Capstone Project Topic Selection and Approval

Overcoming Barriers to COVID-19 Vaccination in African Americans: The Need for Cultural Humility Keith C. Ferdinand, MD, FACC, FAHA, FNLA, FASPC

ABOUT THE AUTHOR

Keith C. Ferdinand is with the Department of Medicine, Tulane University School of Medicine, New Orleans, LA.

See also Benjamin, p. 542, and Rodenberg, p. 588.

“Rescue work by helicopter was slow.

That stopped at dark about 7 o’clock

. . . people began to panic. I told

Kenneth and Keith and those around

me that we may as well make the

best of it, for no one knows we are

here . . . help won’t come until

morning. The rain fell so hard that I

had to take off my glasses & hide my

head. . . . The water, still slowly rising,

had two more inches to go before it

reached the rooftop. We learned:

that communication [and] coopera-

tion are necessary factors for survival

in a disaster.”

—Letter from Inola Copelin Ferdinand

to her sister, Narvalee, after our family

and others spent days amid the

drowning death of my paternal grand-

father and many of her neighbors,

abandoned on rooftops in the Lower

Ninth Ward, New Orleans, LA, during

Hurricane Betsy, September 9, 1965

Racial/ethnic minorities suffer dis-

proportionately from US COVID-19–as-

sociated deaths.1 The tragically higher

COVID-19 mortality among African

Americans from multiple conditions, in-

cluding cardiovascular diseases (CVD)

and certain cancers, highlights deep-

rooted, unacceptable failures in US

health care. The social determinants of

health (limited finances, healthy food,

education, health care coverage, job

flexibility) make disadvantaged commu-

nities more vulnerable to COVID-19 in-

fectivity and mortality and amplify higher

comorbid conditions.2 The Healthy

People 2020 Social Determinants of

Health include the Economic Stability

domain, with employment as a key issue.

Suboptimal job benefits such as health

insurance, paid sick leave, and parental

leave can affect the health of employed

individuals, and African Americans are

more likely to work in blue-collar service

jobs.3 This toxic gumbo of suboptimal

health and adverse environments pro-

foundly diminishes overall African

American longevity, fueling a decades-

long White–Black death gap, with African

American men having the shortest life

expectancy.2 Although December 2020

Pew Research data note that a growing

share of Americans report they probably

or definitely will accept COVID-19 vac-

cination, African Americans continue to

stand out as less inclined to get vacci-

nated: 42% would do so, compared with

63% of Hispanic and 61% of White adults.4

MISTRUST: A CRITICAL BARRIER TO OVERCOME

Effective public health messaging and

mitigation efforts are required to opti-

mize acceptance of COVID-19 vaccina-

tion and minimize subsequent mortality.

Unfortunately, mistrust in orthodox

health care is a substantial barrier to

COVID-19 vaccine acceptance, and with-

out widespread uptake, the societal ben-

efits of immunization, even with very

effective, safe vaccines, will not be realized.

Despite recent attention to the impact of

structural racism across a wide range of

health conditions in the United States, the

COVID-19 pandemic further unmasks

these inequities. The scandalous history of

orthodox medicine and public health to-

ward African Americans demands recog-

nition or will remain a formidable obstacle

to acceptance of vaccination.

HISTORICAL RACISM IN US HEALTH CARE AND PUBLIC HEALTH

The multigenerational African American

mistrust reflects a legacy of real-life ex-

periences and the shameful historical

racism in medicine and public health.

Since the mid-19th century, and well into

the 20th century, physicians and public

health officials were apologists, and

even advocates, for the less-than-

humanistic care and racist theories

that supported the subjugation and

586 Editorial Ferdinand

A JP H

A p ri l 2 0 2 1 , V o l 1 1 1 , N o . 4

OPINIONS, IDEAS, & PRACTICE

dehumanization of African slaves and,

later, Black US citizens.

