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Trust the Vaccine

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Description

Dr. Bob has two conversations about the work being done to get vaccines to Latino and Black communities. First, Jon Jacobo and Diane Havlir talk about the Latino Task Force, which is testing and vaccinating people in San Francisco’s Mission District. Then, Rhea Boyd breaks down the things that are preventing a lot of Black people from getting vaccinated. Spoiler alert: It’s not about attitudes. It’s about access.

 

This episode of the In the Bubble is brought to you in part by the Chan Zuckerberg Initiative: working to build a healthier, more just and inclusive future for everyone.

 

Follow Dr. Bob on Twitter @Bob_Wachter and check out In the Bubble’s new Twitter account @inthebubblepod.

 

Find our guests on Twitter @Jon_Jacobo, @DHavlir, and @RheaBoydMD.

 

Keep up with Andy in D.C. on Twitter @ASlavitt and Instagram @andyslavitt.

 

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To follow along with a transcript and/or take notes for friends and family, go to www.lemonadamedia.com/show/in-the-bubble shortly after the air date.

 

Stay up to date with us on Twitter, Facebook, and Instagram at @LemonadaMedia. For additional resources, information, and a transcript of the episode, visit lemonadamedia.com.

Transcript

SPEAKERS

Diane Havlir, Rhea Boyd, Dr. Bob Wachter & Jon Jacobo

Dr. Bob Wachter  00:09

Welcome to IN THE BUBBLE. I’m your host, Dr. Bob Wachter. This episode of IN THE BUBBLE is brought to you in part by the Chan-Zuckerberg Initiative, working to build a healthier, more just an inclusive future for everyone. On today’s episode, we’re going to be talking about COVID and Equity. When we look back on COVID, and how it’s changed society and how it’s changed the healthcare system, it may turn out that the increasing focus on equity as a core value may be one of the most enduring legacies, partly because COVID exposed a lot of inequities in the system, and partly because COVID took place at a time of national awakening to the consequences of structural racism, most vividly illustrated by George Floyd, but certainly many, many other cases.

Dr. Bob Wachter 

So today, we’ll look at health equity and COVID and do it through two lenses. The first is going to be a story that I hope you find inspiring I certainly do. It’s one I know well, because it happened here in San Francisco and involve the Mission District, which is a predominantly Latinx very vibrant neighborhood here in San Francisco, where a group of community leaders partnered with health professionals, physicians, nurses and other health care workers, largely from my own institution, UCSF and Zuckerberg San Francisco General Hospital, along with the city and county of San Francisco, supported by a very generous philanthropy to develop a model for testing, for contact tracing, for community education, for community engagement.

Dr. Bob Wachter 

And now as we’ll talk about for vaccination, the results have been really all inspiring. While we’ve seen COVID related disparities in San Francisco, and in the Mission District, they have not been as stark as elsewhere. And San Francisco’s really impressive performance and COVID is in large part attributable to the fact that cases were kept down to a fairly low level in some of our poorest and some of our more diverse neighborhoods in the city. San Francisco’s case in death rates are about 1/3 of the national average and a point I’ve made several times before is if the US mirrored San Francisco’s per capita death rate, there would be about 350,000 Americans still alive today.

Dr. Bob Wachter  02:39

So it’s really an amazing story, completely grassroots building the plane while it’s flying kind of story. And we’ll hear from two leaders of the effort. One is Jon Jacobo, who is a community leader in the Mission District, and head of something called the Latino Task Force. And the other is one of my colleagues, Diane Havlir, who’s a physician who leads our division of HIV, infectious diseases and global health at UCSF and Zuckerberg San Francisco General Hospital. And Diane has really taken a lead in this unique partnership. After hearing from Jon and Diane about the Mission District and about the special efforts surrounding the Latinx population, we’ll pivot to focusing on the black population, particularly in the United States, and COVID.

Dr. Bob Wachter 

And we’ll hear then from Rhea Boyd, Rhea is a pediatrician and a community health advocate also happens to be based in the Bay Area, but her impact has been national and even international, where she has become a leader and helping to illuminate issues around health care and social justice and health equity and racism. During COVID, she developed the conversation Between Us About Us, which is a national campaign to bring information about COVID vaccines directly to black communities. And I think it’s a really interesting discussion. And we particularly tackle this issue that Rhea makes the point was more myth than reality of vaccine hesitancy among the black population.

Dr. Bob Wachter  04:06

So both of these conversations were deep and rich, and as such conversations are challenging. We had to cut some of it to make sure the episode wasn’t too long. And so if you want to hear the full conversations, head over to IN THE BUBBLE’s Patreon page, and we’ve put up both full conversations goes about an hour and a half in total. But we have the edited version here and I think you will enjoy it and learn from it and I think be inspired by it. So let’s begin with the story in the Mission District and bring on Diane Havlir and Jon Jacobo.

Dr. Bob Wachter

Hello, Diane.

Diane Havlir 

Oh, hey.

Jon Jacobo 

Hello, friends.

