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Transcript: VaccineVoices: Promoting Equity in Vaccine Access

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Karey Sutton, PhD: Hello and welcome to today's podcast. I'm your host, Dr. Karey Sutton, the director of research for [the] AAMC Center for Health Justice. Thank you for tuning in.

Today, I'm joined by Dr. Giselle Corbie-Smith, the Kenan distinguished professor of social medicine, director of the Center for Health Equity Research, and professor of nternal medicine at the University of North Carolina at Chapel Hill School of Medicine; and also Dr. Aaron Gerstenmaier, the associate chief medical officer at Community of Hope, located in Washington, D.C. Thanks for joining me. And let's dive right in.

Giselle Corbie-Smith, MD: So excited to be here, Karey.

Karey Sutton, PhD: Thank you.

Aaron Gerstenmaier, MD: Yeah, thank you.

Karey Sutton, PhD: So to begin, Black, Indigenous, and Latinx communities have been among the hardest hit during the pandemic. Preliminary data show that these communities are less likely to have received the vaccine thus far. While there seem to be many issues at play here, such as access to the vaccine and vaccine distrust, certainly the fundamental root cause we can point to is structural racism. So the first question is, why do you think we are seeing these differences in vaccine uptake among these communities? And that could go for either.

Aaron Gerstenmaier, MD: So, I think one of the main things to think about — and what we think about at Community of Hope in the work that we do — is, I think there is varying levels of trust with the health care system and with the government overall. I think that when we look at who are the people that have yet to be vaccinated, I think a large proportion of them are younger patients. And it's a question of whether or not they're even connected with a health care facility or have a provider that they see regularly. And so, I think that there are times when, if you're not connected with a provider or a health care facility in your community, then it's a question of where you're going to get information and who's going to be your trusted source that you're talking to.

Giselle Corbie-Smith, MD: Yeah. Karey, I'll just extend a bit on what Aaron is suggesting here. What I have found is that most people — that this is vaccine deliberation. They're waiting, looking, seeing what's happening, integrating what their lived experience is in the current moment — in the pandemic with the collective experience of people of color, Black and Brown people in this country and globally. And then, further integrating that with their history and their interactions with the health care system to make an informed choice, to think about what they have experienced and the likelihood that a health system that, up until now, hasn't cared — has demonstrated a lack of care of Black and Brown bodies. And trying to understand how this health care system, this public health system could possibly care about them at this moment in time.

I think there's skepticism. I think just like any innovation — we all know about diffusion of innovations — there are going to be early adopters. And I certainly have seen that in my own patient population. And then there are others that are waiting to see what happens and gradually coming along. I spoke recently to a family member who just got the vaccine, is high-risk — and he was reflecting that he was hesitant and wasn't sure why and realized that he just needed to have the information he needed to be able to move forward. So to me, this is indicative; what we have seen played out in the pandemic is the canary for this crazy coal mine around health inequalities. And we have the opportunity now to learn from these lessons.

The other piece of vaccine is, so one is the vaccine uptake — people are that are willing to go forward, literally roll up their sleeves and get the vaccine, show up a second time in some cases to get the next shot — but then, there's also the distribution. Even though we knew this vaccine was coming at an unprecedented pace, we'd seen how testing inequalities had rolled out — we still did not have a race-focused or a vulnerable population-focused approach to the distribution. And this is where we have this tension between equality, where everybody gets the same thing — we want everybody to have the same access — versus equity, which is having access based on need. And this is what we also saw play out.

So, there's the uptake and then there's distribution. Having an online system where people can go online and it's a free-for-all worked exactly the way we expected it to work. People that had time and resources to be able to, one, have a computer, have regular broadband access; spend the time trolling or have maybe a couple laptops open trolling these sites to find a vaccine slot early on; and practice the vaccine tourism — crossing county lines, state lines — to be able to find these vaccines ... that, again, is a system based on equality versus equity. And it played out exactly as any of us who do this work would have expected it to.

Karey Sutton, PhD: Thank you, Giselle, and thank you, Aaron, for making some great points. Let's talk a bit more about something that Giselle raised, which is equity versus equality. And you mentioned something, Giselle, about the vaccine distribution in certain states. Can we talk a little bit more about how states can bake in more of this equity-focused strategy to ensure that vulnerable populations would have better access to the vaccine?

