Kids of color face a higher risk of severe covid – and have the lowest vaccination rates
Early data shows a racial gap in which kids are getting shots.
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Covid vaccines for children 5 and older are finally available, but early data reveals the U.S. is starting to see a repeat of the troubling racial gaps seen in the adult vaccine rollout. Children of color are more at risk from covid than their white peers, and in many areas they are also much less likely to have been vaccinated.
Just six states and Washington, D.C., were reporting both the race and age of kids vaccinated against the virus as of early January, according to the Kaiser Family Foundation. Within that small sample, Black and Hispanic children are being vaccinated at a much lower rate than white children. In Connecticut, Black and Hispanic children under 12 are half as likely to have received a dose of a covid vaccine than white kids, for example. The same is true for white and Black teens in D.C. And though overall covid risk to children is low, it is higher for children of color — and therefore more urgent that they get the vaccine.
In some ways, it’s not surprising. Parents’ decision-making process for their children is often driven by the same personal and political beliefs, concerns about side effects and barriers to access that influenced their own choices.
“People are invoking the right to privacy. They don’t want to disclose whether their children are vaccinated because there might be implications for them,” said Stephanie McClure, an anthropologist at the University of Alabama. “It’s deeply unfortunate that this is the kind of thing that we have to think about when we’re trying to figure out how to respond to this pandemic.”
Experts say having a better handle on the data for kids could help. Just 19 percent of children ages 5 to 11 are vaccinated, according to the Centers for Disease Control and Prevention, and how those shots are distributed is largely a mystery.
The lack of good nationwide data on kids’ vaccine equity is also a reminder that many states have struggled with antiquated systems for collecting public health data and inconsistent reporting practices — along with increasingly partisan public attitudes about covid and vaccination.
Without good data, or regular communication with communities, it’s tough to know where vaccination barriers lie. Too often, McClure said, health officials don’t hear about the challenges rural and minority communities face. A lack of broadband access prevents low-income parents from making vaccine appointments, for instance; a single mother working multiple low-wage jobs might struggle to take her child to an appointment. Nor are they always aware of the latest rumors and misinformation swirling around covid vaccines.
“If you don’t have a regular conduit of information, then your plans don’t include addressing those situations,” she said. “It’s only obvious if you’re looking in that direction.”
And many parents, particularly people of color who have experienced racism in healthcare, are hesitant to get their children vaccinated — especially as news has emerged about rare side effects such as myocarditis, an inflammation of the heart muscle. “They’re not getting them vaccinated out of love,” said Debra Furr-Holden, an epidemiologist at Michigan State University in Flint. “They’re not willing to take that risk when it comes to their children. It’s another layer of complexity we have to wade through.”
The racial inequities and data gaps that have hampered the United States’ covid vaccination campaign for adults appear to be repeating in children. But the solutions that helped narrow the gap among adults may need to be adapted to reach the children most at risk.
Children of color have worse covid outcomes
Just 6 percent of the more than 84,000 intensive-care beds in the U.S. are set aside for children, excluding neonatal care units. Usually, that is enough. But the rise of the easily transmissible delta and omicron variants pushed many hospitals that treat kids to the breaking point.
While fewer than 1 percent of children with covid require hospitalization, the high numbers of cases this fall and winter have translated to large numbers of children needing advanced care. Hospitalizations among people under 18 have hit record levels in recent weeks, and the CDC says that the rate is highest in kids under 5, the only group not yet eligible for vaccination. And although it is difficult to quantify, one study found that 13 percent of children report “long covid” symptoms that lasted more than one month.
“It really just comes down to the math when you have a very large denominator of children infected,” said epidemiologist Elizabeth Pathak, president of the Women’s Institute for Independent Social Enquiry, a progressive nonprofit group, and head of the COVKID Project, which tracks child cases.
What is also clear is that children of color are at greater risk of severe illness when compared with white children. Nonwhite children are more than twice as likely to be hospitalized with covid, and Black children are up to six times as likely to develop MIS-C — a rare, severe complication in which the heart, lungs or other organs become inflamed.
And although covid deaths among children are rare, children of color have been hit disproportionately hard. They make up 52 percent of the United States’ population under 18 but 64 percent of the 841 child covid deaths recorded as of mid-January.
Experts say there are likely many causes for the increased risk of severe illness among nonwhite children. They could include the amount of time the child is sick before being taken to a healthcare facility, poorer overall health due to a family’s economic status, or underlying health conditions. In other words, when covid strikes it often reinforces existing health disparities.
