The challenge of measuring equity in COVID-19 vaccinations

A medical worker holds Pfizer coronavirus disease (COVID-19) vaccination cards at a mobile vaccination drive for essential food processing workers at Rose & Shore, Inc., in Vernon, Los Angeles

Getting the United States vaccinated is Job One for the federal government and the states. Because African Americans and Hispanic Americans are disproportionately likely to experience hospitalization or death if they contract COVID-19, it is urgent to achieve equity in vaccinations as well. In every state reporting statistics by race, a lower percentage of African Americans have been vaccinated than of the general population. If this pattern persists, many hospitalizations and deaths will occur that could have been prevented, and the rate of infections will remain too high to permit the country to get back to normal. Each state should monitor its progress in subgroups as well as aggregates and use the resources it will receive from the recently enacted $1.9 trillion relief bill to reach near-universal vaccinations as soon as possible.

Measuring progress toward equity turns out to be surprisingly complicated. Let me illustrate, using my home state of Maryland as an example.

Maryland has a population of just over 6 million, of which 50% are white, 30% are Black, and 11% are Latino. Whites number about 3 million, Blacks about 1.8 million, and Hispanics about 640 thousand. These numbers do not provide an accurate baseline for determining equity in vaccinations, however, because vaccines have not been approved for use for individuals under age 18, and these young people are not distributed evenly across the population. To determine equity, we need to look at vaccinations by eligible age groups as well as by race.

Nationally, about 22% of Americans are younger than 18, but African American and Hispanic populations are younger than whites: 27% of African Americans and 33% of Hispanics are under 18, compared to 20% for whites. Applying these shares to Maryland, we come up with about 2.4 million Whites, 1.3 million African Americans, and 430 thousand Hispanics who have reached the age of eligibility for vaccination.

But adjusting for age is only one of the complications on the road to determining equity. Here’s why: along with every other state, Maryland established a priority list of categories of individuals who would receive the earliest vaccinations, including individuals over age 75. But individuals 75 and older are not a microcosm of the total population. Because Black life expectancy is well below the national average, the elderly form a smaller share of the Black Population. (The same is true of Latinos, but for a different reason: because the U.S. Latino population is heavily tilted toward children and young adults, individuals 75 and over form a smaller share of their total—even though Latino life expectancy is well above the national average, and above the White average as well.)

If states had begun by inoculating only the elderly, racial and ethnic disparities would have been the inevitable if unintended result. In Maryland, for example, the share of African Americans 75 and up is 8 percentage points below their share of the overall population. Indeed, in each of the 37 states reporting vaccination statistics by race and ethnicity, the Black share of the 75-and-over population is lower than in the general population.

But the states established other priority categories as well—especially health care workers—and these tilt in the other direction. In about three-quarters of the states reporting by race, the Black share of health care workers exceeds their share of the general population, and the number of health care workers is roughly the same as of those 75 and over. In Maryland, the share of African Americans in the health care workforce is 9 points higher than in the state’s population, fully counterbalancing their under-representation among the elderly. (The same is true for many other states.)

We can conclude that if Blacks are not receiving a proportionate share of vaccinations in Maryland, their representation in the priority categories for early vaccinations is not the reason why. And as the following table shows, they are not receiving a proportionate share.

Table 1: Vaccinations in Maryland by race

  White Black                                    
Total doses/18+ population 53% 29%
First doses only/18+ population 33% 14%
Both doses/18+ population 19% 9%

(Source: Census Bureau and author’s calculations)

Within-state statistics confirm these findings. Of Maryland’s 22 counties and other jurisdictions, the four with the highest Black population share—Baltimore City, Charles County, Prince George’s County, and Somerset County—have the lowest shares of their populations vaccinated.

This picture may well change in the coming months. More vaccines are becoming available, and the state is setting up mass inoculation centers, as will the Federal Emergency Management Agency (FEMA). The state has also established a new, more centralized website that should ease the confusion created by dozens of separate vaccination portals.

But more will be needed. Many households in minority neighborhoods lack access to computers and high-speed broadband, so convenient local signup facilities are essential. Trusted community-based leaders can help walk residents through the process and answer questions about vaccines’ safety and efficacy. Mobile vaccination clinics can help overcome problems posed by lack of transportation and impaired physical mobility.

Good governance requires that we continuously measure what we are doing so that as inequities emerge, whether by race, age, or geography, they can be addressed.