Using Disadvantage Indices to Guide State Health Equity Efforts: On-the-Ground Lessons from the COVID-19 Pandemic Support for this brief was provided by Blue Shield of California Foundation. Summary ic, laying bare the longstanding and systemic inequities facing disadvantaged communities. Increasingly, policymakers are exploring how In April 2021, the director of the Centers for disadvantage indices can help guide efforts Disease Control and Prevention (CDC) declared to dismantle structural discrimination by racism a serious public health threat, citing identifying-and then allocating resources "structural barriers that impact racial and ethnic more equitably to-marginalized communities groups differently to influence where a person that disproportionately lack equal access to lives, where they work, where their children health care, education, safe housing, and other play…. These social determinants of health social determinants of health. The COVID-19 have life-long negative effects on the mental and pandemic marks a major widespread use of physical health of individuals in communities disadvantage indices to guide more equitable of color. Over generations, these structural resource allocation, providing an opportunity inequities have resulted in stark racial and ethnic to learn from early state and local experiences health disparities that are severe, far-reaching using these tools to guide vaccine allocation and unacceptable."2 Moreover, as the CDC "Disadvantage and distribution. This brief summarizes a June has noted, race and ethnicity are risk markers 2021 AcademyHealth workshop where public indices can continue health officials shared their on-the-ground ex- for other underlying circumstances that affect to inform how we periences using disadvantage indices to locate health, including socioeconomic status, access to health care, and occupation. allocate resources, COVID-19 testing sites, allocate vaccines, set whether it's for issues up vaccination sites, and conduct community outreach to overcome vaccine hesitancy. While Disadvantage Indices and Equitable around homelessness, early experiences indicate that indices helped Vaccine Allocation behavioral health guide more equitable responses to the pandem- As COVID-19 vaccines neared emergency issues, food insecurity- ic, formal evaluation is needed to examine the approval in the United States, the National comparative advantages and effectiveness of there's a whole list… various indices. Moreover, the pandemic has Institutes of Health and CDC requested that the National Academies of Sciences, Engineering, and, ultimately, we want highlighted the critical need for greater invest- and Medicine (NASEM) develop a framework to actually get to those ment in data infrastructure, especially accurate for equitable vaccine allocation. In an unprece- race and ethnicity data, to both prepare for and structural discrimination respond to future public health emergencies. dented move, the NASEM framework empha- sized that equity matters not only in sequencing pieces, which are priority groups for vaccination but also within underlying all of this, and Still Separate and Unequal each group. For example, older people are at that does come down to By any measure-cases, hospitalizations, and higher risk of COVID-19 infection and worse outcomes because of their age, but older people policy and systems." deaths-Black, Indigenous, and people of color (BIPOC)1 across the U.S. have disproportionate- from disadvantaged groups face even higher – Meeting Presenter ly borne the burden of the COVID-19 pandem- risks because they are more likely to experience Using Disadvantage Indices to Guide State Health Equity Efforts: On-the-Ground Lessons from the COVID-19 Pandemic worse baseline health and less favorable living conditions. There- • Surfaced emerging best practices, lessons learned, challenges, and fore, NASEM explicitly urged that as various population groups other issues from states' use of disadvantage indices to date; and became eligible, "vaccine access should be prioritized for geograph- ic areas identified through CDC's Social Vulnerability Index (SVI) • Raised possible evaluation and other questions related to use of indices that, if answered, could help inform how states apply or another more specific index."3 these tools going forward to address social determinants of health and inform other activities to advance health equity. A disadvantage index like the SVI is a composite measure linked to a geographic area that weighs the relative average advantages This brief summarizes the workshop's collective presentations and disadvantages of residents based on income, race and ethnic- and discussion. Because the session was off the record, the brief ity, education, housing, health insurance status, transportation conveys general workshop content without attributing specific access, and other sociodemographic factors. Initially designed comments to particular participants. The discussion was informed to help public health officials better prepare for and respond to by existing research, though neither the discussion nor this brief emergencies such as hurricanes, disease outbreaks, or chemical incorporates a systematic review of the literature on disadvantage spills,4 disadvantage indices like the SVI also are drawing