Giselle Corbie-Smith, MD: So, I'll just say that the strategies that we've seen worked are strategies that we know have worked in other areas — and we actually saw working around testing. So, it's both a high-tech and a high-touch approach, ensuring that we're accessing networks of individuals or organizations: Faith-based, community-based, federally qualified community health centers [FQHCs] that are actively caring and have been caring for the most vulnerable populations throughout this pandemic have been making stone soup with their limited resources and drawing in and creating networks that can provide care in sometimes a piecemeal way, but sometimes it's the only option for folks. So that network of care that goes beyond our health care system and public health system has been critical. That's the ground game that has gotten us beyond the equality versus equity.

My hope is, as we emerge from this pandemic, we'll learn that we need to continue to engage those networks, make sure that we're not using a medical solution for a public health problem. We're thinking about the broadest way that we can ensure resilience in communities, making sure we have the data to understand what's happening, making sure that we have leaders on the ground that are connected to resources, that — bridging capital between local community leaders that understand the felt needs of those communities to the resources that are available within our public health system and our health care system. And that's my hope — is that we didn't learn from testing, we didn't learn from vaccines, so maybe now we can integrate that learning and be thinking forward about how we have a system that's more resilient and more oriented to the needs of the most vulnerable amongst us.

Aaron Gerstenmaier, MD: Yeah. I mean, I agree with what Giselle is saying. I think one of the things that we noticed in D.C. when we started with the vaccine rollout — starting with a centralized vaccine scheduling system, which I think worked a little bit better than the piecemeal ones in other states where you check every single individual CVS or Rite Aid. But what we found is that when the vaccine rollout came, we did roll out in three — at least initially — of the federally qualified health centers initially with it, along with a couple of pharmacies at that time — tried to distribute those throughout the city. But with the centralized scheduling, it seemed that the large proportion of those appointment slots went to people in the most affluent wards in the district, because exactly — they had the time; the internet; the four, five, six, seven people who are helping them get an appointment at that time. I think the district has done a good job of expanding the number of community partners who have been offering and doing vaccination in the city — all throughout the city, trying to focus on some of the most at-risk communities and zip codes to give them prioritization. But now we're at the point of — the next step of, we've gotten the number of people who were already interested and ready and avid wanters of the vaccine. Now, we have to reach out to the people who are the deliberators or the people who are just — are ready, but don't know how and don't know where to go.

And this is, I think, where you move into the boots on the ground strategy of walk-in sites are great. At Community of Hope, we have walk-in clinics at our sites, but that's still somebody who wants to get the vaccine at that time. And so now it's going out into the community, working with the community partners, going to the schools — as Pfizer has been approved for 12 to 15 — and really starting to be like, "Hey, you're thinking about this, let's talk about it now. Let's give you the vaccine now."

Giselle Corbie-Smith, MD: I think there are so many important points in what Aaron is raising. I just want to underscore, if I could, Karey — the first is the data that — being able to track what is happening and to be able to pivot at critical time points based on a set of goals. And to me, that is essential. We saw the lack of — how the data hindered us in the early part of the pandemic in terms of who was at risk, who was getting sick — and we still have incomplete data. So that data infrastructure is essential and monitoring that. In any approach to equity, having a transparent data system is going to be important to understand how and when you need to pivot. Second of all, he eloquently applies theory. The diffusion of innovation, we've got those early adopters; we now need to focus on the next level of individuals that need support, that need to be able to have these conversations, engage with them.

Assume that their decision-making is going to be in concert with their values and giving them the information that they need to be able to make a decision. Not to coerce someone, not to convince someone. We have to respect that autonomy and also give people the information that they need. This pandemic has been so highly politicized that folks are really sitting on the sidelines confused, and yet we have people that know what an epidemiologist is — they understand mRNA all of a sudden. So, it's also a window for us in medicine and science to really meet people who are interested and really want that information in a way that respects their autonomy as well.

Karey Sutton, PhD: These are excellent points. I want to back up a little bit to something that we mentioned in the beginning. Much of the conversation with the vaccine distribution and much of the pandemic, we've been talking about mistrust. Mistrust, mistrust, there's definitely mistrust among communities of color. Giselle, you recently wrote an article that blanket mistrust has been used to explain disparities in vaccine uptake — and it's masking underlying fundamental inequalities in the system of vaccine distribution. At this point where you're talking about the diffusion of innovation, what are some additional strategies that we can use, recognizing that it's not a one-size-fit-all approach of “address this idea or this understanding of mistrust”? Mistrust in the medical system, mistrust in the government, and mistrust in the "system."

