COVID-19 and Domestic Equity

J. Nadine Gracia, executive vice president and chief operating officer at Trust for America’s Health, and Jennifer Nuzzo, senior fellow for global health at CFR, discuss the COVID-19 vaccine and ensuring it is equitably distributed throughout the United States. 

Learn more about CFR's Religion and Foreign Policy Program.

FASKIANOS: Thank you. Welcome to the Council on Foreign Relations Social Justice and Foreign Policy webinar series hosted by the Religion and Foreign Policy Program. I'm Irina Faskianos, vice president for the National Program and Outreach at CFR. As a reminder, today's webinar is on the record and the audio, video, and transcript will be available on our website, CFR.org, and on our iTunes podcast channel, Religion and Foreign Policy. As always, CFR takes no institutional positions on matters of policy. We're delighted to have Dr. J. Nadine Gracia and Dr. Jennifer Nuzzo with us to discuss COVID-19 and domestic equity. I've shared their bios with you so I'll just give you a few highlights.

Dr. J. Nadine Gracia is executive vice president and chief operating officer at Trust for America's Health, where she works to develop and implement strategic policy priorities and manages their core business functions and internal operations. Prior to joining Trust for America's Health, she served in the Obama administration as deputy assistant secretary for minority health at the U.S. Department of Health and Human Services. There she directed departmental policies and programs to end health disparities and advance health equity and provided executive leadership on administration priorities, including health reform and criminal justice reform. She also led the Federal Office of Minority Health where she pioneered innovative multisector partnerships in the public and private spheres. She also served as chief medical officer in the Office of the Assistant Secretary for Health.

Dr. Jennifer Nuzzo is a senior fellow for global health at the Council on Foreign Relations. She's also a senior scholar at the Johns Hopkins Center for Health Security and an associate professor in the Department of Environmental Health and Engineering and the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health. An epidemiologist by training, Dr. Nuzzo's work includes global health security with a focus on pandemic preparedness, outbreak detection and response, health systems as it relates to global health security, and infectious disease diagnostics. She directs the Outbreak Observatory, which, in partnership with frontline public health practitioners, conducts operational research to improve outbreak preparedness and response. And she's also the lead epidemiologist for the Johns Hopkins COVID-19 Testing Insights Initiative housed within the Johns Hopkins Coronavirus Resource Center. So thank you both for being with us.

Dr. Nuzzo, I think I'll start with you to give us a brief overview of where the vaccines stand for COVID-19 production, logistics, and the timeline for getting the country vaccinated as we now have a new administration—very nascent, under a week old—and what you see coming down the pike.

NUZZO: Sure, thanks so much and I'm really happy to talk about this issue. I know there a lot of questions about it, everybody sort of wondering where they are in line and whether they should take it. So just to offer my perspectives on the issue both as an epidemiologist, so sort of understanding what the value case of using vaccine in this context is, as well as someone who has been working on the field of pandemic preparedness and seeing, if we are to get ready for pandemics, what tools do we need. It's almost always the case that thinking about having a vaccine in hand becomes a game changer. So I'm oriented to the use of vaccine through that lens, which is that it's an incredibly important tool. And I am so very happy that we are lucky enough to have options to vaccinate now.

I get a lot of questions about the vaccine and often these questions are laced with concern in part because of perceptions that these vaccines have been developed in what seems to be an unprecedentedly quick time, a short period of time. And it's partially true. But I think what we have failed to acknowledge is that people have been working to develop coronavirus vaccines since the first SARS virus was identified in 2003. So, in recognizing that we had a new coronavirus that's circulating, another SARS virus, SARS-CoV-2, this virus is called, scientists didn't start from scratch. They built on the, close to, gosh, almost twenty years' worth of research that had been done before. There's a reason why we didn't have a coronavirus vaccine before now and in part that the way vaccines are developed, that the early stage research is often funded by government and it may be done through the NIH or through academic groups. They get the vaccine to a point and then inevitably it has to be sort of turned over to a company to do the very expensive and usually time-consuming clinical trials that will allow a vaccine candidate to be developed into an authorized or licensed vaccine that can be used in people. With the other coronaviruses, it's not just the 2003 one, but there was a later one that was associated with Middle East Respiratory Syndrome a few years ago, there was never a market for those vaccines. The first virus, SARS, disappeared and MERS was never really one that was contagious between people in a sustained way. And so the idea of turning over a vaccine candidate to advance clinical trials just didn't make business sense for companies that would normally take up that take up that work. So I just want to acknowledge all of the scientific progress that's been made to date.

