Equity, North Carolina, and the Vaccine

Celebrating the arrival of a new decade was something Sabrina Clark relished. In January of 2020, things looked promising for the new year. But by the summer, her life had been turned upside down. Her mother and sister, who both had significant pre-existing conditions, had contracted COVID-19. She struggled to rearrange her work schedule to ensure her 14-year-old son had properly acclimated to virtual school. As a college-educated woman, she was well trained in her field, but social distancing protocols meant she could not do her job as before, and she lost significant income. The bills, however, continued to roll in. She took odd jobs to help make ends meet and looked desperately for state and federal leadership to work together to get the pandemic under control. Sabrina needed things to return to normal. Life in rural North Carolina was hard enough and this pandemic version was becoming unbearable.1 As news outlets reported vaccine development progress, she hoped that this could be a tool that leaders could employ to stop the spread.

Yet, at that very time, the Trump Administration was refusing Pfizer’s offer to buy up to 500 million doses, thereby derailing the plan to have every willing American vaccinated by early 2021.2 Instead of securing 500 million doses, the administration only bought 100 million. The general public only learned about this in late December 2020, when vaccine developers announced that they would have limited supply well into 2021. Put into a logistically challenging situation, leaders in the state followed evolving federal guidance. They worked to find a solution that required distributing a fragile vaccine product to 100 counties in five different priority phases with very little lead time.3 These challenges trapped policymakers into a situation that has had a tremendous impact on vaccine equity for North Carolina’s African-American seniors, as well as Sabrina Clark’s quest for normalcy.

As of February 17, 2021, North Carolina has administered approximately 1.2 million first doses of the COVID-19 vaccine to priority groups 1 and 2, including health care workers, longterm care staff and residents, and adults 65 and older.4 White North Carolinians make up 71 percent of the state’s population and 62 percent of the state’s COVID-19 cases but account for 78 percent of vaccinations. African Americans, on the other hand, make up 22 percent of the state’s population and account for 21 percent of COVID-19 cases but only make up 15 percent of first doses. The disparity between white and Black North Carolinians is even starker for second doses. Of the 546,479 second doses administered, white North Carolinians received 82 percent while Blacks received 11 percent.5

The distribution of the vaccine to date is incongruent to the rate of infections, hospitalizations, and deaths experienced between white and Black North Carolinians. Currently, Black North Carolinians have a death rate of 113 per 100,000 compared to 94 per 100,000 for white North Carolinians, 87 per 100,000 for Indigenous People/Native Americans, and 38 per 100,000 for Asian American Pacific Islanders, as of February 17, 2021.6

As North Carolina course corrects its vaccine distribution strategy to address such disparity, it is worth simultaneously analyzing the drivers of the more well-defined African American suffering from COVID-19 and the state’s current inequitable vaccination distribution outcomes. This will allow stakeholders to collectively craft the type of policy that acknowledges the weight of embedded, legacy discrimination and the impact on current health infrastructure and Black health outcomes.

James Johnson, Jeanne Bonds, and Allan Parnell illuminate these points in their 2021 white paper, “Coronavirus Vaccine Distribution: A Race Blind Approach to a Racially Disparate Problem.”7 The authors warn of the many pitfalls of adopting a race-blind vaccine distribution policy (or any race-blind policy) and argue that differential Black suffering from COVID-19, as such, is no accident. Their research reminds stakeholders that appalling quality of life outcomes experienced by African Americans (particularly seniors in this context) in North Carolina are an undeniable consequence of systemic and institutional racism. Many African Americans, whether hamstrung by a persistent education achievement or attainment gap, have faced intense employment discrimination throughout their prime earning years. The authors contend that employment discrimination has led to lower and inconsistent wage-earning, often fast-tracking African Americans (particularly elderly) to racially segregated, polluted, and isolated communities at the end of their careers. More potent exposure to industrial-level chemical pollutants, the prevalence of food deserts, and distance from health care facilities can contribute to and accelerate the onset of major chronic conditions like diabetes, heart disease, and cancer. Over time, these conditions compromise immune systems and peak organ functionality, leaving African Americans more susceptible to COVID-19 infection.

