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What is New York City Doing to Boost Covid Vaccination Where Rates Remain Persistently Low?

(photo: Michael Appleton/Mayoral Photography Office)

Getting vaccinated (photo: Michael Appleton/Mayoral Photography Office)

Uptake of COVID-19 vaccines remains persistently low in pockets of New York City two years into the pandemic, despite being shown to reduce the severity and spread of the virus that has killed nearly 40,000 New Yorkers.

A city health department study in August found a vast majority of covid-related hospitalizations and deaths – 97% – were among people who were unvaccinated. While the vaccine is widely available and the city has made efforts to encourage inoculation, 1.9 million New Yorkers are not considered fully vaccinated. That number – 23% of the city – is mostly made up of vaccine-eligible people, but also includes the under-five population still awaiting federal approval.

“New Yorkers have done a tremendous job getting vaccinated, but I know we can do more,” said Mayor Eric Adams in a statement last month when he announced the return of a limited $100 vaccination incentive. Covid rates had been soaring for weeks, driven by the Omicron variant.

“The more of us protected against COVID-19, the quicker we can get through this pandemic," he said.

But by the end of February, as rates fell again, Adams announced plans to roll back some landmark vaccine requirements as part of a campaign to boost businesses and encourage tourism, backed by the governor and City Council speaker while dividing much of the rest of the city's political and public health establishment.

"Since the rollout of our historic vaccination program an estimated 48,000 deaths have been prevented. That is extremely impressive. Everyday New Yorkers are going home to their families because of that," Adams said in early March, calling the city's mandate for certain business patrons "a success" days before he lifted it. "I'm glad to say that the rates are low enough that the mandatory program is no longer needed," the mayor added of the vaccine passport for indoor dining and other activities, though he did leave in place vaccination requirements for most public and private sector workers.

"I will tell you time and time again, we're going to follow the numbers and we're going to follow the science," he said.

New York City has seen two more covid waves since the August health department study, including the most recent winter surge, which has killed more than 4,900 people since early December. Another city analysis published in January found unvaccinated New Yorkers were eight times more likely to be hospitalized during the Omicron spike than the fully vaccinated.

As of March 14, 39,941 people had died of COVID-19 in New York City, including more than 15,000 since the vaccine became available. Yet while the vaccines are proven to save lives and produce virtually no severe side effects, vaccine hesitancy and rejection remain fairly common in the city.

The highest rates of vaccination are among residents of Midtown Manhattan and certain patches of Queens and Brooklyn. According to city data, 96% of Asian, Native Hawaiian, and Pacific Islander residents are fully vaccinated, a figure that dwarfs rates among Black, white, and Latino residents.

Likewise, low vaccination rates are not evenly distributed across the city. They are concentrated among certain demographics in politically conservative neighborhoods and in lower-income areas with a history of poor government services. Among adults, 87% are fully vaccinated but rates still lag among Black and white New Yorkers and people over 85; only about two-thirds of  each of those populations are fully vaccinated.

Only 36% of New Yorkers have received a booster shot, which many medical experts say is necessary to the vaccine's efficacy. The rates are even lower among 13-17 year olds, and Black and Latino residents, of whom 21%, 24%, and 26% have gotten a booster, respectively.

By large margins, white and Black New Yorkers are less likely than their Asian and Latino counterparts to be “fully vaccinated” – a definition that currently means have received the one-dose Johnson + Johnson vaccine or two doses of either the Pfizer of Moderna covid vaccine, but could soon be expanded to include a booster dose.

The low vaccination rates among some seniors, who are more likely to die from the virus than any other group, have sounded the loudest alarms among experts.

Overall, the lowest vaccination rates among those eligible for covid vaccination are among white children in parts of Brooklyn and Staten Island, according to city data. East Williamsburg, a predominantly Orthodox Jewish neighborhood in Brooklyn, and Tottenville, a Roman Catholic section of Staten Island, have the two lowest rates among children, with 18% and 25% of 5-17 year olds fully vaccinated, respectively.

