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Invited Commentary
Public Health
September 30, 2021

Toward Equitable COVID-19 Vaccine Distribution—Building Trust and Investing in Social Services

Author Affiliations
  • 1Division of Medicine, Denver Health, Denver, Colorado
  • 2Office of Research, Denver Health, Denver, Colorado
  • 3Department of Medicine, University of Colorado, Aurora
JAMA Netw Open. 2021;4(9):e2127632. doi:10.1001/jamanetworkopen.2021.27632

Racial and ethnic minority groups across the US have experienced higher rates of COVID-19 cases, hospitalizations, and deaths than non-Latino White groups. A previous study1 revealed the stark social challenges (ie, social determinants of health) that increase the risk of COVID-19 exposure and worse outcomes among racial and ethnic minority groups. To mitigate these disproportionate impacts of the COVID-19 pandemic for racial and ethnic minority groups, we must increase COVID-19 vaccination rates. Racial and ethnic minority groups, however, have had persistently lower vaccination rates than non-Latino White groups. According to the Centers for Disease Control and Prevention, as of July 6, 2021, more non-Latino White people (47%) have received at least 1 COVID-19 vaccine dose than have Black (34%) and Latino (39%) people.1 As a result, Black and Latino people continue to be at a higher risk for COVID-19 infection and death. These concerns are compounded by the spread of new variants.

In this issue of JAMA Network Open, Carson et al2 conducted qualitative, community-engaged focus group interviews of racial and ethnic minority groups in Los Angeles to identify factors that influence vaccine decision-making and acceptability. The authors presented themes and subthemes from 13 virtual focus groups with 70 diverse racial and ethnic minority participants, most of whom were residents of high-poverty zip code areas or essential workers. Their findings highlight the important need to address factors that contribute to inequitable vaccine distribution through national, state, and local health policies, as well as through community-led strategies that support informed deliberation and trust.2 As the authors note, limitations of their study include the generalizability of findings to other high-risk groups or geographic areas. Additional or different challenges may also be faced by racial and ethnic minority groups in other states where policies and experiences differ. In addition, some themes may not have been captured because US Food and Drug Administration approval of the COVID-19 vaccine occurred after the study had started.

From the onset of the pandemic, public health officials and practitioners noted the need for community-based strategies to provide COVID-19 information in a way that is trusted as well as culture and language concordant. The study by Carson et al2 found a number of factors that led many people to delay receiving the COVID-19 vaccine, including unclear and unreliable COVID-19 vaccine information, uncertainty about cost and scheduling, medical mistrust, concern for inequitable access or differential treatment, eligibility uncertainty, and fears of politicization or pharmaceutical influence. To build trust, we must engage racial and ethnic minority–serving community organizations and invite them to sit at the head of the table as we partner on strategies that will close the gaps on COVID-19 vaccine disparities. The study by Carson et al2 recommends improving empathic bidirectional vaccine deliberation that does not shame individuals who need additional information before they can make the best decision for themselves and their families. Across the country, there are examples of community-informed strategies reporting some successes in improving vaccine uptake among racial and ethnic minority groups.

In Colorado, for example, community health workers (ie, health educators, promotoras, or navigators), who are trusted and already embedded in high-risk neighborhoods, delivered COVID-19 information in a culture- and language-concordant way to minimize misinformation about how to reduce exposure and increase vaccine deliberation. Financial support from charitable foundations, as well as the state and city of Denver, Colorado, allowed several racial and ethnic minority–serving community-based organizations to deliver the COVID-19 vaccine to areas of Colorado that were disproportionately impacted by COVID-19, such as meatpacking plants and other remote areas where there are a large number of individuals with limited English proficiency and individuals who are undocumented.

