Recently, I drove from my home at the northern tip of Manhattan to a school in the Bronx to get my first dose of the Moderna vaccine. The next day I stood in the kitchen, periodically rubbing my aching right shoulder—a minor side effect of the COVID shot—while watching a live, online memorial for my friend Keith, who’d passed away last month. Strains of gospel music emanated from an iPad. Testimonials honoring him steadily flowed in a chat stream on the screen. He was one of two friends who died in as many weeks.
Occasionally, I looked out a window, reflecting on the sudden departures of these dear friends, neither of whom died conclusively of COVID-19 but whose passing felt more acute, unfamiliar, disconnected, and somehow more painful amid the pandemic. This disease continues to alter and thwart how we mourn, celebrate, and coexist in proximity to one another. And a new lexicon, now commonplace, adds to the disconnect, as we confront terms such as “essential workers,” “herd immunity,” “vaccine hesitancy,” and “virus variants.”
We are in a phase of the pandemic that could not be more celebratory. By April 19, 90% of American adults will be eligible to receive a COVID shot. And yet people of color, like me, are facing the harshest realities of a health care system entrenched in bias, systemic inequity, and suspicion. As the vaccination effort continues to roll out with increased speed under President Biden, only 8% of those who have received at least one shot of the vaccine, according to the Centers for Disease Control and Prevention (CDC), are Black Americans (who make up 13.4% of the U.S. population). Some 9% of the doses have gone to Latino Americans.
According to a recent Kaiser Family Foundation analysis of 40 states that report racial and ethnic data on patients who have received at least one dose of the COVID-19 vaccine, white Americans have been vaccinated at nearly twice the rate of their Black and Hispanic counterparts. Vaccination, like so many other aspects of American life, has not only emerged as a racial-justice issue, but as a matter of life and death.
“It’s a debacle that we didn’t anticipate these challenges,” says Dr. Olajide Williams, chief of staff of the Department of Neurology at Columbia University. He is also the founder and president of Hip Hop Public Health, a nonprofit organization that fuses hip-hop music and culture with medical research in an effort to achieve health equity and encourage positive behavioral health among young people, including Black and Latinx youth. I reached out to Williams (whom I’ve known for nearly a year) after receiving my first vaccine shot—at a location in a largely Latino and Black neighborhood, where many of those getting vaccinated were, I observed, white patients.
“We should have anticipated that there were going to be COVID disparities,” he explained. “Every disease, every condition, every illness, every infectious epidemic affects the most vulnerable people the worst. We failed to anticipate disparities, and so again they took hold. You have to understand, [nonwhite] individuals are the most uninsured or underinsured, live in the most challenging housing conditions, where it’s going to be hard for them to socially distance if they get infected. They also are the most likely to be deemed ‘essential workers’”—sometimes in low-wage jobs and other positions that help to keep society functioning—“and they just don’t have the flexibility to take time off if they feel a little flu-like symptom. So they tend to work—and work sick—until they can’t work anymore. But in that time they’ve infected multiple people before staying at home. The rest of the social system creates this milieu that allows the virus to spread in these communities much more readily than other communities. We also have to understand that these communities generally have a higher burden of ‘comorbid illnesses.’”
So-called comorbidities are preexisting medical conditions that patients may have before contracting COVID-19. This is especially important among Black Americans—who have lower life expectancies than white Americans—and in some Black communities, which record a higher incidence of diabetes, asthma, hypertension, HIV infection, and other long-term conditions. According to a study published last fall, Black, Hispanic, and white COVID-19 patients treated at the same medical center in New York had similar recovery outcomes when controlling for age, sex, and comorbidities. But such a controlled environment does not mirror the real world. Given the emerging research and acknowledgment of discriminatory medical bias toward minorities as well as inequitable health care delivery and access, Black and Hispanic patients with comorbidities—especially in the midst of a pandemic—are less likely to receive the medical care they need to treat infection. The structural inequities that put poor people and, often, people of color at risk for comorbidities are the same ones that have resulted in them having the lowest rates of vaccination, highest rates of infection, and highest rates of hospitalization.
I am not poor, but I am a middle-aged Black man, and I do have comorbidities. Ten years ago I suffered the second of two heart attacks and ended up with kidney failure, which sentenced me to four years of dialysis. Then a best friend—who’s more like a brother—donated a kidney to me. Every day I take half a dozen pills, three times a day. As a result, “vaccine hesitancy” wasn’t an issue for me—as a partner, a son, and a father of two daughters. Being the beneficiary of medical science myself, I went on faith, trusting that the new COVID-19 vaccines were effective—and safe. That said, the phenomenon of vaccine hesitancy has been a red herring for the undervaccinated, especially those who are Black. Past instances of notorious medical experimentation on people of color—most notably the 40-year “Tuskegee experiment,” in which the U.S. government tracked the impact of untreated syphilis on Black men—are often touted as one reason why folks aren’t eager to get a rapidly mass-produced vaccine. But other complicating factors may play more of a role, including health literacy, unequal treatment compared to that received by white patients, distrust of large institutions, access to vaccination sites, and fear of (or unfamiliarity with) injections.
