COVID vaccine resistance in underrepresented communities

Despite advances in the science of diabetes, including a huge armory of new drugs, over 34.2 million people still suffer. More than 88 million adults are at risk for diabetes, disproportionately affecting Black and brown communities. Individuals with diabetes, high blood pressure, and heart disease are also the same people at the highest risk of contracting and dying of COVID-19. Despite being overrepresented in the virus’s terrible complications, we are still not reaching those communities as we should.

While vaccine acceptability is rising, it is still shockingly low in Black communities. There are rational reasons for this based on how African Americans historically have been mistreated at times by the scientific community and the previously documented medical bias. Still, it’s important to engender confidence in a vaccine that could start to address the uneven and unfair impact of the coronavirus on underserved communities as a whole.

There’s been a huge push from the scientific community to ensure their enrollment into clinical COVID-19 vaccine trials. Many scientists, such as myself, are ecstatic to see a concerted effort to finally minimize disparities in the scientific process from the very beginning with diverse leadership and thoughtful planning. One example of success in this area is Moderna’s 30,000-person COVID-19 vaccine clinical trial, of which a third includes underrepresented individuals. Nothing says “this solution was made for you” more than intentional inclusion in the trial phase.

As a diabetes doctor and scientist, I am extremely worried about those who are resistant to taking vaccines. Each week I go to my clinic, knowing there will be pushback to life-extending advice I give my patients suffering from diabetes. It feels like this could be a losing battle if we don’t pay attention and adapt our messaging and our strategy.

During every clinic, I work harder and harder to convince my patients to take their medications and trust me and the medical system. It doesn’t help that our systems move so slowly: Time spent on pre-authorizations and approvals is longer and longer. Yet blood pressure control, glucose control, blood, and smoking rates in diabetes are worse than ever. Insulin, a life-saving medication with alarmingly higher costs, still causes many to have a deep distrust in starting this medication.

The secret rule of 50/50 is alive and well: 50% of people take their medications generally 50% of the time. The reasons are complex and deeply rooted and are not just patient-related (literacy, self-efficacy). Providers and health systems are implicated here due to communication issues, prescribing patterns, access, and time limitations.

We seemingly have not learned from our previous failures, and we keep forgetting about the “prevention paradox,” which prioritizes individual health over population health. We haven’t been paying attention to the root causes of chronic conditions like diabetes and have been spending way too much money on ventilators and not enough on personal protective equipment.

We must reach our communities where they are, surrounded by people and institutions they trust. Blast emails and high language will not work here. We need trusted community members demonstrating and showing the vaccine is safe and explaining why it is safe. We need researchers from all walks of life who have participated in this research to explain why this vaccine came out so fast. We need field health educators and diverse outreach groups to take up the cause. We need to be nimble and adapt as needed, and we need to track the safety of the vaccine in all communities.

But as a diabetes researcher for years, I am also hopeful.

I’ve worked with all types of stakeholders, government officials, pharmaceutical companies, payors, institutions, other health care providers, and nonprofits wanting what’s best for these patients and allocating real resources to improve research and care delivery. I have seen a change in those at the table, including more women, such as myself, and more underrepresented people.

According to Dr. Rosalind Ramsey-Goldman, a bright spot on this front is community-academic partnerships (CAP), and where health systems work with community leaders to understand decision-making regarding participation in clinical trials a colleague who has participated in these initiatives. Using a playbook that incorporates their insights, community leaders offer plain-spoken language to community members about key components of clinical trials, so neighborhoods have the confidence to test new treatments.

There have been breakthrough scientific drug advancements, unheard of in other industries, with several new classes of medications — more in the last 10 years than the previous 30. My husband jokes that you cannot watch a football game without seeing at least two new diabetes medication commercials per half.

These next few months are absolutely critical for our future as a community and a society.

I still go to my clinic every week and fight the good fight, knowing if I can convince one patient to go on insulin or get one insurer to cover a newer diabetes medication, I am winning the battle one patient at a time. And I am eager to see the systems above me change to help my patients more. I hope my deepest fear about vaccine acceptance dissipates and that our great scientific breakthrough doesn’t become our greatest defeat — 2020 has been hard enough.

This article is dedicated to the family, memory, and work of Dr. Nicholas V. Emanuele, a diabetes physician and researcher.

Amisha Wallia is an endocrinologist.

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