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Can The United States Bridge The COVID Vaccine Gap?

Can The United States Bridge The COVID Vaccine Gap?

Unless otherwise noted, all photos are originals by Sarah Rice.

DETROIT — Phil Talbert is standing in a strip mall parking lot, trying to stay warm on a cold April morning while promoting COVID-19 shots to the unvaccinated.

Talbert, 61, is leading a group of vaccine "street teams" dispatched by Michigan officials to one of America's poorest, Blackest cities; he is part of a project management and community outreach firm that has previously worked with the state, and the vaccination campaign is just another contract job in that regard.

But Talbert is Black and lives about a mile and a half away from this neighborhood, which is located between downtown and the city's west side. He has seen loved ones battle the disease, including two friends and three family members who died. "We are all from Detroit," he says. "This is our community."

Talbert tries his best to project a friendly presence from behind his mask, clipboard in hand, hooded sweatshirt pulled up around his neck, but just starting conversations is difficult.

A woman in a red sweatshirt and black leggings shoos him away, saying, "Don't want it, don't know what's in it." A uniformed security guard from nearby Henry Ford Hospital pulls up in his squad car and practically closes the car door in Talbert's face, followed by another hospital employee, a woman who politely ends the conversation, saying she wants to wait to learn more.

“I tried talking to her,” Talbert shrugs, “she’s at the hospital, she sees it, but she didn’t trust [the vaccine].”

Finally, Talbert engages Claude Searles, a former autoworker dressed in fatigues on his way to the convenience store. He says he hasn't gotten the vaccine, but he listens as Talbert runs through the street team's talking points, emphasizing protecting loved ones.

Afterward, Searles tells me he's thinking about going, not for himself, but for his mother, because he doesn't want to get sick and infect her. A few minutes later, he's back, this time with a friend who, much to Talbert's delight, is also interested in hearing more.

Talbert has been at it for about 30 minutes at this point, putting in a lot of time and effort for the sake of two "maybes." But when it comes to closing the Black-white gap in COVID-19 shots in Detroit and across the country, there may be no other option.

America and Detroit both have a racial vaccine gap.

In many ways, the United States' vaccination campaign has been a colossal success, with a reach and speed that most peer countries can only envy.

However, some population groups in this country have fallen noticeably behind, and one of them is Black Americans, whose vaccination rate is roughly two-thirds that of white Americans, according to Henry J. Kaiser Family Foundation estimates. A similar disparity exists in Detroit, where the citywide vaccination rate is the lowest for any jurisdiction that the state tracks on its website.

The gap is especially troubling because it appears unlikely to close anytime soon. The White House announced this week that more than half of all American adults are now fully vaccinated, but Deputy Mayor Conrad Mallett Jr. told me in an interview that “it would be fantastic if we could get to the middle or high 40s” by September.

Charles Williams, a minister and civil rights leader in the city, believes it will take a year or more for citywide rates to catch up to the rest of the country, which, if true, would add to the long list of indicators of health and well-being on which Detroit lags behind the rest of the state.

Of course, this would increase the number of people who contract the disease, as well as the potential for new variants to emerge.

It's tempting to blame all of this on political indifference, and that may be true in some parts of the country, but racial disparities have been a highly visible focus for local and state officials here since the start of the pandemic, and reducing vaccine disparities in particular has been a priority for the federal government since Jan. 20, when Joe Biden became president.

It's difficult to say how much their efforts have helped, and what else can or should be done, but officials, front-line workers, and community leaders all agree on one thing: the challenge is massive.

They argue that the issue is one of both “access” and “hesitancy,” rather than one or the other, and that it is the result of forces at work for generations. As Mallett put it, “you are not going to tear down the aftereffects of systematic racism in three months.”

The Decision-Makers Are Well-Aware of The Racial Disparity

COVID-19 has held up a mirror to the country's racial and economic disparities since its inception in the United States, nowhere more so than in Detroit, where the population is nearly 80% Black and one in every three residents earns at or below the federal poverty line.

Detroit was one of the first major cities to be hit by the pandemic, and for a few weeks last year, the city's health-care system was on the verge of collapsing due to the devastating effects on the city's vulnerable population.

