Overcoming Racial Disparities in Vaccine Hesitancy and Access

THE WASHINGTON FOREIGN PRESS CENTER, WASHINGTON, D.C.

MODERATOR:  My name is Jen McAndrew, and I am today’s moderator.  Our briefer today is Dr. Eliseo J. Perez-Stable, Director of the National Institute on Minority Health and Health Disparities at the National Institutes of Health.  He will discuss how minority communities are grappling with vaccine misinformation, the value of fact-based health communication, and how federal and local officials are working together to counter disinformation, build public trust, and improve vaccine confidence and access for underserved populations.

And now for the ground rules.  This briefing is on the record.  We will post a transcript later today on our website.  Dr. Perez-Stable will give an opening statement, and then we will open it up for questions.  We have only a limited amount of time, but we’ll try to get to as many of your questions as possible.  And with that, over to you Dr. Perez-Stable.

MR PEREZ-STABLE:  Yes, thank you, Jen, and good morning everyone.  It’s really my honor and privilege to be here to talk to you today about the work we do every day at the National Institutes of Health.  I direct the National Institute on Minority Health and Health Disparities.  And as you know – are familiar with, the National Institutes of Health focuses on research and science.  However, in my role as director of the entity that is dealing with health disparities and minority health, I have been involved in a variety of projects related to the COVID19 pandemic and health disparities.

About a year ago was when it was noted that the – there was a disproportionate burden being observed in African American communities, subsequently American Indians as well as Latino Hispanic communities in the U.S.  And over the course of this past 13 months, this pattern has not changed.  About 50 percent of all cases, about 45 percent of mortality, has occurred in Latinos, American Indians, Alaska natives, and African American communities and Pacific Islanders, even though we represent about a third of the U.S. population.  This has been due to the underlying structural inequities that have existed in these communities for decades that have not been attended to significantly over this time.

And this pandemic was just this opportunity to cause havoc in our communities, communities living closer together, two families in one setting, lack of ability to shelter in place, employment that did not allow for the privilege of teleworking like I have been doing primarily for the past year.  And this is the main reason that we’ve seen disproportionate infections and morbidities.

There are more cases – more diagnosis of diabetes and heart disease in these communities that have led to an increase in mortality, hospitalization and mortality, among those who do get sick and then delay coming to the hospital because of under insurance or lack of insurance in many cases.  The mortality trends have continued.  They’re about double.  It has been estimated that up to two years of life expectancy may have been lost for Latinos and African Americans in this past year.

So as a response, NIH has focused a lot on research.  In my area on the social, behavioral, and economic consequences of the pandemic have been a primary emphasis.  We, using additional appropriations from Congress, were able to stand up 69 projects to promote testing, interventions in these underserved and vulnerable communities – a program we call RADx-UP.

And then in last summer as a consequence of the vaccine trials being launched, working with my colleague Dr. Gary Gibbons at the National Heart, Lung, and Blood Institute, we set up a program called COVID – Community Engaged Alliance against COVID-19 Disparities.  We call it CEAL for short, C-E-A-L.  And it started as an effort to increase and enhance participation in the trials being sponsored by the U.S. Government and Moderna and subsequently other pharmaceutical companies.

We, though, set up a structure leveraging our community-engaged researchers that we had funded for many years to develop networks within their states to promote adequate information, address misinformation, and promote trust in science amongst our communities of color.  This has been ongoing now for about eight months.  We’ve focused primarily on African American and Latino communities but have also included other minority communities and American Indians.  We are at 11 states right now and planning to expand it.

Of course, in December we started to deploy the vaccine, beginning first with Pfizer and then the Moderna product.  And remarkably, over these four months, the United States has immunized well over a hundred million people.  This is an unprecedented effort on the part of public health.  However, we are seeing inequity in the distribution that I expect will be decreased substantially as we’re going to get more and more people vaccinated.

Reports from states that feed into the Centers for Disease Control and Prevention provide us some picture of where we are doing with proportional distribution of vaccines by race/ethnicity.  And even though some states that have gotten a really good handle on the pandemic, such as California, for example, Latino or Hispanic populations there have been under-immunized compared to the burden of disease that they carry in the state or the proportion of the population.  In other states such as Maryland or Alabama, where African Americans are more important of a minority, they’re much closer to the proportion of their burden of disease for their proportion on the population.

