A few weeks ago, I learned I’d qualified for a Covid-19 vaccine. I began devoting my days to shot chasing. I joined local vaccine-hunting groups on Facebook, where members reported driving all over the state to get their jab, and I preregistered for state-run mass vaccination sites. A week later, I received a text message from the preregistration service: Was I available that Saturday? Hell, yes. I happily drove for an hour to a drive-in site.
But the next day, I called a friend, Salvador, who lives in the same county as I do and has the same medical condition, although his is more severe. Had he gotten his shot, too? He hadn’t. In fact, he didn’t even know he was eligible. He didn’t know where to sign up, or where the sites were. When he later tried to book an appointment, the only available slot was during his work hours. He desperately wants the vaccine, because he lives with his elderly parents and their jobs all require them to work in person. But, he says, he’ll just have to wait.
“It’s ridiculous how you’ve got to really go out of your way to get this vaccine,” he said. He found a few spots two and a half hours away, but he couldn’t spend the day driving. “The working class in general has to go out of their way just to be immunized, in order to work in a safer environment.”
We are in the midst of the most ambitious and sweeping vaccination program in history. Every week, we smash records, with millions of Americans vaccinated daily. But soon, this dramatic curve upward in the charts is going to falter, in large part because of access. So far, states have done an incredible job at immunizing people like me, who can drive hours at the drop of a hat to be vaccinated. But for all the talk of people refusing the vaccine for ideological reasons, there is in fact a significant portion of the population who want the vaccine and aren’t able to get it—because the sites are too far away and they don’t have a car; because they can’t take off work to find, go to, and recover from vaccine appointments; because they didn’t know they were eligible in the first place. And frequently, in heartbreaking irony, they are the very people who are most vulnerable to Covid-19.
The next challenge of the pandemic will be reaching these hardest-to-reach Americans. And it can’t happen soon enough. Cases of Covid-19 have begun ticking upward again, driven by variants like B.1.1.7, which researchers believe is more transmissible than earlier versions of the virus. In order to stem the rise of existing variants, and the emergence of new ones, we need to halt cases as quickly as possible. Political leaders, reluctant to close nonessential businesses, require masks, and implement stay-at-home orders, have put all of their faith in vaccines to stop the deadly spread.
In order for vaccines to make a lasting dent, however, we’re going to need to get more creative about how and where we vaccinate people. Think fewer mass vax sites and more mobile units going door-to-door. Closing these gaps in access will be vital to returning to some form of normalcy. Otherwise, we will continue battling surge after surge as the virus evolves faster than we can stop it.
The news about the Johnson & Johnson Covid vaccination pause, then, couldn’t have come at a worse time. The highly effective, single-dose vaccine was intended to reach people in rural areas, those on the move, and those who don’t have a lot of time to take off work. The J&J jab is a great way to reach the most vulnerable because it’s easier to store and transport, and it’s one-and-done; no need to come back for another visit. But after news that regulators are pausing the vaccine while they investigate extremely rare blood clots, confidence in the vaccine’s safety seems to have dipped.
“It is a setback,” Dr. Jason L. Schwartz, an assistant professor of health policy at the Yale School of Public Health, told me. Even though the United States should have enough mRNA vaccines from Pfizer-BioNTech and Moderna to cover all adults by summer, he said, “the Johnson & Johnson vaccine gives us a whole lot more agility in terms of where we can bring vaccines. It’s ideal for mobile vaccinations, for vaccinating the homebound, for groups where timing a second dose and coming back to the same site is a challenge.”
“We’re now entering a phase, over these next few months,” Schwartz said, “where it’s less about just trying to keep up with all the people banging down the door to get a vaccine as quickly as possible.” Next, he said, the challenge will be “trying to find those hard-to-reach groups to try and make vaccines available where people are.”
The U.S. vaccination strategy has largely involved setting up mass vaccination sites and pharmacies, with people left to figure out how to sign up on their own. “They’ve up to now largely had all of those slots filled,” Dr. Justin Feldman, a social epidemiologist and a fellow at the Harvard FXB Center for Health and Human Rights, told me. “But at some point, more and more of them are going to be having free appointments, and you have to put more investments into getting those additional willing people.”
