Vaccine equity: If we build it, will they come?

In partnership with the federal government, California launched two massive Covid-19 vaccination sites this week. One is at Cal State LA in East Los Angeles, a community deeply affected by the Covid-19 pandemic. I hope these new sites will make it easier for Angelenos to get vaccinated. But I still wonder: If we build it, will those from historically underserved communities come?

As a physician specializing in infectious diseases, I’ve studied the geographic and social factors associated with Covid-19 health disparities in Los Angeles. I also understand the vital role vaccines play in ending the Covid-19 pandemic. We currently have two vaccines that are safe and more than 90% effective in preventing symptomatic Covid-19, with several promising vaccine candidates in the pipeline.

But what good are vaccines without vaccinations?

Current vaccination programs in the region — and many across the United States — rely on the use of technology and are not well-suited to older people, especially not older people of color.

Here’s an example: On a recent Sunday, a tweet told me that the Los Angeles Department of Public Health had just released additional Covid-19 vaccination appointments online. I sprung into action. I checked the website, then texted a friend in Washington, D.C., whose 86-year-old grandmother, a Black woman and resident of Inglewood, a city in Los Angeles County, had been looking for a vaccine appointment. A minute later I refreshed the website, but many of the slots had already been taken. I called my friend, who said she needed to call her aunt, who would call her mother to make an appointment on her behalf.

All that took time, and the appointment slots had filled up.

This isn’t an isolated occurrence. The high-stakes online appointment system is inaccessible to many older individuals. Over the past month, I’ve helped several family members and friends navigate the online appointment system, including my 84-year-old Spanish-speaking abuelita, who lives independently but does not use the internet. Not only did she not know she was eligible to be vaccinated, but she wouldn’t have been able to do it by herself since using technology to make an appointment isn’t in her skill set.

Los Angeles, where I work, is the current epicenter of the Covid-19 pandemic in the U.S. As in other cities, the disease has not affected all communities equally. Poorer communities and communities of color here have been particularly devastated by Covid-19. People 65 years and older are at high risk for severe illness from Covid-19 and account for approximately 70% of all Covid-19-related deaths in Los Angeles County. Elderly Hispanic and Black people in the region are especially vulnerable to Covid-19. Yet these are the populations that LA’s vaccination programs are leaving behind.

Equitable access to Covid-19 vaccines has been a priority from the start — at least on paper. An analysis of early vaccination data from 23 states demonstrates lower vaccination rates among Black Americans — about half that of white Americans. In Los Angeles, vaccination disparities are also being observed in older populations, with lower vaccination rates among Latino and Black seniors.

On a recent Friday, I volunteered to administer vaccines at a mass vaccination site at The Forum in Inglewood, the predominantly Black and Hispanic community where my friend’s grandmother lives. While it was exhilarating to witness the happiness, relief, gratitude, and occasional tears of joy from vaccine recipients, I couldn’t help but notice that most of the people who were vaccinated were white/Caucasian people, who make up only about 5% of Inglewood residents.

Many of those getting vaccinated told me how difficult it had been to get an appointment. One person told me that several family members, all working from computers at home, spent two days searching for appointments, constantly refreshing the website to secure their grandparents’ vaccination slots. Once they had a slot, they needed to take the afternoon off and drive their grandparents to The Forum.

Not everyone has access to the internet, flexible work schedules, and cars. These things should not be barriers to vaccination, but they are.

To be clear, I was happy for those getting vaccinated. But their stories reminded me how the current vaccination programs are perpetuating existing health disparities.

The new mass vaccination site at Cal State LA is located within a hard-hit community of mostly Black and Hispanic residents near a transportation hub, a deliberate effort to improve accessibility. But there are other barriers to vaccinations.

Positioning vaccination sites within a community can overcome some barriers, but location alone does not ensure access for community members. For that, it’s important to work with communities to improve outreach, vaccine education, and identify and reduce barriers to vaccine access in the local context. This can be done by leveraging existing community organizations, like churches, community health centers, and local businesses to disseminate accurate information about the vaccines, including eligibility. An approach using residential ZIP codes for vaccine distribution and community outreach could help to focus on our most vulnerable communities.

Reliance on technology is another barrier to vaccination. While vaccine supplies are limited, it’s essential to establish equitable appointment systems that are accessible by seniors and prioritized groups, not preferentially those with Internet access, those who are social-media savvy, or those with family members who can make appointments.

Key to achieving the goals of vaccine equity are the collection and public reporting of vaccination data by race and ethnicity, which is currently missing for half of vaccine recipients. As Dr. Marcella Nunez-Smith, who chairs President Joe Biden’s Covid-19 equity task force, has said, “We cannot address what we cannot see.”

But in the meantime, I will continue to rely on Twitter alerts, the internet, and old-fashioned phone trees to reach underrepresented people and help them get vaccinated.

Paul Adamson is a physician and a fellow in infectious diseases at the UCLA David Geffen School of Medicine in Los Angeles, Calif.