COVID-19, which has taken over 250,000 lives, is now the third leading cause of death in the United States, behind cardiovascular disease and cancer. This marks a monumental loss for public health, which has deployed sanitation policies, vaccination programs, surveillance technologies and new medicines to keep infectious disease from the top three causes of death since 1938.
With most states now much higher than the 5% COVID-19 test positivity limit recommended for reopening — and at least 10 states exceeding 20% positivity — announcements of vaccine deployment as early as December couldn’t come soon enough. But for public health experts, concerns about community acceptance of vaccines cast a shadow over the promising news. Without trust in public health interventions like vaccines and contact tracing, the gains made on infectious disease control will continue to diminish.
Research conducted in May reported that only 67% of participants were likely to accept a COVID-19 vaccine, with acceptance rates as low as 40% to 50% in some subgroups. Those less likely to accept a COVID-19 vaccine were younger, less educated or unemployed and had lower risk perception. Considering that 70% of adults intend to get a flu shot, but only 40% follow through, public officials will need creative and effective strategies to reach the estimated 70% to 80% vaccine uptake required for COVID-19 herd immunity.
Race also plays a role. Acceptance rates were 3 to 6 times higher among white, Hispanic and Asian respondents compared to Black respondents. This should come to no surprise for those who acknowledge racial bias. Debunked medical myths are pervasive in medicine to this day. We must attend to the distrust in Black communities, which is rooted in the legacies left by the Tuskegee Syphilis Study and generations of unethical research and medical maltreatment.
We must also counteract anti-immigration rhetoric and punitive citizenship policies that create barriers for the delivery of public health interventions. For example, due to the public charge rule, those seeking residency may fear becoming permanently ineligible if they engage with government health agencies.
At the same time, society has become fragmented. Conflicting messages between political leaders and health officials have diluted public health communications and eroded trust. What would normally be considered basic pandemic response — social distancing, testing and contact tracing — have now become such politicized and polarizing topics that in some communities contact tracers and public health officials are faced with brazen lack of cooperation, vandalism and even death threats.
Building community trust is going to be an essential component of moving forward to vaccine deployment and beyond. Lessons learned from other outbreaks confirm that understanding local needs and prioritizing trust and engagement of the community facilitate cooperation. The economic consequences of COVID-19 social distancing measures are experienced differentially, and these differences must be taken into consideration through tailored public health engagement. In some communities the priority may be to confront conspiracy theories and vaccination misinformation; while other communities may call for improving cultural competency or addressing economic barriers. In all cases, we must enlist trusted messengers to receive information on community needs and deliver on those needs to encourage uptake.
Community-based health workers (CBHWs), also called promotores in Latinx communities, can serve as bridges between health services and reticent communities. CBHWs are trusted lay members of the community trained to provide outreach, education, social support and advocacy. Evidence suggests that the use of CBHW for health-related activities like screening and education are a low-cost and cost-saving approach to improving health and increasing access to and use of care, particularly for vulnerable groups.
Communities across the country have been building a workforce of contact tracers drawing from all sectors — government, health, faith-based, nonprofit, academic and so on. However, social and economic reinforcements are needed in more vulnerable communities where virtual employment, health care, housing and child care are pervasive barriers to following quarantine and other public health guidance. Hiring culturally and linguistically appropriate CBHWs directly from within those communities will be key.
Announced in June, the Baltimore Health Corp Pilot Project is a $12M investment funded by Baltimore City along with private and philanthropic dollars to fill 300 community health worker positions with recently unemployed or underemployed community members. These CBHWs conduct contact tracing, provide education to residents from a trusted source and connect people to resources like food and economic assistance — while generating jobs. The program prioritizes community engagement and draws on the expertise within the community.
Baltimore’s response joins a growing movement to develop a sustainable CBHW workforce with a pipeline to careers in health and social service sectors. A long-term CBHW strategy can generate trust within communities, improve efficacy of COVID response, address health care workforce gaps and improve community resilience through health and economic improvements.
Building trusted connections to health care, facilitating economic empowerment and supporting community resilience within our most marginalized communities is not just the right thing to do, it is imperative for an effective pandemic response.
Amanda Latimore (firstname.lastname@example.org; Twitter: @LatimoreAmanda) is a social epidemiologist and faculty member at the Johns Hopkins Bloomberg School of Public Health. She is the Director for the Center for Addiction Research and Effective Solutions (CARES) at American Institutes for Research.