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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.

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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.

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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.

  • As the author of the piece I’d like to acknowledge that a few comments have attempted to pathologize and diminish the experience of millions of people.

    I’ll directly respond to the supposed “paradox of a racist society without racists”, a quote taken from a man who has unquestionably reaped the benefits of our prejudiced system, who has never felt the cold sting of racism but fancies himself an authority on the matter. A professor at a school that profited directly and indirectly from the sale and labor of African and African-descended people. An institution whose participation in chattel slavery, a vile capitalist racist system, went to the highest levels. So high, that in the eighteenth century four people named Titus, Venus, Bilhah, and Juba were assigned to forced labor at Wadsworth House, Harvard’s second oldest surviving building, and residence of the University’s Presidents.
    https://news.harvard.edu/gazette/story/2017/02/understanding-harvards-ties-to-slavery/

    The true paradox of this racist society is that professed racists and more commonly, people who hold racist/prejudiced beliefs, are walking around in plain sight. The people who cannot see or feel the effects of racist/prejudice beliefs and actions either refuse to, or they haven’t looked in the right place. They haven’t looked at themselves or engaged with the meaning of things they believe and the privileges they hold. The uncomfortable truth is that this country has created legend out of genocide and massacre, turns villains into heroes and certain members of society cannot bare to face it and what it may say about them.

    For those who feel uncomfortable with my reference to systemic racism, I ask you open your hearts and ask yourself why? Why does acknowledging the existence of prejudice and racism make you uncomfortable? Who and what does that serve? How do you propose we unite as a county on truly equal terms? What of the call for accountability, unity and healing the core of the piece? Are you even interested?

    • STOP just stop. The “white savior hero” is the most hateful stuck up and racist person there is. You constantly agitate us – “this country is evil – capitalism is evil, blacks are subhuman to white America” – your sick cult is obsessed with this crap that only makes us Angier and hateful and less inspired to work hard and improve our standards.
      I didn’t begin to succeed until I stopped listening to you racists. And I have a good life thanks to a COUNTRY THAT GIVES PEOPLE OPPORTUNITY AND LIFTS MINORITIES OUT OF POVERTY if they want to work

    • Kareem, I am a Black American Howard University College of Medicine trained physician. I am unapologetically pro-Black. I am very aware of the systems and structures in place in this country that limit the opportunities of other Black people. I want to dismantle those systems and build new ones that give ALL Black people a fair shot in this country.

  • The biggest concern about this vaccine is not about race, but rather those who are in power can end up getting the vaccine when they don’t need it urgently. Then there is also news that the wealthy people in CA are willing to pay the doctors tens of thousand of dollars to get the vaccine.

    Look at the case of the Stanford medical residents boycotting because the professors who works from home were allocated the vaccine but only less than 10 medical resident where allowed the vaccine. Even those who works with covid19 patients were not in line to get the 5000 dosage of vaccine.

    Then the news says that congress were in line to get the vaccine. Aren’t all the Democrats working from home, why do they need to fall in line with the vaccine when there is not enough for the frontline healthcare workers.

    One article in stat did mentioned about the people with privilege could end up getting the vaccine ahead of the people who really needs. The news seems to be justifying that article.

  • I tried hard to read and understand this article. The obfuscation is amazing. Can someone please rewrite in plain English because it’s important!

  • If you want to discussed racism, the first health care workers published on news in NY to get vaccine is Black, the first healthcare workers in LA is to get vaccine is Black.

    The act of exploiting racism create an extreme scenario where Black people has to be put everywhere, movie, commercial, the first in vaccine, etc. But isn’t that by itself also another racism ?

    Let’s live a normal life and view people as people instead of white, black, brown, yellow. Let’s stop exploiting racism an stamping racism on everything to get some advantage.

    If you cry wolf too often, people won’t believe you if there is a real wolf.

    • Is it pro forest fire to repeatedly promote Smokey the Bear? These repetitive images are part of the country’s efforts to reverse centuries of white genocide against Blacks. If these images make you feel uncomfortable, they are doing their job…

  • Systemic racism – catch phrase of the year- does it exist?, and attacking all whites as white privileged is the key to solving the issue? Even though we may not have reached absolute racial equality yet, we as a country have come a long way in a short amount of time and good studies have determined that America is the least racist country in the world.

    • I agree with George. Regarding the meaning of “systemic racism” . Harvard professor Harvey Mansfield writes in The Wall Street Journal that the phrase incoherently “describes a society that is so little racist that no one can respectably advocate racism, yet so much racist that every part of it is soaked with racism,” leaving us with “the paradox of a racist society without racists.” I would add that even though systemic racism allegedly is everywhere, you need an advanced degree in one of the grievance studies programs to ferret it out

  • At this point, after months and months of mostly nonsense about how racists doctors are – indirectly anyway – granted none of the articles said that in so many words, but they repeatedly railed about racism in the healthcare system, and when you looked at it, the racism in many cases absolutely had to be coming from doctors- after dozens of such articles – I had formed the opinion they are mostly to bait people, and decided to stop responding.
    BUT, then THIS comes along – this article actually compares HIV rates among men of different races, I should say among gay men of different races, and offers that as evidence of some kind of racism on the part of somebody.
    According to all the public health info I have ever seen, HIV infection, from gay sex, requires taking semen from an infected man. Orally or anally.
    From all I have been told those are the only two ways.
    I simply do not believe any racists forced gay black men to take in semen – that is, if they want to use protection, they can do that, just like anyone else.
    I do not want to be too crude pointing out the mechanics of infection, but feel it is necessary to point out how completely absurd this proposition is.
    I did not stop any gay black men from using condoms – as far as I know, no one in government, or any other type of power did- was it the KKK maybe? This is just ridiculous. I do not want anyone to get sick, but it seems obvious gay black men are more reckless than others and end up getting sick much more often. It seems pretty likely part of the higher rate of Covid19 in the black population is due to similar less caution than other groups as well.
    If anyone is offended, please take note i restrained myself from many sarcastic comments I could have made. I am making a sincere point. To not get sick from infectious disease, take the known and simple precautions.

  • The Democrat party politicized the vaccines and is responsible for unfounded distrust of them.

  • Let’s stop putting racial team on vaccine. Give it to health workers first. We are short of health are workers and it is hard to replace them once you lost them. We also owe them a lot for taking risk to care for people with covid19. It takes years of education and training to be an ICU or to be emergency or critical care doctors, or even a nurse.

    Why is congress getting vaccine when we are very short supply? Unlike health care workers, they are easily replaceable. It does not takes years of higher educations or training to be a congressman. You just have to give up your dignity and knows that you will makes promises in the elections that you have to plan of fulfilling.

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