interest indices. A select bibliography of relevant, current literature is as tools to advance health equity more broadly. AcademyHealth, included at the end of the brief. with support from Blue Shield of California Foundation, held a June 2021 workshop to explore how states are using disadvantage Structural Discrimination and Health Equity indices to respond to COVID-19. Drawing on the perspectives of Rectifying systemic discrimination-be it racism, sexism, ageism, policymakers, researchers, and others, the workshop: or any other "ism"-requires examination of the root causes of • Provided an overview of disadvantage indices and how diverse structural discrimination, or the way that laws are used to struc- states are using these tools to inform equitable COVID-19 vac- ture systems, such as education, employment, housing, public cine allocation, distribution, and outreach; health, and health care, to advantage dominant groups, according to a framework developed by the Institute for Healing Justice & Equity at Saint Louis University (see Figure 1). Figure 1. Framework to Identify Root Causes of Systemic Discrimination Source: Yearby, R. "Structural Racism and Health Disparities: Reconfiguring the Social Determinants of Health Framework to Include the Root Cause." J Law Med Ethics. 2020 Sept;48(3): 518-526. 2 Using Disadvantage Indices to Guide State Health Equity Efforts: On-the-Ground Lessons from the COVID-19 Pandemic In the case of COVID-19, for example, paid sick leave can influence whether lower-income essential workers get vaccinated, because those Health Justice Framework Principles with paid leave won't lose wages to take time off to get the vaccine •Legal and policy responses must address the impacts of discrim- or recover from possible side effects. Broad access to paid sick leave ination and poverty on the social determinants of health, which in turn threaten to exacerbate the health, financial, and social dates to the rise of unions during the New Deal era, which overlapped impacts of a public health emergency on low-income communi- with Jim Crow laws that legalized racial segregation. As a result, many ties, communities of color, and other marginalized communities. people of color, along with women, were excluded from unions and •Interventions mandating healthy behaviors-such as staying collective bargaining agreements that extended paid sick leave to at home from work when sick, mask wearing, and minimizing workers. That structural discrimination remains today, especially close contacts outside the home-must be accompanied by le- for lower-wage workers, erecting a barrier to vaccination for many gal protections, accommodations, and social supports to enable people with frontline service jobs who face greater risks of contracting those behaviors while minimizing economic, social, and cultural COVID-19 and suffering complications if infected. harms. •Because emergencies typically exacerbate longstanding and While disadvantage indices can help identify vulnerable communi- interconnected crises in low-income communities and com- munities of color, legal and policy responses must address root ties, indices alone cannot fix longstanding inequities; they must be problems in addition to immediate needs. paired with effective action to dismantle structural discrimination •Historically marginalized communities must be engaged as and remove systemic barriers that keep people from attaining their leaders in the development of any interventions and the attain- best possible health and well-being. To that end, the Institute for ment of health justice. Healing Justice & Equity at Saint Louis University has devised four principles for policymakers to consider as they work to advance health equity (see Health Justice Framework Principles at right).5 States gravitated to the SVI. Most states using disadvantage indices opted for the SVI, according to the Nature Medicine study, per- Most States Use Indices to Guide Vaccine haps in part because of the index's CDC imprimatur. Along with Allocation NASEM's recommended use of an index, noting the SVI by name, the Biden administration in January 2021 also urged local officials By the end of March 2021, across the CDC's 64 local vaccine alloca- to use the SVI or another index to get "vaccines to residents at tion jurisdictions-50 states, the District of Columbia, five cities, and highest risk and in high-vulnerability areas" and "describe how they eight territories-34 states and three cities had incorporated disadvan- have or will provide equitable access to COVID-19 resources within tage indices into their vaccine allocation plans, according to a recent highly vulnerable communities."7 Nature Medicine study. 