People were especially vulnerable to getting and spreading the virus due to poor housing conditions and the need for essential workers to continue showing up to work even during the pandemic's peak. Lack of insurance or access to health care providers contributed to high rates of untreated heart and lung conditions. Forty-two percent of Black people in the Detroit area lost a family member to COVID-19.

Even before vaccinations were approved, there was growing concern that similar disparities would plague the rollout. The National Academies of Sciences, Engineering, and Medicine issued an advisory on reaching traditionally marginalized population groups, which was supposed to guide the federal distribution strategy. However, there is little evidence that the Trump administration followed those directives.

The Biden administration took a more aggressive approach from the start, establishing a "health equity task force" within its coronavirus response team and appointing Marcella Nunez-Smith, a Yale epidemiologist and nationally recognized health disparities researcher, as its leader.

According to administration officials, the task force meets daily and can focus on addressing specific, local problems. For example, early in the rollout, it helped orchestrate delivery and administration of vaccines in a heavily Black section of Birmingham, Alabama, that hadn't received any supply. At other times, the task force advises the rest of the COVID response group on broader policy decisions, such as hoarding.

In both cases, it collaborates closely with state and local authorities, which means working with officials who have a comparable combination of experience and expertise in Michigan and Detroit.

Michigan's chief medical officer, for example, is Joneigh Khaldun, an emergency room doctor and former public health director for the city of Detroit who still practices at Henry Ford; and Mallett, the deputy mayor in charge of the city's pandemic response, is a former executive at Detroit Medical Center, a major safety-net hospital.

The “all-of-government” collaboration has resulted in a number of initiatives, such as tax credits for small businesses that provide paid leave to vaccine recipients and $50 debit cards for people who drive neighbors to appointments.

“I believe they have left no stone unturned in their efforts to vaccinate as many Detroiters as possible,” said Phillip Levy, a Wayne State University professor and emergency medicine physician who has worked closely with the city’s government on programs to reach the city’s underserved populations.

However, “some of the things put in place have not worked as well as people hoped... It’s been a heavy lift,” according to Levy.

The history of mass vaccination centers is a case in point.

The Most Vulnerable People Didn't Get Vaccinated

On March 18, elected officials were upbeat at a launch event for a new, federally run mass vaccination site at Ford Field, home of the Detroit Lions football team. Among those speaking was Garlin Gilchrist, Michigan's Democratic lieutenant governor and a Detroit native.

“As a Detroiter, I felt this personally, having said goodbye to 27 people as a result of this virus,” said Gilchrist, who is Black, adding, “The virus hit our city hard... and today, right here at Ford Field, southeast Michigan becomes a symbol of hope.”

One reason for optimism is that government agencies have been using data to target their vaccine efforts. A key tool is something called the Social Vulnerability Index, which is a number on a scale of zero to one that takes into account specific factors in a given population, such as income, English-language capability, racial composition, and access to public transportation.

The Biden administration used SVI to help guide the placement of mass vaccination clinics, which was one reason they chose Ford Field, which is centrally located and near several high-SVI neighborhoods. However, the facility, which closed last week, drew significantly more people from the suburbs than the city.

According to official statistics, residents of upscale, predominantly white Oakland County received more than four in ten doses at Ford Field, while residents of Detroit received less than one in ten.

Rev. Williams, pastor of Detroit's King Solomon Church on the city's west side, said he wasn't surprised. Detroit is a sprawling metropolis with inadequate public transportation, and Ford Field's downtown location puts it near some high-poverty neighborhoods but far away from many more, both psychologically and geographically.

“There are a large number of people who don’t go to Ford Field for Lions games, who don’t go downtown because of parking, and who simply don’t leave the neighborhood,” Williams explained. “People just don’t feel comfortable going to a place they never go.”

The emphasis has shifted to the communities.

Officials from the federal, state, and local governments say they never imagined Ford Field would be able to care for the city's most vulnerable residents on its own.

