Broad skepticism about the safety and effectiveness of potential Covid-19 vaccines has created major challenges for policymakers and health officials as they develop vaccine programs. Much of this has been attributed to the anti-vaccine movement and the constant attacks on science by the outgoing presidential administration.
When discussions focus on skepticism in communities of color, particularly the Black community, the conversation tends to center around the argument that their distrust is rooted in history and a collective memory of racist policies such as the Tuskegee syphilis experiment and early 20th century forced-sterilization policies. This line of thinking is harmful.
By focusing on historic wounds, we lose sight of the bigger picture and stifle necessary conversation around larger systemic issues that are worthy of critical analysis. When discussing racism, people in the United States tend to compartmentalize it as mainly a historical problem. This serves age-old racist tropes that pathologize and dismiss communities of color as begrudged monoliths that simply cannot “get over” historical wrongdoing. It ignores the lived experience of people today and fails to acknowledge the impact of racism and racist policies on their lives.
Marginalization is not a passive process
Communities are being actively disenfranchised today by policies created and enforced by people in positions of power. These partial narratives of historical injustices create the space to absolve policymakers and health care institutions of their roles in maintaining systems that are actively harming people. This is an important and necessary distinction that places the onus of bridging the trust gap squarely where it belongs, on those in power.
This language of distrust around vaccines is too imprecise. The “distrust” is actually a lack of confidence, which Merriam-Webster defines as “faith or belief that one will act in a right, proper, or effective way.” Lack of confidence that institutions will act in “right, proper, or effective” ways is a direct response to historical and current actions — and inactions — of those bodies. This context is important if policymakers hope to reach communities of color and bridge the confidence gap.
Health and health care disparities are crushing communities of color in this country. Health care systems and their practitioners play a significant part in this. Relative to white people, Black people are less likely to have their pain adequately treated. Black and Indigenous women are three to four times more likely to die in childbirth than white women, regardless of education or socioeconomic factors.
Or consider the current state of HIV/AIDS, a pandemic that emerged in the U.S. in 1981 and that has not yet been quenched. In 2016, the Centers for Disease Control and Prevention projected that at current rates of HIV transmission in the U.S., the lifetime risk for infection for Black gay and bisexual men is 1 in 2. Compare that with 1 in 4 for Latinx/Hispanic gay and bisexual men and 1 in 11 for white gay and bisexual men. The CDC routinely conducts HIV behavioral surveillance of persons at high risk for HIV infection. In the three years following the CDC’s projections for lifetime risk of HIV infection, from 2017 to 2019, Black and Latinx gay and bisexual men consistently reported less awareness and significantly less uptake of HIV pre-exposure prophylaxis, an effective intervention to curb transmission, compared to their non-Hispanic white counterparts.
Systematic marginalization has measurable consequences and palpable outcomes
Many people of color have had bad health care experiences or have lost loved ones to the shortcomings of the American health care system. In many of these communities there is a collective understanding that blind faith in this system, a system that has failed them time and again, can lead to poor outcomes or even death. In this context, distrust in vaccines or the health care system as a whole is a logical reaction and a protective coping response to overwhelming adversity.
Today’s institutions were not created out of thin air, and they do not exist in history-free vacuums, immune to the influence of politics or larger societal problems. U.S. health care institutions have their own troublesome pasts and current practices that operate on theory developed by people deeply invested in maintaining white supremacist, capitalist, patriarchal power structures.
But all is not lost. We have the great opportunity to create a new culture of public health.
As jurisdictions design their Covid-19 vaccine programs, I urge them to turn to the newly revised 10 Essential Public Health Services as a framework for direction. Originally developed in 1994 by a federal working group, the revised framework was developed this fall by the de Beaumont Foundation, the Public Health National Center for Innovations, and a task force of public health experts. To communicate effectively and build trust in communities, policymakers and institutions must center equity and account for the ways that systemic racism affects their public perception. To meaningfully address the public health crisis of racism — a pandemic of racialized trauma — institutions need to improve and innovate their approaches through ongoing evaluation, research, and continuous quality improvement. This will require a paradigm shift on both personal and institutional levels.
To create equitable vaccine programs, we must go beyond addressing historical trauma and account for the traumas people experience in the here and now. Racial trauma is like other forms of trauma: Its impact is widespread, it is intergenerational, and it can have severe social, physical, and psychological consequences. We already have proven public health frameworks, such as trauma-informed care, to address trauma. It’s time to broaden their application.
Trauma-informed care would provide a useful framework for public health institutions and policymakers to contextualize collective racial trauma as they build their Covid-19 vaccine programs and engage with communities that have experienced health-care-related racial trauma. Trauma-informed practice understands and considers the prevalence of trauma, the complex impact it has on people’s lives, and promotes healing and recovery rather than practices that may inadvertently retraumatize.
Recognizing that governmental and health care institutions have played roles in the traumatization of communities is key. Similar to rifts in interpersonal relationships, healing the fractured relationship between the health care system and communities of color will take time and will not always be comfortable or easy. But this is necessary work. The methods should actively promote cultural humility, avoid blame, and acknowledge the wounds of the past and present. Efforts should prioritize transparency, safety, and preventing retraumatization.
To earn the trust of communities, institutions must show them that their concerns and needs matter. They should work with communities and hold themselves accountable to them.
For any hopes of a successful vaccine program, public health institutions will need to continually demonstrate their commitment to healing, empowerment, and collaboration as we together create pathways for recovery — a commitment to act in a right, proper, and effective way, through policy and action.
Julian L. Watkins is a physician with the New York City Department of Health and Mental Hygiene and a leader in Culture of Health Leaders, a national leadership program supported by the Robert Wood Johnson Foundation. The opinions expressed here are the author’s own and do not necessarily represent the opinions of the New York City Department of Health of Mental Hygiene, the Culture of Health Leaders program, or the Robert Wood Johnson Foundation.