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Covid Vaccines Are New. The Challenges of Reaching Everyone Are Not.

For fair distribution of a coronavirus vaccine, trust and access are key. U.S. community health centers have both.



The Covid-19 vaccine from the first batch of Moderna's vaccine is seen at Hartford hospital in Hartford, Connecticut on December 21, 2020. (Photo by Joseph Prezioso / AFP) (Photo by JOSEPH PREZIOSO/AFP via Getty Images)

The biggest challenge in the mass vaccination effort for coronavirus won’t be logistics. Commercial firms manage complex logistics for specialized medications and vaccines daily, at scale, and exceptionally well.

At Direct Relief, we perform the same functions for humanitarian health purposes, delivering life-saving medicines requiring cold-storage and handling to people in all 50 states and 80 countries, often after emergencies and in areas where commercial activities don’t have a strong business reason to engage – insulin for kids with Type 1 diabetes in Sudan, cancer drugs for children in Malawi, and flu vaccine for island-wide vaccination campaigns in Puerto Rico.

The greatest hurdle for access to the vaccine is the same one that exists for every other type of health service – reaching people who are disconnected or don’t have easy access to needed health care – typically, the least fortunate. The goal is universal access for this vaccine,  ASAP  – and it’s the right one. But universal access doesn’t exist for anything else in health care, thus the hurdle. Hurdles are well marked because you need to see them, or you’ll get tripped up by them.

The Pfizer vaccine demands constant refrigeration at 70 degrees below zero, Celsius — Arctic-level cold – while the Moderna vaccine requires roughly the temperature of a standard freezer. Broad expertise exists in the U.S. about keeping vaccines cold, transporting them to every part of the country, and what to do if a freezer fails along the way. (Short answer: Have a backup.)

It won’t be easy — the country’s robust cold-chain infrastructure for vaccines and drugs is geared mainly for carefully monitored refrigeration, not carefully monitored “ultra-cold” frozen. But, we can overcome the higher degree-of-difficulty operational issues presented by lower temperatures. Once we do, the people with regular access to health care will be able to get the vaccine: most will dutifully show up at their doctor’s offices, at hospitals, in retail drugstores, and at stand-up vaccination sites.

But reaching everyone else — the millions of Americans who rarely see a doctor and can’t afford the ordinary medicines they need — is a problem that even the best medical supply chain can’t solve.

The existence of vaccines and being able to transport them don’t save lives; vaccinating people does. The “last mile” issue is always the hardest and most expensive one, logistically. But, on this one, a concurrent last mile hurdle is not a logistics issue – it’s a personal-decision issue and will depend on trust and a personal connection.

The people I mean are those who don’t seek medical care until they’re sick enough to be rushed to the emergency room, who have no health insurance or avoid care because of steep deductibles, or face other obstacles.

Telecommuting isn’t an option at their blue-collar jobs, many of which are “essential.” The home they return to after work may also be home to extended families or others, increasing their risk of infection. They may be experiencing homelessness or live in a rural area far from the hospital. They include undocumented people who fear that a visit to the doctor could lead to their deportation. They include Black and Latino residents who have been infected, hospitalized, and died at higher rates from Covid-19 and have been slammed harder by the pandemic than whites, but have less trust in vaccines because of past government-sponsored medical interventions, such as the infamous Tuskeegee Experiment.

Top-down distribution schemes will get vaccines physically close to these people, but final physical and personal connections will be essential. The organizations best equipped to reach them are 1,400 nonprofit community health centers, which collectively run 14,000 clinical sites throughout the U.S. They serve as the critical health safety-net for 30 million people who rely on them every day for affordable and high-quality primary health care, including vaccinations. 

A History of Inclusive Care

The health centers were created in 1965, a year after the landmark Civil Rights Act of 1964. The ’64 legislation outlawed segregation in schools and public accommodations and discrimination in voter registration and other areas of civic life. Still, it had not included health care for Black Americans whose access had historically been severely limited. Fifty-five years later, 63 percent of health center patients are members of racial or ethnic minority groups.

Perhaps because they are locally run and exist only in medically underserved areas or for medically underserved populations, these nonprofit organizations receive astonishingly little public attention given that they comprise the country’s largest health system for primary health care. Funded mainly by Medicaid reimbursements for those patients who have it and annual appropriations, they don’t turn anyone away. They serve anyone regardless of their ability to pay, and their extensive, standard reporting data reflects provably good health services on objective measures at lower costs than other providers.

These centers have deep experience doing whatever it takes to bring health services to the people, adjusting their operational plans to the realities. We see them do it after every emergency, which always hit those with the least cushion the hardest, just as Covid is doing at this moment.

Health workers at Bee Busy Wellness Center in Houston, for instance, first realized they needed a mobile clinic when the floodwaters of 2017’s Hurricane Harvey cut off whole communities from much of the city. The mobile unit also reached people too wary to trek to a brick-and-mortar clinic even if it were possible — including a community of residents originally from Somalia, Ethiopia, Eritrea, and Sudan. Some of them had never before been to a doctor.

Trust is an essential, if intangible, currency in many aspects of life, and ultimately, it may be the most profound one in this vaccination push. But it can’t be declared into existence by decree or order. It only exists to the extent it’s earned, and health centers have been earning it for 55 years by doing what Bee Busy did after Harvey – showing up, showing respect, making a connection, and keeping their promises.

Community health centers have been quietly ramping up for this moment. Many have prompted their patients to get flu shots this fall. While the primary motivation was to avoid the “twindemic” of coronavirus and seasonal flu, it also served as a dry run for the Covid vaccine push. In Chicago, Esperanza Health Centers set up a drive-thru flu shot operation on one side of its parking lot and did Covid-19 testing on the other side, using social media to promote the effort.

In many cities, multiple community health centers have banded together to run vaccination or health care fairs to reach thousands of people per day. The community health centers in Puerto Rico have stepped up to an extraordinary degree in the three years following Hurricane Maria’s devastation. On a single day in August 2019, nearly 3,000 people lined up at the convention center in San Juan, Puerto Rico, for free vaccinations, dental check-ups, and visits with OB-GYNs, psychologists, and nutritionists, provided by 20 community health centers.

Looking Ahead

Some of the leading vaccine candidates require two doses, the second one within a fixed period after the first. Doubling the number of injections adds complexity to planning and administration. But health centers are operational every day and have made rapid adjustments with telehealth and patient-contact procedures over the recent months of lockdowns and quarantines. As a result, they’re as well if not far better positioned than other alternatives to serve their communities in the upcoming mass vaccination campaigns.

Most public discussions about health care focus on health insurance, which is essential and related but is also a different thing than providing the care itself. This upcoming vaccination effort is about the latter.

In community health centers and free and charitable clinics, we’re profoundly fortunate that we have thousands of sites and dedicated clinicians who have earned the trust of the people hit hardest by the virus and whose access to the vaccine is essential to getting through the pandemic together.

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