Racial minorities have, as with most diseases, suffered disproportionately during the COVID-19 pandemic. Yet, it is racism, rather than race, that mediates the bulk of poor health outcomes for racial minorities, including COVID disparities. The chronic effects of social disadvantage and discrimination affect the hypothalamic-pituitary-adrenal (HPA) axis, autonomic regulatory pathways, epigenetics, and other pathophysiological mechanisms that increase risk for cardiovascular disease, diabetes, and other chronic diseases that lead to poor COVID outcomes. Social genetic research has shown that racial discrimination accounts for 50% of the black/white difference in acute viral inflammatory responses. Within the United States, counties with higher proportions of African Americans have higher numbers of COVID-19 cases and deaths; such counties have more crowded living conditions and lower social distancing scores, higher unemployment, and lower rates of health insurance. Structural racism and residential segregation have forced a disproportionate number of racial/ethnic minorities into low-income neighborhoods that are more physically crowded and have fewer resources. People travel farther for supplies and testing, and often rely on public transportation to do so.

As such, racial disparities in COVID are largely due to structural racism. As new treatments and vaccines become available, one way to minimize the stigma and increase the acceptability among racial/ethnic minorities is to avoid saying that “racial/ethnic minorities are being prioritized.” To many people of color in the United States, those words may come across as meaning prioritization for experimentation or unknown harms. Rather, we should acknowledge that what we are prioritizing are the mechanisms (e.g., structural inequities) that put people at risk, which are more common in racial/ethnic populations. That shifts the conversation to people with individual risks because of their occupation (e.g. essential workers) or medical burden, or groups of people at risk because of where they live (e.g., congregant living, buildings with multi-generational living or poor ventilation), rather than people with brown or black skin.¹

The National Academy of Medicine’s recommendations for phased COVID vaccine delivery are based on risk groups (e.g., high-risk healthcare workers, older adults in congregant living facilities) with a cross-cutting consideration for equity based on the Social Vulnerability Index of the Centers for Disease Control and Prevention (CDC).² The CDC defines social vulnerability as the resilience of communities (the ability to survive and thrive) when confronted by external stresses on human health, stresses such as natural or human-caused disasters, or disease outbreaks; socially vulnerable populations include “those who have special needs, such as, but not limited to, people without vehicles, people with disabilities, older adults, and people with limited English proficiency.” Racialized minority status is included as a variable in the SVI. Thus, by factoring in how people and communities become at risk for diseases like COVID, we can more accurately address these risks in an evidence-based and less-stigmatizing way.

Immunizations offer our best hope for stemming the COVID pandemic, but there has been significant concern about ‘vaccine hesitancy’ in light of findings from a national survey by Kreps, et al, about COVID vaccine acceptability.³ They found that Blacks, the uninsured, people with a personal contact who had COVID, and those who believed that the pandemic would actually worsen were less likely to report accepting a COVID vaccine. Given the existing profile of COVID disparities, these findings are particularly worrisome.

Yet, in a related JAMA Commentary, Opel, et al, reminded us that true vaccine hesitancy occurs when people are reluctant to get vaccinated despite an available vaccine, whose safety and efficacy profiles are known, and that has been approved for use.⁴ This is quite different than the hypothetical scenarios in Kreps’ study, in which vaccine acceptability varied substantially based on factors such as effectiveness, durability, and adverse events. Thus, part of the reluctance among study participants may have been due to a lack of sufficient information about the vaccines to make an affirmative decision.

As of late December 2020, two COVID vaccines reported to have 95% efficacy and no serious adverse effects other than a possible severe allergic reaction. An efficacy of 90% (vs. 50% or 70%) was associated with an increase in vaccine acceptance in the Kreps study, as was a lower rate of adverse events. Vaccine recommendations by the CDC and the World Health Organization (WHO) were associated with higher rates of reported vaccine acceptance, as were recommendations by Joe Biden (v. Donald Trump).

Then President Biden’s first action was to create a COVID-19 Task Force comprised of scientists, clinicians, health policy experts, government experts, and public health professionals. This group, co-led by SGIM’s Dr. Marcella Nunez-Smith, will help restore public trust that it is scientists and other health professionals who are making decisions about COVID vaccine policy and implementation. Many states have their own certifying boards in place to re-evaluate data from the highly politicized FDA to assure the public about the safety of the vaccines.

Yet, in order to truly make inroads into racial/ethnic communities, we must acknowledge and address the sociopolitical factors that have led to vaccine hesitancy within these populations—historical and current institutional mistrust. Trust is not a compartmentalized construct; erosion in one institution (e.g., criminal justice) can affect trust in another institution (e.g. healthcare); institutional trust (e.g., health care) can affect interpersonal trust (e.g., trust in physicians) and vice-versa.⁵ In this incredibly tumultuous time of racialized state violence (e.g., police brutality) and racial reckoning, pandemic, and economic devastation, racial/ethnic minorities have suffered disproportionately in many aspects of their lived experience. Much of this could have been prevented, minimized, or relieved by governmental institutions, but the response, under the Trump administration, was woefully insufficient.

President Biden, as noted, has already taken steps to shore up the erosion of public trust in our public health and medical institutions. More action will be needed, such as the protection of essential workers with PPE and paid sick leave, the provision of temporary housing for COVID positive persons living in high-risk conditions for disease spread, and other measures that directly impact the ability of populations most affected by structural racism to reduce the risk, morbidity and mortality from COVID-19 within their communities. This is what will be needed to rebuild trust with the governmental institutions and medical agencies looking to deliver COVID-19 vaccines to high-risk populations.

President Biden will also need to show that he is ready to combat white nationalism. The terror that results from knowing that white nationalists are freely roaming the country—killing black and brown residents while wearing police uniforms, and executing coup d’état attempts at the encouragement of then-president Trump—has undermined trust in government in a deep, substantial, and long-term way for many racial/ethnic minorities. One of my clinic patients told me, “If the government is trying to outright kill you in the street, why not do so with a so-called vaccine?” President Biden is going to have to show a zero-tolerance policy for white terrorists in the United States, currently listed as the largest threat in the country. We have long tolerated white violence in the United States, but this must end if we are to unite the country, seek peace, and regain trust in our most fundamental institutions, especially by the most marginalized.

This election has proven that millions of Americans are ready. We have seen grassroots organizations working hard all over this country as people “say yes!” to democracy and to government. We will need to leverage that type of organizational operation in high-risk communities, with trusted, high-profile leaders who are armed with information, science and facts. Vaccine delivery may not happen inside of hospital walls for some racial/ethnic minority populations, but it can happen in collaboration with healthcare and public health organizations. General internists will be critical links for this collaborative work.

General internists will also be critical in the “ground game” of vaccine implementation. Never has the trusted space of the patient/provider relationship been more important to making life-saving decisions that can bring this country back from the brink of disaster. Physicians have, perhaps temporarily, returned to the status of heroes in the public space because of our efforts during the pandemic. We must leverage that public trust and good will now, particularly among those whose trust has been so badly broken, in every patient encounter—every clinic visit, every hospitalization, every on-call conversation. And we must lead by example.

We have a long hill to climb in order to get to COVID-19 herd immunity for the most high-risk populations and for the country as a whole. But we currently have the tools, the people, and the motivation in place. We have never had more to lose or more to gain.