Dr. Bob Wachter

There they are.

Dr. Bob Wachter 

Alright, so let’s start with you, Jon. Talk about the Mission District.

Jon Jacobo 

Oh man, where do you want me to start? How much time do we have?

Dr. Bob Wachter 

What’s interesting, different, special about it?

Jon Jacobo 

So, you know, for those that don’t know, the Mission District has historically actually been, we would call a new arrival kind of community to receive folks back when it was the Irish, the Italians, and in the 50s, 60s, and 70s. And more pronounced in the 80s. It has really become kind of the Latino stronghold, if you will, where a lot of folks were able to come from Mexico and Central America directly to and I have that special connect and really resonate with it because it is where my parents were received when they fled El Salvador during a civil war, and landed right here on Cortland Street.

Jon Jacobo 

And of course, you also for those that don’t know, are in San Francisco, where there’s an incredible amount of wealth. And over the last 20 plus years, more than that, this same neighborhood has been confronting, gentrification, has been confronting issues of economic inequities, where we have folks that, you know, are maybe making $150,000 plus a year, living next door to folks that are making $43,000 a year. So there’s a lot of issues that obviously are plaguing the neighborhood, but the vibrancy and the beauty of that ethno cultural district is still very pronounced.

Dr. Bob Wachter  06:26

And Jon, when COVID hit Did you have any special worries, concerns, about how it might impact your community and that district?

Jon Jacobo 

You know, the very first thing that we were all most concerned about was when we hear shelter in place, we think of folks that are barely making it in an economy that is fully opened. And when you take away jobs, what that will mean to folks that try to pay rent, that try to feed their family. And so that was really the beginning thoughts for us is how are we going to help support those that have already been battling to survive in this neighborhood. Did we know there was going to be health disparities? I think to some degree, we all had an idea, but never that it was going to be as severe as what it turned out to be.

Dr. Bob Wachter

Alright, so Diane, let’s turn to you when you first learned about COVID. What were you thinking about the community? You work at Zuckerberg San Francisco General, which is in the Mission District. Did you have a vision that this would be a particular issue and problem for the Mission? And did you have any thoughts about how you would jump in if there was a problem?

Diane Havlir 

Thanks, Bob, I think the first thing that we noticed with COVID, and most pandemics, it was the same with AIDS, it’s people in the hospital that one sees, it was so dramatic from the very beginning in San Francisco, that normally in the hospital, maybe 20%-25% of the people in the hospital or Latinx, all the sudden with COVID it was 80% of people who had COVID. And that was just such a stark fact and statistic right in our face. And what immediately came to mind is okay, we need to take care of people in the hospital, we need to figure out how to do that.

Diane Havlir 

But we also need to understand what is happening at the community level, how is the virus spreading? How can we mitigate it? Who’s spreading it, are people symptomatic or asymptomatic? Many, many different questions. And when one has those questions, and one wants to understand the first step in doing that is to reaching out to the community, it takes a community to overcome a pandemic, and see who might be interested in developing a partnership. And that’s exactly how things started.

Dr. Bob Wachter

So all right, you have an idea that it’s striking the Latinx community disproportionally, you want to reach out to the community. How did you even begin that process?

Diane Havlir 

Well, from the AIDS work that we have done for a decade in Africa, we had done population level studies out of Brick-and-mortar facilities, and working with communities to really combat the AIDS epidemic where the majority of people are asymptomatic right now. So it’s just I would say it was intuitive. We had worked before with communities. And we’re like, we need to do this now here, right in our hometown in our backyard.

Jon Jacobo 

And if I could just, are you asking how the connect happen or where?

Dr. Bob Wachter 

Yeah, how, you know, you have these two groups, and they have, in some ways, they’re living in different worlds. And what I saw yesterday when I toured the site was sort of seamless integration. And I imagine that was not someone snapping their fingers. But that took some hard work and some connection. So how did that actually happen?

Jon Jacobo

You know, I will say in some ways, you know that old saying like cliche saying like the stars aligned, right? But number one, I really want to kind of uplift the name of a very special individual, retired health nurse at 186 that work with Diane for a very long time, Dion Jones, who is a very esteemed and beloved community member in the Mission District, her daughter ran a very amazing kind of group Loco Bloco here. And of course, you know, their connection to members within our Latino Task Force, which is the taskforce that was born out of the response to the pandemic, we’re able to kind of say, hey, you know, we got some folks that UC that are looking to, you know, do some work.

Jon Jacobo  10:28

And so that kind of began that conversation, but it came through a very trusted source and that of Dion Jones. But what I would say is that, and I’ve noticed this from the beginning until today, I would say that our worldview, kind of the philosophy of how we approach helping people is very, very, very aligned with Dr. Havlir, or Dr. Marquez, in this harm reduction model in this trying to be supportive and working from the ground up. And so even though yes, at first, we had outlined some rules and making sure that we shared power in an equitable way where it’s, you know, balanced, all those things laid out, but it’s been seamless, because the personalities and the ideologies are so similar in how we serve. So it has been kind of seamless, actually.