In 1851, Samuel Cartwright, a

leading medical authority, maintained

that a slave must be submissive to his

master. He identified drapetomania,

the “disease” of running away, with

specific remedies: removal of both big

toes and “whipping the devil out of

them.”5 The extensive history of Blacks

receiving violent medical treatment

and experimentation includes medical

schools utilizing enslaved Black bod-

ies as “anatomical material,” early

gynecologists experimenting on

enslaved women, compulsory sterili-

zation, and the saga of Henrietta

Lacks, whose cancerous cells, taken in

the segregated Johns Hopkins ward,

were experimented on, reproduced,

and disseminated without her knowl-

edge or consent.6

Most prominently, the infamous

“Tuskegee Study of Untreated Syphilis

in the Negro Male” remains a symbol of

African American mistreatment, deceit,

conspiracy, malpractice, and neglect

by the medical establishment. Social

scientists and medical researchers

have repeatedly pointed to this un-

ethical study as a reason many African

Americans remain wary of mainstream

medicine and participation in clinical

trials, and why there are fewer phy-

sician interactions among African

Americans and increased mortality for

older African American men, as has

been consistently documented.7

GOVERNMENTAL PROGRAMS FOR EQUITY IN COVID-19

Organized government initiatives are

essential to link scientific understanding

of SARS-CoV-2 to public health policy and

social justice. Institutionalized strategies

at a national level include the National

Institutes of Health’s Community En-

gagement Alliance (CEAL) against COVID-

19 disparities, which targets African

Americans, Hispanics/Latinos, and

American Indians/Alaska Natives, who

account for over half of all reported US

cases.8 Specifically, CEAL’s community

outreach efforts are designed to increase

clinical trial diversity and to overcome

misinformation and mistrust regarding

treatments, diagnostics, and vaccines.8

This ongoing program seeks to identify

and connect with some of the hardest-hit

communities.

Furthermore, state, territorial, and

tribal perspectives may swiftly identify

disparities and problem areas in COVID-

19 incidence, burden, and vaccination

and more precisely deliver culturally

appropriate messaging. One example,

Louisiana’s COVID-19 Health Equity Task

Force (www.sus.edu/lacovidhealthequity),

was initiated after an alarmingly high Af-

rican American mortality rate was identi-

fied in the state. It has reported to the

governor multiple recommendations for

testing, monitoring COVID-19’s impact,

and policy changes aimed to reduce in-

equities for multiple statewide racial/

ethnic communities.

CULTURAL HUMILITY

The best path forward to controlling the

pandemic and achieving health equity

will require specific, targeted programs

and public health engagement pro-

mulgated with the spirit of “cultural

humility.”9 More than traditional “cultural

competency,” a detached mastery of a

theoretically finite body of knowledge,

cultural humility is a communication

imperative, originally described as an

ongoing process requiring physicians

to engage in conversations with pa-

tients, communities, colleagues, and

themselves. Notable aspects of cultural

humility include self-reflection and self-

critique, learning from patients (avoiding

cultural stereotyping), developing and

maintaining respectful partnerships,

and actively continuing these positive

relationships.

Consequently, vaccination concerns

in communities of color must be

addressed with cultural humility, as

opposed to simply deeming reluctant

individuals as solely uninformed, fool-

ishly recalcitrant, or merely antivaxxers.

Identifying and overcoming vaccination

hesitancy in a multicultural America is

not simply a social nicety, but rather an

essential action to achieve national

levels of immunity and eventually elimi-

nate disparate outcomes among diverse

cultures and racial/ethnic backgrounds.

To communicate the risk–benefit of

COVID-19 vaccines, it is essential to have

input from the mass media, public health

services, policymakers, and “trusted

messengers” (individuals with a prior

history of service and goodwill in the

underserved and minority communities).

According to established international

law, the United States must ensure

equality and nondiscrimination in its

dissemination of new COVID-19 vaccines.

Individual decisions about accepting

vaccination are not simply technical cal-

culations, but value decisions that this

particular intervention is intended to help

and not harm themselves and their loved

ones. Culturally sensitive, literacy-level

appropriate education, delivered with

cultural humility, is optimally respectful

communication, with feedback and

evaluation of the messaging.

CONCLUSION

The best path forward to overcoming the

COVID-19 pandemic in the United States

requires specific, targeted programs and

Editorial Ferdinand 587

OPINIONS, IDEAS, & PRACTICE A JP H

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2 0 2 1 , V o l 1 1 1 , N o . 4

public health engagement that promote

diversity in clinical research and partner-

ships with communities of color. The un-

acceptable devastating death and disability

from COVID-19 will be eliminated only by

effectively and respectfully delivering miti-

gation, prevention, early diagnosis, effective

acute care, and, finally, immunization to the

increasingly diverse US populations. Inher-

ent in this challenge, culturally humility is a

crucial component.

