The highly uneven, racialised impacts of the COVID-19 pandemic are well documented. In the US, Black and Latinx people are 3 times more likely to die from the virus than White people, according to federal data. A key response from the medical community has been to improve the racial diversity and makeup of vaccine trials. These actions aim to ensure the safety and efficacy of vaccines for people of different races.
While important, this alone cannot redress the entrenched inequalities which affect Black, Indigenous and People of Colour (BIPOC) communities. Drawing on a specific trial in a Latinx community of San Diego county, a recent paper demonstrates how trial designs fail to redress structural racism and may introduce new harms.
A Phase III AstraZeneca vaccine trial was recently launched in San Diego county, with an aim to recruit individuals from Latinx communities. The study’s lead investigator described the trial as bringing opportunities to a “previously underserved” population.
However, what exactly constitutes “opportunity” in this case? Answering this question demands consideration of the social, political, and economic environment of all participants. During community meetings, the lead scientists of the study failed to answer key questions. For example, would people of colour would be prioritised once an effective vaccine was approved? Or would participants receive a share of the profits of the vaccine, in exchange for their bodies being tested upon?
These questions reflect the long history of medical racism and exploitation within disadvantaged communities. It is important that scientific communities establish relations of trust with these marginalised populations. A crucial way to ensure this is through prioritising their pressing needs, rather than simply focusing on data extraction.
Similar to other vaccine trials, AstraZeneca promised only temporary care to participants. Rather than strengthening existing public health infrastructure, carers were dispensed through mobile and temporary clinics. This parachuting in of medical experts has been criticised for failing to address health inequities on a long-term basis.
Furthermore, this temporary care fails to address the root causes of disparities in COVID-19 infection rates. Discussions of health inequalities often promote notions of racial determinism, focussing on genetic causes of disease at the expense of addressing social and structural factors. For example, in National City, the military, shipyard industry and traffic emissions have resulted in disproportionate dumping and release of toxic environmental waste into the city. Children have significantly higher asthma hospitalisation rates and National City reports 4 times as much hazardous waste than more affluent parts of the city.
In contrast to the more passive term “social determinants of health”, structural violence explicitly identifies social, economic, and political systems as the causes of the causes of poor health. The forms of structural violence mentioned above are not acknowledged or addressed in the vaccine trial design. Researchers must critically interrogate whether their commitments to serve marginalised communities can be successful without addressing histories of environmental racism.
The Conceit of Consent in Vaccine Trials
People’s capacity to consent must be considered in light of broader social, economic, and political situations. For example, one implicit “opportunity” of many vaccine trials is access to healthcare. AstraZeneca promised healthcare to participants for the duration of their involvement, making it attractive to many. This desire for affordable healthcare is likely to reshape capacities to consent, and/or drive trial participation. This complicates the process of obtaining true informed consent.
Furthermore, residents of National City disproportionately lack health insurance, are elderly and are essential workers. In fact, only about 20% of adults have health insurance, according to the county’s public health data. Therefore, many may be pressured to participate in clinical trials if other sources of reliable care are unavailable or have been systematically depleted. The rethinking of informed consent for these trials within broader frameworks of medical racism and structural violence is essential.
Improving Vaccine Trials
Diversifying vaccine trials has in many cases been framed as an attempt by pharmaceutical companies to atone for past neglects. However, they lack key strategies for redressing structural inequalities. Emergencies cannot be used to justify postponing the necessary work of improving infrastructure and redressing systemic racism. Finally, it is vital that considerations of equity pervade all phases of vaccine development – from trial, to delivery, to cost, to distribution.
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