Dr. Bob Wachter 

Great. So in the early days, let’s say March, a year ago, no vaccines, the issues, and the tests were just emerging. So what were the things that you began tackling once this partnership became a thing? Maybe start with Jon.

Jon Jacobo 

So the first thing was really kind of messaging. You know, this pandemic hits, you know, what is it? What are we doing? What is it directives, to uplift another one of our value team members, Suzanna Rojas, who is the chair of our Communications Committee, started early on with just masking letting individuals in the community know that masking was an important thing. I’m talking about, you know, loud speaker in a car and Driving through the neighborhood and kind of shouting at people on 24th and bar in a loving way that they love.

Dr. Bob Wachter  12:01

How do you do loving shouting that? Can you do that for us? What is a loving shout out of the speaker?

Jon Jacobo 

Latina mothers have a very, very defined way of doing that. I don’t know if I could replicate it. But you know, like even myself included, like walking to Garfield Park, talking to our day laborers, our folks that just you know, a lot of folks that don’t have living rooms, because they live so many people to a place they use the park as kind of that living space, just walking out there handing out masks and having general convo’s to really kind of make it a normal thing. So that’s kind of how the outreach first started. But once we partnered with the UC and with Dr. Havlir where we had to then kind of change the messaging and actually speed it up a little bit to Hey, by the way, we’re gonna be doing testing.

Jon Jacobo 

And so for us, it was having community conversations with different community groups that maybe had been mistrustful of the UC, or had concerns of testing or, you know, why are we doing it here in this neighborhood? Are we the guinea pigs, right? And really trying to combat some of these ideas and say, look, I know that in the past, we’ve had these improprieties with medicine and other parts of the world, and that there’s a lot of mistrust. But right now, we’re in a pandemic, and everybody wants to do what we’re doing to some degree, they want testing, they want access to these things. And so we had to use our credibility to tell folks look, I know that you may not trust them, but you trust us. And we’re telling you that we have faith in this, so have faith in us. And that was really the beginning. And then I think Diane could speak to the back end, that really important kind of lift on their side.

Dr. Bob Wachter 

Yeah, Diane says to talk about testing from your perspective, sort of how testing got ramped up, and then how you embraced, one of the things that’s been impressive to me is there was a ton of real work that needed to be done, you know, on the ground, really important for today. But you also came in with somewhat of a scientific mindset, meaning we want to study the situation, learn from it, disseminate the knowledge. So how did you think through all that.

Diane Havlir  14:03

So I think what we did was we needed to, and we had conversations about this in order to respond to the pandemic, one needs data, and what we needed to understand how many people in the mission were infected at this time, how many people had been affected in order to do that we needed to do testing. So as Jon said, we the face of this, to get these data to help the community was the community itself. I could just remember we were sitting around saying, we’re saying everybody stay at home don’t come out. And we requested 4000 people come out of their house and get tested. And I was just, we were in the foxhole all together late at night, not just wondering what was possibly going to happen when we opened three sites all at the same time.

Diane Havlir 

And you know, what happened? People came out and the reason people came out was because it was a community facing event. So first question was, how many people are infected? In what can we learn about symptomatic or asymptomatic infection. And the other thing about trust is, we have this principle, as soon as we get new data, the first thing we do is share it with the community. We’re not keeping it all secret. We’re not saying we want to get some publication; we don’t want to tell anybody; we share it with the community. And we have a question and answer. And of course, we do all the other academic things. But that has been really fundamental to the partnership.

Diane Havlir 

So what we learned at the beginning was that, yes, the Latino community is being disproportionately affected by the pandemic, but it’s not because they’re Latino, that’s not like, that’s not the reason why it’s because the way the virus spreads, it spreads through symptomatic and asymptomatic people. And it’s people who are not able to work at home, on their computers, during shelter in place who have to go out. And they were the ones keeping our city going during all this time. And they were the ones most exposed to getting COVID. And they were getting COVID. And because of the disparities that Jon talked about, economically, they were living in very crowded housing conditions.

Diane Havlir  16:07

And that was really the first piece of information that we had to get, yes, the communities being disproportionately infected. Yes, we need resources to help. And then the other thing is, it’s not just good enough to test people. This is something we know from HIV, you can’t just bring technology, you have to measure something, you need to act on that. And what we realized is that we did not develop a test model. We’re understanding the science, we’re generating data, but we’re doing test and respond. And this is where I think the partnership is so beautiful from the standpoint, what’s respond?

Diane Havlir 

Well, respond is you have people from the community working with people who are infected, who are scared, they want to understand more about the virus, we have to explain to them why isolation is important, how one can do isolation at home, how there’s other services in the city, we supply food, we supplied information. And all of that was through a program the respond part of our program designed by the Latino Task Force members of our collaboration. And it really was prototyping, I think, a model for rapid action during a pandemic.

