Want People to Take the COVID-19 Vaccine? Confront Racism in Health Care

SHANOOR SEERVAI: Welcome to our new season of The Dose, the Commonwealth Fund’s podcast about what the U.S. could do differently when it comes to health care. I’m your host, Shanoor Seervai, and I spent a good part of the summer thinking about how to make the conversations we have here meaningful to you.

As the COVID-19 pandemic lingers and continues to disrupt our lives, I want to share with you my intention to feature emerging voices and focus on ideas for the future. It’s a simple pledge, but I think that while we have plenty of stories and data about the problems with our health care system, it’s time to get talking about the solutions. In that spirit, I am delighted to be in conversation on this episode with Rhea Boyd, a pediatrician and public health advocate. We’re going to talk about how to counter mistrust about the COVID-19 vaccines and emerge from the pandemic to a healthier future for everyone. Rhea was a Commonwealth Fund Fellow in Minority Health Policy at Harvard University in 2017. More recently, she codeveloped a national campaign called “The Conversation” to bring credible information about the COVID vaccines directly to Black, Latinx, and Spanish-speaking communities.

Rhea, welcome to the show.

RHEA BOYD: Thanks so much for having me.

SHANOOR SEERVAI: We now have an FDA-approved COVID vaccine and we even have mandates — we’ll get to that later. But some Americans are still reluctant to get vaccinated. Why?

RHEA BOYD: You know, I might even describe that differently. I would say some Americans still have not been vaccinated. Why? And the why includes some folks who have some reluctance to get vaccinated, and it includes some folks who absolutely just don’t have good access to information about the COVID vaccines or to actually get the COVID vaccines in a way that’s cost-neutral and convenient for them.

SHANOOR SEERVAI: And what do you mean when you say cost-neutral? Because they’re supposed to be free, right?

RHEA BOYD: Yeah. This is a huge point. Even though the vaccines are free, it doesn’t mean that actually obtaining one of the COVID vaccines is cost-neutral. So if we think about the cost that goes into obtaining any medical service or procedure in our country, we have to account for the travel cost to get there.

So the Biden administration has done, honestly, really incredible work to place more than 95 percent of Americans within five miles of a COVID vaccine. But if you don’t have a car, walking five miles is quite a tall order, especially if you have any infirmity or disability. And then if you do have a car, your gas tank has to be full, which costs money. If you are going to take the bus, you have to buy a bus ticket or bus fare or train fare. That cost money. If you have to park there when you get there, because the site that you’re going to you have to walk into, it costs money sometimes to park. And then that same transportation cost exists on the return.

So we have to take into account the costs simply just to show up and to get back to where you were, and then the opportunity costs, right? We’re talking about forgone wages for time you took off work, depending on if you have a site that’s walk-in where you might have to stand in line. And so it’s not something you could do on your lunch break and just be back in time to continue your shift, but also the cost of child care. If you are the primary caregiver to children who are too young to be alone at home, how are you going to pay to have them watch while you get the service? Are you going to a site that allows you to bring multiple children with you?

These are the costs that we have to account for when we think about who is getting vaccinated and who has yet to be vaccinated. And Kaiser Family Foundation has done some really incredible data that helps us better understand that a sizable proportion of folks who have yet to be vaccinated are actually low-income Americans, many of whom don’t have access even to just health insurance. And so when you think about people on a budget, then you have to say, well, it’s not completely free. Even if when you get there, the service you’re getting is free.

SHANOOR SEERVAI: So let’s break that down a little bit. Which are the demographic groups that are less likely to have received a vaccine?

RHEA BOYD: Data from Kaiser Family Foundation tells us that folks who earn less than $40,000 a year per household are the least likely to have gotten a COVID vaccine. We see lower rates among young folks between 12 and 17 and in the ages of 17 to 35.

And then folks who lack health insurance. If you look along racial and ethnic lines, Black folks in this country as a population have the lowest rates of vaccine uptake. And the second are Hispanic or Latinx populations.

SHANOOR SEERVAI: So are the income barriers you described truly the main barrier, or are they racial, or is it a combination?

