Bisola O. Ojikutu is an infectious-disease physician at Brigham and Women’s and Massachusetts General hospitals, and directs the community-engaged research program at Harvard’s Center for AIDS Research. Julie H. Levison is an infectious-disease physician at Massachusetts General Hospital and co-directs the community research program at its Chelsea HealthCare Center. Kathryn E. Stephenson is an infectious-disease physician at Beth Israel Deaconess Medical Center and directs the clinical trials unit in the Center for Virology and Vaccine Research.
The New England Journal of Medicine reported this month that the covid-19 vaccine candidate mRNA-1273 induced robust antibody responses among participants in a clinical trial sponsored by the National Institutes of Health. With multiple potential vaccines in the pipeline, cautious optimism is emerging that a safe and effective covid-19 vaccine is within reach.
However, as physician-scientists who are invested in improving health among vulnerable populations, we fear that the glimmer of hope ignited by these findings may be short-lived. Even if a safe and effective vaccine is developed, serious problems loom. Surveys indicate that many Americans would not obtain a coronavirus vaccination were it available.
The consequences of low participation are all but certain to be grave among people of color, whose vulnerability to the novel coronavirus is high — and whose interest in vaccination is likely to be low. The covid-19 fatality rate among black Americans is more than twice that of whites. Latinx individuals are hospitalized at more than four times the rate of whites.
The Pew Research Center reported last month that 44 percent of black Americans say they would not obtain a covid-19 vaccine (54 percent of black survey respondents said they “would definitely or probably get a coronavirus vaccine if one were available today," as would 74 percent of Latinx respondents). Associated Press polling in May found that only 25 percent of black Americans and 37 percent of Latinx individuals would be willing to be vaccinated.
These data are not surprising. Like covid-19, H1N1 “swine flu” resulted in more severe cases among black and Latinx individuals than among whites. Still, anticipated acceptability of the H1N1 vaccine was low, as was actual vaccination, particularly among people of color. Similar disparities have been noted with established vaccines. While 71 percent of white individuals 65 or older obtained pneumococcal vaccine, only 56 percent of black and 49 percent of Latinx individuals have done so in recent years. Vaccination rates for seasonal influenza and human papillomavirus are also disproportionately lower among black and Latinx individuals, who are in high-risk demographic groups.
Reasons for low vaccination rates among people of color include underestimated perceptions of infection risk, general anti-vaccine sentiments and lack of access to health care. For many patients of color, including immigrants, financial concerns are paramount. Out-of-pocket costs, transportation expenses and inability to take time off work are likely to be significant deterrents.
Stigma may also thwart vaccination efforts. Any vaccination rollout is likely to prioritize “highest-risk” populations, a characterization that carries baggage. There are widespread, racist assumptions that black and Latinx people living with diabetes and obesity — two conditions that predict severe covid-19 infection — are “poor” and “lazy.” In some communities, “high risk” is code for being less hygienic.
Mistrust is the most insidious challenge. Anti-vaccine sentiments specific to covid-19 are evident among many black Americans, and calls for people of color to have priority access to a new vaccine have been met with suspicion. Vaccine conspiracy theories — such as the now-debunked belief that HIV was spread throughout sub-Saharan Africa via polio vaccine campaigns — have gained footholds in some areas. Beyond conspiracy theories, many people of color can recount stories of how they or someone they know were treated unjustly in a health-care setting. Evidence of structural racism in black and Latinx neighborhoods, including poor-quality hospitals and suboptimal schools, adds to suspicions about interventions promoted by the pharmaceutical industry, researchers or the U.S. government.
Mistrust contributes to underutilization of health-care services in communities where health outcomes are already poor. Without trust, covid-19 vaccines will go unused.
Trust must be earned. Here are six steps to begin that process:
- Include people of color in all phases of vaccine development, from the scientific team to vaccine administrators. Efforts to distribute a covid-19 vaccine among black and Latinx populations should be led by people from those communities.
- Be transparent about the vaccine development process and safety data. All studies should be published in peer-reviewed journals before the vaccine is widely distributed.
- Articulate clear messages. A vaccine campaign needs to be widely implemented now. Trusted sources should be engaged in this effort. The messenger is as important as the message.
- Protect people from potential harm. If a vaccine licensed for “emergency use” causes more harm than anticipated, people need assurances that they won’t shoulder undue medical costs.
- Dismantle all financial barriers to vaccination. This includes not just fees but also flexible clinic hours.
- Most important, address health inequities and structural racism that have led to the gross racial and ethnic disparities in covid-19 infection and beyond.
Covid-19 caught the world off-guard. But learning from the past can ensure better outcomes. Starting now is the best way to make sure that those who most need a covid-19 vaccine can trust it, afford it, acquire it and be protected by it.
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