Reaching for Equity in the Last Mile
I breathed a deep sigh of relief when I learned that my father, a 65-year-old Black man, received his first vaccination. After reaching a grim milestone of a half million deaths nationwide, it seemed inevitable that the worst of this pandemic would hit home, a predominantly black area of Los Angeles. My relief did not simply stem from knowing that, a few weeks later, he would be immune, but also that he even obtained access to a coveted vaccine amidst a rollout that has been chaotic and disorganized. I wondered, how did my father, who still uses AOL for email and types with 2 fingers, figure out how to make that appointment? Then the light bulb turned on; he didn’t schedule the appointment, my sister did.
Patiently, my sister navigated a labyrinth of multiple county and state websites with glitchy appointment systems, across multiple screens and with countless refreshes to secure him a spot. Compared to some, it was relatively easy. In Alameda County, where I practice, if a patient has internet access, they might go to the MyTurn state website. There, they might be virtually directed to a vaccine site all the way in San Francisco, only to discover no slots were available. They might then go to the County “Calvax” website, but then be unable to complete the sign-up form without an email address. Those without access to the internet have even fewer options, relying mainly on their primary care provider and hoping to see a flyer or hear word of a local vaccination site for which they simply have to call. These are just a few of the obstacles that many Americans face when trying to schedule their vaccine. Meanwhile, multiple electronic access codes, intended to reserve vaccine slots for people of color and disabled people, were obtained by educated, white individuals who then scheduled their vaccine, bypassing all vaccine eligibility criteria and waits. Unfortunately, the current systems in place for vaccine distribution continue to fail the communities who need the vaccine most, while favoring those with privilege.
Since the start of the pandemic, Black and Latino communities have been decimated by COVID-19. For the first time in decades, the life expectancy of US citizens has declined most notably among minorities. A recent study projected life expectancy for Black and Latino people will drop by approximately 2 and 3 years, respectively, while the life expectancy for white people is projected to decline by less than 1 year.
Though we’ve seen infections & hospitalizations decrease during this vaccine rollout, disparities in vaccine distribution remain stark, but not surprising given how vaccine access has been structured. In 23 states reporting ethnicity, data shows white residents being vaccinated at twice the rate of Black residents. Black people in Philadelphia and Washington make up more than 40% of the population but just 20% of vaccinated people for whom racial data is available. In Texas and California, Latinos make up 39% of the population but just 21% and 18% of those vaccinated. In Arizona, Whites make up 55% of the state but have received 76% of vaccines (Bloomberg Vaccine Tracker). The same structural inequities that have left minority communities more prone to infection are also playing out in vaccine delivery and distribution.
The system needs to be turned on its head, because as it stands currently, it is not built for the communities most at risk. So how do we fix this system? How do we reach out to the communities who have been left behind? There is no one simple solution. Establishing equitable vaccine distribution will require a multi-faceted approach at a hyper-local level.
“Vaccine hesitancy” should not be confused with “healthy skepticism” and should be addressed with facts. At least 60% of Black Americans say that they do not have enough information about when they can get vaccinated, and say they don’t have enough information about where to get vaccinated. Access to information about the vaccine must be widely disseminated in multiple forms and venues.
Disjointed online appointment systems should be replaced with, or at least complemented by, robust live (phone or in-person) appointment scheduling systems. Nearly 40% of Black and Hispanic adults report not owning a computer or having access to broadband compared to only 20% of white adults. Overreliance on technology innately excludes large portions of the population who don’t rely on or even have access to technology, while creating ample opportunity for misuse.
When we talk about COVID-19 vaccination in the Black and Latino communities, the media and others hone in on hesitancy. We fail to acknowledge that 70% and 80% of the people in those communities want to get vaccinated. Yes, for many minority communities, vaccine hesitancy is a valid & complex idea rooted in systemic discrimination and structural racist policies spanning hundreds of years. And hesitancy may be too simple a word to describe the array of reasons people may not rush to get the vaccine. But most importantly we cannot place blame on the victims of this pandemic for it. We should not use hesitancy as a scapegoat for the inequity we see in vaccine distribution and instead focus on dismantling the current structures in place that prevent equitable vaccine delivery
A person’s zip code is just as powerful a predictor of COVID-19 infection and death as anything else and also may indicate how likely you are to receive a vaccine (KHN, NYT). A place-based approach to vaccine distribution should be used to focus on areas with the greatest numbers of COVID-19 cases, hospitalizations, and deaths. GIS Technology can be deployed using census data to identify communities and zip codes most vulnerable to COVID-19 related infections and death. Efforts like this have been met with success in California.
Trusted community partners such as grass-root organizers, faith-based organizations, and social service providers can ensure equitable access to vaccine information and delivery. These are experts and community leaders who acknowledge and understand people’s genuine fears and lived experience of healthcare in America. Strategies like this have been effective in cities like Baltimore & Philadelphia. Organizations such as Stop the Spread have also had success in building partnernerships. When trusted partners are brought to the table, marginalized groups are not forgotten and vaccine delivery is done in a culturally palatable way.
Simply planting a mass vaccination site in a minority neighborhood is not equity. We have seen how that does not does not necessarily equate to increased access for the communities they are intended to serve. In addition to partnering with trusted leaders, federal, state, and local health authorities need to employ a grassroots on the ground campaign to vaccine delivery. The release of the Johnson & Johnson vaccine is a game changer. The one-shot dosing regimen and ease of storage allows us to deliver the vaccine to people where they prefer to be met. Vaccines should be given in schools, community centers, barber shops, and even churches. Mobile vaccine units can be deployed to reach out to populations that have traditionally been difficult to access, such as the homeless and those living in rural communities.
A car, email address, and computer access should not be prerequisites to receive a vaccine in a deadly pandemic. When and where to get vaccinated shouldn’t be a source of confusion for the average American. Current systems need to be overhauled and modified by the people who understand the communities most at risk. If the system is not designed with equity in mind, then how can we hope to control the pandemic when the most disenfranchised communities can’t get a vaccine. As Dr Eugenia South eloquently stated in a recent post, “Equity isn’t hard, but it does take intentional work to overcome the inequitable inertia of the status quo”.
