Trump team COVID vaccine plan will fail people of color. Fast does not mean equitable.

Government agencies worldwide are starting to authorize new vaccines against the novel coronavirus. Now the hard work of distributing this scarce resource begins.

In the United States, several groups of experts have recommended that Americans at highest risk get vaccinated first. But late last month, Health and Human Services Secretary Alex Azar announced that vaccine shipments would be divided among states based simply on the size of their adult populations. In short, the more adults, the more vaccine. 

On one level, this seems fair and obvious. There are about 31 million adults in California and roughly 525,000 in Vermont. Of course, California should get more doses. The per capita formula is also quick and easy to calculate, and expediency matters as the pandemic continues to generate horrific numbers of hospitalizations and deaths. 

However, when we make this decision on the basis of speed above all else, we risk failing to distribute the vaccine equitably. We're not prioritizing those who are at the highest risk of getting COVID-19 and dying from it — especially Black people. In a pandemic that has starkly revealed the myriad ways the structural racism embedded in American life leads to worse health outcomes for communities of color, ignoring equity would be a serious mistake.

States vary wildly in high-risk people

Of course, it would not be the first time in American history that expedience was prioritized to the detriment of people of color. It was expedient to secure passage of the Hill-Burton Act for hospital construction by ceding to the demands of Southern politicians that hospitals remain segregated. It was expedient to separate federal Medicare insurance for the elderly (an automatic benefit favoring mostly white Americans) from Medicaid insurance for the poor (a benefit still unavailable to large numbers of people of color due to eligibility criteria and application procedures that vary from state to state).  

In a pandemic, expedience is especially tempting. But both history and science tell us that faster is not necessarily better. Why? Because vaccination has two goals: to protect those at highest risk from severe disease if they are exposed to COVID-19, and to reduce the spread of the virus from person to person. Meeting both goals means vaccinating those at highest risk first. And this is where the “strictly by the numbers” allocation to states breaks down. 

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Populations at higher risk are not spread equally across states. The proportion who are over 65 years of age varies from 21% in Maine to 11% in Utah. The percentage of Black Americans ranges from 38% in Mississippi to less than 1% in Montana. Nearly half of New Mexicans are Hispanic or Latino, compared with less than 2% in West Virginia. States even differ in their share of people who are front-line health care workers or residents in long-term care. 

Vaccine shouldn't worsen inequities 

Of course, each state will make its own decisions about who is vaccinated first. And initial vaccine supply will be allocated to front-line health care workers and long-term care residents. But if subsequent vaccine doses are meted out to states based solely on population size, as opposed to risk, we could very well end up with more doses in states with populations at lower risk, and relatively fewer doses in states with populations at higher risk. And if the expedient distribution approach continues, racial and ethnic disparities in vaccination will contribute to an already inequitable status quo where Black and Latino populations live sicker and die younger because fewer resources are available to the communities where they live and work. 

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Alternatively, the federal government could account for the different COVID-19 population risks across states by applying a risk-based assessment at the national level before deciding how many vaccine doses to send to each state. While the risk-based assessment may not include race and ethnicity as factors because of federal anti-discrimination laws, failing to account for risk in any way will lead to an inequitable distribution of vaccine — we see this happen persistently with flu vaccines.

And the last thing we want is for our COVID-19 vaccination strategy to add to the substantial racial and ethnic disparities in COVID-19 illnesses, hospitalizations and deaths that are already in plain sight. 

Truth be told, none of this is simple. Under every scenario the vaccine doses have to be manufactured, traverse the country, be stored at subzero temperatures, and be injected into arms. It is not that much more difficult to make sure they reach the arms of Americans who need them most, first — regardless of where they live.

Dr. Eric Schneider is senior vice president for policy and research at The Commonwealth Fund. Follow him on Twitter: EricSchneiderMD