Public Health Weekly

An Epidemic of Vaccine Inequity

The latest Covid insights from former CDC Director Tom Frieden

Dr. Tom Frieden
Medium Coronavirus Blog


Photo: Paul Bersebach/Orange County Register via Getty Images

As predicted, a fourth surge of Covid appears to be beginning in the U.S., fueled by spread of variants and premature reopening. As CDC reports in its Covid Data Tracker, cases are up 7% nationally, and the test positivity rate is also inching up, now at 4.7%. Because the pace of vaccination has been accelerating, my prediction is that despite a fourth surge, deaths won’t increase substantially. But we must solve systemic issues of vaccine inequity, both in the United States and globally.

One particularly concerning trend is in Michigan. Hospitalizations in Michigan are increasing rapidly, especially among 40–49 year olds. There is a 30% increase in cases at middle and high schools associated with new outbreaks, in tandem with increased community transmission. Fewer people are staying home, a rate that is now similar to pre-pandemic levels. Is this a harbinger of spring surges elsewhere?

Vaccines are getting into arms

Vaccinations are continuing at a high rate: 2–2.5 million per day. That’s about 1% of eligible Americans every day — the challenge isn’t to increase much more but to keep up that pace to meet the new goal of 200 million doses of vaccine administered by the beginning of May. And, even more importantly, to improve targeting. Expanding eligibility helps. Increasing availability of the J&J vaccine helps. And communication about expanded eligibility, how to schedule appointments, and where to get vaccinated helps.

It’s essential that we fix the horrific inequities in vaccine administration. Scarcity is the enemy of equity. North Carolina and Chicago have succeeded in providing vaccination that is roughly equivalent to the population breakdown, but nearly everywhere else — at least where I’ve seen the data — is only reaching Black and Latinx people at about half the rate of White people (Asian and Native American/American Indian access is variable, depending on the population — see Navajo Nation below as one example).

This is even worse than it sounds, because Black and Latinx people are much more likely to get Covid and to die from it. In effect, other than the long-term care program, we are aiming our shots in a way that doesn’t do nearly as much good as it could.

It’s not enough to be concerned about equity, and it’s not enough to have programs that attempt to address it. We must succeed. Vaccinating specifically in hard-hit communities, with the J&J vaccine in addition to Moderna and Pfizer, is one important approach that needs to be scaled up, and fast.

Vaccines are saving lives already, and will save even more in the coming months. As I estimated last week, at least 40,000 more people would have died in U.S. nursing homes and elsewhere since the beginning of 2021 without vaccines. To give credit where credit is due: the Long-Term Care vaccine program is a big success!

And as reported in NEJM, there was a marked decline in SARS-CoV-2 infections among health care workers at a medical center in Jerusalem after a vaccination program was initiated there. Another example of vaccinations working!

Three big gaps in the U.S. vaccination program

1. Equity. Black and Latinx people are still about twice as likely to be killed by Covid but only half as likely to be vaccinated. We mocked up a data visualization (data not real!) to show how metrics could be reported. Every place should publish something like this to track their progress as they implement programs to fix inequities.

2. Doctors. Covid vaccination should be available in just about every doctor’s office, in addition to pharmacies and community vaccination sites. Many people who are reluctant to get vaccinated elsewhere will get vaccinated by their doctor. We need all hands on deck to end the pandemic.

3. Convenience. Polls show that many people who want to be vaccinated haven’t been able to get vaccinated. Variability among states — and even within states — is big. Particularly as the J&J vaccine becomes more available, one-shot vaccination at malls and other sites will be important. Convenience trumps reluctance.

Two questions about vaccines

First, how strong and long-lasting is vaccine-induced immunity? It looks very strong, but duration will take time to determine. And there will undoubtedly be some vaccine failures — people who get sick after being fully vaccinated. Such failures have been amazingly rare so far, and, when they have occurred, illness has been mild.

Second, will variants evade vaccine protection?

