|Proceedings of a Workshop—in Brief
COVID-19 Vaccines: Studying Historical Successes (and Failures) for Equity-Centered Approaches to Vaccinating Indigenous Communities, undocumented Immigrants, and Communities of Color
Proceedings of a Workshop—in Brief
The National Academies of Sciences, Engineering, and Medicine’s Roundtable on the Promotion of Health Equity hosted a public webinar titled COVID-19 Vaccines: Leveraging Historical Successes (and Failures) for Equity-Centered Approaches. This webinar focused on previous historical efforts to vaccinate individuals, what proved successful, and what proved unsuccessful.
Communities of color experience significantly higher rates of infection from COVID-19 and significantly higher mortality rates when compared to White Americans (Selden and Berdahl, 2020), with members of Indigenous communities having the highest case rates and mortality rates in the United States (Williamson, 2021), said Winston Wong, roundtable chair. Communities of color also have gotten vaccinated at a slower pace compared to White Americans (CDC, 2022). As of August 21, 2021, only 51 percent of Americans had received the recommended full course of necessary vaccinations to protect against COVID-19 infection, with communities of color lagging behind White Americans.
There are many decades of experience in administering vaccines and educating the public about vaccines such as the flu vaccine, the polio vaccine, and the H1N1 vaccine. These previous efforts to vaccinate communities of color can inform current COVID-19 vaccination efforts. What were the successes and the failures?
This webinar builds upon two previous webinars hosted by the Roundtable on the Promotion of Health Equity, Pursuing Data on COVID-19: The Health Inequity Multiplier, and Contact Tracing and the Challenges of Health Equity in Vulnerable Latino and Native American Communities. This workshop continues this conversation by focusing on communities that have typically been left out of conversations about vaccinations and why they are important, including Indigenous communities, undocumented individuals, and Alaskan Native communities.
A group of five panelists participated in the webinar via questions and answers. The first set of questions was specific to each panelist. The second set of questions was open to all panelists.1
1 This Proceedings in Brief is meant to summarize the key points from the workshop presenters. It is not designed to be a complete historical overview. For further information, please watch
Chuck Sams, whose heritage is of Cayuse, Walla Walla, Cocopah, and Yankton Sioux, was asked the first question: How has the enduring context of systemic racism and the marginalization of vulnerable communities historically affected the current moment with COVID-19 vaccinations, particularly for Indigenous groups?
Sams explained that his people, now based in northeast Oregon and southeast Washington State, traditionally roamed areas now known as Montana, Wyoming, southern Idaho, Nevada, northern California, and southern Canadian provinces. Activities included hunting, gathering, and fishing. There were kinship relationships with several other tribes throughout the Pacific Northwest and the central-western states in the United States.
Due to the concept of manifest destiny and the creation of the Oregon Trail, Europeans began to enter Indigenous territories and settle there in about 1760. These Europeans brought with them measles, dysentery, and smallpox; over the 100 years between 1760 and 1860, 95 percent of the Indigenous population died of these three diseases. In spite of the history of Western films showing that Native Americans died during gunfights with White settlers, it was measles and smallpox that killed the majority, as their immune systems were unprepared to handle those diseases. Even among the White settlers on the Oregon Trail, 10 percent died due to illness.
Sams noted that, originally, the indigenous tribal homelands were about 6.5 million acres as understood by the confederated tribes. Today, however, there is a 250,000-acre reservation based primarily in Oregon but also partly in Washington State.2 Current tribal membership is just over 3,100 tribal members for the total Confederated Tribes of the Umatilla Indian Reservation. Half of the tribal membership lives on or near the reservation; the other half are scattered across the United States.
The workforce on the reservation, however, is primarily nontribal members, who make up 60 percent of reservation workers. It was a nontribal worker who brought COVID-19 into the reservation. In March 2020, Sams was appointed incident commander for managing the COVID-19 virus on the Umatilla Indian Reservation. The incident command team decided from the beginning to use the best available science and relevant data, such as weekly case counts and testing counts. He noted that the tribe was fortunate to work early on with the federal government to get access to testing equipment. This meant that infection rates were significantly lower when compared to other tribes in the United States. For example, the Nez Perce tribes (Idaho) and the Warm Springs tribes (Oregon) suffered double-digit deaths and in some cases triple-digit deaths.
The stories of tribal members who survived the mass epidemics of 1760–1860 were used, said Sam, to guide the response to COVID-19. There were both oral stories and some written documents that indicate that those individual tribal members who isolated were the survivors. It wasn’t the smartest or the bravest, he said, that survived—it was that they moved away from the larger tribal villages. This was an important message to ensure that tribal members quarantined and sheltered in place when necessary.