But in the context of the vaccines that we have now, it is true, from isolation of a new virus to the availability of authorized vaccines in under a year, that is a fast time. And there's two reasons for that speed. The one is the vaccine technology that's being used. So the vaccines that we are currently inoculating people with here in the United States are based on a new technology called mRNA vaccines. And basically what it is, is a genetic code that gets injected in your body that can use that information to make a protein that it will present on some of the surface of your cells, your immune system sees that protein, learns to recognize it, goes after it, attacks those cells, and in the process gets trained to recognize that protein the next time it should invade your body. That protein is what the SARS virus, SARS-CoV-2 virus, uses to infect yourselves. So we've never used an mRNA vaccine like this. The advantage to this approach is that you can develop a candidate in really a matter of days. So that's a shorter period of time, because once you figure out what the genetic code is for that protein then you know how you're going to make your virus. What then takes time, and this is true of all vaccines, is to do the rigorous clinical trials that can establish that the vaccine candidate is both safe and effective. And there we have had an unfortunate benefit of speed, in the sense that the reason why we were able to go through the same rigorous clinical trials and get to a authorized vaccine more quickly than we would for other vaccines, is unfortunately because so many people have gotten infected with this virus that we were able to achieve statistical significance in the clinical trials more quickly than with other diseases where you have to wait a long time to accumulate enough people in your placebo group who get infected. So it's an unfortunate benefit of the pandemic that has really gotten to we're looking at almost a hundred million global cases being reported either today or tomorrow. But that has enabled us to get to the point of the vaccines being available.

Now, of course, comes the hard part. And unfortunately, while there has been a lot of effort that has gone on to the science and to assure that the vaccine is safe and effective, in my view much less effort has been put into figuring out how we were going to distribute this vaccine in a way that's both fast, because the sooner we get it into arms the faster we protect people, particularly seeing that the increased transmission of the virus in recent months, but also with respect to our knowledge of who is most at risk, both in terms of exposure and in terms of severe outcomes like hospitalizations and deaths. And one thing that's been abundantly clear since pretty much the start of this pandemic is that we don't all share those risks equally. And so in vaccinating, we must be mindful of the disparities that exist and make sure that we don't leave behind the communities who have been disproportionately affected by the virus.

So the Biden administration has set a goal of doing a hundred million vaccinations in a hundred days, which amounts to about a million vaccinations a day. We're averaging about that now. I think in the coming weeks there'll probably be some questions about the availability of vaccines that could affect our continued progress on that front. But other vaccines are in development and may help alleviate some of the supply bottlenecks that are currently being experienced. Now I think the hard work is figuring out how we administer these vaccines, both with an eye towards speed because we don't want this virus to continue to circulate and outpace efforts to vaccinate people, we want to be able to protect as many lives as possible by using the vaccine, but we also don't want to administer vaccines in a way that further entrenches the disparities that we've seen. And unfortunately some of the anecdotal reports is showing that the coverage of vaccine has not been achieving those equity goals. So there's just a report today that African Americans are underrepresented in those who have been vaccinated to date. It's both a function of access issues and the challenge of trying to vaccinate people quickly. There also mistrust issues that similarly need to be addressed. And it's also the fact that most states aren't even tracking their vaccination progress with respect to these equity goals. And so that will be, I think, a challenge in the weeks and months ahead is to make sure we're making sufficient progress while not leaving communities behind.

FASKIANOS: Thank you, that's a perfect segue now to Dr. Gracia to talk about your work addressing health disparities and what you feel needs to happen in order to ensure that the COVID-19 vaccines are distributed equitably and we're not leaving those populations behind.

GRACIA: Thank you very much and good afternoon, everyone. It's really a pleasure to join in this conversation today. I'm really honored to be here and, in particular, in the context of religion and social justice and knowing how much you as religious leaders and those of you of faith and civic institutions are so vital in the efforts to advance equity in the COVID-19 pandemic, not only in the response but also in the recovery. And we are certainly sitting here at a time in the United States where we have more than twenty-five million cases of COVID-19 and more than 420,000 lives lost and always remembering that these are individuals and not statistics, and that there are countless family members and friends and neighbors who mourn their passing. And as we're talking about here, the pandemic has exposed and it's exacerbating our deeply-rooted structural and systemic inequities, which continue to challenge us. And these disparities we know existed long before the COVID-19 pandemic. And while disparities show themselves during so-called normal times, they're certainly exacerbated during emergencies. And we see these not solely in health, per se, but we see these in the structural drivers of health that lead to what we see as differential power and resources in communities, such as unequal social and economic and environmental conditions, whether it's substandard or lack of access to affordable housing to lack of good jobs, to less access to healthy food grocers to less availability of health care services and poor quality schools, as well as greater exposure to pollution. And we often in public health will frame this as the social determinants of health, which have such a significant influence on health and how this is unfolded before our eyes. We're seeing how these conditions have put certain communities at greater risk of exposure, of illness, of hospitalization, and of death from COVID-19. And much of that inequity really has spanned generations resulting from poverty, from discrimination, structural racism, and disinvestment in far too many communities.

