Discuss the strategies around equity in the distribution of the COVID-19 vaccines.
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Aletha Maybank, MD, MPH: Hello everyone. Welcome back to, I guess this is season two of Prioritizing Equity series. A lot has happened over the last month in this world and in this country. We have a new administration at this time who has issued major executive orders as it relates to advancing equity. And just to list a few of them, because I think it's just really powerful. And for those who don't know me, I didn't introduce myself. I have to get back in the habit of doing this. I'm Dr Aletha Maybank, chief health equity officer at the American Medical Association. But we have seen in the last week or so, several orders. One's related to transgender and reversing the previous administration's ban on transgender Americans being able to join the military and the appointment of Dr Rachel Levine as the first and highest ranking transgender person in HHS as the HHS assistant secretary. We saw also the rescinding of the 1776 commission that directed agencies to not do work really around the progress of racial equity.
And then we saw the release of the racial equity executive order that really called for it, and I quote it because I think it's really important, “to pursue a comprehensive approach to advancing equity for all, including people of color and others who have been historically underserved and marginalized and adversely affected by persistent poverty and inequality. Affirmatively advancing equity, civil rights and racial justice and equitable opportunity in the responsibility of the whole of our government.” To see racial equity mentioned explicitly is a tremendous progress from my perspective and I think for many of us in the equity space in this work. And I think it will go leaps and bounds for what can happen, what's the potential, the hope, the possibility of re-imagining our future I think happened a lot through this vehicle. However, in light of all of these progressive opportunities, we are very clear that we're still in this moment of our pandemic.
We have over 25 million cases in this country. Deaths are almost at the point of now 430 000, expected to reach 500 000 by the end of February. Vaccine rollout is in full swing, and we know that there are gaps in equities that is almost to be expected at this point in time. The Kaiser Family Foundation, who's really set up some excellent tools on collecting and reporting vaccination data. As of the 19th reported that 17 states were recording some vaccination data by race and ethnicity, including 16 states reporting the distribution of vaccines by race and ethnicity as well. But we understand looking at this data that Black Americans share vaccines. They're smaller than the share of their cases as well as their deaths and the same pattern for Latinx and Hispanic Americans as well.
And just to take a city by example, this week, Chicago, where AMA headquarters is located, reported out their data, and I think this is an important part of equity, they're very transparent about it. Setting up the data where 52% of whites received the vaccine, 15% of Blacks, 17% of Latinx and 14% of Asians. Understanding that 70% of the data is actually still missing as it relates to race and ethnicity. But she quotes that, “Equity is not only part of our COVID strategy, equity is our strategy.” And so they now have rolled out, I think, an explicit plan. So to deepen our conversation today, we have with us leaders. We have back to this space, so we have talked to Dr Torian Easterling before who is now first deputy commissioner. I don't think he was first deputy commissioner when we spoke to him last.
And he can talk a little bit about that and what that means because I think it's an important shift and chief equity officer at the New York City Department of Health. And we have Mr.— and he's going to help me with this, but I'm going to do my best—Kaakpema, because we folks know I'm not the best with names, but Kaakpema Yelpaala.
Kaakpema “KP” Yelpaala, MPH: Perfect. Thank you.
Yelpaala: Well done.
Maybank: Also, known as KP, who is chief executive officer and founder of access mobile International. So thank you both for joining me today and taking time out of, I know your tremendously busy schedules. I'm going to start off because I think it's an important way that we start it off before. It's just where you are located and just how are you doing in this space as a leader and doing this work. Dr Easterling?
Torian Easterling, MD, MPH: Great. Thank you so much, Dr Maybank for inviting me back. So great to be back. And I've certainly been following the series. And so, congratulations on the success of the series. KP, very nice to meet you. I'm glad to be in conversation with you today. Where I am, I'm in New York City. As you've mentioned, I've stepped into a new role as the first deputy commissioner and chief equity officer. And so very similar to the work when you were here, making sure that we are aligning our internal and external equity approaches. But also in my first deputy commissioner role, which is sort of the second in command, making sure that we're also moving on our non-COVID priorities because while we are responding to our public health emergencies, we do have the imperative to make sure that we are also meeting the priorities that New Yorkers are also facing from, you name it, criminal justice issues to housing insecurity.
