A person holding a vial of the COVID-19 vaccine.

A 2006 skit on "Saturday Night Live" featured Kenan Thompson, the Black comedian, so suspicious of being treated by a white doctor that he won’t give his address and Social Security number, sure that will lead to surveillance vans outside his house and listening devices in his Girl Scout cookies. When the doctor tries to calm Thompson down with a shot, he shouts: “I know what this is: Tusk-ee-gee, Tusk-ee-gee, Tusk-ee-gee!”

It was a joke, of sorts, decades in the making. As humanity fights to end a global pandemic, there is new urgency to resolve the fundamental issues that made the skit so disturbingly resonant more than a decade ago.

The U.S. Public Health Study at Tuskegee was a government research project now infamous for its staggering breach of ethical standards. Begun in 1932, 600 Black men—mostly sharecroppers from rural Alabama—were recruited to track the course of syphilis, with the promise of free meals and medical care. 

More on the COVID-19 Vaccine

But they were deceived: Patients were treated by placebo. By the study’s end, 40 years later, 128 had died of the venereal disease or its complications, the wives of 40 of them had been infected, and 19 of their children were born with the disease.

The legacy of that deceit has endured and helped shape attitudes toward the current pandemic, including why Black Americans are less likely to say they will be vaccinated against COVID-19, even though they are almost three times more likely than whites to die of it.

Americans' confidence in the vaccine has grown steadily, according to monthly nationally representative surveys taken between October 2020 and January 2021 by Consumer Reports (PDF). But by the start of this year, 42 percent of Black Americans who have not yet gotten a COVID-19 vaccine still said they were not too likely or not at all likely to get the vaccine, compared with 33 percent of Hispanics and 31 percent of whites. 

‘COVID has allowed us to take this opportunity to slow down and make it about patient-centered care. This is an opportunity for medicine to reset.’

Maysa Akbar, PhD

Clinical Psychologist, Yale School of Medicine

CR's survey also suggests that Black women and younger Blacks who have not yet gotten the vaccine may be particularly unlikely to get one. It found that only 46 percent of Blacks ages 18 to 44 said they are somewhat or very likely to get vaccinated, compared with 80 percent of those 60 and older. And 48 percent of Black women said they were either not too likely or not at all likely to get the shot, compared with 35 percent of men.

Those findings are mirrored in other recent surveys, including from the National Foundation for Infectious Diseases.

But where some see only barriers, others recognize a possibility for change. “COVID has allowed us to take this opportunity to slow down and make it about patient-centered care,” says Maysa Akbar, PhD, an assistant clinical professor of psychology at the Yale School of Medicine and the author of “Urban Trauma: A Legacy of Racism" (Publish Your Purpose Press, 2017). “This is an opportunity for medicine to reset.”

That reset is taking many forms, from executive orders signed by President Biden to establish a COVID-19 Health Equity Task Force to mentorship programs for Black medical students to grassroot efforts.

More Black Americans Say They Are Unlikely to Get Vaccinated
Source: CR nationally representative survey of 2,223 U.S. adults conducted Jan. 7-19, 2021. Percentages are Americans who have not yet gotten a COVID-19 vaccine and say they are "not too likely" or "not at all likely" to get a vaccine when one becomes available to them.

For example, last April a Philadelphia-based Black physician named Ala Sanford organized some of her colleagues to offer free COVID-19 testing in churches and community centers in some of the city’s poorest neighborhoods. And the Black Doctors COVID-19 Consortium was born. As of February, 23,000 people have been tested by consortium doctors, now 32 strong. Building on the bonds of trust created by the barrier-free testing, the group began distributing the COVID-19 vaccine in February.

That level of care and consideration counters the narrative of medical mistrust that was Tuskegee.

‘It’s not just the history, it’s the lived reality of everyday life that people experience in racism that makes the hesitancy come through.’

Susan Reverby, PhD

Medical Historian, Wellesley College

Accurate information from trusted sources can be another antidote to vaccination hesitancy, says James Dickerson, PhD, Consumer Reports' chief scientific officer. “As a scientist I tend to be more cautious about everything,” he says. “And the fact is, the development of these vaccines was the most accelerated in the history of the planet, which does give rise to questions.” But, Dickerson says, the research on the safety and effectiveness of the vaccine is compelling, showing that it is “efficacious across all communities.”

Acknowledging Deep-Seated Distrust

That the reticence of Black people to get the vaccine is a consequence of Tuskegee is indisputable, says Susan Reverby, PhD, a historian of American healthcare at Wellesley College and the author of “Examining Tuskegee: The Infamous Syphilis Study and its Legacy” (University of North Carolina Press, 2013).

But she believes it has become a “condensed symbol” for racism and mistrust in medicine that is rooted in experiences that extend to the present day.

“It’s not just the history, it’s the lived reality of everyday life that people experience in racism that makes the hesitancy come through,” Reverby says. It’s about “what happened to you throughout your lifetime or what happened last week to your grandmother when she went to the emergency room that really matters.”

A white physician in the field draws blood from a Black male patient.
A 1950s-era photo of a physician drawing the blood of a Tuskegee Syphilis Study participant.
Photo: National Archives

Others agree. “There is a direct line from distrust that was present before the pandemic to the sort of vaccine hesitancy that's being reported now,” says John Dovidio, PhD, a professor of psychology and clinical health at Yale University. “If I'm mistreated by white people and by major white institutions, the police, or other places, I should expect to be mistreated by medicine,” he says.

Even New York’s mayor, Bill de Blasio, said issues of trust were at the heart of the relatively low rates of Black New Yorkers getting the shots.

