The COVID-19 pandemic, Black mistrust, and a path forward.

As Black Emergency Room physicians, we've had a front row view as COVID-19 has ravaged our community, disproportionately killing African-Americans, Latinos, and other minority groups [1,2]. We cheered the arrival of a vaccine, and, along with many other front-line providers, lined up early for our appointment filled with hope that an end to this pandemic could be near.

Unfortunately, this elation has been short lived. Early signs from the current vaccine rollout show Black Americans nationwide are receiving COVID vaccinations at half the rates of White Americans [3,4]. Even amongst those fighting the virus every day, few of our Black colleagues want to get vaccinated [5].

As Black healthcare providers, we recognize our unique role in providing not only for the health of our patients but for the health of our communities. We provide a brief historical primer and urge specific action to prevent worsening of health disparities.

There is a historical legacy of exploitation and persecution at the hands of the US healthcare system which has affected generations of Black communities. During slavery, physicians used slaves for involuntary medical experimentation for both developing cures and profit. Medical exploitation was further perpetuated in the modern era as evident by the Tuskegee Syphilis Project, the biomedical capitalization of Henrietta Lacks, and forced sterilization initiatives [6].

Decades of torment have led to generalized mistrust of the healthcare system among many in the Black community. Discrimination, experiences around racism, and fear of experimentation are but a few of the many elements that contribute to this mistrust, and ultimately negatively impacts the acceptance of and willingness to seek healthcare [7,8]. This notion becomes more apparent when it comes to the topic of vaccinations. A December 2020 survey conducted by the Kaiser Family Foundation showed that about a quarter of the public remains vaccine-hesitant, saying they probably or definitely would not get a COVID-19 vaccine even if it were available for free and deemed safe by scientists. More importantly, 35% of Black adults say they definitely or probably would not get vaccinated citing major reasons as fear of contracting COVID-19 from the vaccine itself or having a mistrust of vaccines in general. Among all Black Adults, about half (48%) say they are not confident that the development of a COVID-19 vaccine is taking the needs of Black people into account [9].

COVID vaccination presents an opportunity for a healthcare system historically plagued by injustice and discrimination to begin to make amends. We offer concrete strategies that healthcare and governmental institutions can employ now to address COVID-19 vaccine hesitancy in the African-American community.

First, we must acknowledge past and present injustices rooted in structurally racist policies and care delivery systems. Institutions should mandate iterative cultural competency training for all clinicians and trainees that emphasize how social determinants contribute to health inequity across communities of color. For communities historically subjected to experimentation and exclusion, transparency in describing vaccination risks and benefits and accountability in vaccine delivery are critical when engaging on the topic of COVID-19 vaccination. Second, we must develop messaging that acknowledges concerns while providing pertinent information and education. Our communities have heightened apprehension about side effects and safety rooted in historical abuses. Messaging must explicitly address these aspects in a culturally sensitive way to allay fears. Third, we must partner with trusted sources such as faith-based organizations, political advocacy groups, and grass-roots organizations to engage Black communities about the risks and benefits of the COVID19 vaccine in a personalized, culturally sensitive way. These are community leaders who acknowledge people's genuine fears and the Black experience of healthcare in America. Recognizing the potential sway that trusted Black voices have in the community, we can leverage community anchors to foster dialogue and build trust. Finally, we must redouble our efforts to overcome barriers to access particularly for those most disenfranchised. If primary care, health education, and preventive health are already less accessible for Black patients, we cannot expect that, without significant action, the COVID vaccine will magically become easy to get. Efforts need to be targeted to reach communities when and where they prefer to be vaccinated. Vaccines should be distributed in churches, barbershops, and community centers.

The trauma from centuries of experimentation, neglect, and disenfranchisement cannot be overcome overnight. Yet, action must be taken now to alleviate the pandemic's devastating toll on communities of color given that it is far from over. With genuine communication, relevant messaging, thoughtful partnership, and a relentless focus on removing barriers, we can build transparent and equitable mechanisms to address vaccine hesitancy in the communities most at risk.

Declaration of Competing Interest

The authors have nothing to disclose.