COVID-19 vaccination and concerns regarding reaching marginalised communities

We are at the edge of our seats and in constant action in the public health community as we prepare to roll out the COVID-19 vaccine, globally. Marginalised communities such as migrants, people living with HIV and/or TB, LGBTQAI+ communities, sex workers, the urban and rural poor, among others, have often found themselves left behind in the roll-out of mass public health initiatives.

This is not only distressing for entire communities and restricts them from living their full potential, but it also skews the health quintile for entire countries. By not protecting our most marginalised, we put communities and geographies at risk; we burden our health systems and hit mortal blows at our economy, slowing down our collective development.

This is an opportunity to flip that narrative. By putting the most marginalised communities first — which is the right thing to do — we also ensure we take prevention to the last mile, therefore protecting the people, as well as ensuring our health systems are not triaged. Having room to function at its optimum is critical in care.

With limited initial doses of vaccines being available, most countries are prioritising health care workers, front line workers, older people in nursing homes, and people with pre-existing morbidities to receive the vaccines first.

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One of the greatest challenges that the governments would now face is to bring the lens of intersectionality into the vaccine roll-out. Prioritised eligibility for the vaccine now understandably comes down to our roles and identity in society. It does not entirely account for those being disparately affected by COVID-19, i.e. the most marginalised.

These include people who most often do not have access and agency to health systems and care, such as migrants, LGBTQIA+ communities, sex workers, among others.

Within these communities too, vaccine disparity is bound to creep in as the line of eligibility gets drawn. Intersectionality of other vulnerabilities such as gender and disabilities present a greater challenge to access.

Where access to the vaccine is available, we would also need to ensure that existing stigma attached to the marginalised communities do not come in the way of effective vaccine roll-out.

Access to information and vaccination is poor among migrants, especially those who are undocumented. Furthermore, implementation policies require identity cards for vaccination and lack of such documentation and incorrect gender entries in the identity proofs will become a barrier for the LGBTQAI+ and migrant communities.

As public health practitioners, we have to actively dialogue and partner with policymakers and implementers, to ensure implementation strategies are grounded in the lived realities of these communities.

Public health is only as effective as its reach to the public and at the last mile, the very pockets where the marginalised struggle to survive. Therefore, the community needs to be at the very centre of the implementation of the vaccine roll-out.

We need to be consistently and continuously aware of the environment we are operating in and from where the community draws its understanding of the vaccine. An important deterrent to effective implementation of vaccination is the presence of a plethora of misinformation across the globe about the vaccines.

Governments and implementers will need to design communication and advocacy efforts targeted at faith leaders as many may have publicly dissuaded their followers from taking the vaccine.

Individual governments at the most local levels and community institutions will need to be prepared to rapidly identify any such prevailing deterrent and undertake adequate advocacy measures to ensure successful implementation of vaccination.

Social media, given its ease of use and spread, can play an important as well as a deterrent role in enabling successful implementation. There is a need to integrate online and offline platforms as well to address misinformation.

As accurate information is being amplified, it is critical to continue the emphasis on prevention advocacy as well, such as messages on masking, sanitising, among others. Vaccines will not replace key infection control but will complement these efforts. This is going to be a steep learning curve.

Depending on the pre-existing condition of the health systems, each country will face new challenges in implementing the vaccination. Storage, cold chain, funding for implementation, reliance on existing programmes and shifting focus away from them are some of the concerns associated with implementation.

In India, new vaccinators are being identified and trained to ensure vaccinators of the routine immunisation programme are not burdened and this is a great approach. We look forward to seeing the monitoring of implementation and adverse events done through the EVIN system and India has started capacity-building efforts to employ the system.

At the same time, it is critical that our guidelines listen to and empower communities to address challenges through their institutions such as Swasth Samitis, i.e. health co-operatives and youth groups.

This will ensure that the vaccine response is effective, efficient, and meaningful and truly leaves no one behind. With seed funding, pool funds and localised funding, we are confident that we can reach the last mile and protect our most marginalised communities.