Public Health Weekly

Equity Isn’t Just Ethical, It’s Essential

The latest Covid insights from former CDC Director Tom Frieden

Photo by CDC on Unsplash

There’s lots of good news to report on vaccines, but the virus and variants are also gaining ground. Variants are spreading rapidly in the U.S., driving (along with premature re-opening) the fourth surge that’s now underway. Here, I’ll explain why equity is not just about fairness, but essential for pandemic control.

The fourth surge is here

The feared fourth surge is building. CDC reports in its Covid Data Tracker Weekly that cases are up more than 8% nationally over the past week, and test positivity rates have risen slightly, to 5.1%. The situation in Michigan, which now has the highest rate of new cases of any state over the past seven days, is getting worse — and other states are at high risk of following this trend.

Vaccines — light at the end of the tunnel

The news on vaccines just keeps getting better. A CDC study of mRNA vaccines published in this week’s MMWR found that both the Pfizer and Moderna vaccines blocked 90% of infections. Vaccinated people won’t spread much disease. This has HUGE implications for developing guidance for fully vaccinated people and altering the trajectory of the pandemic.

Pfizer released new data from clinical trials showing that their vaccine protects for at least 6 months. Protection will likely be longer — so far we only have 6 months of data — and only time will tell how long. Studies have also found that these vaccines work well against at least some variants, and are highly effective against the B.1.351 variant first identified in South Africa.

Getting vaccines in arms

Now we have to get vaccines into arms around the world. Transfer of mRNA technology is key, because this technology can be tweaked for variants and is less susceptible to production problems. A biological vaccine process made into a chemical, more predictable one.

There’s no question that the vaccines are working. Look at the striking impact of protecting the elderly in Michigan. Vaccines rock but, we’re failing to get them to where they are most needed.

Israel is crushing the curve with vaccines. But more places need more vaccine — and quickly — especially Brazil and other places that are being hit hard.

Despite glitches (see: J&J/Emergent’s 15 million botched doses), supply keeps increasing. The U.S. is vaccinating more than 2.5 million people a day now. BUT: the quality of vaccination — getting vaccines to those at highest risk — is important, and probably more important right now than quantity. See why below.

Vaccine reluctance keeps decreasing. And more availability and more convenience will overcome much of the remaining reluctance. A new survey from Kaiser Family Foundation shows that the “wait and sees” are deciding to get vaccinated — but that the proportion of “reluctants” is holding steady.

Variants going wild

The news on variants is mixed, but mostly bad. On a positive note, Israel’s success shows that these vaccines beat these variants. But many new variants are spreading rapidly in the U.S.

Deaths aren’t falling nationally as rapidly as I had anticipated they would — likely because the variants are not only more transmissible but also more lethal. Eric Topol summarized the data on variant lethality well.

Some think SARS-CoV-2 may be running out of genetic tricks and won’t be able to evade vaccine-induced immunity, and I hope they’re right, but hope is not a plan. We have to anticipate the possibility of vaccine escape mutants and reduce uncontrolled spread wherever it occurs.

Vaccine equity is imperative

Now the most important point of this article and the reason I wrote it this week after planning not to write one: equity, equity, equity. This is not just about what’s right ethically, but what’s essential for pandemic control in both the near- and long-term. Uncontrolled spread anywhere is a risk everywhere in the long-term because of the possibility that even more dangerous variants will emerge. But that’s not the only problem with the current unequal distribution of vaccine.

If we just chase the number vaccinated, we miss the point. Equitable vaccine distribution will lead to maximum impact from vaccines — for fairness, to reduce deaths, to reduce cases, and to reduce risk of emergence of even more dangerous variants.

100 million people in the U.S. have received at least one dose of vaccine. But about 50 million people over age 50 (~37 million age 50–64 and ~13 million age 60+) haven’t been vaccinated at all. Vaccinating these people, who are disproportionately Black and Latinx, will prevent many more deaths than vaccinating young people.

Think of it this way: targeting vaccinations to people at highest medical risk — who are 10 to 100 times more likely to die if they get infected — is 10 to 100 times more likely to save a life. We’d have to vaccinate 10 million people at low medical risk to save as many lives as vaccinating 100,000 to 1 million people at high medical risk.

And targeting vaccinations to the communities at highest risk for spread is MUCH more likely to prevent cases than targeting vaccinations where there is low risk of spread. In some low-risk communities, 0.6% of the population may be infected each month, while in high-risk communities, it may be 6%. With a vaccine that offers 90% protection, if we vaccinate 1 million people in low-risk communities, 5,400 cases would be prevented. In contrast, If we vaccinate 1 million people in high-risk communities, this would prevent 54,000 cases — 10 times as many. This difference will compound in future generations of spread, so the actual impact could be 40 times to even 100 times larger.

In other words, a single well-targeted vaccination could save 10 times more lives, and prevent 100 times more cases, than vaccinating a low-risk person in a low-risk community. This is the essential fact we must act on. Equity isn’t only good ethics. It’s essential for epidemic control.

“The availability of good medical care tends to vary inversely with the need for it in the population served.”

— Dr. Julian Tudor Hart, in The Lancet (1971)

President and CEO, Resolve to Save Lives | Former CDC Director and NYC Health Commissioner | Focused on saving lives. twitter.com/drtomfrieden