Race for the Vaccine

Racial politics must not warp a question of public health. Covid-19 inoculations should go to the most needy first.

When the Covid-19 vaccines arrive, demand will greatly outstrip supply. Treating one person means not treating another. An anguishing question follows: Who first?

That ethical quandary may soon become a practical one, now that two pharmaceutical teams—Pfizer with the German firm BioNTech; and Moderna—have reported vaccines that prevented the disease in at least 90% of volunteers in preliminary clinical trials. The Food and Drug Administration could approve the vaccines for use in the United States within weeks.

Public-health experts and bioethicists consider three basic questions about different groups of people when judging how to maximize the communal benefit of scarce drugs. 1) Is the group at high risk of exposure? 2) Does the group play a critical role in maintaining the healthcare system? 3) Are certain groups more likely to transmit the virus to others?

There seems to be consensus that frontline healthcare workers should go to the front of the queue. After them, the vaccine could go to essential workers who keep communities running, or to people with medical conditions that put them at risk for terrible outcomes if infected.

But after that? The answer given by some health experts is that the government should prioritize recipients according to race. This would be a mistake.

Dr. Jose R. Romero, chairman of the Centers for Disease Control’s Advisory Committee on Immunization Practices, ACIP, which advises the government on distribution, has indicated that the committee will consider ranking Blacks and Latinos as priority recipients. “They are groups that need to be moved to the forefront,” he said.

Lawrence Gostin, a professor of global health law at Georgetown University, said racial priorities were “an ethical imperative,” citing “historic structural racism that’s resulted in grossly unequal health outcomes for all kinds of diseases.”

And the dean of George Washington University Law School, Dayna Bowen Matthew, a consultant to ACIP on the prioritization issue, said that racial inequality produced the underlying diseases that increase risk of mortality. “And it’s that inequality that requires us to prioritize by race and ethnicity.”

Does it?

First, let’s consider what we know about risks to Blacks and Hispanics. Members of these groups are infected with the virus at three times the rate of Whites and die at least two times as often. Their risks of exposure are increased because they are more likely than Whites to work lower-paying jobs that require interaction with the public and to travel to those jobs by public transportation. Blacks and Hispanics are also more likely to live in homes with many family members sharing close quarters.

The National Academies—non-governmental institutions that offer expert advice on science policy—have proposed an allocation plan giving priority to communities that rate high on the Centers for Disease Control’s Social Vulnerability Index, which takes into account poverty, unemployment and health-insurance rates, among other socioeconomic vulnerabilities. The index would be applied to each of several priority phases, the first being healthcare workers, the second being those who are medically at risk due to concurrent illness and age, and so on.

Since certain minorities are more likely to be socially vulnerable to infection with the virus—a status with roots in past discrimination—they will disproportionately receive the vaccine early under that approach, consistent with the public-health goal of maximizing communal benefit.

But a person’s race, per se, does not put him or her at greater risk for becoming infected or dying from Covid-19. Race is a correlate but risk is the cause. Therefore, allocating the vaccine based on the moral impulse to correct past injustice would not maximize communal benefit.

Also, many Blacks do not welcome the prospect of going to the head of the queue. “As a Black woman there is no way I’m lining up first for this vaccine,” wrote a New York Times reader from Clifton, Virginia, in a comment thread. “Two words: Tuskegee Study,” she added, referring to the decades-long U.S. Public Health Service study in which Black men were deprived of known treatment for syphilis to track the progress of the disease. 

Another reader concurred: “Black folks do NOT want the vaccine first…They do not want to be guinea pigs yet again.” 

These comments align with a recent STAT-HarrisPoll showing skepticism among some Black Americans about getting vaccinated. Only half of the Black respondents said they would get the vaccine if it lowered the risk of contracting the infection by 90%, while nearly two-thirds of the full sample would do so.

Likewise, efforts to get Black participants in vaccine research have been challenging. Two Black university presidents, C. Reynold Verret of Xavier University and Walter Kimbrough of Dillard University, were strongly criticized when they encouraged their campus communities to enroll in Covid-19 clinical trials. Again, many people cited the notorious Tuskegee Study.

Inclusion in clinical trials is important both for demonstrating to different communities that the vaccine will not harm them, and for understanding safety and effectiveness across racial groups. Fortunately, several medical schools at historically black colleges are making headway in hosting Covid-19 vaccine trials on their campuses.

An effort to encourage people to take the Covid-19 vaccine, not race-based prioritization, is what will best protect Black Americans from coronavirus. Compensation for past injustice is worthy of debate in other venues, but has no place in vaccine allocation.

Sally Satel, M.D., is a resident scholar at the American Enterprise Institute and a visiting professor of psychiatry at the Columbia University Vagelos School of Medicine.