Authored by: Katie Bollbach, Director, U.S. Public Health Accompaniment Unit (U.S. PHAU), Partners In Health; Evrard Nahimana, MD, MMSc-GHD, Africa Regional Policy and Partnerships Advisor, Partners In Health
Last month, every adult in the United States became eligible for COVID-19 vaccination. In light of surging cases and evolving variants here and around the world, it was an important step forward. However, it is just as important to highlight that eligibility does not equal access. Throughout Partner In Health’s (PIH) work throughout the world, we have seen time and time again that simply making health care available without understanding and eliminating barriers to access perpetuates inequitable outcomes. And given the return to “normal” will only be achieved when we the entire globe reaches a 70 to 90 percent vaccination rate, an equity-centered approach is the most direct and just path to reach population immunity, ensuring no one – not in the U.S. and not elsewhere – is left behind. This means that even with open eligibility, epidemiologic evidence and justice both demand we build structures to ensure those most at risk get vaccinated. And learnings – whether they are from successes or failures – must be shared if we want a shot at bringing COVID-19 under control.
In the U.S., based on risk, transmission, and equity, there is a clear case for prioritizing vaccination efforts on older adults, communities of color, and essential workers.
From an epidemiological perspective, vaccination serves two main goals: directly protecting those at highest risk of severe disease outcomes (“risk-based vaccination”) and reducing transmission among those who are most likely to acquire and spread illness (“transmission-based vaccination”). Risk-based data dictate that we must prioritize groups that have experienced higher death and hospitalization rates. In the U.S., this includes those over 65 who have born more than 80% of COVID-19 deaths, and Black, Indigenous, and Latinx adults, who have experienced two- to three-fold higher hospitalization and death rates from COVID-19 than their white counterparts. Frontline essential workers are also at heightened risk of both contracting and transmitting COVID-19 based on the nature of their work, making them a clear priority for vaccination. The intersection of these groups compounds the risk of poor outcomes.
Racial and social injustice reinforce this epidemiological challenge: historically marginalized groups have disproportionately suffered from COVID-19 and therefore deserve priority protection. In particular, the burden of disease born by communities of color is a pervasive feature of U.S. systems. Our institutions are deeply infiltrated by systemic racism that continues to ensure these communities remain underfunded and undervalued. Additionally, they are further excluded by a lack of recognition of demographic and structural barriers. For example, a focus on mass vaccination sites fails to consider transportation challenges, while strict universal age-based prioritization during the initial vaccine rollout excluded many members of high-risk communities of color who have shorter life expectancies due to baseline health inequities. The consequences have been measurable: by May 17, 2021, among 41 reporting states, white people had received at least one COVID-19 vaccine dose at a rate 1.5 times higher than Blacks and 1.4 times higher than non-white Hispanics. Whites also received a higher share of vaccinations as compared to their overall share of cases and deaths.
While these challenges can seem insurmountable, it is both possible and vital to concurrently combat the COVID-19 pandemic and the U.S.’ structural inequities. To do so, vaccination programs should focus on three key areas, each of which is more successful if done in concert with the others.
First: Improving vaccine demand through community engagement
Community engagement is an essential and crosscutting part of vaccine programs built on bidirectional communication and collaborative decision-making informed by a nuanced understanding of community needs. Vaccine programs should work with trusted partners who are representative of the communities they serve and who are empowered to openly communicate needs. In the U.S. and internationally, many communities and partners have been hosting informational events (town halls, door-to-door outreach, etc.) aimed primarily at addressing vaccine hesitancy. However, engagement must go further: community members must be able to influence and inform policies and programs, to speak and to be heard, and to make informed decisions regarding vaccination.
- Exemplar: in Chicago, bolstered by the Chicagoland Vaccine Partnership – a community coalition formed to aid the push for equitable vaccination – the city launched an initiative to dedicate vaccine resources to 15 vulnerable neighborhoods. As part of the Partnership, PIH developed a training program to equip local leaders with resources for engaging community members in dialogue, ensuring relevant vaccine information reaches everyone, including public health planners. Thus far, over 113 organizations and 266 members have become a part of the initiative, a diverse and adaptive community network with broad health and social aims and a mandate for long-term system improvement that will last beyond the pandemic.
