These days, when the chaos of the past few months feels all too impossible, only one place on the Internet helps me breathe, at least a little: the New York Times Coronavirus Vaccine Tracker.

Perhaps I refresh the page a little too eagerly. But a vaccine, the only true solution to our pandemic, doesn’t seem that out of reach; over 140 are currently in development. Four have already reached Phase III clinical trials, meaning that scientists have basic evidence of their efficacy and safety and seek to demonstrate widespread applicability in human subjects. The Trump administration’s Operation Warp Speed has invested billions of dollars in developing the most promising candidates, and Bill Gates has committed to funding seven factories so that they can be mass-manufactured at unprecedented speeds. Dr. Anthony Fauci, our leading infectious disease expert, has said that he’s “cautiously optimistic” that a vaccine will be available by the end of the year.

But despite this abundance of hope, I’m also nervous. The pandemic has already made clear that health care disparities simply reflect the already life-or-death consequences of systemic inequalities in race, citizenship, and socioeconomic class. I fear that a COVID-19 vaccine will widen these gaps—and global and domestic track records with other infectious diseases do not do much to calm my concerns.

So, briefly, let’s imagine the day that scientists announce successful development of a vaccine. Let’s step away from the immediate relief and think about the mechanics of our next steps. How will this vaccine be distributed, and how might this process further disadvantage those who have always been most vulnerable?

It starts globally. Even before vaccines are fully approved and manufactured, wealthy countries get a head start when they enter into advance agreements with vaccine manufacturers that give them priority access. Many times, these countries also hoard supplies for themselves. We saw this during the 2009 H1N1 outbreak, our last global pandemic: Australia, for example, delayed exporting supplies after gaining early-on manufacturing capabilities for the vaccine, and globally, countries categorized as “high income” by the World Health Organization claimed 90 percent of the initial vaccine supply. So far in the COVID-19 pandemic, individual countries’ stockpiling of other essential supplies—most notably, personal protective equipment—suggests that this time, governmental policies won’t be any less selfish. Our country is a prime culprit: in April, German officials accused the Trump administration of medical “piracy” for diverting an international shipment of N95 masks, meant for their police officers, to the U.S.  

Lower-income countries might turn to the World Health Organization, which will collaborate the Coalition for Epidemic Preparedness Innovations (CEPI) and Gavi, a global vaccine alliance, to provide two billion vaccine doses for individuals in lower-income countries. CEPI, Gavi, and the Serum Institute of India have already secured over one billion doses for low and middle-income countries through manufacturing deals with AstraZeneca, the company behind one of the most promising vaccines in development—though it should be noted that the United States and the United Kingdom had already obtained millions of doses from the company through similar agreements. 

But this is far from enough to address the challenges of equitable global vaccine access. For example, in the likely scenario that the COVID-19 vaccine requires refrigeration, unreliable access to electricity in lower-income countries may pose additional logistical hurdles. Moreover, an estimated 80 percent of refugees live in lower-income countries. These countries will likely exclude them when requesting vaccines—despite the fact that densely populated, poorly resourced refugee camps are perhaps the most vulnerable in the world for mass transmission.

Regardless, you might think that the United States would be safe from these problems. But despite our country’s global wealth, inequalities riven in American society leave many residents still in jeopardy.

This is obvious even in non-pandemic scenarios. First, there’s health insurance—or lack thereof. Adults without insurance often pay as much as 40 dollars just for the yearly flu vaccine. And while 94 percent and 90 percent of children under three who are insured privately or through Medicaid respectively are vaccinated against measles, that number is only 75 percent for those who lack insurance. Government programs that provide vaccines for uninsured children have existed since the ’90s, but many times, their parents are unaware of their eligibility.

Melanie Siefman, a physician in Washington, D.C., noted in a 2019 interview with NPR that even with insurance, low-income Americans often lack access to transportation or cannot afford time off work, further preventing them from receiving vaccines. If the COVID-19 vaccine requires multiple trips to the clinic—as is the case with a leading candidate from the Massachusetts-based Moderna, which is most effective with two doses administered one month apart—this problem becomes even more pronounced.

Many physicians view anti-vaxxers’ refusal to participate as the foremost threat to any COVID-19 vaccine solution, but socioeconomic gaps in access may wreak even greater havoc on public health. “Based on my population, [an outbreak] would be more because of just inadequate vaccination because [low-income families] are just not coming in, and not because of the anti-vaccine group,” Siefman said.

Other barriers besides socioeconomic class may also prevent some communities from accessing a vaccine. Rural Americans, for example, may live far away from their health care providers, while language gaps bar many immigrants from receiving accurate information. Studies have also identified race-based disparities in coverage for existing vaccines, such as those against influenza, HPV, and tetanus: Latinx, Black, and Asian Americans have consistently lower rates of vaccination than their White counterparts—even when adjusting for factors such as education and health insurance. This suggests that other issues, such as racial differences in quality of care, also have outsized consequences in public health.

As it stands, vaccines in America are likely to be distributed in a tiered system, with essential workers and vulnerable populations gaining first access. Trump administration officials have promised a free COVID-19 vaccine “for any American who is vulnerable who cannot afford the vaccine, and desires a vaccine.” But some health care professionals have already criticized the administration for its chaotic distribution of remdesivir, a potential COVID-19 drug, in an opaque process that neglected many hospitals serving low income populations with particularly acute needs.

Here’s the thing about pandemics: if a solution doesn’t apply to everyone, it’s no good. Even the most selfish of Americans should recognize that global, national, and local economies cannot restart if a significant proportion of their populations cannot safely leave home. But beyond this, I hope that we all understand that identity or circumstance should never determine one’s right to live. Basic human empathy should be enough to guarantee universal access to the vaccine.

We have so much to look forward to. For many of us, when the news seems particularly grim, hope—that our situations are transient, that we’ll be able to go to class and gather in crowds and hug our friends again soon—is all that keeps us going. Let’s make sure that that hope reaches everyone, equally.

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