When David Hicks, DO, MPH, deputy health officer for Jefferson County in Alabama, was asked in an interview a month before the release of the first COVID-19 vaccine if he would get it, he said he didn’t yet have the information to make an informed decision.
Now he does. Vaccines were approved, he did his research, and he got vaccinated. Now each day he’s out front of his community sharing what he’s learned and recounting his experience.
In consultation with bioethicists, Hicks and his colleagues have crafted what he calls an “all-hands-on-deck” strategy, enlisting faith leaders, family physicians, community advocates, and other influencers to provide people with the information they need to make sound decisions – as opposed to trying to dictate what they must do.
Jefferson is the most populous county in Alabama; Birmingham, its seat, is home to some 210,000 people, almost three-quarters of whom are Black. Hicks, a Black man, is fully aware of the potential impact of his guidance and of the urgency of his message within Black communities.
The pandemic has struck Black communities with a vengeance. Black Americans are twice as likely as white Americans to become infected with COVID-19, three times as likely to be hospitalized with the virus, and more than twice as likely to die from it.
They’re also less likely to get vaccinated.
In a survey conducted in October by the Kaiser Family Foundation and The Undefeated, half of Black adults said they probably would not or definitely would not receive a COVID-19 vaccine. Only one in three of the population as a whole said the same.
Hicks has been spreading the word – speaking on radio shows and in virtual sessions with church and social groups, government officials, the state NAACP – answering questions and dispelling myths. Public health officials across the country are guardedly optimistic that such efforts are, incrementally, making a difference. A December survey indicated that the percentage of Black adults who don’t intend to get vaccinated had dropped to around one in three.
Overcoming distrust, said Stephen Sodeke, PhD, a bioethicist at Tuskegee University in Alabama, is a formidable task. Healthcare professionals must first listen to people’s concerns, since they’re well founded, he said. “We haven’t been listening,” Sodeke said, “and we should be able to admit that.”
In a recent virtual town hall that addressed vaccination hesitancy, Sodeke reiterated his message. “We must listen with compassion to the concerns and fears,” he said. “We must encourage vaccination for the common good,” but acknowledge people’s right to choose.
Distrust of the healthcare system among Black Americans runs deep. In Alabama, those tasked with lifting their communities from a pandemic recognize that they must be mindful of this history, and that their message must resonate with respect.
Informed by bioethicists and their own experiences, public health officials have learned that simply telling people they must get vaccinated isn’t enough. A troubling history must be addressed.
Legacy of Distrust
Over the course of four decades, from 1932 to 1972, 600 Black men were recruited for what was called the United States Public Health Service Syphilis Study at Tuskegee. Most of the men were sharecroppers in the vicinity of Tuskegee, in Alabama’s Macon County, two hours southeast of Birmingham. The majority had syphilis; all were promised they would be provided free healthcare by the federal government.
The men were told they were being treated for “bad blood.” They were given placebos, monitored, but never treated, despite the fact that by 1947 penicillin had become the standard treatment for syphilis. Those with the disease were never informed of their diagnosis. Some died; others went blind. Wives were infected; babies were born with congenital syphilis.
“It was an absolute disregard for the lives of those men, but also for the larger community that they were being sent back into,” said David Williams, PhD, MPH, of Harvard’s T.H. Chan School of Public Health.
What happened in Tuskegee wasn’t an isolated incident. Jay Pearson, PhD, MPH, an assistant professor at Duke University’s Sanford School of Public Policy, cites Henrietta Lacks “and other Black women whose bodies were literally used as living laboratories” in cancer research.
“One population disproportionately pays the cost for advances” in medicine, Pearson said, and is then “systematically discriminated against and denied access to those advances.”
“I submit to you humbly,” he said, “my people are aware of that friction.”
The scope and injustice of the study at Tuskegee was shocking. Out of it came the Belmont Report, establishing fundamental ethical guidelines for research involving humans.
But distrust endures. In that October survey of Black Americans, seven of 10 said the healthcare system often treats them unfairly because of their race. More than a third of Black women said they had been treated unfairly when seeking healthcare for themselves or a family member within the past year.
‘Got to Go to Church’
Another outcome of the investigation into the syphilis study was the founding of the National Center for Bioethics in Research and Health Care at Tuskegee University. Its mission is to explore moral issues in research and medical treatment involving Blacks and other underserved people.
Until 2018, Sodeke served as director of the center; he now works at the Center for Biomedical Research at Tuskegee and in the university’s College of Arts and Sciences. His work is focused on educating future researchers in ethical practices and advancing equity in medical research and treatment.
In order to gain trust for the COVID-19 vaccination in Black communities, Sodeke said, “We’ve got to go to church.”
Engaging pastors and other community leaders is critical, and doing so is at the core of the strategy now employed by David Hicks and his Jefferson County Department of Health colleagues.
“We’ve worked with our community partners to get the African-American clergy vaccinated,” Hicks said, to thereby allay fears. Pastors have also offered their churches as vaccination sites.
The health department has held information sessions with the presidents of community associations and reached out to sororities and fraternities. Hicks appears on hip hop, R&B, and gospel radio stations, taking questions from DJs and callers.
Across the country, Hicks said, Black physicians are stepping forward as advocates for vaccination, sharing their own experiences.
In sum, he said, “It’s an all-hands-on-deck approach to make sure that people get the information.”
At the University of Alabama at Birmingham, the Minority Health & Health Disparities Research Center is leveraging longstanding relationships that have been reinforced throughout the pandemic with its participation in the Alabama Community Engagement Alliance Against COVID-19 Disparities initiative. Focus groups have been convened in three Alabama counties, including Jefferson, six with primarily African-American participants and two primarily Latinx.
Lori Bateman, PhD, a medical sociologist at the UAB School of Medicine, said that in every focus group – African American as well as Latinx – when distrust was examined, participants brought up the syphilis study at Tuskegee, underscoring the pervasiveness of its legacy.
Be Informed
Sodeke sees vaccine hesitancy diminishing, both within his Tuskegee community and beyond. He said that if asked in November or December to estimate the percentage of Black people who would decline to be vaccinated, he would have suggested perhaps 70. He’s now more optimistic.
Concerns voiced about the vaccine have ranged from allegations that a microchip is planted to monitor movement to claims that Black people will be given an inferior dose. Hicks is now most commonly hearing questions about side effects and safety issues – concerning pregnancy, for example – and national surveys reflect that.
Selwyn Vickers, MD, FACS, dean of the UAB School of Medicine, joined Sodeke earlier this month for a virtual town hall titled “VACCs Facts.” Racial and ethnic health disparities have been “smoldering embers in our country,” he said. “This pandemic has turned those smoldering embers into massively burning flames, and we’ve seen the compound effect.”
Skepticism toward the vaccine is well founded, Vickers said. “The principle, though, is that we have to be informed by our past, not limited by it.”
