My patients don’t trust the health system, so why should they trust vaccines?

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Post by Asher Tulsky

I work in a large safety net hospital in Boston. Early in the pandemic, when all of the primary care clinic operations were closed, I began to do COVID-19 screening in our Influenza Like Illness clinic (ILI). Unfortunately, we had few test kits available at the time, which meant testing only the highest-risk individuals. I remember having very difficult conversations with patients about why I couldn’t test them, even though I knew there were drive-in clinics across town testing any patients who came through. Fast forward to the availability of COVID-19 vaccines: we now have an abundance of vaccines in stock but face a very large minority of patients who deliberate whether or not to receive them. The question that I heard once – but I suspect has been voiced multiple times – is: “You wouldn’t test us when we asked to be tested. Now you want to give us something we don’t know the long-term consequences of?”

We’re struggling to vaccinate all of our patients (many of whom are at high risk of serious COVID-19 illness) because there is clear lack of trust in the health system to do what we clinicians believe to be in patients’ best interest.

I’m reading Medical Apartheid, a book written in 2007 by health and science writer Harriet Washington, who chronicles hundreds of years of medical mistreatment and involuntary experimentation on African Americans. Considering this history, I fully appreciate why our patients are very ambivalent about something many physicians see as potentially lifesaving. Most everyone is familiar with the Tuskegee Study, a federally sponsored study of the natural history of syphilis that ran from 1932 to 1972 in which treatment was withheld from a cohort of African Americans who had been told they were receiving treatment. What many people don’t appreciate is the long history of enforced experimentation on enslaved people in our country, including surgical procedures (without anesthesia) by some of medical history’s “giants.”

So how do I, as a white male physician with clear privilege, establish trust with my patients so they will accept the vaccine that I believe could save their lives as newer, more deadly variants come into our community? A few of my patients have told me that my recommendation is sufficient for them. But I most often hear “I’ll wait and see.”

My institution is working diligently to identify ways to engage patients in this conversation and move them from ambivalence to acceptance, but it’s difficult. Even our clinicians of color are struggling with this. We all know that lost trust is hard to regain. It begins when all patients feel welcome wherever they go for care. All patients need to feel that they are heard and that their concerns are validated. There also needs to be a universal commitment to eliminating racism from health care. This won’t happen overnight, but every institution needs to start right away. The next pandemic is not far off.

Dr. Tulsky is a primary care internist at Boston Medical Center. He also serves on ABIM governance as the chair of the Internal Medicine Specialty Board and chair-elect of the ABIM Council.