In Mississippi, for instance, thousands of vaccine appointments are unclaimed. But that’s not because people don’t want them; it’s because they can’t access them, Feldman said. “You still have very large chunks of the willing population who have not yet been vaccinated, and they tended to be lower income, lower education,” he told me. “We have such a fragmented society, and we don’t have this strong social infrastructure that that’s going to be able to reach people who are by definition hard to reach,” Feldman said. “It’s going to be a struggle, and it’s going to take a lot of work.”
Flashy headlines about Republicans or members of the military declining the vaccines obscure the complexity and underlying inequalities of who has already received a shot and who hasn’t. White Americans have the highest refusal rates, for instance, but while Hispanic Americans are the most likely to say they want the vaccine, only 26 percent of Hispanic Americans have had a chance to get vaccinated, compared to 34 percent of white Americans, according to a survey from the nonpartisan Kaiser Family Foundation.
Here’s what the surveys really tell us about hesitancy: About one-fifth of Americans don’t want the vaccine, or would only get it if required. But that leaves 80 percent of the country open to vaccination—a rate that would surely help quash the virus’s progress through our population. In theory, if the 80 percent were equally distributed throughout the country, we would likely reach a level of protection sometimes referred to as herd immunity.
For communities where people are eager to get vaccinated but face logistical challenges, that means coming to where they live—setting up walk-in clinics, no appointment needed, in churches and rec centers, or offering shots at workplaces. In California, vaccinators have gone to fields to reach farm workers. “You need to work with churches, you need to work with other religious organizations and community organizations that are trusted in communities. You need to bring the vaccine to people’s neighborhoods and even into their houses and apartments,” Feldman said.
Running ads—on TV, bus stops, social media, the radio—would let people know that they qualify and how to sign up. Making that sign-up process as quick and easy as possible is also important. Working with community health centers and primary care providers will continue to be important, and there are new ways these resources could be mobilized. In the United Kingdom, for instance, primary care providers send a text message to patients who qualify for the shot, offering an appointment nearby or even doing house calls.
Schwartz envisions pop-up booths at state fairs and doses offered at dollar stores. “It’s going to be that kind of ingenuity, that kind of creativity, to make vaccines impossible to miss,” Schwartz said. “We’ve got such an important opportunity here to try and max out the benefits of the vaccines. This is the time to try everything we can to reach as many people as we can.”
If supporting the massive vaccination drive is the carrot for policymakers eager to get the national economy back on its feet (along with, you know, safer, happier people living and being able to see friends and family again), the evolving virus is the dangerously large stick. “The biggest remaining obstacle to closing the book on Covid-19 is this question of variants,” Schwartz said. “That’s the biggest hurdle we have left to understand: the pace at which the variants are mutating, the pace at which they’re spreading, and then the pace at which they may eventually evade the protection our vaccines provide.” For now, the Covid vaccines work very well against variants, which is a huge opportunity. “Viruses cannot mutate if they don’t replicate,” Dr. Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases and the chief medical adviser to the president, has said.
The shining goal many have read about in the past year has been herd immunity. Reaching that will be tricky. “It’s not just that there’s a herd immunity threshold, we hit it, and then everything’s fine,” Feldman said. “Herd immunity is kind of continuous. So the more people who have either been infected or vaccinated there are, the harder it is for the virus to spread as easily.”
“I try not to think about herd immunity as a finish line,” Schwartz said. “We’re not going to know it when we’re there, it varies from place to place. I’m in the camp of let’s vaccinate as many people as possible.” Success will not be measured by a fixed statistic, he said, but by a sustained flattening of cases.
Salvador is still looking for his shot. He hopes that more spots will begin opening during non-work hours, as others complete their vaccinations. And next year, if he needs a booster, he’d love to be able to walk into his local pharmacy and just get it. “Just as it would be for a flu vaccination,” he said. “But I don’t know that’s actually going to happen.”
This is exactly the future experts hope for in the U.S. We have all of the tools we need to make easy, fast, accessible vaccinations a reality. Ingenuity and organization already brought vaccines through development and testing to the point of administration in record time; now we need to finish the job.