At a time when health care providers are accelerating mass vaccinations to get the COVID-19 vaccines into as many arms as possible, others are concerned that approach won’t work for everyone who needs a vaccine.
Those who work with people experiencing homelessness, refugees and others who associate government and institutions with some form of trauma, are concerned about how and when the vaccines are going to reach these populations.
“In public health, we’re always looking out for who’s not at the table,” said Kim Toevs, communicable disease director with Multnomah County. She said that means thinking about barriers to access for people who have been marginalized by health institutions in the past and who may be distrustful.
Distribution of the COVID-19 vaccine has been the subject of much criticism. In the urgency to vaccinate people against COVID-19, health care providers are scaling up efforts with drive-through and large venue settings to serve thousands of people at once.
On Jan. 20, the state’s four major health care providers — Kaiser Permanente, Oregon Health & Sciences University, Legacy Health and Providence — teamed up to open a mega vaccination site at the Oregon Convention Center. Vaccinations, with both the Moderna and Pfizer/BioNTech being offered, are free and will be administered at a rate of up to 7,500 a day, depending on the availability of doses. OHSU also plans to open a drive-through vaccination clinic in a parking lot at Portland International Airport.
As of Wednesday, 238,759 doses of the vaccines had been administered in Oregon, with 180,412 Oregonians receiving at least one dose, and 27,464 people being fully vaccinated. About 12,000 doses now administered daily.
Outside In, one of the county’s state-authorized vaccine providers, had vaccinated 100 members of its staff as of last week, and hopes to begin vaccinating its clients as soon as possible. The homeless health service organization serves between 5,300 and 5,800 patients each year out of several health care facilities around Portland, including a mobile medical unit that could become a key service point for reaching people who are unsheltered. The medical unit is stationed at the Clackamas Service Center two days a week, and services almost exclusively unhoused people in Multnomah and Clackamas counties.
“They’re not able or not comfortable seeking care elsewhere,” said Liz Leigh, the safety and disaster preparedness manager for Outside In. “A lot of our patients out there see us for their primary care needs. So ideally we will be able to navigate the system in a way that can provide vaccines to all of our patients that are interested in receiving it.”
Leigh said Outside In would like to have their clients be able to come to a place that they trust, by an organization they are familiar with, rather than a mass vaccination setting.
“For so many unhoused and impoverished persons, seeking health care is already such a cumbersome task, for a lot of ways, for a lot of reasons,” Leigh said. “And the idea of going to receive access at a mass facility like the OHSU drive-through at the Convention Center — which is fantastic for a lot of people — doesn’t make the most sense for everybody in our community. Whether or not they’re unhoused, that is not the most trauma-informed approach for everybody; it’s not the most thoughtful approach for everybody. Especially those who have hesitancy toward health care and we just want to be able to help support both the physical and emotional journey of our patients.”
Any anticipation around who gets the next shots depends on the supply of the vaccine.
Federal guidelines for vaccinations have categorized recipients according to work exposure and health risks, but those were recently expanded to include people 65 and older. That's a significant expansion from the initial Phase 1a levels, which prioritized hospital, urgent care and nursing home workers and residents, tribal health programs, EMS and other first responders.
With that expansion was the announcement by U.S. Health and Human Services Secretary Alex Azar that the federal government would release its reserves of COVID-19 vaccines to states. But it was revealed a day later that those reserves didn’t exist, delaying plans to expand eligibility to older Americans.
Without that anticipated increased supply vaccines, Oregon Gov. Kate Brown said the state won't be able to begin vaccinating older Oregonians until Feb. 8, starting with people 80 and older.
According to the Centers for Disease Control and Prevention, people age 65 and older account for more than 80% of the deaths attributed to COVID-19 in the United States. In Oregon, 77% of the state’s 1,700 COVID-19-related deaths have been among Oregonians 70 and older.
Of the more than 4,000 people tallied as experiencing homelessness in the county’s 2019 Point in Time Count, nearly 1,000 of them were ages 55 and older, and the figures indicate a significant aging trend over time. In 2019, the percentage of people 55 and older increased 23% over the previous count in 2017, with a 75% increase in the number of people 70 and older (44 in 2017 to 77 in 2019).
