Vaccine Hesitancy in Black & Indigenous Communities in the US & Canada

Historical Trauma in Action

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Since the beginning of the COVID-19 pandemic, Black and Indigenous communities, in the US and Canada, have been disproportionally impacted with more infections and deaths [1, 2]. The arrival of effective vaccines gave the whole of the planet some much-needed light at the end of the COVID tunnel. However, vaccines the beginning of the rollout has revealed considerable ambivalence about getting the lifesaving shot in both Black and Indigenous communities. It would be facile to attribute this hesitancy to a lack of education and a general distrust of authorities, as this focuses responsibility exclusively on Black and Indigenous individuals and is conveniently dismissive of the long history of medical racism and trauma perpetuated on these communities. 

 

Historical Trauma

It is vital for medical professionals and policy makers to understand that vaccine hesitancy in these communities is not founded on baseless fears, solely born of antivaxxer scaremongering. The US and Canada have a long history of medical racism, in particular, cruel nonconsensual medical procedures and experimentation on Black and Indigenous persons.

 

Black Medical Trauma

Racist beliefs about biological differences have existed since the Enlightenment when naturalists were cataloguing the natural world and extending this categorization to people. They fanatically measured and compared, and specifically sought out ‘data’ to support the notion that White people were ‘naturally superior’. Early examples include: “lighter weight of brain; exceedingly thick cranium; a thick epidermis” [3]. The racist myth that Black people experience less pain dates from this era, this belief, has been shown to persist until this day, even among medical residents, such that Black people’s pain is systematically underestimated and undertreated [4]. 

One of the most horrific and well-known medical abuses of Black people is the Tuskegee Syphilis Experiments (1932-1972), where government researchers purposefully withheld treatment from a sample of Black men infected with syphilis, in order to track the course of the disease when left untreated [5]. Researchers prevented participants from accessing viable treatments (i.e., penicillin) by prohibiting medical screenings during the WWII draft and directly intervening with other health care providers who tried to treat participants. Additionally, researchers neglected to discuss mechanism of disease transmission which caused harm to participant’s sexual partners and children. Over this long study, a succession of researchers justified their actions on scientific grounds such as the need to understand the progression of the disease. The multitude of unethical actions in this study are astounding and the erosion of trust that this event created continues to reverberate today.

Other notorious traumas include gynecological experimentation on enslaved Black women. Following the 1808 federal ban on importing slaves, a newfound White enthusiasm for the survival of slave children led to a surge in gynecological experimentation. Much of this experimentation was conducted without anesthesia, despite its availability, justified by the ‘less physical pain’ myth [6]. A more recent example from the 1950s, is the nonconsensual sampling, of Ms. Henrietta Lack’s cells, which were then shared with other scientists and created into a standard set of cells (HeLa cells) that continue to be widely used in medical research today. In addition to the lack of consent, none of the companies that profited from Ms. Lack’s cells provided any compensation to her family, and, for decades after her death, scientists compounded this injustice by publicly revealing her name, sharing her medical records, and even publishing her cells’ genome online [7]. 

Many states in the South, and California, have been shown to have employed forced sterilization as a means of controlling Black bodies. “Mississippi appendectomies” were unnecessary hysterectomies performed at teaching hospitals in the South primarily on poor Black women as practice for medical students. North Carolina’s eugenics program under the guise of population management, specifically targeted Black citizens for forced sterilization. Finally, there is mounting evidence that forced sterilization, primarily of Black women, continued for decades in women’s prisons in California, and that it is still happening today [8-10]. 

 

Indigenous Medical Trauma. 

For generations, Indigenous people have transmitted cultural knowledge by verbally passing down traditional teachings, stories, songs and codes of conduct. So too have the traumas sustained by their ancestors been passed down through the generations. The atrocities of Wounded Knee, The Trail of Tears, and the residential school system are just a few of the historical traumas that have impacted Indigenous ways of life through colonization, forced assimilation, and imposed medical procedures and experimentation. 