Jon Jacobo 

If I could just add to that, you know, I think a lot of that comes from the ability for us as a collective early on, to go knock on 1400 doors four times over four days, and actually register and talk to community members at their door on their level, the people that would go out would always be paired with one Spanish speaker. And of course, we spoke English so we can communicate with everyone. But we were also taking in just anecdotal data from people like what are people saying? What are their concerns? What are their fears, and a lot of what we heard to Diane’s point, and a lot of what we knew intuitively, is that, you know, okay, guys, you want me to come get tested? I don’t have any symptoms. If you tell me that I’m sick, I have to stay home for two weeks. How do I have food? How do I you know, who pays my bills, there’s so many questions that are that are literally embedded in the inequities that are causing this pandemic to begin with. And so this community wellness team, this response that Diane is talking about has been pivotal to our success in ensuring that people stay home and are taken care of with dignity.

Dr. Bob Wachter  18:12

And how do those problems get addressed? So were there new resources that came in based on your data that allow people to stay at home and shelter?

Jon Jacobo 

So we, you know, with the UC side had the clinical response team, which was able to speak to these individuals, you know, that now are being told they’re COVID positive at a time of folks remember where many people couldn’t even get a COVID test, and what that meant for them and what the fears were back when everybody thought it was radioactive, and who knew what would happen? We developed a community wellness team, which allowed us to, A, have, think of it like a case manager, somebody that can talk to you from a community side, and just check in with you day to day see what you may need, then we were able to ensure that we had a food box delivered to you that would last for two weeks.

Jon Jacobo 

And it was food that’s culturally relevant. It’s connected to our mission food hub, which distributes about 9000 boxes a week to families throughout San Francisco. So we know it’s culturally relevant, it connects cleaning supplies. And then ultimately, we worked on a new city policy that was created known as the right to recover alongside supervisor Hillary Ronen, to ensure that if you’re missing work, we can at least take care of you at minimum wage for the two weeks you have to stay home. And that is a game changer for folks that again, are barely surviving, but we’re asking them to do what’s right for society and stay home. So all those things were able to allow us to get people to actually stay in.

Dr. Bob Wachter

Let’s move forward in time to vaccination. So how is the rollout of vaccinations going in the community and what has been the role of […] facilitating vaccination in the Mission District? Maybe Diane, why don’t you start?

Diane Havlir  20:04

I think that the overall city strategy we had was to do large sites complemented by community sites. And we were very on board with our mayor’s approach. And we knew that we needed to set up the site in the mission right next to our testing site, because testing remains, you know, very important in the pandemic response. So we all just had a meeting, we said, we’ve got to do it, we’ve got to set up a low barrier vaccination site, operating under all the same principles that we had set up our testing site. And February 1st, it was kind of amazing. We didn’t think we could do it, but we set up a vaccination site.

Diane Havlir 

And every week, we adapted to the different criteria that the state in the city were rolling out about who was eligible. And I do think something that we did a survey in January, when the nationally people were saying with surveys of which I’m not really sure the generalizability to the communities where we’re working, the way they do the surveys. But when we surveyed people who we knew were at the highest risk for getting infected at the time, there was a 13% positivity rate. 85% of people said this is before the vaccines were available. This was in January, that they wanted to get vaccinated. And we were caught, we were thrilled, we were a little bit astounded.

Diane Havlir 

But I think part of the reason was, and Jon can speak to that is that it isn’t so loud had been working with the community all along and had built trust about telling people, what do we know, what don’t we know? And what do we think is the best thing to do with this moment. So I think that, that 85% really reflected the trust that we had built over the last, you know, seven to eight months previously. And I just one of the highlight moments of our collaboration was when community health workers, all the people worked on a collaboration could get vaccinated, and we did it on our site. And I think everybody felt at that moment, things are going to turn around and things are going to be different.

Dr. Bob Wachter  22:05

Jon, what do you take from there sort of what were the issues for the community, and how important was this the 6 months or almost a year that you’d spent building up trust around once vaccines became available?

Jon Jacobo 

You know, I would say that it has been pivotal. And the reason I can say that with confidence, at least in the very anecdotal kind of experiences that I share is we work with different communities throughout the state, two or three other communities that we try to partner with, to provide insight for with the Latino community, one on the East Coast as well outside and a separate part of the country. And understanding where their community is, in terms of vaccine attitudes. And when we talk to them, and we hear their stories or hear their concerns, reminds me of where we were, you know, maybe 9 months ago.

Jon Jacobo

And the reason is for exactly what Diane said, has been the groundwork that we’ve laid to build trust, and to really make COVID a real thing, and make the trust in science, the trust in medicine, a real thing. And so part of this survey that Diane was talking about as well, when we like to always kind of highlight because you know, we take some pride in it is asking where people trust, where they get their information from, who do they trust, right? And when it comes to COVID. And of course, in first place, you know, or like doctors and science and those things, that’s great, because that’s where we want to get our information from, right? The experts. And in second place, you know, ahead of local leaders and government and state leaders and federal leaders is the Latino Task Force, you know, coming right in its second place as a trusted source for information.