So our efforts at NIH primarily have focused on this promoting testing through community-engaged research, and also this CEAL effort to promote trust in science, because this misinformation campaign has been incredible.  And we really rely on trusted messengers, which tend to be local experts.  Everybody always thinks, well, we’ll get a celebrity to promote this.  No.  The best person to promote this are a nurse, a physician, a pastor, a trusted community leader, and do locally or regionally.  And I think there has been research on this that we know that this is how it works.

So I will pause there and entertain questions.  I’m sure you’ll have many.  Thank you.

MODERATOR:  Great, thank you.  We’ll now turn to the Q&A portion of the briefing.  If you have not already done so, please take the time now to rename your Zoom profile with your full name and the name of your media outlet.  You can virtually raise your hand to ask a question or submit your question in the chat field.  We do have a advance-submitted question from Katerina Sokou in Greece.  Her question is, “Do you have an estimate of the cost of vaccine hesitancy to the health and economic opportunities of underserved populations?”

MR PEREZ-STABLE:  So thank you for that question.  It is an important and complicated one, but let me address two points.  First, vaccine hesitancy traditionally has not been disproportionately present in minority communities.  With COVID, what we saw from the early surveys in let’s say May, June, and September was that an increasing proportion of African Americans were less likely to accept the vaccine.  Fortunately, we were able to mobilize physicians, African American leaders, as well as science leaders in government to address this directly.  And the latest poll from the Kaiser Family Foundation showed that over 60 percent of African Americans will accept the vaccine, so the hesitancy has decreased significantly.

The cost can be measured in excess cases of disease and therefore lost productivity at work, excess hospitalizations which then would increase the burden on society, and of course mortality and the loss that that represents both emotionally as well as economically.  These kind of studies have not been completely done.  We are embarking on such a study now, globally, for health disparities within NIMHD, and we will try and parcel out what the cost of COVID has been in our communities.  So thank you.

MODERATOR:  Thank you.  We have another question that was submitted in the chat field from Bernd Debusmann.  I believe he is with Arabian Business in the UAE.  I’ll read his question:  “How much of an issue is language in terms of access for the Latino/Hispanic community?  What is being done to address the issue of vaccine misinformation that is out there in Spanish?”

MR PEREZ-STABLE:  Thank you again for that question.  So about 70 percent of all Latinos and Hispanics that live in the United States were born in the United States.  About 20 percent actually are predominantly Spanish-speaking, and up to half of all Latinos actually speak Spanish at home.  So language is an important issue and having quality, accurate translation of all our educational materials that NIH is endorsing or producing is really a high priority for us.  There are many Latino investigators across the country, particularly in areas with high proportions of Latino populations – Texas, Florida, California, the Southwest in general – where there are expert scientists who know how to do this and do it very well.  It is an important – as important as having it actually in simple language so we don’t get bogged down with sophisticated medical terminology in communicating our messages.

Misinformation present in social media is a problem and a challenge across all of society.  I believe that we, as a scientific community, may have been a bit passive in responding to this initially because we need to also promote facts, promote science, not necessarily counter every single unusual claim made about either COVID-19 or the vaccine, such as, “Oh, they’re injecting a microchip;” “Oh, I’m going to be infertile from it;” “Oh, I’m going to get sick from it.”  We do address those directly in our materials and unequivocally answer when we have clear information that counters this type of information.

Remember that scientists tend to always think, well, we’ve got to consider all the aspects.  And in this case, we need to just be very clear in simple language, and as a former primary care doctor, I know that that’s how we need to – often to respond to patients’ questions about particular issues.

MODERATOR:  Thank you.  We have a couple hands raised, so we’ll go to some live questions.  First, I’d like to call on Juergen Baetz from DBA in Germany.  Please, unmute yourself and ask your question.

QUESTION:  Hi.  Thank you so much for doing this briefing.  So I write for media in Germany, where vaccine was really scarce and people don’t know whether they will be able to get it even six months down the road.  So for us it’s interesting how to explain the vaccine hesitancy that we already see in the U.S. and that, it must be feared, will become an even bigger issue in the weeks and months to come.  You mentioned misinformation, and, of course, Tuskegee gets mentioned, distrust in government, but then also why is the hesitancy bigger in racial and ethnic minority groups?  I know it’s a big question, but just the mindset is:  How do you explain to my German readers why is this happening?  Thank you.

MR PEREZ-STABLE:  Well, thank you for your question.  The African American community has had a conflicting history with science and with government.  You mentioned Tuskegee.  There are similar examples – multiple other examples – and the healthcare system has not been the most user-friendly for that community in particular, so that distrust is definitely present.  It’s a distrust in institutions, it’s distrust in systems.