On March 8, Mayor Adams said the city will run an ad campaign and focus groups targeting young people. "No, I'm not happy about those numbers," he said, at an unrelated press conference, when asked by a reporter about the low covid vaccination rates among children.

"We have to get them vaccinated," Adams said. "And parents must play a role, we need their help. The more vaccinated individuals we have the better we could do."

As of March 14, only 44% of children 5-12 years old, the youngest eligible age range, are fully vaccinated in New York City.

On March 10, Schools Chancellor David Banks announced a vaccination campaign to reach children 5-11 in partnership with the city’s health department and its Test and Trace Corps, which is run out of NYC Health + Hospitals. The campaign entails robo-calls to parents, fliers in schools, and informational town hall events.

Children are far less likely than adults to develop serious symptoms from the virus but New York City saw a dramatic rise in children hospitalized during the Omicron wave. Black residents were more than twice as likely to be hospitalized during the surge than white residents, in part because of delays in getting a first vaccination dose and lower rates of booster shots, according to a third report from the city Department of Health and Mental Hygiene (DOHMH).

"That happened on my watch," said New York City Health Commissioner Dr. Dave Chokshi about those racial disparities, in an interview with Gotham Gazette on March 9. He was responding to the question of what he thought he got wrong as health commissioner.

"That's something that I felt very deeply even for all of our efforts around vaccine equity," said Chokshi, shortly before he was set to hand the departmental reins to his Adams administration successor, Dr. Ashwin Vasan. "Those were the outcomes and that is suffering that we need to confront and do more about."

Black New Yorkers also experienced more delays in diagnosis, less access to outpatient treatments like monoclonal antibodies, and structural factors that lead to higher rates of chronic illnesses – all elements that raise the risk of getting seriously ill or dying from COVID-19, according to the DOHMH report.

Vaccine Hesitancy
Public health officials have grappled with how to overcome the mix of vaccine hesitancy and new and longstanding healthcare accessibility issues driving low vaccine rates.

Only 53% of residents in the Borough Park zip code of 11219, an Orthodox Jewish section of Brooklyn, are fully vaccinated, the lowest rate of any zip code in the city. Far Rockaway's 11691, a mix of Caribbean, South American, and Orthodox Jewish enclaves in Queens, has the second lowest rate in the city.

Both areas were hit hard by early waves of the virus.

“Many communities of color have a justified skepticism of the safety of the COVID-19 vaccine, stemming from historical mistreatment and abuse at the hands of government and medical officials," said Council Member Selvena Brooks-Powers, who represents Far Rockaway, in a statement.

"It’s also important to highlight that in the initial stages of the pandemic, many of these same communities were not prioritized for dissemination of testing and vaccination resources," she added. The city needs a concerted media campaign in her district and to reopen vaccine sites that had closed, Brooks-Powers said.

Driving low rates in Borough Park is a belief among some residents that antibodies from prior infections are effective in controlling the virus, according to Larisa Boas, who coordinates vaccine outreach at Jewish Community Council of Greater Coney Island under a city grant. There are also unproven fears that the vaccine affects fertility, Boas told Gotham Gazette.

"Traditional outreach doesn't work for all of the Orthodox communities," Boas said. "Many of them are very insular...They are consuming their information differently than New York City as a whole."

Elected officials representing several Orthodox Jewish communities with low vaccination rates did not respond to requests for comment for this article.

Staten Island's South Shore, where vaccination rates are as low as 62% of residents in one zip code, is another of the city’s small number of more conservative areas where anti-vaccine sentiments are high. The South Shore's representative in the City Council, Minority Leader Joe Borelli, did not respond to multiple inquiries for this article. Borelli has been outspoken against vaccine mandates but has encouraged New Yorkers to get vaccinated.

