Vaccine lessons for India from Black America
Those hesitant to take vaccines are often those whom social health systems have categorically harmed and historically failed to heal
According to recent data by the Kaiser Family Foundation, which analyses racial health disparities in the United States (US), White adults are nearly twice as likely to have received at least one Covid-19 vaccine dose than Black adults. Over a third of Black adults prefer to “wait and see” how vaccines will work for others before getting vaccinated. Almost four in ten Black adults (38%) are concerned they won’t get vaccines from a place they trust, and one in five Black adults (20%) are concerned they will have difficulty travelling to vaccination sites.
Such data, which reveals that Black Americans face access barriers and are less willing than others to get Covid-19 vaccines, adds a nuance to mounting evidence since early 2020 that Blacks are nearly three times more likely to die from Covid-19, and suffer disproportionately more Sars-CoV-2 infections than White Americans.
The reasons are amply clear. Blacks are likely to be poorer; live in crowded spaces; work in occupations that routinely expose them to the virus; face mass incarceration: and have an overwhelming burden of cardiovascular and respiratory diseases, diabetes, obesity and HIV. Racial health disparities in the US are based on entrenched histories of structural discrimination against Blacks by White health providers and policies, medical experimentation on Black bodies and everyday forms of racial and police violence, which puts Black lives at greater risk in the pandemic, and engenders deep-seated distrust in modern medical systems.
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In this light, Black America’s “vaccine hesitancy” today rests on a carefully preserved living archive of personal stories and is a mindful reaction against the unaccounted harms on their bodies through history. Ask about vaccine uptake and Blacks will cite the infamous “Tuskegee Experiment”, in which 600 poor black men from Alabama were recruited to a government-run study of syphilis in 1932 without informed consent; the men were flagrantly “studied” over 40 years and left to die without any treatment, compensation or justice (despite the availability of penicillin). Apart from generational trauma for Blacks, Tuskegee caused a decline in life expectancy among Black males over 45.
Stories like these have left open wounds on Black conscience and are kept alive by ordinary Blacks and radical anti-race activists today. Contemporary incidents such as the murder of George Floyd trigger Black memory about figures such as Henrietta Lacks, a Black woman seeking cancer treatment at Johns Hopkins Hospital in 1951, whose cells were stolen and used in medical research without consent for decades after her death. These stories inform everyday health experiences of Blacks – including their hesitancy towards vaccines. This drew official acknowledgment too, with Anthony Fauci saying that Covid-19 exposes the “undeniable effects of racism” on health systems.
What can India learn from these experiences of Black America?
First, India needs its own real-time vaccine hesitancy data, especially as the pandemic afflicts and ravages the rural poor who routinely face disabling barriers to health care. Data should be gathered after empirically and ethically identifying communities where vaccine hesitancy exists. Further, vaccine hesitancy needs to be treated as a part of broader vaccine decision-making rather than as a stigmatising subject that (re)produces disparaging stereotypes against the rural (and urban) poor.
Second, vaccine hesitancy data must be textured to reflect granular socio-cultural realities of rural (and urban) life. In biostatistical terms, it must be “thick data” (qualitative observations, feelings, reactions and stories). Thick data alongside statistics can play a vital role in documenting why vulnerable communities are hesitant to take vaccines in their own terms and using their evidence can substantively involve localcommunities in finding solutions. It is callous and insufficient to impose top-down “explanations” (such as illiteracy, backwardness) and diminish people’s experiential beliefs against biomedicine, as biased urban citizens (and netizens) do.
Third, data must be transparent and shared with key stakeholders. Along the lines of Black clergy and cultural icons, local “vaccine ambassadors” from panchayats or other grassroots networks trusted by rural communities must decentralise and facilitate data-based vaccination drives alongside health workers. Data shows Black vaccine hesitancy reduced significantly when Blacks realised they were adequately represented in vaccine trials or received trusted messengers. Indian vaccine manufacturers and the State must also make public Phase III trial-data along with side-effects and efficacy data, which must be shared with vaccine hesitant communities. In the words of Jerome Adams, former US Surgeon General and a Black American, “people need to know that you care before they care what you know.”
Fourth, India needs more nuanced overall health metrics. The demands of Black Americans for racial health justice exist alongside published government data on racial health disparities. Health metrics in India must likewise be expanded to explicitly reflect categories such as caste, class, gender, ethnicity and religion. On the ground, barriers to health care in India are conditioned by unique structural markers of difference. The reasons for vaccine hesitancy among a poor, rural Dalit woman and a middle-class Brahmin man are very different. Indian data must transparently capture nuances of the socio-cultural determinants of health.
Fifth, public health systems need to be overhauled and make last-mile vaccinations accessible and equitable. In India, mistrust in vaccines for the marginalised is grounded in everyday experiences of being misled, misinformed and maimed by malpracticing and fractured health systems. This includes experiences of neglect and abandonment faced by the rural poor. To address vaccine hesitancy, we must first acknowledge — as Black America’s experiences indicate — that people who are hesitant to take vaccines are often those whom social health systems have categorically harmed and historically failed to heal.
Nikhil Pandhi is a doctoral candidate in medical and cultural anthropology at Princeton University. He ethnographically researches global health and the social-cultural determinants of health in India
The views expressed are personal