-19 vaccines.