RHEA BOYD: I think this is what has been so hard about the vaccination effort. I think that it’s a combination, which means no single silver bullet will actually ensure that everyone in this country can get vaccinated. For example, making the vaccine free is not going to overcome, as we were talking about, the other cost to actually get the vaccine that are more burdensome to families who live on a tighter budget.

And then layer to top these multiple access factors is this massive international disinformation campaign that is targeting all Americans, but specifically folks of color. We saw this early, before any of the vaccines were even released. There were posts on social media sites that catered towards communities of color, that catered toward social justice causes, that were already trying to undermine people’s confidence in the scientific process to create the vaccines that have just continued to spew disinformation about the vaccine’s safety and efficacy.

SHANOOR SEERVAI: So that’s one factor that’s contributing to lower vaccination rates in Black and Latinx communities, but what are the other factors?

RHEA BOYD: So the other thing I like to talk about is what it means that the country was trying to embark on such an ambitious goal. Like what does it mean when you actually try to make sure every single person — right now, age 12 and above — receives a medical procedure or makes a medical decision. What that means is we now have to look at our infrastructure in this country that supports people making medical decisions. And we know that infrastructure is not evenly distributed. One of the main things that helps people make medical decisions is access to medical providers, preferably that they trust and that they’ve had a long-term relationship, but just generalized access to a medical provider who can give you credible information about the medical decision that you’re making and give you information within the specific context of your health history. So that they can say, “Well, you are immunocompromised. This vaccine is safe for you. You should receive it and you can get it right in our office today.”

So what I’ve been talking about is, what does it mean that we have populations that we know are uninsured and underinsured? Populations who don’t just forgo the COVID vaccine, they forgo all manner of recommended medical care, regular screening procedures, even getting checked out when they have pain or infirmity. People don’t do that because they hate medical care. People do that because medical care is insanely expensive in this country. As we all know, it’s one of the leading drivers of bankruptcy in households.

And so people are making real choices about where they can afford to spend time and what medical care they can afford to receive. And I think what we’re seeing is that, particularly for low-income communities and populations of color, that people who don’t traditionally have access to our health care system don’t have a way in to actually counter the disinformation they’re hearing. They can’t run that by a provider because they’re less likely to have a regular provider. And they don’t have a way in to actually receive the vaccine in a way that’s familiar to them. “I go to this clinic once a year. I come to this clinic for my diabetes care and I’m up to date on my diabetes management. So it’s easy for me to also receive the vaccine here.” If people don’t have those pathways in place, it makes it much more challenging than for people to, out of the blue, then decide to make such a serious medical decision.

SHANOOR SEERVAI: So then could we interpret the decision not to get vaccinated as informed skepticism?

RHEA BOYD: I think I interpret it as an inaccessible health care system that is actually unwilling to change its structural model to serve everybody in this country. And instead, on top of an inaccessible system, is now trying to levy mandates on people to receive a service as if people are simply choosing not to receive it. And I just want to say to everybody listening, this is critical. Please do not talk about Black folks’ trust or low-income folks’ trust when we talk about whether or not they choose to get medical procedures in this country, especially because we know the history of the inaccessibility of our health care system to these communities.

If we look from slavery times and Reconstruction, what was one of the main pillars of Reconstruction? Health care for newly freed slaves. If we look at the civil rights movement, what did Black folks ask for? Health care. If we look at post the L.A. riots and other major uprisings and rebellions across the country, what is always attendant, including of Black Lives Matters and the movement for Black lives? Health care is. Black people have been asking for health care again and again and again. And instead, at a time when our country wants to give people health care, the only thing we’re willing to give them is the COVID vaccine. And we want to make it seem as if that makes it totally open that you receive health care. And people have questions about that. What if they have a side effect from the COVID vaccine that actually requires they receive more medical care? Is that going to be covered right now? Right? These are the questions and calculations that people are taking. And why talking about trust is completely inadequate for us to understand the barriers that marginalized communities, particularly Black folks in this country, have faced for centuries just getting any type of health care, let alone a vaccine.