However, both based on data that have been collected through surveys and my own experience, I do believe that individual clinicians regardless of their race and ethnicity can overcome this with open, direct, and frank conversation.  I think the reason a lot of people get turned off is they’re dismissed, their concerns are not paid attention to, their questions are not answered – they’re not listened to.  And we really do need to pause, listen, and respond in a respectful and direct way and not assume oh, that’s crazy, why are you bringing this up.

Fortunately, the African American professional community has mobilized on this topic in a way that is remarkable.  Blackdoctors.org; I have been part of NAACP town halls, where we have had tens of thousands of listeners in different contexts; we’ve had scientists, we’ve had pastors, we’ve had advocates and community organizers, as well as regular people come and talk about issues around COVID and issues around the vaccine.  And I do believe that the latest data do show that we are moving the needle to a higher proportion, so the acceptance of vaccine – theoretically, of course – by the African American community has gone from about 40 percent to over 60 percent in a matter of a few months.  And so we just need to keep moving in that direction.

I would also point out that in other vaccine issues – for example, childhood immunizations – minority communities have actually been more accepting, even, of vaccines than the white community.  And for measles, mumps, rubella – the baby immunizations that we all administer – are over 90 percent in all racial ethnic groups as of most recent data available.  And the vaccine hesitancy or the anti-vaxxer movement pre-COVID was primarily an issue that took – had most traction within a white, middle-class community for reasons I don’t understand.  I don’t pretend – but I’m just observing what the data would show.

But you’re right that this distrust, historical mistrust in systems has surfaced in the context of what has happened with COVID.  But I think we have tried to address that directly and I do believe we are – “we” meaning not just NIH but all of the African American professional community and leadership – are making a difference.  And the same has happened with the Latino community and the American Indian community, although the hesitancy in those communities has been considerably less than what has been reported for the African American community.  Hope that helps.

MODERATOR:  Okay.  Just as a reminder, you can submit questions in the chat field or virtually raise your hand.  We do have another question from Michael Persson, De Volkskrant, in the Netherlands.  Please, unmute yourself and ask your question.

MR PEREZ-STABLE:  I think you’re muted.

MODERATOR:  We can’t hear you, Michael.  We can see you but we can’t hear you.  Maybe try submitting it in the chat.

Okay, we’ll give him a minute to type up his question.  In the meantime, do we have any other questions?  I just see Michael’s hand raised.  Okay.

MR PEREZ-STABLE:  I would add a comment just in general that the equity of distribution of vaccines has been much discussed as well, and I can just share my personal experience in getting vaccinated.  I’m – I don’t see patients anymore, so I wasn’t in the first group of being vaccinated, but I’m over 65, so once the D.C. vaccinate – made itself available, I said, well, let me go on the website and try to get an appointment.  Well, it took me about three times, and I’m pretty good with doing this technology thing.  I say, well, I can get one nearby.  Well, it ended up being two miles away, which is fine.  And luckily, it was a Saturday.  But you can see the issue, that these structural barriers were there.  If you’re 80 years old and living alone, and maybe don’t have a computer, you had no way to get a vaccine.  If you call the phone number – which I did once, because I wasn’t sure my appointment was confirmed, the first thing I heard was, “There are 300 callers ahead of you.”  And you have to have the time and the patience to wait on the phone.

So we’re getting over that as supply has improved, and we are committed to the notion that by June or beginning of summer there will be vaccine available for every adult in the United States who wants one, every person over the age of 16.  So do we have the question —

MODERATOR:  Thank you for sharing.  We do have another question.  I see Michael is probably still typing.  We do have another question submitted.  This is from Geni Lozano from Catalunya Radio in Barcelona.  Her question is:  “How things like what is happening right now with AstraZeneca vaccine in Europe, or Johnson & Johnson here – how could these things impact in the hesitancy that already exists in the U.S.?  And could you please elaborate a bit more on what is the best way to overcome this hesitancy?”

MR PEREZ-STABLE:  Right.  So I would – first of all, the AstraZeneca vaccine has not yet been authorized by the FDA here, so we have no experience with it.  I closely all the reports and the association with this immune-mediated clotting and thrombotic and hemorrhage, so similar to what we see with other drugs, which is a rare event, but a real – apparently appears to be real. And I think it’s one of the things to remember, and sobering, that nothing is without side effects.  No matter how infrequent, sometimes they can be severe.  We saw that early on with the messenger RNA vaccines, Pfizer and Moderna vaccine, causing severe allergic reactions, anaphylaxis-like reactions, that, if unattended, would lead to death.  So clearly you never want a preventive intervention like this to lead to a severe adverse effect or death, but it is one of the realities of medicine that nothing is without some potential side effect.

