Long before the first covid-19 vaccines went into arms, certain groups in the US felt the impact of the pandemic more severely: those who whose jobs had to be done in person, who were suddenly labeled “essential”; those who were shut out from government assistance; and certain communities of color.
Officials promised that the vaccine drive would be different, and that equity would be a priority. So far about 63% of US adults have gotten at least one covid-19 shot, and President Joe Biden has set a goal of increasing that to 70% by July 4. But many people in hard-hit communities still haven’t received effective communication about vaccines, and they may continue to face practical barriers to getting shots. As a result, their communities are still more severely affected. In Washington, DC, for example, the racial gap in covid-19 cases has grown rather than shrunk since vaccines became widely available.
Plans to increase equity have varied from place to place, with mixed results. Mississippi, which is home to a larger percentage of Black people than any other US state and initially saw stark vaccination disparities along racial lines, has almost reached parity. That success has been largely due to church leaders’ role in encouraging people to get vaccinated.
In California, however, special sign-up codes meant for Black and Latino communities were misused by wealthier people working from home, who shared the codes among their social and professional networks, according to the Los Angeles Times. And in Chicago, community members say, a digital divide and other access issues left vulnerable populations out—despite a neighborhood-level equity plan.
So are there lessons to be learned?
Equity = accessibility
Achieving equity is often a question of accessibility, says Emily Brunson, associate professor of anthropology at Texas State University and principal researcher of the CommuniVax project. Many things can be hurdles to getting a shot, including inconveniently located vaccination sites with limited hours, the need for transportation to those sites, and the difficulty of taking time off work.
“The problem right now is that it’s being talked about so much as a choice,” says Brunson, who points out that white Republican-voting men are particularly reluctant to get vaccinated relative to the rest of the US population. “Focusing on things that are choices takes away the spotlight from really severe access issues in the US.”
One success story took place in Philadelphia, thanks to an effective collaboration between two health systems and Black community leaders. Recognizing that the largely online signup process was hard for older people or those without internet access, Penn Medicine and Mercy Catholic Medical Center created a text-message-based signup system as well as a 24/7 interactive voice recording option that could be used from a land line, with doctors answering patients’ questions before appointments. Working with community leaders, the program held its first clinic at a church and vaccinated 550 people.
“We’ve worked really closely with community leaders, and every clinic since has evolved in terms of design,” says Lauren Hahn, innovation manager at the Penn Medicine Center for Digital Health.
By including community members early on, Hahn hoped, the program would give the people coming in for their shot the feeling that the clinic was made for them. And after their appointment, patients were sent home with resources like the number for a help line they could call if they had any questions about side effects.
“We want to make sure that we’re not just coming in and offering this service and then walking away,” she says.
Data needs to guide practice
Researchers say that having complete data on who is—and isn’t—getting vaccinated can improve the vaccine rollout and prevent problems from being obscured. Data gaps have been a problem since the early days of the pandemic, when few states were reporting cases and deaths by race. Though Joe Biden has emphasized equitable vaccine distribution as a priority, the CDC reports having race and ethnicity data for only 56.7% of vaccinated people.
Not everyone wants more information to be made public, however. In Wisconsin, Milwaukee County executive David Crowley says there can be resistance to collecting and publishing data that shows disparate health outcomes among racial groups. “We have to say that racism has been a problem,” Crowley says. But, he adds, “Look at the data. It’s going to tell you a story right there.”
His county created a covid-19 dashboard that reported detailed racial data before many other jurisdictions in the state, Crowley says. It allowed the county to work with the city of Milwaukee to open special walk-in sites for residents in certain zip codes.
“We haven’t found the silver bullet in all of this,” Crowley says. “But at the end of the day, we know that data is telling a story, and we have to utilize this data.”
Because the data is public, other pandemic response teams outside of government could use it too. Benjamin Weston, director of medical services at the Milwaukee County Office of Emergency Management, says making covid-19 data transparent and accessible helped community groups and academic researchers know where to focus their efforts.
The dashboard has also helped them see, in stark terms, that the communities hit hardest by covid have historically faced broader health challenges. After seeing that covid rates were high in places where people typically have cardiac issues, for example, the county decided to offer CPR training at covid vaccination sites. EMS division director Dan Pojar says he expects about 10,000 people to get CPR training that way.
“That’s an opportunity for us to work with other health systems to flow education and different initiatives into these communities,” Pojar says. “Covid is what really catalyzed this type of analysis work.”
It might get harder from here, not easier
Public health and equity researchers were not surprised at the pandemic’s disparate effect on certain communities, according to Stephanie McClure, assistant professor of anthropology at the University of Alabama. Health disparities along racial and economic lines have the potential to become a national and local focal point—in April, CDC director Rochelle Walensky declared racism “a serious public health threat”—but that tide hasn’t yet turned, McClure says.
Prioritizing equity could become more difficult as the US vaccine rollout shifts to a new phase. Some states have asked the federal government to send them fewer vaccines as sign-ups plummet. Some are also closing mass vaccination sites or consolidating efforts. McClure, who leads the Alabama team of the CommuniVax project, says that although it makes sense to respond to changes in the pandemic, those adjustments need to be thoughtful and measured—especially in regions like the South, where a smaller portion of the population is vaccinated.
McClure says people may think that sites are being taken away because residents didn’t show up fast enough, which can feel like a punishment. “Nobody wants to be told that they’re bad,” she says. “Or it can also be interpreted as ‘We’re taking this back because [vaccinations are] over, or because it’s not really that serious, or because you have enough people who are vaccinated,’ none of which is true.”
Persistence is vital
McClure says it’s important for public health officials to follow through on their promise to work to get everyone vaccinated. That means keeping in touch with hesitant communities to know if there’s a surge in interest so that vaccinators can quickly meet the demand.
“It’s the old public health trick: you make it easy for people to say yes,” she says. “You continue the surveillance and monitoring and get the best data you can on vaccination, and then you plan in cooperation with the community. How often should we come back? How often should we remind people that this is available?”
She says the pandemic has been a useful case in point in a long history of health inequities that didn’t start and won’t end with covid. After the emergency state of covid-19 has passed, officials will need to keep the momentum going—especially at the local level, where so many access problems have emerged.
In Alabama, for example, National Guard mobile vaccination units were set up with the ultra-cold freezers needed to transport and store mRNA-based covid-19 vaccines. “Why not, when this particular push is over, leave those freezer units with the federally qualified health centers that are already in those communities?” McClure says. “You’re starting to build the infrastructure for being able to deliver vaccination on a consistent basis.”
Brunson, the principal researcher of the CommuniVax project, says covid-19 vaccinations can be used as a way to open other conversations about health needs that are going unaddressed. If a community hard-hit by covid-19 also suffers from high rates of diabetes, vaccine efforts could open the door to long-term engagement with people who feel their health hasn’t been a priority.
“It's really the opportunity to change,” she says.
This story is part of the Pandemic Technology Project, supported by The Rockefeller Foundation.