Editor's note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.
“I just don’t trust it.”
This is the response I received from my patient, a 60-year-old woman living with HIV and Type 2 diabetes, when I asked why she refused the flu vaccine. She was the third patient to decline my offer that afternoon in my busy infectious disease clinic in Boston, Massachusetts. Their reasons ranged from potential side effects to believing they won't catch the flu to the overt distrust this patient expressed. All had conditions putting them at higher risk for serious health problems and even death from influenza. All were Black.
After each refusal, I explained the importance of getting vaccinated against the flu, especially given this year’s anticipated “twindemics” of COVID-19 and influenza. I also diligently shared research on its safety and effectiveness — all to no avail.
I wish I could say that this was an atypical afternoon. But distrust regarding vaccination is not unusual among my patients, most of whom are people of color.
I worry deeply about what this means when it comes time to offer my patients — as well as others like them across the country — a vaccine against the novel coronavirus.
Distrust regarding vaccination is not unusual among my patients, most of whom are people of color.
Low vaccination rates are not new in Black communities. During 2018-2019, for example, only 39% of Black adults received influenza vaccination versus 49% of White adults. Similarly, while 71% of White people 65 or older received a pneumococcal vaccine, only 56% of Black individuals did so in recent years. This is particularly concerning because Black patients suffer worse outcomes from these potentially dangerous infections.
Given these data, predictions of low acceptance of a COVID-19 vaccine by Black individuals is unsurprising. The percentage of adults who would get a COVID-19 vaccine if one were available decreased across all racial and ethnic groups from May to September, according to the Pew Research Institute. Among Black people, though, the decline was more of a free fall, with those saying they’d get the vaccine plummeting from 54% to a mere 32%. That’s compared to 52% of White respondents.
Low acceptance of a COVID-19 vaccine could be devastating for Black communities. Black individuals are nearly three times more likely than their White counterparts to be infected with COVID-19. Black patients are more likely to wind up with severe COVID-19 infections, and hospitalization rates are 4.7 times higher than among White patients. The death rate from COVID-19 among Black individuals is estimated to be more than twice as high as among other racial and ethnic groups.
We must ensure that when safe and effective COVID-19 vaccines are available, Black patients — who already suffer from significant health inequities — have access to them and are willing to get vaccinated.
Black individuals are nearly three times more likely than their White counterparts to be infected with COVID-19.
If we hope to address low uptake of COVID-19 vaccines, we first need to understand what drives it.
The cost of vaccines and limited access to health care certainly are important barriers to vaccination. But one of the most potent variables contributing to low levels of COVID-19 vaccine acceptance among Black individuals is distrust. This lack of trust fuels several concerns: doubt about data on safety and effectiveness, skepticism about the speed of vaccine development, and suspicion regarding the motivations of policymakers and vaccine developers.
Centuries of mistreatment of Black individuals in the name of medical experimentation lie behind this distrust. Among the shameful examples are the unethical surgeries performed on enslaved Black women without anesthesia and the infamous Tuskegee syphilis study. Structural racism and health care disparities have also led to distrust of research, health care institutions, and government agencies. In addition, feelings of distrust have been heightened in light of recent, highly publicized acts of police violence involving Black victims.
Can we overcome this distrust? My honest answer is maybe.
It certainly will require a highly committed and well-resourced effort to lessen the impact of vaccine distrust.
First and foremost, the Black community must be intentionally engaged as a partner in the process of distributing and administering a COVID-19 vaccine, educating people about it, and encouraging uptake. Partnership must involve sufficient financial resources, a long-term commitment, a diverse vaccine workforce, and equitable compensation for the investment that communities will make around vaccines. As suggested by the National Academy of Sciences, outreach to engage historically Black colleges and universities and faith-based institutions has occurred, but such efforts must be supported with more substantial funding and sustained over time if we hope to build vaccine confidence within the Black community.
Dismantling the systems that contribute to structural racism in our health care institutions and throughout our country will mitigate distrust. It will take political will, institutional support, ongoing community engagement, and personal commitment to overcoming inequity in COVID-19 and beyond.
Secondly, Black community leaders, physicians, and other trusted stakeholders must lead initiatives to increase vaccine acceptance. Black physicians should be involved early in monitoring vaccine approval, and they should be the ones to deliver the messages regarding vaccines within our communities. The National Medical Association, the country’s oldest and largest organization representing African American physicians and their patients, has convened a COVID-19 task force that will provide recommendations about the development of COVID-19 vaccines. Individual health professionals can contribute as well — posting messages on social media and conducting interviews on community radio, for example.
Thirdly, we must work hard to ensure that COVID-19 vaccine clinical trials include individuals from the most highly impacted communities. Of course, we need diversity among participants in COVID-19 trials to make sure that vaccines work well for people of all ages and from all racial and ethnic backgrounds. Moreover, though, the likelihood that Black individuals will trust a vaccine is greater if we are involved in its development. In speaking with Black COVID-19 vaccine trial participants, they have shared that family and friends are closely watching their experience — and in doing so have increased their understanding of medicine and research. Hopefully, increased knowledge and awareness will translate into higher willingness to be vaccinated.
Lastly, health care providers must acknowledge that distrust within the Black community is a rational response to pervasive structural racism. Dismantling the systems that contribute to structural racism in our health care institutions and throughout our country will mitigate distrust. But it will take political will, institutional support, ongoing community engagement, and personal commitment to overcoming inequity in COVID-19 and beyond. Efforts to grapple with distrust will take time. But we must start now to build trust among our patients. Their lives depend upon it.
Bisola Ojikutu, MD, MPH, is an infectious disease specialist at Brigham and Women’s and Massachusetts General Hospitals. She is the director of the Community Engaged Research Program with the Harvard University Center of AIDS Research.