Health Equity Issues around Vaccine Hesitancy

Racial disparities are an ever-present issue in public health. However, the COVID-19 pandemic as well as social movements such as Black Lives Matter have brought these deep-rooted concerns under intense scrutiny. According to a study analyzing COVID-19 in black communities, less than 20% of US counties are identified as disproportionately black[1], yet they accounted for 52% of COVID-19 diagnoses and 58% of COVID-19 deaths nationally.1

These alarming numbers signify the crucial goal of prioritizing COVID-19 vaccine distribution among marginalized populations that are disproportionately affected by the pandemic in order to help mitigate the ever-widening impacts of the virus for people of color and prevent increasing racial health disparities going forward. Unfortunately, this has not been the case. There is a consistent pattern seen among African American communities in the US for receiving smaller shares of vaccinations compared to their shares of the total population, COVID-19 cases and deaths.2

Is Race the Key Issue?

Racial health disparities are often attributed to socioeconomic inequalities as African Americans are more likely to live in poverty and reside in neighborhoods with overcrowded households, air pollution, and inadequate access to health care.3 This is certainly the case with COVID-19 as a study by Liao and De Maio showed that both racial composition and income inequality, as well as the interaction between the two, all increased county-level COVID-19 incidence and mortality throughout the US.4

With this mindset, interventions aimed at improving vaccine accessibility would make great strides at mitigating these disparities. Many state governments have initiated targeted measures such as reserving a certain percentage of shots for underserved populations, arranging telephone support lines to help those without internet access, or setting up mass vaccination sites in low-income areas to help those without transportation.5 These efforts should have helped close the racial gap; yet the reality is that the racial gap continues to widen even as eligibility increased (Figure 1). Since measures addressing socioeconomic inequalities do not seem to have the desired effect, perhaps there are other racially based factors influencing these trends.

Figure 1. Percent of Total US Population that Has Received a COVID-19 Vaccine by Race/Ethnicity, March 1 to April 5, 2021

According to the data collected by the Kaiser Family Foundation (KFF) for Maryland, only 23% of African Americans, 5% of Hispanics, and 7% of Asians are vaccinated compared to 63% of White residents.2 Data from other states also show similarly observed trends of African American and Hispanic populations receiving smaller shares of vaccines even though they constitute a larger share of infected cases as opposed to the white community.

Prince George’s County: A Case Study

Prince George’s (PG) County in Maryland is a suburban area located next to Washington, DC. With a population consisting of 64.5% blacks and a median household income of $83,034, it is known as the wealthiest African American majority county in the nation.6, 7, 8 With such a notable designation, one would expect its residents to not fall victim to the typical racial inequity trope. Yet, PG County bears the unfortunate double title of having the highest number of COVID-19 cases as well as the lowest percentage of people who have received at least one COVID-19 vaccine dose in the state (Figure 2).

Figure 2. Total Cumulative COVID-19 Cases and Percent of Individuals Who Have Received At Least 1 COVID-19 Vaccine Dose in Maryland by County, April 9, 2021

The Maryland Department of Health has already established a telephone-based support line / appointment system and a mass vaccination site at Six Flags America in PG County. With its affluent background as well as the state government’s vaccine outreach efforts, socioeconomic inequalities do not seem to be major factors for this county’s racial gap.10 Other influences must be at play.

Vaccine Hesitancy

African Americans and other people of color have repeatedly indicated distrust of the US healthcare system. This hesitancy over any medical intervention, including vaccinations, is rooted in deep-set systemic racism, marginalization, and neglect.11 In particular, the infamous Tuskegee Syphilis Study comes to mind when the black community contemplates whether to get the COVID-19 vaccine. This raw and painful medical history is a major deterrent to any federally-backed health campaign, to the point where even disproportionately high rates of incidence and mortality cannot mend that trust.12

Innovative grassroots campaigns such as the Health Advocates In-Reach and Research (HAIR) have been developed to help combat medical misinformation and hesitancy. HAIR utilizes barbershops and beauty salons in PG County as culturally relevant portals for health education and delivery of public health / medical services in the community.13 Public health officials take advantage of this important community relationship in order to disseminate life-saving information to the population through a locally trusted source.

Where Do We Go From Here?

