Should people of color get access to the Covid-19 vaccine before others?

“It’s so important that we get this right. We don’t have a history of doing this well.”

By now, we all know that Covid-19 is not an equal opportunity killer. Black people, Latinx people, and indigenous people are getting the disease more often and suffering more severe outcomes than white Americans.

The most glaring statistic: 1 in 1,000 Black Americans has already died in this pandemic. In the US, Black residents have been dying at twice the rate of white residents.

There’s nothing about being Black, in and of itself, that makes people more biologically susceptible to Covid-19. Instead, the disproportionate impact is due to an accumulation of factors from centuries of racism. Discriminatory housing policies like redlining have made it harder to maintain social distance. Unequal education and job opportunities have compelled people to take on higher-risk work. Poorer health care access has bred more underlying medical conditions.

A society that has foisted all these conditions on minority groups, which now make them more vulnerable to Covid-19, has to ask itself: When a vaccine is discovered, should people of color get priority access?

Christina Animashaun/Vox

There’s definitely a strong ethical and epidemiological argument for it. We’ve got a moral duty to redress injustice, plus a public-health duty to prevent as much death as possible — and since people of color are dying at higher rates, maybe they should be at the front of the line for the vaccine.

Melinda Gates is among those making this argument. When Time magazine asked her who, aside from health care workers, should get first dibs on a vaccine, she said, “In the US, that would be Black people next, quite honestly, and many other people of color.”

But others have raised concerns. What if many non-Black people resent Black people for getting prioritized, heaping more stigma and racism upon them? What if many Black people don’t feel comfortable being among the first in line for a new vaccine, given the horrific history of medical experimentation on African Americans? Some people of color expressed this worry in response to Gates, saying, “In other words, we’re the guinea pigs,” and, “We are not crash test dummies, we’ll go after you.”

Experts at the National Academies of Science, Engineering, and Medicine (NASEM) on Friday proposed a workaround in a new report, which they wrote at the request of the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health. Instead of using race as the criterion, a vaccination program could use location — perhaps at the zip code level or census tract level — when deciding where to concentrate vaccine allocation. That would allow the US to target low-income communities with fewer health care options and more underlying medical conditions.

Prior to the NASEM report, the World Health Organization and the Johns Hopkins Center for Health Security also released reports about how to distribute vaccines fairly on the national level. (How to do this fairly on the international level is a whole other question, tackled here.) All three reports agree that the country should take a phased approach to allocation and that front-line health care workers should get the vaccine in the first phase, before other population groups.

They also agree that racial equity is key. NASEM specifies that it should be a crosscutting consideration in each phase of allocation, meaning that within each population group, vaccine access should be prioritized for geographic areas that are especially vulnerable.

In the preface to the NASEM report, the authors note that the US is at a moment when racism is at the center of national discourse. “Inequities in health have always existed, but at this moment there is an awakening to the power of racism, poverty, and bias in amplifying the health and economic pain and hardship imposed by this pandemic. Thus, we saw our work as one way to address these wrongs,” they write.

The question is: What is the best way to put that commitment into practice?

Two options — a race-based approach and a place-based approach — have emerged as dominant possibilities when it comes to ensuring equity toward minority groups. But each has pros and cons. Let’s break them down so we can tease out which approach works better — and whether there might be a third option.

Why some object to a race-based approach: “We’re not going to let you experiment on us”

We’ve already outlined the pros of a race-based approach: It would drive more vaccine doses to those who’ve already suffered disproportionately without them, and it may save more lives going forward than a race-blind approach. But what about the cons?

“It’s not hard to imagine that if you put Black and brown people first in the line, there’s going to be some real mistrust about whether or not people are being used as guinea pigs, because in the past they have been,” said Helene Gayle, who co-chaired the NASEM committee that put out the new report. “So I think it would probably be counterproductive.”

The American medical system has long experimented on Black people. The most famous example is the Tuskegee experiment, in which Black men were left to suffer and die from syphilis even though a viable treatment — penicillin — was available. From 1932 to 1972, the US Public Health Service and the Tuskegee Institute in Alabama lied to the men in the study, telling them they were being treated for “bad blood,” when really they were being observed as they sickened.

There are many other examples. In the 19th century, the so-called “father of gynecology” J. Marion Sims performed experimental surgeries without anesthesia on enslaved Black women. In the 1950s, Johns Hopkins doctors took the cells of Henrietta Lacks, a Black woman, and propagated them without her consent for use in their research. In the 1990s, the Kennedy Krieger lead abatement repair and maintenance study purposely exposed Black people to lead in their homes to investigate the effects of lead paint. Around the same time, researchers studying aggression subjected Black and Latino boys to a drug called fenfluramine, which later turned out to damage the heart, without properly informing their parents.

The injustice isn’t just in the past: Medical bias is very much still a problem today. Black women are more likely than white women to receive inadequate health care, factoring into their higher maternal mortality rates. And Black people are less likely than equally sick white people to be referred for testing and treatment — including right now, when it comes to Covid-19. Although this inequity is exactly what motivates some to say people of color should get priority access to a Covid-19 vaccine, it’s also what has made many people of color distrust the medical establishment developing and disseminating such vaccines.

