When Virginia Hedrick first heard about the coronavirus circulating on cruise ships off the coast of California back in March, it made her think back to some of the first ships of European settlers that arrived on American shores centuries ago, also teeming with disease.
Various outbreaks and epidemics spread across the continent in the following centuries, particularly measles and smallpox, and Indigenous people suffered hugely disproportionate rates of illness and death.
"So some would say that it was an unintentional spread of infectious disease upon contact. Others would say it was absolutely intentional," says Hedrick, a member of the Yurok tribe who grew up on a reservation in Humboldt County. Now, during the 2020 coronavirus pandemic, American Indians are four times more likely to be hospitalized for COVID-19 than white people, and more than twice as likely to die. For all these reasons, past and present, Hedrick says, Indigenous people should be moved toward the front of the line to receive a vaccine.
"When we think about the historical injustice of this nation, of California, isn't now the time to say that for the first time we prioritized Indigenous people?" she says. "We started to make reparations in the way that we handled and treated the Indigenous people of this continent?"
California health officials have made clear they want equity and transparency to be among the main priorities in deciding how to allocate the first scarce supplies of a vaccine. For example, in divvying up the first doses for health care workers, the state is prioritizing hospitals located in low-income areas before those in wealthy areas.
"We will be very aggressive in making sure that those with means, those with influence, are not crowding out those that are most deserving of the vaccines," Gov. Gavin Newsom said recently at a press conference.
Newsom is referring to current inequities of money, power and access — but state officials also seem willing and even eager to also take into consideration historic injustices when deciding vaccine allocation. The state asked more than 70 organizations to join the Community Vaccine Advisory Committee to help develop an equitable vaccine distribution plan, including the Sacramento-based policy advocacy organization Hedrick runs, the California Consortium for Urban Indian Health.
At the first meeting of the committee on Nov. 25, Hedrick introduced the idea of considering historical injustice as a factor in deciding which groups would be next to get the vaccine after health care workers. At the second meeting a few days later, Dr. Nadine Burke Harris, the state's surgeon general and a co-chair of the committee, said: We heard you.
"We, of course, want to be evidence based. We, of course, want to use the highest standards of rigor," she told the group. "And at the same time, we want to reflect what we're hearing from this group."
How do you define equity and health care equity in particular?
Rather than defining equity as everyone having a "fair opportunity to attain their full potential," as the World Health Organization does, Burke Harris instead proposed adopting a definition from the U.S. Office of Minority Health, which says achieving health equity requires "efforts to address avoidable inequalities and historical and contemporary injustices."
"We really wanted to have that included," Burke Harris said.
Over the next several weeks, the group will have to figure out how to translate those considerations into actionable vaccine policy.
"We have some good agreement on the what, but still some questions on the how," Burke Harris told the committee.
The details will matter. Experts warn California could open itself up to legal challenges if it uses race or historical injustice as a factor in prioritizing who gets the vaccine.
"That is affirmative action. That's choosing one group over another," says Lawrence Gostin, professor of global health law at Georgetown University.
In recent rulings, The U.S. Supreme Court has imposed strict rules on how affirmative action can be used in higher education, and Gostin thinks that federal courts would very likely be hostile to its use in public health. Such litigation could slow down implementation of a vaccine rollout.
Instead of using race, he says, the state should focus on a combination of other factors that can capture race, such as poverty, housing density or education disadvantage.
Eighteen states have indicated they would use the "social vulnerability index," a metric created by the Centers for Disease Control and Prevention. It combines 15 socioeconomic measures to identify at-risk neighborhoods. California has relied on its own "health equity metric" during the pandemic to guide reopening plans on the county level, and Burke Harris indicated the state might use it to decide vaccine allocations.
"Being fair, being equitable, I think that's a noble societal goal," Gostin says. "We just have to do it smart and keep the courts out of it."
Beyond distributing vaccines, states will have to address mistrust
However the state incorporates equity considerations into its vaccine allocation plans, there will still be obstacles. Hedrick is concerned Indigenous Americans may not be willing to take the vaccine first, even if it's offered first.
"I'm working with a community of people who are saying, 'Isn't this a funny time for the federal government or state governments to say, 'Oh, we need racial equity, when it's never been a concern?' " she says. " 'All of a sudden now we want to make sure brown people get this vaccine first?' "
There are more recent examples of medical harm at the hands of government which still haunt tribal communities. In the 1970s, as many as 70,000 Native women were forcibly sterilized at government-funded hospitals and clinics of the Indian Health Services.
Hedrick believes her own grandmother was an early victim of this campaign.
"She gave birth to my dad in 1943 in San Diego, and said that the doctor told her then that she would never have children again, that my dad 'ruined her,' " Hedrick says. "There are many stories like that that you sort of turn your head and think, 'Were you sterilized in that hospital?' "
Any plan to prioritize Indigenous people for a COVID-19 vaccine will have to include serious investments in outreach and building trust, she says. Indigenous Americans need this, she adds, for their own generational healing.
"So that when my granddaughter's looking back at the 2020 pandemic, she'll say, 'This is where we started to turn the tide,' " Hedrick says. "This is where we started to see actual governments do something different."