And when we think about the definition of health equity, that it's a fair and just opportunity to be as healthy as possible, we must really then center equity in our efforts as it relates to addressing the COVID-19 pandemic and now this opportunity that we have through the COVID-19 vaccine. But what we're seeing, certainly, as Dr. Nuzzo discussed, we see that Black and Latino, Native American, Native Hawaiian, and Pacific Islander communities are experiencing disproportionately higher rates of cases and hospitalizations and deaths, that Asian-American communities are facing rising rates of discrimination and prejudice, that their historically underserved communities such as low-income populations in rural communities, as well as certain immigrant communities that are encountering really significant challenges and barriers to accessing services. And that groups that typically have been largely marginalized, whether that's individuals who are homeless or who are in correctional facilities, are experiencing really concerning outbreaks and many others. And these are just some of the many stark realities that we're facing. And we know that these are not just disproportionate health impacts, but that there's also certainly the economic impacts that was alluded to as well.

But when it comes to the moment that we're in, it's really, I think, both complex but a critically important task of COVID-19 vaccine distribution and administration and ensuring that that distribution and uptake are equitable, for this is really an effort unlike any that we've undertaken as a nation. But we should bear in mind that as we embark in this, the vaccinations and barriers to vaccinations have long existed, for example, among people of color both in terms of the challenges in access to, as well as, as was noted earlier, some of the issues with regards to mistrust in government and health system, which is rooted in historic maltreatment through today where there's ongoing present-day racism and discrimination. And as you heard just last week, actually, the Kaiser Family Foundation released a report showing that people of color, in particular, Black and Latino communities, are seeing lower rates of vaccination. And so it really raises the concerns about access to the vaccine as well as ensuring that there is outreach and education to address questions and concerns that communities have.

So our organization, Trust for America's Health, we are a public health policy, advocacy, and research organization in Washington, DC, and just last month we released, in partnership with the National Medical Association and UnidosUS, a report on earning and building trust in access to COVID-19 vaccine in communities of color and tribal nations where we focused on recommendations for policymakers to address access to the COVID-19 vaccine in a safe and equitable way. We had over forty groups and organizations that participated in a convening in which we got their feedback to talk about how do we prioritize equity in particular as a vaccine distribution and administration began. And there were some key recommendations that we outline in this report. One, as Dr. Nuzzo described, and she did it really well, to explain the process of vaccine development, because that's really important to ensure that communities understand the process, that there's transparency and an understanding how safety has been a priority in the vaccine development process. That, two, you're equipping trusted community organizations and networks within communities of color and tribal nations to participate through the spectrum—from the planning, to the education and delivery, and administration of vaccinations—and ensuring that there's meaningful engagement of those trusted entities, including faith-based organizations, faith leaders, religious leaders, to have a seat at the table and really be involved in that planning. And not only that but ensuring that they have the resources and tools to do so. Thirdly, we talked about providing communities with the information that they need to make informed decisions and to deliver messages through trusted messengers and pathways. And importantly, we should recognize that all communities and families want to be healthy, they want to keep their families healthy and safe, but need access to information that is culturally and linguistically appropriate, that provides them with the services that they need. And so importantly as we turn to trusted messengers, it's also ensuring that there's funding that's going to those community and faith-based organizations to be able to do this work, to be able to do the outreach that's needed. Fourth, we recommend that we ensure that it's as easy as possible for people to be vaccinated and that vaccines actually are delivered in community settings that are trusted, that are safe, and accessible. And the challenge can be having vaccination sites. If they're not accessible to communities, especially those that are disproportionately impacted, then you're not going to see the vaccination rates that you're hoping to see. And so ensuring that, in partnership from the federal to state to local, tribal and territorial levels, working within communities, that those types of vaccination sites are truly accessible and trusted in communities. We also have a recommendation on ensuring that there is complete coverage of the costs that are associated with vaccines that are incurred by individuals as well as the administration costs that providers have with regard to vaccinations, because cost really cannot be a barrier with regards to vaccination efforts. And lastly, it's that we ensure that there is funding and the resources to actually have data that are disaggregated. As you heard, there are a handful of states in which we have the data that are showing, by race and ethnicity and other factors, who was actually being vaccinated. But we need to do much more to be able to actually have access to that data. And that's been a long-standing challenge in public health and the surveillance systems and really shoring up the system to be able to do so. Because that will then help us to know which communities are not being reached, where we need to target our efforts, and ensuring that they have access to the vaccine.

