Black, Latino and Indigenous people in the U.S. are about three times more likely to endure COVID-19-related hospitalizations and about twice as likely to die from the virus compared to white people. That stark reality has helped shape President Joe Biden’s national pandemic strategy, which seeks to make equity a key focus.
The White House’s 19-page plan includes goals to improve data collection on high-risk groups; provide equitable access to vaccines, tests and personal protective equipment; expand the public health workforce and fund assistance for social services like child care and paid sick leave.
But the unequal impact of the coronavirus reflects long-standing systemic issues, epidemiologists and community health specialists said. An equitable pandemic strategy will require expansive relationships with state officials and local communities to root out racism and inequities in coronavirus-specific treatments and in government systems overall, they argued.
“Our systems are producing the results they were designed to produce right now,” said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network. “We need to redesign them if we want different results — from how we think about affordable housing to our health care system itself.”
The administration’s efforts to provide a coordinated virus response come after nearly a year of mixed messaging from former President Donald Trump that largely left states to develop their own systems.
In a public health crisis, the federal government can play a valuable role in funding state and local efforts to address the virus and providing new research and guidance on ways to service more vulnerable populations, said Lindsay Wiley, director of the health law and policy program at American University.
As part of the larger virus strategy, the Biden administration created a health equity task force led by Dr. Marcella Nunez-Smith, an associate professor of internal medicine, public health and management with Yale University.
One of the crucial first steps for the task force will be improving and expanding data collection on people infected by the virus and those receiving vaccinations. About 49 percent of the data on COVID-19 diagnoses and about 47 percent of the data on coronavirus vaccinations do not contain race and ethnicity information, Nunez-Smith said in a briefing hosted by the White House COVID-19 response team on Monday.
“We cannot ensure an equitable vaccination program without data to guide us,” Nunez-Smith said. “The CDC will be releasing additional data regarding race and ethnicity and vaccine uptake soon, but I’m worried about how behind we are. We must address these insufficient data points as an urgent priority.”
A Kaiser Family Foundation report examining federal data as of Feb. 1 found that 23 states were publicly reporting COVID-19 vaccination numbers by race and ethnicity.
Providing more comprehensive data on vaccinations, hospitalizations and virus diagnoses broadly can help officials better direct resources to communities in need.
“We can’t target resources unless we know where and to whom they should go,” said Jason Purnell, vice president of community health improvement with the St. Louis-based BJC HealthCare. “If we’re not tracking in a rigorous and reliable way where the greatest need is, it’s hard to direct that sort of asymmetric response.”
The coronavirus pandemic swept through communities of color and low-income neighborhoods the way many public health experts feared. A myriad of factors contribute to the disproportionate effects of COVID-19 on Black and brown communities, said Charlesnika Evans, a professor of preventive medicine with Northwestern University. Daily stress associated with racism and inequities in housing, employment, food and transportation access all lead to disparate health outcomes.
Black, Latino and Indigenous people on the whole have higher rates of some health complications that are markers for more serious coronavirus symptoms, according to multiple studies and federal data. Communities of color also have access to fewer health resources and people of color are disproportionately more likely to be exposed to the virus due to housing constraints and jobs designated as “essential” that require face-to-face interactions.
So while white people represent a larger share of the country’s population, officials need to consider overall risk factors when developing an equitable pandemic response, said Jasmine Marcelin, a medical doctor and professor of internal medicine at the University of Nebraska.
“The fact of the matter is that people in Black, Indigenous and Hispanic communities are dying from COVID-19 at rates that are higher than their share of the population,” Marcelin said. “So if we are to be equitable in any sort of treatments, vaccines, any sort of approach to this pandemic, we have to take into consideration the share of the population that is being impacted.”
Early vaccine data already indicates challenges with resource distribution, though. More than 27 million people in the U.S. have received at least one of the two necessary vaccine doses so far. The Biden administration has ordered 200 million more doses of the two currently authorized vaccines to be delivered by the end of the summer — which would vaccinate an additional 100 million people. But across the country, vaccine rollout has been rocky. States have reported an inadequate supply of doses and trouble with storing them at the necessary temperature — hardships that are exacerbated for higher risk populations.
The CDC said in a report this week that among the vaccination data containing race and ethnicity information 60.4 percent of those people who have received a vaccine dose are non-Hispanic white and 39.6 percent are people of color.
In North Carolina, for example, Black people have so far comprised 12 percent of vaccine recipients but represent 20 percent of the state’s COVID-19 cases and 25 percent of coronavirus deaths, according to the Kaiser report. Hispanic people in North Carolina represent 2 percent of those vaccinated, 22 percent of virus cases and 8 percent of deaths. White people make up 81 percent of the state’s vaccine recipients, 62 percent of cases and 66 percent of deaths.
