Vaccine distribution in burdened communities begins with building trust

Yale’s Dr. Marcella Nunez-Smith worries that without structural change, many people in minority communities will be reluctant to receive the COVID-19 vaccine.
A young African-American girl receives a COVID-19 vaccination.


Even as the COVID-19 pandemic reaches grim new milestones, with 18 million U.S. cases and nearly 320,000 U.S. deaths as of Dec. 22, the emergence of multiple vaccines offers hope that an end to the crisis could be in sight. Two vaccines, by Pfizer and Moderna, have already received FDA authorization, with millions of doses already being delivered to locations across the country.  

And yet some public health experts are nervous. 

While Black, Latinx, and Indigenous Americans are dying from COVID-19 at nearly three times the rate of white Americans, Dr. Marcella Nunez-Smith, an associate professor of internal medicine, public health, and management at Yale, worries that many people in these communities will be reluctant to receive the vaccines. This is in part because of a deep-seated distrust of the healthcare system and of health interventions based on both a history of racism and their lived experiences.

Indeed, according to a recent survey by the Kaiser Family Foundation and the Undefeated, one in five Black adults said they had experienced race-based discrimination in healthcare in the past year and are less likely to say they will get the COVID-19 vaccine, even if it is free and determined safe by scientists. Only half of Black adults said they would “definitely” or “probably” get vaccinated, compared to six in 10 Hispanic adults, and 65% of white adults. 

Such concerns and skepticism should be expected, said Nunez-Smith, who was recently tapped to lead a White House task force on health equity. “Lots of people have lots of questions, as they should,” she said. “Everyone needs to get their questions heard and answered about things like safety, efficacy, and cost.” 

But, she added, in order for people of color to be receptive to messages about vaccine safety, there is a need for “trusted messengers,” in particular healthcare workers of color who are armed with the information people need. 

I think it is important that we talk about providers who identify themselves as being of color, who are from these communities,” Nunez-Smith said. “I get at least five texts a day from colleagues or friends who are asking me ‘Should I take this? Is this safe?’ We need a unified message.” 

Nunez-Smith shared these thoughts during a recent panel discussion on the COVID-19 vaccines, public trust, and health equity. The discussion among leaders in health justice — all of them women of color — also included Dr. Giselle Corbie-Smith, professor and director of the University of North Carolina’s Center for Health Equity Research and a former Yale medical resident; and Margaret Moss, a member of the Hidatsa/Dakhóta tribe and director of the First Nations House of Learning and associate professor in nursing at University of British Columbia. Moss directed master’s and doctoral programs in nursing at Yale from 2010 to 2015.

The event was hosted by the American Medical Association as part of its Prioritizing Equity video series.

Nunez-Smith, highlighted at bottom right, participates in an American Medical Association panel on the COVID-19 vaccines
Nunez-Smith, highlighted at bottom right, participates in an American Medical Association panel on the COVID-19 vaccines, public trust, and health equity.

Blacks, Latinos, and Native Americans are more likely to get sick from COVID-19, to suffer from more severe cases of the disease, and to die; these groups are being hospitalized at rates 4.5 to 5.5 times higher than whites, according to data from the Centers for Disease Control and Prevention. And Black people are over-represented in COVID-19 deaths in 33 U.S. states and territories. Among children, the unequal burden is even greater. A recent Yale study found that three out of four children hospitalized with severe cases of COVID-19 across eight hospitals in New York, New Jersey, and Connecticut were Black or Hispanic.

I cannot close my eyes to the reality,” said Nunez-Smith, who is associate dean for health equity research, director of the Center for Community Engagement and Health Equity, and the founding director of the Equity Research and Innovation Center (ERIC) at Yale School of Medicine. “We’re setting these terrible milestones. Over and over again. [There is a] phrase we can all say in our sleep: ‘disproportionate burden.’ It’s Black and Brown lives that we’re losing.”

During the event, the speakers discussed the terrible legacy of medical experimentation on people of color in the U.S., including the Tuskegee study of Black men with syphilis. Moss also described the U.S. government’s forced sterilization of thousands of American Indian women in the 1970s. 

Racism is a part of the lived experience of people of color when they navigate healthcare systems, the speakers noted. Studies have shown that Black Americans are systemically undertreated for pain compared to white Americans, and that many medical students and residents hold mistaken beliefs about biological differences between the races.

Corbie-Smith said that just as the injustices done to Black, Brown, and Indigenous Americans have been systemic in nature, the solutions need to be systemic, too. 

All of the heinous initiatives that have led to the death and destruction of Indigenous peoples through colonization, to the people that have been enslaved in this country and exploited, have been structural in nature,” she said. “Any interventions need to demonstrate that same intention and fidelity to structural change.” 

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Part of the In Focus Collection: Yale responds to COVID-19

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