The residential school system in Canada (1870-1990s) removed around 150,000 children from their families and sent them to church-run schools under a deliberate policy of assimilation. The physical, mental and sexual abuse of many of these children is well documented, with mortality rates up to 60% at some schools [11]. Survivors have repeatedly reported the occurrence of unethical medical interventions, in particular several nutritional experiments. For example, after discovering severe malnutrition in some residential schools, researchers decided to study the effects of chronic-severe malnutrition on child development, by randomizing the children into a control group receiving no interventions or an experimental group from whom nutrition was further limited for 2-years to stabilize a baseline, lowering their intake to well below the recommended daily levels. Additionally, within several Northern Indigenous communities in situations of malnutrition, authorities desirous to study their efficacy, introduced vitamin supplements rather than increasing nutritious food supplies [12].

During the 1930s, the Canadian government tested tuberculosis vaccines on impoverished aboriginal communities instead of fixing poor living conditions that fostered the disease [13]. Not to mention experimental surgical and drug treatments given at the racially segregated ‘Indian hospitals’ during post-war times [14]. To add insult to injury, multiple breakthroughs from research on Indigenous children were later used to treat the wider Canadian population, yet these same medicines were withheld from Indigenous children. Also, in the 1930s, legislation was introduced in the US and Canada allowing for forced abortion and sterilization of selected populations. There is considerable evidence showing such practices persisted for multiple decades. It’s estimated that as many as 25-50% of Indigenous women in the US were sterilized between 1970 and 1976 [15, 16].

 

Current issues of medical racism

The myth of biological differences in pain tolerance continues today. For example, a 2016 US study found that 25% of medical residents agreed that Blacks have thicker skin and therefore less pain. Stories of Black and Indigenous individuals having their complaints of pain ignored by medical personnel abound in the recent press, for example Dr Susan Moore, a US Black doctor, Joyce Echaquan, a Canadian Indigenous woman from the Atikamekw Nation, and David Bell, a US Black man, all died recently following dismissal of their pain and illness [17-19].

Racial disparities are particularly stark in obstetrics. Today, Black and Indigenous women are 2-3 times more likely to die from pregnancy-related causes, and their infants are more than twice as likely to die as White infants. A 2020 study found that Black newborns in the US are more likely to survive childbirth if they are cared for by Black doctors, but three times more likely than White babies to die when their doctor is White [20, 21]. 

At the outset of the COVID-19 pandemic, both countries’ administrations issued guidelines encouraging social distancing, and frequent hand washing, however many Indigenous communities were left asking how to implement such measures when, in Canada nearly a quarter of Indigenous people live in overcrowded homes and 61 Nations do not currently have access to clean water, and in the US Navajo Nation for example, 1 out of 3 households don’t have indoor plumbing. Navajo Nation president Jonathan Nez, in testimony at a water rights hearing in Oljato on the Arizona-Utah border, said there is “a single spigot on a desolate road, miles from any residence, which serves 900 people” [22]. 

Even the vaccine developers have compounded the situation. Moderna had to slow down vaccine trials due to a lack of BIPOC data and the Lummi Nation exited the AstraZeneca trials over communication difficulties which resulted in the Nation Chief stating that it was “not a good fit for their community” [22, 23]. 

 

Path forward

There is however reason to be hopeful. In the US, communities have taken direct action to specifically address fears and mistrust. For example, the Health Advocates In-Reach and Research network, an initiative that started with training barbers in Maryland to be lay health advocates for colorectal screening, has implemented on-site testing services and facilitated multiple information town halls. In Florida, a statewide, Black-led community task force aims to increase community immunization rates by facilitating access to vaccination sites in BIPOC communities. Minnesota Community Care a nonprofit clinic created videos and flyers to dispel COVID-19 myths. After receiving vaccine doses through the Federal Indian Health Service, Indigenous nations have in ambitious vaccination rollouts, setting their own eligibility criteria and encouraging their communities to consider vaccination as an act of protection towards community Elders. Some of these plans have been so successful that they have been extended to included local non-Indigenous persons [25-28]. 

In Canada, the federal government has prioritized vaccine distribution to hard-to-reach northern Nations in collaboration with local leaders, ahead of the general population. These communities have limited access to local healthcare and are therefore at higher risk. However, one complex issue with targeted prioritization policies, is that they can stimulate fears of ‘experimentation’; it is therefore essential that the Canadian government continues to work in partnership with Nation leaders and healthcare professionals to provide public messaging and information that is inclusive of Indigenous worldviews. For example, messaging needs to focus not only on individual protection, but also on the protection of communities, the land and the next seven generations. Indigenous persons in urban areas are also being prioritized. Information campaigns and community leaders and experts are also mobilizing within the Black community, for example, last week a town-hall style event brought together a consortium of Black health care professionals to address community concerns and answer vaccine related questions [29, 30].

