With the national Covid death toll surpassing 300,000, the first doses of the Pfizer-BioNTech vaccine left a facility in Kalamazoo, Mich., on December 13, kicking off an extraordinary effort to inoculate nearly all Americans against the coronavirus. The vaccination campaign faces enormous challenges: the need to keep that vaccine at –94 degrees Fahrenheit, for one. But the challenges are not only logistical. Serious ethical questions remain about who will be at the front of the line.

The pandemic has magnified long-standing health inequities in the United States. Black, Indigenous, and Latino Americans have died of Covid-19 at a rate more than 2.7 times that of white Americans. Given this disproportionate toll, which was exacerbated by political leaders’ failure to ensure equitable access to testing and care, there’s an urgent need for public officials to prioritize racial and economic equity in allocating the vaccines. “Inequities in health have always existed, but at this moment there is an awakening to the power of racism, poverty, and bias in amplifying the health and economic pain and hardship imposed by this pandemic,” wrote a committee convened by the National Academies of Sciences, Engineering, and Medicine (NASEM) to establish a framework for vaccine allocation.

The committee recommended that the first phase prioritize first responders, frontline health care workers, anyone with underlying health conditions that puts them at “significant” risk, and older adults living in group settings. A second round of vaccine recipients would include teachers and child care workers, essential workers whose jobs increase their exposure risk, and people living in institutional settings like prisons, group homes, and homeless shelters. NASEM also suggested using a metric for vulnerability to guide how the vaccine is distributed geographically, such as the Centers for Disease Control’s (CDC) Social Vulnerability Index (SVI), initially developed for natural-disaster relief, or a Covid-specific vulnerability index. “There really is a bit of a sea change in recognizing that it’s just not acceptable to do what we usually do [when distributing vaccines], which is to maximize benefits. Now we also have to ask, ‘Well, who do those benefits accrue to?’ ” said Harald Schmidt, an assistant professor in medical ethics and health policy at the University of Pennsylvania.

Initial doses of the vaccine are already being distributed to health care workers and older residents of long-term care facilities. Allocations from the federal supply will be made to states based on population size; while that may seem fair on its face, it doesn’t address the fact that certain states have a higher proportion of residents who are more at risk than others. Although a CDC committee sets recommendations for priority groups, states aren’t technically required to follow them, and the CDC has asked states to come up with their own detailed plans for distribution. That means there could be significant variation state by state.

Among the hard choices states face is whether to prioritize essential workers, who are disproportionately low-income people and people of color, or elderly adults, who face the most acute risks of death from the virus. And who counts as an essential worker? The CDC classifies nearly 70 percent of the US workforce as essential, but it’s clear that certain frontline workers, like bus drivers and grocery cashiers, face greater exposure risks than others. “Within each of these groups, there are better- and worse-off populations,” Schmidt said. “We want to recognize that there’s a spectrum of disadvantage and that some groups need vaccines more urgently than others.” In late December, the CDC settled on a compromise between essential workers and the elderly, recommending that some 30 million frontline employees, including teachers and grocery cashiers, receive the next round of vaccines, as well as adults over 75.

At least 18 states plan to use measures of disadvantage to prioritize vulnerable populations or, at least, to plan outreach to them, according to an analysis by Schmidt and other researchers. Tennessee, for instance, plans to reserve 10 percent of its vaccine supply specifically for areas that score high on the SVI, which factors in poverty and race as well as indicators like car ownership and crowded living situations. In California, which will use its own index, Governor Gavin Newsom said he’s committed to “making sure Black and brown communities disproportionately are benefited.” New Jersey’s plan notes that the SVI could be used to determine where to locate vaccination sites. But only half of the states’ initial plans had even a single mention of incorporating racial equity into their allocation decisions.

Furthermore, the national distribution plan created by the Trump administration relies on chain pharmacies and hospitals, which tend to be located in wealthier urban areas. “In its current form, the Trump Administration’s vaccine plan relies on private health facilities that have historically excluded Black and brown communities,” reads a letter from New York Governor Andrew Cuomo, the NAACP, and a number of other groups sent to Health and Human Services Secretary Alex Azar in December. “We need to enlist faith-based organizations, neighborhood groups and local non-profits with deep roots in Black, brown and poor communities to get this done. And we need the funding to do so.”

The media coverage of vaccine access in communities of color has so far been dominated by concerns about hesitancy—the idea that some people, particularly in Black communities, may refuse vaccination due to the health care system’s long legacy of racist discrimination, evident not only in historical scandals like the Tuskegee experiments but also in the ways politicians and institutions have failed communities of color during the current pandemic. ”There have been many instances where Blacks and Latinos have been turned away from [Covid] care, turned away from testing, and died,” said Ruqaiijah Yearby, executive director of the Institute for Healing Justice and Equity at Saint Louis University. “I don’t want people to use hesitancy as a way to say, ‘Then we do not have to give them access to the vaccine.’ ”

Using measures of vulnerability to guide vaccine allocation does carry political and legal risks. Prioritizing prison inmates over children is epidemiologically sound, but some state leaders may balk at the optics. The desire to dispense vaccines quickly may conflict with efforts to ensure equitable delivery: Getting vaccines to marginalized groups may take more time than getting them to people with better access to care. And explicitly factoring race into decisions could draw legal challenges.

While states have significant leeway in how they prioritize their residents, those choices will be open to public scrutiny. Many political leaders have expressed dismay about Covid-19’s disproportionate impact on communities of color; now they have an opportunity to address it, even if this will come too late for those already lost to the virus. And getting vaccine allocation right is just a “first step,” Yearby said. “It cannot be the last thing that we do. It cannot be, ‘Oh, we thought about equitably allocating vaccines, so now we don’t have to think about economic relief or protecting workers.’”