Why Black Americans Don’t Trust the COVID-19 Vaccine, and How We Can Do Better

Sarthak Aggarwal is an MS1 at the University of Chicago Pritzker School of Medicine. He can be reached at Sarthak.Aggarwal@uchospitals.edu.

The COVID-19 pandemic remains at the forefront of public life, claiming the lives of countless Americans and leaving many more worried, scared, and isolated. Recently, promising news about the Moderna, Pfizer, and Johnson & Johnson vaccines has many hoping for a swift return to normalcy—so why are some Americans hesitant to get vaccinated?

The development of a COVID-19 vaccine has been far from routine. Vaccine development traditionally is a lengthy, linear, and painstaking process, requiring an average of ten years and countless failed attempts, so producing a vaccine at pandemic speed meant that many steps in this process ran in parallel. While this allowed a vaccine to be released within a year—a previously unimaginable feat—it also conferred a marked sense of skepticism upon Americans. From rural farmers to public school teachers, many communities remain increasingly wary.

Black Americans stand out as significantly less likely to get the COVID-19 vaccine. According to a Pew survey from late 2020, only 42% of Black respondents said they would take the vaccine, compared to 61% of White adults, 63% of Hispanic adults, and 83% of English-speaking Asian Americans. Likewise, a survey by the COVID Collaborative revealed that just 14% of Black adults claimed they trusted vaccine safety.

A general distrust of the medical establishment has been brewing for years, spurred by the widespread availability of less-than-reputable information online, a distrust of ‘Big Pharma,’ and an overall disillusionment with American healthcare.

However, Black Americans’ distrust in the medical establishment runs far deeper than that.

Centuries of government-sanctioned neglect, exploitation, and abuse have left generations of Black families profoundly jaded towards public institutions. This distrust has been coined by some as the “Tuskegee Effect,” referring to the “Tuskegee Study of Untreated Syphilis in the Negro Male,” which launched in 1932 and involved roughly 600 poor Black men who were intentionally kept untreated for syphilis for 40 years. Subjects were studied by federal health officials while being misled about the study’s intentions, denied standard of care treatments, and left to suffer severe health consequences.

While this study is commonly credited with provoking Black distrust of the healthcare system, it did not occur in a vacuum. In fact, it is only one of countless injustices done to Black Americans in the name of medical research.

Beginning in the 17^th century, African slaves were routinely exploited by colonial doctors to test medical procedures, educate students, and practice experimental surgeries. J. Marion Sims, known as the “father of gynecology,” infamously developed surgical procedures by coercing enslaved women to submit to extremely painful practice operations. The bodies of deceased slaves were often defiled for miscellaneous medical experiments as well. Even after the abolishment of slavery, widespread prejudice and discrimination meant that Black Americans were repeatedly denied the same ethical considerations granted to their White peers.

In 1951, an African American woman named Henrietta Lacks died from cervical cancer, and her tumor cells, ‘HeLa’ cells, were used without her consent by researchers at Johns Hopkins Hospital to set the groundwork for many modern breakthroughs in cancer, immunology, and infectious disease. However, neither Henrietta nor her family had any knowledge of this. Decades passed before the Lacks family received any kind of compensation or agency in the usage of these cells in scientific research. Although informed consent has long been a fundamental principle of medical ethics, time and time again the medical community has disregarded and ignored the best interests of Black Americans.

Structural racism remains ingrained in our healthcare system. As a result, Black families are less likely to be insured or have access to care, and are almost three times more likely than their White counterparts to die from COVID-19. If we don’t address these disparities and consider equitable approaches to solving the current healthcare crisis, we risk bolstering structural racism and distrust in healthcare. The medical community must work hard to ameliorate the harms of the past through reflection on the history and consequences of racism, passionate advocacy for marginalized communities, equitable distribution of health resources, and routine examination and reexamination of ethical standards.

Preliminary inspection of the current vaccine rollout has raised major concerns about inadequate allocation to predominantly Black neighborhoods. While such structural failures have played a primary role in creating significant disparities in vaccination rates over the last few months, the coincident tension between Black Americans and healthcare institutions has serious implications that will become magnified if left unaddressed. However, there are two specific, actionable steps we can take to begin repairing the medical community’s relationship with Black Americans.

