Why Even the Threat of a Twindemic Isn’t Swaying the Most Vulnerable: Black Women

The American Journal of Managed CareFebruary 2021
Volume 27
Issue 2

The fall season was accompanied by an urgent warning from the CDC of an impending “twindemic” of coronavirus disease 2019 and influenza. Despite the warnings, Black women are not lining up for vaccinations.

Am J Manag Care. 2021;27(2):e32-e33. https://doi.org/10.37765/ajmc.2021.88551


Takeaway Points

To address a possible “twindemic” of coronavirus disease 2019 and influenza and the ongoing health issues in vulnerable communities, and to help rebuild trust among these communities, the health care industry must directly and consistently engage with communities of color to foster authentic relationships with those who already have long-standing connections, visibility, and trust in these communities. In addition, it has to listen and act on recommendations from this coalition, as well as look at health care in terms of preventive social determinants of health—issues that determine better or worse health outcomes for individuals.


In September, the United States surpassed 200,000 deaths from the coronavirus disease 2019 (COVID-19) pandemic, with some experts predicting that the death toll could nearly double by the end of 2020. September also marked the start of fall and the beginning of the influenza season, which, although not as deadly as COVID-19, accounts for approximately 20,000 deaths annually. This year, the fall season is accompanied by an urgent warning of an impending “twindemic” of COVID-19 and influenza by the CDC.

COVID-19 has affected our lives in ways we could never have imagined and has made many of us more attuned to our overall health and the need for preventive measures. A recent poll1 conducted by EmblemHealth found that nearly half of New Yorkers surveyed are more likely to get the influenza vaccination this year than in years past, and health systems across the country are reporting unprecedented demand for influenza vaccinations. But, as the past few months have revealed, access to health care in our country is deeply unequal, especially for communities of color. Nowhere has this been more apparent than in New York, the original epicenter of the COVID-19 pandemic in the United States and a microcosm of the devastating impact that racial disparities have on the health of our communities.

At the height of the pandemic in April, Black New Yorkers were dying at a higher rate than any other racial and ethnic group, and at twice the rate of White New Yorkers.2 As the CDC warns of a surge this fall and winter, these rates collide with the sobering statistics around influenza vaccination adoption. Among the 1005 New Yorkers who responded to EmblemHealth’s survey, Black women were significantly less likely to seek access to the influenza vaccination this year than any other group. Only 35% of Black women stated that they have received the influenza vaccination consistently over the past 3 years, compared with 56% of New York City’s general population. Concerns about effectiveness and safety were listed as top reasons to not get the influenza vaccination, which foreshadows the challenges that we may also face as COVID-19 vaccines become available.

As a physician and a Black woman, I view these findings as alarming but, unfortunately, not unexpected. Over several decades, the health care industry has sown mistrust among communities of color, for reasons ranging from the Tuskegee syphilis experiment in the 1930s to the underrepresentation of Black patients in research and vaccine trials that persists to this day.3 In many cases, the former has shaped the latter, with the historical legacy of exploitation fueling the ongoing distrust of research and health care systems in the United States. In the case of Black women and the twindemic, this has the potential to be a lethal combination.

Although COVID-19 has exhibited deadlier consequences among men, women often hold jobs that put them at a higher risk of infection, such as domestic workers, nurses, or home health aides. A New York Times analysis of Census data earlier this year found that 1 in 3 jobs held by women have been categorized as “essential,”4 and data from the Center for Economic and Policy Research indicated that women of color were more likely to have essential jobs.5 Although many female essential workers struggle with taking time off for routine care, the primary deterrents to getting the influenza vaccination among Black women are concerns about effectiveness, safety, and adverse effects. All of these fears are heightened by the ongoing political interference in public health practices and messaging. Nevertheless, the remedy to the fear and uncertainties among underrepresented and disenfranchised communities of color remains within the health care industry’s power and capacity to change.

The health of our nation is at a critical crossroads: one where Black women stand to lose the most as a consequence of historical and systemic failures and their overrepresentation on the front lines of the pandemic. But it’s not too late to enact change that will save the lives of thousands of Black women now and in the future. We can do this by engaging those who are influential in the Black community, from church leaders to hairdressers and barbers; by addressing the shortage of Black physicians,6 whose voices and experiences represent the communities they serve; and by recruiting more Black men and women to participate in research and vaccine trials—not only for the COVID-19 vaccine, but for conditions such as cardiovascular disease and cancer, of which Black individuals have the highest death rate7 and the shortest survival compared with any other racial and ethnic group in the United States.

The consequence of populations of color not being represented in research, testing, and vaccinations is that, ultimately, we will not have equitable access to cures, and without community empowerment, we are doomed to repeat history’s mistakes. Black women and our families deserve better, and our lives depend on it.

Author Affiliation: EmblemHealth, New York, NY.

Source of Funding: None.

Author Disclosures: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Acquisition of data; analysis and interpretation of data; drafting of the manuscript; critical revision of the manuscript for important intellectual content; statistical analysis; provision of patients or study materials; administrative, technical, or logistic support; and supervision.

Address Correspondence to: Diane M. Ashton, MD, MPH, EmblemHealth, 55 Water St, New York, NY 10041. Email: dashton@emblemhealth.com.


1. EmblemHealth study finds New Yorkers overall more likely to seek flu vaccine this year amid COVID-19. News release. EmblemHealth; October 1, 2020. Accessed October 21, 2020. https://www.emblemhealth.com/news/press-releases/EmblemHealth-Study-Finds-NewYorkers-Overall-More-Likely-to-Seek-Flu-Vaccine

2. Black people in NYC twice as likely to die from COVID as white people: data. ABC News. April 17, 2020. Accessed October 21, 2020. https://abcnews.go.com/US/black-people-nyc-die-covid-white-people-data/story?id=70208362

3. Frederick WAI, Montgomery Rice V, Carlisle DM, Hildreth JEK. We need to recruit more Black Americans in vaccine trials. New York Times. September 11, 2020. Accessed October 21, 2020. https://www.nytimes.com/2020/09/11/opinion/vaccine-testing-black-americans.html

4. Robertson C, Gebeloff R. How millions of women became the most essential workers in America. New York Times. April 18, 2020. Accessed October 21, 2020. https://www.nytimes.com/2020/04/18/us/coronavirus-women-essential-workers.html

5. Brown H, Rho HJ, Fremstad S. Mothers in frontline industries deserve better. Center for Economic and Policy Research. May 8, 2020. Accessed October 21, 2020. https://cepr.net/mothers-in-frontline-industries-deserve-better/

6. Sobowale K. We need more Black physicians. Scientific American. July 17, 2020. Accessed October 21, 2020. https://www.scientificamerican.com/article/we-need-more-black-physicians/

7. Cancer Facts & Figures for African Americans 2019-2021. American Cancer Society. 2019. Accessed October 21, 2020. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-facts-and-figures-for-african-americans/cancer-facts-and-figures-for-african-americans-2019-2021.pdf

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