This is only one portion of people experiencing homelessness in Multnomah County. The count’s figures are limited in their scope, due to the inherent challenges in contacting people who are unhoused or doubled up in insufficient housing.
Toevs said the county has hired a coordinator and project manager to engage organizations and develop a plan to administer the vaccine to marginalized populations, including people in shelters and those outside experiencing homelessness. Outside In, Wallace Medical Concern, Central City Concern and Portland Street Medicine, which all serve people experiencing homelessness, are health care partners in the effort to plan for vaccine distribution, she said.
The county currently reaches out to unsheltered people with other health care needs, particularly with HIV and syphilis cases, using a van to travel to campsites. Toevs said this system could be tapped for taking vaccines directly to the streets, provided there are adequate volunteer staff and doses available, the stability of the vaccine can be assured, and people are properly informed on the vaccine in advance.
The decision to receive the vaccine is up to each individual, she emphasized.
“We’re not trying to sell people on the vaccine,” Toevs said. “They’ve got to make their own decision about what’s right for them, but I want them to have accurate information on that, from folks that they trust to give them accurate information.”
The lack of government-issued identification is a common problem among people experiencing homelessness. But Toevs said people who are 65 and older who want the vaccine will not be turned away if they can’t provide documentation.
“We are really into low-barrier,” Toevs said. “We’re really into people not having to prove or bring in any kind of paperwork.”
Central City Concern operates a network of housing, health care, recovery and employment programs, serving more than 13,000 people each year. Its communications director, Laura Recko, said the organization is looking forward to providing greater vaccine access as soon as possible.
“We are working to build our capability to vaccinate our clients, and this will likely take several weeks,” Recko said. “Presently, we do not have a specific timeline for deployment and are working to solve for this need as soon as possible, considering the other COVID-19 related challenges we face as an agency on a daily basis.”
One key challenge is “people power,” Recko said.
“It is difficult to add staff because all systems are drawing from the same pool of skilled health care workers,” she said. “The most successful strategies support mass vaccination of large parts of the population.
“Because of a lack of national strategy for COVID-19, the country is less prepared and less coordinated than we would like,” Recko said, adding that Central City Concern is working with Oregon Health Authority and Multnomah County and developing an internal strategy to meet the needs of the community they serve.
The anticipation for more of the vaccine is the top question among Outside In staff, Leigh said.
“They’re so excited to be vaccinating,” Leigh said. “And their very next question is when can we start providing support for our participants, people in our clinic systems, people who access our day systems, people in our congregate care. How and when can we do that?”
Information and approaches vary from county to county. Allison Hobgood, executive director of the Corvallis Daytime Drop-in Center in Benton County, said she has only recently been contacted to initiate discussions on how to reach people who are homeless. She called the omission of homeless services from the vaccine rollout a “major oversight,” considering the challenges involved.
“They are vulnerable in many ways,” Hobgood said. “Three-quarters of the people we see also identify as having disabilities. It’s really challenging for people to navigate. I think it’s imperative that we give people who are so marginalized a shot at this and not wait.”
Hobgood said she’s concerned about the education outreach needed to overcome distrust in the community about people’s choices, the vaccine itself and how to get it.
“People are understandingly skeptical because people have been treated poorly by the medical industrial complex and everybody else,” Hobgood said.
In addition to older populations, Black, Indigenous and people of color are among the greatest risk for severe COVID-19 and death, according to the Oregon Health Authority, which is overseeing the state’s COVID-19 response.
Latinos are disproportionately affected by COVID-19, making up 1 out of every 3 cases of the disease in the state. Black, Hispanic and Latino people are not only more likely to contract the disease, but four times more likely to be hospitalized and nearly three times more likely to die of COVID-19 compared to white and non-Hispanic people, according to the health authority.
The agency has stated explicitly that the health effects and death rates of COVID-19 are examples of structural racism’s impact on housing and employment among impacted communities.
On Thursday, Jan. 14, Oregon Health Authority’s Vaccine Advisory Committee called for the state to prioritize Black, Latino, Pacific Islander, Alaskan Native and Native American populations for vaccination. The committee also recommended prioritizing multi-generational households, low-income senior and other senior congregate living that have people under the age of 65. That’s in addition to existing plans to prioritize adults with chronic conditions, people in custody and frontline, hourly workers in the next phase of vaccines.