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The equity-enhancing power of mandates

In public health campaigns, education alone goes only so far. A universal rule can close the gap.

A restaurant in San Francisco.MIKE KAI CHEN/NYT

Mayor Michelle Wu’s recently announced COVID-19 strategy, which includes vaccine passports for entry into bars, restaurants, gyms, and entertainment venues, demonstrates leadership in the right direction. However, we believe her efforts — and even more so, efforts at the state level — don’t go far enough to close the shameful inequities that mar every aspect of our pandemic response. Nearly every public health metric — including rates of adult vaccination, child vaccination, and school surveillance testing — is marked by disparities between low-income, predominantly minority communities (like many in Boston) and high-income, predominantly white communities (like Wellesley). After adjusting for age differences, Latino and Black Massachusetts residents have died from COVID-19 at three times the rate of white residents, and remote schooling resulted in disproportionate learning loss for students of color.

Our society’s efforts to remedy COVID-19 inequities so far have largely relied on outreach. But the media campaigns to promote vaccination are not reaching enough low-income people of color. The school emails about COVID testing that the best-off parents are carefully reading are getting lost in the shuffle for too many poor families. So instead of relying on outreach alone, a more aggressive strategy may be needed: expanding mandates.

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Mandates rely on the simple public health principle that universal application of an intervention can be a powerful tool for reducing disparities. For example, fluoridation of drinking water helped close disparities in dental outcomes. Bans on smoking in public places benefit communities equally. Applying taxes to all tobacco products decreases inequity by disproportionately reducing tobacco use in low-income groups.

In contrast, public education alone often worsens health inequities. Education about the importance of folate supplements during pregnancy, to reduce the risk of birth defects, increases inequity in folate consumption unless supplements are provided to all women for free. Or look at disparities in tobacco use. In the 1950s, smoking rates in the United States were comparable across socioeconomic levels. While the overall smoking rate has dropped dramatically since then, tobacco use is now highly unequal: One-third of adults with only a high school diploma smoke, compared with less than 5 percent of those with a graduate degree. Mass media campaigns likely contributed to this inequity because people with more income and education had better access to high-quality information.

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Similar challenges have contributed to inequity in COVID-19 vaccination. Not only do low-income communities have lower access to high-quality information — due to language barriers and other challenges — but the vaccine rollout has also been marred by misinformation that may disproportionately affect these communities. Even the best media campaigns can’t outcompete such misinformation.

For COVID-19, mask mandates are one intervention that has sometimes been applied universally, where benefits might accrue disproportionately to low-income individuals working essential jobs or taking public transportation. However, other important public health interventions have not been broadly applied. For example, uptake of school surveillance testing has been highly unequal, because already overwhelmed parents have to make an effort to opt their children in to testing. As a result, low-income children are missing out on the benefits of testing, putting them at higher risk for infection and loss of schooling. The simplest solution would be to mandate testing for students, as Los Angeles has done. Alternatively, students could be automatically enrolled into testing but parents could opt their children out.

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The crucial intervention that could be mandated to reduce COVID-19 inequities — and end the pandemic — is vaccination. While there is growing recognition that mandates are effective at increasing vaccination rates, public discourse has not emphasized their importance for closing disparities. But if Wu imposed, say, a mandate on vaccination for all private-sector employees in Boston, it could more rapidly narrow some of those gaps.

We recognize that if implemented incorrectly, mandates could be viewed as a form of paternalism that looks past the justifiable historical mistrust some communities of color have of the health system. For this reason, targeted efforts must be made in tandem to ensure community involvement and increased access to services. From a practical perspective, getting vaccinated or signing a child up for testing may not be a priority for people working multiple jobs or struggling to pay bills. In a confusing media environment, mandates have the potential to cut through the noise with an unequivocal message.

With Omicron taking off, it won’t be good enough to simply try our best at outreach if we don’t prevent disproportionate death and loss of schooling in our most vulnerable communities.

Dr. Lakshmi Ganapathi is an infectious diseases physician and an instructor in pediatrics at Harvard Medical School. Dr. Ramnath Subbaraman is an epidemiologist and infectious diseases physician and an assistant professor at the Tufts University School of Medicine. The views expressed here are personal and do not necessarily represent the views of their institutions.

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