The COVID-19 pandemic has exposed the widespread presence of health inequities in the United States. It has also highlighted structural racism. COVID-19 mortality rates are more than twice as high in Black, Latinx, and Indigenous populations than in White populations, and the data reveal a strong socioeconomic gradient according to this data spreadsheet. And as structural racism impacts both the clinical and research realms of medicine, major concerns regarding the COVID-19 vaccine arise.
Although the development of the COVID-19 vaccine has made significant progress, there is a significant gap present when it comes to appropriately testing different racial or ethnic groups. In the Moderna Phase 3 clinical trial report in the New England Journal of Medicine, the data is absolutely shocking. 89% of overall participants were white (40 participants), whereas only 13% were Hispanic or Latinx (6 participants), 4% were Black (2 participants), 2% were Asian (1 participant), 2% were Native American (1 participant), and 2% were unknown (1 participant) (view paper here).
In order to further understand this data, we asked Audrey Jacobsen MD, MPH if the demographics of this study were alarming. She responded,
“This is definitely a concern! The major issue is generalizability of any drug or vaccine when they are limited to one demographic group. I absolutely love this article [attached in the sources below] written by Dr. Jefferson who I got to hear speak on a panel at the recent Doctors for America Virtual Leadership Conference. She advocates for an anti-racist model of drug allocation and prioritization and her same thoughts are completely valid for vaccine development.”
In this paper, Dr. Jefferson notes that people of color have been disproportionately affected by COVID-19 due to underlying health conditions more prevalent in these populations, such as hypertension, diabetes, heart disease, obesity, and chronic lung disease which worsen the effects of COVID-19. Because of this fact, vaccine trials should include participants from these communities, as they have the highest risk of infection.
To match the demographics of COVID-19, Black or Latinx individuals would need to comprise up to 40% of vaccine trial participants nationwide (STAT News), and as we can see this is not the case.
So, why is there a lack of volunteers from minority communities?
Many would jump to say that the lack of volunteers is due to trans-generational mistrust in the medical system. After instances such as the Tuskegee Syphilis Crisis or the case of Henrietta Lacks, many minority communities stay away from participating in clinical trials due to their ancestors’ poor experiences. While this is true, we cannot ignore the fact that our country’s healthcare system is still rooted in structural racism; it isn’t just past events that leave minority communities not wanting to participate in clinical trials, but current events as well. The hours that clinics are open are too limited for people of color who often work multiple jobs to be able to pay for necessities due to lower socioeconomic status and study budgets don’t always pay for interpreters and translators that would facilitate participation by non-English speakers. Study protocols often exclude individuals with chronic illnesses like diabetes and hypertension, which disproportionately impact people of color--an effect of systemic racism in the United States (STAT News).
Dr. Jacobsen adds,
“Again, the article by Dr. Jefferson above addresses this SO well. We are quick to blame past historical traumas for minority distrust of doctors and medical institutions, but often overlook the current structural racism that is seeped in our own institutions, research groups, IRB's etc.
One way to address this is through community based participatory research or CBPR. It's a type of public health research that puts the power and agency in the community rather than the institution.”
Aside from the concerns that underlie scientific research, there are also questions about how the vaccine will be distributed to low-income, rural, and/or minority communities once it is available to the public.
“I agree with authors Liu et al [attachment in the sources section] that there needs to be an ethical framework in place well before vaccine distribution that the mainly private and for profit companies that are developing vaccines need to be held accountable for,” says Dr. Jacobsen, “They summarize 4 principles: ability to develop or purchase, reciprocity, ability to implement and distributive justice.”
This paper points out that vaccines are the only potential intervention for regions or people where access to care is difficult, so these groups should receive priority. But, vaccines should not be allocated if they cannot be used. Therefore, efforts should be made to support low-income communities in distribution and implementation. And in return for making these efforts, countries should be rewarded.
“Which brings me to another point regarding conflict of interest!” Dr. Jacobsen explains, “Most of the companies that are working on vaccine development are for-profit entities (i.e. Big Pharma) so their bottom line isn't focused on any form of equity. The US also doesn't (in general) negotiate for drug prices with Pharma so the cost of that same medication in the US is extremely higher than that in Europe. I also think it's highly problematic that the US didn't join Covax (international coalition for a vaccine development led by the WHO, which has voiced its commitment to vaccine equity). Our healthcare system, as you know, is driven for profit, and I worry that the ultimate price of the vaccine will be not affordable or accessible for widespread distribution to areas that need it the most.”
So, knowing these health equity concerns, what can we as future healthcare providers and scientists do to combat them?
According to Dr. Jacobsen,
“The first and most important is to not lose the energy you came into medical school with. I'm so inspired by all the medical students, including your awesome Instagram platform, who I've seen working hard in communities to make a difference. Seriously, keep it up. Also, don't be afraid to use your voice and speak up against inequities. Medical school is tough and we are often so scared to be wrong, or be judged or not get honors on our rotation that we often don't speak up. This is something I'm still learning and still there are situations where I regret not saying something. Third, as cheesy as it sounds, really listen to your patients so you can be a better advocate and give them a voice when they can't.”
Thank you, Dr. Jacobsen, for taking the time to share your responses.
Jefferson, A. (2020). Adopting an Anti-Racist Model of COVID-19 Drug Allocation and Prioritization, The American Journal of Bioethics.
Adopting an Anti Racist Model of COVID 19 Drug Allocation and Prioritization
Download PDF • 1.12MB
Liu Y., Salwi S., Drolet B. (2020). Multivalue ethical framework for fair global allocation of a COVID-19 Vaccine.