SHANOOR SEERVAI: I’m really glad you said this because we hear the terms around trust. We hear the term most often “vaccine hesitancy,” and I appreciate the way that you’ve reframed that because it points to this history of centuries, really, of systemic racism.

RHEA BOYD: Boom! You got it. We have to account for the fact that Black folks are up against centuries of institutionalized racism, where the systems that we all pay money into as members of society and as just civilians in this country, it has not benefited every racial group evenly. And our health care system is one of those systems. And so when people don’t access our health care system when we want them to, we have to ask how that history has contributed to people’s health care choices and how they manage and make those choices.

SHANOOR SEERVAI: And now in the face of that history, I want to talk about what you mentioned a few minutes earlier: vaccine mandates. You have been campaigning to get people vaccinated ever since the beginning. And now President Biden is mandating vaccines for most federal employees. And we’re seeing some private employers are requiring vaccines, too. Is it a good idea in the face of this history of systemic racism to be mandating something?

RHEA BOYD: It’s a complicated question because what our government, what our nation is facing, is a tall order. That they need to get every single person who’s, at least right now age 12 and above, to make a medical decision. And they need to get them to make that medical decision on a short order. That said, because of what we’ve now said about how structural racism shapes how accessible our health care system is — including how accessible the COVID vaccines are — mandates alone are insufficient and likely to be ineffective. What was keeping people wasn’t that we weren’t forcing them, it’s that there are still barriers that keep them from obtaining it.

And so if you’re going to institute a mandate, for example, at an employer level, then it’s also the employer’s responsibility to make sure that they have had multiple opportunities for all of their staff and employees to learn credible information about the COVID vaccines, and multiple ways to learn that because we know learning styles vary and health literacy levels vary by individual, often by their own educational background and perhaps even their own income level.

And so if employers are going to do it, for example, then you need to get people paid leave to get that vaccine. Then you need to make sure that you can offer vaccination at your work site, if possible, so that when people come in they can just get it there. And sometimes that might even mean closing offices for a day. Like, “This is our day of vaccination for the entire workplace. And tomorrow, because there may be side effects, we will be closed. So there will be no catch-up work, there will be no penalties. Everyone will be paid for that day off. And we will do this together.” Things like that can help ensure that people actually really do have access to receive it on top of the new expectation that they choose to receive it.

SHANOOR SEERVAI: So you’ve just talked about what is needed in addition to a mandate to make this work. But I wanted to ask about your work now. What is the best way to convince people that this is different? Let’s talk about “The Conversation.”

RHEA BOYD: Yeah, thanks. I would love to talk about “The Conversation.” So first, I want people to understand kind of the origins of this project. So the vaccines first received emergency use authorization back in December. And we Black providers across the country started chatting informally back in November, before any of the vaccines were authorized, to say, “What is this we see on social media, and what are these things we hear from people about the vaccines before they’re even out? What should we do to make sure our communities know all the credible information that’s going to come out about these vaccines?” And so this project started really early, acknowledging the structural constraints that limit the spread of credible information to communities of color about health care, health care options, and our health in general. And so we started early, which allowed us to be ready as soon as the vaccines came out.

And so what we’ve created now is both a digital and on-the-ground community outreach to ensure that Black and Spanish-speaking or Latinx or Hispanic communities have credible information about the COVID vaccines. And they can hear that information directly from Black, Spanish-speaking, Latinx, and Hispanic health care workers: doctors and nurses and some of the scientists who worked in the clinical trials — folks who people, we hope, recognize.

SHANOOR SEERVAI: You started your career as a doctor, and now a lot of what you’re doing is about communication and talking to people. So I have two questions: What is it like to be a Black woman doing this work? And when it comes to communication, what is effective and counterbalancing and combating the theories that we hear about vaccines and sterility or zombies and microchips?

RHEA BOYD: I’ll start with the second one first. I think what’s working is going directly to people. So some of the most impactful kind of ground-level outreach we’ve had have been these tele town halls that we’ve had across the South. We have been calling up hundreds of thousands of people week after week in states across the South. We get the phone rolls from voter rolls and we focused on Black folks age 18 to 35, and Spanish-speaking populations and probably about one-tenth of the calls.