The actions taken so far to combat racial disparities regarding COVID-19 vaccine distribution seem promising, however only time will tell if they will prove successful. Nonetheless, federal, state, and local governments need to increase their effort in prioritizing vaccinations of African American populations and rebuilding their trust with these communities. The efforts made by HAIR have slowly encouraged African Americans to contemplate vaccination and the Six Flags America mass vaccination site is a step in the right direction to increasing vaccine access. However, the work is not done until the vaccine is actually in people’s arms. Additional obstacles have occurred, such as with residents from other counties flooding in and booking all of the appointment slots. Government and public health officials must remove these barriers in order to demonstrate that they care and that Black Lives truly do Matter.

By Carissa Kwan and Lalita Meena, HSR.health

References

1. Millett, G. A., Jones, A. T., Benkeser, D., Baral, S., Mercer, L., Beyrer, C., … Sullivan, P. S. (2020). Assessing differential impacts of COVID-19 on black communities. Annals of Epidemiology, 47, 37–44. https://doi.org/10.1016/j.annepidem.2020.05.003

2. Ndugga, N., Pham, O., Hill, L., Artiga, S., Alam, R., & Parker, N. (2021, April 7). Latest Data on COVID-19 Vaccinations Race/Ethnicity. KFF. https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-on-covid-19-vaccinations-race-ethnicity/.

3. Getachew, Y., Zephyrin, L., Abrams, M. K., Lewis, C., & Doty, M. M. (2020). Beyond the Case Count: The Wide-Ranging Disparities of COVID-19 in the United States. Commonwealth Fund. https://doi.org/https://doi.org/10.26099/gjcn-1z31

4. Liao, T. F., & De Maio, F. (2021). Association of Social and Economic Inequality With Coronavirus Disease 2019 Incidence and Mortality Across US Counties. JAMA Network Open. https://doi.org/ doi:10.1001/jamanetworkopen.2020.34578

5. Ndugga, N., Artiga, S., & Pham, O. (2021, March 10). How are States Addressing Racial Equity in COVID-19 Vaccine Efforts? KFF. https://www.kff.org/racial-equity-and-health-policy/issue-brief/how-are-states-addressing-racial-equity-in-covid-19-vaccine-efforts/.

6. State Data Center, & Azimeraw, M., Black or African American Population in the United States, the Washington Primary Metropolitan Statistical Area (PMSA), and the District of Columbia from 1950 to 20107–7 (2014). Washington, DC.

7. Maryland. Data USA. (n.d.). https://datausa.io/profile/geo/maryland#economy. (Last Accessed: 4/7/2021)

8. National Park Service, African American Historic Resources of Prince George’s County, Maryland (2006). National Park Service.

9. Maryland Department of Health. (n.d.). Maryland COVID-19 Data and Vaccination Dashboard. Coronavirus Disease 2019 (COVID-19) Outbreak. https://coronavirus.maryland.gov/. (Last Accessed: 4/9/2021)

10. Maryland Departments of Health and Aging collaborate on vaccine outreach for vulnerable populations. Maryland Department of Health. (2021, February 16). https://health.maryland.gov/newsroom/Pages/Maryland-Departments-of-Health-and-Aging-collaborate-on-vaccine-outreach-for-vulnerable-populations.aspx.

11. Quinn, S. C., & Andrasik, M. P. (2021). Addressing Vaccine Hesitancy in BIPOC Communities — Toward Trustworthiness, Partnership, and Reciprocity. New England Journal of Medicine. https://doi.org/10.1056/nejmp2103104

12. Lee, K. (2021, February 5). Decades later, infamous Tuskegee syphilis study stirs wariness in Black community over COVID-19 vaccine. Los Angeles Times. https://www.latimes.com/world-nation/story/2021-02-05/la-na-tuskegee-study-black-distrust-access-vaccine?fbclid=IwAR3z7SeddRkVN50-3bvuoxmpk9Gpvmjx7EpiEtYL7iHBRSUqEhK3R81U7NE.

13. The Health Advocates In-Reach and Research Campaign (HAIR). University of Maryland – School of Public Health. (n.d.). https://sph.umd.edu/center/che/health-advocates-reach-and-research-campaign-hair#:~:text=The%20Health%20Advocates%20In%2DReach%20and%20Research%20(HAIR)%2C,Public%20Health%20in%20College%20Park.

[1] Disproportionately black counties refer to those counties with an African American population exceeding 13%, the percentage of the overall US population that is African American.