Ed. Note: In this second part article on COVID-19 vaccines, physicians discuss which groups of patients are more likely to be hesitant about vaccination, how you can reach them, and the likelihood of a national vaccine mandate.
As Rodney J. Taylor, MD, MPH, logged on to speak at the virtual COVID-19 vaccine listening session held in Baltimore, he realized the stakes were high. Organized by a city councilwoman and designed to provide information and motivate African American city residents to get vaccinated, the event could help persuade a population that’s particularly vulnerable to more severe disease. His words could help prevent potentially fatal illness and protect their loved ones and others.
When it came time for him to speak, Dr. Taylor, chair of otorhinolaryngology–head and neck surgery at the University of Maryland School of Medicine in Baltimore, didn’t beat around the bush. He immediately acknowledged that the African American community—due to appalling events rooted in history and health disparities still plaguing the medical field today—is more likely to be skeptical of science and medicine and more likely to say that they’re less likely to get the vaccine than the average U.S. citizen is.
“I’m in Baltimore—we are the home of Henrietta Lacks,” Dr. Taylor said, referring to a Black woman who had cells collected for research without her consent; those cells began the HeLa cell line that became a workhorse of biological research. “People know that in the community. She lives on.”
Acknowledging the hesitation, and the reasons behind it, was essential to connecting with the audience, he said.
“It’s, ‘Hey, let me tell you first and foremost, I’m aware, and healthcare disparities are important to me.’ And as a cancer-treatment physician it’s something that I’ve not only studied and researched but tried to ameliorate in my work,” Dr. Taylor said, adding that he sensed that his comments were received favorably. “And so, I told them, I understand; I’m sensitive and connected to it. But now let me tell you about this vaccine, how this disease impacts our community disproportionately, and why I believe this vaccine is important for us—so much so that I’ve moved forward and was eager and excited to get it to protect my family.”
Factors in Vaccine Acceptance
As vaccines continue to be approved, distributed, and administered, certain groups are more likely than others to harbor reservations about getting their shots in the arm despite a health issue that has a higher profile than any health problem ever seen in their lifetimes, other than those who were alive during the 1918 flu pandemic. In addition to explaining the science and process behind the vaccines—a challenge in its own right as physicians try to encourage patients to get the protection they need—clinicians face these extra layers of hesitation that differ by demographics and are rooted in culture.
Age. According to the latest Pew Research Center poll, released in December 2020, age is a big determinant in the willingness to get the vaccine, with 55% of those aged 18 to 29 saying they’ll definitely or probably get the vaccine, and 53% of those aged 30 to 49 saying they would, compared to 60% of those aged 50 to 64 and 75% of those 65 and older.
I think over time, more [younger adults] will get the COVID-19 vaccine, but messaging needs to remind them of the need to protect older relatives. —Dorit Reiss, LLB, PhD
Younger adults are less welcoming of vaccines because they feel less vulnerable than others, said Dorit Reiss, LLB, PhD, a professor at the University of California Hastings College of the Law in San Francisco who has studied the law and vaccinations. “They think the risk for them is lower, and we’re also told that we are at a lower priority than older people,” she said. “I think over time, more will get the COVID-19 vaccine, but messaging needs to remind them of the need to protect older relatives.”
Politics. Attitudes toward the vaccine also differ starkly by political party, with 69% of those with the Democratic party or who lean Democratic saying they would definitely or probably get the vaccine, compared to 50% of those who are Republican or who lean Republican.
Dr. Reiss said the Democratic-Republican difference is a product of the nature of politics in the U.S., but she believes it can be improved. “I think the vaccine issue is suffering from the unfortunate politicization of our public health response,” she said. “It’s important for leaders on both sides of the political spectrum to give a personal example by getting vaccinated in public and calling for vaccinating.”
Anti-vaccination groups. Other groups that have been found to be hesitant about vaccinations as well. Although those in higher income levels say they’re more likely to get COVID vaccines, very affluent segments of the population, including enclaves in California, helped give rise to the anti-vaccine movement.
The highly affluent, Dr. Reiss said, “have more time to put into that. If you’re working three jobs just to make ends meet and need to run from place to place to take care of everything, you don’t have time to read conspiracy theories on the internet,” she said. “Privilege allows you to worry about things you normally wouldn’t have given a second thought to.”
Those who hold extreme political views, whether on the left or the right of the ideological spectrum, are also more likely to be anti-vaccination, Dr. Reiss said, thanks to a tendency toward a kind of chain reaction when it comes to conspiracy theories among these groups.
“People who believe one conspiracy theory can then believe in another, so people at the extremes of the political spectrum can be brought into a different conspiracy theory,” she said. “For example, someone may be brought in with ‘9/11 was an inside job’ and the anti-vaccine stuff will come within the groups later.”
