To mark the beginning of National Minority Health Month, The American Journal of Managed Care® (AJMC®) takes a look at racial inequities in the COVID-19 vaccine rollout and speaks with one expert who fears reality is worse than data indicate.
April marks National Minority Health Month and the theme chosen by the HHS Office of Minority Health (OMH) for this year is #VaccineReady. According to the office, the goal of the campaign is to empower communities to get and share accurate information about the vaccine, participate in clinical trials, get vaccinated when eligible, and practice COVID-19 safety measures.
The disproportionate rate at which racial minorities contracted, suffered complications from, and died of COVID-19 in the past year led to public health officials pushing for an equitable distribution of COVID-19 vaccines even before any were FDA-approved. But now, data show racial disparities in COVID-19 vaccinations are evident throughout the country, as the nation enters its fifth month of the vaccine rollout.
Recent CDC figures indicate that although some states took heed of early recommendations and prioritized at-risk populations, disparities in vaccination coverage have been observed in the majority of states.
In the report, authors underscore the importance of differentiating between vaccine equality (similar allocation of vaccine supply proportional to its population across jurisdictions) and vaccine equity (preferential access and administration to those who have been most affected by COVID-19), noting the latter should be prioritized.
Using the CDC’s social vulnerability index (SVI), researchers categorized counties as low, moderate, or high social vulnerability. Minority status and language are among the 15 indicators included in the SVI.
Investigators collected data from residents that received at least 1 dose of a COVID-19 vaccine between December 14, 2020 and March 1, 2021–the first 2.5 months they were available. Data showed that in this timeframe, high social vulnerability counties had lower COVID-19 vaccination coverage compared with low social vulnerability counties.
Notably, Arizona and Montana both achieved high vaccination coverage in high vulnerability counties across SVI metrics. According to authors, successful practices seen in states with high equity included:
“With only age, sex, and limited race/ethnicity data available at the national level, use of these population-based metrics is an important method to evaluate socioeconomic and demographic disparities,” researchers said.
Despite some state-level successes, several efforts to increase equity in local jurisdictions have been thwarted. For example, in February it was reported that special codes for vaccine scheduling intended to improve access among hard-hit communities of color in California were misused by outsiders, The Los Angeles Times reported.
The codes, which were provided to community organizations in largely Black and Latino communities, were reportedly circulated among wealthier residents who worked from home in Los Angeles and were not yet eligible for vaccines. Similar scenarios have played out in other states.
Tracking data on vaccine allocation rates among racial and ethnic minorities proves challenging at the national level. As of March 29, this metric was only known for about 53% of individuals who received the vaccine, while 66% of these individuals were White, 9% were Hispanic, 8% were Black, 5% were Asian, 1% were American Indian or Alaska Native, and <1% were Native Hawaiian or other Pacific Islander, according to The Kaiser Family Foundation (KFF).
This gap in racial data marks a substantial limitation to understanding just how many vaccines are being administered to minority populations.
“Even if we set numerical goals or metrics for ourselves, our information systems and data collection are so inadequate that we're either operating blindly or not really knowing what our baselines or starting points are because we have so many holes in our information and our data,” said Jewel Mullen, MD, MPH, the associate dean for health equity and associate professor of population health and internal medicine at the University of Texas at Austin, Dell Medical School, in an interview with The American Journal of Managed Care® (AJMC®).
“The story is only half told—if that—if we only have half the data,” she said. “And I worry that things are even worse. And if we're truly, truly wanting to do something about equity, then we have to measure what we're doing.”
Mullen is the former principal deputy assistant secretary for health at HHS and a member of the National Academies of Science, Engineering, and Medicine (NASEM) committee which was tasked with developing a framework to assist US policy makers and global health communities to plan for an equitable allocation of a COVID-19 vaccine in October of 2020.
But due to this lack of data, “it becomes harder for us to hold ourselves accountable to our own work and to stand up and say to the public ‘Here's the evidence that we are trying and we're making progress,’” she explained.
Mullen feels the national vaccine rollout can be viewed in stages and that distribution in certain states in December or January is different than what is being done currently in the spring of 2021. Early on, there was a strong clamor for the then-rare vaccine among Americans. This push was met with disjointed federal and state responses and may have impeded efforts to equitably distribute doses.
“The challenge of not having enough coordination—because it's inherent to our own country, to have every state do its own thing—alongside urgency, led a lot of people to say things like, ‘Trying to do things equitably is too hard and getting in the way of efficient rollout,’” Mullen said.
“Advancing fairness became the culprit, instead of managing a scarce resource in a way that could also help people understand that things would open up” and there would be more access for additional people down the line.
In Mullen’s opinion, the quest for equitable distribution became almost expendable as states and jurisdictions grappled with existing infrastructure challenges and logistical hurdles.
The notion of equity hasn’t fully been abandoned. “But I think while most people could understand why older people in long term care facilities, and frontline health care workers and other responders needed to go first, so to speak, what had happened after that became much more confusing for people and hard to manage,” Mullen said.
These challenges were compounded by both the post-holiday surge in cases and a perceived notion of inequality as reports revealed wealthier Americans with more resources had easier access to COVID-19 vaccines.
