WASHINGTON — To hear top officials in the Biden administration tell it, the effort to vaccinate Americans is a contest against the coronavirus, a determined opponent that could flare into a new surge (as it recently did in Michigan) or evolve into new variants before enough people have been inoculated to stop community spread.
“We’re still in a life-and-death race against this virus,” President Biden said earlier this month. He has frequently announced more aggressive vaccination timelines, promising that there would be enough vaccines for every American by the end of May. His administration kept to that goal even as the Johnson & Johnson vaccine was taken out of circulation because of concerns over blood clotting. According to a recent poll, about a quarter of Americans don’t want a vaccine.
Given the big challenges and high stakes, some have wondered if the administration’s concern with “equity” — the idea that vaccines should first go to socially vulnerable populations, including people of color and essential workers — is slowing the very effort that Biden is so desperately trying to accelerate. Such critics say that simply getting as many people vaccinated as quickly as possible, instead of trying to engineer social outcomes, would have brought the end of the pandemic closer.
“These efforts are well intentioned but have led to more deaths than would have happened had a simple age-prioritization strategy been universally adopted,” said Dr. Jayanta Bhattacharya, a health economist at Stanford University.
So far, the United States has vaccinated 26.3 percent of its population, meaning that herd immunity — when vaccination and natural immunity from recovered coronavirus patients are so high the virus can’t easily spread anymore — is many months away. And, said Brookings Institution health scholar and former Obama administration official Dr. Kavita Patel, “we may have to do this all over again with booster vaccines.” Those boosters could be necessary as early as the fall, leading to renewed debates over vaccine priority.
Equity has been “a priority, but also a challenge,” acknowledges a senior official at the Department of Health and Human Services. That challenge is complicated by the fact that Biden took over the vaccination effort from Donald Trump, who did not make equity a priority. Had the Biden administration been able to start fresh, Patel believes, the equity goal would have been easier to articulate — and implement.
“We should have definitely had a cleaner way to do this that was uniform across the states,” Patel told Yahoo News. “I blame a lot of this on the transition of government,” which took place in January. Biden quickly appointed his own coronavirus response team, a version of which had been working throughout the presidential transition. But by then, states had already been distributing vaccine doses according to plans they had submitted to Trump months earlier.
Getting the coronavirus vaccine out faster means having less time to figure out who gets vaccinated. Equity advocates say the wait is worth it, arguing that a proper vaccine distribution plan has to frankly acknowledge (and account for) the uncomfortable fact that behind last spring’s we-are-all-in-this-together rhetoric is a far more complex reality. African Americans and Latinos are twice as likely to die from COVID-19, the disease caused by the coronavirus, than are whites, according to age-adjusted statistics from APM Research Lab, a data visualization firm.
“Vaccine equity is not BIPOC receiving the same share of vaccines compared to their shares of the total population,” said health equity expert Dr. Uché Blackstock, using a term for Black and Indigenous people as well as other people of color. “It’s when their vaccine shares are based on their shares of cases and deaths. We know we’re doing it right when BIPOC are overrepresented among vaccine uptake.”
That is simply not happening at this point. The Kaiser Family Foundation has found that whites constitute 64 percent of people either fully or partially vaccinated, while only 12 percent are Hispanic and 9 percent are Black (the figures are indicative but incomplete because race data is not available for close to half of vaccinations). These alarming national numbers only reflected what states were doing, and had been doing since shots were first administered under Trump. At work was “a consistent pattern across states of Black and Hispanic people receiving smaller shares of vaccinations,” the Kaiser researchers wrote, “compared to their shares of cases and deaths and compared to their shares of the total population.”
In many cases, coronavirus doses became another scarce resource for the health care industry to avidly market and for people with resources to eagerly consume. The concierge service One Medical, which charges $200 a year to join, began offering its members priority access to the coronavirus vaccine over the winter, before many other Americans had similar access. Some hospitals gave vaccine doses to wealthy donors already well insulated from the dangers of living in crowded housing or working a frontline job.
“We have to take a very deliberate approach,” said Karyne Jones, president of the National Caucus and Center on Black Aging and a founding member of the COVID-19 Vaccine Education and Equity Project. She praises the Biden administration for not measuring the success of vaccination by speed alone. “They've done very well,” Jones told Yahoo News. “They’ve made equity a major issue.”
The Biden administration did say that equity would be key. Whether it has actually acted on that imperative is a matter of debate.
