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March 25, 2021

Vaccine Hesitancy Is a Scapegoat for Structural Racism

Author Affiliations
  • 1University of North Carolina, Chapel Hill
JAMA Health Forum. 2021;2(3):e210434. doi:10.1001/jamahealthforum.2021.0434

Vaccine hesitancy and mistrust of medicine and science dominate current discourse around disparities in who is currently receiving COVID-19 vaccines, a potentially lifesaving prevention strategy. Mistrust of medicine and science is based in a long and sordid history of unethical practice and research on African American, Latinx, Indigenous, and Asian American populations in this country.1-4 However, current concerns about vaccine uptake are a glaring symptom of a much deeper problem—structural racism. The underlying condition of structural racism is a significant contributor to disparities in risk, morbidity, and mortality from not only COVID-19 but also many other conditions. The structures, policies, and practices that advantage some and disadvantage others so that race and ethnicity are consistent predictors of a cycle of unequal access to care, unequal access to educational and employment opportunities, and disproportionate exposure to health risks, as evident in the COVID-19 pandemic. Generations of Black individuals, Indigenous individuals, and those from other racial and ethnic minority groups have lived this cycle for decades with little to no hope for change. Their resulting lack of faith in a system that has so consistently demonstrated little or no regard for their well-being should come as no surprise.

In fact, the blanket of mistrust that has been used to explain disparities in vaccine uptake is masking underlying fundamental inequalities in the system of vaccine distribution. Those of us who work in and with historically marginalized communities see strong evidence that equality does not equal equity. Equality means giving everyone the exact same resources, whereas equity involves distributing resources based on the needs of the recipients. Giving everyone equal access (eg, through online scheduling) has exacerbated inequities in vaccine uptake. When you prioritize equality over equity, you get the results we have seen throughout the COVID-19 pandemic. Disparities grow wider and wider when we consider unequal access to broadband and internet, computers, time to visit online vaccine distribution sites to find an appointment, and the ability to drive hours across county and state lines for an appointment. We must develop and use strategies that provide equitable (not only equal) solutions to address the disparities we are witnessing.5

Stop Using Vaccine Hesitancy as an Excuse

In the news and across public health and health care, attention has focused on individuals’ current reluctance to receive the vaccine. The term vaccine hesitancy puts the focus on the individual. In fact, what I have seen, as a physician and community-engaged researcher, is vaccine deliberation, as individuals weigh the pros and cons of the evidence of vaccine efficacy, loved ones lost in the pandemic, and an overwhelming history of racism in medicine and science. Many Black and Indigenous populations as well as those from other racial and ethnic minority groups are cautiously waiting to see for themselves whether the vaccines are safe—by talking with family members, observing the side effects experienced by loved ones who have received the vaccine, weighing information from trusted sources and local leaders, and talking with health care professionals. In addition, an old adage applies here: “When I know that you care, I’ll care about what you know.” So, when health care systems make shifts that demonstrate trustworthiness and a commitment to equity, more people will likely agree to the take the vaccine and more will cautiously say yes. It is all these sources of information and inputs, assessed over time, that lead some to agree and others to decline. Our role as health care professionals is to stay engaged in these conversations with our friends, family, patients, and communities as they sort these sources of information in their decision-making.

Focus on Equity in Vaccine Distribution

We need structures, policies, and practices focused on ensuring Black and Brown communities and the clinical settings that serve those communities receive enough doses of the vaccine in a timely manner.6 In addition, we need to use strategies that ensure those who are most in need in historically marginalized communities are given preference and provided support to both access appointments and travel to them. Mobile units and pop-up clinics, preferably cosponsored by trusted local community organizations and/or individuals, are 2 examples of structural approaches to advance equity in distribution.7

Use High-Touch Rather Than Hi-Tech Approaches

Current online vaccine appointment scheduling shows the deep digital divide between those who may not have access to or feel comfortable with the internet and those who can successfully navigate health information technology. Vaccinations are an extremely important factor in mitigating the COVID-19 pandemic. However, the digital chasm between what needs to be done and the health care system that provides the solution is widening. We need high-touch (ie, person-to-person) practices, particularly in Black and Brown communities, to bridge the digital divide. In communities with the highest risk of infection, local community health workers have demonstrated their expertise in getting more people tested and connecting them with the care they need.8 This same trusted workforce needs to be mobilized to address current vaccine uptake disparities and institutionalized to continue meeting the needs of historically marginalized communities.

