Hourly workers may not be able to take time off during the day to go to a clinic – especially if it requires a two-hour bus ride. If they do not have paid sick leave, they may be afraid to miss work if they experience side effects for a day or more. There is concern about the cost, because the message that the coronavirus vaccine is free has not yet been transmitted.
Governors, public health officials and specialists in health disparities are addressing these issues, sometimes called social determinants of health, as they finalize their vaccine distribution plans for underserved rural and urban areas. The disparities existed before the pandemic, but the coronavirus mirrored and expanded them many times, mainly in the black, Latin and Native American communities.
President Donald Trump left many decisions about the pandemic to the states. President-elect Joe Biden, who has already appointed a coronavirus advisor to focus specifically on race and health, has promised a more cohesive national approach to coronavirus, although states retain their traditional and strong role in vaccination.
“I look forward to more consistent messages nationwide,” said Mississippi’s top health worker, Thomas Dobbs. Julie Morita, executive vice president of the Robert Wood Johnson Foundation and a veteran of several immunization initiatives since her tenure as health commissioner in Chicago, noted that the federal government has taken a leading role in other recent health emergencies, including H1N1 and Zika . “In my 20 years in public health,” she said, “the best and strongest health responses were those that were coordinated at the federal level.”
Experts said a good starting point in planning an equitable immunization campaign is to ensure that affected communities have a voice in making decisions about when and where vaccines will be available – and that states include in their plans places where people they are already used to receiving care, where there is trust, familiarity and comfort.
“We will go wherever the community asks us to go,” said Dobbs. Aware of Mississippi’s racial legacy, Dobbs has been working with a health equity task force since the pandemic began. Part of its emerging strategy is to make vaccines available at coronavirus testing centers in all counties and to have at least some vaccines available in the early evening, when people are leaving work.
New York Governor Andrew Cuomo recently announced a similar Covid-19 Equity Task Force across the state to “break barriers to vaccination and ensure equitable distribution” as more doses of the coronavirus vaccine arrive.
“Their job is to come up with an operational logistical plan: How are we going to put it in the Black churches? How will we reach the public housing authorities? How do we put it in community centers? How do we do a public education campaign for the black and Latino community and for the poor community saying that this is safe? ”Said Cuomo. “There is very real resistance to taking this vaccine, especially in the black community – there is a story that would give someone the right to be skeptical.”
Morita said that state and local governments need to ask themselves, “Where [the vaccine] needs to be. What time? How to make it easily accessible, after hours, on weekends. “
“And you have to make sure it’s clear to them that the vaccine is available for free. Having enough money to pay for something is a barrier, ”said Morita, who is also advising Biden on the coronavirus transition, but stressed that he was speaking only on behalf of the RWJF.
So state and city officials are thinking of making injections available in places like churches, offices, mobile vans, county public health clinics, federally qualified health centers, community colleges, supermarkets, as well as some doctors’ offices – and have at least a few options at times other than 9 am to 5 pm, said Blaire Bryant, associate legislative director for health at the National Association of Counties.
But Bryant also pointed out that due to huge tensions over the underfunded and overworked public health workforce – which is running an unprecedented mass vaccination campaign while trying to control an unprecedented pandemic – there are tensions and trade-offs in finding out where to locate vaccines . Sites will also need the right refrigerated storage capacity, especially for the Pfizer / BioNTech vaccine.
“There is a lack of public health professionals. How do we find out where it is best to send our team? ” she said.
This is one of the reasons why some states, like Mississippi, are planning to double their coronavirus testing sites so people can get tested or injected. They have already resolved some of these barriers to care for the sites, which have been in operation for months. And some are attended by community health workers, who live in these neighborhoods, are generally multilingual and have the patient’s trust.
“Community health workers will be the key” to building trust and vaccination, said Lisa Cooper, a doctor and professor at Johns Hopkins University who runs the school’s Center for Health Equity and Urban Health Institute. “They can reach people where they are.”
So far, the FDA has given emergency clearance for two vaccines and supplies are still very limited, going to top health care professionals and long-term care facilities. But that will start to change early next year.
The federal government relies heavily on pharmacies, starting with chains like CVS and Walgreens, to deliver the vaccine, which raises concerns that they will not be easily accessible in some minority communities or rural areas. Pharmacies are also able to go to communities, for example, by running a vaccination clinic in the parking lot of a church or community center. This would be a marriage of community trust and practical vaccination know-how.
But pharmacies will not be the right choice in all environments. Therefore, states, which must submit vaccination plans to the Centers for Disease Control and Prevention, seek to include a much wider range of providers, many of whom are already rooted in high-risk communities. The National Association of Community Health Centers says that some of its members are already involved in the first wave of vaccination in progress. Many offer flexible hours and will be well positioned to start vaccinating essential workers – millions of whom are already their patients – when it starts in early 2021, spokeswoman Amy Simmons said.
Some localities are already thinking about other social determinants of health, such as language barriers. For example, the health department in King County County, Washington, which includes Seattle, has already created a website specifically dedicated to information about the Covid-19 vaccine in 18 languages.
Many communities are looking at mobile vans as a way to solve the transportation problem. “Places need to be traversed in many communities,” said Sharon Knight, interim executive director of Stop the Spread, which focuses on underserved communities. She said it is also important that vaccination sites have some options for direct care or telephone appointments, as not everyone can make an appointment online.
Reminding people about when and where to show the second dose will also be a challenge, especially for those who do not have access to the internet.
Other health professionals may have some wisdom to share, said Morita.
“Dentists are good at reminding patients” when it is time to enter, she noted. “And – I don’t have pets – but I’m told that vets are good at that, too.”