As the gap in vaccine uptake between Black and White Americans narrows, we look at factors contributing to increasing vaccination in Black people in the USA. Talha Burki reports.
On Dec 14, 2020, Sandra Lindsay, a Black intensive care nurse from New York City, became the first American to receive the COVID-19 vaccine outside a clinical trial. At the time, she stated that she hoped to “inspire people who look like me, who are sceptical in general about taking vaccines”. The pandemic has disproportionately affected Black American people. They are twice as likely to die from COVID-19 as non-Hispanic White people, and almost three times as likely to be hospitalised. As the USA began to roll out the vaccines late last year, there was a lot of concern that structural barriers and vaccine hesitancy would restrict take-up in African American communities.
The latest data from the US Centers for Disease Control and Prevention (CDC) suggest that such an eventuality has been avoided. Black American people are less likely than White people to have received the vaccine, but the gap is narrowing. Across the 43 states to report data, 54% of White American people and 46% of Black American people had had their first dose of vaccine, a difference of 8 percentage points. This contrasts favourably with the situation in late April, when the difference stood at 14 percentage points (38% of White American people vs 24% of Black American people).
According to the CDC, as of Oct 9, 2021, 65% of the US population had received at least one dose of a COVID-19 vaccine. Of the 61% of vaccinated individuals for whom information on race or ethnicity was available, 60% are White and 11% are Black. This is suboptimal, since Black American people represent 12% of the country's population. But the CDC data also indicate that the share of recent vaccinations to go to Black American people exceeds their share of the total population (14% vs 12%).
Reed Tuckson, managing director of Tuckson Health Connections and a community leader with the Black Coalition Against COVID-19, attributes much of the success to co-ordinated efforts by people of colour. “There has been an aggressive outreach campaign to the Black community from our medics, our health leaders, our church and faith organisations, and our own community-based organisations”, he explained. The Black Coalition Against COVID-19 has conducted a series of live-streamed meetings, known as town halls, in which experts discuss matters such as vaccine safety, on occasion reaching 750 000 people in a single evening.
“It is absolutely essential for the Black community to see people of colour participating at every level of the fight against COVID-19”, added Tuckson. “We are asked questions like ‘who is on the committee that approves the vaccines?’; we have to be able to show that Black scientists are making decisions, and Black people were on the clinical trials.” Kizzmekia Corbett, who helped develop the Moderna vaccine, has assumed a prominent role in encouraging vaccine take-up.
Gary Bennett is the Bishop-MacDermott Family Professor of Psychology and Neuroscience at the Duke Global Health Institute (Durham, NC, USA). “It is great to have luminaries backing vaccination. But what really makes a difference is when the community gets behind it”, he said. “If you have a local pastor, or someone who works in the grocery store, who can share positive views on their experience of vaccination with their social network, then that motivates people to get vaccinated themselves. Peer influence really matters.” The Biden administration has proved amenable to imaginative solutions, such as situating information points and vaccination centres within barber shops and beauty salons.
“During the spring and summer of 2021, we saw a massive ramping up in the availability of the vaccines and the physical locations where they were being offered”, Bennett told The Lancet Infectious Diseases. “That was vital—we know that ethnic minorities and people from lower socio-economic groups have historically had to travel much further to be vaccinated, which can be quite a barrier.”
Studies have consistently shown high levels of vaccine hesitancy among African Americans. A review of 13 studies on attitudes towards COVID-19 vaccines found that Americans overall had a hesitancy rate of 26%, compared with 41% for African Americans. But the experience of the past year indicates that hesitancy is no more intractable in the Black community than in other communities. Nonetheless, the mistrust many African Americans feel towards the institution of health care needs to be addressed.
In the 1980s, Tuckson was commissioner of public health for the District of Columbia. It was the height of the AIDS epidemic. “The number one rate-limiting step for me, in terms of engaging with the Black community in the fight against AIDS, was Tuskegee”, he recalls. “All these decades later, and Tuskegee has still been a huge obstacle when it comes to engaging the Black community in the fight against COVID-19.”
The Tuskegee Study of Untreated Syphilis in the Negro Male ran from 1932 until 1972. It involved 399 Black men with syphilis, who were deliberately deprived of treatment, even after the advent of penicillin in the 1940s. Nor were they informed of the true nature, or even the name, of the so-called study in which they were participating. The researchers simply watched them die, and then examined their bodies. It was only after an exposé in the New York Times that the study was discontinued.
“Tuskegee is an institutionalised memory”, said Tuckson. “It exists in our minds and culture as a proxy for a much larger set of feelings and emotions, things to do with the racist way Black communities have been treated by the institutions of this country.” He added that attitudes to health care are shaped by the wider context of race relations in the USA, such as the events that led to the formation of the Black Lives Matter movement and the ongoing attempts to limit the right to vote.
Tuskegee was not an isolated event. There were comparable atrocities, such as the forced sterilisation of Black women in the mid-20th century, and experiments with whole-body irradiation of Black patients with cancer. “Mistrust is a feature of the way in which people of colour encounter and experience the health-care system”, Bennett told The Lancet Infectious Diseases. “But we must not lose sight of the fact that on the individual level physicians remain a trusted entity among Black Americans. The risk is that by imagining that mistrust is the primary driver for people of colour, we miss opportunities for medical professionals to engage with patients and remind them of the importance of vaccination.” Bennett noted that recent data on the drivers of hesitancy with regard to COVID-19 vaccines have not shown that the Black community has a distinct profile. “People order them differently, but the top three to five drivers are the same across different racial groups”, he said.
Over the past year, attitudes to vaccination among African Americans have shifted in waves. “We saw a lot of movement about 6 months ago, with people who were against the vaccine starting to at least consider it”, said Tuckson. “Then there was a kind of plateau, which coincided with a misinformation campaign flooding the Black community. Now we are seeing movement again, partly because people are seeing the immense pain and suffering caused by the delta variant, and partly because vaccine mandates are coming into force.” Bennett strongly supports the mandates. “The best approach from a public health perspective, for all populations, are policies that require vaccination”, he said. “Those policies would work across the board—the sooner we can implement them, the better.”
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