And some studies suggest that nonwhite children have a harder time escaping covid infection overall. Although white children account for the most covid cases nationally, researchers at Children’s National Hospital in D.C. found that Black and Hispanic kids made up the majority of children’s covid infections at a community testing site in March and April 2020.
The hospital’s chief of emergency medicine, Joelle Simpson, suspects the racial disparity stems from structural factors that result in greater exposure to the virus. These include the inability to distance in crowded homes or parents who work in front-line jobs, which tend to be staffed by nonwhite workers.
Vaccination status is the greatest predictor of how a child’s body will deal with covid, Simpson said: “It is very rare for a fully vaccinated child to have severe complications if they’re otherwise healthy.”
Without sustained efforts to close racial gaps in child covid vaccinations, the virus’s disproportionate harms to children of color could intensify.
There are also knock-on effects from the influx of children needing care for covid. Care for children with sickle-cell anemia, cancer or broken limbs might be delayed if healthcare staff are overwhelmed by covid patients. “What really breaks my heart is the kids who come in but it’s not covid and it is something serious,” Simpson said.
Government Institutions Lens
Holes in data collection are hampering vaccine outreach
Throughout the pandemic, missing or delayed data on cases or vaccinations has made responding the virus harder. Governments have also been slow to mount outreach campaigns to increase vaccination rates.
Most state health departments report county-level vaccination data to the CDC without information on both recipients’ race and age, hiding any relevant trends. And only six states and D.C. report child vaccination numbers that include both race and age in a way that allows them to be cross-referenced. It is difficult to directly compare that handful of states, because each lumps children into a different set of age categories, and many have different criteria for classifying people as Hispanic or Native or Asian.
Some states have legally limited sharing of childhood vaccination data. Idaho doesn’t report the race of children receiving vaccines at all, citing a state law prohibiting disclosure of minors’ data on privacy grounds. “It’s hampered our understanding,” said Diana Schow, a public health researcher at Idaho State University.
Problems with how the United States collects and reports health data predate the pandemic. Many small health departments still rely on faxes and manual entry of paper records. And because the United States has no national unified health record system, it is difficult to cross-reference data between anything so basic as race and age.
The CDC has launched a $500 million initiative to improve how the U.S. collects public health data at all levels. But hiring and training qualified staff and updating archaic computer systems has proved extraordinarily difficult in the middle of a pandemic. “You can’t fix it by throwing a million dollars at somebody,” said Pathak. “We’re really flying blind in so many ways.”
Pathak’s COVKID Project compiles data on child cases, hospitalizations and deaths from multiple sources and extrapolates rates where data is lacking. Its research and modeling suggests that child cases are far higher than the official numbers.
“I actually think if we had racial ethnic data on [vaccine] uptake, we might find in many communities racial minorities are doing better” than white populations, Pathak said. The disparate vaccination rates among Arizona counties, for instance, belie the idea that nonwhite people don’t want the vaccine.
“It’s not that there’s not research out there, it’s just been ignored,” Pathak said. “We have people in power making policy decisions based on some fantasy of how they think people will behave.” Even when an effective vaccine is available, she added, “none of that is going to make any difference if people won’t accept it.”
In many places, particularly rural counties with large Black populations, the job of persuading people to get vaccinated — or get their children vaccinated — has fallen to grassroots or community groups rather than local or state governments. That includes Alabama, which has one of the lowest overall covid vaccination rates in the country. Roughly 1 percent of children under 12 have gotten the shots.
McClure, the University of Alabama anthropologist, recently met a high school cheerleading coach from Pickens County (population 19,000) whose squad members didn’t want to get vaccinated. The concerned coach held a meeting with the girls and their parents to answer their questions about covid and the benefits of the vaccine for teenagers. In the end, most of the girls decided to get the shot.
“The coach did this on her own, but this is the kind of thing the public health department needs to support,” McClure said.
The state has done little to encourage vaccination among children, she said, and many rural communities have struggled to get access to vaccines at all. Rural Black people, especially seniors, often have limited internet access, which is necessary to sign up for vaccine appointments or to even learn about where vaccine clinics are taking place. And in Alabama and elsewhere, clinics are often concentrated in primarily white areas.
