COVID-19 and Health Disparities: Could Eroded Public Trust Impede a Rebound?

December 10, 2020
Gianna Melillo

Gianna is an associate editor of The American Journal of Managed Care® (AJMC®). She has been working on AJMC® since 2019 and has a BA in philosophy and journalism & professional writing from The College of New Jersey.

What people believe about health and public health, although challenged before the coronavirus disease 2019 (COVID-19) pandemic, is even more crucial now as vaccine distribution efforts could soon begin.

Perhaps one of the biggest revelations brought by the coronavirus disease (COVID-19) pandemic is the faltering information ecosystem, guilty of perpetuating falsehoods and assumptions disguised as hard facts, and potentially inhibiting progress on closing disparity gaps.

Americans faced the challenge of health literacy before COVID-19, but the swell of misinformation that has clogged social media platforms has helped sow distrust and skepticism among a nation suffering under an already stressful pandemic.

A Cornell University study analyzing 38 million English-language articles on the pandemic concluded President Donald Trump was the largest driver of the current "infodemic," The New York Times reports; the study has yet to be peer-reviewed.

According to The American Journal of Tropical Medicine and Hygiene, an infodemic is “an overabundance of information—some accurate and some not—that makes it hard for people to find trustworthy sources and reliable guidance when they need it.”

Althoug misinformation comprised only 2.9% of the whole COVID-19 conversation in the Cornell study, “The 1.1 million articles identified as covering, factchecking, or repeating misinformation represent a large volume of information that is likely to have significantly affected public perceptions of the pandemic.” The researchers continued, “It is especially notable that while misinformation and conspiracy theories promulgated by ostensibly grassroots sources….do appear in our analysis in several of the topics, they contributed far less to the overall volume of misinformation than more powerful actors, in particular the US President.”

According to a report from The Commonwealth Fund, Americans are less likely than individuals in other countries to have a positive opinion of the government’s pandemic response. Fewer than half of White, Black, and Latino Americans have a positive opinion of the president’s handling of the crisis.

When it comes to state and local government, 35% of Black respondents of the Commonwealth Fund International Health Policy COVID-19 Supplement Survey offered a “good” or “very good” assessment compared with 54% of White respondents (P ≤ .05).

“Past research has shown that Black Americans’ public trust in institutions—more so than any other racial or ethnic group—is shaped by their awareness, and experience, of inequities faced as a group,” the report reads. The disproportionate impacts of the pandemic on Black Americans may have contributed to low government approval ratings.

However, when asked the same question with regard to hospitals, doctors, and nurses’ handling of the pandemic, 86%, 80%, and 79% of White, Latino, and Black respondents answered with a positive assessment, respectively.

“During a pandemic, the ability to communicate effectively and manage uncertainty is key to maintaining people’s trust and confidence,” the authors wrote.

For Latino Americans in particular, the role of the trusted messenger is imperative, said Sonja Diaz, founding executive director of the UCLA Latino Policy and Politics Initiative, during a September teleconference. “We know that those are doctors and health care workers, teachers and family… it’s definitely not politicians,” Diaz said. “It's really important that you have actors, including local and municipal actors that are being able to disseminate [accurate information].” In Latino communities, “For a vaccine, it's really important to ensure that any sort of rollout, along with just emergency preparedness, has culturally and linguistically competent contours,” she explained.

Further results from a cross-sectional study published in JMIR Public Health and Surveillance show that participants identifying as races other than non-Hispanic White were more likely than White individuals to consult doctors and religious leaders for sources of COVID-19 information.

“As public health professionals, it's important that we consider targeting information sources that are used and trusted by certain population groups in order to make sure that COVID-19 information is reaching a diverse audience,” said Shahmir Ali, an author of the paper and doctoral candidate at New York University's School of Global Public Health. Getting COVID-19 information out to the public via sources certain populations already trust will be crucial to improving health communication campaigns.