Partner With Trusted Organizations With Ties to Historically Marginalized Communities

Much has been written about having trusted voices as part of a marketing campaign to improve vaccine uptake. Indeed, this is a useful practice but falls short of a true partnership. True partnership requires ensuring leaders and organizations in communities are fully engaged with and remain an integral part of the planning and implementation of the solutions. True partnerships are more than images of an individual who looks like the target population with their sleeve rolled up getting a vaccination. Partner organizations must be shoulder to shoulder with health care professionals and public health colleagues as we continue to fight for the lives of every person in this country.

Addressing disparities in vaccine uptake requires a multipronged approach centered on the needs of historically marginalized communities. The approach must recognize that vaccine deliberation is rooted in structural racism and be designed to clearly demonstrate the trustworthiness of medicine, public health, and our health care system.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Corbie-Smith G. JAMA Health Forum.

Corresponding Author: Giselle Corbie-Smith, MD, MSc, University of North Carolina- Chapel Hill, 323 MacNider Hall, 333 S. Columbia St, Chapel Hill, NC 27599 (gcorbie@med.unc.edu).

Conflict of Interest Disclosures: None reported.

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Washington  HA.  Medical Apartheid: The Dark History of Medical Experimentation on Black Americans From Colonial Times to the Present. 10th ed. Doubleday; 2016.
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Pacheco  CM, Daley  SM, Brown  T, Filippi  M, Greiner  KA, Daley  CM.  Moving forward: breaking the cycle of mistrust between American Indians and researchers.   Am J Public Health. 2013;103(12):2152-2159. doi:10.2105/AJPH.2013.301480PubMedGoogle ScholarCrossref
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Novak  NL, Lira  N, O’Connor  KE, Harlow  SD, Kardia  SLR, Stern  AM.  Disproportionate sterilization of Latinos under California’s eugenic sterilization program, 1920-1945.   Am J Public Health. 2018;108(5):611-613. doi:10.2105/AJPH.2018.304369PubMedGoogle ScholarCrossref
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Nakayama  DK, Jensen  GM.  Professionalism behind barbed wire: health care in World War II Japanese-American concentration camps.   J Natl Med Assoc. 2011;103(4):358-363. doi:10.1016/S0027-9684(15)30317-5PubMedGoogle ScholarCrossref
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Bibbins-Domingo  K, Petersen  M, Havlir  D.  Taking vaccine to where the virus is—equity and effectiveness in coronavirus vaccinations.   JAMA Health Forum. Published online February 12, 2021. doi:10.1001/jamahealthforum.2021.0213Google Scholar
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Bachireddy  C, Dar  M, Chen  C.  Medicaid and COVID-19 vaccination—translating equitable allocation into equitable administration.   JAMA Health Forum. Published online February 17, 2021. doi:10.1001/jamahealthforum.2021.0114Google Scholar
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Towns  R, Corbie-Smith  G, Richmond  A, Gwynne  M, Fiscus  L.  Rapid Deployment of a Community-Centered Mobile Covid 19 Testing Unit to Improve Health Equity.   NEJM Catal. Published online October 22, 2020. doi:10.1056/CAT.20.0522Google Scholar
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US Centers for Disease Control and Prevention. Engaging community health workers to support home-based care for people with COVID-19 in low-resource settings. Updated January 12, 2021. Accessed March 11, 2021. https://www.cdc.gov/coronavirus/2019-ncov/global-covid-19/home-based-care.html
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