So, that work is still happening. And how I'm doing, I'm sitting at this moment of that there is hope, that we're almost at the shore and really to safety and also sitting at this moment, taking me back to last year where so preparing for the birth of my daughter. And so this intersection of really trying to protect the time that I have, the little bit I have with my daughter while also trying to meet the demand of the work in this historic moment that we're in. So it's a lot, and it's challenging, but I'm also really inspired by all the work that's been happening in New York City and across the country.
Maybank: Thank you. KP. How are you doing? What are you doing?
Yelpaala: Great. Well, thanks for having me, Dr Maybank. Very nice to meet you, Dr Easterling. I am in Denver, Colorado. We've been working on COVID response since early last year. We work with a number of hospitals and health systems in the US including some in Los Angeles. So even from early last year, when LA was first going through its first phase of COVID, we then started working with health care providers there around how they could better engage communities of color. And then it's felt like I was talking to someone, I felt like they described it well. January 1st to me felt like day 366 of COVID. It's been very intense.
I think personally, we have concern for family members, and we're thinking about all those kinds of things. I have young children going through all those issues with virtual schooling and then their school community. So I think for all of us, it's impacting us personally and professionally. I feel very fortunate. I have the opportunity to work from home. I feel blessed. Not many people have that opportunity and privilege. Personally, it has been intense, but I think we're making our way and now partnering with folks around this next phase of priorities.
Maybank: Thank you. And can you just tell a little bit, because the audience may not be as familiar with access mobile. So can you just tell us this a little bit about what it is?
Yelpaala: Okay. So access mobile is an organization that we work globally, and our focus is on what we call multicultural patient engagement. So really thinking about diversity and inclusion and how we engage people around their health care needs. We're a digital health company. We're venture backed. We prefer to use mobile channels because we believe when we look at BIPOC populations, a lot of them you don't find on the patient portal. If we want to reach them, the mobile channel becomes a great way to do that. And so we work with health systems and pairs in the US and internationally doing that work.
Maybank: Thank you. I appreciate that. And for those who don't know what BIPOC is, that's Black, Indigenous and people of color.
Yelpaala: Thank you.
Maybank: And everybody can be familiar. Okay. So I'm going to just give a quick story. So I'm in New York City and I've been here since really the beginning of COVID. I'd been going back and forth between Chicago here and then wherever else in the country I needed to be. But now I've been in New York City for the most part. And initially, I've been working from home, and I felt a little bit out of the loop not being able to be in the health care space or the public health space. If I was in Torian's role, my old job, I would be engaged in action and activity and really being a public servant, which is such an honor. And then when you step away from it, you actually feel like there's a void.
And so now with the vaccinations ramping up and trying to figure out what we're going to do, I said this is a good opportunity. Now they need people, and I can get out and I can go volunteer. And so I reached out to Torian, I'm going to call you by first names now because we're on that basis, to say, hey, I want to sign up. So I signed up through the system. And the first message that I get last week says everything's on hold. And I think great success in New York City, they had over 600 plus volunteers.
They, I think, hosted something like 14,000 sessions or something to where you can give that exact update, but it said on hold, I couldn't do anything because of the concern of the supply of vaccine. And so it really hit me. So Torian, can you give us an update on what is happening in New York City and probably, I guess the state. You would have a sense of that a little bit, but definitely in New York City just as it relates to the supply issue of the vaccine and what challenges. Is that starting to pose for you all or opportunities as well?
Easterling: Certainly. So you're absolutely right. So we think about this supply capacity because you have to think about the access points and then also the eligibility criteria. We'll also talk about demand. In December, when we first started to roll out the vaccine distribution plan, the focus was really on eligibility criteria and we knew the group, it was really limited to health care workers and staff and residents in long-term care facilities and then also our access points, which were very limited, right? It was really to the health care workers and then the federal program with the pharmacies that were supporting the long-term care facilities. As the eligibility groups opened up, from our perspective in New York City, we started to think more about our locations that we wanted to make available for the eligible groups and that included beyond health care workers and now as of January 11, the governor has announced that the people at the age of 65 are eligible and there are other groups that are now also eligible at this time.
So it's been moving from capacity and eligibility, now really looking at supply. In New York City, we have over 1.2 million doses that have already been delivered to the city. But when you think about all the different access points, we have almost over 200 access points from city sides to FQHC, to hospitals, thinking about also our pharmacies. And think about that on a weekly basis, we get anywhere between 100 000 to 200 000 doses. And so not many when you're thinking about the allotment that can go to all the different sites, and we've made this data available. The doses that we have received, the doses that we've administered, but then also the doses that we've had on hand. Last week before we received this shipment, doses that we had on hand for first dose were under 19 000.
