Don’t Forget about Minority Groups in Allocation of COVID-19 Vaccines in the United States
On Wednesday, November 18, Pfizer and BioNTech announced that they had finished the efficacy portion of clinical trials on COVID-19 vaccines, finding that the vaccines prevented 95% of cases of the disease, and submitted these results to the Food and Drug Administration for approval. COVID-19 has already claimed over 254,000 lives in the United States and 1.34 million worldwide, so a vaccine is necessary to reduce mortality rates and slow the spread of the disease.
To determine an equitable distribution of COVID-19 vaccinations to the American people, the Advisory Committee on Immunization Practices (ACIP) has set goals to decrease mortality rates and serious disease as much as possible, preserve the functioning of society, reduce additional burden of the disease on people already facing healthcare disparities, and increase the chance of high quality of life and maximize health and well-being. The committee is making its decision with the framework of four ethical principles: maximize benefits and minimize harm, mitigate health inequities, promote justice, treat affected groups, and remove barriers to COVID-19 vaccination, and promote transparency about policies. Although these aims and ethical guidelines sound ideal in theory, these lofty aims of ‘promoting justice’ and removing barriers to healthcare that have plagued minorities and lower-income families for generations are difficult to translate into concrete policy. We need to take steps to ensure marginalized groups who are discriminated against in the American healthcare system time and again are given fair and equal access to COVID-19 vaccinations.
COVID-19 already disproportionately affects communities of color: The COVID-19 death rate for African Americans is twice as high as expected based on their population, and Latinos and Hispanics make up a larger percentage of confirmed cases than their share of the population. The United States government and public health policymakers need to avoid the perpetuation of this pattern when it comes to the distribution of COVID-19 vaccinations. Historically in the United States, there have been disparities in quality, access, and affordability of healthcare for minority groups, whether this is based on gender identity, sexuality, disability status, religion, socioeconomic status, or race and ethnicity. Taking action to combat the disproportionate effects of COVID-19 on people of color is vital given these historical treatment disparities. Steps by the United States government to rectify the devastation of COVID-19 on people of color could mark a turning point in the American healthcare system’s history and begin to dismantle the institutional racism underlying these rampant treatment inequalities.
Racist myths in medicine that prevent patients from receiving proper care have persisted for centuries. False 19th century beliefs that “black people’s nerve endings are less sensitive than white people’s,” “black people’s blood coagulates more quality than white people’s,” and “black people’s skin is thicker than white people’s” are still held by medical students and residents as recently as in 2016. Similarly, in a 2012 study published in the American Journal of Public Health, there was a clear correlation between pediatrician’s implicit racial biases and the way they regarded a patient’s pain. In a simulated surgery on an African American or white teen, they were less likely to prescribe necessary pain medications for black patients. A meta-analysis of 20-years-worth of studies on the analgesic treatment disparities for people in pain in the United States showed Black or African American patients were a staggering 22% less likely to receive any pain medication than their white counterparts.
The Agency for Healthcare Research and Quality reported in the 2010 National Healthcare and Disparities Reports that African Americans and American Indians received 40% worse quality of care than Whites, Asians received 20% worse quality of care than Whites, Hispanics and Latinos received 60% worse quality of care than non-Hispanic Whites, and low-income people received 80% worse quality of care than high-income people.
In that vein, Native American peoples receive wholly inadequate access to comprehensive healthcare systems, and agencies like the Indian Health Service (IHS) that provide care for Native American peoples across the country are severely underfunded. Thus, Native American peoples have a life expectancy of 4.4 fewer years than the United States’ average and have higher mortality rates for many preventable illnesses, including chronic liver disease and diabetes.
The Trump Administration undermined enforcement of the Health Care Rights Law, a civil rights provision of the Affordable Care Act (Section 1557) that protects patients from discrimination in healthcare. Weakening the interpretation and enforcement of this law allows healthcare providers and insurance companies to discriminate against groups of people by denying access to necessary healthcare and information. This federal ruling directly undercuts protections for the LGBTQIA+ community (especially transgender and gender-diverse individuals), people with disabilities, women, non-English speakers, and others who already face rampant discrimination in the American healthcare system.
As shown above, the current phased approach to vaccine allocation for COVID-19 by the CDC and ACIP starts with Phases 1a and 1b of distribution. In Phase 1 (1a and 1b) when there will be limited vaccines available, they will be first given to healthcare personnel and first responders (Phase 1a) then likely people with comorbid and underlying health conditions that pose a significantly higher risk and adults age 65 and older and living in overcrowded settings (Phase 1b). The National Academies of Sciences, Engineering and Medicine proposes that in Phase 2, when there is a larger number of doses available, it will vaccinate K-12 teachers and other school faculty, essential workers, people in homeless shelters and group homes, individuals with mental or physical disabilities or serious mental illnesses and the staff that work with them, individuals with comorbid and underlying health conditions that pose a moderately higher risk, and other adults not included in the first phase. This phase will focus on increasing access to vaccinations for high-risk populations. In Phase 3, children, young adults, and those working in industries, crucial to the ‘function of society’ and at an increased risk of exposure to COVID-19 will be vaccinated. Finally, in Phase 4, everyone in the United States not included in Phases 1a, 1b, 2, and 3 will receive the vaccine.
However, the criteria delineated in the CDC and ACIP’s current plan for vaccine allocation are broad and still leave room for prejudice by federal agencies and healthcare workers in charge of distributing vaccines. The line between pre-existing health conditions with “significantly” and “moderately” increased risk to COVID-19 is not clearly drawn. These uncertainties in language create loopholes in which the healthcare system can continue to prioritize certain groups and ignore the needs of others. When medical policies are left up to interpretation by doctors, they intentionally or unintentionally let their personal biases affect the care they provide to patients. If a healthcare worker is racist, sexist, homophobic, or otherwise prejudiced, they can manipulate the vague guidelines laid out by the CDC and ACIP to hurt patients based on the color of their skin, gender identity, sexuality, religious beliefs, socioeconomic status, or disability status. Additionally, the current guidelines fail to account for mental illness when people with mental health conditions lead lifestyles that increase risk for contracting COVID-19, often have underlying health conditions that increase risk of developing more serious cases of the coronavirus, and mental health facilities face new challenges as the people they serve are diagnosed with COVID-19.
The CDC and ACIP’s classification of “significant” and “moderate” increased risk of COVID-19 with a comorbid or pre-existing health condition should be measured quantitatively or the CDC and ACIP should explicitly state the stage of progression or severity of certain diseases falls into each of the two categories, instead of placing that decision in the hands of a healthcare worker who lacks the years of experience in public health that these government committee members have. The framework should also take into account mental health as people with mental illness have been shown to have increased risk of COVID-19, furthermore increased risk of contracting more serious cases of the virus. The CDC and ACIP need to clarify the ambiguous language in their current guidelines and account for mental illnesses to ensure fair access to vaccination for groups like people of color, the LGBTQIA+ community, and those from low-income households, who often do not receive the care they need from the American healthcare system as is.
Learn more at the Vaccine Student Working Group on Ethics & Policy