We need to continue reducing uncontrolled spread wherever it occurs, for ethical as well as epidemiologic reasons. The risk of dangerous variants is proportional to the amount of uncontrolled spread.

Vaccine side effects are rare

We also need to look closely at the data about the AstraZeneca vaccine and possible increased risk of blood clots. No vaccine is 100% effective or 100% safe, and some people will experience adverse events after vaccination. The challenge will be to determine if those events are caused by the vaccine, or are just coincidence.

As reported in BMJ, after 20 million doses of the AZ vaccine have been administered, less than 40 blood clot cases have been reported. Is there a link? Maybe, but even if so, it is not strong — and the benefits of vaccination still far outweigh risks. We need to resist drawing causal links where none may exist.

We’ll find out about vaccine failure when there are breakthrough cases, and about very rare adverse effects, if there are any, when many millions of people are vaccinated. So far, the vaccines are astonishingly safe and effective.

One great success story about the effectiveness of vaccines and a public health approach: the Navajo Nation has crushed the curve. Their impressive vaccination campaign has resulted in 57% receiving at least 1 dose (compared to 26% of the US population). They also maintained a mask mandate and continue to provide free masks and hand sanitizer and discourage travel. The result: cases and deaths have gone down to zero.

Global vaccine inequity

Global vaccine inequity is horrific. There is simply no ethical justification for healthy young people in any country getting the vaccine before seniors or health workers in any place where the virus is spreading. We must rapidly increase vaccine production and distribution to all countries, regardless of income level.

Although the vectored vaccines are less expensive, easier to store, and are single-dose, mRNA technology has a lower risk of missing production targets, is more adaptable to variants, and faster to scale. Basically, mRNA technology is as close as an insurance policy as we can have against production delays and variant vaccine escape. But we must scale up production of vaccines that are proven, with publicly available data, to be safe and effective.

Vaccine nationalism is ethically inexcusable but politically inevitable. Inevitable unless, of course, you’re Norway. Again showing moral and financial global leadership. Norway played a critical role in the development of many global health initiatives, and may well help create a better global system of solidarity and safety.

Cases are increasing again in many countries. Brazil, Kenya, Ethiopia, Poland, and the Philippines are just some of the countries struggling to control transmission and treat patients. We need control measures and vaccines quickly, for everyone. Until all are safe, we are all at risk.

Covid and mental health

The MMWR reports important new data on the mental health harms of the pandemic in the US, with at least 12 million more Americans struggling. There have been large increases reported in depression and anxiety, especially among young people and those with lower levels of education. Availability of treatment hasn’t kept up.

Lab creation unlikely

It’s very unlikely that SARS-CoV-2 was created in a lab. The genetic information strongly suggests that the virus evolved naturally. Is unintentional lab release a possibility? Yes, as the review commission has noted. In many ways, what happened doesn’t change what we need to do going forward. Whatever happened, we need better global lab safety and security.

The last smallpox case in the world was from a lab error in the UK. A flu strain accidentally released in the former Soviet Union in the 1970s may have spread around the world. Let’s work together globally to make laboratories safer and reduce the risk of future health threats.

Two great unknowns

First, what will humans do? Will we lose motivation to continue our fight against the virus as vaccines roll out? Will we fail to maintain patience, discipline, and solidarity?

Second, what will the virus do? Will variants evade the vaccine?

The future isn’t certain, but it is certain that our actions can make it safer.

It’s been said the only thing certain in life is death and taxes. To that, we must add the threat of future pandemics.

Covid is far from over, and the next pandemic could start any time. We must be better prepared, healthier, and more coordinated globally. Our public health and primary care systems need long-term investment.

Microbes outnumber us. If we work together, we can outsmart them.

“Encountering apathy, ignorance, and avarice is the lot of all conscientious health officers. As preventive measures in the health area are more successful, the public is less inclined to support the programs which ensure this success.”

John Duffy



Dr. Tom Frieden
Medium Coronavirus Blog

President and CEO, Resolve to Save Lives | Former CDC Director and NYC Health Commissioner | Focused on saving lives.