In an effort to support vaccine deliberation, the Colorado’s Champions for Vaccine Equity initiative, administered by the Colorado Department of Public Health and Environment, aims to convene health care practitioners of color with racial and ethnic minority groups to discuss the COVID-19 vaccine at community settings (eg, churches, schools, and community-based organizations). The Colorado Vaccine Equity Taskforce, administered by Immunize Colorado, is composed of racially and ethnically diverse stakeholders and serves as the state’s unifying voice for vaccine equity through communications, policy recommendations, and community engagement.3 Despite these efforts, more needs to be done—as of July 5, 2021, COVID-19 vaccine disparities persist in Colorado: vaccination rates among non-Latino White individuals are 2-fold higher than among Latino individuals.1 The focus group study by Carson et al2 highlights the need for well-planned and funded health policies at the federal, state, and local levels that will not only improve COVID-19 vaccine equity but also improve investment in social resources for racial and ethnic minority groups.2

Overwhelming evidence continues to support such investments. For example, between 2018 and 2020, life expectancy decreased by 3.3 years in Black individuals and 3.9 years in Latino individuals compared with non-Latino White individuals, whose loss was 1.4 years.4 Life expectancy for the US as a whole decreased by 1.9 years, which is 8.5 times the mean decrease in 16 other high-income countries.4 In addition to deaths from COVID-19, deaths attributed to non–COVID-19 health conditions were also exacerbated by social challenges and low access to health care. Previous data indicate that despite spending a larger amount of our gross domestic product on health care (17.2% in 2016), we fare worse in life expectancy compared with other high-income countries.5 A number of health justice issues contribute to this lower life expectancy faced by racial and ethnic minority groups in the US, including racism in medicine, variability in health insurance coverage (which is largely based on immigration status and socioeconomic status), and less investment in social services compared with other nations. Among 10 other high-income countries, the US is the only country that spends more on health care than on social services—care that ultimately only contributes approximately 15% to 20% to health.6

As Carson et al2 detail in their findings, we, as health care practitioners and public health professionals, must increase our reach as we repair the damage from the COVID-19 pandemic by investing in community engagement and community-based strategies, social services, and the creation of policies that eliminate structural racism. The Biden Administration’s COVID-19 Equity Task Force has identified equity as a priority in its national COVID-19 response strategy, insisting that there’s a “moral imperative” that ensuring safety and health of those at the highest risk is “simply the right thing to do”; that the vaccine must be “available for everyone,” and that this might mean “bringing the vaccine right to the people.”7 Bringing the vaccine to the people means understanding that everyone needs information in different ways, faces different social challenges, and has a different lived experience. It means treating people with dignity.

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Article Information

Published: September 30, 2021. doi:10.1001/jamanetworkopen.2021.27632

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Cervantes L. JAMA Network Open.

Corresponding Author: Lilia Cervantes, MD, Denver Health, 777 Bannock, MC 4000, Denver, CO 80204 (lilia.cervantes@cuanschutz.edu).

Conflict of Interest Disclosures: None reported.

Centers for Disease Control and Prevention. Health equity data. Accessed July 15, 2021. https://covid.cdc.gov/covid-data-tracker/#health-equity-data
Carson SL, Casillas A, Castellon-Lopez Y, et al. COVID-19 vaccine decision-making factors in racial and ethnic minority communities in Los Angeles, California. JAMA Netw Open. 2021;4(9):e2127582. doi:10.1001/jamanetworkopen.2021.27582
Daley  J. Colorado Public Radio News. To get the COVID vaccine to more Hispanic and Latino Coloradans, the new goal is meeting the unvacinated where they are. 2021. Accessed July 15, 2021. https://www.cpr.org/2021/06/15/covid-vaccine-hispanic-latino-colorado/
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The Commonwealth Fund. U.S. health care from a global perspective, 2019: higher spending, worse outcomes? 2020. Accessed July 22, 2021. https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019
Bloomberg Law. Biden’s Health Equity Task Force to Spotlight Social Disparities. Accessed July 16, 2021. https://news.bloomberglaw.com/health-law-and-business/bidens-health-equity-task-force-to-spotlight-social-disparities