What's clear through this crisis is that we really can't succeed to getting to the other side of it without caring for everyone and prioritizing equity. And that includes in the COVID-19 vaccine distribution and administration. And with some of the more recent COVID-19 relief bills that were passed in December, there's more funding now getting to states and localities. That's going to take time with regards to the distribution and administration, and so really working in partnership to ensure that communities are being reached as it relates to having access to those resources for vaccinations. And as was alluded to with the Biden-Harris administration, that with this new administration and the priority on not only COVID-19, but on prioritizing and centering equity, there really is opportunity here to ensure that we can have equity in the COVID-19 pandemic response moving forward and in the recovery as well. And we all certainly have a role to play. And certainly you as religious leaders, your voice and engagement are so essential. So I look forward to the conversation that we'll have this afternoon on how we can further really address some of the inequities that we see and how we work to advance equity not only for COVID-19, but for the health and well-being and economic vitality of our nation moving forward.

FASKIANOS: Thank you very much. Let's go now to all of you for your questions. You can click on the "raise hand" at the bottom of your screen. If you're on a tablet, you can click on the "more" button and raise your hand there. And you can also type your question in the Q&A. And the first question comes from Bishop John Chane, and he was formerly with the Washington National Cathedral: "Given the mutation of COVID-19, why are the variants in Great Britain, Brazil, and South Africa different from the original COVID-19? And what are the elements in these countries that make these variants so different? And why in some cases, more lethal and more virulent?" And I would just add to that it's obviously here in the United States. We've seen it's now circulating here in the U.S. So Jennifer, do you want to start?

NUZZO: Sure, so all viruses mutate and this virus has, previously, pretty much since as soon as it was identified. But the mutations haven't really got the level of attention until now, in part, because they didn't really change much. I will call it for simply because the scientific name is so impossible, a string of numbers, it's really terrible, but this is unfortunate, I'm going to say the “UK strain” really got global attention because of an observation that it seemed to be producing more secondary infections than the previously circulating strains or the previously dominantly circulating strains. There is some question as to whether the virus is also more lethal though. I think that data aren't clear on that at this point. But anyway, the idea that the virus potentially could grow cases more quickly just because with each infected person they may have a viral load, we don't fully understand the mechanism, may affect more people than an average person who was infected with the virus that didn't have that mutation. That is obviously worrisome, because if the epidemic accelerates even further that obviously makes control much harder. I think the bottom line right now, just the public health takeaway, is what the discovery of these variants very much underscores is the need to act with urgency, but it doesn't, at this point, change what we need to do. So the more people who get infected with the virus, variants or not, the more opportunities there are for mutations, the more possibilities that these mutations could produce functional differences like either in transmission ability or in severity or potentially the ability to evade vaccines or medical countermeasures. We don't have data get to suggest that as a problem right now fully. There is a little bit of concern from the variance from South Africa that they may produce a different immune response. But so far there's still confidence that the vaccines will work. But it just raises the possibility that maybe perhaps one day we will be dealing with viruses that are harder to control with the tools that we have. So the takeaway is that these things add urgency.

One challenge in all of this is that not all countries are looking for genetic mutations. And the ones that do, we don't all do them at the same frequency. So the UK and South Africa are two countries that have done some of the most sequencing in the world. And they are unfortunate to have found these variants and reported them because now countries have responded with travel restrictions and all sorts of penalties that sort of hurts the messenger. The United States, for having the largest epidemic in the world, we have only a sequence of very, very small, like tens of thousands of our cases versus the twenty-five million that we've had. So that's just to say that our understanding of what variants are out there and where they are and where they aren't, in my view, is very much flawed based on completely inadequate surveillance. That said, what we've discovered so far suggests that we need to get serious about controlling COVID, pursue the vaccination efforts while we can, but also we can't give up on our public health efforts. And we must double down with urgency because again, the goal is to protect people with vaccine and not to let the virus outpace those efforts.

FASKIANOS: Jennifer, are we ramping up our sequencing here in the U.S.?

NUZZO: I do believe we're doing more sequencing than we were doing, but I think it's a marginal difference from where we were before.

FASKIANOS: Okay, I'm going to go next to David Greenhaw. And please unmute yourself. David, are you? Good. You just need—there you go. Please identify who you are.

GREENHAW: Yes, I'm David Greenhaw, president emeritus of Eden Theological Seminary in St. Louis, an ordained minister of the United Church of Christ. I watched and participated in a parallel event we did a week or two ago on global equity, and I've been thinking about the generosity that people have. And if we could engage their generosity, that is, they're not simply serving their self-interest by getting a vaccine, but by getting a vaccine they're actually trying to save another life. And it occurred to me given the need for financial support globally, has there been or could there be something like a March of Dimes where people would be called to save a life by "get a vaccine, give a vaccine," so they'd be encouraged to give five to ten dollars, whatever the global support rate is and do that. Do you know of such efforts and do you have any thoughts about the efficacy?