When it came time to vaccinate tribal members, a plan was developed and vaccination shipments were available through the Oregon state government from the federal government. Once vaccination began, people on the Umatilla reservation were vaccinated first, followed by all non-Native tribal employees. Mass vaccination events were held at the tribe’s Wild Horse Resort and Casino. The tribe also worked closely with the Oregon National Guard, who were effective in streamlining the vaccination process.
Most recently, the reservation has seen an uptick in infections of children between the ages of 12 and 17. In one case, the entire freshman class of the reservation high school had to quarantine. Sams expressed concerns about mutations and said the tribe was continuing to work with the Indian Health Service, the CDC (Centers
the workshop recording at www.nationalacademies.org/our-work/roundtable-on-the-promotion-of-health-equity.
2 According to Sams, the rest of the land was ceded back to the U.S. government.
for Disease Control and Prevention), and the state health authority in Oregon.
Sams concluded his response by noting that although Indigenous peoples have a negative history with vaccinations, the tribe was able to use that negative history to educate the tribal membership on the importance of vaccination. He concluded that the tribe has reached 70 percent herd immunity in the reservation and the surrounding communities.
Dr. Anne Zink, the second panelist, is the chief medical officer for the state of Alaska. She sees her job as “promoting the health and well-being of Alaskans across a state that is larger than Montana, California, and Texas combined.” Her question was: How did the 1918 pandemic affect the response to the current pandemic? How has the enduring context of systemic racism and the marginalization of vulnerable communities historically affected the current moment of the COVID-19 vaccine?
Zink noted the critical role played by geography. For example, the capital city of Alaska can only be accessed via boat or plane because there are no roads in and out of the capital. It is important, she said, that “we could either let geography determine us or find ways to use geography as an asset.”
Alaska is made up of rural communities, many of which have been marginalized or underserved for years. Since Alaska is the least populous state in the United States, people wondered how a person could get infected with COVID-19. Zink explained that “our communities are more like little cruise ships floating in the tundra. We have densely populated houses and communities, but they are surrounded by a lot of space between them.” She noted that some rural residents travel almost 150 miles each way to access health care; 60 percent of Alaskan communities are accessible only by small plane, and 8 percent are accessible only by roads and highways. There are 229 federally recognized tribes in the state. 32 communities in Alaska have no running water or sanitation (Alaska Department of Energy Conservation, 2015). 75 communities in Alaska lack any type of law enforcement, including access to police courts and other related services (Indian Law and Order Commission, 2013).
The communities that survived the 1918 pandemic, as described earlier by Chuck Sams, were those that did not let anyone into or out of their community—oftentimes at gunpoint, noted Zink. This experience led to a similar response during the COVID-19 pandemic. However, this response made food and health care inaccessible. The conflict between isolating a community to keep infection rates low versus the health consequences of isolating (for example, no prenatal care) shows the limitations of geography, she said.
The 1918 pandemic, Zink said, really determined the history of Alaska. The traumatic history of the pandemic resulted in entire cultures, communities, and languages being lost. Additionally, mistrust of traditional Western medicine developed. All of this led Zink to realize that the historical trauma of the 1918 pandemic would have to be addressed to move forward in fighting COVID-19.
Zink told a story about a tribal leader who left his home community of Dillingham to live in the woods with his mother and grandmother during the 1918 pandemic. When they returned to Dillingham, there were many kids and dogs, but few adults who were left alive. The tribal leader reported that he would not allow this to happen to his community with COVID-19; he said he was “not going to allow this to repeat in my history.” The community must learn from the 1918 pandemic experience and build new, modern concepts (e.g., testing and vaccination) upon this traditional history.
Most communities have community health aides, who have been very successful in providing health care information and services. The tribal system empowers the health aides with the tools needed to fight COVID-19 such as testing services, contact tracing, and isolation. The benefits of these efforts were that no one was hospitalized and no one died, despite lacking running water and a sewer system.
Alaska has a network of state–tribal health organizations, the tribal caucus, which Zink partners with. They meet weekly. The tribal caucus is 100 percent self-governing, which is critical, as tribal sovereignty was a criterion in getting vaccine doses directly to tribes. There is a sovereign nation supplement,3 and this made it much easier for the state to distribute the vaccine.
Zink reported that the tribal partners have been “amazingly successful” in getting vaccines out, and 10 communities are at 70 percent or greater vaccination levels for those over age 16. There are other communities, she said, that experienced no deaths and 100 percent vaccinations. She explained that she is “hopeful that this will help to undo some of the historic trauma and be able to move to more healthy and wealthy communities moving forward.”
The key to this success, said Zink, is that tribal leaders and the state tribal health consortium members were responsible at every step, from communications to actions. This was crucial, she noted. The right partners must be at the table. Although the state provided supplies and resources, the tribal leaders were responsible for this success.
