By Anne Calef and Luc Schuster
Special thanks to Trevor Mattos, Dr. Regina Larocque (MGH), Dr. Julia Koehler (Boston Children’s), Dr. Scott Dryden-Petersen (Brigham & Women’s) & Dr. Bisola Ojikutu (MGH)
April 9, 2021
After a rocky start, Massachusetts has made progress in its vaccination efforts. As of April 6, 2021, a little over 2.6 million residents had received at least one vaccine dose, amounting to almost 40 percent of the state’s total population. Beyond urgently vaccinating as many people as possible, we must also ensure that vaccines are being distributed equitably across racial groups since the pandemic has only amplified existing health inequities, hitting communities of color, especially Black and Latinx communities, particularly hard. Vaccine equity is also important from a public health standpoint: In order to control the viral spread between communities it is important to target the places where transmission rates are the highest. In this brief, we estimate age-adjusted vaccination rates (a common public health approach for when age impacts the distribution of an event) in order to analyze racial and geographic gaps in vaccine distribution. Key findings include:
Estimating age-adjusted vaccinations attempts to control for different age distributions within racial and ethnic groups. Since age is a leading vulnerability to COVID-19, Massachusetts, like many other states, decided to vaccinate older residents first. Black, Latinx and Asian populations in Massachusetts trend younger than the White population not just because of demographic shifts but also because of higher pre-mature death rates for Black residents. By estimating a vaccination rate that accounts for different age distributions, we can see whether disparities in rates by race result from reasons other than the concentration of older residents in the White population who, because age was prioritized, were most likely to be first in line.
That said, age is obviously not the only factor in the state’s prioritization strategy, and people working in many frontline industries that have also been prioritized are actually more likely to be workers of color—for instance, the Black share of health care industry workers in Massachusetts is greater than the Black share of the population. All else equal, due to this prioritization of frontline workers, we’d expect people of color to have been vaccinated at slightly higher rates in Massachusetts.
But even after controlling for age, the vaccination rate for Asian, Black and Latinx residents is lower than the vaccination rate for White residents. The difference is most notable for Latinx residents, who have a vaccination rate that’s almost 30 percent lower than that for White residents. Racial vaccination rate disparities are much larger when not making this age-adjustment, however (click “Crude Rate” tab in the graph below).
An equity-driven approach to vaccination demands that we prioritize efforts to vaccinate people in communities hardest hit by the pandemic—in other words, not just targeting the elderly but also targeting Black and Latinx communities and municipalities with that have been hit hardest by the virus. Estimated age-adjusted death rates for Black and Latinx Bay Staters were more than triple the age-adjusted death rate for White residents. COVID-19 infection rates have continuously been highest in cities/towns with higher shares of people of color, particularly Latinx residents. This is due to many disparities in social determinants of health and the many ways that racism can adversely affect wellbeing. Residents in hard hit cities/towns, for instance, are more likely live in “overcrowded” housing, work in frontline positions and have lower incomes—all variables associated with an increased likelihood of being infected with COVID-19. Black and Latinx residents are also more likely to have disparate access to healthcare resources and higher rates of certain comorbidities that can increase risk of severe disease such as hypertension, diabetes, and asthma. If we were adhering to an equity-based approach, we would expect to see higher vaccination rates for Black and Latinx residents than for White residents, particularly in hard-hit cities, as well as overall higher vaccination rates in those cities and towns that have been most impacted.
When we apply the same methodology to large cities and towns, we see that many communities report large racial gaps, with Latinx vaccination rates often the lowest. For this analysis, we did not include towns with a population less than 35,000 because of the small sample sizes for individual racial groups. Vaccine data for “Multiracial” and “Unknown” were also omitted because we could not match the categories to Census population categories. Recent reporting has highlighted racial disparities in vaccination by looking just at crude vaccination rates. When we estimate age-neutral rates those disparities shrink slightly but remain in the vast majority of places. For example, in Lawrence the crude vaccination rate is 75 percent for White residents while for Latinx residents it is just 7 percent. When we control for the different age distribution of White and Latinx residents in Lawrence, we estimate that 37 percent of White residents were vaccinated and 6 percent Latinx residents were vaccinated. In other words, even when attempting to hold age constant, the estimated vaccination rate for White Lawrence residents is still six times higher than the rate for Latinx residents.
