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Weighing Equity and Speed in SARS-CoV-2 Vaccine Distribution: California

Written by: Emily Han - Edited by: Maura McDonagh, Shayan Hosseinzadeh, Sami Morse & Kathleen Navas

Throughout the course of this pandemic, the equitability of SARS-CoV-2 vaccine distribution has been the foremost concern of many public health experts. Devising a strategy to roll out a vaccine in a nondiscriminatory manner is integral to a successful pandemic response, especially considering the significant socioeconomic disparities that exist in SARS-CoV-2 prevalence. The subject of many studies, these socioeconomic and sociodemographic disparities have been traced to exposure patterns, racial inequities in our healthcare system both within California and nationally, and disparities in pre-existing conditions. As these disparities differ between countries, it is important to realize that prevalence is not due to genetic susceptibility but linked to “entrenched forms of discrimination.” In combating these societal disparities with a balanced vaccine roll-out, however, we must be careful not to sacrifice speed, while extra doses pile up as we begin this race against a quickly mutating virus.

However, as Pfizer-BioNTech and Moderna have started rolling out their vaccines, high-risk groups are not necessarily being prioritized, which has worried health equity advocates. In California, the most diverse state in the nation and the state with the largest population of Hispanic individuals, racial disparities are particularly relevant for consideration in formulating a vaccine distribution plan. Although there is empirical evidence supporting the need for marginalized communities to receive priority vaccination, such as Latinx individuals having a 20% higher mortality rate from SARS-CoV-2 infection due to social determinants of health, the Surgeon General of California Dr. Nadine Burke Harris has kept California vaccine distribution based on age and occupation. This approach is endorsed by many public health experts, so long as steps are taken to mitigate health inequities. A rollout based strictly on race and ethnicity may cause issues on account of legal complications and the potential for mistrust amongst communities of color, considering the painful history of medical mistreatment of these populations. While concerned people of color can take heart in the representative demographics of Moderna’s Phase 3 trials, it should be no surprise that a history of poorly conceived studies and modern evidence of racism regularly experienced by POCs in doctors' offices have led to mistrust, and by extension, avoidance.

In their phased rollout, the state of California began the race to vaccinate by prioritizing healthcare workers and long-term care residents in Phase 1A of vaccine distribution, with the hope that all 3 million essential healthcare workers and long-term care residents receive their first dose by early February. Now, with the state entering Phase 1B Tier 1, California is opening vaccinations to individuals aged 65 and older and employees working in high risk-exposure sectors, such as education, childcare, agricultural services, and emergency care. Following this stage, the California public health website states they will be entering Phase 1B Tier 2, vaccinating individuals in congregate care facilities and people working in the transportation and logistics sector, industrial, commercial, residential, and sheltering sector, and the critical manufacturing sector. Next, Phase 1C is set to take place with some specific focus on equity, utilizing the California Healthy Places Index (HPI), which examines factors like transportation, the number of resources available to communities, and accessibility to healthcare services. Utilizing the HPI would allow for identification of communities more susceptible to contracting SARS-CoV-2, and grant these populations access to vaccination, with 20% of the vaccine supply intended for the lowest HPI quartile zip codesthe most disadvantaged communitiesand the remaining 80% accessible to older adults, regardless of race or income.

In general, California’s distribution protocols remain fluid, as the state juggles two conflicting priorities: equity and speed of vaccine delivery. Generally speaking, vaccine availability will be greater in areas of high density cases like the Central Valley, encompassing the heavily Latinx-populated San Joaquin Valley. In southern Los Angeles, home to many Black and Latinx people, vaccination rates among vulnerable healthcare workers and communities of color are disproportionately low. Although there are confounding factors that will take years to address, such as the gaps in trust between healthcare professionals and these populations, California is attempting to resolve issues on which it can have immediate impact, like accessibility to vaccination. For example, in the large metropolitan area of Los Angeles county, officials will introduce six vaccination sites including three Rite Aid pharmacies, Martin Luther King Jr. Community Hospital outpatient center, and St. John’s Well Child & Family Center. Still, on account of major barriers, such as vaccine appointments requiring internet access, a long queue for vaccination, reliable transportation, and English proficiency, individuals lower on the socioeconomic ladder find it harder to get inoculated.

Thus, although racially marginalized residents are still a priority in California, decisions are complicated by an interest in vaccinating Californians as quickly as possible, to reach herd immunity.

As the overall percentage of susceptible individuals goes down (due to both vaccination and previous infection), viral strains with modified versions of the SPIKE protein have emerged. As we become familiar with the UK variant (among others), we should be wary of the possibility of a strain that isn’t susceptible to the current vaccines, and we could see more alarming news like this NYT article describing the ineffectiveness of the AstraZeneca vaccine against the South African SARS-CoV-2 variant. Nonetheless, as Dr Nadine Harris, California’s Surgeon General clarifies, if thoughtfully executed, the vaccine distribution process can effectively achieve both equity and speed simultaneously.


Results from ongoing research and the current understanding of COVID-19 are constantly evolving. This post contains information that was last updated on February 8, 2021.

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