“We knew that mass vaccination sites were important for speed and volume, and we did that,” Khaldun said, “but we also knew that you still had to do community, neighborhood-based work, that you had to get vaccines into neighborhoods where people could and wanted to access them.”

The federal government has targeted neighborhoods in one way by forming a partnership with retail pharmacies, which already have vaccine delivery capabilities and are located throughout the country; in Detroit, two dozen pharmacies participated in this program.

In three months, you will not be able to dismantle the ramifications of systematic racism.

Detroit's Deputy Mayor, Conrad Mallett

Another initiative enlisted Federally Qualified Health Centers (FQHCs), a network of community clinics across the country that offer discounted or free care based on one's ability to pay. These have been particularly successful at administering vaccines to underserved communities, but there are only so many of them, and they still don't reach into many neighborhoods in Detroit.

Probably the most localized efforts are those run directly by the city, which include ongoing clinics at recreation centers and churches, some open during the week and some only on Saturdays, as well as an ongoing series of pop-up clinics that open for a day at one location, then move to another in an effort to reach a larger portion of the city's population.

Williams thinks this is the right approach, but it isn't enough. What Detroit really needs, he says, are many more small clinics that can cover all of the neighborhoods on a consistent basis. The pop-up clinics are "very unpredictable," Williams says. "You have to be watching the morning news, reading the newspaper to actually know where and when there's a site in your area."

When I suggested this to Mallett, the deputy mayor, he said the clinics already cover a large portion of the city, and while he agreed it's worth considering establishing more, he cautioned that traffic to the existing clinics has already slowed significantly, so adding more clinics may not significantly boost the rate, at least on its own.

“We do about 2,000 shots a week,” Mallett explained, “and we could easily do 2,000 a day.”

Many people are skeptical of the shot and those who promote it.

Vaccination rates are low in other parts of Michigan as well, including politically conservative, predominantly white counties to the north, where residents have been defying mask orders and are far more likely to believe COVID-19 is a hoax.

This is fundamentally different from the situation in Detroit, where residents are understandably concerned about the virus; the problem is that many of them do not trust the vaccine for reasons deeply rooted in their experience as Black people in America.

The legacy of the infamous Tuskegee experiments is high on the list: from the 1930s to the 1970s, the Centers for Disease Control and Prevention studied the course of syphilis in 400 Black men without informing them that they had the disease and without offering antibiotics even after they became standard treatment.

“People may not know the details of Tuskegee,” Talbert, the street team worker, explained, “but they understand what happened and will say, ‘I don't want anybody experimenting on me.'”

Community leaders say that distrust in medical science is fueled not only by awareness of these historical travesties, but also by personal experience with the medical system.

“There’s a genuine concern about the care that many of us receive when we go to the doctor’s office and end up in the hospital,” Williams said. “If you talk to any Black family, we all have the same strategy: somebody has to be there around the clock, in the room, to stay on top of these nurses and to make sure the doctor comes by, because if we don’t practice that strategy, the system will lean on us.”

On top of that, the Black Lives Matter movement has highlighted widespread distrust of government, undermining public officials' ability to overcome doubts, according to Reed Tuckson, a former public health commissioner in Washington, D.C., and co-founder of the Black Coalition Against COVID, an independent national nonprofit.

“You have people in the Black community literally screaming out loud that my life has to matter, that you have to respect my dignity,” Tuckson said. “It bleeds over to the trustworthiness that people have or feel about the drug industry, about government agencies that are administering information, and it bleeds over to the relationship that Affirmative Action has with the Black community.

All of the officials and leaders I spoke with said they expected skepticism, but they underestimated the ability of charlatans and cranks to spread so much nonsense on social media.

“People say, ‘There’s a microchip in the shot,'” said Norman Clement, executive director of the Detroit Change Initiative, a community action group. “It doesn’t make sense, but that’s what they’re getting from YouTube, Facebook, and misinformation sites, and it’s been going on for a year.”

Both the message and the messenger are important.

All of this sounds bleak, but the officials, health care professionals, and advocates I spoke with believe they are already making progress, thanks in part to the same efforts that work on other populations, and in part to more targeted campaigns.

