At the time of writing, estimates suggest that there have been over 4m cases of COVID-19 and around 121,000 deaths in the UK. COVID-19 has also brought devastating economic and social problems, exposing existing structural and systemic disparities within countries and globally. The impact on society as a whole may linger for many years.
The quest is to urgently overcome the pandemic before it takes further toll. As scientists and practitioners have improved their understanding of the disease, they have also expanded the tools to overcome it. We have seen the benefits of public health measures and now vaccines represent a vital addition to our toolbox in the fight against the virus.
However, global data suggests that we are dealing with increased vaccine hesitancy and reluctance. In the UK, this is especially among black, Asian and minority ethnic (BAME) communities, who are vulnerable and have suffered a higher impact of the disease.1 There are many reasons why BAME groups have been more affected, among which are social inequality and racial discrimination.1
GPs are uniquely placed to help tackle COVID-19 vaccine hesitancy. At the roots of the problem are mistrust and misinformation - and this is what GPs need to address.
How distrust develops
Successful vaccination programs depend on the general population's acceptance that the vaccines are effective and safe. Of course, there have always been 'anti-vaxxers' and we are also dealing with some individuals who do not believe in the existence of COVID-19 and are utterly irrational to the science of the disease.
However, people in BAME communities who are reluctant to use the COVID-19 vaccines have genuine concerns at the root of their vaccine hesitancy. Some of these stem from individual and group experiences of healthcare and others relate to inclusion and access to credible information.
Having personal experience of 'being treated differently' or ignored when seeking health care help in the past can create a foundation for future fear or mistrust in future engagements.2,3,4
Under-representation in clinical trials
Ethnic minorities often do not appear in significant numbers in research. The result of this is that people have difficulty accepting the results of such studies if the participants do not share similarities with them.
Subjects of experiments
A third, related problem is the opposite – where people suspect that they are subjects of experiments; a feeling that bears out a long history of abusive practices against minority groups, including:
- Denying slaves medical treatment or performing experiments on black slaves without their consent (and without anaesthesia) in the US.5
- The Tuskegee Syphilis Study spanning 40 years of experimentation, using black people as guinea pigs and without their knowledge in the US.6
- A more recent example of using experimental drugs on Nigerian children without seeking permission from parents.7
What worries our BAME patients about COVID-19 vaccines?
Some of the main concerns our patients have are:
- Vaccine safety, particularly considering the speed of their development. The main anxieties this creates relate to possible side effects and worries over the vaccines causing sterility, neurological conditions or death etc.
- What's in the vaccines? Some fear they contain HIV or that they can change your DNA and turn you into a 'chimaera’.
- Worries over religious acceptability – for example whether they contain ingredients that are not halal.
- Fears that minority groups - especially blacks - are being used as 'experimental' guinea pigs.
These fears can spread easily and rapidly among different social groups, particularly on social media. Whether as short viral videos on TikTok and Instagram or passed as truth from one WhatsApp group to the next, their power to influence viewers is immense.
What GPs can do to help?
As GPs, we are uniquely placed to counter false reports and address patient’s concerns. Though we now have limitations on patient encounters, we can still guide our patients in different ways. For example, in addition to traditional or online consultations, GPs could share educational posts or videos on social media with their own COVID-19 or vaccine experience to boost others' confidence.
The UK government recognises the barriers to vaccine acceptance among minority groups and recommends various methods that we can use to counter these effectively.8
The suggestions emphasise tailored communications, using multiple media platforms, for example, addressing vaccine safety and effectiveness, including 'rushed approval', and open, transparent dialogue about vaccine development and side effects in culturally relevant ways.
These are some of the ways I counter the misperceptions patients have presented to me.
No minority groups involved in clinical trials
The available data for Pfizer BioNtech trials show black/African Americans were the second-highest race in the trial (9.8%) compared to white (81.8%) and Asian (4.4%).9
Oxford AstraZeneca's clinical trials in various countries, including the UK, Brazil and South Africa show a demographic composition as follows:10
- UK - White: 91.7%; Black: 0.5%; Asian: 5.3%
- Brazil - White: 67.9%; Black: 9%; Asian: 2.5%
- South Africa - White: 12.5%; Black: 70.8%; Asian: 0
While minority groups are in small numbers, there is evidence of their presence which can refute claims that their involvement was only for experimental reasons.
