• Discrepancies in Vaccine Uptake: What’s Really at Work?

    I was recently on a Zoom meeting about COVID-19 vaccine distribution and allocation when the discussion shifted to vaccine hesitancy in the Black community. I found myself, rather frustrated, blurting out, “My Black patients aren’t hesitant! They want the vaccine, they just can’t get it!"

    physician placing band-aid on patient's arm

    I am not naïve enough to think that none of my patients are refusing the vaccines, I know that some certainly are, but from my experience thus far, I’ve spent far less time addressing questions about hesitation and much more time trying to help my patients through the process of getting a vaccine. From identifying a site with available vaccines, to getting registered, to getting to the site, to completing paperwork … so much goes into the process that we take for granted and may not recognize as possible barriers to vaccination for our most vulnerable populations.

    I practice in an area of Alabama known as the Black Belt. Originally named such for its rich, dark topsoil, this region is also aptly named for its predominant African American population. Some counties comprising Alabama’s Black Belt are among the poorest areas in the nation and many have the highest incidences of poverty, worst education rankings, fewest medical professionals and poorest health outcomes in the state. The majority of my patients are Black, and I have had many discussions over the past year with them about COVID-19. We talk about loved ones who have been lost, the importance of wearing masks and using good hygiene practices to reduce spread, the signs and symptoms of the disease, and the hope of getting back to some sense of normalcy. Many of them, like me, have lost relatives, family friends and close acquaintances to the disease and, quite frankly, are terrified of contracting COVID-19.

    In the early stages of the ongoing campaign to get Americans vaccinated against the virus that causes COVID-19, I found myself increasingly frustrated by the opinions I kept reading that stated as if it were a matter of fact that the African American community would overwhelmingly reject the vaccines. Despite knowing the traumatic past experiences Black people in this country have had with the health care system, I just could not foresee large numbers of people refusing to be vaccinated against a virus that we were literally watching claim the lives of African Americans at a disproportionately high rate.

    A few weeks into the nationwide vaccine distribution effort, though, reported numbers gave life to the disparity in vaccine uptake by African Americans. Even at the time of writing this, the CDC reports that of those who are fully vaccinated, 64.9% are White, non-Hispanic; 11.1% are Hispanic/Latino; and 8.5% are Black, non-Hispanic. I assume that one could infer that this disparity is solely related to vaccine hesitancy and refusal but, as a Black family physician practicing in rural Alabama, this discrepancy is so eerily similar to those seen in health outcomes, education and wealth disparities in many of the predominantly African American counties in my state that I cannot draw that conclusion. My daily struggle with the social factors that affect my patients’ abilities to live their healthiest lives won’t let me believe that every African American in this country who is eligible to receive a vaccine, but has not received it, is in that position by choice.

    When COVID-19 vaccines first became available in our state, aside from first responders, they were restricted to individuals 65 and older. Having read many of the articles forecasting impending vaccine hesitancy among African Americans, particularly in my state, I felt it was my responsibility to be prepared to address any concerns related to the vaccines that my patients would have, especially related to race. In addition to studying specific vaccine information, I was ready to talk about J. Marion Sims’ horrific medical experimentation on enslaved Black women,  Henrietta Lacks’ cell line and the U.S. Public Health Service Syphilis Study at Tuskegee. If I believed what I’d heard, these historical factors would be what my Black patients would bring up as their reasons to not want the vaccines. Right?

    Wrong. I am yet to have a patient mention these particular incidents. Why? Not because they didn’t happen and certainly not because they aren’t stains on the institution of medicine that we all can — and should — learn from, but I believe it’s because they don’t have to look to the distant past to affirm discriminatory practices in medicine and reasons to distrust the health care system and some of its professionals. Some have experienced racial discrimination in medicine firsthand; they didn’t have to learn about it from some other source.

    Studies have shown that patients of color reportedly experience longer wait times, less interaction time with physicians, inadequate treatment of pain, less thorough diagnostic workup and other biases compared to their white counterparts. We must acknowledge that discriminatory practices in the health system did not end with the abolition of slavery or the repeal of Jim Crow laws, and that the field of medicine is not immune to institutional racism. Present-day health care inequities, a continuation of historical inequities, are real and surely contribute significantly to African Americans’ suspicion of the entire health care system — including, now, COVID-19 vaccines.