As the nation seeks to maximize COVID-19 vaccinations to speed the pandemic’s end, the need to address the aspects of our healthcare system and our history that have contributed to the abiding distrust, experts agree, is imperative. Though some of that work has commenced, to both mixed results and marked success, there is still much to be done, including in the following three areas.

Widening Access to Healthcare

It almost goes without saying: To have faith in the advice your doctors give you, you must believe from experience that they have your best interests in mind. But for many Black Americans, those fundamental bonds of trust are not so easily established, at least partly because compared with whites, fewer are insured and they have less access to healthcare in the first place, says Reverby of Wellesley College.

Even in March 2020, before the pandemic caused massive job and insurance loss, the differences in rates of uninsured people were striking. Whereas 6.2 percent of whites were uninsured, 9.6 percent of Blacks were, according to the American Community Survey from the U.S. Census Bureau.

There are also barriers in addition to lack of insurance, including inconvenient or unreliable transportation and the fact that “healthcare resources are more prevalent in communities where people are well-insured,” according to a 2020 report from the Office of Disease Prevention and Health Promotion. And some reports show that in some parts of the country, vaccination sites tend to be located in white communities, not Black or brown ones. 

A Saturday Night Live shows Keenan Thompson refusing medical treatment.
The 2006 "American Medical Association" skit from "Saturday Night Live" features Kenan Thompson as a patient invoking Tuskegee in protest to medical treatment.
Photo: NBC

Because access to care will be critical to a successful vaccine campaign, the Biden administration has pledged to build new medical facilities and temporary mobile clinics in underserved communities and hire 100,000 public health workers.

Outreach is an important part of the plan. On Jan. 21, President Biden signed an executive order establishing the COVID-19 Health Equity Task Force that, among other duties, will be tasked with creating “culturally aligned communication, messaging, and outreach to communities of color and other underserved populations,” according to the text of the order.

Some municipalities are doing their own outreach. In Detroit, a city with a nearly 80 percent Black population, only 3 percent of residents had received a vaccine as of Jan. 28, compared with an 8 percent vaccination rate for the entire state. The city’s mayor, Mike Duggan, says he has accepted bids from companies looking to provide free transportation to vaccination sites, opened more vaccination appointments, and hired 80 operators to schedule them, all in an effort to get the vaccine into the arms of more Detroiters.

Expanding the Ranks of Providers of Color

A lack of diversity among physicians may also underpin the mistrust people of color feel about seeking out healthcare. Blacks comprise 13.4 percent of the U.S. population but only 5 percent of physicians, according to the Association of American Medical Colleges.

But there is evidence that among Blacks, sharing a racial or cultural background with a doctor can promote communication and trust, and lead to greater willingness to engage in preventive health behaviors, like getting vaccines.

Improving those ratios could have a positive impact on health, a 2018 study from the National Bureau of Economic Research suggests. In an experiment, researchers randomly assigned Black male patients to Black or non-Black doctors to see whether having a doctor of their race affected patients’ decisions about preventive care. They found that “Black men seen by Black doctors engaged more, and agreed to more invasive, preventive services than patients seen by non-Black doctors.”

‘The systemic answer . . . to figure out how to retain more people as well as infuse more [Black doctors] into the workforce so that your outcomes start to shift in the positive direction.’

Italo Brown, MD

Stanford University School of Medicine

The lack of Black representation among physicians is an indictment of the medical system’s “baked in racism,” says Italo Brown, MD, a clinical instructor of social emergency medicine at Stanford University School of Medicine, who says he has already been vaccinated himself.

He describes what he calls a “leaky pipeline” in which many Black people in medical school drop out because of openly hostile training environments, inadequate financial support, and lack of outreach and mentorship.

“The systemic answer to that would be to look at these gaps critically, to figure out how to retain more people as well as infuse more [Black doctors] into the workforce so that your outcomes start to shift in the positive direction,” Brown says.

The ongoing global pandemic may be spurring more people, including more people of color, into the medical profession. Last year, the number of Black first-year med students increased by 10.5 percent, and applications for the 2021 year are even higher, according to the Association of American Medical Colleges.

Confronting Confirmation Bias

Convincing skeptical Black people to get vaccines also involves overcoming their biases—bred from history and personal experience—that predispose them to be leery of the government and medical establishment.

These biases can lead some to interpret new information, even false information, as support of a belief already held, a phenomenon known as confirmation bias, says Akbar, the Yale psychology professor. In the context of the coronavirus vaccine, she says confirmation bias can lead some “to seek out conspiracy theories and find comfort and community in like-minded people,” and conclude that the vaccine, which studies have shown to be safe, is the opposite.

Demystifying information about the pandemic is one of the aims of the COVID-19 Prevention Network website, created by the National Institutes of Health. By providing information about the science behind the vaccines and answering questions—like “Is joining a COVID-19 vaccine or antibody study like being a guinea pig?”—the network uses an engagement model to spread awareness and halt hesitancy.

A nurse about to get the COVID-19 vaccine.
Sandra Lindsay, a nurse at Long Island Jewish Medical Center, is one of the first people to be inoculated with the COVID-19 vaccine.

Some states are similarly trying to make inroads into communities of color to dispel distrust. In New York, for example, the Vaccine Equity Task Force is engaging Black churches, public housing, and community centers to run a public education campaign targeting the Black and Latino communities in the hope of breaking down resistance to vaccination.   

Acknowledging and engaging communities of color through targeted outreach and media campaigns featuring trusted institutions and voices may help dispel misgivings about the vaccine and provide counter-narratives to unfounded rumors about them, Akbar believes. “Equipping people with information to make informed decisions may be the best weapon against vaccine hesitancy.”

Editor's Note: The article, originally published on February 6, 2021, was updated to include more Consumer Reports survey data.