But Is it Fair? Bioethics, COVID-19 Vaccine Distribution, and Advocacy

We speak with Mildred Solomon, EdD, President of the Hastings Center and Professor of Global Health and Social Medicine at Harvard Medical School, where she directs the school’s Fellowship in Bioethics, about the COVID-19 pandemic, health equity, and vaccine distribution.

The Advisory Committee on Immunization Practices (ACIP) has provided recommendations for allocation of coronavirus disease 2019 (COVID-19) vaccines.1 In the most recent iteration, published on December 22, 2020, vaccine rollout was categorized into the following priorities:

  • Phase 1a: healthcare personnel and long-term-care facility residents
  • Phase 1b: persons aged 75 years or older, non-healthcare frontline essential workers
  • Phase 1c: persons aged 65 to 74 years, persons aged 16 to 64 years with high-risk medical conditions, and essential workers not included in phase 1b
  • Phase 2: all other persons aged 16 years or older who were not recommended in phase 1

With vaccine distribution in full swing, health equity research has come to the forefront of the conversation. Research has shown that Black, Hispanic, and Native American populations experience disproportionately higher rates of severe acute respiratory coronavirus 2 (SARS-CoV-2) infection and COVID-19 related mortality compared with other populations.2,3 The driver of higher infections and mortality rates: difference in healthcare access and exposure risk.

We speak with Mildred Solomon, EdD, President of the Hastings Center and Professor of Global Health and Social Medicine at Harvard Medical School, where she directs the school’s Fellowship in Bioethics.

The populations most heavily affected by the COVID-19 pandemic are also the populations that have higher percentages of comorbidity and historically lower access to care. What is your perspective on ACIP’s guidance? Are there other subgroups or communities that should also be considered a priority?

Dr Solomon: Yes. I do think that the ACIP has given very good advice to the CDC and it looks like the CDC is adopting that advice. The first people to get this will be healthcare providers. I think that it’s appropriate.

Secondly, it will go to people who are over 65 and those who live in congregate housing, nursing homes, or assisted living and that’s because they are at risk for the most severe harms. But we also have equity concerns.

Mortality cases in the Black population are almost 4 times higher than in the White population.4,5 Latinx infection and mortality rates are also higher, and the pandemic has been devastating among Indigenous populations.6,7 So we really need to go where the greatest harm is occurring and that means communities of color and Indigenous populations. 

There are 2 ways to do that. The group after people in nursing homes, congregate housing, and elderly is going to be essential workers. Every state defines “essential workers” in different ways, but there is a subset called “frontline workers,” such as grocery clerks, delivery people, truck drivers, and public transportation workers, and those are the people who are at greatest risk of contracting or transmitting the disease.

It turns out that a very large percentage of frontline workers are people of color. So by focusing on those frontline workers, we would simultaneously be addressing those at greatest risk of infection and transmission. We’d also be identifying people who are from poorer communities and communities of color that are more at risk. So I totally endorse the decision to make them the next group.

Some people argue to vaccinate people over age 65 rather than some of the frontline workers, but there’s an argument on both sides. If you want to prioritize people over age 65 next, it is because you’re privileging the fact that they are more likely to get severe illness and they’re at greater risk of death.

If you prioritize the essential frontline workers, then you are putting more emphasis on trying to reduce transmission but also on the equity concerns that these are the people who need protection the most because they’re the most vulnerable.

And also there’s a social recognition of the contributions that they’ve made by continuing to do their jobs, which have kept the rest of us going. So I think there’s a sort of acknowledgment of their sacrifice for everybody else that also should put them at the head of the line.

How do you expect factors such as resource and infrastructure limitations to affect the distribution of a potential vaccine? How can we ensure specific communities will not be overlooked, and what can we do now to prepare our clinicians and advocates in these areas?

Dr Solomon: This is a huge question especially because Pfizer’s vaccine requires such specialized cold transportation. It may end up that Pfizer’s vaccine is only going to be used in places that have that kind of refrigeration, such as academic medical centers and major urban centers. I hope that’s not the case.

But we have to make a purposeful effort to reach communities that are not just the convenient community to reach. And providers, our health systems, public health agencies in hard-to-reach rural areas should be making noise to make sure they’re noticed.

The National Academies of Science, Engineering, and Medicine published an important report called “A Framework for Equitable Allocation of Vaccine for the Novel Coronavirus.”8 They’ve promoted the use of something called a social vulnerability index, which is a way of looking at the social capital of a given region.

It looks at the social determinants of health, income level, quality of housing, and transportation, which would affect people’s ability to access vaccine sites and crowding and other factors that affect transmissibility. This is why prisons are eventually going to be one of the priority areas.

We have people identifying places that have less social capital and less access, and are more likely to be overlooked. They’re calling on states and regions to make sure that they have plans for ensuring that people who live in those areas are offered the vaccine.

How can clinicians and other members of the healthcare community improve the vaccine hesitancy that is experienced by so many communities?

