The Time is Now

By: Kelsey Murry & John Purakal, MD

Editors: Cathleen Bury, MD & Emily Cleveland Manchada, MD, MPH

COVID-19 has exposed what many minority populations have long known to be true about America. The pandemic has laid bare the inequalities that pervade healthcare in our country.

Over the first few months of the US pandemic, the age-adjusted mortality rate was 2.7 times higher for Black and Latinx individuals and 3.3 times higher among Indigenous communities than for non-Hispanic whites.(1) These considerations frame many of the sentiments regarding the trustworthiness of the recently developed COVID-19 vaccine. Some say that they don’t want to deal with adverse effects, while many others are concerned about the time frame in which the vaccine was developed. With the Pfizer/BioNTech and Moderna vaccines’ emergency authorization, the monumental task of distribution of the vaccine is underway. Despite mounting evidence of the safety and efficacy of these vaccines, one daunting question facing providers regarding their minority patients remains - Will they take the vaccine if offered?

Previous negative experiences in healthcare may serve as a deterrent to vaccine acceptance among Black, Indigenous, and People of Color (BIPOC) communities. In a poll conducted by the Kaiser Family Foundation and The Undefeated, 1,769 adults were asked questions that shed light on perceptions of healthcare experiences and explored these responses by race. The results showed that Black people are more likely than white people to report that they were refused a test or treatment that they thought they needed, or that their healthcare provider did not believe that they were telling the truth.

Among those surveyed, 70% of 777 Black responders believe that our healthcare system treats people unfairly based on their race or ethnic background, while 43% of Hispanic and 41% of white people surveyed share the same sentiments.(2)

Although there is much more research to be done, one thing has become apparent—BIPOC communities do not trust the healthcare community. We owe these populations every ounce of our attention and effort to earn the trust that science and medicine have lost. Where do we begin?

First, we must reframe how we view mistrust and vaccine hesitancy within BIPOC communities. The ways that we currently discuss mistrust puts the onus of vaccine hesitancy solely on the minoritized. We need to get to the root of the problem. Medicine has historically violated and taken advantage of BIPOC communities. By acknowledging this first and foremost, we instead place the task of earning trust on the medical community. Our medical education taught the valuable information that came as a result of unethical trials but glossed over the fact that much of it was gathered at the expense of marginalized individuals. Most of us by now are familiar with the Tuskegee experiment, but the abusive practices bestowed upon BIPOC individuals by the medical community extends far and wide. Historically, we recognize notable figures such as James Marion Sims, “the father of gynecology,” who forced enslaved Black women to undergo surgeries without anesthesia because he believed that Black people did not experience pain.3 These practices went to the state level, proven by the Eugenics Project in North Carolina from 1933-1973 involved state-led action resulting in sterilization by choice or coercion of over 7,600 people, disproportionately targeting minorities.(4) Dr. Eugene L. Saenger of the University of Cincinnati conducted a radiation study from 1960-1971, in which experiments led to irradiation of 88 men, women and children, most of them poor, uneducated Black people. It was reported that large amounts of radiation exposure caused some to die in just a few hours.(5) Though the medical community continues to strive towards equity and ethical practice, modern-day events such as the reports of forced gynecological procedures on immigrants held in ICE detention centers continue to erode trust between the medical community and BIPOC communities.(6)

Emergency Medicine is not absolved of culpability. In 2003, the Polyheme trials, conducted purportedly with “community consent,” consisted of giving incapacitated trauma patients a temporary oxygen substitute consisting of treated human hemoglobin as a pre-hospital treatment in place of normal saline. This study qualified for the Exception From Informed Consent (EFIC) guidelines, also known as Final Rule, issued by FDA & HHS in 1996, which allowed for the study under the several criteria. Most notably, a life-threatening situation where available treatments were “unproven” or “unsatisfactory”, and community consultation with public disclosure were required. In trauma populations with disproportionate rates of BIPOC patients, ethicists even expressed concern about gold-standard treatments (in-hospital blood transfusion) being withheld when these treatments are neither unproven nor unsatisfactory. Further, communities were not made known of prior studies showing increased cardiac events using Polyheme, and the only way to opt-out of the study was by calling a number to receive a blue wristband. Education and awareness of the trials were not widespread, and ethicists found the consent process was questionable, at best. The trial eventually drew criticism from the medical community and national media, further deepening mistrust in communities of color. (7-9)

By familiarizing ourselves with the historical and sociological context in which conversations about vaccination occur, we can begin to acknowledge the fear that many BIPOC individuals have about the COVID vaccine. It is critical that we recognize the marked difference between mistrust of the medical community among BIPOC American and the baseless fears created and perpetuated by so-called “anti-vaxxer” groups. We do a disservice to members of marginalized communities by conglomerating them with anti-vaxxers and conspiracy theorists. Ostracism serves no purpose other than to alienate BIPOC communities further. We must acknowledge the elephant in the room, and recognize the historic and modern realities that have formed this mistrust

In addition to hesitancy formed from prior experiences with the medical community, the dynamic and rapidly changing messaging and guidelines regarding the COVID vaccine give further reasons for pause. No community wants to feel like the guinea pig for new therapies. Recently gathered data reveals this hesitancy acutely amongst the BIPOC community. BIPOC communities are frustrated with the constant change in messages and guidelines regarding COVID. A recent survey published by the AP-NORC based on interviews with 1,117 US adults showed that only about 24% of Black respondents and 34% of Hispanic respondents plan to take the vaccine, with most citing a concern for vaccine side effects.(10) A similar poll published by The COVID Collaborative showed that only 14% of Black and 34% Latinx individuals believe in the safety of the vaccine.(11)

