America’s unjust status quo threatens the intervention we need most
In 1954, a very risky experiment took place across many different cities in the United States. Families lined up for hours in the summer heat so parents could have their children immunized against polio. At the time, polio was affecting children in the US in waves, mostly in the summer, and mostly around communities with swimming pools, schools, and daycare facilities that offered the virus plenty of chances to jump from one person to another. Notably, if you look at the photos of those vaccine trials, most of the participants were white children, and most of the trials took place in white areas of cities or in the suburbs — which were mostly white at the time.
The Reality of Polio Was Different
The differences between how those trials — and public health surveillance of polio — treated whites versus Blacks was so intertwined with the racial realities of the time that many epidemiologists actually convinced themselves that polio was a disease that did not affect Black children like it affected white children. The truth was quite the contrary.
Like so many other diseases and medical conditions seen throughout the history of the United States, polio disproportionately affected people of color, and it was segregation and discrimination which caused the numbers to be skewed artificially and/or by design.
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A Familiar Story
Sadly, this story is again playing out as the Covid-19 pandemic has taken hold in the United States. From the get-go, Covid-19 has disproportionately affected people of color in the United States. At first, it was the wealthier and whiter sectors of the country that were getting tested the most because many of the people living in those areas had access to healthcare. As Dr. Usama Bilal, an urban epidemiologist at Drexel University, and his colleagues pointed out early on in the pandemic:
We have documented a dynamic situation regarding disparities in COVID-19 testing in two US cities. There are wide disparities in testing availability for the most deprived neighborhoods in Philadelphia, a city early in the epidemic, while these disparities seemingly dissipated in NYC, a city with more widespread testing later in the epidemic. However, we consistently see a very strong positive correlation with the % of tests that are positive in both cities, and this disparity is widening over time. These results suggest potential greater community spread in these neighborhoods and is aligned with recent data showing that social distancing is socially patterned, with less social distancing in lower income neighborhoods due to structural constraints.
Later on, as the pandemic progressed, most of the confirmed cases of Covid-19 were found in People of Color. The reasons for this are clear to those of us who study disease patterns for a living. People of color — on average — are less affluent than whites. People of color — on average — hold jobs that require them to go to work every day, or jobs that do not allow them time off to stay home if they are sick. People of color — on average — live in crowded housing, so if one member of a family or residential unit brings in the disease, it passes to others quite efficiently. People of color — on average — have less access to preventative health care and nutritious food, resulting in comorbidities that place them at higher risk of complications from the disease. Finally, people of color — on average — are more likely to mass transit or work in environments that are crowded.
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The pandemic has certainly illuminated disparities in a way that has made many of us working in public health and healthcare stop and take inventory of what is happening. Whether or not something will be done about the patterns we are witnessing on a grand scale is another matter.
Disparities inform much of how diseases progress, and any quality public health agency would be wise to pay attention to the distribution of those disparities. Political considerations aside, if a disease or condition affects Group A more than Group B, we must look to see what it is about Group A that is causing this, so we can help them get through the epidemic, before we turn to Group B and help them next.
That is the public health ideal, in any event. Through that lens, we’d do well to consider the biggest future public health intervention in this pandemic — vaccine distribution.
“Equitable Allocation” of a Covid-19 Vaccine
Recently, the National Academies of Science, Engineering and Medicine published a report titled “Discussion Draft of the Preliminary Framework for Equitable Allocation of COVID-19 Vaccine.” This draft report basically states that a Covid-19 vaccine should not be allocated on a first-come, first-served basis because there are groups in the United States who will be unable to be first in line to get the vaccine when they need it. For many people of color, it may be difficult to go stand in line to get a COVID-19 vaccine. They are more likely to be working jobs that will not allow them to take time off, or they will be taking care of their families at home.
As an epidemiologist and a seasoned American, I am fearful that an inequitable allocation of the vaccine will keep our public health status quo going strong. Simply put, it looks likely that the populations who are driving the epidemic in the United States will continue to drive it because they will not be adequately protected against infection. I worry that the service staff who ride the bus or the train to and from work, the housekeeping staff who clean hotels and hospitals, the older Latino grandparents living with their children and grandchildren who all go to work or school, and the Black grandparents with obesity and diabetes living in a food desert will have less access to the vaccine.
