Exploring social determinants of health: COVID-19 vaccine challenges and solutions

Background

According to the World Health Organization (WHO), Wuhan Municipal Health Commission in China reported, on December 19, 2019, a cluster of cases of pneumonia in Wuhan, Hubei Province. A novel coronavirus, SARS CoV-2, was identified in December 2019 as the cause of the disease now known as COVID-19, its name derived from past coronaviruses plus the year of discovery. Coronaviruses can cause “the common cold as well as dangerous illnesses such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS).” ¹

The virus quickly spread on a global scale. According to the WHO, COVID-19 has infected populations in the nine figures and has led to fatalities in the seven figures. Since the “Spanish flu” of 1918, the global community has not experienced such an epidemiological event and the COVID-19 pandemic has indeed left an unprecedented mark. One of the countries that has experienced the worst consequences from COVID-19 is the United States. On January 21, 2020, the Centers for Disease Control and Prevention (CDC) confirmed the first US case in a man from Washington state in his 30s who had returned from Wuhan, China, a week earlier on January 15. ² At that point, concern existed that the disease could possibly spread throughout the country. Since that first case, the CDC reports that the United States has had tens of millions of confirmed cases and fatalities have increased into the seven figures. Fortunately, the physical, spiritual, and psychological devastation caused by the COVID-19 virus have been alleviated by the creation of vaccines.

The Pfizer-BioNTech, Moderna, and Johnson & Johnson vaccines provided protection that saved millions of lives from the lethal health consequences of the COVID-19 virus. Yet, when vaccinations were available, ambiguity arose over why Black (people of the African Diaspora) and Brown (people of the Latinx Diaspora) communities were not being vaccinated at the same rate compared with dominantly White communities. Due to the consequences of historical medical racism, the medical community’s consensus was that the mistrust by Black and Brown communities of the medical establishment had negatively influenced potential opportunities to access COVID-19 inoculations. ³ Although the monstrosity of racism continues to permeate doubt in communities of color, it is not, however, the main reason Black and Brown people lagged in vaccinations. Rather, as we argue, the social determinants of health, in particular issues related to (1) access, (2) allocation of resources, and (3) misinformation, led and continue to lead to poor vaccination outcomes. Our recommendations in response to these three challenges, all supported by careful analysis of the notion of dignity, focus on equitable vaccination access, distribution, and health literacy in Black and Brown communities.

COVID-19 vaccination access

According to the CDC, “The social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” ⁴ Health is also determined by the resources and supports available in people’s homes, neighborhoods, and communities. These factors contribute to the health and well-being outcomes of individuals as well as the communities in which they live during the COVID-19 pandemic. Furthermore, at every stage of the COVID-19 pandemic, the access to vaccinations has been imperative for creating the best health outcomes.

The social determinant of location influenced access to vaccination. For most of 2021, vaccines held the status of “emergency use,” which made vaccine access broadly challenging. This emergency use status was a significant barrier in the months in which COVID-19 surges were high and vaccines were not accessible to the public. Of the three available vaccines, the first vaccine approval for “general use” was the Pfizer-BioNTech vaccine in August 2021, months after the vaccine roll-out in February 2021. ⁵ News of vaccines aiding in the fight against the spread of COVID-19 brought optimism, but communities of color largely did not participate in these vaccinations. Black and Brown communities did not have immediate access to general health care and health care resources. ⁶ The challenges communities of color face to access local health care is a factor that maintains or exacerbates health inequities.