And so we did have to cancel appointments and reschedule them for this week. We just reopened our vaccine hubs, those city sites that you were referring to as of today. And so then that caused us to let folks know from our staffing and then also for the New Yorkers who had registered for those appointments that we were going to cancel our city sites and move them to another week. And so now we're coming back online because supply has been slow and certainly with the federal administration now really laying out their plan, it's really been hopeful and optimistic for us because this is really going to give us an opportunity to plan ahead for we were going week to week now, but certainly with the announcement of three weeks. This certainly gives us more opportunity to work with the state, get our approvals, and then make sure that we can communicate to New Yorkers.
But staffing, certainly something that we'll continue to look at our vaccinators as well. We have a number of different opportunities and potential ways that we're going to really do bringing in vaccinators, working with medical students, nursing students, retired physicians and clinicians, bringing them in as well. So you should be getting that notification.
Maybank: Okay, great. So when you elevated in that particular part of the conversation as well, and to me, as an equity strategy, is the level of communication that you all are doing. And can you just speak a little bit more about the specific equity strategies that you are employing? Because this is where I feel that many folks are not hearing enough about that are in the spaces to do this work. I think many folks are figuring it out and they have to, and they're responding in the best ways that they can. Many folks understand more and more what the gaps are, where the problems are, but they're not hearing enough about—so what are the actual strategies for equity? What does that mean? And so can you just speak to operationalizing that, what that looks like? And then, KP, I'm going to ask you the same question to follow up on that.
Easterling: Certainly. I think three ways that we're really looking at this. So one, on the data side. Really looking at how we can use our data to inform how we are setting up our access points. So back in June of 2020 through the city-wide racial inclusion and equity task force here in New York City which is being led by deputy mayors and also our first lady, we have been thinking about the neighborhoods that were disproportionately impacted. And so these are the neighborhoods that have had long standing inequities and also had high risk of exposures related to COVID-19. We looked at those neighborhoods, and we've identified locations where we're setting up our access points. And that means where are we going to actually be hosting vaccination centers and allowing those residents to come to get vaccinated. And so many of the neighborhoods that we've identified, we already have established those centers.
And we're certainly now making sure that the next step is matching those appointments with residents who are from those neighborhoods as well. I think the challenge for us, and just being transparent, is that we've looked at those eligibility groups. And certainly in those eligibility groups, they're going to be some structures and structural inequities because you think about health care workers, they certainly tend to lean more towards White individuals. And then also when you think about age, certainly Black and Brown individuals do not have the luxury of living to 75. We know the life expectancy in the Black and Brown community. So when you think about people who are 65 and older, we really have to tailor our engagement to those who are in the eligibility group. And then the other point is around access. So really building out a comprehensive engagement strategy, it doesn't always have government at the forefront, right?
And so we have a faith-based engagement strategy. We have a senior engagement strategy that is thinking about the vendors that we're actually contracting with, we have been contracting with through the years, that's really trained to do a lot. The messaging, scheduling the appointments, and then also offering transportation to those individuals that are eligible as well. And so we've been doing a number of different trainings to make sure that those organizations are certainly eligible. And then our data because we do know the neighborhoods where we're seeing low vaccination coverage. And so, what do we need to do in those neighborhoods where we're seeing low vaccination coverage, where we have partners where we need to get out more messaging and matching that with a lot of the hesitancy data that I know that we've seen nationwide. We've also done it here in New York City, making sure that our strategies are also in telling how we're combating this information and addressing consistency.
Maybank: Great. Thank you. And I think that you bring—this is a critical point of equity. KP and I were on a call about this and KP, you can chime in on this as well, is that an equity strategy to me is more focusing on the communities of need. It's not an equality strategy, right? And equality strategy may say we identify those by age, right? But the reality is that there's a need for people by age, not saying that fully, but we have to look at those most in need. And therefore we have to have greater specificity with our data and really use our data to pinpoint where that need is. And so it may not be all people who are 65 and older who have the greatest need, but where we geo-locate and find folks across the city. That's an important concept and context to equity and it's rough for people sometimes to really get that and understand. KP?