And what’s effective about that is 1) we knew that the South is an area of the country where insurance rates are the lowest. KFF [Kaiser Family Foundation — ed.] has some data that says 97 percent of adults who live in the coverage gap, which means your income is too high to qualify for Medicaid but too low to qualify for any premiums, insurance premiums, and so you don’t get any of the tax credits for the marketplace and then you can’t qualify for Medicaid, and so you’re uninsured. The South is also where most Black people in this country live. So we wanted to make sure that we had a concentrated effort to go to folks in the South. But one in 10 residents across the South don’t have the internet. And so, although we’ve created all these glossy videos and we have ad buys on Google and YouTube to make sure people can see these videos, we know that some of our communities who are the most disenfranchised don’t have access to them.

And so we needed to just go to people and call them up on the phone. This is also a method that was used for Census outreach that was really effective. And so we call hundreds of thousands of people, about 5,000 people, 5,000 to 7,000 people stay on the line every time. And we talk directly to people. And in hearing people’s questions is how I came to understand the actual barriers that people are facing. People aren’t calling up bringing up conspiracy theories. People are calling up saying, “I have diabetes. Is it safe for me to get this?” Or one man called up and said, “Y’all told me to get this COVID vaccine, so me and my wife did. My wife got COVID two weeks ago and she died. What happened to her? You told us this vaccine was going to save her life.”

And it was this chilling moment where we could talk about how vaccination works and how — although these vaccines are incredibly effective, some of the most effective vaccines maybe ever to hit the market — at the same time, your individual protection is linked to community protection and community spread. And what does it mean that you live an area of your state that has incredibly low vaccination rates and high levels of community spread? It means even though you and your wife made this critical choice, if all of the rest of the people on the call with us and all of your neighbors, your coworkers, the people at the grocery store and the post office, if they haven’t similarly made that choice, then every time you encounter them it places you potentially at risk.

And so it allowed us to have a conversation essentially with strangers. I mean, we don’t know any of these people calling in, but it’s incredibly intimate and it’s incredibly personal. Because that concern about people dying either from the COVID vaccine or despite having the COVID vaccine is rampant. People have heard stories and they want to share those negative stories to understand if they’re true. And we’re able to give people the evidence so that they can shift to understand if it’s true. We’ve had similar experiences talking in churches to hundreds or sometimes even a handful of people.

So I think that’s what works. And I led with that question because what this means to me as a Black woman is essentially everything. I’ve described this as the most important work I’ve done in my career. And I think it may be the most important work I ever do, which is the opportunity to go and talk to Black people across the country. Knowing that only 5 percent of our workforce who are physicians in this country are Black. There’s not enough of us to talk to everybody. And so through these opportunities, I get to speak to people I would never otherwise meet. You’re not going to come to California to hear what I have to say when you live in rural Mississippi, but I can meet you over the phone and tell you everything I know. I can tell you what people asked about in Alabama. I can tell you what they asked about in South Carolina. And we can talk through what’s working in Georgia, what’s working in Mississippi. We can share the fact that all of us are concerned about the same things: “Is it safe? How do I get it? And is it going to work if I choose to get it?”

I feel really honored, honestly, to be able to do that. It feels like a service to a community and populations who have nurtured me and cared for me my whole life. For the few of us who are in this system who are Black, who also feel like we want to make sure we are narrowing health inequities for Black communities, or for the few folks who are Latinx and want to make sure they’re narrowing health inequities for Latinx communities, I can participate in building projects that enable us to do that. And then that we can then turn to the rest of the system and advocate for bigger changes that allow what is now just a project around COVID vaccines to be a model for how we increase health literacy around other screening, like screening for colorectal cancer or breast cancer or other medical issues like diabetes and heart disease that are major killers of Americans and disproportionately claiming the lives of folks of color in this country. That this is a model you can use to communicate to those communities, to make sure that people have the information they need to make decisions that are in their best interest.