When access to routine health care, including vaccinations, is geographically problematic for Black and Brown communities, access to COVID-19 vaccinations can unsurprisingly also be an obstacle. Health care facilities in counties with higher Black and Brown demographics were less likely, in May 2021, to serve as COVID-19 vaccine administration locations. ⁷ In addition, the location of vaccination sites was significantly farther from where people lived in Black and Brown communities compared with White communities. ⁸ As a result, vaccination sites were not at walkable distances, a vaccination deterrent especially for those who are not ambulatory, do not own a car, or lack easy and reliable access to public transportation. Black and Brown households in rural and urban areas have limited transportation options or rely on public transportation, if available. Pharmacies and states partnered with Uber and Lyft in helpful initiatives to bring people to vaccination sites, but the initiatives lasted for the short period of May 2021 to July 4, 2021. ⁹ The difficulty of access to vaccination sites that many faced must not be overlooked in understanding the different vaccination rates between largely Black and Brown communities, on the one hand, and largely White communities, on the other.

An additional barrier to access is one impacted by mobility, employment, shifts, and schedules. People of color work in a disproportionate number of low-paid, shift-working, frontline employment positions, so access barriers and work schedule inconveniences might also contribute to lower vaccination rates. Many Black and Brown individuals have job schedules that significantly limit the window in which they can schedule vaccination appointments and this challenge is compounded at vaccination sites that did not offer flexible time slots. Vaccination appointments could be time-consuming and difficult to reserve. This challenge was met positively by the “vaccination angels,” those persons willing to aid others in navigating the complicated technological terrain of vaccine reservation systems. During the US House Ways and Means Committee on February 26, 2021, Ashish Jha, Dean of Brown’s School of Public Health, advised,

The difficulties of signing up to be vaccinated are a failure of the system. Scheduling an appointment for a vaccine should take minutes, not hours. It should involve a few clicks on a webpage or a quick phone call, not crashing web portals or endless phone calls with five different health care providers. The communities that have been hit the hardest by pandemic, Black and Latino communities, are the communities least likely to have been vaccinated. . . . We must do better. ¹⁰

To address these issues, vaccination appointments should be available at flexible times outside of traditional work hours to accommodate workers with numerous work shifts and schedules. This issue could also be addressed through long-term partnerships between pharmacies, state governments, and ride-sharing companies, such as Uber and Lyft, providing roundtrip rides to vaccination appointments.

Allocation of COVID-19 vaccinations

The WHO has reported over 50% vaccine wastage globally every year, in part because some points of vaccination, such as health care providers in poor or rural areas, may not have the resources to support cold chain requirements. ¹¹ Cold chain systems are supply chains that specialize in the planning, storing, loading, and movement of temperature-sensitive products such as foods and medicines shipped or stored with specified temperature requirements. The Pfizer-BioNTech and Moderna vaccines have new mRNA technology that required temperature-sensitive shipping and storage. Without these proper temperatures, the vaccines would not be effective. This requirement created numerous challenges because the US infrastructure is not robust in cold chain systems, especially the health care cold chain systems. The necessary infrastructure to support distribution of hundreds of millions of vaccinations does not currently exist in the United States. Although a challenge in all communities, it is especially detrimental in Black and Brown communities with inadequate health care resources.

In response to concerns that developing a robust and cohesive health care cold chain systems infrastructure is not plausible (at least not in the time needed to address the current COVID pandemic), an important factor to realize is that other potential options exist. One possible solution is to eliminate the cold chain altogether by making vaccines that can withstand more natural temperatures. ¹² Another option is to embrace the advancements of technology into monitoring and logistics systems to alleviate vaccine waste. Although the time has largely passed to implement such suggestions for the current pandemic, the ethical duty to plan requires considering these possibilities and aiming to put them in place for future epidemics and pandemics. A broader point that reflection on access challenges and vaccine waste raises is whether a rethinking of the whole structure is needed. Instead of individuals traveling to be vaccinated, why not rely on home delivery and other logistics to bring vaccines to the people? This idea is not new. The polio epidemic provides an instructive historical example, to which we now turn.