6 Indices used included the SVI, the Commu- nity Vulnerability Index, the Area Deprivation Index, and the Cali- Availability and ease of use also factored into decisions to use the fornia Healthy Places Index (see page 5 for more information about SVI. "We selected the SVI because we had been exploring this index the Healthy Places Index). Researchers found that local jurisdictions in areas of preparedness, maternal/child health, and environmental used indices and other place-based measures to: health. But, also the key ingredients of the index, including instruc- • Define priority groups or geographic areas, tions on how to run it, were publicly available online, so it was very • Prioritize disadvantaged groups by increasing shares of vaccines easy to share with others who had questions about it or wanted to or vaccination appointments, run it themselves as well," a state official said. Similarly, another presenter shared, "It's a CDC index-it has a lot of authority. People • Tailor outreach and communication, don't need to explain much to their governor… it makes sense to • Plan the location of vaccination sites, and be risk averse and just say I probably better go with what causes the • Monitor vaccination receipt. least friction in the moment." Practical applications and adaptions. The SVI and other indices Lessons Learned: Real-World Use of often rely on Census tracts as the unit of geographic measure, and Disadvantage Indices several jurisdictions described augmenting or imputing data from During the workshop, state and municipal public health officials other sources to generate ZIP-code-level mapping. In one large from diverse jurisdictions shared on-the-ground experiences of using metropolitan area, for instance, public health officials adapted indices to help advance equity in locating COVID-19 testing sites, the SVI to include employment information from the American allocating vaccines, setting up vaccination sites, particularly mobile Community Survey to monitor variables known to affect health and pop-up clinics, and conducting community outreach to overcome equity, such as people working in high-risk service occupations. To vaccine hesitancy. prioritize where to locate testing sites, another state used the SVI in 3 Using Disadvantage Indices to Guide State Health Equity Efforts: On-the-Ground Lessons from the COVID-19 Pandemic tandem with mortality rates for comorbidities known to put people Moreover, public health officials in some jurisdictions faced charges at higher risk of negative outcomes if infected with COVID-19. of discrimination for using disadvantage indices. "The attack on- under which some of these indices came… all started with some When vaccines became available but initially were in short supply, region where people said vaccine allocation has to be based on one state used an index to help identify and "geofence" disad- science and not on social values. It never occurred to me that the vantaged neighborhoods by ZIP code and prioritize residents for Social Vulnerability Index for some people reads like a critical race online vaccination appointments. In another state, where politics theory index, you know-so it's incredible," a presenter said. At the hampered vaccine uptake, health officials used risk-based phases same time, public health officials were mindful that using a disad- and age-based criteria for vaccine distribution at the county level vantage index might have unintended consequences. "There were while allocating extra vaccine to counties with the highest risk a lot of very important discussions around, 'Are we stigmatizing populations as identified by the SVI. Counties could move through people who live in these communities? Are we scapegoating certain the risk phases and age groups independently of other counties, communities?' And those were all very tough conversations…. I enabling counties with more disadvantaged residents to rapidly vac- do think it really made an impact, and I think brought resources to cinate all willing people, a state official said. "Equity was a cross-cut- bear in places that may not have had as many resources." ting consideration of this plan… and in our conversations with the governor… everyone understood and kept at the front of mind that In one state, a county's SVI score was used as a multiplier against equity was something that we were very, very invested in." However, the county's population of people eligible to receive a vaccine. For the state has lagged in overall vaccination rates, with the official example, if the eligible vaccination population in a county was saying, "We have done a wonderful job of equitably distributing and people aged 65 years and older and first responders, the state would administering vaccines in the state…. The population that we did sum the two populations and then multiply the total by the county's not plan on having to target is the rural white conservative, and that SVI percentile. For some counties, the population used to allocate is the bulk of the hesitancy in the state." vaccines would increase, while in other counties, the population would decrease, a presenter said, adding, "Although mathematically In some states, foundations and community-based organizations this made a lot of sense, this was very difficult to explain to policy- used SVI-guided geo-mapping to target outreach to vulnerable makers, media, and members of the general public." communities. States also incorporated monitoring based on the SVI into statewide reopening frameworks, taking both a carrot and The official continued, "There were many audiences that appreciated a stick approach to encourage counties to focus on disadvantaged the use of SVI allocation and the continued attention to equity. How- communities. "We used health equity to guide how reopening ever, there were also objections. Some entities felt that they should be happened county by county. So, for each