Yelpaala: Right. I think that's spot on. I think for policy makers, particularly looking at … I'm just going to talk about state governments, and what we observe. Equality is the easiest argument. We're just going to offer equality and access based on the phasing of priorities. But as to your point, that's different from acknowledging that even if we make equal access, not everybody is going to be able to equally access the vaccine. And then certain populations have historical racial and social injustice and mistrust, and they also want access. So you need actually, I think, both strategies. I'm empathetic to policy makers when they're thinking at that level of framing the lens of equality through the facing. But then equity goes to what you're talking about, just making sure that people that are getting most hit, that we're intentional about those strategies.
Maybank: And do you want to talk about now some of the work that you're doing in terms of your on the ground engagement and strategies with communities that have been made most vulnerable?
Yelpaala: Great. So I'll talk briefly about two examples. So we partner with Emory Healthcare in Atlanta. Last year, they were focused on COVID testing and really thinking about the disproportionate burden of morbidity and mortality on COVID for Black people. And so, they actually funded an initiative to focus on about 200,000 people in the Atlanta area and how we could facilitate more access. The model we call a connected community of care is basically what people are talking about around the country, which is health and wellness goes beyond the four walls of a hospital. And so, we're partnering with churches, Black-owned businesses, industry as the trusted messengers to the people they influenced around testing. And that model, it worked pretty well around testing access, and we're now trying to use that same strategy. But because we already built the infrastructure and relationships for testing, we can quickly use those same channels to communicate vaccination.
In Colorado, it's a similar strategy. We work with COVIDCheck Colorado, which is the largest statewide testing initiative. Health equity is in the core of their strategy. So they're doing all the right things in my view. They're measuring all the testing they do, and who's getting access based on how they see need in the state trends. Also, going to where people are so doing pop-ups in neighborhoods where the need is there, but it may be harder for people to get access. And so I think those strategies have been working really being intentional, tailoring messaging, building partnerships. I think what COVIDCheck has done well too is, for example, we'll promote something such as you don't need an ID to get a free test for COVID because we know there are plenty of undocumented folks who may want a COVID test, but they feel uncomfortable if an ID is required. So those are some of the nuances of how you execute the messaging and make sure it becomes broader and more inclusive to all pockets of the vulnerable populations.
Maybank: Absolutely. And I remember when Zika and Ebola were here, and I was in that role, we did a lot of engagement. Not just simply engagement, but partnership and mutual conversation with many folks who were either hardest hit as well as folks that were from the continent of Africa or their families were, and they were our employees. Really embracing that our employees are also assets and experts to this and can help inform I think our processes and what we put forward. Torian, can you speak to some of the work especially around language, because I think this is something that doesn't get brought up in terms of language engagement, even ability. That's another area that tends to go to the wayside, and not many people are really conscious about the impact for those who are disabled as well.
Easterling: Yeah. Just to think back around on something KP was saying earlier for policymakers and future policymakers, there's always going to be the pressure to move fast. And so, the question is how do you move fast, but also ensure equity? And I think that this is going to be the challenge, even the challenge during this distribution plan as we roll out the vaccines and making sure that you're having dialogue, your staff is having dialogue with community partners to make sure that they are a part of the planning process. That's key, and so that's making sure that there's the infrastructure during preparedness is there and so you're not really scrambling to set it up during a public health emergency. So I think that's been helpful to address the question that you're presenting because we can certainly point to the way that our forms are in translated. And we're translating our forms in the top 13 languages, but we also look at additional dialects.
So for instance, when we were doing testing in certain neighborhoods in the South Bronx where we know that there are West African dialects, but we know that Arabic is, certain dialects around the Middle East, are being used in that neighborhood. We've translated our documents in those dialects to make sure that residents were being engaged. And so we partnered with the masjid, we partner with other faith-based organizations in that area to make sure that we were able to not only have our forms translated in those languages, but we were also trying to make sure that we also have language access available onsite. So having someone that actually spoke that language to help someone navigate through the testing site. And so we are matching, trying to make sure that our vaccine sites are matched with those languages as well. Certainly English and Spanish, but certainly moving beyond English and Spanish and thinking about those other languages as well.
Many of the forms right now that we've been using, as I said, have been translated and can be translated online, but certainly having someone onsite. We've heard time and time again that that's really important. We also have the unique opportunity to really marshal resources from our other city agencies. And so, we've been working with the mayor's office here in New York City on persons with disability. We've been partnering directly with them to examine and assess all of our vaccine sites to make sure that they are accessible. And not only just thinking about mobility, but also thinking about sight and other forms of disability to make sure that individuals who are walking out to the site is very visible. Individuals can see where you need to go, where the lane is and how they're able to register. And even when we think about our website and any technology that we're using, certainly having our colleagues from the mayor's office of people with disability to really examine and make sure that they're also accessible as well.