In the mid-twentieth century, the polio epidemic was a huge health crisis in the United States. On April 13, 1955, one day after it was licensed in the United States, the first polio vaccine, called the trivalent inactivated poliovirus vaccine (IPV), arrived at the Mayo Clinic. ¹³ Shortly after, churches and schools were designated vaccination sites that distributed the IPV vaccine to their local communities. In contrast, with very few exceptions, churches and schools were not designated as vaccination sites during the COVID-19 pandemic. The political and religious complexity of the US society introduces many reasons why churches and schools were not included. Still, the omission of churches and schools as major catalysts in the vaccinations of the communities they serve was an ineffective local public health decision and strategy against the COVID-19 virus.

Mobile clinics, however, are a suggested solution to vaccination access. For the past few years, WHO has been using mobile clinics in the most impoverished areas of the world. ¹⁴ Convenient and accessible, mobile clinics have been proven effective among vulnerable populations in dire need of health care access. As previously mentioned, Black and Brown communities had many challenges to access COVID-19 vaccinations. Using the mobile clinic model can be helpful in solving the racial gap of COVID-19 vaccinations. In a mobile clinic case study on COVID-19 vaccinations, a health care initiative partnered with CVS Health and sent mobile vans to long-term care facilities (LTCFs) across the United States. According to the case study, the vaccine distribution system used a computer algorithm that was efficient in the rapid distribution of vaccines to 47,907 LTCFs from mobile clinics linked to 1214 CVS depots. ¹⁵ This promising case study should be used as a blueprint for use in Black and Brown communities in which mobile clinics can be established to distribute vaccines and other health care resources efficiently.

If the previous challenges appeared daunting, issues of access, allocation, and mobility exist amid a great deal of misinformation about the virus and vaccinations disseminated in social media and other platforms. Consequently, health literacy remains an important facet in vaccination responses.

Health literacy

Since the term was introduced in the 1970s, health literacy is understood as a person’s ability to access, understand, and use health information and health services. ¹⁶ Black and Brown communities that have limited health care access can endure health illiteracy that leads to the liabilities of being less educated, having fewer health-promoting behaviors, and having worse health outcomes. Vaccine-related misinformation, with social media as a major source of its distribution, may exacerbate the levels of vaccine hesitancy, hampering progress toward vaccine-induced herd immunity and potentially increasing the number of infections related to new COVID-19 variants. ¹⁷ Examples of misinformation include claims that the vaccines have computer chips in them, possess cancer-causing radiation, or lead to infertility.

These claims about COVID-19 vaccines have been proven multiple times to be false. To combat misinformation, mobile clinics can serve as mediums to build relationships that teach health literacy in Black and Brown communities. As discussed, mobile clinics can be a great resource to provide vaccinations and other health care services. Mobile clinics can also provide health literacy resources to the people. To create relationship-building opportunities, local medical systems that service communities in which Black and Brown people reside should establish and seek to nourish long-term dialogue and support programs. Black and Brown communities need partners, not acquaintances. Equitable vaccination access, distribution, and health literacy in Black and Brown communities are not only important factors in effective vaccination participation; they also are ethically mandated. Although we could offer a number of philosophical and theological arguments to support this claim, we root our arguments about the core importance of vaccine resources in the simple notion that members of Black and Brown communities are worthy of such access because of their dignity as human beings. To this ethical justification we now turn.

Vaccinations and human dignity

One useful theoretical framework for thinking about some of the aforementioned challenges of widespread vaccination in response to the COVID-19 pandemic is the concept of dignity. In this section, we first describe the theoretical framework that undergirds those claims. This description is needed for two reasons. First, public health measures, even if those measures are sensible and effective, need an ethical justification. Second, different disciplines (e.g., ethics, bioethics, and political theory) have understood and articulated the concept of dignity in different ways and therefore clarification is necessary.

