To beat COVID-19, we must address a legacy of inequity and mistrust

As more COVID-19 vaccines gain regulatory approval and move from the manufacturing lines into people’s arms, there is a renewed hope for eventually getting back to some semblance of normal. But this pandemic is occurring amidst deep and growing racial and social inequities in this country. And these inequities are inextricably linked to this pandemic.

We have seen in New York City and elsewhere, where COVID-19 has disproportionately burdened certain communities over others. In particular, economically disadvantaged communities — where people are more likely to be essential workers required to work on site, use public transportation, and live in crowded housing — are hard hit. This past spring, when testing became more widely available after an inconsistent and disconnected launch, public testing sites were more concentrated in whiter and wealthier areas. Residents in more socially vulnerable areas, who were less likely to have access to transportation and financial resources, had to travel farther distances if they wanted to be tested.  

Because of the complex histories of race and class in this country, as well as the fumbling of equity issues in the response to COVID-19 so far, we have created a paradox where the most at risk are also the most skeptical of solutions.

According to the Kaiser Family Foundation, significant hesitance and distrust persists among those who are most at risk. Among those hesitant to get the vaccine, more than half cite lack of trust in government to ensure safety and effectiveness of the vaccines. And while there is some progress towards building trust, this gap remains particularly pronounced among respondents of color. Similar levels of mistrust can be seen in rural residents, and those classified as essential workers.

The ability to reverse this course is within reach, and there is publicly available data to get started. 

The Centers for Disease Control and Prevention’s (CDC) Social Vulnerability Index (SVI) uses U.S. Census data to explore vulnerability factors ranging from socioeconomic status, household composition and disability, minority status and language, housing and transportation. Other sources include University of South Carolina’s Social Vulnerability Index (SoVI), the Federal Emergency Management Agency’s new National Risk Index, and the Surgo Foundation’s COVID-19 Community Vulnerability Index — an expansion on the CDC’s SVI, which accounts for health care systems and health risk factors.

Social vulnerability data can be used to target and enhance communication strategies and foster community partnerships to proactively address concerns, dispel myths and improve transparency. The HIV/AIDS epidemic and even the swine flu pandemic taught us that public health must work directly with the community to build trust, and of the consequences of failing to do so. We must work with trusted community messengers, such as religious leaders, community-based organizations, and non-traditional partners to co-design communication strategies to build trust. 

The National Academies of Sciences’ Framework for Equitable Allocation of Vaccine for the Novel Coronavirus recommends the use of the SVI for vaccine allocation planning, and the CDC has adopted data-driven recommendations that appear to avoid legal ramifications for prioritizing one group over another based on race. Despite this, only about half of all states mention racial equity in their vaccine plan. But even if every state does eventually mention equity, what is lacking is a system of accountability. This accountability is not merely an administrative function, but an ethical responsibility of the government to reach those with disproportional risk for coronavirus exposure and ultimately COVID-19. True accountability will foster trust through transparency. 

We have become very good at observing and describing inequities in health, and COVID-19 is no exception. We now have the information freely available to help inform strategies to target the most vulnerable and start to work towards reducing inequities in our response. The next step is to use that information to actually reduce these inequities. Of course, better vaccination strategies will not magically undo generations of systemic racism and poverty while also increasing access to health care and economic opportunities overnight. But in building our exit strategy from this pandemic, we have within our power to also begin to build a more just and sustainable future for everyone.  

Jeff Schlegelmilch is director of the National Center for Disaster Preparedness (NCDP) at Columbia University’s Earth Institute, and the author of “Rethinking Readiness: A Brief Guide to Twenty-First-Century Megadisasters” from Columbia University Press. Follow him on Twitter @jeffschlegel. Jonathan Sury is a project director at NCDP and principal architect of NCDP’s response specific social vulnerability mapping resources. Follow him on Twitter @JonathanSury.