When health officials in Alabama have launched vaccination campaigns in rural areas, turnout has tended to be low. “The assumption is, well, these people aren’t interested and we can’t make them,” McClure said. “That may or may not have been the case, but if you don’t have a way to find that out, that’s the conclusion you draw.”
An Alabama health department spokesperson said it “has continued to prioritize minority and under served communities with local outreach,” holding vaccination clinics in 24 counties early in the pandemic and through a new communications campaign. The department has also partnered with academic medical centers, and its pediatric medical officers regularly make television appearances.
Even in more urban areas, the distribution of vaccine clinics and outreach efforts has been uneven. The city of Chicago disproportionately allocated doses to high-income, primarily white ZIP codes during its initial vaccine rollout, researchers at the University of Chicago found. They calculated that 118 deaths between August 2020 and June 2021 could have been prevented if everyone had had the same level of access to vaccines. The city did not respond to a request for comment.
Some governments have figured out what the Alabama cheerleading coach knew: Equitable distribution of vaccines means taking the vaccines to the people rather than the other way around.
Genesee County, Michigan, which includes the city of Flint, created vaccination sites in churches and started offering free testing without barriers, free rides to vaccine appointments and a hotline to order at-home covid vaccination. “We’re union towns,” said Furr-Holden, the Michigan State epidemiologist. “People here know how to organize.”
But in areas where vaccination is seen as a political statement, public health outreach campaigns tend to bend to local sentiment. Perhaps nowhere is this trend starker than in Arizona. The Navajo Nation, which at one point had a higher covid death rate than any state, took both child and adult vaccination seriously. As a result of efforts by the Navajo and other tribal governments, Arizona’s Apache County, which is 72 percent Native, has an 86 percent child vaccination rate — among the highest in the country. But in Mohave County, which is 77 percent white, less than 10 percent of children are vaccinated.
These statistics mirror the adult rates in the respective counties, said William Humble, director of the Arizona Public Health Association and former state health director. Moreover, they mirror local politics: Apache County leans heavily left while Mohave County is right-leaning, making vaccination a political stance.
“I don’t think there’s any way to break through that other than policy initiatives,” such as requiring vaccination to attend schools or travel, Humble said. In highly polarized Arizona, that’s unlikely to happen.
A history of medical abuse increases skepticism among people of color
As vaccination rates picked up in early 2021, workers at nonprofit Bread for the City in D.C. noticed something strange about the people coming into their food kitchens. Although 95 percent of their clients are Black, the vast majority of their vaccinated clients were white. “We thought the reason why was access to resources,” said Communications and Events Manager Kenrick Thomas.
In October, Bread for the City began offering vaccines at its facility in D.C.’s Southeast quadrant, which is primarily Black. The group also put flyers with vaccine information into people’s grocery bags as they left the organization’s monthly free farmers market. “When we were able to make it specifically available to our clients, not just the community, we saw actual change,” Thomas said. Thus far, the organization has given shots to more than 2,700 people.
But although the racial vaccination gap is narrowing in D.C., it is still significant: 66 percent of the white population is vaccinated, compared with 52 percent of the Black community. The numbers for children are far worse. Just 11 percent of Black children and 22 percent of Hispanic children under 12 have received at least one dose — while 46 percent of white children have, according to the Kaiser Family Foundation.
Thomas said much of this is due to access issues, but notes that rumors about vaccination abound. One particularly prevalent one his clients have relayed is that vaccines trigger autism in Black boys; another is that the covid vaccine makes children infertile. “The biggest reason I hear, from adults and kids, is it’s just very new,” Thomas said. “This vaccine hasn’t been out for even two years.”
That concern isn’t specific to Black communities, although vaccine skepticism does appear to be higher in this group. A survey of parents in Cook County, Illinois, in June 2020 — before vaccines were authorized for children — found that 48 percent of Black parents said they would hesitate to give their children the shot, compared with 33 percent of Hispanic parents and 26 percent of white parents. The findings track with other research showing that nonwhite groups tend to be more skeptical of healthcare services overall and less likely to sign up for experimental treatments.
The skepticism is well-founded. “There’s a lot of history behind Black people being at the wrong end of the healthcare industry,” Thomas said. Medical abuse dates back centuries to when slaves were used as unwilling experimental subjects. A more frequent reference is the infamous Tuskegee study, a federally funded project in which physicians tracked Black men with syphilis without treating them or informing them what research program they were really a part of. The decadeslong experiment ended only in 1972, and many Black people personally know some of its unwitting participants.