county to move forward… receiving more vaccine than was available to them…. Other entities if your least healthy community… did not also meet the same test questioned the use of the SVI because it included race and ethnicity as positivity-if it was higher, then they could not move forward. We part of its domains and was therefore seen as discriminatory." also wanted to develop what we call an accelerant-it was sort of like having your stick but also having a carrot… so they had a way Similarly, in another state, an official said, "There was a lot of pushback to demonstrate if they were doing more testing and more work in from a lot of different kinds of stakeholders around this pandemic…. their least healthy communities, that they could actually then move If you have just as many people upset on both sides, you might have forward" even if other indicators lagged, according to a presenter. gotten it just right." To help people understand the importance of equity in vaccine allocation and monitoring disparities in vaccination Equity or 'Discrimination'? Using disadvantage indices to identify among vulnerable groups, state and local health officials launched high-risk communities and target resources accordingly can poten- public education campaigns and engaged business leaders. tially help the most vulnerable people in those communities as well as the broader community. One presenter stressed the need to high- "Some entities felt that they should be light how using a disadvantage advantage index "helps everybody… receiving more vaccine than was available that getting the vaccine to the people who are disadvantaged… helps us all." Nonetheless, some states rejected local efforts to ad- to them…. Other entities questioned the vance health equity. In Texas, for example, Dallas officials reversed use of the SVI because it included race and course on a plan to prioritize vaccine doses for people living in the ethnicity as part of its domains and was most vulnerable ZIP codes, primarily communities of color, after therefore seen as discriminatory." the state threatened to withhold vaccine allocations.8 – Meeting Presenter 4 Using Disadvantage Indices to Guide State Health Equity Efforts: On-the-Ground Lessons from the COVID-19 Pandemic California Healthy Places Index Long known as a bellwether state, California is at the forefront in leveraging information about the state's nearly 40 million residents and the communities they live in to guide public policy. Recognizing that the health of Californians is shaped dramatically by "non-health" policies and community conditions related to housing, education, economic, social, and other factors, the California Healthy Places Index (HPI) details community conditions that predict life expectancy. Developed by the Public Health Alliance of Southern California in partnership with the Virginia Commonwealth University Center on Society and Health, the HPI can be used to compare and explore local factors influencing health across the state. The purpose of the HPI is to prioritize public and private investments, resources, and programs. The tool contains user-friendly mapping and data resources at the census tract level across California. The HPI also provides scores based on community conditions to enable comparisons between areas, as well as deeper dives on conditions in any given area. The tool also includes detailed policy guides to support specific policy interventions that improve community conditions and health. The HPI combines 25 community characteristics into a single indexed score. In addition to the overall score, the index also contains eight sub-scores for the following policy action areas: economic, education, housing, health care access, neighborhood, clean environment, transportation, and social factors. The index was created using statistical modeling techniques that evaluated the relationship between these policy action areas and life expectancy at birth. The statistics were designed to maximize the ability of the HPI to identify healthy communities and quantify the factors that shape health. The graphic below shows the eight policy action areas, their weights within the index, and the 25 community characteristics that contribute to the overall HPI score. In addition to the characteristics calculated in the HPI, a mapping tool includes additional selectable data layers such as: health outcomes, race/ethnicity, climate change effects, and other layers that can inform decisions to advance resilient, equitable communities in California. Action Clean Healthcare Policy Area Economic Education Transportation Social Neighborhood Housing Environment Access Weighting 32% 19% 16% 10% 8% 5% 5% 5% Low-Income Automobile Two Parent Renter Severe Employed In Pre-School Retail Density Ozone Insured Adults Access Household Housing Cost Burden Low-Income Active Homeowner Income In High School Voting in 2012 Park Access PM 2.5 Commuting Severe Housing Indicators Cost Burden Bachelor's Housing Diesel PM Above Poverty Education or Tree Canopy Habitability Higher Supermarket Uncrowded Water Access Housing Containments Alcohol Outlets Homeownership Source: About the California Healthy Places Index. Accessed at https://healthyplacesindex.org/about/. Fiscally administered by the Public Health Institute The HPI was used to develop