    Still, it would be an error to assume that the discrepancy in vaccine uptake is solely due to vaccine hesitancy and distrust on the part of African Americans. We can no more assume this than we can identify a single factor to account for other health care disparities faced by African Americans and people of color in this country.

    Not One Factor, But Many

    So what do we know exacerbates many of those disparities? Social determinants of health, of course. Just as social determinants of health are primary drivers of health inequities, I believe that factors such as where we live and work, literacy levels, and access to technology and transportation are also primary drivers of COVID-19 vaccine inequities, making those who are already at higher risk even more vulnerable. As more vaccines become available and the number of people eligible to receive them increases, I worry that they still are not widely accessible, as is evident in my community and among my patients.

    Where you live. As the vaccine rollout began, inequitable distribution to rural and predominantly minority communities was devastating. Patients called the clinic all day asking if we knew where they could get a vaccine. I couldn’t understand how communities that were being hit so hard by this disease weren’t allocated vaccines proportionate to the risk of the population. I found myself overwhelmed by patients, family, friends and strangers at the gas station who saw me wearing scrubs asking where they could receive a vaccine. At the same time, I was devastated knowing that these people who were at greatest risk for worse outcomes were at a significant disadvantage based simply on where they lived.

    Access to technology. Online registration has been a preferred method for many vaccine sites. Although this streamlines the process, I have found that technology has been a barrier for some of my patients. People who don’t have internet capability because of where they live or financial constraints, or who simply don’t know how to navigate the internet or don’t even have reliable phone service, are at a significant disadvantage with this method of registering for appointments.

    Access to transportation. I have several patients who don’t have a car and don’t have access to public transportation. So often I have patients cancel appointments because they don’t have a way to get to my office or they tell me that they have to pay someone to drive them to their appointments. I have patients who are putting off needed specialty care because they don’t have a ride to get outside of the county. For them, and others in similar situations, transportation is a serious barrier. Getting to a vaccine site in their county, traveling to another county where more vaccines are available, or going to a drive-up vaccine clinic simply aren’t options for them.

    Where you work. Many people in the community I work in either commute to another county for work or are employed in local plants or factories and aren’t able to make it to Monday-Friday vaccine clinics held during usual working hours. Whereas those who have more job security and flexibility are able to wait in line for hours at a time to receive a vaccine, others must choose whether to be vaccinated or go to work that day.

    Education and literacy levels. At least a few patients in my clinic have difficulty reading and/or writing. While my staff and I are aware of those patients and take extra care to make sure they are comfortable and have assistance, I wonder: How many people are avoiding receiving a vaccine due to worry about having to complete paperwork without assistance?

    These are just a few factors that could negatively impact patients’ ability to receive a vaccine.

    I discount the narrative that the discrepancy in vaccine uptake is due solely to hesitancy and refusal on the part of African American patients. While that is certainly a contributing factor, just as important are the social factors that impede access to COVID-19 vaccines. It has been frustrating for me trying to get my patients arranged for vaccines, so I can only imagine that it has been frustrating for patients, as well.

    Just as identifying social determinants of health alone is not enough, neither is simply identifying social factors that would prohibit maximum vaccination of vulnerable populations. Many of us, as family physicians, are in positions to help with planning of vaccination efforts in our communities. We sit on task forces, are part of working groups or hold public health positions in our communities. We must advocate for processes that make these vaccines accessible for all.

    During April, National Minority Health Month, we pay special attention to the inequities that minority populations face in this country. The selected theme for this year is #vaccineready. Let us do our part, as family physicians, to address historical and current concerns that could be leading to vaccine hesitancy among our patients in minority populations and ensure that social factors do not negatively affect their ability to receive vaccines.

    Brittney Anderson, M.D., is a fellow of the 2021 AAFP Health Equity Fellowship. She practices family medicine in rural Alabama and is a clinical assistant professor in the Department of Family, Internal, and Rural Medicine in the College of Community Health Sciences at The University of Alabama, Tuscaloosa. Her views are her own and do not represent those of the organizations with which she affiliated.



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