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How can the U.S. make vaccine access more equitable? Here's what a former CDC director says

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Soon after COVID-19 was first identified in the United States, disparities in testing, cases, hospitalizations and mortality began to emerge. Inequities by race, ethnicity, geography, disability, sexual orientation, gender identity and other factors were quickly evident.

So how does the U.S. ensure that more Americans have adequate access to a vaccine?

Here's our Q&A with Dr. Richard Besser, former acting CDC director and president of the Robert Wood Johnson Foundation.

COVID-19 has only highlighted existing inequities in this country — lack of hospitals, food deserts, to name a few. With states in dire straits, what needs to happen on the federal level to address those needs? 

The COVID-19 pandemic has affected every community in the United States, but some populations have been hit significantly harder than others. Black, Latino, and Native Americans have all experienced rates of infection, hospitalization, and death that far exceed their proportion of the population. Just this week, new life expectancy numbers for the United States brought these disparities into stark focus: life expectancy during the first six months of 2020 declined by 2.7 years for Black Americans, 1.9 years for Latinos, and 0.8 years for Whites.

A key factor driving these disparities is a difference in the risk of exposure to the virus that causes COVID-19: a greater proportion of people of color are frontline workers who must interact with others on a daily basis in risky settings in order to put food on the table and to pay the rent. But the reasons go deeper than that. People and communities of color entered this pandemic at a significant disadvantage due to historic and ongoing racism and discrimination. A greater proportion of people of color work in jobs that pay lower wages, lack sick leave and family medical leave and lack health insurance. In the United States, skin color still has an outsized impact on whether people have the resources to keep themselves, their families, and their communities safe from COVID-19. 

Many of the decisions regarding the response to COVID-19 are ultimately made at the state or local level: whether to mandate masks or open schools; the size of gatherings that are allowed or the kinds of services that restaurants and bars can provide; and which groups should get priority for receiving vaccinations. But the federal government has a crucial role to play in making recommendations, providing additional resources, and creating incentives for states to align with the federal strategy. These tools can help to ensure that issues of equity are a central component of the response.

In addition, if we truly believe that everyone in America should have the ability to be protected as much as possible from COVID-19, Congress must come through with additional economic relief for those with low incomes and who have been hit hardest. Economic support is a public health intervention; it gives people the ability to follow public health guidance. This relief must include direct cash payments, extensions of supplemental federal unemployment insurance, increased rental support and extensions of eviction and foreclosure moratoriums, additional nutrition assistance, school funding, and paid sick and family leave for more workers. Without this kind of support, those who are at greatest risk of exposure will continue to be hit the hardest. 

How does using age as a deciding factor for who gets access to a vaccine hurt communities of color or more vulnerable communities in this country?

Vaccine recommendations from the CDC are developed by an independent advisory committee called the Advisory Committee on Immunization Practices (ACIP). It is composed of some of the world's leading scientists, infectious disease experts, and medical organizations. The group makes recommendations for all vaccines that are used in the United States. 

When the Pfizer and Moderna COVID-19 vaccines were approved for emergency use in late 2020, ACIP laid out a series of recommendations for who should be vaccinated first. These recommendations took into consideration the risk of exposure as well as the risk of having severe disease or dying if one got infected. The phased approach was also meant to ensure an equitable approach to vaccination. ACIP recommended that frontline healthcare workers and people who live in long-term nursing care facilities should be up first, followed by those over age 75 and essential workers. While the ACIP recommendations don't carry the force of law, typically states adhere to them. 

Unfortunately, soon after vaccination started, states largely abandoned the ACIP guidance, with many moving to a rollout where anyone age 65 or above could get vaccinated after healthcare workers and long-term care residents and workers. As a result, few states have put an intentional focus on vaccinating all essential workers, a group with high risk of exposure and which accounts for a high proportion of cases among people of color.

While it is critically important to get people vaccinated quickly, our obsession with overall numbers, weekly averages, and speed makes it harder to ensure vaccines get to those at greatest risk. While rates of vaccination have risen steadily overall, we're not getting vaccines into enough of the right arms; data show that people of color are once again being left behind. We need to redouble our efforts to ensure that people most at risk of exposure to Covid-19 are prioritized for vaccination. 

Technological barriers have also emerged as an issue with vaccine access. With the administration pushing vaccines to pharmacies, how can these companies better reach vulnerable communities to get them vaccinated?

I am encouraged by the administration's recent move to ship vaccines directly to local pharmacies and federally qualified community health centers. While this must be coordinated with state entities, this approach will bring vaccines into the community to locations where people regularly receive vaccinations. This helps build trust.