One reason to take those claims seriously is that surveys, including studies of Detroit residents conducted by University of Michigan researchers, show that Black Americans who were previously skeptical of vaccines are becoming more enthusiastic as time passes and more information becomes available.

“When I read so much of the news these days, it makes it seem like there’s something abnormal about Black people, that they just don’t get it, can’t get it,” Tuckson said. “And I think it’s important to realize that, while we still have a lot of work to do, we’ve made a lot of progress.”

One recurring theme I heard was the importance of tone in persuading people who are hesitant about the shots. “I hate to even use the word ‘hesitancy,’ because I don’t want to shame people,” Khaldun said. “I think it’s OK for people to have questions about the vaccine, and to have a place where they know their questions will be answered.”

We can't hit any more home runs, so we'll have to rely on singles.

Phillip Levy is a physician and professor at Wayne State University.

Conveying basic information that many people may still not understand, such as the idea that shots are always free, remains critical, as does the messenger. Doctors are thought to be the most trusted sources of information and reassurance when it comes to vaccines, but this doesn't always help in low-income communities where people don't have regular health care providers.

Tuckson's group, the Black Coalition Against COVID, has one goal: to reach people who may only see doctors at emergency rooms or urgent care centers. The coalition has also focused on social media to reach people who may not watch CNN or read the Detroit Free Press.

“I was shocked when I started getting emails from people saying, ‘Hey, I saw you blowing up on Instagram,’” Tuckson explained.

However, the most powerful appeals may be those made one-on-one, preferably in familiar settings and in the context of a conversation about something else.

“I’m here to see if there’s anything that you need. Are you behind on your rent? Are you looking for gainful employment? Are you having difficulty with child care? Let’s see if we can plug you into those services, and by the way, can I ask if you’ve taken the vaccine,” Williams said.

Although progress is slow, it has the potential to provide long-term benefits.

That's the basic idea behind a fleet of five specially outfitted Ford minibuses operated by Wayne State University and Wayne Health in collaboration with the state, which paid for three of them. (Director Steven Soderbergh purchased the other two to show his appreciation for the city's help while filming a film here last year.)

On a recent Saturday, I was able to see one of these clinics in the parking lot of the Celebration Church on Detroit's east side. It was the same day as a weekly food bank, and the plan was to offer vaccinations to people as they passed by. The Detroit Change Initiative co-sponsored and promoted the event.

As we waited for the food bank to open, the church's pastor, Gregory Davis, described what he hears from parishioners who are hesitant to get the vaccine. Some repeat social media myths, he said, but others offer more sophisticated arguments, such as the difference between "emergency authorization" from the Food and Drug Administration (which the shots already have) and full approval (which the vaccine does not have).

Davis said he had to persuade his own 26-year-old daughter, who is a blogger who follows the news closely, to get the vaccine because “there’s just so much fear out there.”

Before the food bank began, the clinic's staff met with Davis and the local volunteers to discuss logistics and strategy. It sounded similar to the approach Phil Talbert and his street team took in April, with a focus on empathy, a determination to answer all questions with data, and an emphasis on how getting the shot can help protect a person's loved ones.

Joyce Smith, a 65-year-old retiree from the east side who has lost relatives to COVID, seemed to benefit from the strategy. She had been thinking about the shots for a while, but was worried because she has a lung condition and thought it might be dangerous for her. The reassurance from the mobile clinic staff helped; plus, she was hoping to travel this summer with her sister, who has lost relatives to COVID.

Still, in the 90 minutes I was there, only Smith and one other person received a shot, which appears to be the norm for the past few weeks. “We’ve gone from mass vaccination to mop-up,” said Levy, the Wayne State professor who developed and oversees the mobile effort.

However, there are potential long-term benefits to this approach. The mobile clinics provide some other services, such as blood pressure screenings, as well as the opportunity to make appointments for regular checkups. The hope is to get more people integrated into the health care system, thereby striking a blow against the inequality that made COVID-19 so deadly in cities like this.

“The work of public health is not easy,” Khaldun explained. “Everyone may not want to hear it or be ready to receive the vaccine, but that does not mean it is not worthwhile.”

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