The Johnson & Johnson vaccine is slightly less efficacious in preventing disease, but similarly effective in preventing death.  And so as a one-dose vaccine, cheaper to produce, easier to store, I think it has a huge role to play in the United States and on the world stage.  And I’ve no reason to say one vaccine over the other, this is better, do – go for this one or that.  The best vaccine possible is the one you can get, the soonest possible time.  And none of us really think this is going to be a one-time vaccination campaign.  COVID is probably going to be with us for my lifetime, anyway.  And so we’re likely to see boosters or annual vaccinations sort of similar to what we see with influenza respiratory infections.

And then I would challenge this group to tell me, what is the vaccine hesitancy in your country?  Because I’m not sure that this is a U.S.-only phenomena.  If we have 30 percent of the adult population of the U.S. hesitate to be vaccinated against COVID – they don’t say categorically not.  There’s a group that says categorically not, but if you add that to those who say, “Well, I’m not so sure,” I think that we can persuade them.

And you say:  What can we do?  Well, the best way is to provide accurate scientific information through trusted messengers, and those trusted messengers may begin with us – leaders in government, science leaders in government, but it really has to go all the way down to your local level: local leaders, community organization leaders, faith-based organization leaders, local clinicians – and not just doctors, but nurses – and role models.  That’s number one.

And number two is to remove all structural barriers, make it as easy and – as possible.  Now, the vaccine is free, so there’s no cost to anyone.  There’s no need to show anything to – other than the normal things we do in health care, make sure they’re the person that you’re – that says they’re getting the vaccine, so some identifier.  But no one is checking anything else, and there are no consequences for getting into some database so someone’s going to come after you or anything like that.

So I do think that the structural issues does take a commitment to doing that.  I think that our government is committed to doing this.  But these things are not always simple to implement just because you want to do them.  And we learn as we do it, as we roll it out.  So I do think that smaller countries, sort of more homogeneous populations are able to do a great job with this.  The challenge in the United States, of course, is we’re 50 states with all their own jurisdictions and all own authorities, but – and also very heterogeneous country in terms of population.  But I think we’ve done a remarkable job to get to where we are now, but it’s far from over, and we’ve still got to keep pushing the vaccination of as many people as possible.

MODERATOR:  Michael Persson has submitted his question in the chat – from De Volkskrant – and I will read it.  His question is:  “Do you have a goal for vaccine acceptance among minority communities?  If the 40 percent hesitancy is similar to the 40 percent hesitancy among white conservatives, what percentage would be needed to get to national herd immunity?”

MR PEREZ-STABLE:  Well, there I will – I will answer that by referring to my colleague and expert, Dr. Tony Fauci.  But this is well known in public health science.  If you – when you get to 80 percent, either immunized or immune from natural infection, you begin to see the benefits of what public health scientists have for a long time called herd immunity.  Some people don’t like that term as sort of the herd referring to animal herds, but it is a term that has been used traditionally.  And we have seen that people talk about this with respect to other kinds of pandemics.  Of course, you don’t want to necessarily get to herd immunity by natural infection only because the cost is huge, as we’ve seen how many people have died in the planet as a consequence of COVID, almost 600,000 in the United States alone.

And if you go back to other era, the measles – the measles epidemic, I was – I’m old enough to have had measles as a child.  And the cost of measles, most people did fine.  Most kids were not – did not get that sick, but a certain proportion would get very sick and die, or develop encephalitis and have lifelong consequences.  So we didn’t necessarily want to achieve herd immunity to measles just by letting every child get infected.  We really reached it by a very effective vaccine distributed at that time, in the 60s, in the late 60s and early 70s, where we have achieved now 95 percent immunity, and I would say that the majority of the residents I taught during my – the last 25 years at UCSF had never seen a case of measles, because it just – they – unless they were all in certain countries, because it had been essentially eradicated from the United States for domestic transmission.

So I think that if we get to 70, 75 percent, we begin to discuss that we really are achieving our goal, and remembering that the immunity from COVID is not – may not be lifelong like it is from other infections, so we may have to boost in a year or two years.  We’ll see – the data will indicate to us when we need to have another vaccine – another dose of the vaccine.

MODERATOR:  Thank you very much for all these helpful insights.  On behalf of the U.S. Department of State, I would like to thank Dr. Perez-Stable for giving his time today to brief the foreign press today.  And good morning to everyone.

MR PEREZ-STABLE:  Okay, thank you.

MODERATOR:  Thank you.