First, institutions must prove they are worthy of trust, not ask Black communities to trust more. Many public campaigns aim to convince Americans of vaccine safety by touting experimental data, but such initiatives overlook the distrust that lies at the core of Black vaccine hesitancy. Ultimately, these campaigns implore communities to simply ‘be more trusting.’ However, the painful history of oppression at the hands of such institutions provides little motivation for Black Americans to acquiesce, and it is unreasonable for the onus of repairing centuries of racism to fall on Black Americans. Instead of requesting more trust, organizations must convincingly show that they are worthy of it.

This requires a multiyear, grassroots effort on the part of medical and federal institutions and close collaboration with trusted players in minority communities who can foster mutual respect, communication, and education. Current efforts include the creation of the Washington D.C.-based Black Coalition Against COVID-19 (BCAC), which is composed of influential Black physicians, faith leaders, scientists, and community groups in collaboration with major health organizations such as the National Institutes of Health. Efforts to expand such partnerships have been initiated in other parts of the nation as well, and while it is still unclear whether these emerging efforts will have a significant impact on COVID-19 vaccination rates, they will be vital in preparing us for future health emergencies. Only by building these genuine relationships with trusted messengers in Black communities will institutions gradually erode the distrust that has accumulated overtime.

Second, we must increase Black representation in healthcare delivery and policy. Unfortunately, it is unsurprising that many Black Americans feel like outsiders in the healthcare system—according to the Kaiser Family Foundation, 65% say it is difficult to find a doctor who shares their same background, and 1 in 5 report race-based discrimination in healthcare over the past 12 months. Amplifying Black representation in medicine would provide these individuals a sense of agency in decisions affecting their health. A substantial body of research suggests that patients who share the same race or ethnicity with their physicians experience improved shared decision-making, higher medication adherence, and decreased implicit bias. Bolstering Black participation in healthcare will generate more trusted messengers who can advocate for the best interests of their communities while offering higher quality of care. This has been particularly evident during the ongoing pandemic, in which Black physicians have played vital roles in COVID-19 vaccine research, education, and administration.

Sadly, African American enrollment in medical school remains dismal, and the percentage of medical school enrollees who are Black males is lower than it was 40 years ago. This trend reflects the deep inequities in education, income, and community resources propagated by structural racism. Black students are less likely to have physician role models or participate in advanced academic programs, and more likely to receive disciplinary action. These students are not less capable than others, but are profoundly disadvantaged by the biases embedded within the system itself. For many Black students, weak support networks, poor educational resources, and high costs completely eliminate healthcare as a feasible career path.

This alarming phenomenon can be ameliorated by supporting Black students interested in healthcare, strengthening pipeline and outreach programs, and reinforcing existing efforts to eliminate structural racism within education and healthcare. According to the Association of American Medical Colleges (AAMC), engagement in premedical pipeline programs can bolster the success of students of color by providing them with mentorship, resources, and experience. Federally-funded Health Careers Opportunity Programs, as well as state-funded and foundation-based initiatives, have been especially effective in increasing the numbers of Black men in health professions.

Much remains to be done to address the racism and history that lies at the heart of so many health disparities today, and it has seldom been more apparent that these disparities have grave, real consequences. The current pandemic has highlighted many of the inequities that remain entrenched in American healthcare, as well as the need for thoughtful, systemic reform and advocacy. Black communities are some of the most severely affected over the past year, and as the nation moves forward with the COVID-19 vaccine rollout, we must acknowledge this critical opportunity to expand education, understanding, and change.