the health equity metric that was incorporated in California's approach to assess progress toward reopening safely by reducing disease transmission in all communities. Specifically, the health equity metric focused on the test positivity rates in the most disadvantaged neighborhoods, to ensure that these communities did not significantly lag behind the overall county test positivity rate before moving between tiers of reopening. In its planning and administration of the COVID-19 vaccine, the state has used the Vaccine Equity Metric (VEM), containing data from HPI, to identify Quartile 1 neighborhoods – where California's most vulnerable communities who have been disproportionately impacted by COVID-19 live – so that the state can focus its ongoing vaccine communications and outreach efforts. In addition, given that an HPI score was not calculated for some zip codes due to issues of statistical reliability and validity, the California Department of Public Health derived scores for those areas to develop the VEM. This methodology was applied to 351 zip codes. With the goal of health equity always on our mind, California has made great strides in vaccinating Californians and equalizing VEM Quartile 1 (Q1) and Quartile 4 (Q4) vaccination rates. The HPI is also an important resource used by local health departments to inform their community health assessments, and is used by state programs to identify granular place-based factors impacting health outcomes and life expectancy. 5 Using Disadvantage Indices to Guide State Health Equity Efforts: On-the-Ground Lessons from the COVID-19 Pandemic "The more perfect [an index] is sort of scientifically from a data Typically, county health departments are the face of public health perspective, the more complex it is and therefore challenging to in local communities, and too often, those faces don't reflect the implement and communicate and defend, and so I think officials, diverse communities they serve, with a representative from a non- policymakers, really have to balance those tensions to get to better profit public health group stressing that the public health workforce than rough but good enough," a presenter said. "really needs to reflect the communities that are most impacted." Another way to connect with communities is to provide ongoing Building and sustaining community partnerships. While a disad- funding-not piecemeal grants-to support community groups as vantage index can help identify where to deploy resources, an index a resource to tap for advice and referrals to support public health alone does little to inform how to deploy resources to advance health activities and advance equity efforts. Building relationships with equity, health officials stressed repeatedly, noting that community community-based primary care clinicians also can help cultivate partnerships are critical. "Access is not just putting points on a map. community connections. One state, for example, awarded grants It's not just setting up these vans here and there-you really do need to help primary care providers meet CDC requirements to pro- to think about how to connect people to vaccines in the way that they vide vaccinations, recognizing that as trusted information sources, would like to be connected to them," a presenter said, adding, "The community-based clinicians can help overcome vaccine hesitancy. most important thing is to talk to people and to really engage with There is also a role for philanthropy-foundations, for example, can communities and understand where they're coming from, what their often be nimbler than government, especially in a crisis. needs are… trusting communities and community wisdom, I think, is something that we could all do a little bit more." "The most important thing is to talk to people and to really engage with People in the community-especially those with lived experience of inequities-know the community and understand both what communities and understand where they're messages and messengers will resonate-for example, recruit- coming from, what their needs are… ing barbershops and churches as trusted information sources in trusting communities and community African American communities. "We often talk about community engagement-that is not enough, we need to be true partners with wisdom, I think, is something that we could them…. work with barbershops to get out vaccines-that's the kind all do a little bit more." of partnership we need." – Meeting Presenter Building and sustaining community partnerships takes both time and ongoing attention, with one official saying, "I think one thing Evaluating Index Effectiveness and Other Research that we should be thinking about going forward-beyond COVID Questions and learning from COVID-is that those relationships have to be While anecdotal experiences indicate their usefulness in adding well established. We can't in the heat of the moment, at a moment of measures of equity to vaccine allocation, there is little, if any, formal crisis, try to go into the community and figure out how we're going evaluation yet of the indices' effectiveness in leveling the playing to actually connect with and engage and empower the community." field for disadvantaged communities. "It seems almost a conceptual truth in the situation where you're allocating vaccines, and