The planned Covid-19 booster rollout threatens to worsen existing inequities facing minorities and lower-income communities, paving the way for Americans with the wherewithal to navigate their way to the front of the immunization line, health experts say.
Unclear messaging, complex appointment registrations, and a lack of a unified strategy were among the barriers for underserved populations during the initial vaccine rollout last winter. Some policy watchers worry the Biden administration—when it begins offering boosters for most Americans—may repeat many of the same steps that they say reinforced cultural, language, and geographic obstacles to vaccine access.
“In the absence of more refined guidance, you allow the opportunity for inequities to creep in,” said Ameet Sarpatwari, assistant professor of medicine at Harvard Medical School. “It’s problematic not to have a benchmark by which the localities are going to dictate priority.”
Minority and socially vulnerable communities are among the hardest hit by the pandemic. The Centers for Disease Control and Prevention in July said Black and Hispanic or Latino people are nearly three times more likely than white people to be hospitalized over an infection.
Vaccine access has also plagued these groups since the earliest days of the U.S. immunization campaign. For Black and Hispanic people, the share of vaccinations in January was smaller than the group’s share of cases in all reporting states, according to the Kaiser Family Foundation. Those groups’ overall vaccination numbers still lag behind those of their white counterparts, the KFF reported in August.
Only 52% of the U.S. population is fully vaccinated, the CDC reports. Policy experts say more needs to be done to reach those still in need of doses.
“We need to understand better why we are not able to reach half of the U.S. population,” said Pinar Keskinocak, director of Georgia Tech’s Center for Health and Humanitarian Systems. “We talk about vaccine hesitancy, which of course is real, but by itself I don’t think it explains the whole story.”
The Biden administration plans to start offering boosters on Sept. 20, pending sign-off from the Food and Drug Administration and recommendations from the CDC.
Vino Palli has first-hand experience with vaccine inequity.
A doctor in New York City, Palli watched as “a very diverse community” struggled to navigate “so much confusing messaging” from the government during the first vaccine rollout. And when “lines around the block” began collecting for their jabs, most people were from more privileged backgrounds.
“Of course people who have access to the internet and were savvy about making appointments were the ones who were making appointments,” said Palli, CEO at MiDoctor Urgent Care & Corporate Covid Solutions. “All the wealthy neighborhoods, somehow they were on top of things. And they were able to make appointments online and call the clinic.”
President Joe Biden’s booster plan may already be shaping up to be a similar situation.
“Right after the announcement came from the president, we had several calls from patients fighting for the boosters,” Palli said. “You don’t see African American or Hispanic patients coming back saying we want the booster. It’s the same sort of scenario again.”
Difficulties around scheduling a vaccination date marked a greater barrier for people in some communities than others early on in the immunization campaign.
“People with more resources were better able to navigate those systems or were driving further to get vaccinated,” said Julie Swann, a North Carolina State professor who aided the CDC during the H1N1 pandemic.
Another issue was “the language of appointment systems—maybe it had a Spanish front page, but you still need English to make an appointment,” Swann said.
Vaccine prioritization was also potentially problematic, she said. In December 2020, the CDC’s Advisory Committee on Immunization Practices recommended that health-care workers and long-term care facility residents be the first to get jabbed. ACIP recommended that the elderly and front-line essential workers be next in line.
Earlier priority for other essential workers, a high proportion of whom are people of color and who often need their salary to support their family, could have helped further reduce Covid-19 infections, according to Swann, who conducted research on the impact of vaccine prioritization.
Under boosters, if there isn’t a different prioritization, “we’re going to be repeating those same things,” she said. “You cannot telecommute if you work in a meatpacking plant. It just doesn’t work that way.”
Testing the Boundaries
The CDC has voiced its commitment to vaccine equity, working with community-level partners to make sure jabs are within reach for Hispanic, Black and other groups. But health experts contend that those with means may have the tools at their disposal to reach the front of the pack.
One issue is “power dynamics at play in society in general,” as higher-income Americans are more likely to go to pharmacies for booster shots without revealing that they’ve already had two previous immunization shots, Sarpatwari said.
“People of means in general are more likely to test the boundaries than those who are more marginalized in society,” he said. “As a result, it’s those people who might get boosters first.”
Yet lessons learned from the first rollout may curb inequities with boosters because there’s now “an infrastructure in place that we can use,” said Reed Tuckson, co-founder of the Black Coalition Against Covid.
The initial vaccine rollout was “heavily weighted toward organizations like pharmacies,” and mass-immunization sites like athletic arenas, but “a significant number of people in the African American community are not really looking to go outside of their comfort zone outside of the institutions they know and trust,” said Tuckson, who was formerly Washington, D.C.'s commissioner of health. Now, more immediate sources for vaccination are in place.
Access isn’t the same problem it once was, Tuckson said. “Since that delta surge has emerged, Black people have been accepting vaccines more at a greater percentage than our population in the country.”
As of Aug. 29, Black and Hispanic or Latino Americans initiated the vaccination process in the previous two weeks at a higher rate than their percentage of the U.S. population, the CDC found.
The FDA’s full approval of Pfizer Inc.'s Covid-19 vaccine also “gave a good bump” to vaccination rates, while increasing employer vaccine mandates “are going to have a significant impact on many who were resistant,” Tuckson said. What’s more, “some people will see that booster recommendation as providing more evidence for safety.”
Still, health experts say the administration can take steps to promote greater access once the booster rollout begins.
“There are a lot of cultural convictions people have” that have resulted in “trust issues,” Palli said. And with third shots around the corner, “we need to educate.”