Our goal must be to make it as easy as possible for people to get vaccinated. We can achieve that goal by doing many things: ensuring there are phone bank systems to allow those without computer access to register for appointments; providing free transportation so that people without cars can get to vaccination sites; and running vaccination clinics around the clock and on weekends so that people who work during the day can still get vaccinated. When states turn vaccine registration into a first-come, first-served process, as we are now seeing in many parts of the country, those with wealth, connections, and time to navigate a complex process have an inherent advantage. That's unfair and unwise. It is heartening to see efforts to reduce these inequities. 

You're leading a discussion on the COVID vaccine on the federal level — what is top of your mind heading into the forum? What needs to happen right now to ensure more Americans, particularly those most in need, get an injection in the next few months? 

The National Forum on Covid-19 Vaccine, organized by the CDC, is bringing together government officials and those in the private and nonprofit sectors to support the implementation of a safe, effective, and equitable vaccine distribution process. I'll be moderating a panel that includes key federal leaders who are providing support and leadership for these efforts. We will talk about what is being done to speed up distribution and, just as importantly, what is being done to build trust and to ensure that vaccines are getting to those at greatest risk.  Ensuring that we follow the public health roadmap for vaccine distribution and administration is crucial to saving as many lives as possible and getting us to the end of this pandemic as quickly as we can.  

Over the next few weeks and months, it is absolutely critical that we make equity, accessibility, and coordination the hallmarks of our vaccine distribution effort. That should include:

  • The federal government ensuring that all states have accurate and timely estimates of vaccine allocations, as well as providing states with additional resources to report vaccine data by race, ethnicity, occupation, and neighborhood.
  • States and communities making it easier for people who need vaccines the most to obtain them, especially those who cannot take time off of work to get vaccinated, those who do not have access to the Internet to make appointments online, and those who live in neighborhoods that lack healthcare providers. 
  • Local health departments partnering with trusted community voices — faith leaders, community organizers, local medical practitioners — who can address people's concerns  about getting vaccinated and help inspire more trust and confidence in the process. 
  • People with low risk of exposure waiting their turn to be vaccinated until the United States has enough supply to make vaccines available to anyone who wants them.

You're a pediatrician and a parent. Do you feel comfortable with CDC's revised guidance to get back to in-person learning, even as COVID mutations present a clear risk of closure and infection, particularly in "red zone" areas of this country? 

The updated guidance from CDC is good news for our children, families, teachers and staff. It lays out a clear roadmap for getting children back into the classroom safely. If we commit to following this guidance, and Congress comes through with additional funding that is so desperately needed, we can reopen schools safely in all communities without compromising safety and the important battle to control community transmission. 

In the early days of the pandemic, we closed schools out of an abundance of caution based on what science tells us about how flu is spread. The urgency of that moment called on such extreme measures to prevent community spread. Guided by science and data, we've learned since then that, when provided with the requisite resources, schools can bring both children and adults back into the buildings safely. In fact, rates of transmission in schools tend to be considerably lower than the communities in which they're located. 

Substantial federal funding is urgently needed so that districts can hire staff for screening and testing, to upgrade ventilation systems, to properly clean buildings, to decompress classrooms to maintain social distancing, to secure enough personal protective equipment, and to implement testing where indicated. Teachers and school staff should also be included as essential frontline workers for the purposes of receiving COVID-19 vaccines, though many studies now show that this does not need to be a prerequisite for in-person learning. If we follow this roadmap, we can finally welcome millions of children back into the classroom where they belong.

Economists project the impacts of COVID learning loss on children could last decades, particularly for those kids in more vulnerable communities. What do we need to be doing, besides reopening K-8, to make sure these kids aren't worse for wear when they enter the workforce? How can we avoid a similar outcome with a future health crisis? 

Just as the pandemic is having a disparate impact on Black, Latino, and Native Americans, the failure to invest in our schools equitably has led to a disproportionate toll on the education attainment of Black and Brown children and of children in lower income neighborhoods. This neglect has been made even clearer during this pandemic, but our failure to invest in these schools predates COVID-19. More children in lower income communities are denied access to in-person learning, children with disabilities are denied the services they need to thrive, and working women are disproportionately losing their jobs by staying home to provide child care for children who are not in school. There will be long-term health and economic ramifications for these failures, including widening achievement gaps and potentially lower future earnings for these students. 

The United States needs to fundamentally alter its approach to school funding. A system that relies primarily on property tax revenue is fundamentally inequitable and will keep current disparities permanently entrenched. Our approach needs to recognize the intrinsic connection between a good education and good health. More education is linked to higher-paying jobs, reduced risk of chronic diseases, and longer lifespans. The benefits go beyond academics and social connections. For millions of students, especially Black and Brown children, schools provide lifelines — healthy meals, a library, an internet connection — that might not be available for them anywhere else. Investing in these schools and these children should be priority No. 1.

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