Hearing Submission for the Record by RWJF Executive Vice President Julie Morita, MD, on Building Trust and Battling Barriers: The Urgent Need to Overcome Vaccine Hesitancy

The following hearing submission for the record was delivered by former Robert Wood Johnson Foundation (RWJF) Executive Vice President Julie Morita, MD, to the U.S. House of Representatives Committee on Oversight and Reform Select Subcommittee on the Coronavirus Crisis.

Chairman Clyburn, Ranking Member Scalise, and Members of the subcommittee:

Thank you for the opportunity to provide a submission for the record for this hearing. My name is Julie Morita. I am the executive vice president of the Robert Wood Johnson Foundation, the nation’s largest health philanthropy, and I served on the COVID-19 Transition Advisory Board in my personal capacity. Previously, I served as: commissioner and chief medical officer of the Chicago Department of Public Health; an Epidemic Intelligence Service officer at the Centers for Disease Control and Prevention; and a member of the CDC’s Advisory Committee on Immunization Practices.

It has been a little more than six months since the first COVID-19 vaccine was authorized for emergency use in the United States. Since then, approximately 180 million Americans have received at least one vaccine dose, and more than half of Americans ages 12 and older have been fully vaccinated. As our vaccination rates have increased, COVID-19 cases, hospitalizations, and deaths have declined significantly.

However, national numbers and trends do not reflect the wide variations in vaccination rates among certain populations and within communities across the country. We have also seen that people’s concerns about getting vaccinated—the focus of the committee’s hearing today—are often connected to the broader systemic issues that have contributed to these wide variations and prevented our vaccination campaign from being as effective as it could be.

Our Foundation believes that everyone deserves a fair and just opportunity to live the healthiest life possible. Given the safety and effectiveness of the vaccines now authorized for emergency use, it is clear that vaccination is our ticket out of this pandemic and holds the key to a return to our normal lives. Indeed, in a perfect world, everyone who is eligible for a COVID-19 vaccine would want to get one. But it is just as clear that when it comes to these vaccines—or any vaccines—trust must be earned. We must explore the root causes and many forms of people’s concerns; work to understand their connections to issues of equity and access; and, perhaps most importantly, we must listen to and learn from those who are not yet comfortable with getting vaccinated.

The root causes and many forms of vaccine concerns

It would be easy to paint everyone who has concerns about COVID-19 vaccines with the same broad brush. However, it would also be unwise and counterproductive to do so. The Kaiser Family Foundation’s vaccine monitor reveals a more nuanced picture:

• Among those who prefer to “wait and see” before potentially getting a COVID-19 vaccine, Black Americans have the highest rates.
• Among those who plan to get a COVID-19 vaccine only if they are required to do so, people ages 18-29 have the highest rates.
• Among those who say they definitely will not get a COVID-19 vaccine, Republicans have the highest rates.

These data can reflect different lived experiences. Black Americans have been disproportionately affected by the COVID-19 pandemic, have higher rates of disease and illness generally, and have suffered the health consequences of structural racism and discrimination—including at the hands of our medical and public health systems—for generations. Young adults, who tend to be healthier, may view themselves as “invincibles” who feel that a vaccine may be unnecessary, especially when older adults tend to have the most severe cases of this particular virus. And as the Kaiser survey notes, Republicans may not trust government agency assurances about a vaccine’s safety and efficacy.

As someone who has spent a lifetime in medicine and public health—from my own practice as a pediatrician to running the Chicago Department of Public Health—I have seen firsthand how vaccines save lives and improve health. I have also seen up close how people’s personal journeys to vaccine confidence can be long and difficult—if they get there at all. I have spent countless hours with my patients’ families and the residents I served listening to concerns about vaccines, answering people’s questions to the best of my ability, and working to respect and appreciate viewpoints that are different from my own. My career has taught me that while “vaccine hesitancy” may be a catchall term used in our public discourse, it is home to an incredibly wide variety of histories and perspectives that can look very different in a pediatrician’s office, the neighborhoods of Chicago, or communities nationwide.

