Building Vaccine Trust Across Racial Divides

Trusting relationships between physicians and patients will be crucial for easing COVID-19 vaccine hesitance among groups that are hit disproportionately hard by the virus: minorities and low-income populations.

Cleveland Clinic vascular surgeon Lee Kirksey, MD, believes individual physicians and healthcare organizations must play an active role in vaccine communications – not simply to allay doubts about the vaccine itself, but also to inject greater equity in the delivery of care during the pandemic. “This is a time to reach out to patient populations and to assume the role as a trusted provider of healthcare, because we know that for one hospital, for one healthcare system or for one state to do better than another leaves us all vulnerable,” Dr. Kirksey says. “Until we are able to address this successfully across the board, in all geographies and all communities across age, race and in economic issues, herd immunity won’t take place.”

Dr. Kirksey draws on his experiences as a physician invested in long-term patient relationships and as an African American who understands the historical and cultural factors contributing to distrust of institutions. The “deadly irony” of the pandemic, Dr. Kirksey says, is that low-income people of color are the least likely to get the vaccine and the most likely to be hard hit by the virus.

Black and Hispanic people are four times as likely as Whites to get COVID-19 and three times more likely to die from it, Dr. Kirksey says. Polls indicate that about half of African Americans say they likely will not get the vaccine when they are able to.

Skepticism and resistance occur across demographic sectors and affect even well-established vaccination programs, he says. “Uptake of the flu vaccine is about 50% nationally, so it’s not like we’re doing a gangbuster job with other population health initiatives,” Dr. Kirksey notes. Quick development of mRNA vaccines by Pfizer and Moderna has fueled unsubstantiated concerns that safety corners were cut to fast-track FDA Emergency Use Authorization. “The fact is that this technology has been used for more than a decade for other conditions,” Dr. Kirksey says.

African Americans may carry around all those concerns as well as others created by 400 years of systemic disparities, Dr. Kirksey says. The notorious Tuskegee Syphilis Experiment, in which the U.S. Public Health Service spent 40 years studying syphilis in Black men without informing them of their illness or offering treatment, created wariness that endures across generations. More recently, lead-tainted water in Flint, Michigan, home to a large Black and low-income population, confirmed for many that institutions cannot be trusted with the health of poor Whites and people of color.

“The issue of distrust based upon historic events resonates in people’s minds,” Dr. Kirksey says.

Daily living can compound that perspective, he adds. “You don’t have to look very far outside of health care to see examples of how a Black person may believe that the playing field is not even. Those micro aggressions and larger issues are visible on a day-to-day basis.”

Confidence cannot be built overnight, Dr. Kirksey says, but he believes institutions and individual physicians can make a difference. A silver lining of COVID-19, he adds, is the opportunity for healthcare to lead the way on an important social equity issue.

What the government can do

Dr. Kirksey advocates for an aggressive public health strategy that:

• explains the role of data-driven research in the development of the vaccine
• funds information campaigns so community-based organizations can share vaccination facts and messaging
• brings transparency around vaccine-related facts, including side effects and safety issues

What doctors can do

Dr. Kirksey believes that physicians who bring a spirit of collaboration to patient interaction can help build trust. “When someone with experience — or when an institution with experience – offers information and options with clarity, and with some degree of certainty, that provides a great deal of comfort. That’s what Cleveland Clinic offers,” he says.

Patient trust may be more easily built when caregivers share their racial or cultural backgrounds, Dr. Kirksey acknowledges.

“There’s very good medical evidence that physician-to-patient racial and cultural similarities allow for more productive relationships, interactions and shared decision making,” he says. “Patients are more likely to be compliant with their medications and more likely to follow healthcare advice. But right now, about 5% of practicing physicians in the U.S. are Black Americans. And about 13% of Americans are Black. So the numbers just don’t work out that everyone who wants a Black physician will have one.”

Cultural competency is vital to bridging that gap. Physicians treating patients of different races or backgrounds should be considering the implication of those differences.

“I might see that a patient needs increased physical activity because they’re overweight and their diabetes is poorly controlled,” Dr. Kirksey says. “I have to recognize that maybe that patient lives in an overcrowded metropolitan community and they don’t have access to state parks. Recognizing that, maybe I could tell them about a program for Medicare patients that allows them to go to a local gym free of charge. That’s a culturally competent recommendation based upon understanding of that patient’s circumstances.”

Cultural competency benefits any practice, he adds.

“As a Black physician, I should focus on that when I’m speaking to a White patient, and the same goes for White physicians and patients who are Asian, Hispanic, Black, American Indian, or Alaskan native. There’s a lot of discordance in patient-to-physician interaction.”

Shaping the vaccine conversation

Dr. Kirksey recommends that physicians in any setting ask patients about their willingness to be vaccinated, and to approach the conversation with information rather than the intent to talk them into the vaccine. “I try to meet patients where they are and refrain from judgmental, medical paternalism,” he says. Patients might not instantly change their minds, he adds, but that conversation can lay the foundation for rethinking vaccination in the future.

In his practice, Dr. Kirksey has seen plenty of patients move away from reluctance, whether it’s about having surgery or adopting habits that support better health.

“It’s an underappreciated skill to be able to explain to a patient the gravity of their condition while not scaring them out of a potential treatment,” he says. “Frankly, I think it’s a skill that one becomes much better at over the course of their career in practice.”

The importance of achieving COVID-19 vaccination rates high enough to establish herd immunity – at least 70%, he says – call for more of that now. Dr. Kirksey is heartened by the science and focus that have enabled vaccines to be brought to market in less than a year, but knows that widespread vaccine compliance will be necessary to return to a world not run by COVID-19.

“This is the final hurdle that we must overcome and compliment the common practices of face coverings and hand washing,” he says, “making sure that people understand that this is the light at the end of the tunnel.”