This commentary is by Anne N. Sosin, a policy fellow at the Nelson A. Rockefeller Center at Dartmouth College and the co-lead on research on Covid-19 and Rural Health Equity in Northern New England at Dartmouth’s Center for Global Health Equity.
Vermont offers a critical lesson for a nation grappling with stark inequities: protecting the most vulnerable not only mitigates the sharp disparities in Covid-19 infections and deaths seen across the U.S. but also contributes to improved outcomes at population level.
The state’s expansive use of housing policy to shelter vulnerable Vermonters who could not comply with social distancing orders, aggressive strategy for responding to outbreaks in its long-term care facilities, support in responding to an outbreak among seasonal workers, and mobilization of pop-up testing in communities have all contributed to the state’s well-earned status as a model not only for the U.S., but also across the globe.
However, the decision by Vermont’s leadership to abandon its plans to prioritize the essential workforce — the grocery clerks, teachers, transport drivers, factory workers, and others — for vaccination not only represents a departure from an approach consistently centered on equity but also threatens to limit the effectiveness of this campaign.
Vermont has chosen an “age-banding” approach because it prioritizes those most at risk of death from Covid-19. On the face of it, this appears to be the most equitable approach. Its advantages are manifest as other states struggle with overly complicated prioritization schemes, haphazard rollouts, and line-jumping.
Vaccinating older populations, our governor said, also reflects our commitment to those who have cared for us and brings an end to months of social isolation, denied grandparent visits, and fearful grocery trips. I felt no small amount of relief seeing a photo of my own mother receiving her first dose of the vaccine and joy in knowing of the long-anticipated reunion it would enable with my daughter.
Yet, if age banding is an equal and efficient approach, it alone is not an equitable or effective one.
Equity, as Vermont has taught the country, requires prioritizing resources for those not only at greatest risk of severe illness or death from Covid-19 but also for those at highest risk of infection. Vermont’s data clearly highlights that essential workers are at higher risk for infection, as is the case across the U.S.
Essential workers are also significantly more likely to transmit the virus to others in their households and community — and therefore play a critical role in shaping the overall trajectory of the pandemic. The overrepresentation of Black, Indigenous and people of color communities in the essential workforce is a significant reason that we see racial disparities in Vermont and nationally.
In Vermont, we also see hidden rural disparities across socioeconomic and occupational lines. Recognition of the importance of occupational exposure in driving disparities as well as transmission at population level was central to the deliberations of the national committees convened to prioritize the earliest doses of vaccine. The National Academies of Science, Engineering and Medicine Committee on Equitable Allocation of Vaccine for the Coronavirus underscored the primary role of structural — and not biological or cultural factors — in driving Covid-19 disparities. Notably, the committee cited consistent evidence on the role of occupation and housing in structuring Covid-19 inequities in its recommendation to prioritize the essential workforce.
The CDC’s Advisory Committee on Immunization Practice similarly voted 13-1 to prioritize essential workers in December.
What is underappreciated about the frameworks from the national academies and the advisory committee is the leap forward that they represent in how to move from broad notions of equity to concrete approaches that align with public health effectiveness. By prioritizing those most at risk of infection alongside those at risk of severe disease, the guidance seeks to not only minimize death but also to disrupt transmission at population level.
In short, equitable prioritization that includes the essential workforce is not simply a reflection of our values as a state or our economic interests — it’s critical for slowing Vermont’s epidemic, particularly as vaccination efforts move beyond the long-term care facilities, where deaths have concentrated. The public health impacts of these decisions are not inconsequential, as the state continues to average more than 100 cases a day, with Vermont officials projecting similarly high case counts through March.
Absent a shift in epidemiology, the state can anticipate upward of 3,000 cases per month, and concerns continue to mount over the emergence of more transmissible variants. This, combined with growing evidence that vaccines do indeed decrease transmission as well as data showing that somewhere between 10% and 30% of persons with Covid-19 may develop “long covid,” or chronic illness, means that several monthlong delays in reaching those most at risk of infection will have meaningful and potentially long-term impacts on population health.
Vermont has already committed its existing vaccine supply to its current scheme; however, the federal government continues to increase allocations to states. The state leadership can and should use this additional supply to re-prioritize its essential workforce as a near-term priority as other states have done, not only as a reflection of its commitment to equity but also as good public health practice.
“I am so proud to live in a state that has taken such good care of its most vulnerable,” a state agency leader recently related to me during an interview as part of our Dartmouth team’s ongoing research on Covid-19 and rural health equity. I too am grateful for the visionary leadership, strong policies and heroic efforts that have made equity not just a mindset but also a foundational part of the state’s performance in responding to the pandemic.
For months, our essential workforce has carried us forward as state — and COVID-19 along with them. Now, we should carry through on our commitment to equity and bring it forward in the vaccination line.