In January, the White House placed Dr. Marcella Nunez-Smith, a respected Yale University health economist who had been an adviser on the presidential transition, in charge of making sure that vaccines are equitably distributed. Her job, in essence, was to prevent what happened with One Medical becoming a national phenomenon, with scarce vaccine doses being concentrated in wealthier, whiter communities that had suffered the fewest health and economic effects of the pandemic.
“Equity is our North Star here,” Nunez-Smith said at an early February briefing of the White House COVID-19 response team. She and Jeff Zients, who heads that team, discussed efforts to ship vaccines to local pharmacies and community health centers.
Later in the briefing, a BuzzFeed reporter wondered if there would be an “inevitable trade-off in terms of efficiency versus equity.” Equity requires patience, which takes time. As the reporter observed, the administration’s twin goals — to vaccinate as quickly and as equitably as possible — were not entirely compatible.
“I don’t accept that premise at all,” Zients shot back.
Yet disparities persist even though Biden and his top public officials have been talking about them for months. The administration insists it is up to the equity challenge, pointing to partnerships with community health centers and pharmacies. It has opened both mass vaccination sites and mobile vaccination units. It has run advertisements on popular Black radio programs like “The Rickey Smiley Morning Show,” as well as on the Spanish-language network Telemundo.
Some say that equity is best achieved through efficiency of getting vaccines to states. “I think it’s possible to achieve both speed and equity,” former Baltimore Health Commissioner Leana Wen told Yahoo News. “Ultimately, speed also helps with the equity goal.”
That’s what states like Wisconsin have concluded, putting aside equity-first goals in favor of moving faster. “Early on it looked like maybe we had been too elegant with the categories,” admitted a doctor who’d created the state’s formula for equitably distributing the vaccine.
That formula is no longer in use, and the once-lagging state is being touted as a vaccination success story. At the same time, simplicity seemed to also give public health officials there some flexibility. To address disparities in Milwaukee, for example, they set up a vaccination clinic inside a popular Black barbershop and otherwise increased access there.
“The state did a really good job of messaging to everyone that if they’re sending us doses, we need to get them into arms — and if we don’t, they’re going to send them to someone else,” Milwaukee’s health commissioner told the Washington Post.
“Simplicity often becomes the more elegant way to do things,” Patel said.
The challenge is in balancing simplicity and speed with equity and access, and figuring it all out at a time when vaccines are still somewhat scarce and hesitancy is deeply entrenched in segments of the population. Last month, the Biden administration announced it is devoting $3 billion to “fact-based messaging,” a tacit admission that it sees the vaccine wall looming and is still finding ways to break through to people who either don’t want a vaccine or don’t know how to get one.
“We’re definitely underperforming with our vaccine rollout,” said Dr. Marty Makary, a Johns Hopkins University surgeon who has been critical of the Biden administration. “The whole rollout has been very frustrating,” he told Yahoo News, putting the blame on what he described as an “old-guard medical establishment” that has been “too rigid” in its approach.
All this comes as states continue to hold an average of 22 percent of their vaccine doses in reserve. That’s partly so that people can get their second shots of the Moderna or Pfizer vaccine, which both require a booster dose several weeks after the initial jab. It’s also partly out of equity concerns. After all, if people with free time on their hands, good internet access and the social capital to navigate bureaucratic systems were given the opportunity, they would likely claim an even greater share of vaccines than they already have.
Simply reverting vaccine distribution into a free-market free-for-all would probably alienate not only people of color but older people too. “The irony is that the people who most need quick access to the vaccine may be those who are least likely to have internet skills or access to make an online appointment,” a scholar at the Stanford Center on Longevity told the Pew Charitable Trust.
“Expanding eligibility” before people of color have been vaccinated at sufficiently high rates “systematically discriminates” against them, argues Dr. Jorge A. Caballero, a professor of anesthesiology at Stanford. Holding back doses by restricting who has access to them, on the other hand, allows public health officials to vaccinate people who are more difficult to reach: immigrants, veterans, people on Native American reservations and city residents without access to good health care or reliable information.
Washington, D.C., for example, has used only 73 percent of the doses it has been provided, below the national average. “We are absolutely focused on equity,” the district’s health commissioner, Dr. LaQuandra Nesbitt, has said in justifying that approach. Her department released vaccine doses in part based on ZIP code; in a city as geographically segregated as Washington, doing so has had the intended effect of getting doses to immigrant communities and communities of color.
There was an unintended effect, too, with frustrated people in the district’s wealthier, whiter neighborhoods hunting for shots elsewhere, potentially depriving people in those communities.
