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How do we establish trust around healthcare—including the COVID-19 vaccine—with Black, Indigenous and People of Color (BIPOC)​ groups and historically underrepresented populations?

, MSW, Executive Vice President of Health Equity and Community Engagement for the , helps address questions like these. Chambers draws upon more than 20 years’ experience in chronic disease prevention, health promotion and BIPOC community engagement to explain why accessing healthcare can be so challenging for these populations. While there are many barriers—from the historical burdens of underrepresented populations to accessibility and affordability of care—there are also tangible approaches to help make healthcare more equitable for all.

Can you tell us about the history of vaccinations in underrepresented populations in America?

Before we get into the history, we have to get into the entire experience of BIPOC people in America. The experience of BIPOC communities in America has historically been "second class," including the way they engage with the healthcare system. When we consider how we’ve treated these populations socially and economically, we shouldn’t be surprised that they’ve had a sub-par experience when interfacing with healthcare. In the context of COVID, we have to account for the lived experience of communities of color. The narratives of past abuses by the medical system—like the Tuskegee syphilis trials, for example—are replaying for many BIPOC people when they’re considering engaging with the healthcare system today.
 
When we put economic barriers in place that prevent someone from being able to access healthcare—a doctor’s appointment or a vaccine or treatment—what do we expect people to do? These limits could be geographic accessibility or affordability.

What kind of disparities in care do you see? 

With COVID-19, communities of color were the last to get tested. The confusion around who could get tested and when, created additional barriers. There was an assumption that testing hours were convenient to under-resourced, low-income populations. For populations working in low wage-earning jobs who couldn’t take the time off from work to go to a testing facility, that presented a major barrier for getting a COVID-19 test.

So, COVID-19 testing wasn’t made accessible to all?

Exactly. Availability does not equate to accessibility. What did it cost a low-wage-earning individual to go get a test? A full day’s pay for taking time off work, plus the financial expense of having to get to an inconvenient testing site.
 
The recommendation for a 14-day quarantine period on low wage-earning populations was additionally problematic. People in these populations couldn’t even afford to take 1 day off work, let alone 14. How do we expect them to trust the healthcare system when it seems like the healthcare system doesn’t understand their lived experience?

How do you see the COVID vaccine process playing out in communities with less health literacy and less access to care? 

If we've learned nothing else from COVID-19 testing on a social level, I hope we approach vaccination with the acknowledgement that everyone is not starting at the same place. We cannot have a one-size-fits all approach in our distribution around the vaccine and in our messaging and education around the vaccine.
 
We took a one-size fits all approach for COVID-19 testing and quarantining, assuming that everyone was starting from the same place and that approach would fit everyone—and it clearly did not. We should have been thinking about equity. We already know that Black and brown communities in this country are starting at a historical deficit, so we should have been more intentional about our strategy. Our vaccine strategy must be vastly different from the way we responded with testing when COVID-19 first came on the scene.
 
We need to identify anchor systems in communities of color that people can go to. This may mean taking healthcare outside the 4 walls of hospitals and doctors’ offices and into workplaces, food pantries or other community facilities.

What are your predictions for the future with regard to the COVID-19 vaccine reaching underserved and underrepresented populations? 

We need to look at the entire health ecosystem—from manufacturers to distributers to insurers and business groups—so that they are all part of the conversation and solution. We cannot assume that we’re going to get to mass distribution and vaccination with the same historical approach that we’ve applied to every other vaccination. We need to look at the data on vaccination rates for different communities of color for different vaccines and see what the numbers tell us.
 
Why should we assume that historically low vaccination rates are going to change just because we introduce a new vaccine? Instead of assuming that BIPOC people will line up to get this vaccine, we must create a message that resonates with these communities and validates their past experiences. We have to look at what our commitment has been to diversify clinical trials for this vaccine. We can’t get people to trust us if we keep doing the same thing that has perpetuated distrust for so many years. All it takes is for one group to have an adverse reaction to perpetuate distrust from an entire population.

Can you talk about the experience of communities of color within the healthcare system? How would you describe that experience? 

Let’s acknowledge the role that race and unconscious bias play in the administration of healthcare. I applaud the organizations out there that are putting mechanisms in place to prevent themselves from ostracizing individuals because of their race, ethnicity, sexual orientation, sexual identity or anything else. When you control for health insurance status, these other variables make the healthcare experience unpleasant for many individuals, including those that are low-wage earning or have low health literacy.

And the consequences of this ostracization?

It leads to misdiagnoses, delayed care, premature mortality and so much more. And remember, it all goes back to the lived experience of underrepresented populations; no one wants to come to a place where they’re not going to be treated well. No one wants to have that type of experience.
 
COVID-19 was the lighter fluid on the fire. When COVID first surfaced, we started talking about chronic conditions like asthma, diabetes and heart disease, as if they hadn’t existed for decades. For years, people have dealt with these chronic issues and they’ve have had to postpone care due to a number of reasons, which could be access related, affordability related or because of their historical experience when trying to access care.
 

What are your recommendations for how people in the science and healthcare fields can improve this inequity?

Think about the social context in which healthcare takes place. Whether a flu vaccine or COVID vaccine, really consider what factors could prevent someone from receiving treatment. How can we improve access—could we partner with work sites to bring vaccines into the workplace for low-income and under-resourced individuals?
 
Ask yourselves where this vaccine is on the priority list for patients who are trying to put their lives back together due to unemployment, the overall impact of the pandemic, natural disasters or other issues. When considering the distribution for this vaccine, it will also be crucial for us to consider how we can get it to underserved populations at a time and in a way that meets their needs. That goes back to working with grassroots organizations and anchor systems within these communities. We must understand, the communities are saying “why now.”  Why the sense of urgency now? Many have been knocking on the unanswered doors of healthcare for some time only to walk away “stabilized” but not “cared for.”

Thank you for taking the time to share your expertise on low-income and underrepresented populations within the healthcare system. Is there anything else you would like to add?

The COVID-19 pandemic has given us an opportunity to dismantle the systems and structures that have perpetuated racism and bias for many years. We must look at the role that legislative, regulatory and institutional policies have played as BIPOC have tried to seek their fundamental right to quality healthcare. The path forward for BIPOC does not have to look the same as the historical path; however, it will if we are not willing to be provocative enough to chart a new path. Each of us can play a role in moving towards achieving health equity, the question is, do we have the passion, commitment and fortitude to do so?