And then beyond that, I think the work is then to shift our field so that we stop harming people, right? Like we refer back to the Hippocratic oath that says, “First, do no harm.” We need more than just not wanting to hurt people. And so I think there’s a number of us — and it’s a growing interest across medicine, thankfully — that medicine has to become an antiracist endeavor. Not just one that’s passive in the face of other forms of racism, but one that’s actively seeking to dismantle other forms of racism and ensure that everyone has access to our care, everyone benefits from our care, and everyone lives longer, healthier, happier lives.

SHANOOR SEERVAI: Undoing harm and also making sure that people can live healthier and happier lives. That’s a long project that’s going to take a long time. But if we think about specific strategies being deployed now to reach people, one of our producers in L.A. told me that she’s seeing billboards and signs on buses around town that feature Black and brown patients and say, “Your questions matter.” Or, looking at stuff you’ve been tweeting, for example: “You’re not a Guinea pig. 150 million Americans beat you to it.” Does that have an impact?

RHEA BOYD: The mass calls where we try to just reach everybody with shouting one thing out, I think probably has some impact. But if I had to guess it’s size, I would say it’s probably minimal. I think the much more high touch I’m going to try to talk to every single person and at least have that person maybe share the information we share with somebody else who has a similar question, I think is probably the most effective and the most expensive way to do the work. I still try to use Twitter mostly to shape how the media talks about Black people and our choices around the vaccine. And to talk to legislators about what needs to be done, saying, “Rapid tests need to be free. For everybody. All the time. And sent to our houses. And we need to know how to use them.” And then we should create guidelines around how schools use them and how employers use them so that we can, at the same time that we have a really robust vaccination effort, have a robust effort to make sure that we’re trying to control community spread using all of the tools in our disposal, including masks and distancing and all of these things that we know would help limit spread.

SHANOOR SEERVAI: And finally, Rhea, you’ve talked about such a wide range of strategies for addressing the concerns that people have around vaccines. But if you could pick just one thing, wave a magic wand to make it happen tomorrow, what would you do?

RHEA BOYD: I want to respond with something that also takes on this underlying assumption that you shared that doing this work so that our system doesn’t harm people takes a long time. I think, if anything, the pandemic has shown how short a time we can do a ton of work over, and how much money we can pour into something. We’ve been fighting over whether our country can have universal health care for decades, at least throughout my lifetime. And here we are pouring billions of dollars into a single medical intervention for people — billions of dollars. And to see that happen over months tells us that if people want to get it done, and we are all aligned politically that this is a top priority in this country, we will do it.

That is the blueprint. I’m not asking for people to trust our health care system or have our health care system be better a generation from now. I’m saying, fix our mess today. Hire new people. If you have an executive at your hospital or at your clinic site who doesn’t know anything about racial equity, they don’t have the qualifications to be an executive and they need to be let go. Like, there are so many people who do this research, who do this work, who understand what it would take to do this at scale across our medical system, that all we need is a go and we are ready to go. And I think projects like ours are one example of how ready people were. Those vaccines weren’t even out and Black doctors were like, what are we about to do about this very predictable problem that’s going to come up in access to information about the vaccines? Like, let’s fix it before it even comes up. We can predict all of the problems that are coming. Like another problem that’s coming that we should have some plan for that I have not yet seen plans for is the chronic disability that our nation will be facing from folks who have long COVID. Across age groups, people will need insurance to get the care that they need to deal with that. People will need other providers outside of clinical medicine to deal with their cognitive delay, their challenges completing their schoolwork, their challenges going to work. That is a problem that we could be addressing now, and thinking of the racial groups who are most likely to be affected by that in school and in the workplace, if we just all get aligned that that’s a top priority in the country right now.

SHANOOR SEERVAI: Dr. Rhea Boyd, thank you so much for being here today.

RHEA BOYD: Of course. Thank you for having me in asking what I thought.

SHANOOR SEERVAI: This episode of The Dose was produced by Jody Becker, Karl T. Wright, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. I’m Shanoor Seervai. Thanks for listening.