Giselle Corbie-Smith, MD: So, for me, the issue of mistrust is real. I mean, we've seen that, and we see this beyond minoritized populations. We see this in rural America. We see this among young, White men in rural America in particular. And what I would say is that this is not solely an individual problem, this is a systems problem — and we need to be looking at the systems that we've created that have gotten us exactly the results they're intended to get. I mean, our systems give us what they're built to give us. And so, if we want equitable systems, we need to pull back — recognize the individual nature of decision-making, but also recognize that it happens in a context of the systems of care that we've built, and if we want something different, we need to do something different.

There's certainly historical reasons that people might mistrust our health care system. Again, our health care system have demonstrated over and over again — by not pivoting, by not shifting, by not making changes — that the well-being and the lives of Black and Brown people are not a primary concern, because if it was, we'd have a different system. So, for me, that's the fundamental. Mistrust has been thrown out. It's a “blame the victim” term, and it's distressing to me because then it obviates the need to make changes within a system. And I want us to be able to look at the system — recognize that mistrust is a symptom and not the driver of the system.

Karey Sutton, PhD: And Aaron, could you talk a little bit more about your patient population as well, and thinking about — in the district and the strategies — thinking about mistrust as well with your patient population?

Aaron Gerstenmaier, MD: Yeah. So, I mean, I think when we talk about a little bit with mistrust in the system, we also have to take a look at what the health care system is doing in general in those areas. There was a recent article that came out in Nature that talked about the life expectancy difference between Black and White communities in the district and looked at it — about 17 years as the difference for males in the district and 12 years for the difference in females, with the biggest cause of that life expectancy difference being heart disease, cancer amongst males; heart disease, cancer, perinatal causes amongst females. And you're looking at those, and those are tied to the health care system. Those are tied to structural racism in terms of where our grocery store is located; tobacco advertising; access to parks, sidewalks, places where people can exercise.

And so, what we want to do is take a look at the health care system — as Giselle mentioned — as one of the bigger things that we can do overall, but then look at what we can also do on community level, what we at Community of Hope can do to build trust with our patients, our communities — and part of that is being a presence in those communities. We've been offering up walk-up testing for the community since June, July at no cost for our patients. We've had relationships with other community organizations — Martha's Table, which is in the district providing food resources for patients. We've had teen nights and backpack giveaway at the start of school. And so, what you as an individual organization are trying to do is — how can we show ourselves to be present in this community, a part of this community, so that even if you're not our patient, you know who you are, you have friends who are our patients, and you are connected to us and know that you can trust us, that we have the community in mind as we're moving forward?

Giselle Corbie-Smith, MD: And that, to me, is just such a beautiful example of demonstrating trustworthiness. And the shift from blaming the victim to taking that onus of responsibility on a health care system to show up when you don't want something, to be there and to be a contributing member of the community, and to demonstrate that when we are in a community disaster or crisis, we're going to be here. We're here in the good times. We're here when it's hard as well. Aaron, I just want to thank you for that.

Karey Sutton, PhD: Yes. Thank you, Aaron, and thank you, Giselle, for these insights. I do want to really talk about some lessons learned. Both of you have been on the front lines and doing the groundwork long before the pandemic. So, could you please offer some lessons learned to our listeners on this topic or anything applicable?

Giselle Corbie-Smith, MD: I would say — as we've seen the different phases of the pandemic and the impact on historically marginalized communities — that as I said, my hope is that we can learn that we need to move beyond sort of individual behavior and think about how we can reorient our systems to focus on ways that we can ensure everyone has the opportunity to live a healthy life based on their needs. We can think about how — and be intentional about how — we connect those systems so that we have a more robust network, as opposed to the net that we saw and all the fault lines that we saw between health care and public health and community-based organizations and those networks.

I think we have a real opportunity now. We can't let this... I'm not a PR person, but don't let a good disaster or a good crisis go to waste. Well, this has been probably one of the best crises — depending on how you define best crisis — that any of us have had and experienced in our lifetime. And so, how do we use what we have experienced to ensure everybody has an opportunity to live a healthy life?