For two reasons, reflection on dignity is helpful in moving forward ethically with public health measures in response to public health crises and, in particular, the COVID-19 pandemic. First, the term “dignity,” when invoked, often carries with it significant rhetorical force. Claims that a person’s dignity has been violated are not taken lightly. Relatedly, the concept is understood (contrary to some of its detractors ¹⁸ ) to be robust enough to support respect for human rights and the general treatment of others. This robustness is evidenced by the inclusion of “dignity” at the outset of many leading human rights documents and national constitutions. Article 1 of the Universal Declaration of Human Rights states, “All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.” ¹⁹ Article 1 of the Charter of Fundamental Rights of the European Union declares “Human dignity is inviolable. It must be respected and protected.” ²⁰

This brings us to the second reason that reflection on dignity can be helpful in public health contexts, especially in pandemics like COVID-19. One of the most perplexing features of the COVID-19 pandemic is that the necessary responses to the pandemic required separation and distance at a time when human beings were in most need of interaction. ²¹ The poorly named “social distancing” is an apt metaphor. To slow the spread of the virus, lessening physical proximity was needed, but not the emotional or communal distancing that also often occurred. This claim is evidenced by contrast in resource availability (a plethora in some communities, a scarcity in others) as well as failures to share knowledge, understanding, and explanation among communities. Dignity is a helpful concept here because of its twofold engagement with human beings: first, as unique individuals and, second, as members of a broader community. This tension between the good of individuals and the good of collectives is at the heart of several public health ethics considerations and may very well be the key ethical issue at the most abstract level of thinking about public health ethics.

Attending to the dignity of human beings in general is to recognize those beings as “like us” in relevant respects, that is, answering affirmatively the question, “Who counts as one of us?” ²² The normative implications of relying on this concept are, broadly speaking, threefold: first, respecting the dignity of others prohibits the intentional killing of them; second, it prohibits denying human beings opportunities needed to realize what it is to be a human being; and finally, it requires that human beings are not treated in ways that humiliate them. If these three violations are avoided, the dignity of others has been respected. The normative implications of relying on this concept within health care and within the interprofessional and multidisciplinary ²³ field of public health are, understandably, more specific. We take up each in turn.

First, we consider the prohibition on killing. In considering public health during a pandemic, such as COVID-19, measures must be taken to mitigate the impending deaths that the virus will cause. Both action and inaction can result in negative public health outcomes, including the sickening and death of many; thus, dignity’s prohibition on killing does not only apply strictly to situations of direct killing of another. Reflection on the concept also draws attention to policies, dissemination of information, and hygienic practices that bear on the health of others. For example, consider requirements or requests for masking. ²⁴ Public health policies rooted in the respect for dignity would support masking and other practices that lessen the likelihood that immunocompromised individuals, young children for whom vaccines are not yet available, or others unable to be vaccinated due to health reasons would contract the virus and die. In other words, the suggestion is that the lens through which the health of the public should be considered is one that focuses on the vulnerable. This focus includes the understanding that many vulnerabilities are created by the structures individuals encounter, not (merely) by the features they possess, and this focus exemplifies what it means to take seriously the affirmative answer to the membership question and to the substantive response to the individual. When members of a community are disproportionately affected and placed at risk in a pandemic, evidenced by the plight of the Black and Brown members of society during COVID-19, a prohibition on killing, coupled with the second substantive feature of dignity, requires the reconsideration and critical evaluation of health care and public health structures.

The second consideration is denials of opportunities. To treat with dignity the immunocompromised, children, and others requires affording them opportunities necessary for the realization of their humanity. Safely moving about spaces in a person’s daily life can be especially challenging in a pandemic. This need for safe mobility is yet another argument for masking, good hygiene, and support for scientific research to aid in addressing factors that plague public health. The interconnected nature of local communities and of the world makes it so that risky behaviors can have greater implications on others and thus calls for justification of such behaviors considering the weight of their consequences. One important example of an opportunity necessary for realizing one’s humanity is access to health care and, though other instances exist, as the pandemic has progressed, this access means access to vaccination against COVID-19 and to regular testing.