Second: Ensuring adequate vaccine supply through equitable resource allocation and site operations
In order to achieve coverage for all, but especially disadvantaged people who are most in need, we must ensure priority communities have an adequate supply of vaccines when and where they are needed. As such, vaccination programs must collect disaggregated coverage data to grasp the full extent of the local landscape. But many communities continue to lack this information. As of May 19, 2021, the CDC reported that race/ethnicity was known for only 56.1% of those who had received at least one vaccine dose.. To understand disparities in access, innovate and operationalize “last mile” strategies, and monitor progress toward outcomes, this data must be available so vaccine allocation and distribution can break down common barriers to access: limited hours of operation, complex scheduling and registration systems, inaccessible sites, and language barriers. Equity demands that instead of blanket tactics like mass vaccination, which may be less resource intensive but are also less effective in reaching historically oppressed communities, we invest in strategies that reach those most in need.
- Exemplar: in Ohio, using collaborative spatial mapping, community, government, and academic partners comprehensively document and visualize available resources and vaccination needs of communities most vulnerable to COVID-19. Through census tract-level analysis, the team identifies gaps in coverage and insufficiencies in public transportation. Four major health systems and two local health departments are now using recommendations based on this mapping to place mobile and pop-up clinics. The mapping will also inform the deployment of Community Health Workers (CHWs) to provide vaccine education, assist clients to locate and register for appointments, and furnish transportation assistance.
Third: Leveraging this opportunity to invest in long-term public health systems
COVID-19 is only one disease among many that disproportionately disadvantage certain communities. The programs we put in place now are foundational to functional, effective, and equitable health systems beyond the pandemic. This longer-term work includes standing up a community health workforce that is critical to the recovery and rebuilding of our public health systems. In particular, we must invest in care resource coordination, taking a lesson from global community health playbooks and connecting those in need with care and support programs that address social determinants of health. We now have an opportunity, with vaccination, to link individuals into such support structures that can improve pandemic response as well as community well-being, as we move forward.
- Exemplar: in Rwanda, CHWs are trusted community members who bring access to health care, social supports, and information to those hardest to reach: the elderly and immobile, communities in remote areas, and high-risk groups. CHWs will continue to play an important role in the COVID-19 vaccine rollout, building upon the nation’s workforce and supply chain investments over the past two decades to drive demand and promote both a smooth rollout and a high uptake when supply is more widely available. Already, CHWs are being deployed to identify, support, and facilitate vaccine access for priority populations including those with underlying medical conditions. While in many places in the U.S. CHWs are contributing to local COVID-19 response, we can learn from places like Rwanda how to best execute larger scale community-driven approaches to achieving coverage and equity.
If we work together to understand and increase vaccine demand, to allocate resources equitably, to break down barriers to access, and to invest in the long-term health of our communities, we can stop COVID-19 and, at the same time, reduce health injustice. With a concerted and collaborative effort and a strong commitment to justice, we can protect ourselves and one another, save lives, and build a more sustainable future that creates access – not just eligibility – for all.
View our full white paper, “Eligibility Is Not Access: Prioritizing those most at risk in the next push of vaccine rollout” to learn more about our efforts to support equitable access across our partner sites.
About Partners In Health and the U.S. Public Health Accompaniment Unit
Partners In Health is a social justice organization that responds to the moral imperative to provide high-quality health care globally to those who need it most. In May 2020, PIH launched the United States Public Health Accompaniment Unit (USPHAU) to help states, cities, and communities rapidly scale up a more equitable and comprehensive public health response to COVID-19. Building on PIH’s 30-plus year track record of fighting epidemics and strengthening health systems around the world, the USPHAU is working shoulder-to-shoulder with partners around the country to advise, implement, and troubleshoot new strategies and initiatives to combat COVID-19, while preparing for the recovery and rebuild efforts that we know must urgently follow. The USPHAU is committed to building and strengthening resilient and responsive health systems in the U.S. that are rooted in access and equity for all.
More information: Partners In Health’s U.S. Public Health Accompaniment Unit | Partners In Health (www.pih.org)