Most of Mayor Adams' comments on the city's covid vaccination efforts have centered on public and private employer-based requirements, including enforcing a vaccination deadline for municipal workers. The vaccine portion of his plan to combat the Omicron surge, released just before taking office January 1, included preserving the public- and private-employer mandates, and exploring booster dose mandates and covid vaccine requirements for students. He has recently said a covid vaccination requirement for students is still under consideration for next school year.

But in late February, Adams announced the lifting of New York's "Key to NYC" rules, adopted under Mayor Bill de Blasio, which required proof of vaccination for partaking in aspects of social life like dining inside restaurants or attending entertainment venues. The mandates were meant to help keep safe those spaces where different households mingle and to broadly encourage New Yorkers to get vaccinated.

“Two years ago, New York City was the epicenter of the pandemic, but thanks to New Yorkers getting vaccinated and getting boosted we have made tremendous progress,” Adams said in a statement. “I’ve said time and time again that the numbers and science will guide us as we continue to recover and rebuild, and now New York City is back, and vaccinations are why we’re back."

"The fight may not be over, but we’re clearly winning the war. We are open for business and New York City has its groove back,” Adams said.

Public and private employer mandates for employee vaccination will remain in place, "as they are, and have been, vital to protecting New Yorkers," Adams said.

Public health experts, including Dr. Jay Varma, de Blasio's top health advisor throughout much of 2020 and 2021, criticized the plan, calling for caution as rates fall and urgency to continue incentivizing New Yorkers to protect themselves with the vaccine.

Adams has said little as mayor about increasing covid vaccination rates among populations and in communities where they are stubbornly low. His comments this past week about increasing vaccination rates among youth, prompted by a reporter’s question at an education-related announcement, was a rare exception.

In a statement responding to the “Key to NYC” deregulation, City Council Speaker Adrienne Adams, who represents portions of Southeast Queens and has a new citywide perch as speaker, said "we have reason to be optimistic" about lifting restrictions and urged the city to "enact a major effort" to address health disparities.

"In areas that continue to be disproportionately impacted and under-vaccinated, we must pursue a targeted and persistent effort to vaccinate New Yorkers, maintain a high capacity for testing, and invest in public health and wellness," said Speaker Adams (no relation to the mayor).

DOHMH has been touting those exact efforts for many months. But questions remain about their success and providers tasked with reaching the most vulnerable communities say there are serious gaps in the city's model.

Lawmakers responsible for oversight and those representing the most under-vaccinated districts offered few suggestions or did not respond when contacted repeatedly by Gotham Gazette.

The City's Efforts
The COVID-19 vaccine has been widely available in New York City to all but the youngest city-dwellers for almost a year: at massive city- and state-run sites, and more familiar locales like community health centers, pop-up clinics, and mobile vans, and even at home.

City health officials say their goal is to vaccinate as many eligible New Yorkers as possible with a focus on the oldest and youngest – the age groups with the lowest vaccination levels – and people who are immunocompromised or have comorbidities and are thus the most vulnerable.

Public health agencies have relied on a handful of tools to reach residents in low-vaccinated communities, deploying temporary sites, partnering with community-based service providers, targeting ad campaigns, and staging informational events.

A criss-cross of committees and task forces guide outreach efforts: the city's Task Force on Racial Equity and Inclusion; the state's Vaccine Equity Task Force (both prioritizing many of the predominantly Black and Latino areas with low covid vaccination rates and high covid mortality); the Vaccine Partner Engagement Project run by the city health department; the T2CBO (community-based organization) program under the city’s public hospital system; and a "fruitful" working group for organizations serving seniors, operating out of the Mayor's Office, that has not met since Mayor Eric Adams took office, according to nonprofits involved (City Hall did not respond to an inquiry about it).

While the city and state say they target vaccines, staff, and other resources to areas with low uptake, they rely on local providers to act as "trusted messengers" to bring people in. Roughly $125 million in city funds has gone to 100 CBOs and 17 federally-qualified health centers, Dr. Chokshi, then the city health commissioner, reported at a February 23 City Council oversight hearing.