you don't have any leftover vaccines, and you offer more to worse-off "The more perfect [an index] is sort of people then… more disadvantaged people get vaccinated before scientifically from a data perspective, better-off people, and that is right both in equitable terms and in the more complex it is and therefore public health terms because more disadvantaged people are more challenging to implement and communicate likely to get and spread the virus," a presenter said. and defend, and so I think officials, Nevertheless, participants agreed on the importance of evaluating policymakers, really have to balance those disadvantage indices, both to determine the relative effectiveness of tensions to get to better than rough but different indices and how to best deploy them. One participant said good enough." the question isn't whether using an index is "more equitable, but how does it make it more equitable. So, it's not yes, no-it's really – Meeting Presenter under what conditions and for whom." 6 Using Disadvantage Indices to Guide State Health Equity Efforts: On-the-Ground Lessons from the COVID-19 Pandemic Participants also discussed how granular geographic areas need to be The use of disadvantage indices also has illuminated the potential to ensure an index's accuracy. The SVI, for example, aggregated data at of unifying health and other equity efforts across state government, either the county or Census tract level-typically, 1,200-8,000 people. including state health departments, Medicaid programs, governors' But in densely populated urban areas, Census tract-level data can offices, and other state agencies to address issues ranging from mask wide variation in sociodemographic characteristics. Even ZIP chronic disease to homelessness, food insecurity, behavioral health, code-level data might not be specific enough, with some participants and re-entering the community from the juvenile justice/corrections saying health and other equity work often happens at the neighbor- systems. Rather than characterizing communities as disadvantaged, hood level. Other questions included whether proxies such as rates of policymakers can change the lexicon to talk about investing in "com- poverty or uninsured people might be good enough to target disad- munities of opportunity," a participant said, and use the SVI or other vantaged areas. Responding to a question about whether the indices place-based measures to center health equity discussions on economic are more effective than "more commonly used measures," a public development and gain business community buy-in. Other possibilities health official said, "This is very much still an emergency response, so include using indices to help build data linkages and referral networks I have not been able to do that kind of look-I'd be very interested in among health care providers, health plans, accountable care organiza- learning what people find." tions, and community organizations to work together in addressing the social determinants of health underlying health inequities. Implications: Indices Potentially a Powerful Health Equity Tool "Disadvantage indices can continue to inform how we allocate resources, whether it's for issues around homelessness, behavioral While researchers have long documented significant racial and ethnic health issues, food insecurity-there's a whole list… and, ulti- health disparities in the United States, the undeniable and glaring mately, we want to actually get to those structural discrimination inequities laid bare by the pandemic have created new urgency-and pieces, which are underlying all of this, and that does come down an opportunity-to educate policymakers, especially elected officials, to policy and systems," a presenter said. about why health equity matters in a real and powerful way. "There's been a change in the lexicon across our state… where every elected And there is little time to waste, as the same presenter observed that official now really understands about the conditions and some of the capturing policymakers' attention, coupled with generous federal structural racism and institutions. So, it was and continues to be, I relief and recovery funding, creates a limited window of oppor- think, an amazing opportunity for us to shift the dialogue as we're tunity to advance both health equity and broader public health starting to think about what does the future look like. How do we start initiatives. "We have the attention of governors, of legislators, of the making investments? How do we start really thinking in a new way in business community in a way that I think we've never had their at- our recovery and beyond?" one participant observed. tention before, as they have seen what a pandemic can do and how integral public health is in a way [to the economy] that I don't think Throughout the workshop, participants identified opportunities to people really ever understood." learn from experiences using disadvantage indices to advance health equity, including investing in the public health data infrastructure, especially improved collection of race and ethnicity data. One partic- About the Author ipant stressed the importance of "improving the data infrastructure" Alwyn Cassil is a Principal at Policy Translation, LLC. through a "more sophisticated and souped-up data system that