Dr Solomon: It’s a special case of trust, right? And the reason I think it’s so difficult is because there are many different reasons that people feel vaccine hesitant. Those many reasons come from many different kinds of subgroups.

The distrust of the vaccine by the Black community is very legitimate because there have been so many episodes in our history of untrustworthy behavior on the part of researchers, whereas other concerns about vaccine hesitancy are based on misinformation. So it’s complicated.

I think one of the things we can do is study how to do it. There’s a need for research here so that we are evidence-based in how we approach this problem and design communication messages.

Another is to work closely with people who are already trusted in those communities. There are well-trained people inside each of these minority communities who we have an obligation to reach out to, listen to, hear what their concerns are, be in real dialogue with, and then work with them to develop messages that they feel comfortable with.

We have to be humble but also diligent in finding partners in different communities. What we can do tomorrow is find the experts, the representatives, the trusted potential partners inside these communities and reach out to them and discuss how to work together.

Vaccination cards are being distributed in the United States. What are your thoughts on mandates for the COVID-19 vaccination by the federal government or private businesses?

Dr Solomon: I’ll tell you my instincts here, but I think we need a national conversation to really think about this carefully. We have to make sure that it’s done to protect the public health without exacerbating privacy and surveillance concerns.

I think if the government were to require anything, it would be for schools. Employers and airline travel are interesting. I feel like the devil may be in the details of how we identify people and make sure that fraud isn’t possible.

And the other interesting case is whether there have to be mandates for healthcare workers, and that’s been admirably debated inside most healthcare organizations. My understanding is that most health systems do mandate that healthcare providers receive, say, the flu vaccine, for example.

So I suspect that this will become a mandate for healthcare workers by their employers. And of course they’re the number 1 people who are going to be offered the vaccine under the push that we’re having right now.

So I think that that’s going to be a foregone conclusion when all healthcare providers are going to get vaccinated. And that employer and healthcare organizations are going to require it, and I have no problem with that. I think that’s appropriate.

How can we best move forward to provide better work-life balance for our frontline workers? We are now seeing research and data being published surrounding this topic, but no resolution. Do we have to wait until the end of the COVID-19 pandemic before tackling this issue?

Dr Solomon: Our frontline workers are heroic, but are we really doing what’s needed to support them? We had a national crisis in clinician burnout well before the pandemic. Now there have been a lot of studies and there’s chronic burnout. There’s chronic workplace stress for our healthcare providers and it’s coming from many, many sources.

It’s a crisis in the nation, and it was underway long before the pandemic. And now put the pandemic on top of that, and it’s just awful. 

So there needs to be national attention. Those at the federal level, at the state level, and among the healthcare systems need to provide spaces where healthcare providers should have refuge among their colleagues in their specialty societies.


1. Centers for Disease Control and Prevention. The Advisory Committee on Immunization Practices’ updated interim recommendation for allocation of COVID-19 vaccine – United States, December 2020. Published December 22, 2021. Accessed January 21, 2021.https://www.cdc.gov/mmwr/volumes/69/wr/mm695152e2.htm

2. Mackey K, Ayers CK, Kondo KK, et al. Racial and ethnic disparities in COVID-19-related infections, hospitalizations, and deaths: a systematic review. Published online December 1, 2020. Ann Intern Med. doi:10.7326/M20-6306

3. Ogedegbe G, Ravenell J, Adhikari S, et al. Assessment of racial/ethnic disparities in hospitalization and mortality in patients with COVID-19 in New York City. JAMA Netw Open. 2020;3(12):e2026881. doi:10.1001/jamanetworkopen.2020.26881

4. Louis-Jean J, Cenat K, Njoku CV, Angelo J, Sanon D. Coronavirus (COVID-19) and racial disparities: a perspective analysis. J Racial Ethn Health Dispartities. 2020;7(6):1039-1045. doi:10.1007/s40615-020-00879-4

5. Yaya S, Yeboah H, Charles CH, Otu A, Labonte R. Ethic and racial disparities in COVID-19-related deaths: counting the trees, hiding the forest. Published online June 7, 2020. BMJ Glob Health. doi:10.1136/bmjgh-2020-002913

6. Power T, Wilson D, Best O, et al. COVID-19 and Indigenous Peoples: an imperative for action. J Clin Nurs. 2020;29(15-16):2737-2741. doi:10.1111/jocn.15320

7. Curtice K, Choo E. Indigenous populations: left behind in the COVID-19 response. Published online June 6, 2020. Lancet. doi:10.1016/S0140-6736(20)31242-3

8. National Academies of Sciences, Engineering, and Medicine.A Framework for Equitable Allocation of Vaccine for the Novel Coronavirus. https://www.nationalacademies.org/our-work/a-framework-for-equitable-allocation-of-vaccine-for-the-novel-coronavirus Published October 2, 2020. Accessed January 21, 2021.

This article originally appeared on Infectious Disease Advisor