The COVID-19 pandemic has disproportionately affected specific demographics, with Black, Latinx, and Indigenous communities being among the hardest hit. As vaccinations ramp up across the country, data has shown that — despite some efforts to provide vaccines to typically underserved populations — people of color are at higher risk yet are still less likely to be vaccinated.
In this article, recommendations from experts from the city, tribal, state, and public health domains discuss inequity in COVID-19 vaccination rates, and provide recommendations for improving and increasing vaccine distribution among traditionally underresourced communities.
Disproportionate Investments for Equitable Outcomes
“Especially when you're taking a health equity standpoint, I can't overemphasize enough, that, in order to have equitable outcomes, it takes a disproportional investment.” - Dr. Robert Onders
This statement came from Dr. Robert Onders, administrator of the Alaska Native Medical Center. According to Dr. Onders, disproportionate investments in the American Indian/Alaskan Native* population like the “sovereign nation supplement, and the recognition of tribes as a unique jurisdiction, [were] critical in trying to get to equitable outcomes through the vaccine allocation.” The “sovereign nation supplement” he’s referring to is the additional shipment of vaccinations for American Indian/Alaskan Native populations that “elected to receive vaccines through the state instead of Indian Health Service.”
The relationship between tribal nations and the federal government is complicated and fraught, to say the least. But Dr. Onders described the federal government’s decision to allocate additional vaccines to tribal nations a “critical decision point.” He also lamented that “there's other communities across the United States that were not as fortunate to get that disproportional investment in order to get equitable outcomes.” He hopes that the supplemental vaccines will reverse the “disproportionate burden in Alaska Native people,” who have suffered from the highest death rate in the state.
Starting in January, thanks in part to the supplemental vaccines, tribal health organizations began offering vaccines to anyone over the age of sixteen. In areas where multi-generational households are common, quickly expanding age eligibility was another way to protect the most vulnerable. Dr. Onders described the value of youth interacting with elders, often through multi-generational households, as an important motivating factor for many young people. Especially important is protecting elders who carry language and cultural traditions: “It's not just about protecting themselves, it's about protecting the entire community.” Without a disproportionate investment in Alaska Natives, individual and collective losses would occur.
Trust and Trusted Providers
All of the experts agreed that trust is of the utmost importance when it comes to administering, receiving, and distributing the vaccine. Christine Keung, the chief data officer for the San Jose Mayor’s Office on Technology and Innovation, reflected on the legacy of racism and how that is affecting trust during the pandemic and vaccination period. In regards to the COVID vaccine rollout, she feels that “we have an opportunity to learn from Flint, Michigan—a shameful example of how bad process, bad data, and bad decisions led to devastating economic, psychological, and medical consequences for 100,000 people. Today, Flint has secured a clean water source and has laid safe pipes to nearly every home in the city. But new pipes can’t compensate for the residents’ continued lack of trust in their government to provide their most basic needs.”
One of the best ways to increase trust during the vaccination process is by relying on community health providers. In Alaska, Dr. Onders reported that “the vaccine is being given to trusted healthcare providers, whether that's the tribal health organizations or Indian Health Service in those communities, that's the historic provider of services rather than a stand up mass vaccination clinic by a provider that has never been in that community before necessarily. So I think there is that familiarity and that trust component that's occurring within the tribal health system.” Especially for communities that have an understandable, historical distrust of government healthcare providers, using familiar and trusted health professionals who live in the community is of significant importance.
Trusted providers are also having to do more than simply inject a vaccination; they are also on the front lines of appointment scheduling, crowd control, and official communications. A higher level of trust and familiarity will not just help increase vaccine uptake, but also improve the overall vaccination experience. As Keung points out, “The first thing you see on the CDC’s COVID Data Tracker are its key performance indicators: COVID cases, deaths, and vaccines administered. But as the number of vaccines administered increases, we should consider measuring the experiences of communities most affected by our decision making. How long are the lines? How many tries did it take to get an appointment? How did community health workers manage hundreds of patients crowding a narrow sidewalk of a crowded intersection?”
Trusted, community-based messengers can help improve the experience of vaccination (and relevant follow-up care), assuage fears over medical experimentation, and connect with recipients to improve uptake rates. According to a study by the Kaiser Family Foundation, “people’s personal health care providers are the most trusted source for information on COVID-19 vaccines, with 85% [of the surveyed public] saying they trust their own doctor or health care provider at least a fair amount for reliable vaccine information.”
The User Experience
“Good policy considers service delivery process and recipient experience.” - Christine Keung
Both trusted health providers and vaccine recipients are a part of the user experience equation. In the case of vaccinations, aspects of user experiences include things like the above-mentioned wait times, comfort with and confidence in providers, ease of access to personal vaccination status, and coordinated and flexible staff support. Although perfectly meeting every single aspect during a global pandemic and emergency-use authorization is incredibly challenging, equity needs to be front and center on all sides of the vaccination user experience.
For tribal nations in Alaska, “the key was we didn't have to learn a different system. We used the same tracking mechanism, same ordering mechanism, same reporting mechanism that you would use for childhood immunizations, which I think helped speed the process as well. And that it comes down to the end user too, because it was nurses who have been using what we call VacTrAK as a reporting system for years. Essentially, we're able to use that same system for COVID vaccines, and so there wasn't any new training that was needed — everyone knew the system already.” Considering how current systems and user experiences could be transferred to the COVID-19 vaccinations helped get vaccines to the most vulnerable as quickly and efficiently as possible.
Intersectional and Qualitative Data
Keung believes that the communities most affected by vaccination-related decision making should have a voice in, and measurable impact on, the process. Tamara Rushovich, a PhD student in population health sciences at the Harvard T.H.Chan School of Public Health, concurs with the importance of qualitative data, especially in the absence of intersecting and cross-sectional data.
“Gender and race and age, those kinds of identities don’t operate in a vacuum; you’re not a woman one day, and then your race the other day,” said Rushovich, “It’s all happening together.” Her newest study, “Sex Disparities in Covid-19 Deaths Hide High Toll on Black Women,” details how most states’ data collection and aggregation actually obscured the fact that the highest death tolls were among Black women. Most of the data that Rushovich and team found at the state and national level was only available by one metric, rather than being cross-referenced by these multiple identities. They were able to parse data from Michigan and Georgia, and eventually the CDC offered national data with sex and race as cross-metrics, but the general lack of detailed information led many to incorrectly believe that there was only one way to understand COVID-19 mortality data: by gender or race or age.
Rushovich and her co-authors also found that “there’s variability within and across races,” including a larger disparity between Black men and Black women than the disparity between white men and white women, which “provides evidence that racism intersects with gender to shape COVID rates...biology alone is a poor candidate to explain the sex disparities; there is reason to believe that social factors play a role as well.” This type of intersectional data lens is tremendously important, and Rushovich feels strongly that existing, non-sectional data should be complemented with community and participatory engagement. Targeting vaccinations by only one metric is going to even further entrench and disadvantage what appears to be an invisible race-by-gender divide within COVID-19 mortality.
“All this talk about equity means little if we’re not measuring outcomes, and driving results with concrete actions towards those outcomes,” said Keung. “But the outcomes we prioritize, and the way we measure those outcomes, impact equity.” The ideas and recommendations within this article are a starting point, as it’s incumbent on leaders and organizers at every level of government, community engagement, and public health to prioritize and drive equitable outcomes.
*In this article, the terms Native, Native American, and American Indian/Alaska Native are used interchangeably, in accordance with the Urban Indian Health Institute’s practices. These terms acknowledge the varying ways that North American Indigenous peoples are forced to identify within the American racial structure and English language.