As America prepares for the first doses of a coronavirus vaccine to be approved for use, the looming legacy of centuries of segregation in America’s largest cities could thwart effective inoculation of some of the nation’s most populous ZIP codes.
Twentieth-century zoning policy that has segregated American cities by race and systematically disenfranchised communities of color has led to stark health disparities along the geographic boundaries of urban neighborhoods, including “pharmacy deserts,” areas where access to medicine is limited. Inequity has only been exacerbated over the past two decades, as many community-trusted independent pharmacies in historically underserved areas shuttered.
“Segregation exists and will impact the way that the COVID vaccine is distributed,” said University of Southern California School of Pharmacy Professor Dima Qato, who holds doctorates in pharmacy and public health. Qato has studied pharmacy deserts in Black and Hispanic communities.
The vaccine distribution strategy the U.S. Centers for Disease Control and Prevention has chosen, giving priority to essential workers, was picked specifically to try and overcome health disparities laid bare by COVID-19. But at a time when millions need to access doses as quickly and as close to their homes as possible in order to extinguish the spread of a virus that has already killed 282,000 Americans, inequity in health care access may present one of the most difficult hurdles to widespread vaccination and could diminish the effectiveness of the vaccine everywhere.
“It’s not just about the inequity, it’s about public health,” said Massachusetts General Hospital Physician-in-Chief Dr. Katrina Armstrong, who has studied health access inequality for years. “For people to be protected we need our neighbor, our colleague, our community to be vaccinated too.”
Entities that are organizing vaccine distribution must be proactive in addressing these inequities before they are rolled out, Armstrong said.
“One of the paradoxes of racial disparities is that these disparities seem to be smallest when we don’t have treatments and greatest when we do have treatments,” she said. “Once we developed treatment and vaccines for COVID, history shows us that this disparity is going to get larger unless we do something about it now.”
In order to close this gap, health experts told Bisnow that the vaccine should be distributed in places of worship and community centers; the federal government should organize a racially, socially, culturally and religiously diverse vaccination distribution team in order to build trust within a variety of communities; the vaccine should be made accessible to all, whether or not they have the ability to pay; and those organizing its distribution should provide the public with more clear, transparent messaging and information about the vaccine and how to access it.
“The same problems we had with voting — where we needed to distribute something very quickly, through a public means — are the problems that we’re going to face distributing the vaccine,” Armstrong said. “We need to make an investment now for making points of access … and it’s much more than just a building to distribute the vaccine in.”
Unequal Access And The Role Of The Drugstore
The pandemic has already had an outsized impact on communities of color, revealing the lasting impact of segregation on minority health. And, while government entities say they are working on ensuring equitable access to the vaccine, this may not become a reality without concrete planning and increased transparency, experts say, with real estate at the heart of that planning.
Many low-income communities of color have been systematically disenfranchised through a government program known as redlining, which occurred in the mid-20th century, blocking them from accessing loans to make investments in the community, cutting off these areas’ path to increase wealth. Those who live in areas that were redlined tend to more frequently be people of color and are at greater risk for pre-existing conditions such as asthma, diabetes, COPD and hypertension according to a report by the National Community Reinvestment Coalition.
There is also a lack of pharmacies and retail health clinics in lower-income, urban communities of color compared to economically advantaged communities, academic research published in pharmaceutical and medical journals over the past two decades shows. Trusted access to pharmacies has been limited further in recent years, as many independent retailers — who are more likely to serve low-income areas — have closed down, Illinois’ Qato said.
Pharmacies, especially independent, community-focused ones, have historically played a huge role in administering vaccines to adults and will be a key location for the administration of the coronavirus vaccine.
Between 2009 and 2015, while the total number of pharmacies increased by 7.8%, 12.8% of all independent pharmacies closed, according to a 2019 article published in JAMA Internal Medicine, a medical journal.
Independent pharmacies that provided service to low-income, uninsured populations in urban areas were even more likely to close their doors over this time frame, the research published by JAMA showed. New pharmacies that have opened tended to do so in areas with a high percentage of insured residents, Massachusetts General’s Armstrong said.
Even in neighborhoods with chain retailers, chains often lack an element of trust that will be needed to bring in those that live in the communities to take the vaccine, Amstrong said. Experts said that those who provide the vaccine will not only need to secure the physical space to be able to inject the vaccine, but they'll also need to build trust in communities that are historically skeptical of the medical field.
“In a lot of the less affluent communities, [chain pharmacies that administer drugs for commercial health plans] have choked independent pharmacies out of business, but they don’t fill the hole,” Pharmacist Society of the State of New York President Tom D’Angelo said. “That’s been an issue, but we’ve been trying to fight that for years.”
While CVS and Walgreens have already announced partnerships with the federal government, some independent pharmacies in New York have begun coughing up between $7K and $10K for freezers to ensure they can provide their communities with vaccines, even though there is no promise of repayment from the government.
They are currently not on the list to receive the first round of vaccines, he said. Still, D’Angelo said that independent pharmacists are already coming together to scout out locations to distribute vaccines to the community en masse once they receive the doses.
