Should Race be used in vaccination guidelines?

The draft report of the CDC’s Advisory Committee on Immunization Practices (ACIP) on November 23, 2020 suggested the use of Race in prioritizing the allocation of limiting COVID19 vaccination as a means of promoting justice and reducing health inequities. This move was controversial and the final ACIP recommendation released on January 1, 2021 removed the explicit use of Race, and emphasized the use of age once health care workers were vaccinated, before moving into further specific risk groups that prioritized congregant living and occupational exposure. Is there any scientific and epidemiological evidence that Race should be used to prioritize the limited supply of COVID19 vaccines? In short, yes.

The United States has had more direct discussion of the role of Race in American life this year than in the rest of my life combined, focused on COVID19, the BLM movement, the spate of Confederate monument removals, and the differential treatment of White protesters who attacked the U.S. Capitol on January 6, 2021. However, the idea of using Race to help allocate limited vaccine supply caused an immediate, and guttural pushback. Why?

CDC data shows that Race is a predictor of increased risk of COVID19 cases, hospitalizations and deaths.

The CDC describes Race as a proxy for poorer outcomes, and Black, American Indian and Latino/a persons all have substantially elevated COVID19 mortality as compared to Whites:

Race and ethnicity are risk markers for other underlying conditions that affect health including socioeconomic status, access to health care, and exposure to the virus related to occupation, e.g., frontline, essential, and critical infrastructure workers.

Measures of Biological Aging and Distribution by Race

Telomeres are caps on on DNA strands whose length provides a measure of cellular aging, and an emerging body of research suggests that cellular aging is more rapid for Blacks as compared to Whites, even after controlling for other factors that influence Telomere length, such as poverty, obesity, smoking and exercise. This remains an emerging field that is limited by the samples available for study, so more work is needed. Life expectancy at birth is 4.6 years less for Black males as compared to White males at birth; and 1.8 years shorter given survival to age 65 (red underline males; yellow highlight females). It is longer for Hispanic males and females, a complex phenomenon know as the Hispanic/Latino paradox.

The discovery of Telomere length differences by Race support the Weathering hypothesis explanation originally put forth by Arline Geronimus in 1992 to explain shorter Black life expectancy, that posited that the cumulative social stress and Racism experienced by Blacks in the United States leads to accelerated aging. Subsequent work has identified Allostatic Load, a cumulative measure of stress processes that is linked to the processing of Cortisol that floods the body during fight or flight situations, as a likely pathway through which Blacks experience accelerated cellular aging as compared to Whites as measured by Telomere length. More recent research has confirmed the independent effect of Racism and “living while Black” on Telomere length and allostatic load. There is a plausible biological pathway linking Racism to shorter life expectancy, particularly remaining life expectancy given attainment of age 65.

Age is by far the largest predictor of COVID19 mortality, in the U.S. (data through December 20, 2020), and a far stronger predictor than is Race (The relative risk for Race is 2.6-2.8–see figure 1, while age 65-74 has 90 times the mortality compared to age 18-29–figure 2). However, given the evidence of differential cellular aging identified among Blacks as compared to Whites, Race may well be a reasonable age-modifying variable that would allow us to better target those at most risk of death from COVID19. For example, the top priority group after front line care workers is persons age 75+ a standard that could be modified to be age 73 for persons who are Black, for example, using life expectancy at age 65 results shown above. This would easily be implemented via electronic medical record notification and a different age cut in mass inoculation events. A similar adjustment could be made for American Indians, as well as for Hispanic/Latino individuals though for the latter the excess mortality due to COVID19 is in the opposite direction of the Hispanic/Latino paradox and may be more related to occupational exposure than cellular aging and Weathering, making that subgroup finding all the more striking.

The United States was fully unprepared to have a conversation about the use of Race as a modifying variable for distributing a highly sought after commodity, in part because White people tend to lay the blame for worse mortality outcomes for Blacks as solely being the responsibility of people who are Black. We tend to exempt ourselves from any responsibility for the systems we live in that benefit us and harm others. We have strong scientific evidence that Racism and the social stress of living while Black in our society causes cellular level harm that plays a role in poorer outcomes experienced by Blacks, including reduced lifespan. There are scientific advances that are needed to better understand and operationalize the use of allostatic load and telomere length for public health interventions, but the most important task may well be that White people learn to talk about how Race impacts our world today in a less defensive, and more informed posture. It will be hard, but we will only get better with practice.

About Don Taylor
Professor of Public Policy (with appointments in Business, Nursing, Community and Family Medicine, and the Duke Clinical Research Institute), and Chair of the Academic Council at Duke University . I am one of the founding faculty of the Margolis Center for Health Policy. My research focuses on improving care for persons who are dying, and I am co-PI of a CMMI award in Community Based Palliative Care. I teach both undergrads and grad students at Duke. On twitter @donaldhtaylorjr

2 Responses to Should Race be used in vaccination guidelines?

  1. Minivet says:

    Black people have said loudly that if they’re bumped up in line by race as a criterion, a lot of them will (reasonably) think of themselves as being guinea pigs a la Tuskegee. I suspect that was part of why the idea was rejected.

    Other disparately race-associated criteria like prioritizing essential workers should have a similar effect.

  2. Pingback: How do you know what you know? – Health Econ Bot

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