By: Kate Hopkins, Director of Research, Vaccine Acceptance & Demand, Sabin Vaccine Institute

COVID-19 vaccine inequities were a central theme in global leaders convenings over the last two months, including within the 76th United Nations General Assembly, the Global COVID-19 Summit, and the G20 Summit. While there is an undeniably stark gap in health and vaccine equities between high-income countries and low- and middle-income countries (LMICs), which have been further exacerbated by the COVID-19 pandemic, it is also important to recognize disparities within countries. To achieve both national and global vaccine equity, longstanding biases and structural barriers which have served to marginalize communities need to be understood, as they influence a population’s access to and acceptance of COVID-19 vaccination and impact on routine immunization.

The CommuniVax Coalition is comprised of social and behavioral scientists, public health professionals and community advocates all seeking to increase vaccine acceptance and vaccination access to Black, indigenous and people of color (BIPOC) communities within the United States. The Coalition invited national stakeholders of similar scopes to engage in listening sessions to discuss working toward an equitable COVID-19 vaccination campaign. The Sabin Vaccine Institute (Sabin) was invited as a discussant, along with 12 other partners, to share experiences conducting community-centric work as part of the larger pandemic response and to discuss any key policy shifts at various levels of government, which could assist in sustaining important health equity improvements experienced to-date. While Sabin has a global focus -- driving and supporting efforts to make vaccines more accepted, equitable and accessible, especially in the LMICs -- bi-directional learnings from historically marginalized U.S.-based BIPOC populations and communities within LMICs could inform vaccination programming efforts within both settings.

The semi-structured conversation, as facilitated by the Coalition, touched upon four seemingly universal and intertwining themes to assist with achieving a more equitable COVID-19 vaccination campaign, while creating enduring transformational recoveries from the pandemic:

  • Systemic exclusion LMICs from global health programming and of specific racial and ethnic minority groups from national healthcare systems must be acknowledged; and both
  • An equity-centered health system redesign, inclusive of community-based partnership strengthening, and
  • A more sustainable funding mechanism is required to restart societies and economies.

Despite pledges for global solidarity, we have witnessed the innate drive for nationalism during the pandemic. Many economically disadvantaged LMICs rely on doses donated or shared through mechanisms like COVAX. However, high-income countries have reached agreements with manufacturers for their own accelerated COVID-19 vaccine supply and delivery while also spending trillions on domestic economic recovery. As of November 1, 2021, the U.S. and Canada have reported 68% of its population as having received at least one COVID-19 vaccine dose, as compared with 8.5% of the African population. While COVAX has more recently projected 1.2 billion initial doses to be reserved for and delivered to LMICs by Q1 2022, high-income countries, such as the U.S. and Israel, are implementing booster vaccination campaigns due to concerns about emerging COVID-19 variants and waning immunity. The World Health Organization (WHO) is advocating for global solidarity through resource- and a binding pandemic treaty to close this gap and provide equitable access to vaccines.

As the Coalition discussed, the COVID-19 pandemic has also unequally affected many racial and ethnic minority groups within the U.S. Vaccine equity at both the national and global levels could be achieved from similar solidarity amongst localized governments if focused on understanding local social determinants of health, which are influenced by an array of conditions in the places where people live, learn, work, play and worship. These social and behavioral constructs have historically prevented these populations from obtaining opportunities for equitable economic, physical and emotional health, putting them more at risk of COVID-19- and other disease-related morbidity and mortality.

Coalition stakeholders shared there is a critical need for mechanisms of continuous feedback loops between grassroots to grass tops entities (i.e.; community-level to policy-maker level) to allow for hyperlocal issues and identified strategies to be shared with higher-level authorities, where often change is affected. The voices of local, community-level leaders must be heard at the decision-makers’ roundtables. Andrea Thoumi, health equity policy fellow of the Duke-Margolis Center for Health Policy, suggested structural-level systems redesign efforts to address systemic exclusion should include government appointments centered around health equity to acknowledge systemic exclusion, connect with community leaders and minimize the power differential in affecting change. A recently published case study reported COVID-19 vaccination events held in North Carolina amongst Latinx community members employing such strategies reached substantially more people who identify as Hispanic/Latino/Latinx compared to events without such key points of collaboration.  

Solutions need to be community-centric and often the strategies which yield the best vaccine uptake are those that reach target populations within their own communities at churches, schools, parks and community centers. Case studies spanning the U.S. have shown community-led mobile and pop-up COVID-19 vaccination clinics established within these frequently accessed trusted spaces can increase the likelihood of historically marginalized individuals accessing COVID-19 vaccines and result in better uptake. Jacquelyn Dalton, director of community engagement at Health Leads, shared storytelling strategies have been utilized successfully to depict on-the-ground realities of health disparities across communities in the U.S. while also featuring the healthcare leaders who are addressing the root causes.

Mobile clinics and storytelling approaches are not unique to just high-income countries, but have often been used to yield improvement of health-related outcomes in LMICs, especially within rural populations or amongst individuals cut off from health services (immigrants, refugees, and/or newly displaced persons).

Ongoing research is required to fully understand the social and behavioral dimensions of vaccine acceptance and vaccination uptake from the micro, meso and macro levels to strategize potential solutions addressing those dynamics. This knowledge can continuously inform decisionmakers in how best to meet the needs of the populations they serve. Sabin’s Social and Behavioral Research Grants Program is a mechanism to support this cause, encouraging collaborative partnerships between academics and locally based health programs and policy and practice communities. This community-centric approach allows for the strongest opportunity for translating research findings into locally informed solutions or implementation strategy agendas. The Coalition echoes this sentiment, sharing instances where partner organizations had not previously worked directly alongside public health institutions but have since built interactive relationships, have exhibited successful vaccination uptake outcomes and have a foundation established with public health strategies for the future.

Lastly, not only does COVID-19 vaccine inequity impact marginalized communities epidemiologically, it will have a lasting and profound impact on socioeconomic recovery in LMICs, already financially disadvantaged. The United Nations Development Programme, WHO and the University of Oxford’s Global Dashboard on COVID-19 Vaccine Equity reports that had low-income countries mirrored high-income countries in vaccination rates, their GDP forecast for 2021 could have increased by $38 billion. Many Communivax Coalition stakeholders shared similar concerns around sustainable national funding for health equity. U.S. federal COVID-19 response and recovery funds are often bottlenecked within intermediary organizations (often state and county government offices) and not reaching the community-based workforces implementing action plans. Alternative payment models and Medicaid reimbursement for staff within these organizations is critically needed to ensure momentum is sustained within at-risk communities.

Coalition members also discussed the threat towards prevention efforts created by political leaders who may be eager to view the landscape from a more post-pandemic lens in which the focus moves to COVID-19 treatment modalities. Not only is it important to recognize that this viewpoint is one of privilege for communities and/or countries with high vaccination and treatment access, but it also continues to put those marginalized populations at risk.

Since December 2019, the COVID-19 pandemic has framed public health as a highly politicized issue, which is it not and should not be. Dr. Daniel Salmon, director of the Johns Hopkins Institute for Vaccine Safety, clearly stated that restored trust in local public health is required to foster vaccine acceptance. Public health authorities should be serving and speaking for the local populations in need, and therefore be informed by these communities. Kelly Murphy, director of early childhood and maternal health at Families USA, stressed for the need to center vaccine equity as vaccination campaigns roll-out for children under 12 years of age and as partnerships transition from vaccination to other social determinants of health, post-COVID-19. If the lessons learned are not addressed, the same equity gaps will emerge.