The 9pm text said: “Muchas gracias doctora por la oportunidad de recibir la vacuna de Covid.” (Thank you doctor for the opportunity to receive the Covid vaccine.)
After a long week helping 125 low-income Latino immigrants find their way to a mass vaccination site, it felt good. But we also knew that at that pace, it would take years to protect everyone at risk.
Latino immigrants have been among the groups hardest hit by Covid-19. Whether in urban settings (from Los Angeles to Boston), in California farm country, or in Nebraska poultry factories, low-income Latinos have been working to keep the economy going and food on the table, allowing others to shelter at home. Because of the combination of work exposures and crowded living conditions due to low-wage work, the toll on Latino immigrant communities has been very high, resulting in more than three times the number of deaths, per capita, as white Americans.
Despite the large burden of disease amply exemplified by these excess death rates, multiple factors make us fear that Latino immigrants will be pushed aside in the vaccine rollout.
First, current vaccine priority algorithms are inequitable, particularly those that focus on age. Almost 90% of deaths among whites have been in people over 65, but, as CDC data clearly indicate, among Latinos and African Americans more than one-third of those dying of Covid-19 have been younger than 65. And although shared living spaces have undoubtedly fueled the rapid transmission of Covid-19 in immigrant communities, living in a crowded house does not qualify people for the vaccine. As for essential workers, it’s one thing for a hospital employee to prove they are a healthcare worker, but another thing entirely for a day laborer getting paid in cash to show proof of occupation. Finally, while people all over the country are struggling with poorly designed websites and busy call centers, these approaches are particularly insurmountable for low-income Latino workers who lack the digital skills, language capabilities and time to overcome these barriers.
As data becomes available showing the disparities in vaccination rates, much of the media attention has focused on the problem of vaccine hesitancy among some minority groups, rather than the problem of unequal vaccine access. We think that’s a mistake.
Vaccine hesitancy is very real, especially among communities of color. Many Latino immigrants mistrust the healthcare system, in part because of a history of health system abuse in their countries of origin. The current rumor that the Covid vaccine results in infertility resonates strongly with Puerto Ricans and others who recall or were told about the infamous sterilization of women without informed consent in Puerto Rico between 1930 and 1970. Among undocumented immigrants, the fear of deportation and family separation is often front and center, and can dissuade many, including those in mixed-status families, to avoid seeking healthcare.
According to a recent Kaiser Family Foundation survey, about a third of Latinos say they will not get the vaccine or will do so only if required by work. But 70% want the vaccine. Among them, about 40% say they will get is as soon as it’s available to them, and the rest want to get it, but after they see how it goes with others.
Easy access is the best way to overcome hesitancy. In the Latino immigrant community, word of mouth is key and there is no more “trusted messenger” than your friend or family. So, let’s get the vaccine to those who are eager to get it, and let them encourage their friends and family to get vaccinated as well.
To be clear, we are not advocating for race- or ethnic-based prioritization of vaccine groups. We are simply asking that we follow the data by adopting an “age or place” approach to vaccine implementation. We know where the Covid-19 hotspots are. And it should come as no surprise, given Covid-19 disparities and segregated housing history in this country, that many hotspots are in high-density Latino, African American or Native American areas.
This is where we need to go to vaccinate. Working with trusted community organizations and leaders, easily accessible (ideally walk-up) vaccine clinics should be set up in heavily hit neighborhoods. Partnering with high-penetration pharmacies is also a good idea to facilitate access.
This will take some work, flexibility and investment. There is a long tradition of successful outreach by bilingual and bicultural healthcare workers (also known as promotores) to low-income Latino immigrants, but they need to be expanded and supported in this work. Vaccine messaging, in Spanish, needs to say loud and clear that the vaccine is available to everyone, regardless of immigration or health insurance status, and that their information is protected and will never be shared with Ice. Doctors who speak Spanish can be credible sources of information and debunk the many myths about the vaccine. Bilingual hotlines should be available for people with questions and concerns. Among the fears we hear, immigrants without a doctor tell us they worry about experiencing a side-effect to the vaccine and having no one to turn to.
All this can be done. Many groups did this successfully to expand access to Covid testing, and we can learn from that.
In Baltimore, we set up outdoor testing sites in low-income Latino neighborhoods where the Covid-19 overall positivity rate throughout the pandemic has been a shocking 30%. In areas like these, the risk of Covid-19 is so high that it makes no sense to worry about people “cutting the line” – everyone should be offered the vaccine.
The Biden administration’s plan to distribute vaccine to community health centers and safety net hospitals is sound. But states need to ensure that their vaccine implementation algorithms do not disadvantage Latino immigrants. Moreover, outreach and access strategies need to be critically examined before attributing disparities to vaccine hesitancy.
Continuing the current approach is not only unjust and unfair to Latino immigrants, it makes no public health sense: high transmission rates in communities with low rates of vaccination will only increase the pressure on the virus to mutate and perhaps reduce the vaccine’s effectiveness.
Walk-up neighborhood sites helped expand access to Covid-19 testing. Let’s keep it simple and do the same for the Covid vaccine.
Kathleen Page, MD, is an associate professor at the Johns Hopkins School of Medicine
Alicia Fernández, MD, is a professor of medicine at the University of California, San Francisco
Zackary Berger, MD, PhD, is an associate professor at the Johns Hopkins School of Medicine