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Equity on the Horizon.

The horizon always recedes as we approach; it feels like trying to find the end of the rainbow. This imagery is fitting for the topic of equity in public health, since actually achieving such a goal has been elusive. There is no quick fix.


Thinking about COVID vaccine confidence, for example, there are currently higher levels of confidence in white communities, and lower levels in communities of color. The broader context dominates over the specific details, and in this case the context is well-earned distrust that communities of color hold for public health in the U.S. (for a bit more background, see our Dec. 8 post, “Should I trust FDA on COVID vaccines?”). Changing that context means tackling big issues. Many of the steps will require years of dedicated energy for structural change, such as shifting the public health workforce to become representative and inclusive of the communities they serve. This particular effort would be starting at a rudimentary level in many places: public health departments often do not know the demographic composition of their own staff and, if these figures do exist, departments are not willing to share publicly. At the same time, public health departments routinely ask for and publish this exact information from the people they serve. We are not surprised that race and ethnicity data are incomplete for our COVID-19 response; this information is only available for about 66% of cases.


For all the attention to equity in the COVID-19 response, we're still in a very early stage and there is a long way to go to realize meaningful progress. But we can still move forward even if we’re not reaching the figurative horizon until bigger structural changes take place, and here are some steps to keep us moving in the right direction:


1. Speak plainly.

Both age and race/ethnicity are among the list of protected classes that can not be used as a basis for discrimination. CDC has issued explicit age-stratified vaccine allocation guidance. COVID vulnerability among older populations is based on biological characteristics, while vulnerability due to race/ethnicity is driven by social constructs (like structural racism). Is this a justification for differential attention to one community versus the other? Both result in disproportionate burden. Let’s start speaking plainly and ask why we’re not using race and ethnicity to drive vaccine prioritization?


2. Stop using trickle-down theories.

At the state level, some plans do address race/ethnicity more directly, and the next step is to translate this intent into action -- more on this below. But most state plans fall far short, with acknowledgement of equity as an important issue followed by an approach that may be best described as a “trickle down” approach: vaccine rollout will serve all people, and therefore people of color as well. This is captured in plans that describe essential workers as disproportionately people of color, and with prioritization of essential workers for vaccination, a conclusion that the result will be prioritization of communities of color. We believe this vague approach could result in a typical outcome of programs in the U.S., with disproportionate benefit for white communities.


3. Map, prioritize, and fund according to geography.

Structural racism has led to pretty clear geographic divisions by race/ethnicity across neighborhoods (for example, the “inverted L” we mentioned in our Nov. 25 post, “If everyone has COVID, why don’t I know anyone with COVID?”). This provides a feasible and actionable path for providing equitable vaccine access: Allocations by site, for clinics serving priority communities, with a proportional budget to match.


4. Implement for impact.

Go to communities with coordinated campaigns. This includes the messaging, the coalition building, and the dedicated resources needed to serve communities on their terms. Accessible community sites can be converted into immunization centers for short periods of time; and dedicated teams can rotate across communities to make these free vaccines accessible in real terms, without requiring costly transport or hours taken away from jobs that are essential but may not offer paid time off. This may also be a good time to truly mobilize medical reserve corps and community emergency response volunteers, many of whom were sidelined earlier in the response because of increased COVID vulnerability (volunteers may be retired professionals who are older, or have underlying comorbidities). These folks can now be immunized themselves and help stand up community-based vaccine clinics.


5. Set goals and monitor progress.

CDC has a simple counter: doses distributed and administered. Let’s see some information, at the state and county level as well, about whether we’re achieving any semblance of racial/ethnic equity in vaccine rollout. This information should be compared with specific goals established for vaccine coverage: at the state and county level, we have good estimates of the number of people who are eligible for vaccination, and real-time tracking will show if our impact matches our intentions.


6. Elevate and include.

Without pushing anyone off the glass cliff. Following from the example of public health staff representation and inclusion mentioned above, there is an opportunity right now to bring some new voices onto the team. Public health departments have recruited scores of contact tracers who are from the communities they serve. Among them will be people who have a lot to offer leaders in terms of insight, practical feedback, and implementation tips. Also critically important: empowering clinical providers. Doctors and nurses serving communities of color are trusted voices. These clinicians should be engaged, included, and provided with the information they need for their own vaccine confidence, which they can then share with the communities they serve.


COVID-19 vaccine rollout is an amazing moment in public health, made possible only through the crisis of the pandemic. Never let a serious crisis go waste: there is suffering and pain, and there are also opportunities that don’t exist in normal times. If we start moving in the right direction now, we may be able to set a course that gets us to the equity horizon sooner than we might have imagined.

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