Shifting Power, Creating Demand and Requiring Accountability: Achieving Vaccine Equity in the US

Bisola O. Ojikutu

Abstract

The COVID-19 pandemic has amplified pervasive and well-tolerated racial and ethnic disparities in health outcomes and in access to critical interventions, such as vaccines in the US. According to the Centers for Disease Control and Prevention, Black, Latinx and Indigenous individuals are more than three times as likely to be hospitalized and twice as likely to die from COVID-19. Yet, the rate of COVID-19 vaccination within these groups lags well behind White individuals nationally. In order to achieve vaccine equity, change must occur. Equity in access to health care interventions is a matter of social justice and is most often measured by the distribution of resources. Broadening the concept of health equity to include shifting decision-making power to marginalized communities, creating demand, and requiring accountability with regards to data and outcomes are essential and will improve vaccine uptake and overall health well beyond this pandemic.

Introduction

By any reasonable measure, the COVID-19 pandemic should force the United States towards a belated reckoning with inequity. From disproportionate access to diagnostic testing, to lack of transparency and inequitable distribution of treatment, to stark racial and ethnic disparities in COVID-19 related hospitalizations and deaths, the events of this past year have amplified the need to actuate meaningful and measurable structural change. Given the urgency to end this pandemic, no issue requires actionable change to promote health equity greater than access and uptake of COVID-19 vaccines. According to the most recent available data, Black and Latinx individuals have been vaccinated at significantly lower rates than their White counterparts and at disproportionately lower rates compared to their percentage of cases, deaths, and total population.¹ Inequity is the systemic disadvantage of one social group versus others (by race, ethnicity, gender, gender identity, class, sexual orientation, or the intersection of any of these characteristics) through unfair allocation of resources which manifests in disproportionate economic conditions, adverse social circumstances, and poor health outcomes.² Such inequity is inarguably unjust. Conversely, equity in access to health care interventions, such as vaccines, is a moral imperative guided by the principles of distributive justice and the fair allocation of resources among diverse members of a society.^3,4 Intrinsically, equity is a matter of social justice.

Of note, fair allocation of resources does not mean equal allocation. To achieve equity, resources can and should be allocated disproportionately to address disparate needs within populations. This is a fundamental tenet underpinning health equity. In the case of COVID-19 vaccinations, the principles of distributive justice might suggest prioritizing access within the highest incidence neighborhoods, prioritizing the people residing within those neighborhoods over others, and streamlining access for those people thus removing as many barriers to uptake as possible. These representative vaccine equity strategies have been recommended in numerous commentaries.^5,6 But ensuring equitable access and uptake of COVID-19 vaccines among most affected communities—specifically Black, Latinx and Indigenous people—requires more than these strategies. Adoption of a broader conceptualization of health equity is necessary. One must also recognize and appreciate the need to shift power, create demand, and require accountability.

Shifting Power

Inequity is not only borne of unjust distribution of resources; it also arises from an unjust distribution of power. Those who have the power to make decisions regarding resource allocation within a society determine what is equitable, how large or small the input of resources should be, and whether or not the effort to distribute those resources is maintained. When those in positions of power are not familiar with the norms, beliefs, barriers, facilitators, and perceived needs of the individuals and communities who are experiencing health disparities, equity is unlikely to be achieved. In fact, efforts to achieve equity may only reinforce the status quo. Shifting power involves shared decision-making between community and the entities that control distribution of resources (i.e., government). Though a collaborative and inclusive power structure may require additional investment in capacity-building within marginalized communities where there has been historic disinvestment, the gains achieved are more likely to be sustained over time.

What does shifting power look like with regard to COVID-19 vaccination? An example of power shift to promote vaccine equity is noted among Native American communities who have been leading vaccination efforts in several states. For example, in Washington State, indigenous communities developed their own messaging campaign in collaboration with community members, decided which modalities they would utilize to vaccinate residents, and increased workforce diversity by training people from their own communities to serve as the vaccine workforce. These efforts are supported by the Indian Health Service, an agency within the federal government’s Department of Health and Human Services⁷, but the decision-making power is at least partially in the hands of the Native American communities. In February 2021, several states with large Native American populations (e.g., Oklahoma and South Dakota) had some of the highest vaccination rates nationwide⁸, which reveals the success of such Native American community organizing. In a pluralistic society where racial and ethnic disparities are pervasive and where many communities have been marginalized, intentional efforts to shift power are essential to promoting vaccine equity.

Demand Creation

Equity in access to interventions such as vaccination is often described solely a function of supply. The problem with that perspective is that people do not always want the resource to which they have access. Thus, there is disequilibrium between supply and demand that threatens equity. For example, much has been said about vaccine “hesitancy” within Black communities. According to a recent Pew survey, anticipated acceptability of COVID-19 vaccines in February 2021 was 61% among Black individuals in the US—up from a low of 32% in mid-September of last year.⁹ Vaccine concerns among Black individuals, as well as other racial and ethnic groups, are driven by historical and contemporary structural racism which has led to a rational mistrust of the institutions (e.g., the pharmaceutical industry, government, academia) that have never proven to be trustworthy. Equity necessitates demand creation, which means mitigating mistrust and increasing confidence in vaccine safety. Authentic partnerships between Black, Latinx and Indigenous communities, industry and academia to conduct research and develop interventions would promote transparency, build capacity within communities, and may increase trust. In addition, employing a diverse vaccine delivery workforce—including health care providers, trained peers, and other “trusted messengers” who are racially and ethnically concordant with the at-risk group and can deliver clear, transparent messaging regarding vaccine safety—is another effective strategy.^10,11 But this approach should not be transient: the importance of workforce diversity and racial and ethnic concordance between health care workers and the populations they serve must be emphasized and may sustainably address deeply rooted mistrust beyond this pandemic.

Requiring Accountability

Accountability refers to the responsibility for identifying obstacles, removing barriers, and demonstrating results regarding health equity efforts.¹² Accountability generally rests with governmental and public health institutions, as well as clinical care providers, who serve as de facto stewards of a community’s health. Though accountability is a multifaceted concept, accurate and timely data are most critical if any entity is to be held responsible for inequitable vaccine distribution. Demographic data regarding all aspects of the COVID-19 pandemic, including vaccination, have been woefully incomplete. Strategies to improve data collection have been proposed by academic researchers and health policy experts.^13,14 However, in addition to improving the completeness of COVID-19 data, disaggregation by race, ethnicity, language, country or region of origin, gender, sexual orientation, gender identity, disability, and geography of residence should be mandated. Data transparency and timely availability for review and assessment by others external to government are also critical to gauging progress towards achieving vaccine equity.

Conclusion

As many have stated, the COVID-19 pandemic has amplified pervasive and well-tolerated inequities in access to critical interventions, such as vaccination. In order achieve vaccine equity, change must occur. Broadening the concept of health equity to include shifting decision-making power to marginalized communities, creating demand, and requiring accountability with regard to data is necessary and will improve vaccine uptake and overall health well beyond this pandemic.

About the Author

Bisola Ojikutu MD MPH is an infectious disease specialist and an Associate Physician within the Division of Global Health Equity at Brigham and Women’s Hospital. She is the Director of the Community Engaged Research Program within Harvard’s Center for AIDS Research and is also a former Commonwealth Fund Fellow in Minority Health Policy.

References

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