Take a look at California's COVID-19 caseload maps, and it's easy to spot where rates are highest: in some of the state's most diverse and low-income communities.
The virus has ravaged urban centers like Los Angeles, infiltrated rural Imperial County and flooded the farmlands of the Central Valley.
But COVID-19 does not claim its victims equally. Latinos make up 40% of the Golden State's population, but 60% of its COVID-19 cases and 48.5% of its deaths. Only 6% of Californians are Black, but 7.4% of COVID-19 deaths.
Now, as California plans to distribute an eventual vaccine to its nearly 40 million residents, the state intends to prioritize early rounds of the shots in the name of fairness for these communities disproportionately affected by the disease.
It's not just race under consideration. The state is in early planning stages, but data like death and infection rates, along with housing status, age, economic stability, health care coverage and ethnic backgrounds could all play a role in who might be among the first groups to get vaccinated, according to the California Department of Public Health's draft vaccination report.
Gov. Gavin Newsom underscored on Monday California's commitment to the "critical nature of making sure that those most in need are prioritized in terms of the access and distribution of this vaccine."
"Along the spectrum of making sure Black and brown communities disproportionately are benefited," Newsom said, "because of the impact they have felt disproportionately because of COVID-19."
California's process might also mirror a federal strategy.
The Advisory Committee on Immunization Practices, which works with the Centers for Disease Control and Prevention on vaccine administration logistics, is considering a phased plan that underscores the "disproportionate burden of COVID-19 disease in some racial/ethnic minority groups."
The approach raises obvious questions.
That kind of prioritization, according to the Journal of the American Medical Association, could raise future political or legal liabilities. While the journal notes in a recent article that the "ethical justification for prioritizing economically worse-off racial minorities rests on epidemiological, economic, and social justice grounds," it's unclear "whether government is permitted to consider race when seeking to ameliorate the effects of past and current discrimination."
State Sen. Richard Pan, a Sacramento Democrat and pediatrician who's written California's strong vaccine laws, said the state's strategy is more than just humanitarian.
To slow the spread of the virus, he said, prioritizing vaccination in certain areas with higher case numbers is a smart and strategic tool to curbing COVID-19's grip on the state.
"There's certainly a social justice part about this. People in these communities are more likely to get sick and die of the virus. We need to recognize that," Pan said. "But for the rest of us going, 'why are these people at the front of the line?' That will actually do more to save you than anything else as well. It's not just that they will benefit more. It's better for all of us."
Here's what the plan could look like:
COVID-19 infection rates
To stymie and control the spread of COVID-19, according to Johns Hopkins Bloomberg School of Public Health, positivity rates should stay below 5%. That number doesn't mean the virus is nonexistent in a certain community, but that it's low enough for public health officials to track where outbreaks are occurring so they can mitigate COVID-19's transmission.
For counties to reopen their businesses and other services, the state's Department of Public Health also mandates they meet certain lower positivity rates within communities of color. Dubbed the "equity metric," counties are required to track positivity rates in areas that might have lower access to, among other factors, housing, transportation, education, medical care and environmental wellness.
In Imperial County, where the average income is $45,834 and 21% of the population lives in poverty, the health equity positivity rate is 12.4%. In Los Angeles County, home to a large Latino population, that rate is 6.5%. In Riverside County, the positivity rate in these communities is 8.5%, while that number is slightly smaller, 8.3% in Fresno County.
Comparatively, Marin County, a bastion of wealth in California, has a health equity positivity rate of 1.3%. That number bumps up to 1.5% in San Francisco County, and to 2.8% in Santa Barbara County.
Richard Carpiano, professor of public policy and sociology at UC Riverside, said "many aspects of privilege" help insulate certain regions against COVID-19, while "vulnerable, underrepresented and historically discriminated and marginalized communities" are hard hit by its spread.
Given those dynamics, Carpiano said, the state's vaccine distribution strategy makes sense.
"The way the numbers are and the risks and where we see the hot spots occurring," he said, "this is the most effective way to address, to alleviate the suffering."
Building trust with Blacks and Latinos
Along with reviewing rates of infection, which will inform vaccine campaigns, health officials also have to understand social dynamics.
It won't be enough to flood neighborhoods with flyers about the importance of getting vaccinated against COVID-19.
Dr. Sergio Aguilar-Gaxiola, director of the Center for Reducing Health Disparities at UC Davis, is concerned with the spread of the virus, particularly in regions that contain large farmworker populations, such as Stanislaus and Fresno counties.
Aguilar-Gaxiola said the state has to implement its vaccine strategy in a careful, considerate way that builds trust with vulnerable Californians. He said "there has been a lot of confusion and chaos" surrounding information about a COVID-19 vaccine that could cause hesitancy within Latino and African American communities.
A dark history of medical experiments, including the Tuskegee study of untreated syphilis in Black men, and a traditional lack of health care access for low-income and undocumented populations, could discourage confidence in the COVID-19 vaccine process.
"There's a significant level of mistrust in the health care system for very good reason in communities that have been exploited and experimented on," said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network. "And that's a lot to overcome."
Along with reassuring certain populations, the state also has to navigate vaccine distribution logistics in other medically fragile, transient and hard-to-reach congregate settings, like nursing homes, homeless shelters, multi-generational households, prisons and tribal communities.
Dr. Rais Vohra, Fresno County's interim health officer, said officials are already preparing for the challenging task ahead.
"There's some neighborhoods that we know may have more percentage of essential workers, people who just can't work from home, who have to be on the front lines of public service...Some neighborhoods and families with many generations living together, not many resources to isolate or quarantine at home or who share transport or use public transport," Vohra said. "Those are the kinds of scenarios I worry about."
Public pushback on vaccine strategy
While public health professionals have warned against assuming the COVID-19 vaccine is a silver bullet to ending the pandemic, news of both Pfizer's and Moderna's efficacy rates in the last week has many excited.
But for most Americans, it will be a long time before their local pharmacy has a stockpile of COVID-19 shots.
Public health officials say the general public won't get vaccinated until the third quarter of 2021, after health care personnel and more vulnerable populations receive the first rounds of supply.
It's fair to anticipate opposition to that tiered implementation, Pan said, given how eager everyone is for the end of the pandemic.
That push-back, Carpiano added, will likely be limited to the court of public opinion given the dire circumstances in certain communities.
"The data is quite clear. We have more than enough cases in certain groups with a more appreciable elevated risk than others," he said. "It becomes a hard argument (for others) to say, 'I'm being discriminated against.'"
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