Given all this, it’s easy to understand why Georges Benjamin, the executive director of the American Public Health Association, said he doesn’t like the idea of giving the Covid-19 vaccine to Black people first. “We’re not going to let you experiment on us,” he said.

Benjamin also told me he’s concerned that giving priority access to people of color could foster a false belief that they’re biologically predisposed to get the coronavirus or to be more infectious than others. “You don’t want to stigmatize people. You don’t want to say African Americans as a class of people ought to get it,” he said.

White Americans may also resent people of color if they get dibs on the coveted vaccine, adding fuel to the fire of racism. Gayle, the co-chair of the NASEM committee, said that could plausibly happen, but there’s something that worries her even more.

“There’s real concern about whether there would be legal challenges to something that is race-specific,” she told me. “In our laws, there are ways in which you can and cannot specifically address a racial group to give them preference. It could very well be challenged if we had a race-specific vaccine strategy. That could end up tying things up in legal considerations.”

The last thing anyone wants is a situation where a successful Covid-19 vaccine has been discovered but nobody can get it because it’s tied up in the courts.

How a place-based approach would work: “Frankly, place is not a bad proxy for race”

To avoid all these problems, the NASEM report says we should not focus on “discrete racial and ethnic categories.” Instead, we should focus on the social determinants of health that make people of color more vulnerable to Covid-19, paying attention to the places where those determinants are most prevalent. People who live in areas of high social vulnerability should be able to get the vaccine at locations easily accessible to them.

Here’s how this would work in practice. Experts would use something called the Social Vulnerability Index, which the CDC created long ago to identify communities that are most at risk in a disaster situation. The index tracks 15 variables that capture many social determinants. For starters: What’s the average income level of people in the area? How crowded is it? How many elderly people live there?

The index draws on census data and can be calculated at the census tract level (generally between 1,000 and 8,000 people). Once experts have tallied up the vulnerability scores for different areas, they’d invite those who live in the most vulnerable areas to show up at community centers, schools, or other convenient locations to get vaccinated.

“We suggested that there should be priority for geographies that are high on the Social Vulnerability Index, because those very factors that make up the social vulnerability are the ones that are correlated with why people of color are at greater risk,” Gayle told me.

In other words, these factors are a good way of getting at race without actually using race as the explicit criterion.

“I think this could be a good idea, because the history of segregation and redlining means that, frankly, place is not a bad proxy for race,” said Kirsten Bibbins-Domingo, an epidemiology and biostatistics professor at the University of California San Francisco who specializes in health disparities.

“The challenge,” she added, “is that the place-based metrics are not perfect. In urban settings, we have rapidly gentrifying areas of the city. So when you build a metric based on older numbers for what that area of town looks like, that sometimes isn’t what it looks like now.”

Another potential critique is that highlighting place may have the effect of erasing race — even though race is a salient factor when it comes to Covid-19 and deserves to be explicitly framed as such. A place-based approach would probably reach more low-income people while leaving out some people of color whose socioeconomic status enables them to live elsewhere.

This is a critique you sometimes hear in debates over affirmative action, in which people question the relative merits of using race or class as the metric. Gayle, for her part, said she doesn’t think that critique holds water in this context.

“Affirmative action was put in place to address issues that were racial. The reason that you were discriminated against was because you were Black. So therefore you have to address that it was about race — it wasn’t about class,” she said. By contrast, “We’re looking at what are the factors that make people more likely to get an infection or have a serious outcome — it’s not necessarily a race-based issue, it’s racism. So we’re addressing the issues that are linked to racism” — namely, social determinants of health, such as income level.

What if we combine the race-based and place-based approaches?

Given the resistance to a race-based approach, including among many people of color, it probably makes sense to start with a place-based approach. But just because we start with one metric doesn’t mean we have to restrict ourselves to that one metric forever.

Bibbins-Domingo said that we should begin by allocating doses based on location, but simultaneously ask people to fill out a form specifying their racial or ethnic background when they show up to get vaccinated.

“If I were in charge,” she said, “I would want to actively monitor the demographics of who is getting vaccinated — to make sure the groups disproportionately affected are actually the ones receiving the vaccines. And if they’re not, I’d want to work with the civic leaders in those communities to figure out how we could do this better.”

In other words, we need to actively monitor whether plans are working out as intended, and be willing to pivot if not. We also need to build trust.

Mandel Ngan/AFP via Getty Images

“Trust is everything. I think one of the best ways to get communities of color to trust the vaccine is to get more people of color into the vaccine studies,” Benjamin said, referring to the problematic under-enrollment of minority groups in trials. And once trials are done and a vaccine is available, some people of color may need convincing that the vaccine is safe and effective. “You have to have messengers that people trust. That might mean people who look like them, who have similar life experiences. Or it could be sports figures and music figures.”

Failure to reach the populations that are most vulnerable would be a tragedy for them, and a disaster stretching well beyond this pandemic. It would further entrench people of color’s well-founded mistrust of the medical system, which could increase hesitancy to get other sorts of vaccines in the future, leading to more infectious outbreaks and more deaths.

“It’s so important that we get this right,” Bibbins-Domingo said. “We don’t have a history of doing this well.”

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