Vaccine Distribution and Federal Action

Once an immunization becomes available, mixed views on health officials’ and governments’ handling of the pandemic among vulnerable populations can lead to roadblocks in effective and efficient vaccine distribution.

Data show Black Americans are the most hesitant to receive a COVID-19 vaccine, and their skepticism is only growing, USA Today reported in October. Although surveys from May showed 54% of Black adults were willing to get a vaccine, that number declined to 32% in a September survey.

One focus group found skepticism and distrust of the government due to historic medical mistreatment of Black Americans (including, but not limited to, the Tuskegee study and forced sterilizations) contribute to the population’s hesitancy to receive a vaccine.

However, “We can’t make assumptions about why people might be concerned about a vaccine,” said Jewel Mullen, MD, MPH, the associate dean for health equity and associate professor of population health and internal medicine at the University of Texas at Austin, Dell Medical School, in an interview with The American Journal of Managed Care®.

“We can’t make assumptions at the individual or community level about what concerns are operative. That requires giving up a little bit of our tendency to craft a public health message that’s just loaded with recommendations to get a shot, to helping people understand their personal risk,” Mullen explained.

Lack of participation in vaccine clinical trials may also lead to adverse outcomes in minority populations, as it will not be clear whether the vaccine is safe and effective for them. There are no significant genetic distinctions by race or ethnicity when it comes to vaccine efficacy, but higher rates of chronic diseases and other environmental factors leading to poor health among minorities may impact how well the vaccine is received by people of color. Similarly, race does not, in and of itself, make people more biologically susceptible to COVID-19, yet certain preexisting disparities make it so that minority populations are disproportionately affected by the disease.

Pharmaceutical companies developing new vaccines have attempted to combat the trend of low minority participation in clinical trials. Results from Pfizer’s phase 3 trial of an experimental vaccine—which was found to be 95% effective—noted 42% of participants had “racially and ethnically diverse backgrounds.” But ultimately, the vaccine’s overall efficacy hinges upon at-risk populations’ willingness to receive it once approved.

As part of a nationally coordinated strategy to address disparities, the National Institutes of Health and the CDC instructed The National Academies of Sciences, Engineering and Medicine (NASEM) to construct a framework for equitable allocation of COVID-19 vaccines. Within the framework, experts call for a 4-phase approach to distributing a COVID-19 vaccine to prioritize individuals at the greatest risk of developing complications. The framework also prioritizes health care workers. Mullen is a member of the committee that helped develop NASEM’s guidance.

“Part of making sure that equity is upheld is doing all we can to support distribution and administration to those most at risk first,” Mullen said.

To set general priorities among population groups, the framework took into account the following criteria: risk of acquiring infection, risk of severe morbidity and mortality, risk of negative societal impact, and risk of transmitting infection to others.

“Rather than applying discrete racial and ethnic categories to allocation phases, the allocation framework focuses on the underlying causes of health inequities that are linked to systemic racism and the social determinants of health,” the framework’s overview reads.

Although coordination will need to be carried out at all levels of government to ensure an equitable distribution of a vaccine, on the federal level, President-elect Joe Biden has indicated a robust effort will be made to address the disparities laid bare by the pandemic.

In November, Biden announced members of his administration’s COVID-19 transition panel, including Marcella Nunez-Smith, MD, MHS, an associate professor of internal medicine, public health, and management at Yale University and the associate dean for health equity research at the Yale School of Medicine.

“We’re going to protect vulnerable populations who are at risk, most at risk from this virus, older Americans, and those with preexisting conditions," Biden said at the panel’s announcement. "We’re going to address the health and economic disparities that mean this virus is hitting the Black, Latino, Asian American, Pacific Islanders, Native American communities, harder than White communities. Focusing on these communities is one of our priorities, not an afterthought.”

Next: How partnerships and data are influencing outreach strategy.

Read Part 1 of this 3-part series here: COVID-19 and Health Disparities: Preexisting Factors Impact Exposure, Recovery