con- nects these different [equity] pieces, so you can look at all these differ- Endnotes ent factors and do it in a more holistic way. The other thing I will just 1. CDC, Risk for COVID-19 Infection, Hospitalization, and Death By Race/ say… that collection of the race and ethnicity data itself is challenging." Ethnicity. Updated June 17, 2021. Accessed at https://www.cdc.gov/ coronavirus/2019-ncov/covid-data/investigations-discovery/hospitaliza- tion-death-by-race-ethnicity.html. One state health official recounted using vital records to capture race 2. Media Statement from CDC Director Rochelle P. Walensky, MD, MPH, on and ethnicity data, saying, "I was pulling literally tape from archives to Racism and Health. April 8, 2021. Accessed at https://www.cdc.gov/media/re- get race and ethnicity data off of people's birth certificates because… leases/2021/s0408-racism-health.html our health care feeds just did not contain information." In the same 3. National Academies of Sciences, Engineering, and Medicine. 2020. Framework vein, another official said, "If I can say anything, it's to invest in your for Equitable Allocation of COVID-19 Vaccine. Washington, DC: The National infrastructure…. We had to do a lot of workarounds, and at this point, Academies Press. https://doi.org/10.17226/25917. a year and a half later, it's not that sustainable, and so I think we're 4. CDC/ATSDR SVI Fact Sheet. Centers for Disease Control and Prevention. really looking forward to how can we be more resilient in the next Accessed June 28, 2021, at https://www.atsdr.cdc.gov/placeandhealth/svi/ fact_sheet/fact_sheet.html. response and really connect our systems a little bit better." 7 Using Disadvantage Indices to Guide State Health Equity Efforts: On-the-Ground Lessons from the COVID-19 Pandemic 5. Benfer E, et al. "Health Justice Strategies to Combat the Pandemic: Eliminating "Minority Health Social Vulnerability Index Fact Sheet." Centers Discrimination, Poverty, and Health Disparities During and After COVID-19," Yale Journal of Health Policy, Law, and Ethics, Forthcoming. Available at SSRN: for Disease Control and Prevention. Accessed at https://www. https://ssrn.com/abstract=3636975 or http://dx.doi.org/10.2139/ssrn.3636975. minorityhealth.hhs.gov/Assets/PDF/MH%20SVI%20Fact%20 Sheet_7.15.2021.pdf. 6. Schmidt, H. et al. "Equitable Allocation of COVID-19 Vaccines in the United States," Nature Medicine, Vol. 27, May 18, 2021, pp. 1298-1307. Accessed at https://doi.org/10.1038/s41591-021-01379-6. Murphy K, Wilkniss S. "Equity in COVID-19 Vaccines: Emerg- 7. The White House. January 21, 2021. National Strategy for the COVID-19 ing Lessons from the Front Lines." Families USA. April 8, 2021. Response and Pandemic Preparedness. Accessed at https://www.whitehouse. Accessed at https://familiesusa.org/resources/equity-in-covid-19- gov/wp-content/uploads/2021/01/National-Strategy-for-the-COVID-19-Re- sponse-and-Pandemic-Preparedness.pdf. vaccines-emerging-lessons-from-the-front-lines/. 8. Platoff E, Garnham JB. "Dallas County axes plan to prioritize vaccinating communities of color after state threatens to slash allocation," January 20, 2021. Schmidt H, Gostin LO, Williams MA. "Is It Lawful and Ethical The Texas Tribune. Accessed at https://www.texastribune.org/2021/01/20/dal- to Prioritize Racial Minorities for COVID-19 Vaccines?" JAMA. las-vaccine-plan-communities-of-color/. 2020;324(20):2023–2024. doi:10.1001/jama.2020.20571. Additional Reading Srivastava T, Schmidt H, Sadecki E, Emily, Kornides M. Social Atkeson A, Allen J. "Using Data Strategies to Advance Health and vulnerability, disadvantage, and COVID-19 vaccine rationing: Racial Equity." June 25, 2021. National Academy for State Health A review characterizing the construction of disadvantage indi- Policy. Accessed at: https://www.nashp.org/using-data-strate- ces deployed to promote equitable allocation of resources in the gies-to-advance-health-and-racial-equity/. United States (July 8, 2021). Available at SSRN: https://ssrn.com/ abstract=3882863. Karmakar M, Lantz PM, Tipirneni R. "Association of Social and Demographic Factors With COVID-19 Incidence and Death Rates Thoumi A, Tewarson H, Johnson K. March 2021. "Prioritizing in the US." JAMA Netw Open. 2021;4(1):e2036462. doi:10.1001/ Equity for COVID-19 Vaccinations: Promising Practices from jamanetworkopen.2020.36462 States to Reduce Racial and Ethnic Disparities." Washington, DC: Duke-Margolis Center for Health Policy and National Governors Krieger, N. et al. "A warning against using static US county-level Association Center for Best Practices. Accessed at https://health- community data to guide equity in COVID-19 vaccine distribution: policy.duke.edu/publications/prioritizing-equity-covid-19-vaccina- Temporal and spatial correlations of community characteristics tions-promising-practices-states-reduce-racial-and. with COVID-19 cases and deaths vary enormously and are increas- ingly uninformative." December 1, 2020. Working Paper Series, The Harvard Center for Population and Development Studies. Accessed at https://cdn1.sph.harvard.edu/wp-content/uploads/ sites/1266/2020/12/20_Krieger-et-al_equity-in-vaccine-distribu- tion_Volume-20_No-_5_final.pdf. 8 Using Disadvantage Indices to Guide State Health Equity Efforts: On-the-Ground Lessons from the COVID-19 Pandemic Endnotes 9