START SMALL: Subsidiarity Principles Show that Local Approaches Can Work in COVID-19 Vaccination Program
Written by Meryl Justin Chertoff, Executive Director, SALPAL
Think we need to “go big” on COVID-19 vaccination? Consider this data:
- In Israel, more than 40% of the population already has been vaccinated against COVID-19 (this excludes Palestinian territories);
- In West Virginia, more than 9 percent of the population has received the vaccine, 50 percent higher than the national rate;
- As of January 25, North Dakota had used 85 percent of its doses, and New Mexico 77%; while Massachusetts and Virginia stood at 49 and 43 percent respectively.
What accounts for these striking differences? While Israel’s excellent national health service, and distribution choices made in West Virginia certainly matter, one factor unites all the examples above—they are small. Distribution is done at the smallest relevant level of government, a concept that in Europe is known as subsidiarity.
Subsidiarity trusts local authorities to tailor public programs to local needs. Originating as a Catholic religious governance theory, it has become a governing principle in the European Union and shares attributes of American federalism theory. Ironically, the EU has come under fire for ignoring its own subsidiary principles in vaccine procurement. But subsidiarity is not simplistic deference to state power as opposed to centralized federal control. It asks a functional question: what level of government can do a particular task best?
In the case of COVID-19, that question may get different answers in different states. Small states like Rhode Island and Connecticut are highly decentralized and have strong local public health infrastructure. States like New York have vastly different infrastructure to serve health needs in urban and rural communities, so a hybrid approach is needed. It is notable that West Virginia, a state that has shown great affinity for the vaccine-skeptic Donald Trump has nonetheless emerged as a winner in the race to vaccinate its residents. One reason is that it has tailored its approach to local norms.
An effective vaccination program will be nimble and will be administered where people are. That means relying on local and neighborhood-based community structures, even to the extent of allowing local public health officials some evidence-based discretion as to which individuals and groups are most at risk for contracting the virus, spreading it, and suffering the worst outcomes.
Intergovernmental tensions can also impede an effective response. In an interview last week with POLITICO, Houston Mayor Sylvester Turner urged federal authorities to bypass Texas state government in its COVID-19 distribution strategy and work directly with local public health authorities. His concern that the state of Texas is not committed to vaccination in urban areas mirrors similar tensions that marred access to voting last year in Harris County, where Houston is located. It also mirrors divergent approaches to mask mandates and business closures in Atlanta in conflict with Georgia; and Miami-Dade in tension with the State of Florida.
An approach based on subsidiarity enhances flexibility in vaccine response and allows intermediation by the trusted messengers who can encourage the vaccine adverse to take the plunge. Clergy, teachers, coaches, and other community leaders can lead by example; and vaccine administration can occur in the company of neighbors and peers, building the trust that has been undermined by historical and cultural inequality and injury. Emphasis on local vaccine administration also reduces the need for vulnerable individuals to find transportation, or access difficult-to-use electronic portals.
It is not only the deployment of community centers and clinics that can make the task go more quickly. Private companies with ubiquitous local footprints are also stepping up, with companies like Amazon, Starbucks, and Costco partnering with state and local authorities, to help scale the vaccination effort. These companies, as a familiar presence in diverse communities, can play a critical role in logistics and communication.
Of course, none of these efforts will completely succeed as long as vaccine supply, and personnel trained to give injections remain as a limiting factor. But with the infrastructure in place in communities nationwide, there is the potential for vaccination to be both local and nationwide, for all who want the shot in 2021.