The concerns highlighted by these and other surveys are valid; many therapies including the approved COVID vaccines do have side effects. Suggesting otherwise, particularly to communities that have been taken advantage of by medical professionals in the past, is akin to gaslighting. Instead, we should employ trauma-informed care principles to acknowledge certain side-effects and explain why some people have them the best way possible. A trauma-informed approach takes into consideration the whole person, their past, and the effects that the two have on treatment, trust, and recovery. It openly acknowledges history including previous traumatic medical and non-medical experiences, and actively seeks to avoid re-traumatization. In conversations with our patients, we must discuss the harms of vaccine-related side effects alongside the dangers of not receiving the vaccine, and allow our patients to make informed decisions on their own behalf. Presenting the facts in a digestible manner, and demystifying the process from creation to vaccination can help alleviate the fears held by patients

As Emergency Medicine physicians, we have a unique opportunity to reach the most underserved and at-risk populations. We are plugged into what our communities need and want. Some of our patients see us once, and some see us often. Our influence reaches far and wide. It would be a missed opportunity to not advocate on behalf of our communities and our nation regarding the COVID vaccine.

We can begin this advocacy on a local level. Ideally, we must disseminate resources such as patient education flyers, posters, commercials, and documents that thoroughly explain mRNA vaccine technology without jargon. We can ensure comprehension by ensuring these resources are easy to understand for all levels of health literacy, and provided in multiple languages depending on the area we serve. One of the biggest concerns that people have is how quickly the vaccine has been made and approved. We can take the time to listen to those fears and discuss them. This may be difficult in an emergency department (ED) setting, but with the help of all ED staff including nurses, transport personnel, techs, and others who interact with our patients, those fears can be addressed and allotted the time required to make an impact. Amplify the voices of physicians, nurses, and other clinical staff of color who are willing to lend their assistance and use the connection that they have with their communities to expand progress with hesitant patients.

In addition to enlisting clinical staff, we must focus on educating trusted community leaders. The impact of incorporating people who are already boots on the ground in the community is invaluable. Community outreach projects are an important link between the ED and society. In a similar way that we advocate for voter registration in the ED, educating people in the community about the vaccine needs to happen. Earning trust is difficult, but necessary to change the trajectory of this pandemic. We cannot do it alone.

Combatting misinformation is a team effort. As advocates for one of the largest, most uninsured, and vulnerable patient populations, it is our job to be their encourage behavior geared towards positive change, at every level. In our personal practice, we must lead by example by receiving the vaccine and discussing openly with our patients the processes’ strides and setbacks. In our own cities we must amplify the voices of trusted leaders within the communities we hope to reach. At a national level we must advocate for full transparency and unified, bipartisan leadership to address vaccine hesitancy.

Now is the time for Emergency Medicine physicians to band together and advocate for a consistent, transparent, and unified message, acknowledging the past traumas born by the patients we serve, and striving for a more equitable future, together.

References

1. Staff, A. R. (2020, September 16). The Color of Coronavirus: COVID-19 Deaths by Race and Ethnicity in the US. Retrieved December 2020, from APM Research Lab: https://www.apmresearchlab.org/covid/deaths-by-race#age

2. Washington, J. (2020, October 14). New poll shows Black Americans put far less trust in doctors and hospitals than white people. The Undefeated. https://theundefeated.com/features/new-poll-shows-black-americans-put-far-less-trust-in-doctors-and-hospitals-than-white-people

3. Holland, B. (2018, December 4). The 'Father of Modern Gynecology' Performed Shocking Experiments on Slaves. Retrieved December 2020, from History: https://www.history.com/news/the-father-of-modern-gynecology-performed-shocking-experiments-on-slaves

4. Price, Gregory & Darity, William & Sharpe, Rhonda. (2020). Did North Carolina Economically Breed-Out Blacks During its Historical Eugenic Sterilization Campaign?. 10.38024/arpe.pds.6.28.20.

5. U.S. District Court, Southern District of Ohio, Western Division. In re Cincinnati Radiation Litigation. Fed Suppl. 1995;874:796-833. PMID: 15751169.

6. Dickerson, C., Wessler, S., & Jordan, M. (2020, September 2020). Immigrants Say They Were Pressured Into Unneeded Surgeries. Retrieved December 2020, from New York Times: https://www.nytimes.com/2020/09/29/us/ice-hysterectomies-surgeries-georgia.html

7. Apte, S. (2008). Blood Substitutes--the Polyheme Trials. McGill Journal of Medicine: An International Forum for the Advancement of Medical Sciences Byt Students, 11(1), 59-65.

8. Holloway KF. Accidental communities: race, emergency medicine, and the problem of polyheme. Am J Bioeth. 2006 May-Jun;6(3):7-17. doi: 10.1080/15265160600685556. PMID: 16754440.

9. Dickert NW, Sugarman J. Getting the ethics right regarding research in the emergency setting: lessons from the PolyHeme study. Kennedy Inst Ethics J. 2007 Jun;17(2):153-69. doi: 10.1353/ken.2007.0010. PMID: 18018997.

10. Neergaard, L., & Fingerhut, H. (2020, 9 December). AP-NORC poll: Only half in US want shots as vaccine nears. Retrieved December 12, from AP News: https://apnews.com/article/ap-norc-poll-us-half-want-vaccine-shots-4d98dbfc0a64d60d52ac84c3065dac55

11. Ogden, A. (2020, November 18). Coronavirus Vaccine Hesitancy in Black and Latinx Communities — Covid Collaborative. Covid Collaborative. https://www.covidcollaborative.us/content/vaccine-treatments/coronavirus-vaccine-hesitancy-in-black-and-latinx-communities

John PurakalFebruary 3, 2021