FASKIANOS: Dr. Gracia?

GRACIA: Thank you, David, for that question. And I am not familiar with specific efforts related to that, but there's messaging that you share that there are quite a few efforts as it relates to how to message the importance of the vaccination and groups that are really engaged, both from the public sector with regards to the federal and state and local public health agencies, but also in the private sector that are really working in, one, doing surveys to identify what messaging seems to be most effective in helping to inform communities about the benefits of the COVID-19 vaccine as well as to address concerns that may arise as it relates to the COVID-19 vaccine and importantly to understand that communities are not monolithic. That even in speaking of communities of color or even in speaking of, for example, the Latino community or the Black community that there is heterogeneity across communities and understanding what messages may really resonate and help inform communities to make the decisions with regards to vaccinations. And again, as I pointed out to understanding that individuals and families want to keep their families safe. And there was recently, from the de Beaumont Foundation, a survey that they conducted and some information that they shared and tips with regards to messaging as it relates to the vaccination efforts. And one is really importantly to describe the benefits of vaccination and not solely focused on or emphasize the consequences of not getting vaccinated. And so your point where you talked about that by you yourself getting vaccinated, that you can then help to protect others and encourage others is one of the messages with regards to saying, for example, that the benefit is that it's an important way to protect you and your family from COVID-19 and sharing that message. And then also, certainly not being judgmental as it relates to if individuals have concerns about the vaccines and listening and trying to understand when those concerns aren't being able to address those. So there are those efforts underway. The Ad Council is partnering with the COVID Collaborative, it has been doing work with regards to a public messaging campaign. The Biden administration is also planning, with regards to doing a national campaign as well. But let's also remember how important local trusted leaders are and trusted messengers are, especially as we think about advancing equity where local health-care providers, community health workers, community and faith-based organizations are so critical because they're seen as trusted messengers to really be able to answer questions and also to be able to connect families and communities to access to the vaccine.

FASKIANOS: Thank you. Somebody wrote in the Q&A, anonymously, that also, I think, that Group Luke 10 may be contemplating something like this. The group is collecting funds to help supply PPE to the suffering people of Iraq. And Moms For Peace may be a good place to check. So David, you can look there. I'm going to do a follow on question from Lawrence Whitney at Boston University. Lawrence, do you want to unmute or do you want me to read your question? I'm going to put you on the spot. Why don't you unmute?

WHITNEY: Sure, happy to ask the question. So the NIH recruited a group of religious leaders to in turn recruit a more diverse cohort of vaccine trial participants. So I'm wondering if you're aware of any similar program underway to specifically leverage religious leaders in addressing issues of equity in the distribution phase? And if so, do we have evidence that this strategy is effective?

FASKIANOS: Nadine?

GRACIA: So, I would say, one, there have been examples of states, for example, in execution of their distribution plans. There is variation across the states with reference to the distribution plans and where they've discussed and how they've prioritized equity. But there are states, for example, like Massachusetts, that has really invested in and providing grants both to faith-based organizations as well as community-based organizations to help with regards to outreach and education, messaging, and access to services as it relates to COVID-19. There are other examples of states where they've actually had a faith community liaison that is part of the task forces that are created with regards to the health equity task forces in the states to be able to, again, identify strategies and ways to bring together the various trusted messengers to not only provide them with the education of how to do this and become messengers and communities, but to help identify where those resources are needed in various communities. This is something that is not unique, I would say, to COVID-19. As we noted earlier, when I served in the Obama administration and led the Office of Minority Health, we did this effort as well as it related to the Affordable Care Act and outreach for the Affordable Care Act in working very closely with faith leaders, whether it was to help host town halls, to utilize their places of worship as places where you could actually sign up to get access to healthcare, to health insurance coverage. Similarly with other types of outbreaks such as Ebola and Zika. Similarly connecting with faith leaders and finding that was an important vehicle, again, because of the trust as well as the long established relationships and networks that leaders have in communities.

FASKIANOS: Thank you. I'm going to Rob Radtke next.

RADTKE: Thank you, Irina. I'm Rob Radtke with Episcopal Relief and Development. What consideration is being given to making vaccine distribution more patient-centered? My experience is that accessing vaccines, even for priority and vulnerable populations is extremely difficult. It requires access to computers, high levels of literacy, access to transportation often, and essentially, very, very high levels of personal motivation. And it feels like this has been very top-down. And if we really want to reach vulnerable people, and high priority populations, we kind of have to, my sense is that it needs to be rethought. And I'm wondering where or if that's happening?