“We’re definitely going to need to be prioritized in the next round,” he said. “Those independent pharmacies are the lifeblood of these communities.”
‘No One Is Quite Clear What The Game Plan Is’
As hospitals in major U.S. cities, such as New York, Los Angeles and Chicago, prepare to immunize their long-term care and intensive care staff for a vaccine that could be delivered as early as Dec. 15, the question of just how a cure to the coronavirus pandemic will be administered to the general public, including low-income urban neighborhoods without a nearby pharmacy or retail health clinic, has yet to be clearly defined by state and federal governments.
While the federal entity responsible for vaccine distribution plan, the Centers for Diseases Control and Prevention, released guidelines for distribution of the vaccine and outlined its plan for it, it has not specified specific locations within these communities for vaccines to be distributed, nor has it articulated the specific marketing and education mechanism it will use to develop trust of the vaccine within these communities.
“The problem is there has been a lack of transparency from the federal level,” City University of New York Professor of Health Policy and Management Dr. Bruce Y. Lee said. “It’s equivalent to running onto the football field and no one is quite clear what the game plan is. And it also raises suspicions.”
For a vaccine distribution effort larger and more complex than the country has ever done before, the CDC is the only entity that can effectively provide the leadership the effort requires, Robert Wood Johnson Foundation Senior Policy Officer Dr. Giridhar Mallya said.
“The CDC is best equipped to handle vaccine distribution technically and relationally," he said.
The federal agency works with local stakeholders such as state health departments and community groups, Mallya said. The federal entity could best create a centralized plan that would be effective across a broad and diverse country for that reason, he said.
In addition to the federal plan, all 50 states were required to submit their proposals to the CDC by Nov. 1. While states with major cities such as California, Illinois and New York, outline a more detailed vaccine distribution plan that expands upon collecting community input and underserved communities, there have been few specifics released on the local stakeholders that will be involved in the distribution process, what this messaging will look like, who will cover the costs for those who are uninsured and a specific plan to improve public trust in the vaccine so far.
“In California, our planning process for the eventual distribution and administration of COVID-19 is guided by the overarching principles of ensuring the COVID-19 vaccine meets safety requirements,” a spokesperson for the California Department of Health told Bisnow in an email. “Ensuring that the vaccine is distributed and administered equitably, at first to those with the highest risk of becoming infected and spreading COVID-19; and transparency, by bringing in community stakeholders from the outset.”
The state is coordinating with communities and will host a public information campaign to increase public trust in the vaccine to ensure vaccination of as many people as possible, according to the spokesperson.
“The California Community Vaccine Advisory Committee, which includes advocates for many underserved groups, including the homeless, immigrants and farm workers, is providing input and feedback to the planning efforts and resolving barriers to equitable vaccine implementation and decision-making,” the spokesperson added.
In New York City, Mayor Bill de Blasio plans to prioritize communities of color and those who live in public housing, Politico reported. Members of his administration have been working with community and faith leaders to build trust in the vaccine, according to the administration.
Still, the distribution of 211,275 doses of the Pfizer vaccine and 211,275 doses of the Moderna vaccine set to be sent to the city remains unclear. Fifty-five of the city’s hospitals and health centers have already placed requests for the vaccine, which is set to go to nursing home residents and staff, health care workers and first responders first.
Closing The Gap
Ensuring proper vaccination for those who do not have access to a pharmacy down their street will take a lot more than what has been proposed at the federal level and a more concrete, targeted plan on the local level, experts said, with location a crucial part of that.
The government needs secure spaces like places of worship or community centers as vaccine centers, areas that people trust and frequent and also areas that are a walkable distance from their house, to further curb the spread of the virus, said Lee, who focuses on creating computational models to inform public health policy.
“You’ve got to plan vaccination locations before you get the doses and set up new ones,” Lee said. “Don’t wait until people show up to the pharmacy, make it convenient to get the vaccine.”
In the UK, the country’s National Health Service is working on a plan to set up vaccination centers in empty retail units and community facilities like sports centers, in order to make them as accessible as possible.
In order to set up these centers in communities there must be a set of socially, racially and religiously diverse voices at the table, he said.
“There needs to be adequate diversity in the people running the vaccination program, because we can’t just have one group dictating this, everyone needs to be working together,” Lee said. “If the leaders of this are from one homogenous demographic, it becomes some kind of a strange order.”
On top of all of this, the vaccine must be accessible to all, even those that can’t afford to pay for it and the federal government needs to facilitate more partnerships between health care providers, community leaders and the private sector, he said, while boosting clear messaging rooted in the science.
Finally, Lee said that it is imperative that all those involved in this process slow down enough to ensure the logistics are in place so that the vaccine can be as effective as possible.
“This is not the time to rush,” Lee said. “If you rush too quickly you risk not being able to vaccinate enough people.”
CORRECTION, DEC. 10, 11:45 A.M. ET: Dima Qato is currently a professor at the University of Southern California School of Pharmacy. An earlier version of this article identified her by her previous position at the University of Chicago-Illinois. This story has been updated.