A safe and effective vaccine could play a significant role in mitigating the COVID-19 pandemic. Yet, even if such a vaccine is found, it is highly unlikely that a sufficient number of doses could be produced in the next two to three years to ensure equitable access for everyone. So, when a COVID-19 vaccine becomes available, who should get it first?
Most guidelines for allocating limited supplies of vaccines would put healthcare workers at the front of the line, but there is little consensus about how a COVID-19 vaccine should be allocated beyond this group.
Guidelines for allocating vaccines during an influenza pandemic, released in 2018 by the US Centers for Disease Control and Prevention (CDC), would place certain national-security personnel at the top of the list, alongside healthcare workers.
This reflects the CDC’s pre-COVID-19 tendency to emphasize the securitization of health: An influenza vaccine, the guidelines say, should be allocated in a way that would “maintain national security, healthcare, and other essential community services.”
The WHO takes a different approach in its latest guidelines, released last month and focused specifically on COVID-19. It lists adults aged 65 and older as the highest-priority group, after healthcare workers. The WHO’s overarching goal is to reduce mortality and prevent healthcare systems from becoming overwhelmed.
Yet, for bioethics experts, the guiding principle when allocating limited resources during the COVID-19 crisis should be to “maximize benefits.” They suggest that after healthcare workers are vaccinated, a lottery system would be the most equal way to allocate a limited supply of the vaccine.
Each of these guidelines weighs factors like occupation, age and medical risk differently. All of them have one thing in common: They are silent on race.
There is no question that COVID-19 has disproportionately affected communities of color. In the US, the CDC reports that Native Americans and African Americans are five times more likely to contract COVID-19 than white people. Black and Latino people have died at nearly twice the rate of whites.
In the UK, Public Health England found that people of Bangladeshi ethnicity are twice as likely as white people to die from COVID-19, while the National Health Service revealed that black women are 4.3 times more likely to die than white women.
A range of factors contribute to these inequities. Black, indigenous and people of color communities occupy a disproportionate share of frontline jobs that cannot be done from home. They are more likely to rely on public transportation, live in crowded housing and often suffer from underlying health problems.
Furthermore, the communities have reduced access to health services and a documented history of receiving inferior care. The oppressive nature of white supremacy is profoundly apparent.
The CDC has discussed whether race and ethnicity should play a role in COVID-19 vaccine-allocation decisions. The topic has proven contentious, and there is no indication of how race could shape their guidelines, or whether it would be included at all.
However, given the scale of the disparities in COVID-19 outcomes, a race-neutral approach is not appropriate. What is needed instead is an actively anti-racist framework.
How to design such a framework must be considered in the context of “vaccine sovereignty” — an idea that describes how governments use public funding, supported by the pharmaceutical industry and research universities, to obtain priority access to potential vaccines. This concept — embraced by the US and Europe — turns vaccines into instruments of power designed to decide whose lives matter the most.
The ironically titled Inclusive Vaccine Alliance shows how vaccine sovereignty reproduces global inequity. The group — comprising France, Germany, Italy and the Netherlands — has negotiated priority access to various potential COVID-19 vaccines and is “also working to make a portion of vaccines available to low-income countries, including in Africa,” the Dutch government said.
This display of European “benevolence” toward poor African countries entrenches colonial dynamics. More broadly, it highlights the inadequacy of a race-neutral approach. Historical injustices perpetrated against communities of color must therefore be factored into the design of vaccine-allocation frameworks as part of a more comprehensive process to address the systemic failures embedded in health systems.
In his book How To Be an Antiracist, the historian Ibram X. Kendi quotes US Supreme Court Justice Harry Blackmun, who wrote in 1978: “In order to get beyond racism, we must first take account of race. There is no other way. And in order to treat some persons equally, we must treat them differently.”
During the COVID-19 crisis, that means giving communities of color priority access, alongside healthcare workers, to a vaccine.
In doing so, we must acknowledge the long history of medical experimentation on the communities.
Just a few months ago, French doctors suggested that COVID-19 vaccines first be tested on Africans. Against this background, any effort to vaccinate communities of color first will likely be met with skepticism and fear. An anti-racist vaccine-distribution framework must address this reality.
Giving communities priority access to a COVID-19 vaccine must not be confused with reparations for slavery and colonialism. It takes much more than a vaccine to address the systemic injustices of white supremacy. An anti-racist allocation framework could be a step toward rethinking the race-neutral ideology that shapes the global health architecture.
A. Kayum Ahmed is the division director for access and accountability at the Open Society Public Health Program in New York.
Copyright Project Syndicate
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