FASKIANOS: Jennifer, do you want to start and then we'll go to Nadine?

NUZZO: Sure, just some high-level observations, which is, first of all, this is, I mean, what you're seeing right now is the start of a process that, in my view, should have been started a long time ago. But states have been begging for help and resources for a very long time and very only recently got money to help them start these plans, which I really think was a shortcoming in our rollout of these vaccines. But you're going to see the tension here where there is a need for speed and states are, every day they're being asked by the press how many of your vaccines have you given out versus doing the exacting work of achieving coverage in your highest priority groups. Trying to find those people, trying to meet them where they are, access them, etcetera. The first vaccination in many states focused initially on health-care workers. And so that was a captive audience, a captive population that was within health facilities that could be reached and scheduled. And even that failed to capture, say, staff that weren't on the email systems. So it's really difficult work that's being done.

I'll tell you, a friend of mine, I won't say where she works, but she works in a major city that was trying to schedule vaccination clinics. And they found out that one of their invite signup lists sort of went viral. And when they saw who signed up and the zip codes that the people were coming from and saw the zip codes that were completely not represented in those signups, probably reflecting who is more easily able to get on the computer and schedule and pass the word around, they actually cancelled the clinic and decided they need to start over again to figure out how they can make sure they're also reaching their hard-hit communities. So I think some of it is being worked on now. I think some of the approaches where it's been talked about, for instance, taking advantage of federally qualified health centers, I think we're going to have to go on multiple paths here where we are considering opening up more broadly and do more of these mass vaccination efforts in stadiums, but recognize we cannot only use those approaches because those will leave communities and people behind and that we need other options. And the extent to which the community can also self-organize, and I see those of you attending this webinar as particularly well suited to advocate for the communities that you serve, and to say people need help getting to their appointment and sort of volunteer to organize. I don't think there's a lack of interest. There's just a lack of view and a lack of time and a lack of bandwidth. And I think this is a moment in our history where everyone has to kind of roll their sleeves up and if you have a skill that you can bring to try your best to bring it to the table and help.

GRACIA: I would echo, yes, I'd echo several points that Dr. Nuzzo just mentioned, which is  bringing the vaccination to the community and recognizing that we are at the beginnings and not only where states and localities are just now starting to receive these dollars in funding. At our organization we had long called for the need for planning but needing resources to do that planning and preparation for the distribution and administration. But it's also recognizing that in particular with the public health system, the public health system has long been underfunded. They're at where there's now shortages with regards to the workforce and stretched, stretched for several months in responding to this pandemic. And so the need for the partnerships that you're discussing really are so critically important. And it will require expanding, for example, where vaccinations can be given. So whether that's in federally qualified community health centers or other community health centers in rural health centers, but also having the opportunity for mobile clinics that can go to communities and other types of community centers where they also have trust to be able to reach communities. This is going to be vital. And so not only in the advocacy that you can do to ensure that those types of sites are part of the plan with regards to ongoing distribution and administration, but also are there mechanisms and ways for you to actually engage in and be a part of that distribution and administration, a process as far as the sites that are in communities, because indeed transportation issues, ensuring that communities have access to information that is in multiple languages, that is culturally appropriate, and utilizes different mechanisms. When we, for example, were doing outreach as it related to the Flint water crisis, as well as to the Affordable Care Act, we tailored approaches to say how does the community also get information. So it wasn't necessarily to always only rely on internet technologies, but also the radio, television whether it was community outreach workers and really expanding the approaches so that we can ensure equity with regards to our outreach.

FASKIANOS: I'd like to go next to Sister Markham of Catholic Charities U.S.A. Do you want to ask your question yourself? You can unmute yourself.

MARKHAM: Sure. Happy to ask it myself. I'm Sister Donna Markham and I'm the president of Catholic Charities for the U.S. And I just think from a practicality perspective right now, we're been really trying to encourage our vulnerable communities, especially communities of color, the homeless population, etcetera, to get vaccinated but it's a tough sell because they're not real patient and they're less patient than the rest of us even are. And so when we're encouraging them, they're dispirited. There's no information about how long it's going to take them, even if they're in one of the risk categories by virtue of age or health condition. So I guess my question really is, are there any plans in the works to be transparent about what's happening, to communicate with the public to say, okay, twenty thousand people are ahead of you in line in Oshkosh, Wisconsin? It'll be about it's going to be three months before we call you. I mean, that kind of information, I think, would be really helpful and it would help those of us that are trying to serve those communities if we weren't just kind of sending them down a black hole of mystery. So that's just a question and maybe it's just difficult because nobody wants to get in the public and say, "We really don't know." It is very frustrating. And it does stand in the way of helping those communities.