Clarity on the side effects and safety
Using simple information leaflets and explaining reported side effects from trials is essential to counter misinformation. There is a claim in circulation that six people died in the Pfizer trials. The fact is that only two of those who died received the vaccine, the other four were in the study's placebo arm.9 Likewise, there are explanations for concerns over sterility11 and Bell's Palsy, etc.
Clarity on the ingredients
Explaining how the new gene-based technology works compared to traditional protein-based methods helps address DNA alteration concerns.12 It is also helpful to note the vaccines' constituents to counter further misinformation about vaccines made with HIV or other toxic material.13,14
Information on how the vaccine was developed so quickly
A frank discussion with patients on how new vaccines’ technology has advanced allowing their development in a relatively short time can also be helpful.
Most of what causes delays in vaccine development, such as funding and investment return, were removed with upfront investment by governments. A simplified structure for vaccine data validation and approval by regulators also helped to speed up vaccine development.
This will bring some clarity for those who suspect political or other motives. One of the advantages of gene technology is that we can use viral sequencing to quickly develop new vaccines in large quantities. This is already happening with flu vaccines where new strains are required every year.
There are also helpful resources available for health care professionals to employ in addressing misinformation from the BMA here.
The reversal of vaccine hesitancy will require hard and consistent effort. Knowing how to address our patient's doubts with facts is an excellent place to start. Attentive listening and being careful to understand their fears instead of dismissing them can help those who have difficulty trusting health care workers and institutions.
Studies also indicate that BAME healthcare workers show lower vaccine uptake. Some of the reasons for this may reflect the reasons highlighted in the 2019 NHS Workforce Race Equality Standard report: '.. structural discrimination in the NHS with racial abuse from colleagues, disproportionately high disciplinaries and lack of progression for healthcare workers from some ethnic minority backgrounds.'
It also observes that a lack of confidence in their employer and the lack of the protections of ethnic minority doctors and nurses can contribute to vaccine hesitancy among healthcare workers.
As patients or healthcare workers, the truth is that until the majority of us are vaccinated, all of us are still at risk of the disease. Therefore, it is imperative to do what we can, as often as possible, to address vaccine hesitancy concerns with genuine and supportive care.
- Dr Sylvia Kama-Kieghe is a GP in Sheffield, and founder of AskAwayHealth
- Public Health England. Beyond the data: Understanding the impact of COVID-19 on BAME groups. Published June 2020.
- Ekechi, C. How do we start a conversation about racism in medicine? BMJ Opinion, 25 June 2020.
- Black women are five times more likely to die in childbirth than white women. Why?. BBC Radio 4 Woman's Hour, 15 July 2019.
- Knight M, Bunch K, Tuffnell D, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2016-18. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2020
- Blow, Charles M. How Black People Learned Not to Trust. New York Times, 6 December 2020.
- Centers for Disease Control and Prevention. The Tuskegee Timeline.
- Smith, D. Pfizer pays out to Nigerian families of meningitis drug trial victims. The Guardian, 12 August 2011.
- Scientific Advisory Group for Emergencies (SAGE). Factors influencing COVID-19 vaccine uptake among minority ethnic groups. 17 December 2020.
- Food and Drugs Administration. Pfizer-BioNTech COVID-19 Vaccine Emergency Use Authorization Review Memorandum
- Supplement to: Voysey M, Clemens SAC, Madhi SA, et al. Safety and efficacy of the
ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of
four randomised controlled trials in Brazil, South Africa, and the UK. Lancet 2020;
published online Dec 8. http://dx.doi.org/10.1016/S0140-6736(20)32661-1. Available at: https://www.thelancet.com/cms/10.1016/S0140-6736(20)32661-1/attachment/75bff1ea-804f-4c66-adc1-2f7d0f9b4550/mmc1.pdf
- Goodman, B. Why COVID Vaccines are Falsely Linked to Infertility. WebMed, 12 January 2021.
- RCGP Learning. SARS-Co-V-2 Vaccination Training Module. Reviewed and updated January 2021.
- Medicines and Healthcare products Regulatory Agency. Information for Healthcare Professionals on COVID 19 Vaccine AstraZeneca. Last updated 28 January 2021.
- Medicines and Healthcare products Regulatory Agency. Information for Healthcare Professionals on Pfizer/BioNTech COVID-19 vaccine. Last updated 28 January 2021.