Editor's note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.
“No la quiero.”
I’m speaking with a 66-year-old woman at a medical clinic at San Francisco General Hospital. She has poorly controlled diabetes and a history of sometimes debilitating anxiety. Despite our good rapport, she is very clear: She doesn't want the COVID-19 vaccine.
I pause. “¿Por qué no?” My simple question elicits a long answer. Bottom line: She wants to wait to see if the vaccine is truly safe.
Such concerns are understandable. Many Latinx communities harbor distrust of the health care system, in part because of a history of abuse. This includes anti-poverty policies the U.S. government pursued between 1930 and 1970 that resulted in the sterilization of roughly a third of Puerto Rican women without their consent.
Fears of immigration authorities are rampant as well. Even though the Biden administration has announced that it won’t make routine immigration arrests at vaccination sites, long-standing worries about immigration authorities are hard to overcome.
Also at play is the Trump administration’s redefining of “public charge” to mean someone who uses such benefits as Medicaid, since enrolling could lead to refusal of citizenship. The new administration may reverse this decision, but its effects likely will linger. Other anti-immigrant rhetoric and policies have led to concern about accessing the health care system among undocumented people and those in mixed-status families.
If we are going to address the inequitable impact of this pandemic on marginalized communities — Latinx people have been about three times as likely to die of COVID-19 as White people — we must tackle such concerns.
Of course, vaccine hesitancy is not the only issue, since access to the vaccine is also crucial. Early data already reveal racial and ethnic disparities in vaccination rates. In Texas, for example, Latinx people comprise 40% of the population and 48% of COVID-19 fatalities — but only 15% of vaccinated individuals. Vaccine hesitancy can’t be the main driver for such disparities since only 18% of polled Latinx individuals indicated that they would definitely not get vaccinated.
And although the COVID-19 vaccine is free, obtaining it can be complicated for Latinx patients. For example, 63% of Hispanic adults report not having enough information about where to get vaccinated — compared to about half of White people. Inconvenient clinic hours and locations also make it hard for essential workers to access vaccines.
Virtually all of my patients have voiced concerns about side effects. Will these lead to missing work or an inability to care for children or parents?
What will it take to ensure that Latinx communities, which have suffered so much during this pandemic, receive the vaccine?
First, we need an emphasis on providing vaccine and outreach resources to community health clinics, safety net hospitals, and local pharmacies, which work with many Latinx patients. Individuals at these institutions are expert in the linguistic and cultural competencies needed to succeed. Among their skills is an understanding of how to reach out to patients and how to educate those with low health literacy.
Second, we need national social marketing campaigns to encourage vaccine uptake developed in Spanish and informed by research with Spanish-speaking patients. Television, radio, social media, and billboards can reach a broad swath of people. Involving celebrities can’t hurt: One of my patients resisted my advice to start using insulin until she saw a program featuring Justice Sonia Sotomayor, who has used insulin since childhood.
Third, health departments and health systems need to partner on vaccine uptake with Latinx-serving community-based organizations, including unions and churches that have a long history of successful outreach to workers. Many community-based organizations employ promotoras (community health workers) who are skilled in patient education and outreach. Health care systems also need to be smarter about how they communicate with patients. For example, they should make sure that they don’t reach out primarily via email or provide vaccine access information only online or exclusively in English.
Fourth, Spanish-language media can make excellent partners in vaccine education efforts. Messages should include that the vaccine is safe and free to anyone who is uninsured regardless of immigration status and that receiving the vaccine won't be used for “public charge” determinations. They should also note where and how to get vaccinated.
All this will take intentional investment and leadership. Although I am cautiously optimistic, I also know that our health systems are fragmented, that most public health departments are atrociously underfunded, and that local and state leaders are more likely to respond to voters who clamor for vaccines than to focus on nonvoters who might need encouragement to get vaccinated.
Involving celebrities can’t hurt: One of my patients resisted my advice to start using insulin until she saw a program featuring Justice Sonia Sotomayor.
Meanwhile, there is much we can do as individual physicians.
We can offer to conduct vaccine education talks and webinars for community-based organizations. We can advocate for vaccination sites that are readily accessible to people whose jobs will not allow them time off to be vaccinated. We can ask that hospitals and public health systems take creative steps to build a more linguistically and culturally competent workforce, such as hiring bilingual young people to make outreach calls and enroll patients in vaccine appointments.
Above all, we can talk with our patients. Even if we lower barriers to vaccine access, there will be patients, like mine, who will refuse the vaccine.
When she said no, I did what I usually do. I asked her why, while mentally trying to organize her answers into three buckets: misinformation; difference in health care beliefs; and my least favorite category, everything else.
Misinformation is quite common and comparatively easy to address. It often takes the form of, “Last time, the vaccine gave me the flu.” I tend to explain that a vaccination may make one feel bad for a day or two, but that’s actually a good sign. It means the vaccine is working to ready the immune system to defeat the disease despite being incapable of causing it.
Virtually all of my patients have voiced concerns about side effects. Will these lead to missing work or an inability to care for children or parents? Often lacking sick pay or child care, Latinx workers care deeply about these issues. In these cases, acknowledging concerns and putting any risk in context is crucial. I might say, “So far, over 40 million people have received the vaccine and we have few reports of serious side effects. COVID-19, on the other hand, has killed 400,000 people in the United States alone.”
For patients with traditional health care beliefs, such as wanting to rely only on “natural” remedies, I tend to take an “and” approach. Yes, eating well is important AND vaccinations can also help. I see such discussions as part of a series of discussions in which a key goal of each is to keep the door open to the next.
For everything else, it can take time to sort out what patients are expressing. In the case of this patient, her hesitancy was part of her overall anxiety about her health.
What has helped me most with anxious people is asking them to reflect on what appeals to them about getting the COVID-19 vaccine. Most have talked wistfully about being able to spend time with and hug family members. I respond that getting the vaccine will make their hopes possible sooner.
I often also tell my patients that I have been vaccinated and share my experience. I might say, “My arm hurt for two days and then got better.” And a recommendation that is personal to the patient can be powerful. “I think you should have the vaccine because…” That might be because you have diabetes or asthma, are older, or care for your father, or work in a nursing home.
Ultimately, my patient still said no. I expressed support for her decision to wait, and I hope that over time — perhaps with more discussions and knowing others who have been vaccinated — she will change her mind.
The Latinx community has suffered so much with COVID-19. Now it is time to make the promise of the vaccine real for all. It is the right thing to do, the just thing to do — and the only way to put an end to the pandemic.
Alicia Fernandez, MD, is a professor of medicine at the University of California, San Francisco (UCSF), School of Medicine and a general internist at Zuckerberg San Francisco General Hospital and Trauma Center. She is also director of the UCSF Latinx Center of Excellence, which works to increase Latinx representation among physicians in academic centers.