Aaron Gerstenmaier, MD: Yeah, I definitely agree. I think the other thing to think about from an individual level — or even what we're realizing at Community of Hope — is more and more how kind of other connections, other relationships with organizations citywide can have a big role. So, we've started to have Lyft rides to assist patients in going to get their vaccine. We also have it for — Lyft rides for our prenatal patients, if they need to go and get to the hospital for sonograms, things like that, things that we don't offer for our prenatal patients on-site.

The relationships with different food markets — everything that we can bring to our communities. For a number of years, there were a farmer's market that was brought to the community in Ward 8 for our patients to be able to go and shop at. We have the larger health care-based larger structural changes, but then the way that individual FQHC, community health centers, or faith-based organizations can collaborate and work together to help mitigate some of the issues that we're seeing as we're working on these larger structural changes, and really leveraging those two things together.

Karey Sutton, PhD: No, I totally agree. So, do either of you have thoughts on how the academic medicine community can be part of this solution to improve access to the COVID-19 vaccine, improve the equity in systems? Many of the things that we've talked about today — but how can the academic medicine community be part of the solution?

Giselle Corbie-Smith, MD: What I've seen throughout the pandemic is a couple of ways. The first is, at least within North Carolina, many of our academic health care systems actually have a footprint that's broader than just the sort of main campus. We actually have entities across the state. And so, there is a real opportunity to have a really big systems view of equity — and influencing and partnering with communities across the state.

The other that I would say is — academic health centers often have researchers that can help local entities and also our public health systems think about their data and support them in understanding their data and how to bring that to bear in the pandemic. And that's critically important. And then finally, the clinical systems and clinical ability to stand up pop-up or mobile units that can support testing, vaccine distribution — and support local organizations and partner with them is one of the things that I've seen happen over and over again within our health care system, as we sort of shifted to really think about equity and putting the needs and interests of those most vulnerable communities at the center of how we deploy the care. So, I think academic health centers quite often have a very important role to play in partnership with all these other entities. And it's about bringing those other systems of care together — and often can take a leadership role in doing that.

Aaron Gerstenmaier, MD: I agree. I also think — as Giselle mentioned — a lot of the larger academic centers do have a really large footprint, do have primary care providers and networks spread across the city or across the state. And I think a role of that is — also, as we think of equity is — getting the vaccine in the hands of primary care providers. So much of the time, due to concerns about wastage, concerns about — obviously, initially when we were so limited on the amount of vaccine, places were only vaccinating a couple of days and scheduling way out and everything. And we need to get into a system where the primary care providers have the vaccine and when a patient is in there and the patient is ready, the patient can get it.

Without... We're doing Lyft and Uber. And that's obviously great, but patients don't always have the time to travel to another site to get it. And so, leveraging those connections to be able to get it into the hands of the primary care provider that the patients trust and just kind of eliminate that extra burden in terms of access is a big thing. I would say another thing that we came across as we rolled out vaccination — it took a large amount of staff for us to be able to — rolling out vaccination. And these were staff that we took out of the clinic. And so, the FQHC is a lot of community health centers. We don't have staff to spare. And so, if we're taking staff from the clinic to do vaccination — which is incredibly important — it means that we're limiting patient care and patient access to the regular care that they need.

We actually had volunteers from one of the health centers in D.C. who helped us that gave a regular schedule. These are a couple of nursing students that we have had, and it freed up our medical assistants to get back the clinic. So, we were able to do both without eliminating either of them. We're still able to have vaccine clinics while leveraging or still having access to primary care that all of our patients so importantly need, particularly because the number of visits that happened during the pandemic was significantly lower.

And so, using those couple of things, in addition to leveraging their own staff for pop-ups, for going out into the communities. Depending on where the health centers are, a lot of these academic centers have staff members who are members of the communities that they serve and going out and talking to them and leveraging those connections too. And so, I think, providing those supports — which really just helps to expand who has the ability to give the vaccine. And getting people where they are, when they're ready, and eliminating that barrier is so important.

Giselle Corbie-Smith, MD: I wanted to add a couple lessons learned and sort of opportunities on the horizon. Aaron's comments just sort of triggered a couple of things for me.