By compiling data on vaccinations by race and ethnicity reported by 40 states, a KFF analysis conducted in March shows “a consistent pattern across states of Black and Hispanic people receiving smaller shares of vaccinations compared to their shares of cases and deaths and compared to their shares of the total population.”
In contrast, White individuals have received a greater share of vaccinations compared with their proportion of cases, deaths and their share of total population in most of the states that are reporting race and ethnicity data.
“Overall, across these 40 states, the vaccination rate among White people was nearly twice as high as the rate for Hispanic people (25% vs. 13%), and 1.7 times as high as the rate for Black people (25% vs. 15%).” Researchers added data are subject to gaps, limitations and inconsistencies due to different reporting protocols in different geographical areas.
Not only are data on race and ethnicity lacking when it comes to COVID-19 vaccinations, but among those who do provide information, self-identification may lead to qualitative discrepancies. “As we continue to figure out and learn how to better talk about race and ethnicity in this country, one of the things that we can refine is conversations that help gather the information from people about how they identify themselves,” Mullen explained.
“Part of the impediment there is people don't know how to ask the questions. And another part of the impediment is, some people don't know how to answer the questions, because we ask them to fit themselves into boxes that they don't see themselves in.” This challenge presents a huge opportunity to better understand the true impact of COVID-19 among racial and ethnic minorities in addition to further preparing for future public health calamities.
But overall, vaccination data that are reported no matter how accurate or incomplete, point to a broad failure of administering doses to those most vulnerable to COVID-19 complications and death.
“We’ve seen that what we predicted around the need to provide an effective approach to access for vulnerable communities was a secondary implementation plan,” Mullen said. “In very few circumstances have we seen, I think, a proactive approach to vaccinating people who are more socially vulnerable.”
In an effort to combat these trends, the CDC announced a $2.25 billion grant on March 17 aimed at expanding state, local, US territorial, and freely associated state health department capacity and services. President Biden also declared dialysis centers will be permitted to administer vaccinations to patients who are often at a higher risk of suffering complications from COVID-19.
Even if enough vaccines are produced and disseminated for all adults in the United States, the issues of access and vaccine hesitancy remain steadfast in some minority populations. Although rates of vaccine acceptance are on the rise, there are a myriad of reasons individuals may not want to receive the inoculation. These can range from government distrust, concern about side effects and safety, or falling prey to misinformation.
Exacerbating these barriers are continuous media reports on COVID-19 variants and vaccines, Mullen said. Incessant coverage of these news items has led patients to believe there are “first- and second-class vaccines” or it may not be worth getting vaccinated as more variants make their way across the country.
“It will be great to have the media work with us—who are really trying to focus on equity—so that members of the media can have more insight into how the ways in which they report things can fuel mistrust and potential perceptions of inequity,” she stated. A glut of information, whether reputable or disreputable, can create a cloud of confusion where individuals are unable to synthesize different facts and determine which are most relevant, Mullen explained. “The way in which the media reports on the day-to-day changes also erodes people's trust in the decisions that are being made.”
Furthermore, some proponents of vaccine equity may also be operating under a fallacy and purporting explanations for vaccine hesitancy among minority groups that don’t align with actual sentiments.
“At times I say there’s a bit of intellectual dishonesty, or lack of intellectual honesty if we rationalize what's happened [vaccination disparities] without accounting for the fact that we haven't actually tried to provide access equitably,” Mullen said.
Understanding the interconnectedness of society and subsets of America more broadly is crucial when it comes to addressing vaccine hesitancy, Mullen stated, touching on the large proportion of Republican men who constitute one of the main groups refusing to be vaccinated.
“We can’t have binary considerations about who is hesitant and who is not and what works. We knew from the beginning that there could not be a one-size-fits-all approach to getting vaccines out.”
When it comes to perpetuating misinformation, Mullen likens it to a scam. “Scam artists are more likely going to target people who are susceptible, who have a weakness, who have some kind of vulnerability. [They can] more easily mislead somebody who's already somewhat distrusting,” she said.
Mullen puts the argument this way: “Don't be susceptible to a scam of bad information from somebody else who has an agenda that's not really about you, because they just don't like vaccines, for example…You can fight the scam.”
One key factor that will help encourage uptake is effective communication from community health workers or trusted medical voices. It is also important to recognize that not all minority groups will have the same concerns when it comes to receiving a COVID-19 vaccine, and tailored, locally relevant messaging may help address these reservations.
Two-way communication is vital, Mullen said. Asking individuals what they want to know, and whether what they’re hearing makes sense can help open up the conversation around receiving a vaccine and build trust.
Contextualizing messaging will also aid in this effort. As opposed to telling people all the consequences that may occur should they not receive the vaccine, Mullen instead likes to highlight the sense of agency that will be regained once patients are vaccinated and point out how life will improve post-vaccination.
“I don't want anybody to believe me because I'm a trusted messenger with credentials. I want them to believe me because they can relate to me,” Mullen said.
“I think for all of us who are being trusted messengers, we should check and make sure our information, our communication is having the penetrance that we think [it is]. As a public health person, I know sometimes we love our messages, even when we’re mostly talking to each other.”