“We shouldn’t hold back any doses,” said Alex Tabarrok, an economist at George Mason University whose contrarian views on the coronavirus have earned praise. “It's vital that we vaccinate as many people as quickly as possible. We are in a race with the new variants. Now that a large share of the nursing home population and the elderly have been vaccinated, it’s time to push for speed.”
Existing vaccines work well against the coronavirus variants now circulating. The worry is that the more opportunities the virus has to proliferate, the more opportunities it will have to spawn new variants. And there is no guarantee that vaccines will be effective against those, either. In other words, the race is against not only existing variants but also variants that do not yet exist.
Supporters of an age-based approach say it makes the most sense because of whom COVID-19 is most likely to kill. The average age of a COVID-19 fatality is 72.8; according to data compiled by the Centers for Disease Control and Prevention, the fatality rate for people above the age of 85 is 193 times higher than it is for people in their 30s.
The fatality disparity is much greater between the old and the young than it is between whites and people of color. If saving lives is the goal, then the goal of providing vaccines to the oldest people first makes intuitive sense.
No country hewed more closely to the age-based approach than the United Kingdom. That approach was not uniformly popular, since it ignored the fact that some people have jobs that make them more likely to be exposed. “Teachers ‘disappointed’ and police ‘scared and betrayed’ after vaccines to be prioritised over age, not profession,” went the headline in one British newspaper. But the government of Conservative Prime Minister Boris Johnson withstood such criticism, and the U.K. has become an example of vaccination done right, with 49 percent of its population inoculated.
“The U.K. puts us to shame,” Makary of Johns Hopkins said. “They did it the right way, and they saved many more lives."
The United Kingdom is second in the world after Israel, which has vaccinated 62 percent of its population, doing so starting with elderly people. The factors in Israel’s astonishing success have been widely discussed, and many of them could not be replicated in more populous and more fractured countries.
Yet one lesson from Israel would seem to apply just about anywhere. Writing in late February, by which time the Israeli effort was in the final stages, researchers noted in an Israel Journal of Health Policy Research article that some European countries had not vaccinated even 5 percent of their population. “One key difference that we note,” those researchers concluded, “is that in contrast to Israel, some European countries have not decided to prioritize people for vaccination based on age.”
Chile, which is in third place, with 40 percent of its population vaccinated, used a hybrid approach that prioritized age but also made allowance for certain essential professions.
The lessons are clear, Makary believes. “Make it a simple age-based system, because that’s easier to implement,” he told Yahoo News."If you make something easy to follow, you will get more adoption of that medical intervention."
There are challenges inherent in any approach in a country as complex as the United States, one with a medical system in which competition is much more common than cooperation. The three top vaccinating countries, progressives have been quick to point out, all have a nationalized health care system, meaning that all people, regardless of income, have access to the same medical care. Some equity was baked into their systems, in other words, making it less of a priority when it came to coronavirus vaccination.
Although the federal government is today much more engaged in the vaccination effort than it was under Trump, states themselves ultimately decide the particulars. That has turned each state into a public health laboratory.
The state with the best vaccination record is New Hampshire. It has given at least one shot to 59 percent of its residents, and it has used 97 percent of the doses shipped by the federal government, holding virtually none in reserve for either second-dose or equity reasons. But because the state’s elderly population is predominantly white, New Hampshire has lagged badly in vaccinating people of color, since many of them are younger and therefore were not eligible for vaccination until late March.
The states with the lowest vaccination rates — Alabama, Mississippi, Georgia and Arkansas — have lagged because of high rates of vaccine hesitancy, not because vaccine distribution there has been slowed due to desired equity outcomes. Florida has been not only slow but inequitable, with Gov. Ron DeSantis, a close Trump ally, standing accused of giving preferential treatment to areas of the state where wealthy white Republicans live. Democrats have called on Washington to investigate.
Several states have, like Connecticut, jettisoned the equity approach in favor of speed. In late February, Gov. Ned Lamont said he was scrapping the state’s equity approach in favor of vaccinating by age group. “I’m going to focus on the old business motto KISS — ‘Keep it simple, stupid’ — because a lot of complications result from states that tried to finely slice the salami, and it got very complicated to administer,” he said in justifying the move.
Health equity advocates called the plan “heartbreaking,” but the state has vaccinated 33 percent of its population, putting it in fourth place nationwide.
Several other states around the Northeast made the same shift as Connecticut, away from equity and toward speed. Now all are ranked high in the share of residents vaccinated, even if they had to leave behind one of Biden’s top priorities to achieve that goal.
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