Jon Jacobo 

And I think that lends itself to the credibility of this is a real pandemic. And the people that are in that are coming to get tested. Understand that because they’ve lost family members or have been ill themselves. And they know that we are helping link them to these things to our own newest project. And that I will tell you has been pivotal in not just the attitudes, but in getting I think today will cross 17,000 people vaccinated first and second shots, right, which is a huge, you know, endeavor and a huge lift that this group has contributed to.

Dr. Bob Wachter  24:21

Yeah, spectacular. When the vaccines got closer to a reality, we began hearing about communities of color. Don’t take vaccines, there’s a huge amount of hesitancy on for the black community that often got quickly tagged to Tuskegee, to the Latino community. There was not really an obvious sort of why it may be a little bit of not wanting to put their name on a list or be tracked in some way. First of all, is vaccine hesitancy a real issue or a particular issue in the Latino community or not? And second, sort of to the extent that there was some there was some in every community, were there specific things that you had to do to address in the Mission?

Jon Jacobo 

My answer to this has evolved greatly, I’m going to admit something to all the listeners here, I’m 32 years old, and I’ve never had a flu shot. And many of my peer organizers that are both older and younger than I will tell you the same thing. When the vaccine first came out, a lot of us internally had a little bit of hesitancy as to why. And the conversations vary, when I talked to folks that I grew up with here, in the city in the Bay Area, the answers are a little bit more maybe different, right from when we connect with new arrival, folks that have come from Mexico or Central America, the why is really a wide variety as to why there is hesitancy but it was really interesting for me, and this is kind of again, my experience, and this was when we first did flu shots back in September or October, forgot the month it was.

Jon Jacobo  26:02

And we put them up, I remember thinking, you know what, we’re gonna put it up and nobody’s even gonna want to get a flu shot like it’s, you know, going to be very underutilized. And but, you know, I went, I went along for the ride, because I think it is a great thing to offer, right? And I myself was coming around to it, too. But what really kind of caught me by surprise was that it was utilized, actually. And the people that were going to use it, were a lot of our folks that had, you know, newly arrived to the country, folks that were coming to the COVID test site, and were like, hey, where’s the flu shot? I want the flu shot. Like I’m not I don’t care about the test, no offense, but where’s the flu shot, we would point them across the way, and they’d go over there and get the flu shot. And it was the same at our 701 Alabama site. It’s a very mixed bag. But I will say that, I think maybe then large part through the work we’ve done for the actual vaccines once they came out. It has not been an incredible arm twist to get people to do this, it seems like they have wanted to. And I think it’s because of the severity of the virus and the work that we’ve been able to do.

Dr. Bob Wachter 

Maybe last question, you’ve talked about a lot of macro things and big numbers that people get tested and vaccinated and its impact for the city and the community. Any one anecdote that either of you wants to share that you found particularly meaningful or particularly poignant, as you’ve lived the last year and done this work?

Jon Jacobo 

That’s it right and, and respecting the position you take, I think that’s the most important piece. And I’ll never forget, you know, at the last day of our testing, same individuals walking down the street, and they yell my name from across street, and I look, and they put their hand up, and we were doing the antibody test back then. So they would do the fingerprint in addition to the swab. And they’re just kind of wagging their finger like I did, I did my test. And we were able to convince that one person that then later came and got a vaccine and it takes that little bit but you just sit down you have these conversations and people trust it and they trust the process. They’ll roll with it.

Jon Jacobo 

Maybe for me, it just one that always stay to me was like, at the beginning it just because we’re I’ve been reflecting on the last year, I just think back to the beginning and even for the vaccine to, you know, a small, local business person here, business owner, in the neighborhood that was really like, hesitant, and reluctant was just like, you know, what, we’re not guinea pigs, and they’re just gonna come in here and test us and take our info and leave, and we’ll never hear from him again, I’m not doing no test, you know, like all like just very, very reluctant. And, you know, spent me and one of the other individuals I was with, when we were doing this outreach, spend like 20 minutes, just having a conversation, like, let’s just talk about the truth of what I think it is and what you think it is, and not even try to convince you just laying having dialogue.

Dr. Bob Wachter  28:45

That’s wonderful story and sensitive podcast, people couldn’t see it was not the finger, you might worry about that he was wagging at you. Diane, any story you want to leave us with?

Diane Havlir 

I just remember that before vaccines when we had testing and we tell people, you know, you have COVID, I remember the face and the body language, if somebody was told they were positive, just how tense they looked. And after he was told that, don’t worry, we’re going to help you, we’re going to give food, you’re going to get income, you don’t have to worry about your job, his whole body just relaxed and the look of relief on his face. And it was I’ll just never forget that. And that was really part of this test and response model that you know, we’ve developed.

Dr. Bob Wachter

Well, thank you both for sharing this with us. And I have had a chance to watch it from a little bit of a distance. And but I can tell you it’s extraordinarily impressive. It really is a it should be a national model should be an international model. And it’s really gratifying to see the university and the community and the city and the folks who’ve helped fund it come together to do work that’s been really made a massive difference and saved many many lives. And I really do think it will be something that we carry forward and will make us better at other things that we try to do to improve health and healthcare. So thank you both for that. And thank you to all of your colleagues who’ve worked with you.

