Centering Vaccination Planning on Equity: Intersecting Considerations of Age, Race, and More
Like many older adults, Dorothy, the 72-year-old Chinese American in Seattle’s Chinatown, has had a tough year. She has been coping by mostly quarantining alone, with loved ones occasionally stopping by to bring essential groceries and household items. Months had passed by since she left the floor of her senior housing building, and one day when she went downstairs to her mailbox, she was startled to realize that she had forgotten how to open the mailbox door. Little things like that, on top of having to celebrate her upcoming 73rd birthday alone – contrary to the usual large family celebration with games and food – continue to take an emotional toll. Now, with news that a vaccine may be just weeks away, Dorothy – who does not usually get her annual flu shot – is happy but also has additional worries. She does not fully trust the safety of the vaccine, she is concerned about adverse reactions to it, and very little information about the vaccine has been provided in Chinese.
Centering vaccination planning on older adults, especially older adults of color, is key to a vaccine plan that is equitable and fair. Older adults have been some of the hardest hit by COVID-19. Based on data from the Centers for Disease Control and Prevention, the country has reached over 281,000 deaths from COVID-19, with older adults age 65+ accounting for over 80% of all deaths. Death rates in communities of color persistently outpace the rate in white communities, and rates in nursing facilities where larger percentages of Black and Latinx residents live are particularly alarming.
States have been given considerable discretion in crafting the specifics of their vaccine allocation and distribution plans based on guidance from the CDC and other federal frameworks. But states will undoubtedly need to make specific and difficult decisions about how to prioritize populations in different phases and how to further sub-prioritize within those phases. As states across the country draft their allocation and distribution plans, advocates play a key role in ensuring intersecting considerations of age, race, and more are key factors in any plan centered on equity. That is the only way that Dorothy and other older adults like her will have their needs addressed as the nation pivots from managing the global pandemic to vaccinating millions.
At a minimum, advocates should consider advocating for the following in state vaccine allocation and distribution plans to center them in equity and the intersectional needs of older adults:
- Prioritize communities most impacted and most at risk of infection and death from COVID-19. States must think comprehensively of those impacted; the reality of the virus is that it brings to the forefront intersectional discrimination. Therefore, states must set aside singular paradigms of looking at the impact of COVID-19 on people of color or older adults. Instead, an intersectional approach is necessary and could, for example, explicitly prioritize older adults in congregate settings with higher proportions of residents of color. It should also prioritize older adults of color in the community, such as Dorothy, since the pandemic has impacted them, with many foregoing or minimizing certain home and community-based services and other social supports, all of which accelerate into a potential nursing facility admission. The intersectional impact of the pandemic is consistent with ongoing CMS data showing that Black, Indigenous, and Latinx older adults on Medicare are hospitalized from COVID-19 at significantly higher rates. In addition to prioritizing people most at risk, plans should account for those who work with older adults in these communities, e.g. direct care workers, and also look to local community COVID-19 transmission rates in setting priority categories.
- Include express protections against discrimination. Plans must prohibit discrimination on the basis of age, race, and other protected characteristics in vaccine allocation and distribution. In the rush to respond to the pandemic earlier this year, a number of states released crisis standards of care that allowed for discrimination against older adults. Older adults of color, in particular Black men, have lower life expectancy than other populations, but plans cannot deprioritize them on the basis of projected life expectancy. Although initial doses of the vaccine will be insufficient to immunize everyone, plans must comply with existing state and federal civil rights protections.
- Conduct outreach by incorporating the voices of marginalized communities and those for whom the medical system and government have proven not to be trustworthy due to historical and present-day discrimination. Vaccination rates generally in communities of color lag behind white people, and rates for Black and Latinx older adults are no exception. These rates are informed by histories in certain communities, like the Tuskegee experiment and the spread of smallpox and other diseases among Native communities. Further, present day political circumstances may result in many communities, including immigrants like Dorothy, distrusting government generally and the vaccination more specifically. This reality compels states to create allocation and distribution plans that are informed directly by those communities through the inclusion of focus groups. Focus groups and other forums would be particularly critical, for example, if two doses of the vaccine are required, to get input from older adults about what concerns they have about the vaccine and what kind of follow up is most helpful to ensure older adults get both doses. States must also ensure limited English proficient older adults, who may also have low health literacy, truly understand all vaccine outreach and education materials. Finally, regardless of language, materials should be tested among older adults to ensure comprehension before being widely disseminated. Other culturally competent, innovative educational strategies, even tailoring strategies to different settings, should be leveraged, partnering with trusted community messengers and accounting for the unique ways older adults prefer to receive information.
- Build an intentional process and use racial impact assessments. News that a vaccine could be ready for distribution by mid-December has regulators, states, and healthcare professionals scrambling. Of course, states should be ready with plans as soon as possible. However, states should also be mindful that when timeliness is prioritized and details are left unanswered, systemic racism and implicit bias compound to create disparate outcomes for communities of color, including older adults. To the extent possible, states should create plans under intentional and transparent circumstances, allowing for robust discussion and deliberation. Toward the end of the drafting process, states could consider utilizing a racial impact assessment to analyze the effects of its plan on communities of color within the state before finalizing it. Advocates can also push for innovative equity measures in plans that drive accountability to reducing disparities. Similar mechanisms have been created in state reopening plans.
- Provide robust enforcement and monitoring. State allocation and distribution plans are an important framework for local health officials to follow, but with some limitations. Those same officials may exercise discretion to deviate from state guidance, who may be under significant pressure and also are not free from implicit bias. As such, plans must meaningfully grapple with enforcement and monitoring of the situation on the ground in local communities to ensure that health officials are not running afoul of state guidance, and if they do, mechanisms are in place to readily address it.
In addition to these considerations that state plans must account for, the federal government must coordinate collection and transparency of timely data on who is getting the vaccine and in what communities and settings. Initially unprepared for the onslaught of the pandemic in the early spring, infection and hospitalization data from the CDC lagged behind and often was incomplete, especially racial information. This time, with the benefit of foresight, the federal government should be proactively planning an intersectional approach to collect vaccination data that includes an individual’s race, age, gender, residential setting, and more.
Dorothy and so many older adults like her were some of the first people in communities across the country who had to give up so much of their typical lives as a result of COVID-19. From cancelling non-vital medical services to foregoing the large family gathering at Thanksgiving, their lives, like many of ours, have turned upside down. Some in nursing facilities and others have faced even harsher realities as the virus has demonstrated our country’s racist and xenophobic nature. Advocates can turn a state’s vaccine allocation and distribution plan into an opportunity to fight for equity on behalf of older adults. A vaccine plan centered on addressing the needs of older adults of color will also be the most effective at reducing deaths and finally getting the pandemic under control for all.
The opinions expressed in this article are those of the author and do not necessarily reflect those of the Diverse Elders Coalition.