It is also my experience that the messenger is as important as the message. People may be more willing to get vaccinated when they see their family and friends doing so and enjoying the greater degree of freedom that comes with it. Community groups, faith organizations, and other neighborhood pillars of trust also play a pivotal role in helping people make vaccine decisions. This is often a very personal decision that can require the intimate connection of a trusting voice.

Connections to issues of equity and access

One important lesson I’ve learned is that people’s willingness to get a vaccine often depends on their ability to obtain one. This nation’s vaccination rollout has been far from perfect, and one of the most glaring missteps has been our predominant focus on national numbers. Whether it was in the early days of the rollout (total number of shots administered daily), lately (whether we reach 70 percent of adults having at least one shot by July 4), or ever-present (what constitutes national herd immunity and when will we achieve it), we have tended to neglect the more important metric when it comes to people’s protection from this virus: vaccination rates within communities. It is at the neighborhood level—even by zip code—where we can save lives and suffering if we understand and address concerns raised among vulnerable populations.

Take New Jersey, our Foundation’s home state. Sixty-six percent of adults in New Jersey are fully vaccinated. This is one of the highest state vaccination rates in the country, but that laudable number doesn’t reflect conditions everywhere in the state. In Princeton, a predominantly White community where our Foundation’s headquarters are located, 72 percent of adults are fully vaccinated. But in Trenton, a predominantly Black and Latino community only 14 miles away, it’s only 42 percent.

These types of variations often reflect broader health disparities in communities across the country. For instance, Princeton residents live, on average, 14 years longer than Trenton residents. These inequities, which tend to be compounded by issues of accessibility and born of systemic racism, have been reflected in our vaccination rollout:

• Racial/ethnic disparities: For more than 40 percent of vaccine recipients, race and ethnicity is unknown, often because state and local vaccine reporting systems don’t have the ability to do so. In states that do report this data, Black and Hispanic people tend to have lower COVID-19 vaccination rates compared with their COVID-19 case rates and share of the total population.
• Geographic differences: In 11 states, more than 65 percent of adults are fully vaccinated. By contrast, in eight states (primarily in the South), fewer than 45 percent of adults are fully vaccinated.

Accessibility concerns. The CDC has found that counties with lower vaccination initiation rates have higher percentages of adults with “social vulnerabilities,” including low incomes, living alone, or lacking a computer or Internet access.

Whether people in any given community have easy access to vaccines depends a great deal on the resources available to that community to simplify the process and bring vaccines directly to priority populations. As a leader in the Chicago health department during the H1N1 pandemic in 2009, we partnered with pharmacies and federally qualified community health centers that provided care to the uninsured in neighborhoods with less access to healthcare providers. More than 700 locations in Chicago ultimately received more than 1 million H1N1 vaccines during a critical 12-week stretch.

Those partnerships were critically important, but they required resources to develop and maintain. CDC’s clear guidance, additional funding, and technical assistance were invaluable to our efforts, and I’m pleased that we’re seeing similar efforts today. The CDC, thanks in large part to additional federal funding in the American Rescue Plan Act, has distributed more than $6 billion toward more equitable and accessible COVID-19 vaccination efforts throughout the country. This additional funding is particularly critical for state and local public health departments that have suffered from a severe lack of funding for decades and entered the pandemic without the resources and personnel to deal with a crisis of this magnitude. Such assistance should be sustained as we navigate the current phase of the pandemic, and the funding should remain in place beyond so that we’re better prepared for the next crisis.

Listening to and learning from those with vaccine concerns

We have reached a point where many of those most eager for COVID-19 vaccines have already gotten them. And while there is certainly a segment of the population that continues to express complete unwillingness to get vaccinated, a sizable portion of those who are still unvaccinated may well eventually move from “on the fence” to “yes.” To ensure that as many people as possible in this country get vaccinated in the days and months ahead, we must continue to prioritize equity, access and coordination. Importantly, policymakers must continue to provide the dollars, resources and support so that the public health heroes in every community can make this happen.

Fortunately, one of the most important and effective tools we have at our disposal doesn’t cost a thing: that is, quite simply, the ability to listen.

