Year Two of the pandemic: Which strategies helped Minnesota distribute vaccines equitably – and which didn’t.

Over the past year, Minnesota has made progress distributing COVID-19 vaccines equitably across different racial groups. 

In March, people of color made up only 10 percent of the state’s vaccinated population; today, that number has nearly doubled.

But several challenges linger in the coming year. Minnesota is bracing for another wave of infections from the Omicron variant, and health experts are imploring everyone eligible for the vaccine to get booster shots. But, just 27 percent of the state’s population has received third doses of the vaccine. The state hasn’t released any information on how that number breaks down by race. 

For much of the year, Dr. Nathan Chomilo served as the state’s vaccine equity director. Now, the Park Nicollet pediatrician and state Medicaid medical director is a senior equity advisor to Minnesota Health Commissioner Jan Malcolm, a role he will continue in through 2022. 

In a recent conversation, Chomilo praised the state’s partnership with community organizations, saying that has been crucial to making progress distributing the vaccine to communities of color. He also expressed frustration with the shifting public health messaging from on issues like vaccines and masking, and implored the state to do a better job of including communities with disabilities into the vaccine equity conversation. 

We spoke to Chomilo about the state of COVID-19 vaccine equity at the tail end of yet another tumultuous year. The following interview has been condensed and edited for clarity. 

What do we know about equitable distribution of booster shots in Minnesota? 

At the state level, it is really difficult to figure out if it’s a booster dose versus a third dose recommended for immunocompromised folks. We can see if someone’s had three doses, but we don’t know if that third dose was because of a medical indication, or because they were due for it. And with the shifting guidance, that has been even more difficult. 

Eventually, once we have a more standard set of guidance like we do for our other routine immunizations, we’ll be able to look back through and see how we did by race and ethnicity. We are looking at third doses, capturing both boosters and those doses for folks who are immunocompromised. We are able to see their doses by [Social Vulnerability Index] ZIP Code quartile. But again, it’s not giving us the full picture of boosters.

What does data for third doses in general look like when broken down by SVI?

Similar to data that we see with the larger vaccination question: that Minnesotans in the lowest disadvantaged ZIP codes are getting boosters at a higher rate. The SVI quartile with the most disadvantaged ZIP codes is actually this second-highest rate for third doses. 

You mentioned shifting guidance. We’ve seen a lot of shifting guidance for vaccines in general for the last year. For example, at the beginning of the year, we thought one shot of the Johnson and Johnson vaccine would give equal or almost equal protection compared to the other vaccines, and then that turned out not to be the case. How have you seen patients grapple with that shifting guidance? How has that impacted your practice?

I don’t know that it impacted my practice a great deal because I feel like people’s reaction or perception is aligned with whatever their experiences and trust in government and healthcare was prior to the pandemic. Those families that have had good experiences and reasons to trust healthcare and government, they are frustrated, but they understand that we’re in a pandemic and are adjusting to what we’re learning as we’re learning it. They’ve tried to do the best to make the best decisions in as timely a manner as possible. 

Those who had their trust violated and have reasons to not trust government or medicine will bring up the changes as a reason to be skeptical of recommendations that are coming from me or from other health care providers. ‘Well, you said this earlier, and now it’s changed. How can we trust that?’ That just goes to show the difficulty in communicating during a pandemic and wanting to give folks enough information to make decisions for themselves. 

As we’re seeing with Omicron, a new variant comes along and can reset some—not all, but some—of our understanding. To some people, that just looks like we’re moving the goalposts. But we’re trying to do our best to communicate what we need to do in the moment.

What do you tell patients who express frustration over the changing guidance? 

I think you’ve always got to start from where folks are coming from and acknowledge that they may very well have had experiences that justify that view. I, myself, have been frustrated by some of the decisions and some of the way information has been communicated. At the same time, we’re all in this together and we’re trying to do our best. 

No one I know shows up to work at clinics or work at the health department with an effort to deceive or harm people. We’re all here trying to help our community through this really rough time. We’re really just trying to do our best to get us all through and eventually past this pandemic.

You mentioned you’ve been frustrated with some of the way that information has been communicated. Can you give an example?