Zink concluded her presentation by saying that “we can do this differently, we can write a different history and be able to partner together and recognize that tribal sovereignty” is critical.
The third panelist, Dr. Antonio Tovar, is a policy associate at the National Family Farm Coalition and a researcher with the Farmworker Association of Florida. His question was: It is challenging to vaccinate those individuals living in the United States who are undocumented. Are there data that indicate that they are being vaccinated in lower numbers compared to other population groups? Are there strategies that appear to be particularly successful with undocumented populations?
Tovar explained that it is difficult to count undocumented individuals, and there is published literature available that explain the disadvantages experienced by those who are undocumented. For example, it can be difficult to make and keep appointments, as there is no single policy in place about where the undocumented can receive a vaccination. Additionally, there were many anti-immigrant sentiments in the nation as a whole when COVID-19 arrived, and Florida had passed several anti-immigrant laws.
The Farmworker Association of Florida was initially created to assist farmworkers during natural disasters. He said that because “we have some experience dealing with disasters, we saw this as a disaster in the making. We know from experience that we [farmworkers] do not receive the same support” that the population as a whole does. There are several challenges faced by farmworkers:
- In Florida, the farmworker population includes Haitians and workers who speak only Spanish or Creole, thus requiring the creation of informational materials in a number of different languages to reach everyone. Additionally, there are many workers whose first language is an indigenous language and who do not speak Spanish proficiently.
- The population of farmworkers is younger, and the state policies in place initially were to vaccinate residents over 65 years and then vaccinate those over 55 years of age. However, the lack of access to consistent health care and proper nutrition for farmworkers makes them particularly susceptible to complications and long-term sequelae of COVID-19.
- It is also difficult to schedule a time for vaccination because of work schedules. Farmworkers’ access to vaccine appointments is complicated by the fact that they start work very early in the day (before most people begin work) and work until late in the day (after most people end their workday). Securing child care is often an additional limiting factor that can affect scheduling a vaccine appointment.
3 Under Operation Warp Speed, the federal government’s plan to develop and distribute COVID-19 vaccines, the sovereign nation supplement was created for tribes that chose not to affiliate with Indian Health Service facilities. Rather, their vaccine supplies were from the state, and states were given extra vaccine allocations for those tribes.
What ended up being a successful strategy, he said, was involving employers in promoting the vaccine. Collaborating with the Florida health department, many growers told workers they had to be vaccinated. This led to less resistance to vaccination and easier access to the vaccines.
Dr. Marina del Rios, director of emergency social medicine at the University of Illinois College of Medicine, followed up with her thoughts about the question. She noted that the structural barriers that face undocumented workers go “above and beyond” any already existing barriers such as racism or socioeconomic status. There may be high levels of mistrust in visiting a large, government-sponsored vaccination spot, particularly if the National Guard is staffing those spots.
As explained by Tovar, she agreed that employers making vaccines available at the employment site is an important strategy as long as employers are seen as trusted messengers. It also must be explicit in messaging that proof of documentation will not be required to be tested or get vaccinated.
Dr. del Rios was asked, What strategies are you and your organization using to show that you and/or your organization are trustworthy, and so that the community feels it can trust what you/your organization is saying?
Del Rios noted that one must begin with a set of trusted messengers who are already rooted in the community and known to be community advocates. Often these individuals are labor organizers who focus on worker rights. She noted that, as the other presenters indicated, health care providers, government officials, and researchers have failed communities of color.
She also pointed out that “the early public narrative about COVID and the anti-immigrant bias that crystallized” led to an exacerbation of the realities of how COVID-19 was affecting the Latino community. Illinois Unidos, a local organization that was created in response to the effects of COVID-19 on the Latino community, was also created because of the lack of response from policymakers. The organization supports partnerships, engages people from different sectors, crafts communication messages, and created a health policy group. Global literacy, education, and mental health are also issues of concern. Other strategies might include messaging on radio stations, door-to-door canvassing, and being present at neighborhood bodegas.
The final question was for Dr. Jacinda Abdul-Mutakabbir, an assistant professor at the Loma Linda University School of Pharmacy: According to Johns Hopkins University, “people of color, along with immigrants and differently-abled men and women have endured centuries of having their trust violated.” Is it possible to move past this legacy of historical mistrust and racism?
Abdul-Mutakabbir stated that it is possible to move beyond the mistrust, although she emphasized that the mistrust must be acknowledged. At Loma Linda University, a three-tiered approach was developed, including engaging faith leaders in a COVID-19 summit, promoting vaccine education through trusted community members, and holding vaccination clinics in communities. For example, the vice president of community engagement, an African American man, spoke with African American communities. Faith leaders are also used as trusted messengers, particularly for African American and Latino communities, Abdul-Mutakabbir said.
