Beyond Tuskegee — Vaccine Distrust and Everyday Racism

J. Marion Sims. Henrietta Lacks. The Tuskegee Syphilis Study.

With two authorized SARS-CoV-2 vaccines now available, particular concerns have emerged regarding whether Black communities will choose to be vaccinated. In a pandemic that has disproportionately burdened Black Americans, experts have been scrambling to send targeted public health messages and reduce skepticism. But in late November, the National Association for the Advancement of Colored People (NAACP) and partners reported that only 14% of Black survey respondents trusted the vaccines’ safety and only 18% said they would definitely get vaccinated.¹ In describing the racial gap on this question, many commentators cite three historical atrocities — Sims, Lacks, Tuskegee — to explain Black communities’ distrust in health care systems.² If it were only that simple.

These historical traumas certainly provide critical context for interpreting present-day occurrences. But attributing distrust primarily to these instances ignores the everyday racism that Black communities face. Every day, Black Americans have their pain denied, their conditions misdiagnosed, and necessary treatment withheld by physicians. In these moments, those patients are probably not historicizing their frustration by recalling Tuskegee, but rather contemplating how an institution sworn to do no harm has failed them. As Harvard historian Evelynn Hammonds told the New York Times, “There has never been any period in American history where the health of Blacks was equal to that of whites. Disparity is built into the system,” so we must acknowledge how medical history has institutionalized racism. But fixation on specific historical abuses distracts from the larger narrative of everyday contributions to distrust.

Indeed, not every Black American is aware of these atrocities or would blame them for their distrust. Yet every Black person knows their personal challenges in navigating health care institutions, perhaps even more so during this pandemic. Daily subtle mental assaults are more salient in explaining a lack of trust in medical institutions and, by extension, in Covid vaccines.¹

And trust is critical to health. We know that Black patients prefer to be seen by Black physicians and will go well out of their way to do so. Despite genuinely wanting to address their obesity, for example, Black women will wait months for an appointment with one of us (F.C.S.) because they believe a physician who shares their background will care for them in a way that others cannot or will not. In light of the recent death of Dr. Susan Moore from Covid-19 after substandard care, this reality is all too clear.

Unfortunately, there is even further reason for this belief. Infant mortality is halved when Black newborns are cared for by Black rather than White physicians.³ Physician–patient racial concordance makes the difference between life and death for these infants even though they cannot contemplate historical traumas: they can still experience everyday racism and disrespect. Similarly, in 2018, Victor and colleagues showed that 64% of Black men brought their blood pressure to normal levels after a barbershop-based health intervention, as compared with only 12% of the control group.⁴ As safe, trusted fixtures within their communities, barbershops represent forums of culture and camaraderie for Black men, where they can be heard by someone who can relate to their experiences. These findings underscore the importance of establishing trust in medical enterprises and providing culturally concordant public health messaging.

In fact, concordant messaging has already proven valuable during the pandemic. Alsan and colleagues demonstrated that watching a video with a Covid-prevention message delivered by a Black physician increased information-seeking behavior among Black patients as compared with watching the same message delivered by a non–racially concordant physician.⁵ Even with no live interaction, the messenger’s racial identity affected recipients’ approach to Covid health literacy, which has important vaccine-related implications.

Framing the conversation about distrust in Covid vaccines in terms of everyday racism rather than historical atrocities may increase underserved communities’ willingness to be vaccinated. When we hyperfocus on Sims, Lacks, and Tuskegee, we ascribe the current Black health experience to past racism, rooting our present in immovable historical occurrences and undermining efforts to combat mistrust. Everyday racism, by contrast, can be tackled in the present.

To that end, we need Black physicians and investigators at the forefront of vaccine-rollout efforts. Recently, Anthony Fauci noted that the Moderna vaccine was “developed by an African American woman,” Kizzmekia Corbett. Though this recognition critically highlights the concordance between the Black population and the National Institutes of Health’s lead scientist for coronavirus vaccine research, we need more public health messaging coming directly from Black health leaders, a challenge given that only 5% of U.S. physicians are Black. Black scientists sharing their stories is paramount because they can more directly relate and speak to their communities’ needs. The NAACP study found that Black Americans were twice as likely to trust a messenger of their own racial/ethnic group than one from outside it.¹ When trust is in short supply everywhere, we need all hands on deck to begin rebuilding trust in health care. We believe the best way to learn from the atrocities of the past is to change our present.