Jon Jacobo  30:11

Thank you.

Diane Havlir

Thank you.

Dr. Bob Wachter 

Thank you to Diane and Jon, for that inspiring story. And really a model of what can be done. When healthcare professionals, academic organizations like mine, and maybe just generally big institutions form real and respectful partnerships with the communities in which they live in work. And, you know, it really can work. And as I mentioned, I had a chance to visit the main site that they work on in the Mission District this past weekend. And it’s very real and very inspiring. And the folks that work there are just exceptional. And I really do believe that they’re changing the world. And they are absolutely right. Let’s take a quick break. And then we will talk to Rhea Boyd about issues in the black community.

Dr. Bob Wachter 

Thank you for coming on.

Rhea Boyd 

Thank you so much for having me. I’m excited to chat today.

Dr. Bob Wachter

Where does the idea that Black people are hesitant to get vaccines come from?

Rhea Boyd 

You know, I think it initially came from at least around the COVID vaccines, the early data that came out last summer that said about half of Black folks, when asked if they would get the vaccine, if they were eligible today said no, they wouldn’t. So I think that created this kind of fodder for the media to then describe that response back in the summer as a degree of reluctance to be vaccinated in general.

Dr. Bob Wachter

And was that unreasonable? Or is there a history in the Black community of some reluctance to take vaccines?

Rhea Boyd

I think it wasn’t evidence based to suggest that Black folks have a history of, you know, reluctance to take vaccines. In the article that I published that I was thankful to publish in the New York Times I tried to draw attention to some of the evidence that we have about vaccination rates by racial and ethnic groups. And while we do see racial health inequities in certain vaccination rates, when you look at interventions that have been used to kind of narrow those inequities, you see that like, actually, if you just address some of the barriers to getting vaccination, Black folks are just as likely to be vaccinated.

Rhea Boyd  32:34

You know, they’re I relied on some of the data, you know, as a pediatrician, looking at children’s vaccination rates for really common recommended vaccinations, like MMR and polio, that evidence from the CDC told us that since 2005, there have not been racial health inequities and the children who get that vaccine and that that narrowing of that gap was almost entirely owed to the vaccines for children’s program that started in the 1990s that made vaccinations free for kids. So cost was a major barrier and even now, with the COVID vaccines, half of Black folks who say they’re still waiting to see if they’re going to get the COVID vaccine are concerned that they might not be able to afford it, even though the vaccines are absolutely free.

Rhea Boyd 

So cost is a major real-life barrier and a major perceived barrier that needs to be addressed. And then I also highlighted some of the data from, you know, influenza rates. So before the COVID, vaccines had rolled out, some people were relying on the disparate influenza rates among racial and ethnic groups to say that perhaps, you know, Black folks are more reluctant to get seasonal vaccines. And if the COVID vaccine became a seasonal vaccine, maybe that was an indication that black folks wouldn’t get the COVID vaccine. But there’s great data that looks at black folks who actually have insurance who are on Medicare.

Rhea Boyd 

So these are Black folks who are, you know, age 65 years and above that, what narrows that gap and whether or not folks actually get the influenza vaccine is whether your doctor just offers it to you, which underscored the larger evidence base that tells us that Black folks overall are less likely to have preventative services recommended to them by their health care providers. And so from my standpoint, I think we were premature to call Black folks vaccine hesitant in general, because evidence really shows that when we address the barriers to vaccination, Black folks are just as likely to get recommended vaccines as any other racial group.

Dr. Bob Wachter  34:19

I want to go back to the early days when we were trying to come up with vaccine prioritization schemes. And we chose to go with health care workers, people in congregate living settings, like nursing homes, and also by age older people going first. There was a lot of debate about equity at that time and where it should fit into vaccine prioritization. How do you think that debate played out? And do you think we made good or bad choices about who got their vaccines first?

Rhea Boyd

You know, I think there was a lot of attention to equity. I had read, you know, reports from some of the government bodies that oversee and make recommendations as to how the vaccines would reprioritize and you saw entire sections on equity like there was an intentional focus on equity early on. I think, looking back, one of the challenges was, there was a decision to recommend that states and municipalities use what’s called the Social Vulnerability Index as a marker of who might be most at risk for COVID. A social vulnerability index tries to take into account some of the social drivers of health inequities.

Rhea Boyd 

But the thing the social vulnerability index doesn’t perfectly capture is kind of the experience of folks who live in deeply entrenched forms of residential segregation, like folks of color, who also live-in areas that have been chronically divested. And when you only use a social vulnerability index, and you don’t have another index for racism, to explicitly think about the ways that racism is manifest in people’s lives. As an example, through residential segregation, I think we missed that states would then prioritize people just based upon age as if age could capture what has happened to people who have lived in those settings over generations.