Given the unmistakable legacy and deadly impact of systemic and institutionalized racism that has left many people of color epidemiologically vulnerable, there is a serious argument for vaccine prioritization for African Americans and other historically marginalized communities in North Carolina. Instead of targeted race-conscious health policy, there are often attempts to explain away race specific disparity with overly simplistic notions. The most popular is that most African Americans are too skeptical, given the legacy of intentional medical malpractice directed towards Black people in the United States (i.e., Tuskegee Experiment), to take the vaccine.8 This, to some, justified distribution disparity. This thinking assumes falsely that African American sentiments and experiences towards COVID-19 and the vaccine, while shaped by the ever-present impact of white supremacy, are the same, a monolith. It further assumes that African Americans cannot distinguish the contextual differences between intentional syphilis infection in the 1950s, forced sterilization in North Carolina from 1929 to 1973, and a global pandemic of the 2020s.9

A fairer approach to understanding the race gap in vaccination uptake (and the experience of the pandemic thus far), in addition to acknowledgment acknowledging the impact of systemic racism, is to survey the perceptions of African Americans. Simply put, by asking African Americans about their experience living through the pandemic, the response of state elected leaders, and the vaccine.

To that end, we interviewed eight African Americans from various age groups in southeastern North Carolina, central North Carolina, and the Piedmont to gather their perspectives.10 While not intended to be generalizable of the over 2 million African Americans across the state, their testimonials provide a limited but illuminating insight into how a race-conscious approach to prevention and vaccination should move forward.

The first case of COVID-19 was reported in North Carolina on March 3, 2020.11 For many, watching an unpredictable virus travel nearly 7,500 miles and begin moving through their home state produced a range of emotions. When asked what they thought when they heard about the first case having made it from Washington State to Wake County, a 33-year-old African American woman from a metropolitan area in southeastern North Carolina offered her thoughts:

The virus was here now. But some felt differently. Confident even. A 36-year-old African American and new mother from a major metro area in central North Carolina said that she did not feel fear. The U.S. government’s past record dealing with other infectious disease had inspired confidence.

The community knew, however, that once the virus started spreading throughout North Carolina that it was going to have a different, harsher impact on the African American community. Even with this tacit realization, a graduate student from a southeastern part of the state expressed shock with which the speed and lethality the virus struck his community.

A college-educated single mother was similarly rocked when close family members contracted the virus before they fully understood how it was transmitted.

A testament to the absence of infrastructure and intentional investment which has exacerbated outcomes was reflected in the concerns of a young woman from a Piedmont metropolitan area.

There was serious concern for those faced with the rapid spread in African American communities. Folks were concerned with their pre-existing conditions, making them more likely to have adverse outcomes if infected.

When asked directly about pre-existing conditions, an African American woman from a small community responded frankly.

These concerns of pre-existing conditions and lack of access to health care were warranted. In earlier days of the pandemic, the infection rate for people of color in North Carolina revealed enormous disparity, which has played out in the experiences of Black people throughout the state. A graduate student respondent recalled how many people he knew who had contracted COVID-19 …and how many of those were African American.

Other interviewees responded similarly.

Since March of 2020, more than 730,000 North Carolinians have recovered from COVID-19. Unfortunately, more than 10,000 lost their battle with the virus or complications.12 Here is what the previous three respondents shared about the number of people they knew who had passed away from COVID-19, and how many of them were African American.

When reports that Moderna and Pfizer were nearing the last stages of vaccine trials, President Trump lauded Operation Warp Speed as a success, the federal effort to incentivize a vaccination solution.13 A vaccine for COVID-19 would indeed be a game-changer in the midst of a society that was chafing at the prospect of having to remain in lockdown. Sadly, given the President’s behavior, there was significant skepticism around the motivation for a fast-tracked vaccine. The interview responses reflected this sentiment when asked about their thoughts of Operation Warp Speed.

Given the random nature of the survey pool, most respondents were under age 65 and had not yet had the opportunity to take the vaccine. The one exception was a faith leader from a border county in the southeastern part of the state.

Many expressed passive, cautious interest in receiving the vaccine, but were frustrated with the seemingly haphazard, regionally random rollout.

Not all opinions were negative, as several responses reflected optimism and a recognition of state leadership’s efforts around equitable distribution.

“Would you personally take the vaccine?”

When asked the question “Would you take the vaccine and do you have any reservations?”, as expected there were several varied responses.

Conclusion

The legacy of decades of policy choices in North Carolina, influenced either by racial animus or racial indifference, has shaped the experience of every one of the respondents.141516 However, their opinions and perspective surrounding the pandemic and vaccine distribution were often starkly different. Again, African Americans are not a monolith. What did seem somewhat consistent was the distrust of the intentions of the Trump Administration and a desire for the state government to be more coordinated in their effort to reach rural communities, but this is not a sentiment exclusive to communities of color.