The first is community health workers. We've been able to see what an important bridge community health workers have been in this — that bridge between these systems of care — and I think we need to ensure sort of a universal support for them within sort of our state and local policies, making sure that we have a way that they're trained consistently, certified, integrated into our health care systems and paid appropriately — and the coverage for their services reimbursed as well.

They've been sort of such an important part of being able to reach — particularly early on in the pandemic — people who are patients at home who couldn't come out. So many of us couldn't come out of our homes and continue to be a lifeline in terms of having that continued conversation and helping people get the information they need to be able to make the decision about the vaccine that's in accordance with their values.

And then the other caution, I think, and/or opportunity and potential role for — certainly as a primary care provider, I think of, but also our health care systems and academic health care systems — is all of this deferred care that has happened over the last year will come to roost, and it'll be, again, a situation. We're already seeing it around mental health, where it's disproportionately impacting certain communities that have been historically excluded from care. And so, we need to be thinking now that mental health crisis — that's the tsunami that we're about to crest — is going to devastate our children, our communities that have had the vicarious trauma of the murders of Black and Brown men, women, and children. This is not a small thing, and our mental health care system wasn't ready before the pandemic to be able to address this. Certainly, we will need to shore that up and think about ways to partner again with academic health care systems to be able to provide that kind of care and community-based organizations, faith-based organizations that are already providing that care.

Karey Sutton, PhD: Once again, they are definitely great points shared by you, Giselle and Aaron, and so I want to kind of ask one final question. Given all that we've discussed today, do you have a message of encouragement or hope or optimism for the future, given that we are still in this pandemic and thinking about where we're going moving forward?

Aaron Gerstenmaier, MD: I think one of the things that we're thinking about is last March of 2020; we had to stop and change how we provided care. Starting virtual care meant different outreach to patients, staffing, things like that. I think one of the things that we’re taking from this is that we can now leverage some of the lessons that we've learned during this as a way to expand our reach to our patients and to the community as a whole.

As you talk about kind of the looming mental health and the current mental health crisis, we're looking at, well, how can we use virtual care for our patients as a way to expand access so that we have the ability to reach patients who do want to come into the clinic or who virtual care is obviously not an option — but then those who really need virtual care because they know the time that it's going to take and they have the ability and it's easier than taking the time to come into the clinic and wait for your appointment and everything like that?

And so, what we're looking at is, how can we now leverage this into providing new services for our patients — whether through virtual mental health services; whether it's through virtual primary care, chronic care, prompt care, all of those services of — how can we use what we've learned to provide more services and benefits for our patients?

The other thing is that it also allowed us to take a look at other care coordination services — outreach that we can do to our patients — expand our connection to the community and just continuing to kind of build even more trust in the communities that we serve, so that we can reach more people — and people who may not have another primary care provider that they've been seeing thus far.

Giselle Corbie-Smith, MD: So, I'll say, in terms of what one of the bright spots for me — and the COVID silver lining, right in this really dark, dark cloud that's lasted us over a year — is, I'm reflecting on a quote by Dr. Martin Luther King. One of the many quotes of his that I love but I think is particularly germane for how we're emerging, and if we're intentional, how we can sort of mitigate inequalities going forward.

And he talks about the sense that all life is interrelated, and I think that's been very much evident for anybody that's willing to look — and that all are caught in an inescapable network of mutuality, tied in a single garment of destiny; whatever affects one directly affects all indirectly.

I think if we're able to see how that's happened, there's so many; it's so obvious. We see that locally. We see that nationally. We see this globally. And with that in mind, that realization that this is not just a Black or Brown problem. This is a problem for all of us that we need to be able... We need to get our arms around because we're all impacted by this — and that, to me, is one of the potential silver linings if we're intentional about how we use that moving forward.

Karey Sutton, PhD: Thank you, Giselle. Thank you, Aaron, for joining us today on this episode of “Beyond the White Coat,” and we definitely want to thank you for everything that you're doing to serve your communities during this time.

For our listeners, if anyone is not vaccinated and you still have questions about the COVID-19 vaccine, please talk to trusted community members, your doctors, your nurses, local pharmacists, community health workers, vaccinated family and friends — or you could visit cdc.gov or your local community health department website for the latest information about COVID-19, COVID-19 vaccines, and where to access them.

Thank you again for joining us today.

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