By JOSEPH WILLIAMS

Amid relentless pandemic that for months has cast a leaden pall over her work, Dr. Ebony Hilton in early December received the equivalent of a golden ticket.

An anesthesiologist and critical care physician at the University of Virginia Medical Center, Hilton, 38, was notified she’d be among the first in the nation to get a new, federally approved emergency vaccine to protect her against COVID-19. Soon after she received the notice, Hilton, who is Black, posted a video about it on YouTube, practically radiating optimism.

“We’re finally, I’m hoping, nearing as a nation a light the end of the tunnel,” she said.

Hilton’s excitement, however, is tempered by harsh reality: People of color have been hit hard by the novel coronavirus, and Black Americans have died of COVID-19 at a rate roughly three times higher than whites. Experts agree the virus has exposed health disparities hidden in plain sight, linked to the lingering effects of racism and inequality in the U.S.

Yet finding a way to get a potentially game-changing vaccine – the result of a multibillion-dollar race to invent a drug that can stop a global pandemic – into the arms of a demographic that’s among those who need it most is a conundrum that would vex King Solomon himself.

“This is an unprecedented, unprecedented mass vaccination campaign. We’ve never done this,” says Hemi Tewarson, a visiting senior policy fellow at the Duke University Margolis Center for Health Policy. While the country has had national inoculation campaigns for polio and the flu, she says, the global pandemic – combined with relatively small quantities of a precious vaccine – has raised the stakes to an extraordinary level.

And as the pandemic grinds on – killing thousands of people a day nationwide, swamping hospitals and funeral homes, and doing serious damage to the national economy – there isn’t much time for debate. “Millions of Americans across the country are going to need to get this vaccine,” and quickly, Tewarson says.

Earlier this month, a Centers for Disease Control and Prevention advisory committee recommended that front-line health workers and residents of long-term care facilities such as nursing homes should get vaccinated first. Such recommendations help guide health policy in the U.S. Still, it’s up to states to draft their own inoculation plans for their share of available vaccine doses, raising thorny questions about who’s next in line.

“There are 50 states with 50 allocation schemes,” says Dr. Chris Beyrer, an epidemiologist and professor at the Johns Hopkins Bloomberg School of Public Health. But putting communities of color ahead of other groups for the vaccine is good public health practice, Beyrer says: They are canaries in the COVID-19 coal mine.

“If the uptake is low, the impact will be low,” Beyrer says. And given the complex plans to nationally distribute a groundbreaking vaccine that’s already in short supply, he says, “the devil is in the details.”

Ahead of the vaccine rollout, the CDC’s Advisory Committee on Immunization Practices acknowledged that mitigating racial inequities should be a factor in distributing the vaccine, and said allocation strategies “should aim to both reduce existing disparities and to not create new disparities.” CDC Director Dr. Robert Redfield underscored the need in a statement accepting the committee’s initial recommendation for priority groups, encouraging a future call to prioritize older people in multigenerational households.

“Often our Hispanic, Black and Tribal Nations families care for their elderly in multigenerational households and they are also at significant risk,” Redfield said.

Indeed, a recent National Governors Association, Margolis Center and COVID Collaborative survey found that “many states have incorporated health equity principles in their vaccination plans to varying degrees.”

“For example, North Carolina specifically cited historically marginalized populations as an early-phase critical population group and New Mexico is prioritizing collaboration with Native Americans,” the report states. New Jersey and California have factored in monitoring to “assess and remove barriers related to accessibility, such as transportation and wait times, among other factors.”

California also has developed “a composite health equity metric that measures case rate and test positivity and will be used to inform vaccination allocation,” according to the analysis. Along with mass vaccination clinics, states may partner with community organizations, churches, pharmacists and other groups to distribute vaccines as they become more widely available.

Meanwhile, a Kaiser Family Foundation analysis released last month found that of 47 state vaccination plans, about half included “at least one mention of incorporating racial and/or ethnic minorities or health equity considerations in their targeting of priority populations.”

While some states expected to explicitly prioritize people of color, the analysis says, “others report using more general or indirect methods to do so,” such as the CDC’s Social Vulnerability Index, which takes into account factors such as area poverty, household crowding and minority status and was recommended by the National Academies of Sciences, Engineering, and Medicine as a tool to guide vaccine delivery. Still, the KFF report found only 26 percent of state plans “specifically mention or consider providers that are needed to reach racial and ethnic minorities.”

Tewarson says it’s a good sign that racial equity is on the table, but it’s just the first step: Equitable distribution has to be implemented on the ground.

“Localities are going to have to do that, health systems are going to have to do that, physicians who are seeing people in their offices are going to have to do that,” she says. Any plan, she says, has to include a public relations campaign, and “people are going to have to be talking about this in a way that’s resonating with the public.”

The need for appropriate messaging can be seen in the reaction to remarks by Melinda Gates, co-founder of the Bill & Melinda Gates Foundation, one of the world’s largest philanthropic and global health organizations. In an interview with TIME earlier this year, she said that “Black people (would be) next, quite honestly” in needing to get the vaccine after health care workers in the U.S., as “they are having disproportionate effects from COVID-19.”

The statement, however, triggered a backlash among some African Americans, with Gates accused of calling for the community to be used as “guinea pigs.”

At the same time, openly declaring that race will determine who gets a potentially life-saving drug ahead of everyone else could lead to a reverse-discrimination lawsuit that would probably block its rapid distribution.

In a piece published in October by the Journal of the American Medical Association, experts Lawrence Gostin of Georgetown University, Harald Schmidt of the University of Pennsylvania and Michelle Williams of Harvard University note that the prioritization of struggling people of color “rests on epidemiological, economic, and social justice grounds.” Yet they warn that such an approach may not survive the Supreme Court.

A workaround, they say, amounts to “racially neutral vaccine allocation criteria” that could stand in for race, such as “geography, socioeconomic status, and housing density.” They also point to a tool called the Area Deprivation Index as a framework for allocation that would be more legally acceptable than the CDC’s Social Vulnerability Index.

Plans to help protect African Americans, however, also face a hurdle in the dark, painful history of racial discrimination in the U.S. medical field – including cruel experiments conducted on Black slaves. Shadows of the infamous Tuskegee Study and the Henrietta Lacks case linger over African American suspicions about efforts to push them to the front of the line for a drug whose long-term effects are unknown.