Policymakers have wrestled for months with how to fairly prioritize populations for Covid-19 vaccines. But even as vaccines are being rolled out, there’s little agreement on the exact sequence of priority groups.
Allocation frameworks vary across states, continue to be revised, and, in apparent disagreement with current federal guidance, the Biden-Harris administration announced that its national Covid-19 strategy will open up previously established priority groups.
Amid the flux, equity must remain constant. While states may vary in how they organize the sequences of priority groups, within each group they should ensure that better-off and worse-off groups are equally likely to be vaccinated. Specifically, if better-off groups receive vaccines at higher rates than worse-off groups, existing health and social disparities will be maintained, or even heightened.
One practical approach can help maintain equity: using disadvantage indices to plan, implement, monitor, and course-correct vaccine allocation where needed.
Disadvantage indices such as the CDC’s Social Vulnerability Index (SVI) or the University of Wisconsin’s Area Deprivation Index (ADI) integrate a number of separate variables to capture how vulnerable or deprived, on average, are the people living in a particular geographic area. They combine data on typical income, quality of housing, educational attainment, and more to compute an overall score for an area as small as a neighborhood of 600 people.
A number of states are already using these indices for vaccine allocation, in different ways. But without their broader adoption and fully fledged efforts to integrate them into a coherent strategy, it is unclear how the urgent goal of addressing health disparities in allocating vaccines — which is rightly emphasized in the national strategy — can be accomplished.
Goal number six of the strategy instructs the CDC to “work with states and localities to update their pandemic plans to describe how they have or will provide equitable access to Covid-19 resources within highly vulnerable communities, including Tribal communities, using CDC’s Social Vulnerability Index [SVI] or other indices as appropriate.”
Highlighting the use of a disadvantage index in the national strategy is an important step toward equity. But more specificity is required. Four main uses can be distinguished. As states are reviewing — once again — their allocation plans in light of new federal directions, it is critical to distinguish these and realize their power to integrate what could otherwise become a disjointed set of sprawling activities.
First, the most obvious use is for planning where to place dispensing sites so locations are easy to reach, especially for disadvantaged populations who may have less flexible working hours, informal caring obligations that make it difficult to spend several hours on a vaccine appointment, or transportation challenges. New Jersey already indicates it is doing this. This approach will also help plan locations for nontraditional sites for vaccinating Americans such as school gyms, sports stadiums, community centers, and mobile clinics that were announced under the Biden administration’s national strategy.
This use can also help more fully engage pharmacies, which are intended to be tapped to help with the vaccination effort: an index such as the ADI can enable mapping to the level of neighborhoods, and hence help ensure that people in more disadvantaged areas are not skipped over, in offering vaccines.
Second, disadvantage indices can be used to plan outreach and communication strategies, something that Arizona, Vermont, and Washington are doing. Such efforts matter immensely: Vaccine dispensing sites are worth nothing if people don’t use them, or don’t trust them, perhaps because of patterns of unfair treatment in interactions with health care providers and government services. Working proactively with community groups in disadvantaged areas to determine easily reachable and trusted sites can help match supply with uptake among communities in greatest need.
Third, an important way of promoting equity is to ensure that more vulnerable groups are offered larger shares of vaccines each time a state or city-level jurisdiction receives a new batch. Doing so reduces scarcity for these groups and means they can receive vaccines more quickly. In adapting the National Academies proposal for equitable allocation, planners in Massachusetts, New Hampshire, and Tennessee already adjust the number of vaccines shipped to allocation sites so more-vulnerable populations are offered more than they would have received based on numbers alone. This approach can also counteract the tendency of better-off and well-connected groups to work the system to their advantage.
Fourth, each new vaccine shipment offers an important opportunity to monitor equitable allocation and course-correct, where needed.
Disadvantage indices should serve as the country’s compass for equitable distribution of Covid-19 vaccines.
Monitoring equitable allocation seems to be implied in the Biden administration’s reference to disadvantage indices in its national strategy, and is echoed in its emphasis on a data-driven response. But it is not articulated or carried through as fully as it might be.
The Biden-Harris plan could not be more clear that Covid-19’s disparate impact on racial and ethnic groups is “unacceptable and unconscionable” and that equity is “central” to its Covid-19 response. Yet there is currently no mention of accountability: no targets, no clear reporting requirements, no incentive structures that would reward equitable vaccine distribution. Disadvantage indices can facilitate each of these essential measures. States as different as Ohio and California have already committed to using indices for monitoring purposes, which can, and should be, adopted far more widely.
Importantly, disadvantage indices also matter for clarifying the relationship between racial and social justice. Justice does not require us to ensure that the Obama family receives Covid-19 vaccines before the Clinton family. Race is irrelevant here, as both families can live safely until it is their turn to be vaccinated.
Instead, justice requires us to respond to the fact that communities of color have been hit harder by Covid-19 because they account for larger shares of the nations’ disadvantaged people which is due, in turn, to society being structured in ways that reduce their economic mobility and odds of leading long and healthy lives.
