As efforts accelerate nationally to provide the coronavirus vaccine to communities of color, skepticism about the inoculations is often highlighted as a major impediment. But a lack of pharmacies, hospitals, providers and transportation has emerged as an equally significant concern in those communities, where covid-19 has wrought its worst damage.
Public health experts, physicians and civil rights advocates say attention must be paid to the practical barriers that fuel the disparities that have become a hallmark of the American health-care system. If not accounted for, they say, those same obstacles stand to stymie efforts to bridge a growing divide in coronavirus vaccinations.
“Covid is exploiting not just human virus response, but our structured health-care response as well,” said Janice C. Probst, director emerita of the University of South Carolina’s Rural and Minority Health Research Center. “It finds the gaps.”
Covid-19, the illness caused by the novel virus, has killed 1 out of every 645 Black Americans in the past year. But of the 13 million people who received the coronavirus vaccine during the first month shots were available, just 5 percent were Black, limited data from the Centers for Disease Control and Prevention shows. Those figures also show that Latinos, another community disproportionately affected by covid-19, are underrepresented in getting shots. Race and ethnicity data was missing for nearly half of all coronavirus recipients during that time.
Researchers know that inadequate health-care infrastructure, including a lack of pharmacies, is one of the barriers.
One out of eight pharmacies shut their doors between 2009 and 2015, according to a brief 2019 study published in the medical journal JAMA Internal Medicine. Independent, urban drugstores whose clients are mainly uninsured or publicly-insured patients — two groups who are disproportionately Black and Latino — were most at risk of shuttering, the report said. A separate study shows rural residents are contending with hospital closures and provider shortages that have left 4.4 million residents living in a county without a hospital.
Probst has extensively studied the time and distance it takes to reach medical care, finding in a 2007 report that half of the trips made by African Americans for medical care took more than a half-hour compared with 25 percent of trips White people made. It’s a subject Probst and her colleagues are revisiting through a federally funded research grant to explore the degree to which historically disadvantaged racial and ethnic groups might be located farther from medical resources.
“The magic word is infrastructure,” Probst said. “Covid has brought everything into perspective.”
In Atlanta, Project South, along with the Hunger Coalition of Atlanta, has sought to plug holes in the health-care infrastructure of the city’s historically Black neighborhoods by offering free coronavirus testing or pop-up health education and first aid stations where people sometimes appear with major medical issues, such as uncontrolled diabetes, not just minor rashes.
The Biden administration, which has stressed equity as a cornerstone of the pandemic response, is attempting to improve access to vaccines by shipping a limited number of doses directly to pharmacies and community health centers, with the intention to scale up as vaccine supplies increase.
According to an analysis of state vaccine distribution plans by the Kaiser Family Foundation, about half of the publicly available plans — 25 of 47 — stated at least once that they were considering race, ethnicity or health equity in prioritizing targeted populations.
Only 12 of the state plans, though, highlighted the number of providers needed to reach communities of color — a key factor in delivering vaccinations.
“At the broader level is the extent to which a state outlines equity as a priority, but there is also this question of how is this priority, or focus on equity, then operationalized,” said Samantha Artiga, director of Kaiser Family Foundation’s racial equity and health policy program. “We’ve seen a lot of variation across states.”
D.C. recently started a door-knocking campaign in neighborhoods hit hardest by covid-19 to improve vaccination rates. In Massachusetts, advocates fought to get large-scale vaccination sites in communities of color. But they say newly created “companion appointments” undermine equity by allowing vaccinations for younger people who accompany older residents to appointments — even though younger people are not in current vaccination priority groups.
Researchers at the University of Pittsburgh and West Health Policy Center applauded the decision by the Biden administration to use community pharmacies as vaccine access points — they tend to be open nights, weekends and holidays and have parking lots, capacity and are trusted. But they said not enough attention has been paid to gaps in the health-care system when addressing vaccine uptake in vulnerable populations.
“Pharmacies should be easy to access, but in some places there’s low capacity or low density, and the flood gates are opening,” said Lucas A. Berenbrok, an assistant professor at the Pitt School of Pharmacy who began analyzing travel distances to potential vaccination sites with colleagues.
Transportation, including the logistical gymnastics required for people without a car or who rely on public transportation, has long led to differential access to health care. But it hasn’t been discussed as a potential reason for low vaccine uptake in communities of color “as much as hesitancy or skepticism,” said Inmaculada Hernandez, an assistant professor at the Pitt School of Pharmacy and one of Berenbrok’s collaborators.
Historical discrimination faced by Black people from the medical system — and continuing inequities — must be acknowledged and remedied, said Sean Dickson, director of health policy at the West Health Policy Center. But practical hurdles must be addressed, too, because “we also fail to invest in those communities,” Dickson said. “Otherwise, that puts the onus on Black communities to overcome rather than recognizing there are real structural barriers to accessing health care.”
Alma Stewart, a retired nurse and founder of the Louisiana Center for Health Equity, said too often, not enough attention is paid to the political and business calculus that puts health services beyond the reach of communities of color.
“Those decisions didn’t happen by accident,” she said.
The National Association of Chain Drug Stores said pharmacies are part of the solution, especially in medically underserved and rural areas where pharmacists can take vaccines directly to people with limited access through mobile pop-up sites at schools and in parking lots.
