The state of Covid-19 vaccinations is rapidly evolving, and sometimes it can feel like the health care industry has found itself in a game of "whack-a-mole." Leaders knock down one challenge, only for another to appear just out of reach.
As we have said before, there are plenty of logistical and operational barriers to vaccinating the globe, none of which have gotten any easier. The latest dilemma isn't about syringes or nursing capacity—it's about the lengths some people are going to in pursuit of that hard-to-obtain shot, and the challenges those extra efforts create for health officials trying hard to enable equitable access, especially among economically disadvantaged communities.
What we've been tracking: Vaccine hunters and immunization tourists
For the last several months, vaccine demand has far outstripped supply and overwhelmed existing administrative infrastructure here in the United States. As a result, registration websites routinely crash or require continuous refresh, people line up early each morning in hope of nabbing an unclaimed dose at the end of the day, and some even travel across state lines to capitalize on more favorable prioritization policies (e.g., smokers traveling to New Jersey).
Despite the handful of well-publicized stories about intentionally deceptive behavior—such as people posing as grandparents or paying the elderly to claim them as a caregiver (which even made it into the cold open of SNL)—most of today's vaccine hunters aren't doing anything unethical. They are working within the rules of a system ripe for arbitrage—but it's a system that also disproportionately favors those with time, technology, transportation, and tremendous flexibility. By and large, successful hunters can navigate multiple complicated registration sites, dedicate time to refreshing appointment pages on their laptops with high-speed internet connections, and step away from their white-collared jobs on a dime if they secure a coveted appointment or learn of a site likely to have extra doses at the end of the day. They might not be boarding a private jet, but they do tend to be more affluent, and they do tend to be white.
Technology-based aggregators are stepping in to streamline the "hunting process." New websites match leftover doses to people willing to offer their arm at a moment's notice while still prioritizing vulnerable populations. While this is still a technological solution, vaccine matchers like Dr. B are working to remove some of the more annoying barriers to vaccine access—the time it takes to search and refresh—instead routing people to opportunities closer to home.
All of this means that health systems and public health leaders must work that much harder to rebalance the scales and bolster access for historically marginalized and underserved communities. As we learned from our recent podcast conversation with Parkland Health executives, leaders must work proactively to reduce inequities by adopting a data-driven process for identifying the most vulnerable. Then, they must pair that data-driven outreach with a combination of online and in-person registration, door-to-door vaccination campaigns, mobile vaccination sites, and a triage process that redirects patients to vaccination sites during regular medical appointments.
With vaccine supply expanding rapidly, and with three effective vaccines now available in the U.S., we're likely to see fewer hunters over time. President Biden projects that the United States will have enough doses to vaccinate all American adults by the end of May. But between now and then, we're likely to see more examples of a new kind of consumer behavior: vaccine shopping.
The latest challenge: Vaccine shoppers
Vaccine shoppers aren't interested in just any dose; they are interested in getting the vaccine that they perceive to be the best. To be clear, our guidance (and the CDC's guidance) is for eligible adults to take any Covid-19 immunization available. But consumers are starting to call around to determine which manufacturers' shots are available at different locations, and they're starting to express preferences for one vaccine over another.
To be fair, there are some legitimate reasons for vaccine shopping. If someone is terrified of needles or has transportation constraints, Johnson & Johnson's single-dose option may make more sense. If someone may be allergic to ingredients in one manufacturer's vaccine, then it's great that we now have two other options. But too much shopping for one vaccine over another—especially if those shoppers are vocal about their perceptions of one product's superiority—can exacerbate both perceived and actual inequities. Moreover, if public opinion starts to skew perceptions that one vaccine is superior or inferior, then we risk increased hesitancy and mistrust, especially among people of color.
So far, most states have prioritized the most vulnerable people for Covid-19 vaccination. But as supply ramps up, public health officials and health system leaders may start to prioritize certain vaccines for specific populations. For example, there's already widespread talk of prioritizing Johnson & Johnson's easily transported, single-dose vaccine for vulnerable populations already struggling with access. Those who live far away from vaccination sites, lack easy access to transportation, or have other constraints that may make it difficult for them to follow up for a second dose may all truly benefit from easier access to a "one and done" vaccination.
However, we cannot acknowledge these advantages without placing them in historical and sociological context. Many of the potential beneficiaries mentioned above are also people of color—and if there's even a hint that the one-dose option is in any way inferior to the two-dose mRNA options, some may hesitate to take what's offered to them, concerned that this may be one more example (over hundreds of years) of the medical system prioritizing white lives over their own. Every health care leader and public official must continue to reinforce the message that no vaccine is superior to the others, and that all protect very well against severe disease, hospitalization, and death.
The future challenge: Vaccine avoiders
As supplies continue to increase, vaccine hesitancy and distrust have the potential to create yet another dilemma.
The Biden administration's promise of sufficient supply by May doesn't guarantee anything close to herd immunity—these projections don't account for the number of American adults who still aren't ready to get vaccinated. As of late February, Kaiser Family Foundation estimated that as many as 44% of American adults are still hesitant (22%) or unwilling (22%). If we don't make significant progress in lowering that number, we may soon find ourselves with the opposite problem from what we face today: too much supply, and not enough people who want a shot (or two). Before demand starts to dip, providers and public health officials must ramp up their proactive outreach and their efforts to build trust, particularly among communities of color.
While we're unlikely to reduce vaccine hesitancy to zero, there's much that health care leaders can do to empathetically listen, engage, and educate people in order to ensure demand keeps up with supply—and increase our chances of hitting something close to herd immunity this summer.