Addressing equity through an index that measures a generalized concept of disadvantage helps directly address the situation of worse-off populations but is not limited to race-based justice. As such, it can avoid legal challenges and recognizes that disadvantage can take many different forms that matter independently.
The Biden-Harris administration’s commitments to allocate vaccines equitably and in ways that reduce disparities could not be more timely. To convert this commitment into action in allocating vaccines within and across states, we need to dovetail it with the innovative uses of the SVI and other indices in state-level allocation plans to systematically plan, track, and adjust vaccine coverage rates along the disadvantage spectrum.
Harald Schmidt is an assistant professor in the department of medical ethics and health policy, a research associate in the Center for Health Incentives and Behavioral Economics, and a senior fellow at the Leonard Davis Institute of Health Economics, all at the University of Pennsylvania.
Does everything — just everything — have to be imbued with identity politics and ideology?
States are already so utterly incapable of doing a rapid and orderly vaccine allocation — and now you suggest that they evaluate everyone’s race/income/education/etc?
Go back to academia or wherever — and let’s get the job done.
The science shows clearly that age is the dominant risk factor for dying from Covid. After that, there are factors that make some people more likely to be infected than others, or less able to access vaccine distribution. That said, the CDC advisory committee’s recommendations are essentially criminal in their effect. Right now in Phase 1b, we are vaccinating healthy 25 year-olds in “essential” industries, while truly “at-risk” older people remain vulnerable and are told to “wait their turn.” The notion of vaccinating the “spreaders” is a completely bankrupt idea in this setting…we know who is vulnerable….and that population is much smaller than the population of potential spreaders. Once again, the vaunted CDC has fallen well short of the any reasonable standard of competent.
Well my son has high functioning autism which is a risk for serious disease and is also 28 years old and he also works as a cashier in a grocery store and lives with his parents who are in our 60’s. We are at high risk from him bringing this disease home to us. I spent a lot of money on N95 masks for him to wear but when he is handling germ ridden cash all day long while checking out hundreds of people right before a holiday or a snowstorm like we had this week there is a substantially higher risk of him being infected due to the amount of covid aerosols in the store. Therefore I am in favor of these low wage workers, many of whom live with their elderly parents or in multigenerational households getting vaccinated as soon as possible. Also he works very unpredictable hours, 2 weeks ago he only worked 10 hours and his take home pay was $120 for that week. This week he worked a lot before the snowstorm and the store was packed with people shopping before the storm was to hit. His life is very hard due to his disabilities. Why do you want to discriminate against the disabled when many of these people work in supermarkets? I also have read very few articles where people with autism are advocated for getting the vaccine. There are a few articles where people with Down Syndrome were advocated to get the vaccine and a few where people with intellectual disabilities were advocated to get the vaccine. The point being that people with these disabilities were more likely to have serious disease. Also, people over the age of 75 can stay at home and collect their social security checks. My son isn’t disabled enough to qualify for SSI. The government isn’t going to hand him a monthly check for the rest of his life. And he is still waiting to get his shot, there is a big shortage of supply of vaccine.
I can not really dig through all the vagueness in this OpEd – I am not sure the author even tried to define his terms. I can tell he is worried about some kind of unfairness, but what exactly? Rich vs. Poor? White vs. Everybody else ? I am not getting it, this seems to be written only for people who are already deep into this stuff.
But, generally the problem with “equitable” distribution is, as he says, people can not agree on what it is.
I would suggest yesterday’s interview with Dr. Michael Osterholm, in which he states we are in for a “Hurricane” of UK variant outbreak in a few months, may be reason, IF we have the capability of doing anything intelligent at all, to concentrate all resources on suppressing that outbreak.
And, since they seem to be looming, suppressing all the other variants from their outbreaks. Right now, it appears we are looking at having 4 epidemics at once- Original type, from Wuhan, UK variant, South Africa Variant, and Brazil variant.
Whatever it takes to slow those down should be done – “equitable” or not. Right now, that appears to be getting as many people their first shot as possible, per Dr. Osterholm, and waiting on the second a few months. He says we need to do that ASAP, and is publicly urging the President to order it.
That is of much more interest to me.
I also want to say – I believe CDC let us down by not instituting effective quarantine rules for people entering the US. I realize these variants would likely get here sooner or later – but delaying them even just a few months had tremendous benefits for the country if we use our time well. Moderna is working on a “booster” to handle the South African variant – which we are told can be produced in a few months – that few months might have saved a lot of people, a great deal of money, and lot of emotional pain.
This should help slow distribution down, as if it weren’t already galacial with “essential” workers refusing vaccines at amazing frequency.
So nopw we are going to make what should be a simple process even more complicated than it already is? People are crossing county and even State lines for the SOLE PURPOSE of being vaccinated first, thus depriving some communities of doses that were designated for them. Why don’t we address THAT first instead of going onto throwing race, income, and other factors into the mix.
The original guidelines will work in most communities if people just give them a chance instead of trying to climb all over one another to be the first in line.