Despite that budget, many of the CBOs the city works with are unfunded, according to providers. The organizations -- including healthcare networks, social service providers, religious institutions, and community centers -- typically furnish the space for vaccination and educational events, and encourage their constituents to get inoculated, while the city health department provides the vaccines, the clinicians, and the administrative support.

"We have worked extensively to increase these rates – but we know that vaccine confidence remains low in many communities, and misinformation is rampant," Chokshi told lawmakers at the oversight hearing on February 23, held jointly by the City Council's health committee and COVID-19 subcommittee. "We are working to do more to combat misinformation and build trust through our partners, through media campaigns, through community health care providers and through elected officials like all of you."

The health department has held over 24,000 events, including virtual forums and in-person town halls, with CBOs and faith organizations, and knocked on over 1.7 million doors to raise awareness about the vaccine, Chokshi said. The city has also developed "a surveillance infrastructure" to monitor and combat misinformation on social media and other forums "in real time" and incorporate that analysis into its messaging.

That model has worked well in Flushing, Queens, according to City Council Member Sandra Ung, who has represented the predominantly Chinese and Korean district since January. Vaccination rates in the district are well above the city average, in some areas reaching as high as 99% of residents.

"What was helpful in this district was really working with the CBOs," Ung said in an interview, and "understanding who the communities trust."

"Let those people be the messengers rather than New York City itself," she said. Messaging delivered through Chinese- and Korean-language media has also been key, she told Gotham Gazette.

But vaccine accessibility issues remain in many parts of the city.

In August, city and state officials, including then-Brooklyn Borough President Eric Adams, and representatives from DOHMH, held a press conference at the Beach 39th Street vaccine hub in Far Rockaway -- where only 54% of residents are fully vaccinated -- encouraging residents to get inoculated. But the mass site, one of the few in the district, has since been closed, according to Council Member Brooks-Powers’ office.

In a statement to Gotham Gazette, Brooks-Powers called for a "concerted push from City health agencies" to reach unvaccinated New Yorkers that should include a rigorous media campaign and an eye toward opening more sites "and keeping them open." Brooks-Powers "thinks sites like B39 need to be prioritized, especially if sited in neighborhoods with lower vaccination rates,” a spokesperson said.

'A Lot of Assumptions’
The reasons for ongoing vaccine hesitancy are nuanced, varying from person to person, community to community. In some cases it is driven by political ideology or misinformation. But observations from providers also point to a more personal calculus that could be amenable to government outreach.

"We continue to need qualitative analysis. There are a lot of assumptions that are made," said Dr. Stella Safo, founder of the New York City-based healthcare advocacy group Just Equity for Health, about vaccine hesitancy.

"We see with every surge, with every new variant, people go ahead and either get boosted or get vaccinated for the first time," Safo told Gotham Gazette. "We just saw with Omicron the number of new individuals who were on the fence, who went and got vaccinated when they saw just how much better people who were vaccinated did, than those who were not."

Many of the unvaccinated people Safo and the providers she works with see are not entrenched or dogmatic in their approach to the vaccine but want to let more time pass to confirm the effects for themselves, she said. "I think there are more individuals, certainly among Black Americans, who are in that wait-and-see camp versus stark anti-vaxxing camp, that we have to continue to offer opportunities for."

"Members of these communities are more likely to trust close contacts like relatives, friends and neighbors, and it can take time for vaccine confidence to spread in that environment," said Council Member Brooks-Powers of Far Rockaway.

In white areas with low vaccine rates, including conservative parts of Brooklyn and Staten Island and, in particular, Brooklyn's Orthodox Jewish enclaves, trust has been a challenge. Gotham Gazette made many attempts to contact city and state lawmakers representing those districts and none responded to inquiries for this article.

