Most of the discussion about a coronavirus vaccine has centered on the timeline, President Trump’s promises and the recent halt to one of the Phase 3 clinical trials of a vaccine because of adverse effects to one participant. One aspect of this discussion has been missing: African Americans should be at the front of the line to get the vaccine.

As has happened with most disease outbreaks in U.S. history, socioeconomically vulnerable members of our society are suffering the most from covid-19, the disease caused by the novel coronavirus. In particular, African Americans have contracted and died of the disease at disproportionately high rates as some government leaders have shown a lack of regard for the health and safety of Black and brown people, especially low-wage workers in jobs deemed essential. Without an adequate social safety net, Black Americans are less likely to have health care and financial resources to weather the economic turmoil wrought by the pandemic.

But even if African Americans are prioritized for the vaccine, there’s a catch: In part because of the racist way that compulsory vaccination campaigns were deployed in the early 20th century, as well as other long-term racism in our medical system, a recent survey found that African Americans are less likely to trust medical science and would be less interested in a coronavirus vaccine if it were currently available (54 percent of Black respondents) than their White and Hispanic counterparts (74 percent in both groups). History helps to explain these disparities. Over the past 100 years, medicine has emerged more as a tool for control of the Black community than a solution for illnesses.

During periodic outbreaks of smallpox in the early 20th century, state health departments warned that the disease could not be controlled through quarantine alone, but required mass vaccination campaigns to reduce the number of severe cases that could place others at risk. Public officials frequently used military analogies invoking the need to sacrifice individual liberties to protect the common good against infectious diseases — including smallpox, cholera and yellow fever.

Americans were not always obedient in the face of these state mandates — initially with reason. Before vaccine regulation began with the Biologics Control Act of 1902, a vaccination sometimes proved more dangerous than the disease it was meant to prevent. In 1900, medical texts and newspapers linked the smallpox vaccine to tetanus, syphilis and painfully sore arms that forced laborers to miss work, pushing many to avoid the vaccine.

The issue was even more complicated in African American communities. Black Americans had long been wary of the medical establishment because of various abuses it had perpetrated, including clinical experimentation without consent, the use of scientific racism to deny Black patients care and the unauthorized use of Black bodies for medical training through autopsies and dissections.

African Americans were especially susceptible to forced vaccinations. To be sure, ethnic Whites were also subject to compulsory vaccinations, as well as other strong-arm disease control measures, including the confinement of suspected disease carriers, the establishment of armed quarantines, the seizure of homes to be used as smallpox pesthouses and forced removal of infected people from their homes.

However, African Americans were particularly vulnerable to these coercive tactics because such ideas echoed aspects of slavery’s rationale, including denying their liberty, constricting their mobility and devaluing the Black body, which had become ingrained in American culture. In newspapers that had previously published enslavers’ advertisements offering rewards for the recapture of freedom seekers during the antebellum period, stories appeared decades later, in the early 20th century, about African American “pesthouse fugitives” who had fled their coerced confinement. Consequently, many African Americans hid sick family members to prevent health inspectors from forcibly taking them to pesthouses, where they had a much higher chance of dying.

During the 20th century, public health campaigns also emerged as a way to control Black migration to Northern cities. In 1917, the Chicago Daily Tribune advised officials to “check the migratory tide of thousands of Negro laborers from the [S]outh to Chicago until adequate sanitary and housing arrangements can be made.” Chicago Health Department inspectors roamed the South Side, warning that “danger of a smallpox epidemic lurks because of insanitary living conditions.” The Tribune editor claimed with disdain that migrants displayed “a childlike helplessness in the matter of sanitation and housing,” and had “almost no standard of morals.”

In 1923, the St. Louis health department deployed “a corps of physicians” to the city’s Union Station to vaccinate Black migrants. St. Louis had recently discovered 16 cases of smallpox, with all but one of these cases involving White people. Nonetheless, instead of focusing on vaccinating Whites, health officials targeted African Americans because they were perceived to be the most virulent vectors of smallpox. This approach reflected the racist notion that African Americans lacked cleanliness and hygiene. During the 1920s, local leaders even claimed that school segregation and residential zoning ordinances were necessary because White families’ health was threatened by Black communities’ purportedly unsanitary conditions.

While St. Louis health officials were determined that no Black passenger should leave the station without submitting to a vaccination, many of the passengers “openly and defiantly rebelled,” one newspaper reported, “because it looked like a clear case of discrimination; they rebelled because there was no evidence that they had any contagious or infectio[us] disease or that they came from places where there were epidemics.” Episodes of medical racism like this prompted the Chicago Defender, a Black newspaper, to urge newly arrived migrants to “[r]efuse and resist all orders for vaccination or medical inspection.”

Even after migrants became settled in Northern cities, they continually faced forced vaccination drives. In April 1924, the Defender reported that “men in uniform, purporting to be city officials and men from the department of health” stormed into barber shops and billiard halls along Chicago’s South State Street, and began vaccinating African American patrons “presumably for smallpox.” Without explanation, the police and officials commanded people to roll up their sleeves, using the force of law to compel the order. “[N]o one was allowed to escape,” the Defender concluded.

The handling of smallpox shows that attitudes toward race influence the way that public health campaigns are executed, and these campaigns frequently serve as tools to embed racism deeper within our society. Some of this continues today, as when Ohio State Sen. Stephen A. Huffman suggested in June that African Americans contract the coronavirus at higher rates because they did not follow adequate hand washing procedures.

Even with a vaccine, African Americans will still be among the most susceptible subgroups to coronavirus-related mortality because of the ways in which structural racism has allowed the neglect of Black communities. Pollution, food deserts, a lack of access to quality schools and health care will continue to put Black Americans in harm’s way, even after a coronavirus vaccine is widely available. Beyond structural barriers, African Americans’ skepticism about public health campaigns creates another obstacle toward ensuring the vaccine is accessed by those who need it the most. Both of these variables serve as a stark reminder that this country has much work to do to reckon with its history of racism and to provide for the well-being of all its citizens.