Much has been said about people opposed to or skeptical of coronavirus vaccines. But there’s another group that has yet to get shots, and their reasons are more complex.

by Amy Harmon and Josh Holder for the New York Times

May 12. 2021

It had been weeks since Acy Grayson III, owner of Let It Shine, a home improvement outfit he runs out of his own home in the suburbs of Cleveland, had vowed to get a Covid-19 vaccine.

Appointments were available.

But Mr. Grayson, who never knows how long a job will take or when a new one will come along, had found it hard to commit to a time and a place. The mass vaccination site where appointments were not required was off his beaten path. He did not know that a nearby church, Lee Road Baptist, had been dispensing vaccines on Fridays — but the truth is, even if he had, it is unlikely he would have made the short trek to get one there, either.

“I know you’re trying to find out the reason people aren’t doing it,” Mr. Grayson said on a recent afternoon. “I’m going to tell you. People are trying to take care of their household. You don’t have much time in the day.”

The slowdown in vaccinations across the country has often been attributed to a blend of misinformation and mistrust among Americans known as “vaccine hesitancy.” But Mr. Grayson belongs to an overlooked but sizable group whose reasons for remaining unvaccinated are not about opposition to the shots or even skepticism about them.

According to a new U.S. census estimate, some 30 million American adults who are open to getting a coronavirus vaccine have not managed to actually do so. Their ranks are larger than the hesitant — more than the 28 million who said they would probably or definitely not get vaccinated, and than the 16 million who said they were unsure. And this month, as the Biden administration set a goal of 70 percent of adults getting at least one dose by July 4, they became an official new focus of the nation’s mass vaccination campaign.

In addition to “the doubters,” President Biden said at a news briefing last week, the mission is to get the vaccine to those who are “just not sure how to get to where they want to go.”

If the attention has centered on the vaccine-hesitant, these are the vaccine amenable. In interviews, their stated reasons for not getting vaccines are disparate, complex, and sometimes shifting.

They are, for the most part, America’s working class, contending with jobs and family obligations that make for scarce discretionary time. About half of them live in households with incomes of less than $50,000 a year; another 30 percent have annual household incomes between $50,000 and $100,000, according to an analysis of the census data by Justin Feldman, a social epidemiologist at Harvard. Eighty-one percent do not have a college degree. Some have health issues or disabilities or face language barriers that can make getting inoculated against Covid-19 seem daunting. Others do not have a regular doctor, and some are socially isolated.

Technically, they have access to the vaccine. Practically, it is not that simple.

“Hesitancy makes a better story because you’ve got controversy,” said Dr. Thomas R. Frieden, a former director of the Centers for Disease Control and Prevention. “But there’s a bigger problem of access than there is of hesitancy.”

Socioeconomic disparities in vaccination stem partly from the scarcity of supply in the first phases of the vaccine rollout when Americans lacking the time or ability to scour the internet for appointments lost out: Counties that rank high in a C.D.C. index of “social vulnerability” had lower vaccination rates on average by early April, a New York Times analysis shows. But over the last month, even as supplies have exceeded demand, that disparity has grown.

The gap in vaccination rates between the most and least vulnerable counties continues to grow

For some socially vulnerable counties — characterized by high poverty rates, crowded housing and poor access to transportation, among other factors — low vaccination rates correspond to a high proportion of residents who are reluctant to get vaccinated. The lowest overall vaccination rates are found in counties with both high hesitancy and high vulnerability, with the majority in the South and the Midwest.

But in plenty of disadvantaged places with low vaccination rates, hesitancy is not the full explanation.

In fact, among Americans who said they were willing to get the vaccine, the higher a person’s income, the more likely the person was to be vaccinated, according to Dr. Feldman’s analysis of the census data.

In that group, 93 percent of adults in households earning between $150,000 and $199,000 a year had been vaccinated as of April 30; while only 76 percent of those earning less than $25,000 a year had gotten at least one shot.

“It helps break this question down of attitude versus access,” Dr. Feldman said. “With people who have not been vaccinated, some are disinclined, but others are facing structural barriers.”

In the Cleveland suburb of Bedford Heights where Mr. Grayson and his fiancée, Renea Carnes, live, about 40 percent of adults have had at least one shot, according to an analysis of Ohio Department of Health data. Nationally, about 60 percent of adults have had one shot.

Neither Ms. Carnes’s mother nor adult daughter, who live with the couple, has been vaccinated. Like some other Black Americans, family members said they had concerns about the safety of the vaccines when they first came out. But Mr. Grayson said he had come to believe that vaccination was safe after observing enough people getting a shot without incident. And Ms. Carnes, a hospice nurse, had her second shot last week. The issue for many in their circle, she said, was not hesitancy but opportunity.

“If there was someone standing here right now who was saying, ‘I have the vaccine for Covid,’” Ms. Carnes said, “everyone in the house who doesn’t have it would be getting it right now.”

