Sara Bowsky is Palladium’s Chief Nursing Officer. She supports Palladium’s COVID-19 response across multiple countries and is a core member of Palladium’s COVID-19 global task force.

Last March, as the country shut down in response to the COVID-19 pandemic, those of us in the healthcare community were focused on three things; understanding how to mitigate the immediate impact of COVID-19 on our communities through testing and contact tracing, how to respond when a vaccine becomes available, and how to ensure the most vulnerable are not left behind. Despite some forward-thinking, there was very little put in place to support an eventual massive global vaccine rollout.

Here we are a year later, and despite our progress, much is left to be done.

As a nurse who supported the HIV response in Africa for much of my career, I felt compelled to join local efforts in my home state of California and now serve as one of the volunteers at our community vaccination centres. I have witnessed first-hand a process that must rapidly address unplanned changes in vaccine allotments that impact volunteer needs, appointment scheduling, equity, and beyond.

Every day presents new challenges, yet the communities' needs and gratitude cannot be overstated. People are sometimes nervous, but they're often excited or emotional when they receive their first dose. Even more emotional can be those from underserved populations who bring their grandparents or parents in for their final vaccine. I've found that nothing is as impactful as being part of the solution.

So, while our processes are far from optimal, we end each day feeling accomplished and with lessons for the next day. It is those lessons from on-the-ground experiences that we need to incorporate and share to access harder-to-reach populations.

Addressing the Vaccine Equity Challenge

With challenges at the local level, it's no surprise to find major discrepancies in equity and vaccination strategies across the country; here in California, the priority has been on teachers first and then a very strict list of populations with severe co-morbidities, while in Washington, DC, those with broad number of co-morbidities come before teachers for the vaccine.

Unclear vaccination priorities at the national level have some people crossing state lines to receive their dose, further straining the already struggling system. While local leaders have a good understanding of local population's needs, state-wide prioritisation has fallen short of accessing those in need.

For instance, as of March 2021 in California, the Hispanic population accounts for 21 per cent of vaccinations but comprise 55 per cent of total cases and 46 per cent of deaths. In comparison, white residents have received 35 per cent of vaccines but only comprise 20 per cent of state-wide cases and 31 per cent of deaths.

The question now is how to rapidly evolve our current vaccination system into one that's better equipped to move more people through an equitable process. Until recently, the understanding in the United States was that vaccinations were a local and state responsibility. As the Biden Administration shifts to increase the federal response, there's hope for more streamlined and integrated processes and systems to handle greater volumes, but we can't expect improvements overnight.

At this moment, it is crucial to work closely with local communities and state governments to further optimise what is operational today.
I see how hard our frontline workers and health care administrators are working. They didn't have time to sleep when hospital ICU capacity was overflowing, let alone improve or rethink an entire strategy for vaccinating communities.

Though only a small percentage (15 per cent) of the US population is fully vaccinated, the majority of that population (69 per cent) is white non-Hispanic. This only serves to further highlight the critical need for a truly equitable vaccination process. As more vaccine becomes available and we work to vaccinate the remaining 85 per cent of our population, we need to look at the vaccination processes in place and immediately identify opportunities for greater efficiency and equity.

Building Resilience through Partnerships and Community

It's important to reiterate that incredible solutions to these complex issues are happening every day at the local level and that our National response is stronger than ever. Visit any site and you will find that each vaccination centre, from massive endeavours at football stadiums to local community health centres, are doing things a bit differently to meet the State level vaccination priorities and the local populations they serve.

From what I've seen, there are three key areas where improvements can be made with an opportunity to turn the tide for long-term efficiency and equity.

One of the most important aspects of achieving herd immunity is rapid vaccine rollout while ensuring those carrying the burden of the disease – the communities and people most affected by COVID-19 – are not lost along the way. There needs to be a framework in place to quickly model and understand the data behind the who, what, where, and when of those communities and how to best access them. There are strategies already being tested, from those that are geographically focused on vulnerable communities to those that model based on an increased uptake in places experiencing vaccine hesitancy, but these frameworks and models are just one part of a much larger system tackling inequity.

Often, these are communities of underserved, minority, uninsured, or even undocumented people. According to the Centers for Disease Control's latest research, in the United States, Black and African American people are 1.9 times more likely than white people to die from COVID-19. Latino and Hispanic people are 2.3 times more likely. Yet, white non-Hispanics are more likely to receive the vaccine.

One main contributor to this inequity is a lack of access to healthcare that prioritises their needs. Accessing these important communities and getting the vaccine to the populations that need it most requires a high level of advocacy and engagement with the communities and those who serve them.

Community healthcare workers and advocates need to have a seat at the table where governance decisions are being made and have direct access to inputs needed to serve their communities. As we work through this massive push, our community partners continue to lead vaccination efforts with a focus on ensuring an equitable process. Shifting our larger health systems, pharmacies, and others to take on a larger portion of the vaccine rollout will allow local public health providers and community partners to focus on the disenfranchised, and marginalised populations be it homeless, migrant or other harder to reach populations.

But as we move forward, it will become increasingly difficult to reach those populations and obtain herd immunity. Local community leaders' connections will be crucial in doing so.

Communication is critical, but it has been a significant obstacle to herd immunity. The first year of the COVID-19 pandemic will be remembered as a time riddled with conflicting and oftentimes confusing communications and messages. Now, as the virus and our response to it changes, so do the communication needs around it. Even with the best, most up-to-date information, our communication efforts won't resonate with everyone. What captures the attention of one community may fall on deaf ears in another if developed by and tailored to the realities of another person's lived experiences.

We must engage with community leaders, listen to them, and empower them with the best, most accurate information to take to their communities where it will be best received from a trusted and familiar source.

Finally, there's the need to improve the efficiency of the processes. From scheduling systems and vaccine supply chain transparency to mustering clinical resources and patients when vaccine is available, process inefficiencies must be identified and resolved. We must quickly learn from our efforts by gathering data to see what's working and adapt new methods to address what's not. These best practices must also be shared across the country, so localities don't repeatedly re-invent the wheel.

There's a tremendous opportunity to learn from the field to improve data collection and interoperability and allow for better tracking of unmet needs that will improve overall distribution.

While some hope that the cavalry will arrive in the form of a strong federal strategy to encompass and solve many of these underlying issues challenging local vaccine rollouts, others push for local healthcare communities to tackle them.

But what’s needed is a balanced, adaptable approach – one that draws on the power and actions of communities in conjunction with federal and state agencies, and the collaboration needed to reinforce such a response. If not for today's COVID-19 crisis, but to better serve the future health of our populations beyond the pandemic.

For more information, contact sara.bowsky@thepalladiumgroup.com.