City Council Member Lynn Schulman, the new chair of the Council’s health committee who represents a predominantly white district in Queens with sizable Asian, Latino, and Orthodox Jewish populations, would not comment directly on vaccine hesitancy among her constituents or in the city at large. Nor did she offer suggestions about what the city could do to improve covid vaccination rates.

"New York is experiencing the lowest COVID numbers since the start of the pandemic and it seems to be a good time to begin reducing restrictions, especially for restaurants and other entertainment venues which have suffered greatly," said Schulman, who took office in January, in a statement to Gotham Gazette. "With that being said, it is still imperative for every New Yorker to protect themselves by getting vaccinated and boosted, always follow the science, and explore creating guidelines for future healthcare measures based on case levels and other appropriate criteria.”

Ongoing Access Issues
While officials say they continue to target vaccine resources in under-vaccinated areas, some local providers and community advocates say getting access to the vaccine is still difficult 11 months after the state lifted initial restrictions on vaccine eligibility. A large part of that is being able to navigate the city’s and state's vaccine infrastructure, particularly for older adults, immigrants, and historically disenfranchised groups.

"Our studies show that Bangladeshi and Nepalese communities are still struggling to get vaccine access," testified Medha Ghosh, health policy coordinator at the Coalition for Asian American Children and Families, at the City Council oversight hearing in February.

A CACF survey found a high rate of Bangladeshi and Nepalese adults reported favorable views of the vaccine despite being the Asian subgroups with the lowest vaccination rates. "It's not vaccine hesitancy, but just not knowing where to go and having proper information," Ghosh said.

The same is true of the seniors Shehila Stephens works with as a program director at Encore Community Services, which serves roughly 3,000 older adults across New York City. “I think the number one barrier in these particular communities is that there is so much information coming from the CDC, the department of health, community providers. And it’s changing so frequently that they’ve lost trust in the validity of the vaccination," she said of her unvaccinated clientele.

"They perceive it as we don’t actually know what we’re talking about," Stephens said.

Technological issues in the vaccine sign-up system that plagued the initial roll-out in New York have persisted for older adults and people with limited English and/or digital proficiency, according to Stephens. Early on, the city's online portal was cumbersome and not enough resources were devoted to the city's phone sign-up, creating long waits.

“I don’t necessarily think it’s improved," Stephens told Gotham Gazette. "Our staff still completes the forms when they can online for the seniors because that’s the fastest way to do it. Waiting on the phone is not efficient."

Socially isolated seniors and those who aren't already connected to a service-provider are often out of luck. It is one of several examples providers shared with Gotham Gazette where city vaccine efforts depended on residents having their own advocates.

"A lot of what we heard from our membership is that their older constituents were waiting to hear from their doctor, and we know that many old people don't have a primary care physician," said Allison Nickerson, executive director of LiveOn NY, an association of senior service providers.

Primary care deserts are prevalent in many of the communities with the lowest vaccine rates. Every zip code with vaccination rates below 70% roughly corresponds with the Council districts with primary care doctor-per-capita rates that fall below the city average, according to Primary Care Development Corporation (PCDC). "Without primary care access, communities will have worse health outcomes, both from COVID and other preventable diseases," said Jordan Goldberg, PCDC's policy director, in testimony at the oversight hearing.

Transportation to a vaccine site for New Yorkers with mobility challenges can be prohibitive. The city has had an at-home vaccination program, which since last summer has reached roughly 33,000 residents. But Nickerson and Stephens both said enrollment was difficult and the wait-time to receive the vaccination was long. According to Nickerson, many homebound seniors were reluctant to partake in the program out of fear they'd be left alone when side-effects set in.

Trusted Messengers
Safo said the city should give more primary care doctors the ability to vaccinate patients because they tend to be more trusted than less familiar city- or privately-run sites. That is not happening widely in Far Rockaway, one of the areas she focuses on, Safo said.

"It's about how you make it as simple, as accessible as possible," Safo said. "If the question is how do we go the last mile, that's one of the ways."