Maybank: Great. Thank you. And that's a change that we see even in the new administration in terms of having someone available to interpret via sign language that we hadn't seen before in some of the press briefing. So I think that it's good to see that movement as well in terms of equity and that explicit acknowledgement. So KP, I would like you to speak to the nuance of the urban versus rural context since you have this national landscape and the experience there.
Yelpaala: Right. So I think just Torian's points taken about speed and thinking about quality versus equity. And I think when we think about speed and concentration of population, it naturally pulls us to urban areas. And even in terms of our equity strategies that pulls us into urban areas for our equity strategies. Even in a state like Colorado and in the South, we have significant rural populations, including rural populations of color. Here in Colorado, there's a very substantial Latinx rural population, right? And I think sometimes that gets missed. I don't hear that in the conversation. So on the one hand for us working on the ground, our first goal is everybody who's a yes and says they want the vaccine, and they've chosen, how do we get them in?
I don't care whether you're urban or rural. And I think there's so much focus on hesitancy that sometimes we might not be thinking that way to be like, if we could just find every yes everywhere and make it easy for them, that's going to go a long way towards herd immunity. And I think that when we think about the South, we think about places like Colorado, the urban-rural construct is a bit more nuanced in terms of even populations of color and how we think about access.
Easterling: That's so important. Just to piggyback on your thinking about demand. I think we have to think about demand as demand and hesitancy and how we're making sure to your point, because we know that the natural inclination is to think about hesitancy, but we know in our communities, particularly in Black and Brown communities, it's when you see your neighbor, the person you go to church with, your pastor is going to get vaccinated. Then that's going to inspire and encourage someone else to get vaccinated. And so, how do we match up to your point? Those individuals who want to get the vaccine and we don't have to do a whole lot of encouragement, they're ready. They're fine and they're looking for appointments. And truthfully when we've been doing a lot of the town halls, the first question is how come I cannot find an appointment?
Right. I know that there are questions about the science, and there's question about the vaccine, and we're certainly sharing factual information. But the number one question is, I've been trying to schedule an appointment, how can you help me?
Maybank: Right. And I think that's our test of time right now is getting this vaccine to people who definitely want it, who need it and where the data really points to where we need to go. In ending, these conversations go by quickly, and I really thank you both for your time. What do you think—I know it's hard to fully project, but what do you think is going to be our greatest opportunity? Because we are using equity as a strategy in the work that we're doing over the next couple of months, or even to the next year where it wasn't always explicit. And I think now it's explicit, people are really talking about it. And for the most part, people are really doing it. And I just wanted to hear from you, what do you think is going to be the opportunity learned from all of this? KP?
Yelpaala: So I think with the community and public health infrastructure that we have to put in place to execute access to this vaccine at scale, my hope is that that infrastructure now becomes a quote unquote community asset for all future health equity needs in those communities around health care and wellness. So in essence, we have not had an effective public health infrastructure in place to respond. We're being forced to create it now because of the situation and the lens of equity is in the center. So I think community infrastructure and assets are being created that should support wellness and wellbeing for those populations going forward. That would be my hope.
Maybank: Thank you. Torian?
Easterling: Yeah. I think the shift in the framing as KP is speaking to, as we really think about the broadness of what and how we need to respond to health inequities. I think we also then need to match that up with the structures that we have set up. How is your organization set up? How can you minimize silos? How can you really promote cross collaboration, not only within your agency, but across and other agencies as well? And I think that's going to be the future in this new normality of how organizations have to respond. And those that are not ready to do that, then maybe step aside and allow new leaders to really step in. And we're sort of seeing that, right? Organizations are certainly pushing more for a chief equity officer, making them part of the senior level cabinet. I think that's the step forward. And then that's also going to turn into the policies and practices that we want to see in this new world order.
Maybank: Great. Well, thank you both. Just want to remind for the audience that you can visit our health equity resource center for COVID 19 on the AMA website. And, coming soon, which we're very excited about is that there will be CME that will be available for watching and participating in the Prioritizing Equity video series and it will be on our AMA Ed Hub. We're going to put the link in the chat and anybody is able to go there to get other information as well. So thank you all again. And until the next time, please be well. Thank you.
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