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Based On Our History
If the history of the polio vaccine is any indicator, we’re likely to see the COVID-19 vaccine be distributed in an inequitable way. In the 1950s, it was the parents of mostly affluent white children who were able to stand in line for their children to be vaccinated. Sadly, the social and economic realities that influenced that in the 1950s are alive and well today. When the HPV vaccine that protects women against cervical cancer was licensed in 2006, the level of vaccine uptake was significantly lower for those who were poor compared to those who were not poor. The reasons for this inequity in vaccine uptake range from overall lack of access to healthcare to lack of understanding or information on the benefits of vaccination. It is also worth noting that newer vaccines may be more expensive because health insurance or state insurance plans do not cover their cost until the vaccines are recommended and approved for use by federal and state regulators. In the United States, billions of dollars in public funds have been allocated toward vaccine research and development for COVID-19. Because of this, and based on statements from federal officials, a COVID-19 vaccine will likely be free.
Then there are compulsory measures that local and state governments — or employers — may put on people to enforce that as many citizens as possible get vaccinated. When vaccines are required for school and parents lack the time or the access to have their children immunized, those parents may not have the choice to take their children to private school or opt for at-home schooling. If an employer requires a vaccine that an employee is unable to get, that employee may be without income and unable to pay for necessities. Of course, this assumes that they are not vaccinated or able to get vaccinated because of lack of access and not because of vaccine hesitancy.
What About Vaccine Hesitancy?
Do all Americans have access to equal measures of science-backed truth when it comes to what we know and what we don’t know about the coronavirus, how it behaves in the body, and what we can fairly expect from a vaccine? Sadly, that too is up for debate. At this moment in time, the United States is extremely divided along political lines. It’s deeply concerning to imagine that a significant proportion of the population might not want to jump in line to get the Covid-19 vaccine simply based on a proclamation from one politician praising or trashing it. Sadly, we might see a similar effect if social media “influencers” decide that the vaccine is not for them.
There is also the very real possibility of a magnification or exaggeration of the effects of an adverse event in a vaccine recipient. When I was working at the Maryland Department of Health, a vaccine clinic in 2009 (during the H1N1 pandemic) was being filmed by a news crew, and they caught a nurse giving a vaccine with a defective syringe. Instead of the vaccine solution being injected, it was ejected at the junction where the needle is attached to the syringe. The recipients were then scheduled to get a second vaccine dose “out of an abundance of caution” to make sure they were receiving a full dose. Many of them never did. They didn’t want to take the chance of being “overdosed” by the vaccine, though such a thing is significantly rare.
In an era when one person’s alarming-sounding, but unverified, story can quickly go viral, a few adverse events from a mass distribution of Covid-19 vaccination might translate to many people becoming (unnecessarily) scared of the vaccine. What would be a very rare event — like a rash or a fever — runs the risk of being amplified. This possibility becomes probable if vaccines are approved before Phase III trials are complete. For example, if an adverse event happens in 1 in a million people, it would be difficult to detect it if only 30,000 people are in a trial. It would take 1 million people to be in the trial in order to detect it. Once the vaccine is given to the entire US population, we could conceivably see over 320 events of varying severity, all alarmingly amplified by social media and viral videos.
What Is Past Is Prologue
The history of the United States is rife with examples where people of color and people who are poor or socially disadvantaged end up taking the brunt of an epidemic. In the mid-1800s, an epidemic of smallpox hit Boston. It was the Irish immigrants who made up most of the cases then. In the 1990s, a non-infectious disease arising from poor nutrition resulted in a cluster of Mexican-American children on the Texas border being born with spina bifida, a defect of tissue surrounding the spinal cord where the spinal cord and even the brain is left exposed at birth.
Our public health response today, which should be guided by science and evidence (like it did in the eradication of smallpox), is being hijacked by politics and “the death of expertise.” Political appointees at the Centers for Disease Control and Prevention (CDC) edited scientific reports critical of the current Administration. Otherwise sensible people are falling for lies about the very existence of Covid-19 or the preventative benefit that cloth masks provide.
As CDC now begins to request that states and local governments prepare for a mass dispensing of a COVID-19 vaccine, policymakers must carefully ensure equitable vaccine distribution. Failure to do so may perpetuate the epidemic, especially in groups who are at increased risk of severe outcomes. If the epidemic continues because at-risk Americans continue to live and work in conditions that perpetuate spread of the disease, and vaccines are not readily available to them, the effectiveness of even the most successful vaccine will sadly be compromised.