Early in the pandemic, San Diego County recognized its COVID-19 relief efforts needed to reach its large Latino population, and set up a task force in June to lay out plans — well ahead of when vaccines became available.
Last month, it opened its first vaccination sites where the target population lives and works: Close to the Mexican border. But the people who showed up for appointments were white, more affluent, and didn't live there.
"Even by physically locating the centers down south, a lot of those appointment slots are taken up by people that are from the north of the county and more technologically savvy," says Dr. Christian Ramers, a member of the county's task force, and an executive at Family Health Centers, which runs a network of 23 primary care clinics serving mostly minority and poor populations.
Ramers says Latino people make up a third of San Diego's population, but account for about half of COVID-19 hospitalizations and deaths. And to date, only 15% received at least one dose of vaccine. So San Diego, like the rest of the country, is living a COVID-19 paradox: Those needing vaccine most aren't getting as much of the limited supply as the numbers suggest they should be getting.
"The challenges in ensuring equity are just very, very large," Ramers says. "And even despite having our eyes on the ball, the numbers don't really satisfy anybody."
The Biden administration set twin goals of trying to vaccinate people of color and others most vulnerable to COVID-19, and doing so swiftly. This week, the federal government will start supplying more vaccine to community health centers, whose patients tend to be minorities, homeless and the poor. But what those centers are learning is that speed and equity do not necessarily go hand in hand.
In some cases, health centers say, technology is a barrier, because appointment systems are too complex, or because they require a smart phone.
In many cases, the competition for the vaccine appointments is just too fierce. Jim Mangia, CEO of St. John's Well Child and Family Center in South Los Angeles, says his clinic had to hire 20 security guards at $12,000 a month to manage traffic and disputes among its long lines of vaccine seekers. Many of those in a line hoping to get leftover shots at the end of the day have come from wealthier parts of town, though the clinic generally serves the less well off. (During one incident, Mangia says, someone in line spit at a guard for moving an 82-year-old Black woman to the front.)
The biggest hurdles to vaccination are rooted in the realities of life for racial minorities and the working poor. They make up a large share of public-facing essential workers. Transportation may be a problem, or their daytime schedules may not allow time to hunt for appointments, or stand in line. They might be undocumented or lack insurance.
Many, Ramers say, are still waiting to meet with their doctor or religious leader to ask questions, or get further assurance that vaccination is safe, both medically and legally.
"Hesitancy is not just one thing," Ramers says he's found. Many patients he hears from want to know how the vaccine might affect cancer treatment, or other medicines they're taking or their allergies.
Those conversations take time — and that clashes with the other major goal of vaccination: Speed.
Ramers says California started cutting back shipments when vaccinators don't administer shots quickly.
"There's immense pressure on using the vaccines as quickly as possible, and that tends to favor these mass vaccination sites, which really don't have the ability to target the communities that need it," he says.
That inequity should come as no surprise, given the existing racial disparities across the medical system, says Dr. Georges Benjamin, longtime executive director of the American Public Health Association.
While a great deal of effort went into developing a vaccine, Benjamin says, "we really haven't had a well financed, well-structured national effort to get into communities that we knew would be more hesitant and were disadvantaged by all of those social issues."
The vaccine rollout is happening, he notes, as the country wrestles with racial disparity across public health — from policing to food insecurity. Disparities in vaccination are hard to track in the data, because race information is available for only 55% of those who have received doses. But among the states that do gather race data, disparities show up in early vaccination numbers.
The U.S. now has an opportunity to prove that it is shifting priorities, and trying to bridge those age-old gaps, says Harald Schmidt, an assistant professor of medical ethics at the University of Pennsylvania.
"The longer-term implication of how we dealt with social justice will be very powerful — so we do have to get this right," Schmidt says.
Her center abandoned an online appointment system the Centers for Disease Control and Prevention helped set up called the Vaccine Administration Management System, for example, because it made no sense to her mostly Latino patients. She says it asked 14 difficult questions, phrased only in English: "One of them," Lagarde says, "is, 'Have you ever had an allergic reaction to polyethylene glycol?'
Instead, the clinic announced it would begin booking appointments by phone, and take questions there. But within half an hour, 300 calls from people all around the state crashed the phone system — as well as the backup answering service. So now, Lagarde is rethinking her approach, again.
"I envision ultimately even going literally knocking on doors — because I think it might take that," she says. She hopes to vaccinate not just the patients the clinic knows, but also many thousands of others who've never sought care.
That, again, will take time.
"I need to get to the folks who are not getting into the big hospital systems," Lagarde says. "It's much more time intensive, but they're both needed — and as a country, we need to do both."