Covid field site (photo: Michael Appleton/Mayoral Photography Office)

There are many high-stakes questions to be sorted out in the design of the coming covid vaccination distribution program. But there’s one issue that’s not receiving enough attention: How can we design a plan that avoids exacerbating pre-existing racial inequities and instead meaningfully advances equity?

It’s essential that we answer this question — now.

Vaccine distribution will be the most complicated implementation challenge of this pandemic, even more so in Black communities and other communities of color. We need to ensure that every aspect of the program is structured to avoid short-changing these same marginalized communities yet again.

Throughout this pandemic, Black, Latino, and indigenous communities have suffered from inadequate and inequitable resources. Hospitals in low-income areas have been under-staffed and under-supplied. Testing has been far more accessible in affluent communities. 

Unfortunately, COVID-19 vaccine trials have followed this same disturbing pattern. Black Americans only made up 8% of the Pfizer trial participants. The Moderna trial fared better at 13%. But both fell short of the portion of COVID-19 fatalities among Black Americans: 19%.  

Even more worrisome is the possibility that Black, Latino, and indigenous communities could be underrepresented in the early distribution of the vaccine, further exacerbating the pandemic’s racial health inequities.

There is general agreement that early prioritization should go to health-care workers, followed by residents of congregant settings, and then essential workers more broadly. But the way each of these categories is defined has huge implications for equity.

The health-care worker cohort should, of course, include those who directly provide care to patients, like physicians and nurses. But what about the many other job categories in hospitals? Cleaning staff, translators, cafeteria workers, and security guards all have contact with COVID-19 patients. The same is of course true for home health aides. And all are far more likely to be people of color. Excluding them — or any covid-facing worker in a health-care setting — would be profoundly unfair. 

Similar questions arise with the congregant setting cohort. Clearly residents and staff of nursing homes should be included in this group. But what about jails, where rates of infection among detainees and staff have been alarmingly high? Or crowded homeless shelters, which are known to be high-risk for transmission? Here again, excluding groups in these more marginal settings would disadvantage populations that are disproportionately people of color.

There are questions about the essential worker cohort as well, which rightly will almost certainly include people who work in transportation or on essential infrastructure such as wastewater treatment facilities. But what about those who work in supermarkets, laundromats, food delivery, or restaurants? These low-wage workers have been performing essential functions throughout this pandemic while exposed to the public — and are far more likely to be people of color. They must be included as well, for their own sake, and for the general public that depends on their work.

Once vaccination distribution moves to a broader public phase, decisions about the locations in which vaccines are administered also have implications for equity. The default option is to primarily use hospitals and chain pharmacies. But there are fewer of both in low-income areas. To reach the broadest number of Black, Latino, and indigenous people, vaccination programs should be set up in a variety of accessible local settings, including churches, community centers, public housing developments, and schools. 

It is also critical that there be no barriers to receiving the vaccine based on an individual's immigraiton status. Preliminary plans from the Trump administration would require patients to present a form of ID that is a proxy for citizenship in order to be registered in the vaccination database. This would have disastrous consequences, and cannot be a standard that is used in New York.

And then there is what may be the biggest challenge of all: building confidence in the vaccine among communities that have a century-long history of abuse, exploitation, and neglect by the medical system, in particular around vaccines. Communities of color still experience discrimination and bias in health-care settings today.

To overcome the trust gap, there must be total transparency about COVID-19 vaccine safety, efficacy, and side effects. Additionally, there must be a well-funded, culturally-responsive, multilingual outreach campaign to share this critical information with Black, Latino, and other communities of color. Local community organizations must be mobilized for on-the-ground outreach, at a scale that is more robust than the campaign to promote participation in the Census.

The federal government will be imminently rolling out guidelines on key aspects of the vaccination distribution process. But it will be up to state and local governments to tailor these plans to the needs of their local communities.

It is critical that here in New York City, and across the country, we design a fair and equitable vaccination program that ensures that no one is left behind. Lives depend on it.

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Dr. Uché Blackstock is a Board-certified emergency medicine physician, the founder and CEO of Advancing Health Equity, and a Yahoo! News Medical Contributor. New York City Council Member Mark D. Levine represents parts of Manhattan and is chair of the Council’s Health Committee. On Twitter @uche_blackstock and @MarkLevineNYC.