Very recent data suggests that these active community approaches are gradually working. For example, a January Harris Poll showed acceptance in Blacks increasing from 43% in October to 58%; a further survey by the Urban Indian Health Institute with 318 tribes across 46 states, showed 75% of participants were willing to be vaccinated, also participants indicated that the primary motivation for getting vaccinated was a strong sense of community, including protecting Elders and traditional cultural ways [31, 32]. Things have been slower moving in Canada, due to a lower availability of vaccines, however, recent data is showing that vaccination rates in Indigenous communities are currently significantly higher than those reported elsewhere, with 25% of Indigenous adults having received at least one shot, a rate that is six times higher than in the general population [33]. Currently, reported hesitancy is still high within the Black community however grass-roots information campaigns are ramping up [29]. 

The new US administration has adopted a direct hand-on approach creating a COVID-19 Health Equity Task Force whose mission is to provide recommendations to POTUS, for mitigating inequities caused or exacerbated by the pandemic, as well as suggestions for preventing future discriminations. The task force is composed of healthcare providers, public health experts and members from a breadth of minority communities, as well as state, local, territorial and Tribal representatives. At its head is Dr. Marcella Nunez-Smith, an epidemiologist with considerable experience in health equity research. In a recent interview with the NY Times, she identified several key issues including developing more sensitive data collection to get a more comprehensive and accurate picture of which populations need to be specifically targeted to reduce vaccine hesitation and lag; and the identification and removal of structural barriers (e.g., transportation to vaccine centers, days off work for vaccination and /or recovery etc.) that disproportionately impact BIPOC communities [34].

Finally, as we slowly climb out of the pandemic, it is not just about access and confidence in vaccines, it is also about making sure that Black and Indigenous communities have access to ‘equity in the recovery’ which hopefully means coming out the other end with something more than just a ‘return to previous functioning’ for all.

References

Greenwood, B. N., et al. (2020). Physician–patient racial concordance and disparities in birthing mortality for newborns. Proceedings of the National Academy of Sciences, 117(35), 21194-21200

Hoffman, K. M., et al. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences, 113(16), 4296-4301.

Lux, M. (1998). Perfect subjects: Race, tuberculosis, and the Qu’Appelle BCG vaccine trial. Canadian Bulletin of Medical History, 15(2), 277-295

Lux, M. K. (2016). Separate beds: A history of Indian hospitals in Canada, 1920s-1980s. U Toronto Press.

Mosby, I. (2013). Administering colonial science. Histoire Sociale, 46(1), 145-172.

Owens, D. (2017). Medical bondage. U Georgia Press.

Petersen, E. E., et al. (2019). Racial/ethnic disparities in pregnancy-related deaths. Morbidity and Mortality Weekly Report, 68(35), 762.

Pegoraro, L. (2015). Second-rate victims: The forced sterilization of Indigenous peoples in the USA and Canada. Settler Colonial Studies, 5(2), 161-173.

Plous, S., & Williams, T. (1995). Racial stereotypes from the days of American slavery. Journal of Applied Social Psychology, 25(9), 795-817.

Price, G. N., et al. (2020). Did North Carolina economically breed-out Blacks during its historical eugenic sterilization campaign. American Review of Political Economy, 28.

Roberts, D. E. (1999). Killing the black body. Vintage.

Roth, R., & Ainsworth, S. L. (2015). If they hand you a paper, you sign it: A call to end the sterilization of women in prison. Hastings Women's LJ, 26(7).

Tai, D. B. G., et al. (2021). The disproportionate impact of COVID-19 on racial and ethnic minorities in the US. Clinical Infectious Diseases, 72(4), 703-706.

Wolinetz, C. D., & Collins, F. S. (2020). Recognition of research participants’ need for autonomy: Remembering the legacy of Henrietta Lacks. JAMA, 324(11), 1027-1028.