Introduction

Communities of colour have been disproportionately affected by COVID-19 in the USA.1–4 As one way of addressing this inequity in vaccine allocation, some US states implemented race-based or ethnicity-based based COVID-19 prioritisation. For instance, in winter/spring 2021, Montana enabled Native Americans and other people of colour (POC) to receive vaccines as of 19 January, while opening eligibility to the general population on 1 April.5 In Vermont, the health department expressly acknowledged that systemic and structural racism led to disproportionate impact of COVID-19 among POC,6 and offered vaccines to all residents who identified as black, indigenous or a person of colour on 8 April, opening general eligibility on 19 April.7

An alternative approach is based not on race/ethnicity, but geography,8 9 and assigns higher priority to residents of more disadvantaged neighbourhoods. This approach can address racial justice alongside social justice, as systematic racism curtails, among other things, economic mobility and access to healthcare,10–13 and more disadvantaged areas therefore comprise disproportionate shares of POC.14 In the USA, a comprehensive framework for equitable vaccine allocation was issued by the National Academies of Science, Engineering and Medicine (NASEM).8 This framework explicitly acknowledges the need to respond to the pandemic’s disparate impact on communities of colour. In an unprecedented turn, NASEM combined a traditional phased rollout across priority groups with a novel recommendation to promote equity within each phase. Specifically, NASEM recommended that vaccine access should be prioritised within phases by using a disadvantage measure such as the Centers for Disease Control and Prevention’s (CDC’s) Social Vulnerability Index (SVI). An index such as SVI is a statistical measure of a geographical area’s average vulnerability, based on the relative advantage or disadvantage of its residents, captured along dimensions including income, educational attainment and housing quality.15–18 Noting that the SVI’s variables correspond to populations of colour who have had a disproportionate impact of COVID-19, NASEM recommended setting aside 10% of federal vaccine supply for the most disadvantaged SVI quartiles, to be added to allocations proportionate to population. NASEM further urged planners to undertake special efforts to reach high-vulnerability residents, defined as people living within the most disadvantaged SVI quartiles within the state.8 Before opening eligibility to the general population, the majority of US states (n=34) used disadvantage indices.8 9 Such states could be considered to have not only adopted a strategy to address current public health needs equitably (as more disadvantaged people are more likely to get and spread COVID-19, and die from it)4 but also to be making allocation decisions with the normative goals of restorative justice (by recognising the role of historic and ongoing injustice in COVID-19’s disparate impact).9 19 Whether programme planners transparently communicated such frameworks notwithstanding, vaccine allocation in the USA is a context in which equity has been implemented both explicitly and implicitly.

However, little is known about the US public’s support for such allocation plans. Our objective was to assess the public acceptability of race-based and place-based vaccine prioritisation at the time when the USA was about to open eligibility for vaccines for all residents. Both to be better prepared for the next pandemic and to assess which of the novel equity-promoting approaches that were adopted during COVID-19 might be applicable to other areas of health policy, it is imperative to systematically collate the lessons that can be learnt. While these data are highly specific to the US setting, the analysis could also be indirectly relevant to policy makers in other countries, that, due to unacceptable global disparities in vaccine access, are in earlier stages of allocation and face within-country inequities.