Vaccine Solidarity Requires Social Justice: A Public Health of Consequence, February 2022

In 1999, the Centers for Disease Control and Prevention published a list of the 10 greatest public health achievements that increased life expectancy during the 20th century. Included in this list were mass vaccinations to reduce infectious disease epidemics (https://bit.ly/3oEdSBr). The report was followed by two others in 2011, both of which reported declines in hospitalizations and deaths because of vaccine-preventable diseases domestically and globally (https://bit.ly/2Z4iwjs). Simply put, vaccination is the most cost-effective way to prevent death and disability from vaccine-preventable diseases. Despite this clear and incontrovertible fact, we have witnessed increased vaccine refusal, vaccine hesitancy, and vaccine mistrust over the past two decades.

Although the current rise in vaccine hesitancy and refusal to comply with vaccine mandates is fueled in part by rapid dissemination of misinformation and disinformation on social media, the vaccine refusal movement is not new. As Colgrove and Samuel (p. 234) describe, the history of vaccine refusal is rooted in antivaccination movements that took hold in the second half of the 19th century in the United Kingdom. Stemming from principles of individual liberty and personal freedom, the antivaccine movement and its proponents, in Great Britain and later in the United States, campaigned against state-mandated, compulsory vaccination laws. The politicization of the antivaccine movement as one framed around maintaining individual freedom and its melding with the medical liberty movement laid the foundation for the current antigovernment, antivaccination efforts. Lost in the antivaccine rhetoric was the notion of vaccination as emblematic of a social contract in public health that promotes vaccination mandates not only to protect the health of individuals but also to protect the health of populations.

Fast-forward to the present, and contentious debates about the political, ethical, and societal impacts versus individual liberties of vaccine mandates have resurfaced and intensified. Yeh’s essay (p. 255) describing the concept of solidarity as grounds for enacting mandatory vaccination is predicated on the notion that citizens of a state should be willing to value, support, and take on the risks and costs of a vaccine because these interventions are for the greater good of the state. This notion of solidarity also draws on the concept of the social contract in public health—which requires the recognition of health as a public good and of vaccination as an act of civic responsibility in support of the health of the populace.

DRIVERS OF INADEQUATE VACCINE COVERAGE

An issue with grounding vaccine mandates in a solidarity framework is that concept rests on the assumption that all citizens in a state or community are held in the same value. Since its onset, the disproportionate burden of economic, social, political, and health consequences of the COVID-19 pandemic have been borne by communities of color and marginalized communities—communities that have historically not been afforded the same level of value in our society.

There is a large body of literature documenting the multitude of ways these layers of structural racism affect communities of color, and in an upcoming article in AJPH, Asabor et al.¹ add to it by presenting evidence on the lower availability of an essential public health service in communities of color during the COVID-19 pandemic. Their analysis of the spatial distribution of COVID-19 testing sites shows that cities with higher degrees of racially segregated neighborhoods (Los Angeles, CA; Chicago, IL; New York City, NY; and Houston, TX) had fewer COVID-19 testing sites in neighborhoods with higher concentrations of Black and Hispanic residents than other neighborhoods.

The lower number of COVID-19 testing sites in communities of color is not unique to this pandemic but a reflection of the chronic lack of public health services for vulnerable communities. And this historical underprovision of public health resources in communities of color continues to be a driver of lower vaccination availability and uptake among Black and Hispanic/Latino populations. In fact, state-level vaccination data compiled by the Kaiser Family Foundation show that racial/ethnic disparities in COVID-19 vaccination persist in the same states—California, Illinois, New York, and Texas—included in the Asabor et al. study (https://bit.ly/3HLHOED). As of November 15, 2021, Black and Hispanic/Latino residents in these states lagged White residents in receipt of a COVID-19 vaccine dose, with gaps ranging from −11% (Illinois) to −6% (New York) for Black residents and from −12% (California) to −9% (Illinois) for Hispanic/Latino residents. Compounding and exacerbating the impact of suboptimal public health infrastructure on vaccination uptake is the legacy of medical mistrust, which is another driver of vaccine hesitancy in communities of color.

Although not specifically about COVID-19 but relevant to disparities in vaccination uptake, Jain et al. (p. 304) report on the persistence of a rural–urban divide in self-reported influenza vaccination rates. Their findings show lower self-reported influenza vaccination among rural residents overall and a similar trend of lower vaccination among racial/ethnic minority rural groups compared with their urban counterparts. Again, we see in rural communities, and especially rural communities of color, which have been overlooked and ignored, that public health infrastructure is woefully inadequate and unable to meet the basic public health prevention needs of this vast and diverse population. The backlash against vaccination in many rural communities is yet another manifestation of antigovernment sentiment and often employs a corrupted version of “my body, my choice”—the hallmark slogan of the reproductive rights movement.

ACHIEVING VACCINE SOLIDARITY

Where does this leave us in trying to achieve adequate vaccination coverage? First, we must learn from historical lessons and not ignore the educational, economic, and social inequities that are not just persisting, but widening and fueling inadequate vaccine coverage. Second, we need political support to adequately fund state and local public health actions that protect the health of the most marginalized and historically disenfranchised people. Failure to do so will continue to erode the social contract in public health and trust in our government and its public health agencies. Third, consistent vaccination mandates for essential workers are required across all US states. Such policies will avoid further weakening confidence in our government response to the pandemic and protect our workforce and population (https://bit.ly/30ztTjF).

Without bold action, factors that are at the core of vaccine hesitancy, medical mistrust, and antivaccination movements will remain with us for generations to come no matter the weight of scientific evidence that supports vaccination programs. Although solidarity as a framework for vaccine mandates is meaningful and applicable in more egalitarian contexts, it will likely be successfully applied only if we dismantle the policies and systems of structural racism that sustain health disparities and health inequities by placing less value on the health and well-being of communities of color. This is not a surrender, but a call to action: for public health to positively impact vaccine solidarity, we must first and foremost redouble our commitment to social justice.