Doctors can sign up to distribute vaccines through the city Department of Health and Mental Hygiene’s Citywide Immunization Registry. Physicians who administer other routine vaccinations already have the necessary cold storage, according to a spokesperson. But the vaccines are good for a narrow window making it difficult for some doctors to give them out before they expire, Safo said. The Pfizer-BioNTech vaccines, one of three COVID-19 vaccines approved in the United States, can be stored for one month, according to the FDA.

For some older Black residents, the trusted messenger is not a primary care doctor due to America's history of medical exploitation and ongoing racial disparities in healthcare. These residents often turn to their church and congregation, said Stephens, the senior services provider.

"The 80-and-up individuals, they were most likely born in the 1930s and there’s just a lot of negative history around being told something’s a vaccine," she said. "I think that the city and the state, in general, really missed the mark because they didn’t engage in those types of community-based connections.

The city has been partnering with faith-based organizations, according to Dr. Chokshi, and the state Department of Health has also been working with groups like the Conference of National Black Churches.

Some elected officials and advocates say those measures, and the $125 million the city has put towards community-based outreach, pale in comparison to systemic inequities they are meant, in part, to address.

"All of this talk is easy, even though it's a pandemic, because you can talk about the stuff you've given out and the stuff you're doing" without meaningfully addressing racial disparities in healthcare, City Council Member Charles Barron, a Brooklyn Democrat, told Chokshi at the February hearing, calling the city funding "pittance."

Barron acknowledged the many New Yorkers of color for whom the emergency room is their primary point of care. He criticized clawbacks in safety net hospitals and former Governor Andrew Cuomo's Medicaid Redesign. Barron represents a predominantly Black district covering parts of East New York and its surrounding, where rates in most parts of the district fall below the city average.

"I share your sense of urgency and your sense that things need to change in a much more significant way rather than an incremental way," Chokshi said. "You'll find me in violent agreement with much of what you've said."

The National Black Leadership Commission on AIDS was one of the first organizations to receive vaccine outreach funding from the city in late 2020 because of its existing work mobilizing health resources around HIV/AIDS. The city has been renewing its contract every few months since then, but the way the funds roll in has hamstrung the organization.

"In January we were told that it was being extended to March, so technically it's supposed to end next month. We don't really know what's going on because of the transition of the new administration," Melissa Baker, NBLC's COO, told Gotham Gazette.

"Although this project has now been over a year…because it's emergency funding they say it can't be renewed for a long period of time," said Baker. "If the city contracted the organization for longer terms, we could actually hire people and give them benefits."

The New Administration
Some CBOs have expressed concern that successful efforts have fallen by the wayside in the transition to the new Adams administration. One is the "Vaccine Nonprofit Work Group," which participants said brought large nonprofits together with the Mayor's Office to coordinate vaccine outreach, analyze trends, and troubleshoot obstacles.

"That was really fruitful," said Nickerson, of LiveOn, who told Gotham Gazette the group hasn't met since mid-December. "Given the high rates of unvaccination among older adults, we are hoping that will resume so that we can work together."

"I don’t know why it necessarily kind of tapered off," said Stephens, of Encore, which also participated in the group.

City health department spokespeople referred inquiries about the work group to the Mayor's Office, which did not respond to requests for comment.

Nickerson said the city, through the work group, had directed CBOs serving seniors to target residents in the specific areas where rates were lowest among older adults. In October, that meant Williamsbridge, Central Brooklyn, South Brooklyn, South Queens, Southeast Queens, Harlem, and the South Shore of Staten Island. Since then, those nonprofits have been left in the dark about where to focus their energies.

"It was a really good data driven initiative to look at where work was happening, to make sure everyone would know about a new campaign running, there are materials, there are events that are happening," said Nickerson.

"And we would push that out to the nonprofits so their staff could participate. It was a good system."

[Listen: Dr. Jay Varma on New York City's Battle Against COVID-19]

by Ethan Geringer-Sameth, reporter, Gotham Gazette

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