Since last December, our Foundation and the Horizon Foundation have worked in concert with other public health organizations—including NACCHO, ASTHO, the National Indian Health Board, Association of Immunization Managers, and the Johns Hopkins Bloomberg School of Public Health—on a three-part series of surveys conducted with residents of communities nationwide to gain greater insights into whether and when people decide to go ahead with getting COVID-19 vaccines. The latest series, which reflects responses from May 2021, includes several revealing trends for policymakers and public health officials to consider as we enter a crucial stage of the pandemic.

Highlighted findings from the most recent survey are below; the sub-bullets reflect my personal reactions to these findings:

• Decision-making was “in process” for months; now most have made a decision—overall 72% vaccinated. There was a great deal of deliberation from December through April as individuals and communities were weighing information, cultural and lived experience, and issues of vaccine accessibility in their decision-making. However, with vaccine eligibility expanding to every adult in the United States by the end of April 2021, most have made their decision and gotten vaccinated.
  • This illustrates that the path toward vaccination is a long and winding one for many people, and that patience and perseverance today can pay off tomorrow.
• Conversations with family, friends, and their own research. Hearing from family and friends about their largely very positive vaccine experiences and acquiring more factual information from a variety of sources (e.g. TV, radio, online, podcasts) were very important to decision-making.
  • As more and more Americans are vaccinated, we can hope that the chorus singing these positive experiences will only grow louder.
• A strong desire to return to normal life. For some, a desire to return to normal life was central to their decision-making. Others described it as a benefit once vaccinated.
  • Again, this indicates that the normalizing of vaccination and the budding return to normalcy of tens of millions of people across the country can provide the impetus for additional vaccinations.
• “Lived Experience” was shaped during the pandemic and vaccination rollout efforts. The early days of the pandemic and the disproportionate impact of COVID-19 hospitalizations and deaths on the Latino, Black, and Native American populations had been indelible and traumatizing in some cases. As vaccines rolled out, there were frustrations regarding registration, lack of linguistically and culturally appropriate materials, perception of people “jumping the line,” lack of accessibility without public transportation, and other issues. Despite those circumstances, many indicated that course corrections were made in the process of the rollout.
  • This finding should be central to this nation’s post-mortem once this pandemic ends. We must continue to address these inequities.
• Information needs continue to evolve for everyone—whether vaccinated or unvaccinated. There was high interest in a diversity of topics, including: variants and implications for vaccine effectiveness; whether vaccinated people can spread the disease to those not vaccinated; and whether there will be an annual COVID-19 vaccine shot; and COVID-19 vaccines for children.
  • That’s why consistent, transparent and regular public health messaging is critically important to helping us reach the end of this pandemic.
• Increased attention on children with different information needs. With vaccine eligibility expanding to all adults; the focus on decision-making, particularly among parents, has increasingly turned toward children. There were two specific areas of interest: (1) how effective and safe will the vaccine(s) be for children, and (2) what has been and will be the continued impact of students not being in school? A desire to have students back in school for the purposes of educational growth and mental health was central to many conversations about children.
  • Millions of children have been infected with COVID-19, thousands have developed a severe related inflammatory condition known as MIS-C, and hundreds have died; children of color have been disproportionately affected. As a pediatrician, I believe strongly that all children eligible for COVID-19 vaccines should get them. With children as young as 12 able to be vaccinated against COVID-19 now, vaccines for younger children perhaps coming in the near future, and it is essential to assuage the concerns of parents and caregivers.

Conclusion

When it comes to vaccines during a pandemic, every shot counts. The vast majority of COVID-19 cases, hospitalizations and deaths have occurred in those who are unvaccinated. With more transmissible variants rapidly gaining a foothold across the country, we must redouble our efforts to ensure equity and accessibility are hallmarks of our vaccine rollout efforts. This is essential as we work to vaccinate as many people as possible in every community. On behalf of the Robert Wood Johnson Foundation, I appreciate the opportunity to share our perspective and would be pleased to offer any additional assistance to the committee on these or other pandemic-related issues. 

About the Robert Wood Johnson Foundation

For more than 45 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are working alongside others to build a national Culture of Health that provides everyone in America a fair and just opportunity for health and wellbeing. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook.