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The vaccine rollout so far has shown us that the process has been all but equitable for some of the most vulnerable populations. According to newly posted CDC data, more than half of all American adults have now received at least one dose of a COVID vaccine, and a third are fully vaccinated.
A disproportionate number of those already vaccinated, however, are white. Black and Hispanic communities received a smaller share of the vaccine. As vaccine eligibility nationwide opens up to all adults, it’s worth asking whether that will equate to equitable access.
Richard Besser, MD, a pediatrician, former acting CDC Director, and the current President and CEO of the Robert Wood Johnson Foundation, the nation’s largest non-profit dedicated to health, joins us on this week’s episode to examine how equitable the vaccine distribution has been and where efforts need to be focused.
Following is a transcript:
Marshall: Today we’re going to be talking about equity and it’s such an important issue, but before we really dive into the topic, let’s define for our listeners what it is; because it’s more than just access.
Besser: When we think about it here at the Robert Wood Johnson foundation, we think about equity as an opportunity. Different people are going to need different things in order to be able to achieve the same outcome.
So, at the foundation we developed this graphic to help people understand that and it involves bicycles. So, the idea of equality — say you have a family and you want everyone to ride their bicycle. The idea of equality is well, everyone gets the same bicycle. Well, that’s great if the bicycle fits you; but if you’re a little kid, you need a smaller bicycle. If you have a disability, you may need a recumbent bicycle. If you’re really tall, like me (I’m 6’6″) — if I’m on a relatively small bicycle, I’m not going to be able to go very far.
And so the idea of equity is you give everybody what they need in order to be successful. And in America today, the color of your skin, how much income you have, those are two critical factors in terms of whether you get what you need to be successful.
Marshall: What about knowledge?
Besser: Knowledge plays in, you know, in terms of do people have the information that they need to be successful, but what I find is that so often in America, we will see problems that are the result of structural barriers. Barriers due to structural racism or ableism or so many other different -isms.
And we’ll approach them with, well, let’s just do an information campaign. If people knew more, they would do more. And that played out big time this past year during the pandemic when you saw a pandemic that was hitting every community in America, but not every community in the same way.
Black, Latino, Native Americans were being hit the hardest. And some of the initial responses were: “well, if you just give people information and how to protect their health then we’re going to see that go away.”
And it struck me as absurd because if you really looked at why the pandemic has hit communities in different ways, so much comes down to structural issues. Structural issues, such as who in America is more likely to be in a job that pays a lower wage that has to go to work every day to put food on the table and pay the rent.
It’s more likely to be people of color. Who in America is less likely to have a primary care provider who they can contact if they have symptoms of COVID and want to know what to do. There are so many barriers in America that have been laid bare or lifted up by this pandemic. The time is right now in our country to try and address those so that we truly move towards a more equitable nation in which everyone has a fair and just opportunity for health.
Marshall: Dr. Besser, you said two things just now I want to follow up on. One, is that knowledge, necessarily, isn’t the key. And we are seeing right now, this knowledge campaign being rolled out by the administration to try and change vaccine inequity. So first is that the right tactic for them to be using?
Besser: If all that was being done was an ad campaign, I would say you’re not going to see much impact from that. When you really look at why people are reluctant to be vaccinated or why people want to be vaccinated, a lot comes down to issues of trust. Who do you trust with information? Who do you trust to tell you the truth?
The percentage of Black Americans who have been hesitant, has been higher than it is for white Americans. The gap is closing, but the reason is that the institutions that are saying “get vaccinated” are institutions that have not merited the trust of many communities of color. These are institutions in which people have been disrespected.
These are institutions that over the course of history have actually experimented on people of color. And so when information is coming from institutions that have not engendered trust, it should be the expectation that people are going to be wary. You have to pay close attention to who are the messengers? Who is trusted in various communities. In most communities, people’s local health providers, their doctor, their nurses, people’s faith leaders are trusted voices.
So giving people who are trusted voices factual information, so they can make informed decisions…you don’t want to stigmatize people. You want to meet people where they are.
Marshall: But Dr. Besser trust isn’t built overnight. You mentioned the groups going to those ones that they already have an established trust with. When we talk about equity and ensuring that vaccination equity is being met. How can we do that and ensure those that were hardest hit have that opportunity and that equitable access?
Besser: You know, part of it is this trust equation. The other part is making it as easy as possible and the early efforts to distribute vaccines did not do that.
They did not with intentionality target the communities that had been hit the hardest by making vaccine most readily available there. You know, a lot of efforts early on were these big clinics, these drive-through clinics. You know, clinics that were not working 24-7. You want vaccines to be eligible as, I mean, available as close to people as possible.
And now we’re seeing far more efforts by the administration to do that. To get vaccines into neighborhood pharmacies, to have vaccine clinics in churches and community centers. And these efforts are really paying off.
Marshall: One thing, Dr. Besser though, that does make it “easy as possible” to distribute the vaccines was the Johnson & Johnson one. It had easier storage requirements, no second dose. It was preferred for targeting vulnerable populations, but now we have this pause that went into effect. So how will that impact equity?
Besser: Before I answer that, I need to say that the Robert Wood Johnson Foundation was built on a fortune that came from Johnson & Johnson. And we currently have stock in the company. But there are challenges here. You know, one of the nice things about a vaccine like this is that it’s one and done. One dose. And so for some populations that may be harder to reach, it was a really good option for public health.
Marshall: But that option is now not there.
Besser: I think that the fact that a pause was taken is a good thing. It hopefully will inspire confidence that these vaccines, this vaccine and the other vaccines that are [authorized] for use, that we’re continuing to watch for any signs of any rare adverse events.
But that’s a hard thing to communicate. And for someone who’s deciding to get a vaccine, they may decide that they’re not comfortable with that. So you’re going to have to double down on the efforts for follow-up, double down on the efforts of getting vaccines as close to people in their communities as possible. And making sure you’re not just telling people when they should come back for their second dose, but you’re doing outreach.
You’re doing outreach to make sure that people know when to come, that they’ve got transportation, that it’s as easy as possible, that your hours are flexible. When you do that, when you meet people where they are, you will see that more people step forward and say, “I want to get vaccinated, too.”
Marshall: If, and when it is [reauthorized] for use, maybe in a different subset population, will it then be — being used in those vulnerable populations — be seen as a second-class vaccine?
Besser: I hope not. You know, I think if a decision is made to go forward, it wouldn’t be done with an assumption or an acceptance that it’s a second-class vaccine. You know, with any vaccine or any medication, once it’s used in a larger population, you begin to know a lot more about rare side effects.
And you want to be upfront and honest about that. Also, it would be helpful if the committee that advises the CDC — it’s called the Advisory Committee on Immunization Practices — if they’re able to say something about who is at risk and what that level of risk is, and if it’s determined that the risk is only there for a subset of the population that could affect what they decide to do in terms of the recommendations.
Marshall: So the president has promised that everyone who wants access to a vaccine will have it by May 1, a deadline we’re quickly approaching. And the government’s even picking up the tab for everyone to get a vaccine…
Besser: Well, that’s not all that’s needed. Those things are necessary. But one of the things that is absolutely critical. You know, last year we put out that — from the foundation — equity principles for state and local officials. And what this was, is a series of factors, of principles that local and state officials need to pay attention to if they truly believe in equity.
And the first one is that we need data. Our public health systems, data systems are antiquated. Not only are they antiquated, they haven’t made equity a critical piece of what they were responsible for.
So early on in this pandemic, the studies that were revealing that Black, Latino, Native Americans were being hospitalized and dying at three, four, or five times the rate of white Americans. It was special studies, it wasn’t our data, public health data systems.
Right now, when you look at the vaccine distribution, only about half of the data that’s coming in has data on race and ethnicity. And without really good data and data that you can look at down to the neighborhood level. You’re not going to be able to assure equity, equitable distribution, and you’re not going to be able to hold people accountable for providing the resources that are needed.
This needs to be an iterative process where you’re trying things and then you’re looking, using the data to say, “Are you closing the gap? Are you getting vaccines to everyone in an equitable fashion?”
Marshall: Dr. Besser, that sounds like a pretty big oversight by the government to not have that kind of data being gathered or looked at. You were once CDC director. Was it something that they used to have and just haven’t maintained? Is it something that was just forgotten?
Besser: Well, it’s not something that was there and has been maintained. I think that public health over its history has not looked at issues like racism and sexism and ableism and classism as public health issues. It’s been a patchwork just…
Marshall: What were they then if they’re not public health issues?
Besser: Well, they were demographic factors, but they weren’t within the responsibility of our public health system.
You might measure them and say, “Well, if you look at the rates of pneumonia by race and ethnicity, you’re going to see differences.” But it wasn’t…public health didn’t look at itself to say, “Well, what’s driving that?” Yeah, we’re measuring disparities, disparities are differences, but what are the drivers? What are the reasons for those disparities?
You know, I heard a public health researcher who focuses on racial equity say, “Whenever you see a disparity, a difference by race or ethnicity, that should ask you, ‘Well, what is the inequity behind that?’ And then, ‘What are the structural changes that need to be made to address it so that it goes away.'”
Race is a social construct. It’s not biologic. But the reason — because we see differences by race, it means that we need to make changes so that everyone has a fair and just opportunity. Last week, I was really excited to see Dr. Rochelle Walensky, the CDC director, lift up racism as a public health issue and commit the CDC to addressing that. This is huge.
This has never been done before. And if it’s followed through with resources in action, it could lead to significant changes in our country.
Marshall: But when we’re looking at the next month, the next week, you know, coming into the fall and kids going back to school, will it be enough to start looking at that data now to start working with those community leaders now, to make sure equity is maintained when it comes to vaccine distribution?
When it comes to the states, looking at a micro level, should they have changed access to vulnerable communities and make it an all are qualified approach?
Besser: Yeah. You know, one of the real challenges in America, when you look at our public health system, it’s a Federalist system. So there are very few authorities that are given to the federal government, to the CDC. Each state develops their own systems and their own requirements in terms of data and reporting.
It’s really critical that in each state people push to hold their government accountable for collecting this data and for ensuring that everyone has what they need to be successful. You know, I’m encouraged by this administration standing up a federal commission on equity in COVID response.
Marshall: Are there specific changes you want to see them make?
Besser: Well, there’s a ton. You know, and some of the things were measures that we saw in the American Rescue Act that need to now be followed through with long-term policy changes.
So in the American Rescue Act you saw increases in food support through the SNAP program. That’s Supplemental Nutrition Assistance Program. Say, well, what’s that have to do with health or what’s that have to do with COVID? Why does that matter?
Well, it matters because when children are hungry, they can’t learn effectively. When children are hungry, their parents may have to make decisions in terms of when they’re working or when they’re staying home, that may fly in the face of what’s recommended for public health recommendations for something like COVID.
One of the things that we’re seeing from the American Rescue Act, we funded a study that predicts that the poverty rate in America for children will be reduced by 50% as a result of the money that’s being put in families’ pockets. That is incredible, but this is a time-limited bill. So let’s say — let’s track this over time and see, does it truly reduce childhood poverty by 50%?
And if so, what can we do to ensure that that doesn’t, that we don’t fall back on that once the provisions in that legislation go away. So those are the kinds of things that get me really excited. When you see congressional action, that’s going to lead to truly changes in equity in America. And then you think about, well, what would it look like for that to be permanent?
What would our society look like?