“There is a pharmacy within five miles of 90 percent of Americans,” Steven C. Anderson, the association’s president and CEO, said during a news briefing this month.
Traveling five miles might not seem like a substantial distance, but it can be depending upon ability and circumstance, especially for people without cars living in areas that don’t have sidewalks or accessible public transportation. In many densely populated metropolitan areas, going five miles anywhere means threading your way through traffic jams, congested walkways and crowded buses or trains.
“We have to make sure that people don’t make it all about hesitancy,” Georges C. Benjamin, executive director of the American Public Health Association, said. “If you’ve got to take two buses and walk a few blocks, plus hesitancy, where is the incentive to go get that shot?”
The lack of access comes on top of a constellation of other woes: technology issues — no computer or Internet — that make it hard to register for a shot or figure out where to get one; cellphones with limited talk and data plans; and shift work that conflicts with pharmacy schedules.
Then, there are the shifting priorities of many states that have sparked confusion over when, where and how to get shots as people 65 and older were moved to near the front of the line. Different jurisdictions haven taken different approaches, with front-line workers, who often face the highest risk of exposure to the virus and are disproportionately people of color, being pushed back in the queue.
“We have a fractured health-care system,” Benjamin said.
Federal health-care regulators have told states they need to develop standards for the maximum distance Medicaid managed-care patients should have to travel to see doctors, dentists and pharmacists. In New Jersey, for example, the standards say 90 percent of enrollees in metro areas should not have to travel more than 30 minutes by public transportation or live no more than six miles from their primary-care provider.
Allegra Brown, who doesn’t own a car and lives in Newark, said getting to the doctor or pharmacy is a headache that involves choosing between a $40 round-trip Uber ride or two buses. Public transportation, she said, is cheaper but takes much longer and isn’t reliable.
“I’m not going to lie. There’s been times where I didn’t get prescriptions filled,” said the 23-year-old who prepares grocery orders for delivery at Amazon Fresh and has employer-based insurance. That’s what happened just before Thanksgiving, when she cut her leg, went to the emergency room and left with a prescription for antibiotics. (Amazon founder Jeff Bezos owns The Washington Post.)
Brown went to the pharmacy she’s familiar with only to be told it wouldn’t accept her insurance and was sent someplace else that wasn’t open. Deterred by the time and cost, she said she didn’t try again. Her cut became so infected it required intravenous antibiotics. Experiences like this, she said, don’t engender confidence that pharmacies getting direct shipments of the coronavirus vaccine — which she said she needs “like yesterday” — will simplify her ability to get a shot.
“It’s going to be some time before we get the vaccine, that’s what that means,” she said.
Michigan health officials said they are determined to eliminate differences in drive times to ensure there are no racial and ethnicity disparities in vaccination rates.
“We’ve set out an ambitious, but I think attainable, goal, that no Michigander should have to drive more than 20 minutes to reach a vaccination site,” said Joneigh S. Khaldun, chief medical executive for Michigan’s health and human services department.
“Now, that may be 20 minutes to where there’s a mobile van on a corner. May be 20 minutes to the senior center. That includes our rural areas,” said Khaldun, who the White House announced Wednesday will be a member of the White House Covid-19 Health Equity Task Force. “This is just bread and butter public health. It’s going into the neighborhoods. It’s not asking people to come to you.”
Michigan reduced disparities in covid-19 case and mortality rates between Black and White residents with public health interventions and more money, she said. Officials collaborated with trusted members of the community who used their platforms to educate people about masks and social distancing, placed testing sites in vulnerable communities and helped find housing for people whose homes weren’t conducive to isolating if they tested positive.
“The progress,” Khaldun said, “is fragile.”
According to the Covid Tracking Project, an independent group that collects data on cases, deaths and hospitalizations, Black people, who are 14 percent of Michigan’s population, accounted for 40 percent of the state’s deaths at the end of April. White people, who are 78 percent of the population, represented 45 percent of deaths.
At this moment in the pandemic, Black people make up about 23 percent of deaths statewide, while White people make up 71 percent of deaths. A surge in cases among the state’s White population contributed to the disparity shrinking, figures show.
Like Michigan, Louisiana plans to bring coronavirus vaccines to the people instead of expecting people in health-care deserts to travel, said Robert Maupin, an obstetrician and member of Louisiana’s covid-19 health equity task force, convened by Gov. John Bel Edwards (D).
“The only way to make it work is to make it mobile,” Maupin said. “Whether we’re talking about covid or we’re talking about other areas of health-care access, the patterns are similar.”
Members of the Louisiana task force said the state is using the CDC’s social vulnerability index and is identifying those places that already suffer from a hospital or provider shortage to predict which areas will need additional services to administer the coronavirus vaccine.
It is important to recognize that disparities in covid-19 death rates and in access to vaccines have roots that extend far beyond the disease’s emergence last year and require long-term strategies to solve, Maupin said.
“We’re in covid now, but things cycle through,” said Maupin, who is associate dean of diversity and community engagement at the Louisiana State University School of Medicine in New Orleans. “If we don’t fix the system, when the next crisis comes, we’re going to see the same things. We have to use this moment of crisis as a call to action.”