---

1. “African American Health.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 3 July 2017, www.cdc.gov/vitalsigns/aahealth/ index.html.
2. “Altering the Course: Black Males in Medicine.” Association of American Medical Colleges, 2015.
3. “Amid Coronavirus Pandemic, Black Mistrust of Medicine Looms.” Modern Healthcare, 5 Apr. 2020, www.modernhealthcare.com/patient-care/amid-coronavirus-pandemic-black-mistrust-medicine-looms.
4. Baron, Richard J., and Adam J. Berinsky. “Mistrust in Science — A Threat to the Patient–Physician Relationship.” New England Journal of Medicine, vol. 381, no. 2, 2019, pp. 182–185., doi:10.1056/nejmms1813043.
5. Brownlee, Dana. “Why Are Black Male Doctors Still So Scarce In America?” Forbes, Forbes Magazine, 10 Aug. 2020, www.forbes.com/sites/danabrownlee/2020/08/11/why-are-black-male-doctors-still-so-scarce-in-america/?sh=495f4e6127c2.
6. Fadulu, Lola. “Amid History of Mistreatment, Doctors Struggle to Sell Black Americans on Coronavirus Vaccine.” The Washington Post, WP Company, 8 Dec. 2020, www.washingtonpost.com/local/social-issues/black-vaccine-trust/2020/12/07/9245e82e-34c2-11eb-b59c-adb7153d10c2_story.html.
7. Funk, Cary, and Alec Tyson. “Intent to Get a COVID-19 Vaccine Rises to 60% as Confidence in Research and Development Process Increases.” Pew Research Center Science & Society, Pew Research Center, 13 Dec. 2020, www.pewresearch.org/science/ 2020/12/03/intent-to-get-a-covid-19-vaccine-rises-to-60-as-confidence-in-research-and-development-process-increases/.
8. Hamel, Liz. “KFF/The Undefeated Survey on Race and Health.” Kaiser Family Foundation, 11 Dec. 2020.
9. “Henrietta Lacks: Science Must Right a Historical Wrong.” Nature, vol. 585, no. 7823, 2020, pp. 7–7., doi:10.1038/d41586-020-02494-z.
10. Hoffman, Jan. “How Anti-Vaccine Sentiment Took Hold in the United States.” The New York Times, The New York Times, 23 Sept. 2019, www.nytimes.com/2019/09/23/ health/anti-vaccination-movement-us.html.
11. Hoffman, Jan. “Mistrust of a Coronavirus Vaccine Could Imperil Widespread Immunity.” The New York Times, The New York Times, 18 July 2020, www.nytimes.com/2020/07/18/health/coronavirus-anti-vaccine.html.
12. Huerto, Ryan. “Minority Patients Benefit From Having Minority Doctors, But That’s a Hard Match to Make.” University of Michigan, 31 Mar. 2020, labblog.uofmhealth.org/rounds/minority-patients-benefit-from-having-minority-doctors-but-thats-a-hard-match-to-make-0.
13. Lozano, Alicia Victoria. “Racial Disparities Create Obstacles for Covid-19 Vaccine Rollout.” NBCNews.com, NBC Universal News Group, 5 Dec. 2020, www.nbcnews.com /news/us-news/racial-disparities-create-obstacles-covid-19-vaccine-rollout-n1249627.
14. Lurie, Nicole, et al. “Developing Covid-19 Vaccines at Pandemic Speed.” New England Journal of Medicine, vol. 382, no. 21, 2020, pp. 1969–1973., doi:10.1056/nejmp2005630.
15. Rabouin, Dion. “Black Workers Overrepresented in Essential Work during Coronavirus Pandemic.” Axios, 3 June 2020, www.axios.com/black-workers-essential-coronavirus-c502fc2e-a4fc-4c4f-ae0c-722a50d74ecd.html.
16. Rothman, Lily. “The Disturbing History of African-Americans and Medical Research Goes Beyond Henrietta Lacks.” TIME, TIME, 7 Mar. 2019, time.com/4746297/henrietta-lacks-movie-history-research-oprah/.
17. Warren, Rueben C., et al. “Trustworthiness before Trust — Covid-19 Vaccine Trials and the Black Community.” New England Journal of Medicine, vol. 383, no. 22, 2020, doi:10.1056/nejmp2030033.
18. Weise, Elizabeth. “Pfizer’s COVID-19 Vaccine Finally Reaches Its Last Step: FDA Committee Vote. Most Vaccines Never Get That Far.” USA Today, Gannett Satellite Information Network, 10 Dec. 2020, www.usatoday.com/story/news/health/2020/12/09/ when-pfizer-fda-committee-vote-approval-covid-vaccine/3840096001/.