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 vaccine.
Appointments were available.
But 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 weren’t required was off his beaten path. He didn’t 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,” 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 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 COVID vaccine have not yet managed to actually do so. Their ranks are larger than the hesitant — more than 28 million who said they would probably or definitely not get vaccinated, and the 16 million who said they were unsure. And this month, as the Biden administration set a goal of 70% 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 Joe Biden said at a press 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% 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 seem daunting. Others don’t have a regular doctor, and some are socially isolated.
Technically, they have access to the vaccine. Practically, it’s not that simple.
“Hesitancy makes a better story because you’ve got controversy,” said Tom 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 CDC index of “social vulnerability” had lower vaccination rates on average by early April, a New York Times analysis shows. But over the past month, even as supplies have exceeded demand, that disparity has grown.
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 Feldman’s analysis of the census data.
In that group, 93% of adults in households earning between $150,000 and $199,000 a year had been vaccinated as of April 30 while only 76% 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,” 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 Grayson and his fiancée, Renea Carnes, live, about 40% of adults have had at least one shot, according to an analysis of Ohio Department of Health data. Nationally, about 60% of adults have had one shot.
Neither Carnes’ mother or adult daughter, who live with the couple, have 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 Grayson said he had come to believe that vaccination was safe after observing enough people getting a shot without incident. And 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,’” Carnes said, “everyone in the house who doesn’t have it would be getting it right now.”
“What might help this situation,” added 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.”
Vaccine haves and have-nots
If the nation’s public health system was ever to offer a pizza delivery-style vaccine service, now might be that moment. On Tuesday, 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 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.
“Putting more resources into protecting high-risk populations can be life saving and beneficial to us all,” said Lauren Ancel Meyers, the epidemic modeler who conducted the study with a postdoctoral fellow, Kaitlyn Johnson.
The Biden administration has allocated $6 billion to a network of health centers that serve low-income populations, created a task force on health equity, offered a tax break to businesses that give employees paid time off to be vaccinated, and earmarked $330 million to pay social service organizations in local communities to facilitate vaccinations.
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. Nor is it clear how enduring the effort to vaccinate willing-but-hard-to-reach populations will be.
State and local public health officials have argued that a one-time infusion of cash will not allow them to manage a vaccination campaign that will almost certainly require booster shots or to address the underlying reasons that some residents remain unvaccinated. If the country doesn’t 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% 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, Rhode Island.
The existence of vaccine hesitancy, some community organizers say, can be used as an excuse for low vaccination rates. And the diffuse nature of America’s public health system has left some wondering who, if anyone, is accountable for ensuring equal protection from COVID.
“The president has said he wants this to happen, but who is the onus on to do it?” said Keisha Krumm, executive director of Greater Cleveland Congregations, a coalition of faith communities that has held vaccine clinics at its member churches. “Who is it that, if we don’t get Cleveland to 80% vaccination, you’re fired?”
New vaccination site: the parking lot
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, Missouri, those who work a night shift.
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 have both remained unvaccinated because they cannot afford to take time off work if they have side effects. They hope to schedule vaccines during the two days they usually get off after working two weeks straight, she said, “We just haven’t figured out when.”
Only about half of U.S. adults get the influenza vaccine, which is distributed each year. And 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 Garvin, 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 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,” 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. County vaccination data was unavailable from the CDC for Hawaii and some counties. Colorado, Georgia, Vermont, Virginia and West Virginia were excluded from the analysis because more than a quarter of the vaccination data for each of those states is missing.
High vulnerability is defined as a score above 0.5 on the CDC’s Social Vulnerability Index. In the analysis of most and least vulnerable counties, each quartile contains 25% of the U.S. population.
The CDC’s county-level hesitancy estimates are based on data from the Census Bureau’s Household Pulse Survey from March 3-15, 2021. High hesitancy is defined as more than the national average of 16% 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 Census Bureau’s latest Household Pulse Survey, which was conducted from April 14-26.