In fact, it’s not so much hesitancy as it is mistrust—based on both historical and ongoing racism and disenfranchisement—that contributes to reluctance, compounded by evidence-based disparities based on race. According to a survey published by The Undefeated and the Kaiser Family Foundation last October, 70% of Black American adults believe that medical patients receive unfair and biased treatment “very often” or “somewhat often” because of their race or ethnicity. That same survey noted that only half of Black American adults were interested in receiving a COVID-19 vaccine, even if it were free and determined to be safe by scientists, versus 61% of Hispanic adults and 65% of white adults.
Then there are the systemic issues affecting impoverished rural communities. In some remote areas of the South, for example, people of color disproportionately lack access to local health care, the web or smartphones (for scheduling visits), and transportation options (for getting to clinics). Large numbers are out of the loop when it comes to having sustained contact with qualified health professionals, which contributes to their reluctance. And many, as in urban regions, have a rough go simply scheduling time off from work to get shots.
Dr. Williams recognizes a particular urgency in ensuring that trust is strategically built and that community-grounded, culturally specific messaging reaches the most vulnerable populations about an important, overarching topic: “herd immunity.” Herd immunity occurs when enough people in a population have become immune to a disease so that it can’t be easily or broadly transmitted. When individuals in sufficient proportion become immune, COVID-19, for example, can no longer be transmitted widely from person to person because the virus encounters immune individuals. The percentage of the population that needs to be immunized to achieve herd immunity changes with each disease, based on its contagiousness. (The figure can be as high as 95% for some diseases, such as measles.) The proportion of the population that would need to be immunized to achieve herd immunity against COVID-19 is still unknown. Certain health professionals, including Williams, believe 70 to 90% is where this country needs to aim, given the high transmissibility of COVID-19, as well as the emergence of virus variants, which are mutations of it. The longer the virus is in an individual’s system, says Williams—and therefore in a neighborhood or larger community—there develops a greater chance for virus mutations, leading to more transmissible variants, which increases the percentage of the population that needs to be vaccinated to achieve herd immunity. If not, COVID-19 will continue to linger longer and longer.
“The dangers of these new variants that get produced through this variation-copying process,” Williams says, “is that once in a while you come across a variant that evades vaccinations, or even evades our immune system defenses. And that’s the nightmare scenario, the doomsday scenario in the minds of us physicians and scientists. What happens when a COVID-19 mutation, a variant, crops up in unvaccinated clusters”—say, in a historically disenfranchised community—“our fear with these clusters is that you can have within them what we call ‘super-mutators,’ where individuals with prolonged exposure to COVID-19, or infection, create variants that are resistant to vaccines. Then we’re back to square one. Getting to herd immunity is a race against time. So we have to have vaccine equity and accessibility in these underserved communities.”
While the federal government and states are searching to find the right messaging to educate and allay vaccination mistrust within the Latinx and Black communities, public personalities and activists have stepped up to draw their attention. Last month the Kaiser Family Foundation and the Black Coalition Against COVID launched an outreach campaign, The Conversation: Between Us, About Us, that enlists frontline health care professionals and celebrities, such as comedian W. Kamau Bell, to address qualms and questions about the vaccine choices available to the general public, tailored to various demographic groups. The leaders of the federal COVID-19 response, including National Institute of Allergy and Infectious Diseases director Anthony Fauci, have repeatedly highlighted the transformative contributions of Kizzmekia Corbett—the Black lead scientist in the National Institutes of Health’s efforts to help develop a COVID-19 vaccine—as a way to credibly convey the vaccine’s safety. Also in February, Hip Hop Public Health put out a new rap anthology titled Community Immunity, featuring Darryl “DMC” McDaniels of Run-DMC fame, in an attempt to capture the imaginations of adults and youth of color alike. As part of a new documentary project, Oscar-winning filmmaker Spike Lee had himself filmed while getting vaccinated. And during a virtual summit last month, “Hispanicize #DeTiDepende” enlisted an array of Latinx celebrities, health professionals, and activists, including actors Luis Guzmán and John Leguizamo, as well as journalists Lindsay Casinelli and Paola Ramos, to help create COVID-19 messaging and vaccination outreach for successfully engaging the Latinx community. Endeavors like these will hopefully have a significant impact.
In a few days I’ll be going back to get my second dose. More than a few friends, colleagues, and family members have warned that the side effects are rough, but they’re a small price to pay compared with the benefits—to me, my family, my community, and, yes, even the wider “herd.” I wonder if this country recognizes that ending the pandemic rests in large part on reaching herd immunity, which means prioritizing vaccination of nonwhite Americans and the poor. More to the point, will America be able to save people of color in order to save itself?
The success of the vaccination effort will succeed or fail on our ability to reach the least visible, the least served, the most historically marginalized.
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