California Surgeon General Dr. Nadine Burke Harris Discusses COVID-19 Vaccine Equity with the New York Times

EZRA KLEIN: So I want to talk a bit about the California coronavirus response now. So the vaccine rollout efforts began, at least according to the data, a little bit slowly in December and early January. But they’ve picked up a lot now. The state is above the national average, with about 16 percent of Californians having received a first dose of the vaccine. What lessons got learned here?

NADINE BURKE HARRIS: Simplicity saves lives.

EZRA KLEIN: Tell me more.

NADINE BURKE HARRIS: We had a really, really well-thought-out strategy on rolling out the vaccine, particularly with a strong eye to equity. Listen, equity is our North Star. But one of the things that we recognized was that it was challenging to implement at the end-user level.

And in California, we have an amazing public health system. Much of it is focused at the community level. So we have 58 counties. And our local departments of public health really are connected and in tune with the needs of their local communities.

But it became challenging for folks to understand whether they were eligible, where they should go, how they would understand what their eligibility is, and the implementation on the ground. Because it was happening at our local public health level. Folks oftentimes were confused about the differences between rules that were happening in one county versus another county.

So we listened. We heard. We got lots of feedback….

EZRA KLEIN: So one evolution I’ve noticed here is, when the vaccination efforts started, there was a reasonably complicated eligibility formula or framework. That got simplified and pushed much more sort of towards a direct age framework. And then, more recently, the way I’ve seen California trying to push towards equity and certain goals is by allocating more vaccines for certain subgroups — so 10 percent for educators.

I was on a call this morning with your colleague, Dr. Mark Ghaly, that I think there’s a doubling of the allocation for the lowest quartile of places in the California Healthy Places Index (HPI). They have, I guess, 40 percent of the deaths, 25 percent of the people, and only 16 percent of vaccinations, compared to 34 percent among the highest quartile places. Can you tell me a bit about that, and also why you feel that’s not going to undermine simplicity this time, that it will be consonant with that continued fast rollout?

NADINE BURKE HARRIS: So to answer your first question, yes. So when it came to rolling out vaccine, we did what just about everyone else in the country did in terms of phase 1A, which was prioritizing our health care workers and those in long-term care facilities. And of course, the reason for that is because we need to vaccinate the vaccinators. We need to shore up our health care infrastructure as a very important first step.

But the problem is that our health care providers are predominantly folks who are in the upper income realm. They’re predominantly less likely to be people of color. And so when you vaccinate your health care providers first, and then you get to the end of the point, and look at who across your population has been vaccinated — no surprise — we see that 2.9 percent are African Americans.

We see that of the folks who have been vaccinated, only 16 percent are in the lowest HPI quartile. And that’s because we had to shore up our health care system. And so the next immediate step for California was being able to say, OK, now that we’ve done that crucial step, how do we address these inequities?

And so we look at it. And it’s an equity framework. But it’s also just a smart public health framework.

EZRA KLEIN: Yeah. I mean, this is something that I was thinking about. People, I think, sometimes think of equity and speed as being in tension here. But if you can’t get at the communities where 40 percent of the cases are and 40 percent of the deaths are, then you’re not going to get the numbers down that quickly.

NADINE BURKE HARRIS: That’s the thing. In this case, equity is speed. If people want to reopen their businesses more quickly, we have to target more doses to where we see the disproportionate burden of disease. Because that’s what’s keeping communities from being able to reopen.

And so this is smart from an equity standpoint, from a public health standpoint, and from an economic standpoint. Because we want to quell the spread so that we can reopen society. To answer your second question — why is this going to work when the other one didn’t work — it has to do with front office versus back office.

So the previous system was this question about eligibility, and how do you figure out if someone is eligible, and what sector. So for example, when we’re using a sector-based strategy, which has some strong equity principles built into it, one of the big challenges is, how do you verify eligibility? What if someone is a childcare worker, but they work watching their cousin’s children — all of these different things.

When we address equity through our allocation, that’s a back office thing. It doesn’t require someone who’s at that table checking people in to be able to do anything different from what they’re doing on a day-to-day. What this strategy does is streamline a lot of the back office stuff.

So for example, that MyTurn system where folks sign up for appointments, we can open up more appointments in these Zip codes with the lowest HPI quartile. That’s a back office function. It’s not more difficult to implement. It just someone on a computer programming the My Turn system to open more appointments. And it minimizes confusion. It minimizes the work of operationalizing it while still achieving these equity objectives.

Click below to listen to the full podcast or read the transcript from the New York Times.