Rhea Boyd  36:26

And we missed that people who live in those communities would need explicit resources brought right to their doorstep, because there was no preexisting landscape for preventative services in those divested communities. So looking back, I think we can learn, I hope we have learned a few lessons there. And I hope if we could do it differently, you know, in the future that we will.

Dr. Bob Wachter 

Would you have favored a an explicitly race based prioritization scheme, that you know, we say that after vaccinating people over age 75, let’s say the next group will be Blacks or Latinx? Or do we use proxies, as you say, the social vulnerability index gets at some of the proxies, but maybe not all of them to get at some of the issues that stand in the way of people getting vaccinated. equitably. So I think we’re often reluctant to use race as a, you know, as an explicit marker, but how would you have done that?

Rhea Boyd

You know, two things. First, I think the Blackstock physicians, the doctors Blackstock are right, when they said in the Washington Post, that we should get rid of age entirely. I think they’re right, because one of the things that we know is that age did not capture folks who are more likely to necessarily be exposed to COVID as a result of their living or working conditions. Age criteria also didn’t capture the enormous burden of COVID mortality that we saw in communities of color at much younger ages. You know, there was a paper that working paper that came out of Harvard School of Public Health, I think the lead author was Nancy Krieger, Dr. Krieger that looked at kind of age core tiles by racial and ethnic group, and it looked at COVID mortality rates.

Rhea Boyd  38:18

And what they found was that for Black folks, if you compare Black and White mortality rates for folks aged like 35 to 44, Black folks had like a nine times higher COVID mortality rate, something enormous. And what that said to those of us who kind of looked at that data was, it told us that we needed to pay attention to the ways that chronic exposures to discrimination and divestment in the environments in which folks of color live actually mean they may be more at risk for COVID mortality at younger ages than we might have expected. This is like leaning on theories like weathering, which is a term coined by researcher Arline Geronimus that looks at the ways that telomeres at the ends of our DNA can be shortened by chronic experiences with discrimination, which then ages ourselves and then leads to kind of organ dysfunction and premature death.

Rhea Boyd 

I think when we saw COVID mortality at much higher rates in communities of color at younger ages, it also underscored for me that we needed to move away from age. So if we move away from age, then should we just use explicit race as the criteria of who gets it. I think that also is not necessarily the right approach. Perhaps the right approach might be a more intersectional one, one that thinks not just about someone’s position in society because of their racial, their assigned racial group but also thinks about the intersection of that racial group with their social class, with their gendered identity, and with the community in which they live.

Rhea Boyd  40:08

And if folks who are of racial groups that have been subjugated in our nation’s history, and are part of gendered identities that have been subjugated through our nation’s history, and live-in segregated communities that don’t have equal access to health care services, and basic public goods, like clean water and healthy food, then those people should be at the top of the list. And we can use the area in which they live as the place where we prioritize access.

Dr. Bob Wachter 

Yeah, and then we heard the stories of okay, we get that there’s an access challenge in this particular community of color or a poor community or both. We’re going to make vaccine available there and people driving in from the suburbs to because they hear vaccine is available. So how did you feel when you use it when you began hearing those kinds of stories?

Rhea Boyd 

Yeah, I think people have referred to that as like Vaccine Tourism. You know, it’s troubling. It’s troubling. Even it evidence that even on top of efforts to prioritize communities who are hardest hit, there are some folks in our society who feel so entitled to all of the resources that our society has, that they will take it from somebody else who perhaps is more in need of it than they are. I think that entitlement is a reflection of how white supremacy is manifest in people’s lives.

Rhea Boyd 

And I think it’s something that I hope, this current moment we’ve been in as a nation over the last year with COVID, and police brutality and anti-Asian hate crimes like I hope, […] insurrection, like I hope we come to really confront the ways that white supremacy, as manifested this example, through entitlement to vaccine in neighborhoods that aren’t your own, you know, is really harmful to everyone.

Dr. Bob Wachter 

Yeah. As you talked about how this early narrative about vaccine hesitancy in Black communities was not particularly evidence based. And you’ve done some really important work and exposing that. Now, the evidence-based look at the data would say that vaccine hesitancy is most prevalent in White Republicans. How do you think that’s getting covered? And what is the way that gets covered, say, about how the media handles the narrative about Black people?

Rhea Boyd  42:42

You know, this is a very important question. And it kind of relates to the last thing I just said, which is that there is a reluctance, or perhaps even just an outright denial in our public discourse, to talk about White supremacy and whiteness, and how it shapes health behaviors. Jonathan Metzl, psychiatrist and researcher at Vanderbilt wrote an incredible book that was published, I think, in 2019, called Dying of Whiteness that looked explicitly at the ways that whiteness as a structuring principle, as a way to confer kind of advantages and privileges on white folks, as a population through laws and policies, can actually be harmful to white folks, if it shrinks the pot of public resources that is available to everybody.