I think it was a mistake for the CDC to announce, ‘If you’re vaccinated, you don’t need to mask’ last summer and take masking off the table as a universal way to navigate the pandemic. That’s been a real frustration. 

Another mistake has been the lack of response to COVID-19 as a global pandemic. The Omicron variant shows us what happens when we don’t have a real global approach. We’re in a worldwide battle against this disease and we look at it as, ‘We just need to take care of the U.S.’ That really isn’t in our own self interest, and we’re now paying the price for not having an ambitious global approach to this pandemic.

How often do boosters come up during your discussions with patients?

With my patients, most of my conversations have been around the benefits of the vaccine for 5- to 11-year-olds, since until just a little over a week ago, no kids were authorized for boosters. Every now and then a parent will ask about it, and I’ll certainly say that boosters are common in how we do shots. I point to all the boosters we give kids in the first five years of their life. I am trying to normalize that it’s again one way to protect ourselves. Boosters have been shown to really help decrease the risk of getting severely ill, as well as getting any symptoms at all. 

When you’re thinking about how you want to try to stay in the workforce, if you’re a parent who has a job that doesn’t have great benefits like sick leave or paid time off, those are the types of things that I think are important to stay healthy. There’s a decreased risk of your kids bringing something home and getting you sick. But I also always talk about all the different things we should be doing to help decrease spread and keep our families safe, like masking, distancing, testing, not going out and about when we’re feeling sick, all of those things.

Breakthrough cases of COVID-19 seem to be getting more and more common. Does this topic come up much in your discussions with parents?

I mostly hear questions like, ‘Well, vaccinated folks still got sick.’ That’s a conversation that we have every year beyond COVID. With flu vaccines, for example, people can still get sick with the flu. But if you get it, your child’s chances of ending up in the hospital or passing away are really, really low. 

I think we did ourselves a disservice when we first talked about the effectiveness of these shots. Everyone was excited that they might not get any disease when they heard numbers like 94, 95 percent effectiveness. We should have done better at saying, ‘People will still get sick, people can still get COVID, but what we’ve really tried to do is turn COVID from this horrible illness that has a risk of killing you into something that’s more like a cold.’

State statistics show right now that, for the Black population, 5- to 11-year-olds are at just 10 percent vaccination rate—lower than all other racial categories. What’s being done at the state level to change that?

There’s been a lot of work at bringing the shots to schools. In the first month of the rollout, around 30 school districts held vaccination events. Our team has worked with the Department of Education to prioritize schools by SVI as well as the percent of students who receive free and reduced price lunch. 

There was a really big push with providers to have shots available in clinics, so that when kids are seeing their doctors for their regular checkups, vaccines are offered. For my practice, since the second week of November, I’ve been offering COVID shots to patients as I was seeing them for their regular checkups. 

Community clinic sites are holding a number of different events. Black Nurses Rock worked with a local community center in north Minneapolis that had a Black Panther vaccination event several weeks ago. We’re working with diverse media vendors to get information out there about vaccines available for 5 to 11-year-olds. We’ve been giving shots at Wilson’s Image barber shop in North Minneapolis. That initially was scheduled to just be a six-week initiative, and we’re now planning to extend it into the first quarter of 2022 and potentially beyond then as well. The recommendations I make to the health department are how we have to keep showing up in these places. 

Looking back at the year, what approaches did and did not work for equitable vaccine distribution? 

The approaches that worked best are working with communities and hearing from them about where we should be showing up, where we should be focusing resources. The diverse media vendors and COVID community coordinators have been a really critical piece of that. That’s a model for public health that I really hope we’re able to sustain beyond the pandemic. I think it would help address much more than just the COVID-19 disparities. 

What I think isn’t helpful is just saying that we want to focus on equity. If we don’t provide a framework, or some shared goals that we can then measure, then everything becomes scattershot. And then it’s really hard to know what’s working and what’s not. 

Other struggles have come up. How do we reach our Minnesotans with disabilities? In the equity conversation, we don’t have vaccine data for people with disabilities in the same way we do for race and ethnicity. We sometimes come to them a little bit later than we should.

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