What does appear to be a unique feature of communities of color is the damage done by years of pervasive neglect. It is because of this shameful legacy that special effort has to be made to overcome the barriers of distrust as well as the challenges present due to lack of health care infrastructure (i.e., pharmacies, distance to hospitals, local primary care physicians, transportation, rurality, etc.).17 Blaming “cultural decisions” as the primary driver of disparity in vaccine receipt is an unhelpful excuse to cover the complex and often insidious impact discrimination has had on African Americans in every facet of life. This would include the ability to work from home, the resources to afford proper PPE, the ability to secure fresh food safely, the space to manage one’s mental health, and the ability to seek out the information about the vaccine, make arrangements, and to receive it.

To many, these things may seem trivial. But to those whose everyday lives are marred by the vestiges and innovative forms of discrimination, things are not as easy. Only after we collectively accept this as fact and work tirelessly to eliminate it will we truly achieve racial equity in all outcomes. Racial blindness is racial indifference. It is the kind of policy we cannot afford to create or tolerate.

Footnotes

  1. Clark, S. (2021, February 9). Personal interview [Personal interview].
  2. The Associated Press, Chow, D., & Hiler, C. (2020, December 8). Trump administration passed up chance to lock in more Pfizer vaccine doses. NBC News. https://www.nbcnews.com/science/science-news/trumpadministration-
    passed-chance-lock-more-pfizer-vaccine-doses-n1250357
  3. February 4, 2021, House Committee on Health Meeting, 2021 – 2022 Session North Carolina General Assembly,
    testimony Dr. Mandy Cohen
  4. North Carolina Department of Health and Human Services. (2021). Vaccinations: NC DHHS COVID-19. https://
    covid19.ncdhhs.gov/dashboard/vaccinations
  5. Ibid
  6. The COVID Tracking Project. (2021). North Carolina: Race & Ethnicity Historical Data. https://covidtracking.com/data/state/north-carolina/race-ethnicity/historical/
  7. Johnson, J. H., Bonds, J. M., & Parnell, A. M. (2021, January). Coronavirus Vaccine Distribution: A Race Blind Approach to a Racially Disparate Problem. UNC Chapel Hill. https://kenaninstitute.unc.edu/publication/
    coronavirus-vaccine-distribution-a-race-blind-approach-to-a-racially-disparate-problem/
  8. Centers for Disease Control and Prevention. (2020, March). Tuskegee Study – Timeline – CDC – NCHHSTP. US
    Public Health Service Syphilis Study at Tuskegee. https://www.cdc.gov/tuskegee/timeline.htm
  9. Kaelber, L. (2014, October). Eugenics in North Carolina. Eugenics/Sexual Sterilizations in North Carolina.
    https://www.uvm.edu/%7Elkaelber/eugenics/NC/NC.html
  10. Interviewees have been afforded general anonymity, Personal interviews were conducted via Zoom between February 6 and February 9, 2021. Audio has been saved and protected on an encrypted hard drive.
  11. North Carolina Department of Health and Human Services. (2020, March 3). North Carolina Identifies First
    Case of COVID-19. North Carolina Identifies First Case of COVID-19. https://www.ncdhhs.gov/news/pressreleases/north-carolina-identifies-first-case-covid-19
  12. The COVID Tracking Project. (2021). North Carolina. https://covidtracking.com/data/state/north carolina/
  13. Slaoui, M., & Hepburn, M. (2020). Developing safe and effective Covid vaccines—Operation Warp Speed’s strategy and approach. New England Journal of Medicine, 383(18), 1701-1703.
  14. Stoesz, D. (2019). Reparations: An Estimate of the Consequences of Denying Social Security to Agricultural and Domestic Workers. Available at SSRN 3364315.
  15. Brinkley-Rubinstein, L., & Cloud, D. H. (2020). Mass incarceration as a social-structural driver of health inequities: a supplement to AJPH.
  16. Dozier, N., & Munn, W. H. (2020). Historical geography and health equity: an exploratory view of North Carolina slavery and sociohealth factors. North Carolina medical journal, 81(3), 198-200.
  17. Gee, G. C., & Ford, C. L. (2011). STRUCTURAL RACISM AND HEALTH INEQUITIES: Old Issues, New Directions. Du Bois review : social science research on race, 8(1), 115–132. https://doi.org/10.1017/S1742058X11000130