It is also critical, she said, that individuals of color be taught to see themselves as stakeholders. This gives them an understanding of the vaccine process and encourages making informed decisions. Transparency is also essential. For example, for a brief period the use of the Johnson & Johnson vaccine was halted. Abdul-Mutakabbir reached out to all of her patients to explain that that vaccine was on hold temporarily, and another vaccine was offered in its place.
Empathy and compassion also matter, and making the vaccination clinic a low-barrier place to visit is helpful. She sees this as a part of acknowledging the systemic and structural racism these communities have suffered from. All clinic hours were walk-in, and only paper registration materials were used to avoid the digital divide.
Abdul-Mutakabbir closed her presentation by sharing that she authored a manuscript about their vaccination strategies and included community members as coauthors. This reflects her commitment to acknowledging past mistakes and educating these communities about the current vaccines.
The final segment of the webinar included an open set of questions that all panelists could answer. The first question led to a discussion about whether monetary incentives were a good idea to increase vaccination rates. Zink responded that “we need to find ways to provide rewards in different ways, particularly in Native communities.” However, this needs to be looked at cautiously so that people do not feel bribed or coerced into getting vaccinated. Abdul-Mutakabbir suggested that if employers offered incentives, this would “go a very long way” in getting people vaccinated.
Del Rios cautioned that “we really need to be thinking about eliminating structural barriers in the long term,” and not just focus on the current pandemic. There is a need for integrated public health approaches. Abdul-Mutakabbir said that “we need to continue to use these platforms that we developed to give education on other disease states.” As an example, she suggested educating people about the pneumococcal vaccine and HIV testing.
Sams said that he thinks the reason vaccination rates are high in Native communities is rooted in the historical context of the 1918 pandemic. Oral traditions can help maintain and encourage people to get vaccinated. Zink agreed that oral traditions are important and said that public health officials should be aware of this.
An audience member asked about incarcerated individuals and their families during the pandemic. Zink responded that in Alaska, the Department of Corrections was “at the table with us at every single step.” In fact, sewing machines were provided to incarcerated individuals, and they helped make masks. Some sovereign nations’ supplement of vaccine doses went to vaccinate the entire prison system very quickly. She said that “too many times we silo off corrections as its own kind of island that isn’t connected to the community.
But they are a part of our community, and they are community members, and so we really need to address it collectively.”
Alaska Department of Energy Conservation. 2015. Alaska Water and Sewer Challenge (AWSC): About the Alaska Water and Sewer Challenge. https://dec.alaska.gov/water/water-sewer-challenge (accessed June 2, 2022).
Centers for Disease Control and Prevention (CDC). 2022. COVID-19 vaccine equity for racial and ethnic minority groups. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/vaccine-equity.html (accessed June 9, 2022).
Indian Law and Order Commission. 2013. A roadmap for making Native America safer: Report to the President and Congress of the United States.https://www.aisc.ucla.edu/iloc/report/files/A_Roadmap_For_Making_Native_America_Safer.pdf (accessed December 21, 2021).
Selden, T. M., and Berdahl, T. A. 2020. COVID-19 and racial/ethnic disparities in health risk, employment, and household composition. Health Affairs 39(9):1624–1632.
Williamson, L., L. S. Harwell, T. M. Koch, S. L. Anderson, M. K. Scott, J. S. Murphy, G. S. Holzman, and H. F. Tesfai. 2021. COVID-19 incidence and mortality among American Indian/Alaska native and white persons—Montana, March 13–November 30, 2020. Morbidity and Mortality Weekly Report 70(14):510–513. https://doi.org/10.15585/mmwr.mm7014a2.
DISClAIMER: This Proceedings of a Workshop—in Brief has been prepared by KAT ANDERSON as a factual summary of what occurred at the meeting. The statements made are those of the rapporteur or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.
*The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the institution.
REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by MARIO R. DE LA ROSA, Ph.D., MSSA, Florida International University, and REGINALD D. TUCKER-SEELEY, M.A., ScM, ScD, University of Southern California. LESLIE SIMS, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.
SPONSORS: This workshop was partially supported by The Colorado Trust, the Health Resources and Services Administration, the Hogg Foundation for Mental Health, the Kresge Foundation, and the Veterans Administration Office of Health Equity.
For additional information regarding the workshop, visit www.nationalacademies.org/our-work/roundtable-on-the-promotion-of-health-equity.
Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2022. COVID-19 Vaccines: Studying historical successes (and failures) for equity-centered approaches to vaccinating Indigenous communities, undocumented immigrants, and communities of color: Proceedings of a workshop—in Brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/26622.
For additional information on this workshop series, visit https://www.nationalacademies.org/.
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