Age, race, and occupation: Penn’s experts weigh in on order of vaccination distribution

As the pandemic surges and the nation's COVID-19 vaccine rollout continues flailing with a decentralized distribution plan, the debate surrounding which populations should receive the vaccine first is intensifying, with Penn faculty now weighing in. 

Penn's health and medical experts agree with the Centers for Disease Control and Prevention recommendation for frontline healthcare workers to be vaccinated first. But with essential workers, older adults, and Black, Latinx, and Indigenous Americans proven to face more virus-related risks than the rest of the population, not all experts agree on the precise order of vaccination. 

Some believe that those who have a higher exposure to the virus should be first in line, while others believe that people who face a higher risk of death should be prioritized.

Harald Schmidt, an assistant professor of medical ethics and health policy in the Perelman School of Medicine, sparked controversy after saying in The New York Times that it is reasonable to prioritize essential workers ahead of older adults, given their risks and that essential workers are disproportionately minorities. 

“Older populations are whiter," Schmidt told the Times on Dec. 5. "Society is structured in a way that enables them to live longer. Instead of giving additional health benefits to those who already had more of them, we can start to level the playing field a bit.” 

Assistant sociology professor Courtney Boen agreed with Schmidt that age plays an important role in determining the order of vaccine distribution, but added that social inequalities can often intersect with age — creating even higher risk of exposure for vulnerable populations.

“For me, it’s not a conversation necessarily about ‘either/or,’” Boen said about prioritizing vaccine dissemination to the elderly versus those affected by social inequalities. 

Boen added that the "social exposures" of many Black, Latinx, and Indigenous Americans, such as their disproportionate rates of incarceration and service as essential workers, should influence their spot in line to get the vaccine. 

According to the CDC, members of the American Indian or Alaska Native population are 2.6 times more likely than white Americans to die of COVID-19, while Black, Hispanic, and Latinx Americans are 2.8 times more at risk of death from the virus.

Boen pointed out that the “staggering rate” of early, preventable, COVID-related deaths of these vulnerable populations is an example of accelerated aging — a phenomenon explaining why those who experience excessive stress, economic hardship, and racial discrimination face increased health problems and risk of early death. Social factors like these, Boen said, should be considered in determining the order of vaccine distribution.

“Conversations about vaccination priorities should be mindful of the vast inequities that we’ve seen in terms of exposure and death that are not necessarily age-related,” Boen said.  

Infectious disease fellow Aaron Richterman echoed Schmidt and Boen, acknowledging that while age is an important factor, relying on it alone would have a “structurally racist impact.” 

“If we just leave this up to the systems that exist, and distribute the vaccine through the systems we already have in place, we are going to get an inequitable distribution,” Richterman said. 

Paul Offit, chair of vaccinology at Penn Medicine, said that after nursing home residents and frontline healthcare workers receive the vaccine, a conflict arises for the next spot in line — between those most at risk of exposure and those with the highest risk of death. 

“It’s lose-lose,” Offit said. “I mean, you’re going to be upsetting somebody.”

He added that Black Americans and the elderly population are “certainly” more likely to die if infected, but essential workers are continually exposed to the virus in order for society to function.

“You get to try to decide between 'Who’s most likely to die?' and 'Who do you need to have work so that society can function?' That’s the balance that you [have] to make. And it’s just an impossible one to do,” Offit said. 

He also warned that the ethical questions and continued debate surrounding the order of distribution could “get ugly."

“What may happen, is that there are a lot of people who want this vaccine who are not in front [of the] line,” Offit said. “Are people going to skip the line? When people skip the line, is it because of the color of their skin, or the amount of money that they have? I mean, that's often the case.” 

10,061 vaccine doses were administered in Philadelphia over the last seven days, bringing the cumulative total up to nearly 82,693 vaccine first doses and 20,888 second doses as of Jan. 21. Given the limited quantity of doses available, the city opted for a phased approach for distributing the vaccine to residents. 

The vaccine is now available to individuals in phase 1a and 1b, including healthcare workers who interact with patients and elderly residents of long-term care facilities in phase 1a and high-risk essential workers, people who reside in congregate settings, those who are 75 and older or have high-risk medical conditions, and high-risk essential workers in phase 1b. 

Phase 1c includes lower-risk essential workers and people between 65 and 74 years old, and phase 2 includes anyone who is 16 years or older and has not been previously immunized.

As for college students, Offit and Chief Wellness Officer Benoit Dubé said that because they are generally less at risk of death and serious illness, they should and will be further down the line. 

“We have to be fair and equitable as to who gets it,” Dubé said on Jan. 12. “Many people want it, but some people should get it sooner than others.” 

Dubé added that though Penn does not yet have a plan for distributing the vaccine to students and faculty, it is a dynamic and fast-changing situation, saying that “we might have a different answer tomorrow — that’s how quickly things are moving.”  

He emphasized that a significant and shorter-term impact of the vaccine will be its ability to reduce the stress on hospitals, which in turn will save lives with fewer people becoming seriously ill and at risk of death.

Director of Campus Health Ashlee Halbritter cautioned that even if deaths and hospitalizations do go down as a result of the vaccine, students should not expect to go back to normal immediately.

“A vaccine doesn't change anything. People who are vaccinated still have to participate in [Penn's] screening program, they still have to wear masks, they still have to physically distance,” Halbritter said.