“What might help this situation,” added Mr. Grayson, “is if it was like Domino’s Pizza and you could call someone and say, ‘Can I get my shot?’ And they come give it to you.”

If the nation’s public health system was ever to offer a pizza-delivery-style vaccine service, now might be that moment. On Tuesday, Mr. Biden said Uber and Lyft, two of the country’s largest ride-sharing services, would provide free rides to vaccination sites from May 24 until July 4. Experts say that the collective risk posed by the highly infectious coronavirus has created a rare moment when public health resources are actually being aimed at communities that have long had higher rates of poor health.

A data analysis by researchers at the University of Texas at Austin, for instance, suggests that vaccinating more residents of the Austin ZIP codes hardest-hit by Covid-19 early on in the vaccine rollout would have prevented hospitalizations and deaths across the whole city. In Austin, as in many other areas, there was a large degree of overlap between ZIP codes with the highest social-vulnerability ranking and the highest incidence of Covid-19.

“Putting more resources into protecting high-risk populations can be lifesaving and beneficial to us all,” said Lauren Ancel Meyers, the epidemic modeler who conducted the study.

The Biden administration has allocated $6 billion to health centers that serve low-income populations and offered a tax break to businesses that give employees paid time off to be vaccinated.

But because of public health’s frayed infrastructure, experts said, it may take time to hire health workers, commandeer mobile vaccination units and forge connections with community groups to do needed outreach.

If the country does not reach high levels of vaccination, experts say, the virus is likely to continue circulating in pockets. That may mean a concentration of cases, hospitalizations and deaths in low-income, disproportionately nonwhite populations.

“My concern is that as we get close to 70 percent vaccinated nationally, we are seeing significantly lower vaccination rates for historically disenfranchised communities that are at higher risk,” said Dr. Luis Daniel Muñoz, a community organizer in Providence, R.I.

The diffuse nature of America’s public health system has left some wondering who, if anyone, is accountable for ensuring equal protection from Covid-19.

“The president has said he wants this to happen, but who is the onus on to do it?” said Keisha Krumm, executive director of the Greater Cleveland Congregations, which has held vaccine clinics at its member churches.

Vaccine historians say there is no playbook for vaccinating so many adults with a day job — or, as in the case of Yesenia Guzman, 43, of Mexico, Mo., those who work a night shift.

Ms. Guzman, who works from 9 p.m. to 5 a.m. at the same pig farm where her husband works the day shift, said they remained unvaccinated because they could not afford to take time off work if they had side effects. They hope to schedule vaccines during the two days they usually get off after working two weeks straight, she said, but “we just haven’t figured out when.”

Health officials who serve low-income populations said they have been forced to turn vaccine-willing patients away because of packaging that requires them to vaccinate six to 10 people at a time or risk wasting a dose.

“I’m going to see patients this afternoon for diabetes and tell them, ‘Hey, do you mind coming back Saturday for this vaccine clinic we’re running?’ and they’re not going to come,” said Dr. Chad Garven, associate medical director of a community health center in Cleveland.

As public health departments close down mass vaccination clinics because of low turnout, they are seeking new ways to reach people. In Austin, a group of vaccinators that distributed fewer doses than expected at a school festival set up shop in a nearby El Rancho grocery parking lot to offer shots to shoppers. After the store manager learned what was happening, almost three dozen workers went out to be vaccinated.

“Everyone wanted to get vaccinated,” said Karim Nafal, the store’s owner, “but didn’t know how or where.”

And in Cleveland, the alliance between the church group, volunteer vaccinators and the city’s public health department led to Mr. Grayson getting a vaccine on a recent morning. Hired to do a paint job at the Lee Road church, he was told that vaccines were available down the hall if he wanted one.

“Come on,” Mr. Grayson urged two unvaccinated co-workers, who also offered up their arms. “It’s right here.”

About the data: County vaccination data is from the Centers for Disease Control and Prevention and the Texas Department of State Health Services. Full county vaccination data was not available for Colorado, Georgia, Hawaii, Vermont, Virginia and West Virginia, and some counties. These were excluded from the analysis.

High vulnerability is defined as a score above 0.5 on the C.D.C.’s Social Vulnerability Index.

The C.D.C.’s county-level hesitancy estimates are based on data from the Census Bureau’s Household Pulse Survey from March 3 to March 15, 2021. High hesitancy is defined as more than the national average of 16 percent of a county’s population saying they “probably won’t” or “definitely won’t” receive a vaccination. Non-hesitant is defined as those saying they “probably will” or “definitely will” receive a vaccination, or have already been vaccinated. The averages given for each group are a population-weighted median.

National vaccination estimates by household income are based on data from the latest Household Pulse Survey, which was conducted from April 14 to April 26.

Reporting was contributed by Danielle Ivory, Timmy Facciola, Tiffany Wong, Julia Carmel and Emily Schwing.


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