While town-level vaccination rates for Latinx populations are most often the lowest, some towns’ Black and Asian vaccination rates are also troublingly low. Not surprisingly, we see these low rates in communities that are predominantly lower-income. Asian vaccination rates in Chicopee, New Bedford and Taunton, for instance are all 15 percent or lower. And Black vaccination rates in Everett, Chicopee and Springfield are all below 15 percent. Rates for White residents are also lower in those municipalities.
Not only are there large racial gaps within municipalities, there are also large differences across them. Some cities and towns have troublingly low aggregate vaccination rates, even after adjusting for age. Many with the very lowest aggregate rates are in lower-income communities, with large communities of color, that have been hardest hit by the pandemic. Adjusting aggregate vaccination rates, regardless of race, takes into account that some towns and cities may have populations that skew younger (e.g., Cambridge or Chelsea) while others may have populations that skew older (e.g., Braintree or Swampscott). Even with age distributions held constant, Westwood (50 percent), Medfield (50 percent) and Swampscott (47 percent) have vaccination rates nearly double that of New Bedford (24 percent) and Fall River (26 percent).
Additionally, this has meant that as a state we have not yet succeeded in vaccinating large shares of residents living in municipalities with the worst COVID outbreaks. Overall, there is a negative correlation between vaccination rates and COVID-19 case rates – that is, the higher the COVID-19 case rate, the lower the vaccination rate. Cities such as New Bedford, Fall River and Springfield have some of the some of the highest COVID-19 case counts and lowest vaccination rates. Meanwhile, in Lexington, Wellesley and Weston the opposite is true - their age-adjusted vaccination rates are above 40 percent and their COVID case rate is one-fifth that of Lawrence. As previously mentioned, the towns with the highest COVID-19 burdens are towns with lower median incomes and higher levels of social vulnerability.
Different barriers help explain why vaccination rates are lower in certain communities, and while we don’t analyze those in this short brief, it’s worth noting two broad categories: access barriers and vaccine hesitancy. Once an individual becomes eligible for the vaccine, access barriers can impede getting an actual shot. Common barriers include not having enough vaccination sites accessible by transit, sites having schedules not amenable to individuals’ work and family commitments, technology challenges related to online registration, and information not well-distributed across multiple languages. Further, the process of pre-registering and registering for vaccines can be difficult and confusing, particularly for those who are not native English speakers or lack a computer/smartphone. It’s likely that many of these barriers are more prevalent in lower-income Gateway Cities and help explain some of the lower vaccination rates we find in this analysis.
Additionally, some people eligible for a vaccine may hesitate to get one due to fear of side effects, historical and current neglect by the healthcare system, or a sense that the risk of COVID infection is not that high. Much of the media attention on vaccine hesitancy has focused on Black and Latinx hesitancy, but race is not the only variable here. A recent statewide poll from the Boston Globe and Suffolk University found that 34 percent and 30 percent of Black and Latinx residents, respectively, were hesitant to take the vaccine compared to 19 percent of White and 15 percent of Asian residents that expressed hesitancy. But the poll found even higher shares of hesitancy among those without a high school degree (39 percent) and registered Republicans (43 percent). Consistent with these poll results, a recent analysis from Rich Parr of MassINC Polling Group finds that Massachusetts towns where Trump performed better in the 2020 election are lagging on vaccinations. Ultimately, these factors also interrelate and get at the need for well-coordinated, targeted outreach programs.
The state launched a vaccine equity program in February that seeks to remove barriers to vaccination in the 20 cities and towns that experienced the highest COVID-19 average daily numbers and high levels of “social vulnerability,” including Lawrence, New Bedford and Fall River. However, advocates such as the Vaccine Equity Now! coalition emphasize that this is not enough and have demanded that Governor Baker take additional steps to ensure vaccine equity, including better outreach to targeted communities, particularly with improved language access for those who speak a language other than English, and the appointment of a vaccine czar “with authority and accountability to address vaccine inequities.” In order to control transmission of the virus and to begin to remedy the stark disparities in infection and death—and speed the entire Commonwealth toward herd immunity—Black and Latinx communities need the resources to enable their residents to access vaccination and to inform themselves about vaccines.
Those inequities could become even more evident as age and co-morbidity factors fade in importance when access is broadened to all adults statewide on April 19. Once vaccine access is expanded, any racial, regional or economic gaps will be even more readily evident. Massachusetts has made progress on the number of doses administered and has made efforts to narrow racial/ethnic disparities in vaccination rates. But clearly, the work is far from over.