NUZZO: So, I mean, I think the issue is that the states and the local health jurisdictions just don't have the information that they need in order to be able to tell the public. I mean, one of the challenges is they don't really understand how much vaccine they're going to get and when. And so that's an incredible planning challenge. And then there's also the fact that the federal government announced an intention to expand vaccination efforts beyond the initial priority groups before any state had a heads up. And the day that then secretary of Health and Human Services said we were calling on states to offer vaccines to people sixty-five and up, I mean, no state had advanced knowledge of that. And based on my friends and family I know, a lot of senior citizens got on the phone and started calling to find out when they were next. And there were no systems in place to receive those inquiries. So now they're trying to set up the systems and to bring people in but that that kind of logistic, that kind of scheduling? It's one thing to do it in a clinical environment with health-care workers. But health departments don't have that infrastructure and so they're standing it up. In some cases, private sector organizations have reached out to offer help. I think that's encouraging. There's, of course, always worries that we have to be transparent about those efforts and make sure that that doesn't gain access inappropriately to vaccines. So I don't have an answer for you other than it's not a question of nobody wanting to tell, I think people very much want to be able to say to somebody, "This is when you're going to get your vaccine." And I just think there's no way to do it right now. I mean, even the CDC director, the new CDC director, said the other day that they basically have no idea how much vaccine is coming. I think this is one of the biggest mistakes we've made in this vaccine is that we have overpromised how quickly it was going to be delivered. And my mental picture for me, as someone who's not in the high-risk group, was always that it might be sometime late summer and that was never aligned with what I was being told. But it's based on my own knowledge of how these things are likely to go. And so I think we just have to set expectations, which is that we have never attempted a vaccination campaign of this magnitude. The systems that are needed to do this have not yet been built. And the information that's needed to inform the messaging is not yet there. I think it will get there. I am quite hopeful that we are in for better days, but it's going to take some rocky terrain in the next few weeks until we get to a better place.

FASKIANOS: Nadine, do you want to add to that?

NUZZO: Yes, I would just reiterate that this being such an unprecedented logistical effort and trying to, as was said, even note how much of the vaccine that you have coming to you for the states and localities to be able to do that planning. It has been a challenge. And so I think that's why you're also seeing certainly with the Biden administration wanting to say there needs to be more communication/collaboration from the federal to the state and local levels, to have that awareness, to be able to also manage expectations. And I think with this being certainly a new vaccine rollout effort, knowing that there is going to be limited supply in the beginning phases and that the emphasis is on initially vaccinating those with the greatest exposure and understanding why health-care workers and those in long-term care facilities were the first groups to be to be vaccinated. And that as more and more vaccine becomes available to expanding those populations with regards to who has access to the vaccine. It's not easy. It is not easy to message but communicating, and regularly communicating, providing clear communications are important and updating communities to have that understanding so that there is transparency. But that we can also manage expectations and have an understanding that as communities are waiting for vaccinations, the importance of continuing with the public health measures that are so vital, from wearing masks to the physical distancing to the frequent hand washing, etcetera, and how important that is, as well as part of all of the tools that we have in really working to controlling and stop the spread of the pandemic.

FASKIANOS: I'm going to go to Adem Carroll next. If you could unmute yourself?

CARROLL: I work with diverse communities and a lot with the Muslim community. I see a lot of trust issues. And it's not necessarily among people who won't wear masks, it's people who do. But yet the depth of distrust is so pervasive. So a lot of outreach efforts will be needed. I did want to ask, though, beyond the cultural aspect, reaching the most elderly, it seems that the categories have been made very broad, as you just said, Jennifer. The states were surprised by suddenly throwing open the door to anyone over sixty-five. But somebody over eighty-five is a lot more fragile or vulnerable, I should say, generally speaking. So why were the categories made so broad? Do you have any sense and also, New Jersey is allowing all smokers to be vaccinated. So how do states allow such odd criteria for vaccination? And of course, this all relates to the question of supply, which I think we all have to ramp up production. How can we manage to do that?

FASKIANOS: Who would like to take that first?

