Now Is the Time to Explicitly Emphasize Equity in Vaccine Access

by Jonathon P. Leider, Elizabeth Wrigley-Field, Debra DeBruin, and Nneka Sederstrom


Recent announcements at the state and federal level reflect good news about expanded eligibility for COVID-19 vaccines. Three weeks ago, the Minnesota Department of Health released its updated vaccine guidance about the staging and expected timing of COVID-19 vaccine. President Biden recently said he now expects all adults to be eligible within six weeks, by May 1. Some states, like Michigan, Mississippi, and Alaska are opening up to all adults now. In Minnesota, we’ve recently added about 1.8 million high-risk Minnesotans to the “now-eligible” pool in our current tier in phase 1b. But some subgroups within it remain at still higher risk than others, eg, Black, Indigenous, and People of Color (BIPOC) Minnesotans who are ages 50+.

In a state like Minnesota, which is overwhelmingly whiter the older you get, the early focus on age alone largely meant a focus on older whites. But now is the time for health care systems, community pharmacies, and other vaccine providers to get vaccines into communities of color and seriously focus on implementing effective initiatives to promote access for older and even middle-aged BIPOC populations. It is the minimum we can do, ethically. Why? Because, based on data regarding risk of death, these groups should have been prioritized the moment states opened up to 65+ in January, given comparable levels of risks in these populations. Among white Minnesotans, 89% of COVID-19 deaths outside of long-term care were in folks aged 65+, but only 59% of deaths in BIPOC populations were in that age group. BIPOC Minnesotans are dying at high rates much younger than are white Minnesotans; outside of long-term care, BIPOC Minnesotans aged 50-64 have COVID mortality risk equivalent to white Minnesotans aged 65-74. Limiting eligibility to those 65+ has meant that whites appeared to have systematically better access to scarce vaccine.

Our state’s early focus on speed over equity has resulted in a smaller proportion of BIPOC Minnesotans in eligible age groups being vaccinated, as well. This disparity in vaccination rates among those eligible is not due just to “vaccine hesitancy” in these groups, but instead to challenges with accessing vaccines in a context in which need far exceeded supply. Initially, eligible individuals had to access vaccines using  a hard-to-navigate, decentralized system. Minnesota’s disparities in vaccination rates are not unique. To address these disparities, the state should implement large-scale initiatives to improve vaccine access in BIPOC communities. Indeed, the recent guidance from the state promises a plan “to ensure those eligible for vaccine within [disproportionately impacted] communities are more likely to receive it.” The state acknowledges that communities of color have been especially hard hit during this pandemic.

We’re including a map below that highlights this problem. You’re able to pick a hospital in the state, and set a distance, and see what kinds of gaps might exist in COVID-19 and excess mortality rates among Census tracts within the distance you’ve set. The visualization focuses on White vs BIPOC 50+ for the reasons above and excludes deaths in long-term care (since this group has already been prioritized and vaccinated). While the seven-county Twin Cities metro is driving much of the disparity in the state, most other parts of the state see issues, as well.

Focusing on communities of color does not mean other high-risk individuals ought to be excluded. It does not mean that rural pharmacies or vaccination sites in Greater Minnesota should then be flooded by folks from the Twin Cities looking for a shot. Focusing on communities of color means that we should make concerted efforts to improve access, given both the need to play catch up with vaccinating a population that should have been eligible for vaccination based on their exceptionally high level of risk weeks ago, and the recognition that these communities confront challenges to access even when they are eligible.

Despite their high risks, we have failed at prioritizing communities of color in vaccine allocation, but there is still time to reach them. This means working with local community, cultural, and faith groups to develop intentional partnerships and work with “trusted messengers.” It means investing resources specifically and explicitly in expanding equitable access like a carve out of vaccine allocation specifically allotted to equity based initiatives with an accountability measure. It also means acknowledging that focusing on speed alone undermines equity efforts. Allowing organizations more freedom to reach an equity benchmark will better utilize the tools they have available to them to help communities overcome structural barriers in access to vaccination. Now that we have data regarding weekly progress in immunizing communities by race/ethnicity, we need to be evaluating if our current efforts are effective. What percent of BIPOC communities are served by our federally qualified health centers and therefore how much more impact can we expect on putting more vaccines in them vs other parts of the community? Who is signed up for the Vaccine Connector by race/ethnicity or primary language spoken? What percent of shots given each week in the state is informed by who has signed up for the Vaccine Connector?

Our state describes its vaccination strategy as aimed at impact, but the demonstrated impact based on the trends in Minnesota COVID-19 mortality data show that, in the first phases of the vaccine process, we left our BIPOC communities behind. We must do things differently if we aim to get a different result. It is, quite literally, the least we should do as vaccine availability opens up.

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Jonathon P. (JP) Leider, PhD, is an independent consultant in the public health and health policy space, as well as a Senior Lecturer at the University of Minnesota and Associate Faculty at the Johns Hopkins Bloomberg School of Public Health. He has active projects and collaborations with foundations, national public health organizations, public health researchers and academics, and public health practitioners. His current projects focus on public health systems, the public health workforce, and public health finance. He holds a PhD in Health Policy and Management from the Johns Hopkins Bloomberg School of Public Health. [Full bio]

Elizabeth Wrigley-Field is an Assistant Professor in Sociology at the University of Minnesota, where she is also affiliated with the Minnesota Population Center. Substantively, she specializes in racial inequality in mortality and historical infectious disease. She is also a quantitative methodologist, developing models designed to clarify relationships between micro and macro perspectives on demographic relationships.

Debra DeBruin, PhD, is Interim Director of the Center for Bioethics, University of Minnesota-Twin Cities, where she has held a number of academic leadership appointments. She also served as a Health Policy Fellow in the United States Senate, as a consultant to the National Academy of Sciences’ Institute of Medicine and the National Bioethics Advisory Commission.

Dr. Nneka Sederstrom is the Chief Health Equity Officer for Hennepin Healthcare. She began her career as a volunteer in the Center for Ethics at Medstar Washington Hospital Center that summer. She continued her academic career while working at the Center and received her MA in Philosophy in 2003. After beginning her PhD studies she was made Director of the Center for Ethics and Director of the Spiritual Care Department. She proceeded to hold these positions until she left to join Children’s Minnesota in March 2016. Her academic credentials include a PhD in Medical Sociology and MPH in Global Health Management.