Johnson & Johnson's vaccine raises new questions over health care equity

In the seven weeks or so since public COVID-19 vaccinations began in the U.S., a central question has loomed over the disarrayed process: Who should get the vaccine first? Debates have zigzagged among the elderly, the medically vulnerable, essential workers, or maybe just anyone who’s actually willing to get the dang thing. Now, with the potential arrival of a new promising vaccine from Johnson & Johnson, another layer has been added to the discourse: Who should get which vaccine?

Johnson & Johnson’s vaccine has not yet been authorized by the Food and Drug Administration, but it could start shipping as soon as March if federal regulators approve its emergency application. On the surface, based on clinical trials, there are some significant differences from the already authorized Moderna and Pfizer vaccines.

Johnson & Johnson’s vaccine appears more convenient: It can be stored in a normal refrigerator and requires just a single shot; Moderna’s and Pfizer’s must be stored in special freezers kept at negative 70 degrees Celsius and require two doses, with a period of several weeks in between. But Moderna’s and Pfizer’s vaccines appear more effective: Their vaccines are roughly 95% effective at preventing moderate to serious illness; Johnson & Johnson’s rate was 72% in its U.S. trial, and just 57% in South Africa, where a highly contagious variant of COVID-19 has led to a spike in cases.

It’s important to note that epidemiologists still consider 72% efficacy quite good, and that there wasn’t a single death reported in Johnson & Johnson’s trial. Still, given the history of systemic health care discrimination in the U.S., it’s not difficult to imagine a scenario in which certain communities feel aggrieved for only getting access to the “weaker” vaccine.

COVID-19 affects communities of color disproportionately. Nationwide, Black people have died at 1.5 times the rate of white people, accounting for roughly 64,000 of the 456,000 COVID-related deaths in the country to date, according to the Atlantic’s COVID Tracking Project. Indigenous Americans and Hispanic communities suffer higher death rates than white Americans, as well.

There are several reasons for this, among them that minority Americans are disproportionately essential workers, increasing their risk of exposure to the virus. In the case of Black Americans, they also are being vaccinated at much lower rates than their white counterparts. Earlier this week, the CDC published a report estimating that only 5.4% of vaccinated Americans are Black, even though they make up 13% of the population. Non-Hispanic white Americans are pacing on track with their share of the population.

Much of that disparity comes down to a lack of access, as well as a historical mistrust in the federal government’s medical system.

“It’s going to be a challenging communications and operational endeavor to try and square all of these circles here,” said Josh Michaud, associate director for global health policy at the Kaiser Family Foundation. “It’s valid to raise the concerns about the new vaccine and how they will fit into the overall strategy. Each that we have, particularly Johnson & Johnson’s, presents strengths and weaknesses that are remarkably different.”

The key to that communication, Michaud said, is to dispel any notion of an “inferior” or “superior” vaccine. In terms of preventing hospitalizations—sparing people from serious COVID symptoms and freeing up beds for patients with other serious medical conditions—the Johnson & Johnson vaccine still appears very effective. And not one person who took its vaccine died.

“If your focus is reducing hospitalizations and deaths, you take the vaccine you can get,” said Jeffrey Levi, a professor of health management and policy at George Washington University. “The best vaccine is the one you get in your arm.”

Levi said that Johnson & Johnson’s single-shot vaccine and the ability to store it in a standard refrigerator would be beneficial to isolated, rural communities and those without access to high-powered freezers.

“The equity balances out,” he said. “The simplicity of only requiring one dose increases the likelihood of getting a vaccine. The most important equity issue right now is supply. We need more vaccines to reach more people. There’s a feeling we’re not able to vaccinate a number of people we need to vaccinate—anything to increase that helps.”

Inevitably, some communities—especially in the beginning—may find themselves with access to only one of the vaccines. But in general, as distribution improves, Johnson & Johnson’s—if it’s approved for emergency use by the FDA—as well as other newcomers like AstraZeneca’s Oxford University vaccine, should be used in a multipronged strategy to vaccinate as many people as possible, public health experts say. A single-shot vaccine like Johnson & Johnson’s might be used for pop-up mass vaccination clinics. Others with more effectiveness, like Moderna’s and Pfizer’s, might be prioritized for especially medically vulnerable populations. “You need multiple forms of outreach,” said Levi.

“If I’m offered the Johnson & Johnson vaccine, I’d take it in a heartbeat,” said Michaud. “That’s the kind of communication you want to get across. It’s not really a matter of sending a poor product to certain people and a good product to others. We have to actively fight against that perception.”