Race. According to the Pew Research poll, only 42% of Black respondents said they would definitely or probably get a COVID-19 vaccine, compared to 83% of Asian respondents, 63% of Hispanics, and 61% of whites.
Dr. Reiss said that the Black community is not anti-vaccine in the way we often think of the anti-vaccine movement. “They’re mistrustful of medicine and they have reason to be,” she said. This goes beyond the well-known Tuskegee Syphilis Study in which African American participants thought they were receiving treatment for syphilis but were actually in a study observing the natural history of their disease. The book Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present by Harriet A. Washington, for instance, describes poor Black women unwittingly being enrolled in research experiments and boys, many of whom were Black, being given the now-banned diet drug fenfluramine for an experiment on the relation between criminal behavior and chemical levels in the brain.
“They have a history of being mistreated by the medical establishment, to be very blunt,” Dr. Reiss said. “And we have a history of discriminatory practices—basically, this is an earned mistrust.”
Targeted Talking Points
Paul Offit, MD, director of the Vaccine Education Center at the Children’s Hospital of Philadelphia and a member of the FDA advisory panel on COVID-19 vaccines, said that it’s important to distinguish between those who are staunchly anti-vaccine who will never be swayed, and those who have real reservations that a physician or a trusted community leader might be able to persuade.
“In terms of people who say, ‘I’m not going to give my child any vaccines,’ I still think it’s less than 2% of this country,” he said. “I think very quickly you can determine whether or not someone is really interested in hearing what you have to say—in other words, if they’re persuadable. I often ask, ‘Is there anything I can say that will change your mind? If the answer’s no, then why are we having this discussion?’ But I think most people do trust their doctor. When you choose to not listen to your doctor, you alienate him or her to some extent. You want your doctor to like you—you want him or her to care about you and your illness.”
Another concern is long-term side effects, said Dr. Alexander. “In fairness, people are right: I don’t know what effect these vaccines might have on somebody a year from now. But is there any precedent for a vaccine having a long-term effect like that? The only one I can think of offhand is an extremely rare side effect (subacute sclerosing panencephalitis) from the measles vaccine that can happen years down the road from the time of vaccination. But it’s so rare that people don’t even think to talk about it.”
I think you need to find who the influencers are and then work that way, because it isn’t just a matter of me saying, ‘Look, the vaccine is safe and effective.’ That isn’t going to do it. —Paul Offit, MD
Groups that harbor reservations are most likely to be persuaded by physicians with whom they can identify, Dr. Offit said. “I think you need to find who the influencers are and then work that way, because it isn’t just a matter of me saying, ‘Look, the vaccine is safe and effective.’ That isn’t going to do it.”
In a video posted online, James Hildreth, MD, PhD, an immunology expert, president of Meharry Medical College in Nashville and a member of the FDA advisory panel on COVID-19 vaccines, participated in an event that took this approach. Held at a community center, it was moderated by a director of racial justice ministries in Nashville.
“I know that the trauma, the reaction, to all those things that we’ve been through is deep-seated and real,” he told the mostly African American audience. “We have to acknowledge that up front if we’re going to deal with it. And I’ve tried my best to make sure that I, being in the medical profession and a medical scientist, deeply appreciate the fact that so many people who look like me have that hesitation.
“But,” he added, “they really need to understand that things could not be more different now. The fact that we have so many people of color, not just on the scientific side, but also on the policy-making side, the review side.”
Dr. Taylor emphasized that it’s modern-day health disparities, not just ethically bereft experiments of yesterday, that contribute to the hesitation among African Americans.
“For example, in one neighborhood you might see a police officer or a fireman getting a cat down out of a tree. There are these warm and fuzzy feelings of safety, that someone is looking out for you,” he said. “But go to another community, separated by not a lot of physical distance—only by the demographics—and the sight of police can cause chills up your spine and make you feel uncomfortable.”
In this way, he said, health disparities—not being as likely to get a catheterization as someone else in the same situation, say, or not getting a proper medical referral—create suspicion of the medical community. “We’re not talking about decades ago,” said Dr. Taylor. “People are aware of some of the disparities of either access or outcomes … those smaller, non-public things people have a sense of. When they see the COVID-19 vaccines coming out with rapid speed, there’s just a hesitation.”
Dr. Taylor said he doesn’t discuss vaccines with all his patients—some, after all, are cases of newly diagnosed head and neck cancer and other priorities have to be addressed. But, with many patients in follow-up visits, he does discuss the vaccinations. Clinicians talking to African American patients about the vaccines need to address the standard questions of safety and efficacy, but it’s also worth acknowledging that deep-rooted hesitation.
“I approach them like I would my neighbor,” he said. “And I think that tone sets you up for a positive experience. And I still think, no matter what your background is, to acknowledge that there is skepticism out there. I think you get buy-in and credibility.”
Thomas R. Collins is a freelance medical writer based in Florida.