Who should get America’s Covid-19 vaccine first?

If and when the Food and Drug Administration (FDA) announces that we have a Covid-19 vaccine that works, we will not have enough for everyone in the country who wants it. At least not initially. So how will we decide who gets it first?

If and when the Food and Drug Administration announces that we have a Covid-19 vaccine that works, we will not have enough for everyone in the country who wants it.

The National Academies of Sciences, Engineering, and Medicine, or NASEM, has just issued a report from a panel of experts (of which I am one) recommending a framework for the equitable allocation of the vaccine. To reduce the deadly societal impact of SARS-CoV-2, the framework recommends which groups should be at the front of the line, based on people’s likelihood of death or severe illness if they are exposed, their risk of exposure and the impact their absence from work has on society’s function.

The workers sometimes called “essential,” many of whom take care of our sick and elderly and keep our families fed, our transportation systems operating and our streets safe, can’t work from home. Their jobs put them in close contact with other workers and the public, and they are often given inadequate or no personal protective equipment. Many travel to and from work in crowded public or semi-private transportation. Since the virus does not stop at the door of the factory or nursing home or prison or subway car, these workers bring the epidemic into their homes and communities.

Covid-19 also has had a disproportionate and tragic impact on communities of color; in particular, working-age African Americans and Latinx people are at greatly increased risk. Much of this increase is driven by employment patterns: Racial and ethnic minorities are overrepresented among those employed in nursing and home care jobs, on farms and in meat and poultry factories.

The federal government has made only limited efforts to reduce the risk of workplace transmission of the virus. More generally, the safety and health of the country’s workers are rarely the focus of the country’s attention. The NASEM report is different, in that it is very much focused on workers. Indeed, one of our most important recommendations is that vaccinating large groups of workers must become a national priority. The Covid-19 pandemic has made us reflect on many things, including the importance of the country’s workers in maintaining the functioning of our economy.

Thus, in each phase of the national vaccination program, NASEM’s framework recommends prioritizing specific groups of workers in different industries and jobs, along with people at increased risk because of age or pre-existing health conditions. It will be mostly up to our country’s governors, however, to decide how they want to follow these recommendations.

At the top of the list, when the companies contracted by Operation Warp Speed have produced enough vaccine for only 5 percent of the nation, are health care workers, including hospital, nursing home and home care workers and first responders. Many, if not most, of these people have risked their lives for months treating patients, often without adequate protective equipment. Hundreds of thousands have been infected, and hundreds have died as a result of workplace exposure.

In the second phase of allocation, when we are on our way to having enough doses for as much as half the population, we recommend vaccinating teachers and child care and school system workers, which will help the nation resume the safe education of our children. This phase also includes many previously invisible workers who are now recognized as essential, including the people who plant, harvest and package crops, slaughter and process meat or poultry, deliver food to stores and stock shelves and staff checkout lines.

Food system workers are at particular risk. Many work in facilities where their employers have not made adequate efforts to provide distancing or adequate protective equipment. A large proportion of these workers are immigrants and live in congregate housing; migrant farm workers often sleep in crowded, substandard employer-provided housing, while others live in crowded multigenerational homes. These low-paid workers may be less likely to attempt to use the health care system for care for economic or legal reasons. Perhaps controversially, we recommend that these workers, as well as the rest of the U.S. population, are provided vaccinations no matter what their legal statuses.

In this second phase, we also recommend vaccinating the staff members and residents not already vaccinated at facilities and institutions where people live together and proximity greatly increases their risk. This includes homeless shelters, prisons, jails and immigrant detention centers, all facilities that have had uncontrolled outbreaks of the virus.

Even a fully successful national vaccine effort will not make workplaces completely safe.

Finally, in the third phase, we recommend prioritizing workers valuable to the functioning of society and returning the economy to normal and who are at moderately high risk of exposure. At this stage, if there still is a limited supply of vaccinations, governors will have to make some difficult choices. Which groups should be vaccinated next? Employees of restaurants and bars? Factory workers? University professors? Gym trainers? Performers and entertainers?

While these efforts will no doubt reduce the risk of workplace transmission and prevent countless cases of the Covid-19, even a fully successful national vaccine effort will not make workplaces completely safe. Immunization is not a substitute for the basic efforts we know prevent transmission, including distancing, ventilation and protective equipment. And, of course, vaccinations will not eliminate the other job hazards many of these workers have long faced, nor will they supplement the poverty-level wages with which so many of them attempt to support their families.

This pandemic must change the way we think about the health and safety of the American worker. Low-wage, previously invisible workers of color are, in fact, vital for our health and economy. And as we move forward as a nation, it is vital that we implement policies that recognize worker safety as a bedrock of U.S. success.

David Michaels, Ph.D., M.P.H., is a professor at the George Washington University School of Public Health. He was assistant secretary of labor for the Occupational Safety and Health Administration from 2009 to 2017, becoming the longest-serving administrator in the agency’s history. He is the author of “The Triumph of Doubt: Dark Money and the Science of Deception” (Oxford University Press, 2020).

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