Respect for the dignity of persons again justifies significant public resources to be devoted to this shared task. Furthermore, it requires research and study not only toward the good end of vaccination but also on the public mechanisms that will lead to the manufacture, dissemination, administration, and maintenance of individual health related to the vaccine. One especially insidious case that has come to light is the accusation of vaccine hesitancy laid at the doorstep of Black, Brown, and other racialized and minoritized populations. This is not to say that vaccine hesitancy does not exist; it does. But contrary to many claims of vaccine hesitancy within communities of color, in fact, research has shown that access is the primary determinant. As health care establishments continue to understand better the social determinants of health, continuing sociological research is important to understand better and identify true barriers to access, avoiding stigmatizing and untrue claims.

This brings us to the final normative implication of dignity: the prohibition on humiliating treatment. Respect for dignity requires that individual persons are not placed in situations that demean them or place them outside the community in which they possess membership. Taking dignity seriously within public health requires that individuals are placed in situations that enable them to realize what it is to be a human being with respect to their health and the health of the other members of their shared human community. Public health officials must share relevant, accurate, and clear information about the virus in a pandemic. They must seek to do so in ways that are effective and consider different epistemological approaches, histories of dishonesty and injustice, and different languages and practices of the members of the human community. For one living through a pandemic, to lack access to vital information or not to understand it is to be placed in a humiliating situation. To not be able to judge what is best for oneself and for those whom one loves is to occupy a lesser position in the social hierarchy, a reality not in accord with a public health ethic rooted in dignity.

Attending to the dignity of others in a public health crisis is not easy, but to do so means avoiding killing, affirming opportunities, and avoiding humiliation. Before moving forward to discuss specific issues that have arisen due to COVID-19 and some possible solutions to those issues which are informed by our account of dignity, we note that dignity is not the only ethical concept within public health, nor is it the only one that might be useful in framing such a response.

Some have found dignity to be especially useful for collective action because a variety of traditions and perspectives find the concept resonates with them and, although they come to reflect on dignity from different vantage points, they can affirm its normative implications. Thus, advocates for human rights might draw on international human rights documents and national constitutions to understand the foundations of dignity. For example, the United Nations Educational, Scientific, and Cultural Organization (UNESCO) states its aims in its “Universal Declaration on Bioethics and Human Rights” as “to promote respect for human dignity and protect human rights, by ensuring respect for the life of human beings, and fundamental freedoms, consistent with international human rights law” and prohibiting the violation of “human dignity, human rights and fundamental freedoms” in terms of justice, equality, nondiscrimination and non-stigmatization, respect for cultural diversity, and pluralism. ²⁵ This work is rooted in an account of human dignity understood as

the concept that human beings are, by virtue of their humanity, owed a special degree of moral care and concern. The “respect for life” is a corollary of this principle, namely, that human dignity rightly understood imposes the obligation to act with a high degree of care in matters touching and concerning human life and, at the very least, enjoins harmful or exploitative practices in this regard. ²⁶

Others anchor dignity not in political agreement but in theological or philosophical traditions. For example, Christians, Jews, and Muslims who believe that human beings are made in the image and likeness of God have another rich set of resources for thinking about dignity. For example, James Hanvey argues that the Catholic use of dignity is grounded in an ontology of the person that is rooted in the imago Dei, which is “an attempt to protect the value of all human beings and of holding all societies accountable.” ²⁷

Conclusion

The early stages of the COVID-19 pandemic had a detrimental effect on the sanctity of the human conditions of life, health, and interaction. Fortunately, the Pfizer-BioNTech, Moderna, and Johnson & Johnson vaccines revived these important dynamics. Furthermore, social determinants of health, including the issues of equitable vaccination access, distribution, and health literacy, had great influence on the vaccination status for Black and Brown communities. Access to life-saving treatment and resources was hindered by poor social determinants of health and socioeconomic status, which led to slow vaccination numbers in Black and Brown communities. Although many factors hindered adequate and efficient vaccinations, such issues can be rectified by creating seamless vaccination access, efficient vaccination dissemination, and the zeal to equip Black and Brown communities with health literacy resources, all rooted in human dignity. Indeed, one cannot be valued until everyone is valued.