On July 16, 2020, ABIM President and CEO, Richard Baron, MD, MACP, along with colleagues Toyin Ayaji, MD and Adam Berinsky, PhD, sent a letter to Operation Warp Speed urging leaders to include Black and Brown communities in the development process of a COVID-19 vaccine. Below is the letter in full.
Dear Leaders of Operation Warp Speed,
As a primary care doctor focused on underserved populations across New York City, a physician leader of the largest certifying board in the country, and an expert on effective scientific communication, we write to offer guidance on the importance of building trust in the development process for the COVID-19 vaccine.
Though we come from very different backgrounds and have very different professional roles, we have collaborated to address the issue of deteriorating trust in health care, the implications of that decline with regards to adoption of the COVID-19 vaccine, and the development of strategies to address it.
While we understand you need to be focused on the essential operational details of research, manufacturing, and distribution, we believe that it is entirely predictable that many Americans— especially Black, Latinx, and Indigenous people—will not take a vaccine, however safe and scientifically proven it may be, if they do not have trust in the process and people that produced it.
Therefore, we urge that you immediately take proactive and intentional steps to build trust in the products you bring to market by bringing publicly recognizable, trusted, and accepted Black and Brown leaders into the process of designing and implementing vaccine trials and distribution strategies.
It is likely that many within these communities will have deep skepticism of any vaccine. It is skepticism informed by history and by the ongoing, irrefutable evidence of unequal treatment and disparities in care and outcomes. While 74% of whites say they would “probably or definitely” get a vaccine if one were available, only 54% of Blacks say they would.
This gap in vaccine intentions mirrors other studies of beliefs about vaccines. For instance, a 2017 study found that Blacks exhibit a higher degree of skepticism and concern about the flu vaccine than whites. This demonstrates that while Black Americans are aware of the dangers of the virus to themselves and others, because of current and historical evidence of negative intentions by the medical establishment, they would rather accept the risks presented by the virus than get the vaccine.
The reality is that there are well-documented racial inequities in our health care system—inequities that the epidemiology of the COVID epidemic has laid bare. We know the percentage of Black deaths attributed to COVID-19 is accounting for more than four times its share of the population in two states (Kansas and Wisconsin), and twice its proportion of the total population in eight states.
These disparities are driven not by the biology of race or uninformed choices by Black and Brown Americans. Rather, they are driven by inequities created by our society, and the increased likelihood
that members of these marginalized communities have jobs that can’t be done remotely or live in multigenerational homes, creating crowded conditions in which disease spread is inevitable.
Visible, tangible efforts to address structural racism resulting in disparities in housing, income, and employment opportunities must be part of any overall vaccine strategy. If people see their government directly taking on these issues as part of our overall response to COVID, trust in the process will increase.
Government officials and doctors may not have the credibility to effectively deliver a message about the importance of a vaccine to minority populations. A more effective strategy will ensure that messages come from trusted sources, be they individuals from within these communities or from trusted groups.
That must start with Black and Brown doctors, epidemiologists, and scientists. It should also include faith or community leaders, and be delivered in Black-owned businesses, like barbershops. One example of a successful program can be found in Hennepin County, Minnesota, where trained “lay health advisors” counseled minority women and actually achieved higher screening rates for breast and cervical cancer than traditional medical personnel. Trusted non-medical sources, such as leaders in local community organizations, are additional critical actors who need to be engaged early.
Any hope of successfully offering a novel treatment to Black and Brown Americans must begin with an understanding and take the trust gap seriously as a problem to be addressed, every bit as substantive as having enough syringes and needles with which to deliver a vaccine. And with a vaccine ready as early as this fall, the time to try and earn back the trust of Black and Brown communities is now.
We urge you to act. We stand ready to answer any questions or to help implement a strategy that builds trust with the Black community as the nation recovers from the pandemic.
Toyin Ajayi, MD
Chief Health Officer of Cityblock Health
Richard J. Baron, MD, MACP
President and CEO
American Board of Internal Medicine & ABIM Foundation
Adam Berinsky, PhD
Professor of Political Science
Massachusetts Institute of Technology