Vaccine Allocation Equity

The Robert Wood Johnson Foundation published a very simple but effective infographic to depict the difference between policies and interventions aimed at equality, and those seeking equity:

Imagine instead of a bicycle, the example used:

• Access to the internet, having an email address or a mobile phone to receive notifications, or the knowledge of how to browse the web (or easy access to a friend or family member who can do that on your behalf);
• Being able to understand English at a high level of sophistication;
• Having a stable relationship with a health care provider or clinic;
• Having a stable home address;
• Having access to personal transportation that, if needed, would allow you to travel at short notice to a health care appointment someplace out of your immediate neighborhood;
• Having a job with benefits that allows you to take time off during regular business hours — perhaps even several hours — for a last minute health care appointment, or for feeling ill due to treatments you may receive;

Implementing a vaccine allocation plan that distributes COVID-19 vaccines to the public based on age will promote equality, at least within that age group. However, if the structures supporting the vaccine allocation system rely too heavily upon people having access to the types of things listed above, the system will end up fostering inequity in access to COVID-19 vaccines.

In addition to having suffered disproportionate levels of illness and death during the COVID-19 outbreak, minority populations are disproportionately represented among those lacking access to each of the above benefits. This means they are not only more likely to catch, be sickened by, and potentially be hospitalized or die because of COVID-19, they also are more likely to be left out of the opportunity to access the vaccine in delivery systems that rely upon those things in their processes.

An example of what to avoid can be seen in this story from South Carolina: last Friday, the state health department set up an unpublicized drive-through clinic at the state fairgrounds to give out hundreds of shots. While it was supposed to be appointment only (it’s unclear how those appointments were set up), the clinic ended up accepting many people who drove over to the site and could wait in line for as long as five hours after having received texts from friends who shared information with them about the clinic.

How can accountability for equity be integrated into vaccine allocation decisions?

The Kaiser Family Foundation analyzed state distribution plans to assess how they addressed equity. Examples of explicitly highlighting equity in planning include:

• “[P]rioritizing allocation to areas identified as vulnerable through the CDC’s Social Vulnerability Index (SVI), which determines an area’s social vulnerability based on 15 social factors, including racial/ethnic distribution.” This approach was also recommended by the National Academy of Medicine.
• Creating a health equity team or framework to guide prioritization decisions.
• “[E]mbedding workgroups, task forces, or teams focused on health equity into the organizational structures designing and leading distribution plans.”
• “[S]tates have also articulated plans to directly engage communities into their planning processes and to develop tailored communication materials that are linguistically and culturally appropriate for different populations.”

Guiding Vaccine Allocation After Group 1A

In “Ethical Challenges in the Middle Tier of Covid-19 Vaccine Allocation: Guidance for Organizational Decision-Making,” ethicists from The Hastings Center offers guidance for prioritizing equitable access to the COVID-19 vaccines during the period between what is known as “Phase 1a,” when the vaccine is being distributed to frontline healthcare workers and residents of long-term care facilities, and when the vaccines become widely available for the general population. These “middle tier” populations include “people with a high risk of severe disease or death if they become infected, based on their personal medical and social factors; people who live or work in high-risk settings outside of health care facilities, and certain “essential” workers beyond frontline health care workers.”

The report recognizes both that demand will continue to outstrip vaccine supply for the months to come, and that expanding access to broader populations will be more complex than vaccinating the Tier 1a populations.

The ethical framework proposed in this report argues that public health and health care leaders should be guided by several ethical duties during the allocation process, including

• A Duty to Plan for the management of foreseeable ethical challenges;
• A Duty to Safeguard the health care workforce and vulnerable populations in the community;
• A Duty to Guide health care workers, administrators, and others experiencing demanding work conditions, ethical uncertainty, and moral distress during this emergency;

The report describes the age-only approach to vaccine allocation as a blunt instrument to predict risk, as

“Data show significant racial variation in Covid-19 mortality rates by age, with minority populations frequently experiencing greater mortality at younger ages. Allocation based on age alone would work against efficacy and equity, because primarily white populations would receive vaccines ahead of equally at-risk minority populations who are somewhat younger.”

The authors recommend prioritizing vaccines for people who live or work in high-risk environments, including:

• “Congregate indoor sites such as long-term care facilities; jails, prisons, and immigration detention facilities; meatpacking facilities, and overcrowded housing are strongly associated with high risk of viral transmission, often producing severe Covid-19 illness due to the medical and social vulnerabilities of populations in these settings.” Populations in custody are owed a particular duty of care, as such individuals “are prevented from seeking health care on their own” and deliberate indifference to such populations medical needs has been found by the Supreme Court to be unconstitutional.
• Residents of neighborhoods with high infection rates, including residents and staff in public housing, shelters and transitional housing, as well as “clients and frontline workers in programs serving unhoused populations.”

Tools that may assist in these processes include:

• The Pandemic Vulnerability Index (PVI) or Social Vulnerability Index (SVI), for prioritizing vaccine allocation by neighborhood.
• Local public health data to prioritize vaccine allocation for neighborhoods experiencing high rates of Covid-19 transmission.

How would this approach look in practice? One example can be seen in Tennessee which, in its response plan, set aside 5 percent of the state’s vaccine supply for geographic areas with the highest Social Vulnerability Index scores.

[Author acknowledgement: Thank you to IU McKinney School of Law Professor Seema Mohapatra, as well as colleagues Professor Ruqaiijah Yearby, Professor Lindsay Wiley, Professor Dorit Reiss, and Drs. Ebony J. Hilton, Elaine Hernandez and Matthew Wynia for their guidance and feedback as I continue to learn this literature.]