Marshall: That’ll be interesting to follow up as time passes if they do study that long-term effect. When it comes to kids though, and learning, we also know that there is this learning loss that’s occurring because of COVID. Will we see a greater divide between the different class levels, income levels when it comes to COVID and vaccination rates and you know, in 5 years, 10 years will that inequity be exacerbated when this generation enters the workforce?
Besser: Well, if we’re not intentional about it. If you look at how this pandemic affected children — children’s learning, children’s physical, mental, emotional health — if we’re not intentional about that and say: “Okay, what’s it going to take to catch up and provide the resources that every child needs to be successful?” Then we are going to see gaps down the road.
There was a lot of money in the American Rescue Act for schools, and we need to hold local governments accountable. So that money doesn’t just displace state money that would have come anyway. But it’s used to improve the conditions in our schools so that where you live in America isn’t a determinant of whether you’re going to be successful in school.
You know, one of the greatest inequities in our country is around how we fund public school education. In most places it’s funded off of property taxes. That means that schools that are located in well-to-do communities have far more resources than schools that are in lower income resources.
And given that where you live in America is largely the result of intentional efforts to segregate our nation, then the color of your skin and your income are a big determinant in terms of childhood success. And that is just wrong. That is, you know, that is something that we can take on as a nation and say, “Well, what would it look like to have a more equitable approach to funding education in America?”
That would be a beautiful thing.
Marshall: Definitely beautiful. Beautiful America. I want to broaden this conversation a little bit though past America. When we talk about inequity, and looking globally versus what should we be doing right now in America? We’re worried about obviously our neighbors, our family members, but inequity exists globally.
And so when it comes to vaccination distribution, should we be working on a more global level? We hear about COVAX, but not a lot being done necessarily to participate in COVAX quite yet.
Besser: When I think about the global needs, you know, I think we have a moral and ethical responsibility to contribute to the health of people around the globe. You know, we are the wealthiest nation in the world. And if we’re not contributing, how can we expect others to.
I think as well, you can come at this from a perspective of pure self-interest because if you look at the pandemic and what it will take to be safe here in America… until COVID is controlled everywhere, no one is safe.
When you look at the emergence of variants, they emerge wherever there is transmission occurring. And so there’ve been very significant variants that have been detected in the U.K. and South Africa, in Brazil. It is in our best interest to get the virus transmission under control in each of those places.
And then economically. This pandemic is devastating when it comes to the global economy and the more we can do to control this everywhere, the more we will help to assure that the global economy is up and running. And that will be good for our economic health, as well. So coming at it from all of these reasons, it would be immoral for the United States to hold onto more doses of vaccine than we have people in the United States.
And that currently is the trajectory that we are on.
Marshall: I mean, but we’re taught to put on our own oxygen mask first. To, you know, get our own economy up and running first, to protect our own family first. So how do you talk about that and encourage vaccine distribution like you just mentioned … that we’re on track to have more than we have population and make that understood when it comes to equity?
Besser: I think you can make a case for us putting on our own oxygen mask first. It’s harder to make a case for us having two or three oxygen masks since we can only use one. So, you know, it comes down to that.
What is it that we need to truly meet the needs of people in our country?
And then how do we go forward to help people around the globe with their needs? You know, there’s an approach to global diplomacy that many countries have used and the U.S. has used effectively. It has to do with health diplomacy. You’re doing all we can do to improve the lives of people around the globe is good for building goodwill.
It’s also just the right thing to do.
Marshall: You’re a pediatrician. As we look forward to kids getting vaccinated, is there something we should be looking at to ensure child vaccination equity?
Besser: Well, I mean, one thing that we need to, we keep talking about. There’s so many conversations around herd immunity. We’re not going to get there until there are safe and effective vaccines for children.
And I hope that what we see is the administration relying on the systems of vaccination for children that have worked so well over time. And that’s through children’s healthcare providers, those systems that provide childhood immunizations that provide so many protections for children. Those systems need to be supported as part of this vaccine rollout for kids.