Sixty percent of the states Kaiser lists data for showed a similar pattern, with white people receiving a larger share of the vaccine than their share of coronavirus cases or deaths. Black and Hispanic people represented smaller shares of those vaccinated than their share of cases or deaths in each of the states.
This gap reflects both the hurdles to vaccine access and lack of trust in the vaccine among historically marginalized groups. In mid-January, 35 percent of non-white people said they do not plan to get vaccinated compared to 28 percent of white people, according to a PBS NewsHour/NPR/Marist poll.
The hesitation among some people of color stems from historic and ongoing racism and abuse by the medical industry, Marcelin said, but mistrust of the vaccine is not the only factor.
“There is definitely vaccine hesitancy in Black and brown communities, but there are also a lot of people who want to get the vaccine and simply can’t because it’s not accessible to them,” Marcelin said.
Reliance on online vaccine registration blocks out more than 25 million people in the country who do not have regular internet service. Busy phone lines can force others to wait hours to schedule appointments. And long travel distances to get to COVID-19 testing, vaccine or treatment facilities are prohibitive for many people without personal vehicles.
These types of barriers also disproportionately affect people of color and require new outreach strategies, multiple health experts said. Learning more about the challenges facing specific communities is one place to start.
For example, public health officials generally consider adults ages 65 and older to be at high risk for COVID-19 symptoms and recommend that this age group be among the first vaccine recipients. But Black and Latino people are more likely to experience COVID-19 deaths in their 40s and 50s as well, according to a Brookings Institute report based on CDC data.
The CDC Social Vulnerability Index is a tool epidemiologists suggested local officials could use to better understand how risks vary by region, which can help them make decisions about prioritizing resources. The index scores every U.S. county based on 15 social factors like crowded housing, vehicle access and poverty.
When developing outreach plans, officials and health providers should take advantage of established community networks, Purnell of BJC Healthcare said. This can include church groups, civic organizations, knocking on doors or giving resources to trusted community members. And rather than dictating what people should do to protect themselves, Purnell and Marcelin recommend first asking communities about their concerns and needs.
Some states have tried to come up with ways to factor in under resourced communities into their vaccine plans. Rhode Island has set up clinics in public housing buildings located in harder-hit cities as part of the early vaccination rollout. Health officials in Tennessee are using the CDC Vulnerability Index to direct 5 percent of the state’s vaccine supply to high-risk areas, according to a Washington Post report.
Last year California developed a health equity metric and issued a mandate requiring that the state’s 35 largest counties first reduce COVID-19 rates in vulnerable neighborhoods before they can reopen. Purnell cited an effort in St. Louis called Prepare STL, which trains “community champions” charged with providing vaccine information to people in their social networks.
Efforts focused on equity have had mixed success. States are still struggling to figure out how to prioritize essential workers and people of color in specific regions. Working with states to provide funding and guidance for more local efforts will be an important consideration for the Biden administration, several experts said. In a briefing on Monday, White House press secretary Jen Psaki said the administration will be “supporting additional venues for vaccinations targeted at reaching those at the highest risk” and speaking with governors about their equitable distribution plans.
Federal agencies have discretion to choose where to direct resources like vaccine doses or funding, Wiley of American University said. Such funding during the pandemic has gone toward reimbursing states that are using National Guard members to help with things like administering COVID-19 tests or delivering supplies to food banks and hospitals.
Beyond coronavirus-specific solutions, Evans of Northwestern University said she is encouraged by the Biden plan’s support for broader funding to social services.
Since Biden took office, the CDC has extended an eviction moratorium first implemented under Trump. The president has also proposed a $1.9 trillion pandemic aid package calling for $1,400 individual relief checks, an additional $400 per week in unemployment benefits, $30 billion for rental assistance, $350 billion in funds for state, local and territorial governments, and a $15 minimum wage, among other provisions.
One Republican counter proposal would allocate an estimated $618 billion, including $160 billion for direct pandemic response efforts, an additional $300 per week in unemployment benefits and $1,000 direct checks for individuals making less than $40,000 a year.
Biden hopes to reach a bipartisan deal with Republicans on the issue but congressional Democrats are moving forward with pushing his trillion-dollar bill through with their slim majority.
The giant COVID-19 relief package could go a long way to further some of Biden’s health equity goals, but experts said they will be watching for more specifics on the other objectives discussed in the pandemic strategy report.
“I think it’s a really good start,” Savage-Sangwan of the California Pan-Ethnic Health Network said. “As a next step, I would really look forward to the more detailed plans of how and when those things will happen.”