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Will the most difficult communities get the coronavirus vaccine?

This idea may have never been tried in large-scale vaccine distribution: experts quoted principles of fairness and justice, urging to live in the communities hardest hit by the pandemic, who usually consist of black and Hispanic populations, and preemptively set aside for them Some limited supply of coronavirus vaccines.

An expert committee advising Dr. Robert Redfield, director of the Centers for Disease Control and Prevention, is considering this idea. But when it becomes the focus, its basic concepts and implementation methods must be further defined, and then the method may face legal and political challenges, even if the medical system is struggling to deal with the expected logistical obstacles to the distribution of new vaccines.

The group that develops the distribution plan is the Immunization Practice Advisory Committee, which is composed of medical or public health experts who make recommendations to the CDC to provide a schedule for vaccination against diseases such as influenza or chickenpox.

It will discuss various ethical issues at the next meeting on Friday, but members stated that it will not vote on the final proposal until the vaccine is fully approved by the Food and Drug Administration or authorized for emergency use. It will last for weeks or months. right now.In the United States, there are currently four vaccines in late-stage trials

The plan currently under consideration mainly comes from several proposals, especially one developed by the National Academy of Sciences.

The co-chair of the committee that developed the framework, Dr. Helene Gayle, pointed out that the problem her committee was trying to solve was racism, not race. She said that racism contributes to social fragility, and people engage in low-paying jobs, making them more vulnerable to infections and living in crowded communities and families.

Dr. Gail, a former infectious disease expert, said: “Inequalities in health have always existed, but now, the forces of racism, poverty and prejudice are awakening the health, economic pain and hardship caused by this pandemic.” Served at CDC and currently serves as President and CEO of Chicago Community Trust.

This effect is reflected in certain groups, including people living in crowded communities, who work as nursing home assistants (this situation often applies to people of color), and the proportion of illnesses and deaths from Covid-19 is higher. Much higher than other population

Dr. Eboni Price-Haywood, Director of the Research Center for Results and Health Services at Ochsner Health in New Orleans, said that she often shows the audience a map of New Orleans that depicts low-income housing areas where people rely on public transportation and where grandparents are caregivers. The number of multi-generational families has increased, and poverty levels there are high.

She said that the map is “dominated by black families.”

If the CDC committee follows the framework of the National Academy of Sciences, it will reserve 10% of the total vaccines for people in the worst-hit areas.

Their report says that because races and ethnicities, including blacks, Hispanics, and Native Americans, are disproportionately affected by the pandemic, these inequalities are reduced by explicitly addressing the increased burden of COVID-19 on these populations Phenomenon, the moral distribution framework must be observed in any fair vaccine. “

Harald Schmidt, an assistant professor of medical ethics and health policy at the University of Pennsylvania, said: “I think this is a huge shift. “We can’t go back to color blind distribution. “

But the priorities go beyond the priorities of the hard-hit areas.

The CDC committee recommended that a framework be established to divide the U.S. population into four major categories to distribute vaccines when supplies are short. The vaccine will be carried out in stages.

The first phase provides vaccines to health care workers. This group includes at least 15 million people, including low-paid workers such as nursing assistants and nursing home housekeepers. Dr. Grace Lee, a member of the Stanford University Committee, pointed out that these groups are often overlooked in discussions among medical staff.

She said: “Most people think of doctors and nurses, but we rely on the entire team to take care of patients and keep our health care system running.”

The second potential stage consists of basic workers without medical care, including teachers. It also includes people in homeless shelters and prisons, and staff working there. These include medical personnel with high-risk diseases and people over 65 years old.

Dr. Lee said that an estimated 60 million basic workers do not have medical care. Without knowing how each candidate vaccine is performing, it is difficult to determine which one is a priority.

Subsequent phases include those at a lower risk level who are in the final phase, including everyone who did not provide vaccines in the previous phase.

But any move to weave justice and fairness into the distribution of coronavirus vaccines creates difficulties.

Ellis Monk, a sociologist at Harvard University who studies race, inequality, and health, says that it’s not even clear whether the hard-hit black community is willing to keep more doses of the vaccine for them.

He said: “Considering the history of American medical institutions, many African-Americans have healthy suspicions about the possibility of becoming guinea pigs.”

The National Academy of Sciences framework being considered by the Centers for Disease Control and Prevention prefers an index, the social vulnerability index, to determine which communities are hit hardest by the virus. It aims to help distribute federal aid in hurricanes and other disasters.

The index is based on socioeconomic status, family composition, race, ethnicity, language, housing and traffic conditions.

Committee members have repeatedly stated that they want to ensure that communities that score high on the social vulnerability index can use the vaccine.

Beth Bell, a committee member of the University of Washington in Seattle, said that the social vulnerability index is not the only indicator considered.

The problem is that different indexes can lead to very different results. Dr. Schmidt and his colleagues recently wrote in the Journal of the American Medical Association that any distribution plan that explicitly uses race as a criterion may face legal challenges.

Another measurement method is the “Regional Poverty Index”, which uses healthy social indicators such as crowding to determine the neighborhoods with the greatest needs, but without considering ethnicity.

Dr. Schmidt said that the difference between the two indexes led to a difference in distribution. He and other colleagues reported in another paper that after the current two phases of vaccine distribution, the National Academy of Sciences’ preferred vulnerability index will be used to provide 1.7 million doses of vaccine to the most impoverished black and Hispanic communities, instead of Use deprivation index.

Dr. Schmidt pointed out that the difference in the number of people providing vaccines is greater than the population of Philadelphia.

Dr. Schmidt said: “Usually, for teaching purposes, we will fabricate such a scene.” “For better or worse, this is almost the real situation.”

Dr. Michael DeBaun, vice chairman of clinical and translational research at Vanderbilt, said that in principle, fairness and justice are commendable as a factor in vaccine distribution.

However, he said, what should be done if it turns out that the vaccines that are given priority to the hardest-hit areas with mostly black residents will have serious adverse effects? If clinical trials include more people of color, what if these effects can be expected?

Dr. De Bowen said that this impact “will undermine trust in the CDC and public health.”

Dr. Munch said that acceptance among people of color will also depend on the political climate and “who is in power.” He pointed out that Trump administration officials have repeatedly tried to silence or surpass professional scientists in the CDC and FDA, which makes people suspect that the vaccine is being strictly tested.

Dr. Price-Haywood said that in the distrust of many blacks in medical institutions, vaccine acceptance must be viewed from a larger perspective. People’s reluctance to participate in clinical trials also reflects this. People ask “Is anyone testing me?”

“Besides, she said, “You will feel that “everything is accelerating” and “You did it too fast.”

Another potential problem will be the reaction of different countries, which will be countries that distribute vaccines under CDC guidance.

Dr. Matthew Wynia, an ethicist and infectious disease doctor at the University of Colorado, said: “The allocation recommendation is based on the fact that if we can afford it, generations of underserved and disadvantaged people should stand. You can stop it.” But, he said, some state leaders might refuse.

He said: “We have a very diverse country. There are different opinions on what is fair, especially for long-term underserved communities.”

Dr. Schmidt said that there is no easy answer.

He added: “It might be a fantasy ideal to make it super Duper perfect.”

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