Rhea Boyd 

If the ways that white folks want to demonstrate their racial dominance is through under investing in the social safety net, for example, then when a pandemic hits, and everybody has to lean on that social safety net, you know, everybody, including White folks are less equipped to do so. Because we don’t talk about whiteness, and we don’t know these basic definitions around whiteness, and how it functions to harm health. I think we were ill equipped to try to diagnose why, as you noted, White folks who vote Republican, are among those who say they won’t get the vaccines.

Rhea Boyd  44:11

I saw some data that suggested that perhaps that’s because there are certain segments of our population who also live-in kind of separate information universes, where the information that you rely on and the news that you watch is anti-science, and perhaps even, you know, fake news. And that for folks who are caught in that information cycle, and who have placed their own selves in that information cycle and rely on it, that it does them ultimately a disservice in many ways, but specifically, around information about the safety efficacy and protection of COVID vaccines.

Dr. Bob Wachter 

I want to give you a chance to talk a little bit about the work that you have been doing. So where can people find the work that you’ve been doing?

Rhea Boyd 

Thank you. And if you go to www.betweenusaboutus.org, you will see a campaign that features Black doctors, nurses, and scientists talking about the COVID vaccines or just answering the common questions that we have heard from black folks across the country about their concerns regarding the COVID vaccines. This is a project that is co-produced by Kaiser Family Foundation and the Black Coalition Against COVID. And myself, and I hope people like it.

Dr. Bob Wachter

I’m sure they will. It’s really, really important work. Are you optimistic or pessimistic about at the end of the day that whether the Black community will embrace the vaccines and take the vaccines at rates that are similar to two other populations. And the numbers seem encouraging. It seems like that, you know that, as you mentioned, some of the early surveys showed maybe some element of hesitancy, but it was a time when the vaccines were theoretical. And the more recent surveys don’t show all that much of a gap between the different communities. Where were you landing today in terms of your level of optimism or pessimism?

Rhea Boyd

I’m incredibly optimistic, I will bet on Black people every day of the week, every day in my life. I think what we’ve seen in terms of interest in getting the COVID vaccines is every subsequent survey has shown that a larger and larger slice of black populations in this country are interested in receiving the COVID vaccine. And the main thing that is keeping black folks kind of at the bottom, the second to last and actual access to at least one dose of a COVID vaccine, as they haven’t had equal access. And so I’m optimistic that folks are interested. And I’m really optimistic to see efforts led by Black healthcare workers to bring vaccine to Black folks and to bring information about the vaccines directly to Black folks, I think their work has been so inspiring and has been a model truly for how our healthcare system can narrow racial health inequities.

Dr. Bob Wachter 

Well, great, well, your work has been inspiring as well. And really making a difference in a very, very important part of getting out of this pandemic. So thank you for everything you’re doing. Thank you for spending time with us today.

Rhea Boyd 

Of course, thank you so much for having me, it’s such an honor to be on your podcast.

Dr. Bob Wachter 

COVID will have done many, many terrible things to us and our people, but it will also I think, leave us a better and more equitable society and country, in part because it’s created the motivation and the burning platform and the space to have discussions like the one you just heard. And so thanks again to Rhea Boyd to Jon Jacobo today and Havlir, not only for being with us today, but for the work that they are doing to make us all better.

Dr. Bob Wachter  48:14

We have more great stuff coming up on IN THE BUBBLE, we’ll do a toolkit about getting back to normal and why it’s so hard and why it’s so weird. I just took Newman for a walk this morning and did not wear my mask per the new CDC guidelines. And it was weird, and I was looking at people funny and they were looking at me funny. I think that’s gonna last for a while. So we’re all grappling with that. And we’re going to bring on Craig Spencer and Lucy McBride to help us think about this new stage of oddness, as we try to get back to normal and why it’s so weird and scary.

Dr. Bob Wachter

Speaking about trying to get back to normal, we’ll also do an episode on COVID and the workplace, as we all return in various ways to the workplace and try to sort out how to make it work on site, not on site, hybrid, which days of the week, what the workplace looks like. All of those things have to be worked out. And they are tricky, and more and more of us are getting some experience with it. But there’s a lot to be worked out. And we’ll also have another episode where we have a chat with Justin Sutherland. Justin was a fan favorite a couple of years ago on Top Chef, he’s remarkable chef himself. But for our purposes, he also owns several restaurants. And we’ll talk to him about COVID and the restaurant and dining industry, how they’ve made it through the past year, year and a half. And what the future looks like what the changes in how they do their work are and what all of our experiences going to be going back to restaurants as we all do. So more great stuff coming up. I hope you’ll join us for all of these and our other episodes Until then, stay safe, stay well get vaccinated and we will talk soon.

CREDITS  50:05

We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced our show. Our mix is by Ivan Kuraev. Jessica Cordova Kramer and Stephanie Wittels Wachs executive produced the show. Our theme was composed by Dan Molad and Oliver Hill and additional music by Ivan Kuraev. You can find out more about our show on social media at @InTheBubblePod. Until next time, stay safe and stay sane. Thanks so much for listening

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