CORRESPONDENCE

Correspondence should be sent to Keith C. Ferdi- nand, MD, Cardiology, Tulane University School of Medicine, 1430 Tulane Ave, #8548, New Orleans, LA 70112 (e-mail [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.

PUBLICATION INFORMATION

Full Citation: Ferdinand KC. Overcoming barriers to COVID-19 vaccination in African Americans: the

need for cultural humility. Am J Public Health. 2021;111(4):586–588.

Acceptance Date: December 15, 2020.

DOI: https://doi.org/10.2105/AJPH.2020.306135

CONFLICTS OF INTEREST

The author has no conflicts of interest to declare.

REFERENCES

1. Gold JA, Rossen LM, Ahmad FB, et al. Race, ethnicity, and age trends in persons who died from COVID- 19—United States, May–August 2020. MMWR Morb Mortal Wkly Rep. 2020;69(42):1517–1521. http://dx. doi.org/10.15585/mmwr.mm6942e1

2. Ferdinand KC, Nasser SA. African-American COVID- 19 mortality: a sentinel event. J Am Coll Cardiol. 2020; 75(21):2746–2748. https://doi.org/10.1016/j.jacc. 2020.04.040

3. US Dept of Health and Human Services, Office of Disease Prevention and Health Promotion. Employment. Healthy People 2020. Available at: https://www.healthypeople.gov/2020/topics- objectives/topic/social-determinants-health/ interventions-resources/employment#36. Accessed December 12, 2020.

4. Funk C, Tyson A. Intent to get a COVID-19 vaccine rises to 60% as confidence in research and

development process increases. Pew Research Center. 2020. Available at: https://www. pewresearch.org/science/2020/12/03/intent-to-get- a-covid-19-vaccine-rises-to-60-as-confidence-in- research-and-development-process-increases. Accessed December 12, 2020.

5. Cartwright SA. Report on the diseases and physical peculiarities of the negro race. New Orleans Med Surg J. 1851:691–715.

6. Nuriddin A, Mooney G, White AIR. Reckoning with histories of medical racism and violence in the USA. Lancet. 2020;396(10256):949–951. https://doi.org/ 10.1016/S0140-6736(20)32032-8

7. Alsan M, Wanamaker M. Tuskegee and the health of black men. Q J Econ. 2018;133(1):407–455. https://doi.org/10.1093/qje/qjx029

8. National Institutes of Health. Community Engagement Alliance (CEAL) against COVID-19 disparities. 2020. Available at: https://covid19community.nih.gov. Accessed January 25, 2021.

9. Tervalon M, Murray-Garcia J. Cultural humility vs cultural competence: a critical distinction in defin- ing physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998;9(2): 117–125. https://doi.org/10.1353/hpu.2010.0233

To Work With Marginalized Populations, Empathy Is Key Howard Rodenberg, MD, MPH

ABOUT THE AUTHOR

Howard Rodenberg is with Baptist Hospital, Jacksonville, FL.

See also Benjamin, p. 542, and Ferdinand, p. 586.

Many years ago, I was told never tofollow a great speaker, as there’s no way to look good in comparison. So

I’m hesitant to add an opinion to Keith

Ferdinand’s moving account of his

family’s rooftop rescue from their

flooded New Orleans home. The tale

reveals the fear we have when

confronted with uncontrollable cir-

cumstances, such as natural disasters

or pandemics. It also encapsulates the

hopelessness and desperation we

might feel when we don’t have the

ability to care for our friends, our

families, and ourselves. Many of us

have likely felt this way during the

COVID-19 crisis; more still within dis-

advantaged communities.

Incidents of racist thought and prac-

tice within the House of Medicine have

been well documented, and the negative

impact of adverse social determinants of

health has become clear. These factors

complicate public health programming

within marginalized populations, espe-

cially when public health products or

services come from outside rather than

originating within the community itself.

Given the chronic distrust that results

when policymakers seem unwilling or

unable to correct these ills, is it any

wonder there’s skepticism about a

government-backed coronavirus

vaccine?

It has been noted that people of color

have a right to be suspicious of public

health professionals. We can argue

among ourselves how many of today’s

current health disparities within minority

populations are related to centuries of

institutional racism or contemporary

588 Editorial Rodenberg

OPINIONS, IDEAS, & PRACTICE A JP H

A p ri l 2 0 2 1 , V o l 1 1 1 , N o . 4

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