But McClure, the Alabama anthropologist, says that Tuskegee is often shorthand for a larger issue. “Tuskegee is the maltreatment that is documented. It’s the one that is acknowledged as a historical truth,” she said. That makes it easy for Black people to point to when they talk about racism in the healthcare industry, “as opposed to talking about all the times that you were not listened to, that assumptions were made, that less-than-adequate care was given,” McClure said.
Research does back up these lived experiences. Studies show that Black people are less likely to be prescribed pain medication and less likely to receive appropriate treatment for conditions like cancer and diabetes. They are also more likely to have their concerns dismissed by physicians.
That treatment gap extends to children. Rebekah Fenton, a pediatrician in Chicago, points to research suggesting that healthcare systems subject Black children to the same “adultification” as the legal system, subconsciously treating them as if they had a greater sense of personal responsibility and culpability for their actions than a white child. As a result, the medical care they receive may be more appropriate for an adult than a child.
And ironically, easy access to covid vaccination may worsen hesitancy among people of color, Fenton said: “We are for once doing something that is free and beneficial to people. And yet that is not how America has treated really any health issue, but especially for Black and brown communities.” She often hears concerns about why that has suddenly changed. “I think it’s a very fair question,” she said.
Breaking through these concerns requires a liaison, a well-respected person in the local community who can answer questions without judgment and serve as a role model. In many Black communities, pastors have stepped into this role. “There is a history and a legacy of Black faith involvement” in health initiatives, said Stephen Green, a pastor at St. Luke AME Church in Harlem in New York City. Black clergy were essential in health messaging about the HIV/AIDS crisis in the 1980s, he said, and serve as trusted messengers overall.
Green said he frequently encourages covid vaccination in his sermons: “It’s not just a civic duty, it’s a spiritual obligation. Jesus, through science, has provided us with ways to connect with healing and wholeness.” In recent months, his church has been holding child vaccination clinics after Sunday services that double as toy giveaway events. The church provides a familiar, safe environment where people can get answers about the vaccine from members of their own community. For children, who may be afraid of doctors or needles, the church is a familiar place where the pastor can hold their hands while they get the shot.
Some local governments have increased uptake of covid vaccines among Hispanic people by employing outreach workers known as promotoras, a concept with roots in Latin America. Promotoras are trained to help their community members access resources, answer health-related questions and generally promote good health practices. When covid hit, health agencies and local nonprofits in San Diego County, California, quickly drew on their promotora network, who reached out to thousands of Spanish-speaking people in the area to provide answers and promote vaccination.
“We promotoras are part of the community, our kids go to the same schools,” said Barbara Lugo, a promotora in Chula Vista, California. “We are the role model for them, we lead by example.”
Over the past year, she has helped make appointments, provide safe transportation for undocumented people who are afraid to take the bus, and answer questions through WhatsApp groups. Partly because of such efforts by Lugo and other promotoras, 75 percent of San Diego County’s Hispanic population is vaccinated.
There’s a truism in pediatric medicine: Children aren’t just little adults. They have their own biology, healthcare needs and access challenges. The same is true when it comes to vaccinating kids against covid and overcoming racial differences in access and hesitancy.
“I don’t think it’s as simple as saying, ‘We’ve been at this for a while for adults, we should have figured it out for children,’” said Helene Gayle, president and CEO of the Chicago Community Trust, who led an influential report on equitable vaccine distribution. “There’s a lot of thinking that needs to go into how to make this accessible for children, just like it was necessary to think about how to make it accessible for adults.”
As with adults, the answer seems to lie with taking vaccines to the people that need them — for instance, by making shots accessible in schools at times when parents can accompany their children. Better data collection that takes race and ethnicity into account can help public health experts and decision-makers determine how this outreach needs to take place.
“Reality has shown that there’s a lot of space between a vaccine being available and people being able to get it,” Fenton said, including structural factors, attitudes and experiences that have to be waded through.
And honest communication with families will be the only way to overcome the history of mistrust and medical inequity that persists among nonwhite parents who are concerned for their children’s welfare.
“You’re hearing these messages that sounds really, really scary, and you don’t have the ability to know that those are true,” Fenton said. As a physician meeting with families of color, she said, “I’m really just trying to honor the fact that we’re all doing our risk-benefit analysis. And I hope at the end of that analysis, parents come to the decision, as do young people, that the risk of vaccination is low compared to the significant risk of covid.”