NUZZO: So, there's a few things there. I mean, first of all, the decisions are going to be made by the states. That's just where the constitutional authority, the Constitution puts the primary responsibility for public health on the states. The priority groups were set as guidelines and states have always been free to implement those guidelines as they wish. Many states did follow them. But what you see is that identifying priority groups based on either exposure categories or risk factors for severe illness and death is, I think, in my view, a very ethical way to go about allocating scarce resources. It's just slow and exacting work to try to find those people, particularly when you don't have enough vaccine to cover the entire priority group. And we don't have an infrastructure to say, okay, let's find all of the people who are eighty-five in the community or all the people who are sixty-five plus. It's just, it's really tough and what we saw in the first month of vaccination was very slow rates of administering the vaccines that states had received, in part because they were doing this very exacting work of trying to schedule people according to priority. And in some cases those prioritization schemes were directly hindering vaccination efforts in the sense that some states didn't just say, okay, give it to everyone who works in health facility. But they said, okay, well, we don't have enough to do that so give it to the people who are most likely to be exposed in the health facility. Well, if you're a facility manager that means that you needed to find those people, schedule them, bring them in. You have to figure out which vaccine they're going to get and then you had had to figure out what to do with if you had extra doses in the vial and who you can give that to. You didn't want to be the one health facility that was in the news for giving it to the wrong people. So in some cases, we heard stories about health facilities rescheduling everybody for another day when they could get more to come and take those extra doses. Some states prevented health facilities from offering it beyond once they covered everybody in a certain job category, they had to wait until all the health facilities could catch up. So you're seeing the kind of challenges in working through these things, these plans in real time and realizing where they work and where they don't. And so as there is an increasing recognition that at some level getting the vaccine in arms is better than not, there is going to be this tension between speed and trying to just get coverage so that hopefully we can protect as many people as possible to also wanting to make sure that we cover the people who are most likely to be exposed and most likely to be harmed by the virus. And it's just really, really hard. There's always going to be, I think, that tension there. I hope it'll get easier.

I just want to say one more thing on the misinformation and why it's so hard. So, of course, there are the historical issues. And the fact that hesitation about vaccines predate COVID in all communities. All of us have some level of hesitation, it's just for different reasons. But COVID, I believe, is unique in the sense that, at least in my professional life, it is the first time I am seeing an incredibly organized set of groups that are coordinating and using tools that we never had before to spread disinformation. They're intentionally trying to mislead about not only the vaccine, but the virus for different goals. Some are anti-vax groups that are seeing COVID as a historic opportunity to expand hesitation about vaccines. And all they need to do is just sow doubt. And they are targeting groups that have historic mistrust of vaccines as a way of doing that.

There are also groups that are trying to sell things—alternatives. And so they're spreading disinformation as a way to boost their profits. And we live in a situation where the virus itself has been politicized and groups that are aiming to sow doubt about the vaccines recognize that continuing to sow doubt about the virus is a way to sow doubt about the vaccines. And so some of the work that I've been doing and looking at the rollout of COVID vaccines among health-care workers and hearing about lots of refusals, sometimes because of the vaccine, but also sometimes because even in hard-hit hospitals, they don't believe that the virus poses a threat to them as individuals. And I don't blame anybody for this other than the fact that there are very powerful forces at work trying to sow doubt and we haven't appropriately amassed counter-campaigns to spread the right information and to counter the disinformation that's being unleashed,

FASKIANOS: Unfortunately we have finish early, so I want to give the last word, so my apologies to everybody who still has questions, but I want to give Dr. Gracia a chance to make any closing thoughts on the heels of what Dr. Nuzzo said.

GRACIA: Sure. I was actually just going to pick up where Dr. Nuzzo left off with regards to both misinformation and disinformation and how, indeed, that spread of misinformation, as well as the intentional efforts through disinformation, is widespread and really challenging as it relates to addressing concerns and questions that communities have. I’ll share some resources, certainly for those of you who are actively working on this and wanting to try to really help communities and getting access to information, in addition to the access of information that you may have from local agencies and state agencies, as well as the federal agencies. There's also a Public Health Communications Collaborative that our organization is one of the members of and that has specific resources and actually is tracking some of the misinformation that is out and provides either strategies of how do you respond, do you respond, what are some tactics and techniques. And we know much more needs to be done because the information that is spread is moving at such a rapid pace that that is going to be something that we will continue to grapple with to be able to ensure that communities are getting accurate and timely information.

FASKIANOS: Thank you. And we will circulate these resources. We're going to go back to both Dr. Gracia and Dr. Nuzzo for their thoughts of resources we should share with you all. You both should sign off now because I know you have a two o'clock and I want to give you an opportunity to and I'll say thanks to you while you're leaving. Just some housekeeping notes for the group here. Thank you both very much.

GRACIA: Thank you.

FASKIANOS: So you can follow Dr. Gracia on Twitter @HealthyAmerica1 and you can follow Dr. Nuzzo @JenniferNuzzo. We also encourage you to follow CFR's Religion and Foreign Policy Program on Twitter @CFR_Religion for announcements about upcoming events and information about the latest CFR resources. As always, reach out to us at [email protected] with any suggestions on future webinars or events. We will circulate the transcript and video of this webinar along with resources. Thank you all again. Please stay well, stay healthy, and we will be convening again shortly. So thank you all. Enjoy the rest of your day.