Confidence in Crisis: Strengthening Medical Trust in the Black Community Q & A

Dr Harawa: The last several years have brought increased recognition to the ways in which African Americans have been mistreated within the scientific endeavor. More members of the general public and those engaged in healthcare and research have learned the details of the National Health Service study of syphilis at Tuskegee and of the tremendous contribution the cells of Henrietta Lacks brought to science but without the permission of herself or her family. But there is another part to these stories and other stories where Black individuals were engaged in unethical research that is rarely told. Namely, the systematic changes that the revelation of those nefarious research endeavors brought about. That story includes the fact that the descendants of Henrietta Lacks now serve on the National Institutes of Health Human Data Access Working Group—the body that determines whether or not researchers have access to the rich genetic information of those cells and that story also includes the fact that the revelation of the National Health Service study of syphilis at Tuskegee led to the 1974 National Research Act which required the development of the national commission for the protection of human research subjects and the requirement for institutional review boards to review and approve nearly all research involving human subjects and, finally, the detailed requirements for voluntary informed consent of human subjects. It is because of these processes of consent that the people who take part in research studies are no longer just subjects experimented on, but true participants who take part of their own will and are therefore contributing in a voluntary and active way to the potential for science to benefit society.

But of course as stated in the question, African Americans’ fears around medical treatment and vaccines are not limited to our experiences with research we’ve also experienced poor treatment within the medical system. But when I look at both the recent and not so recent history of how Black people are sometimes treated in healthcare, the dominant through line is one of undertreatment and neglect rather than the type of toxic or otherwise nefarious treatment that some people might fear may be part of a vaccine shot. Unfortunately we’ve seen these stories of neglect even in the COVID-19 pandemic. There have been multiple news stories of symptomatic individuals who were turned away from emergency rooms only to later die at home. We’ve also seen it in studies documenting undertreated pain, ignored concerns of pregnant patients leading to maternal mortality, and the lower frequency of referrals for aggressive procedures for individuals with heart disease and other conditions when comparing Black patients to White patients with similar disease profiles, but it is for this reason that my biggest concern is not about the Black population being given something dangerous or toxic because there are processes well in place to prevent that, and the sacrifice of the participants of some of those studies is part of why those processes are there, my biggest concern is that somehow we will not be prioritized as we should. That we’ll be overlooked or potentially left behind as the already confusing and sometimes unorganized vaccine roll out moves forward. I’m concerned about our overrepresentation in the essential workforce and the criminal justice system. Especially given that the largest outbreaks of COVID-19 throughout this pandemic have been in our prisons and jails but even despite that people in prisons, jails and detention facilities have yet to be prioritized for vaccination in most states. It is disappointing that the tremendous investment in operation warp speed to develop the COVID vaccines was not accompanied by a stronger investment in educating our communities from the beginning about the development and approval process, the novel vaccine platforms being explored, and the people involved in the development and testing of the vaccine including the many Black participants in the clinical trials. Instead, Black educators and providers (such as those on this panel) and Black institutions such as the four Historically Black Medical Schools have stepped in to fill this gap.

So I would argue that we need to continue to advocate that we have a place near the front of the line because we are overdue this place. While we deal with the very real and reasonable fears of members of our community about the vaccines, we cannot lose sight of the goal--that as many of us, as soon as possible, are educated and receive the opportunity to be well protected against COVID-19 disease.

Dr Briggs-Malonson: Thank you so much for that. And so many of those different points that you mentioned were key. It’s not just about the past research or unethical experimentation, its about the contemporary issues—what has occurred in terms of treatment, what has occurred in terms of is there education or is there not education. And those are all the factors that feed into this level of distrust that we continue to have within the Black community and that we have to address.

Dr Mays: Part of what I want to talk about is this notion of social determinants as one of the risk factors for COVID-19 disease. Much of the information that has gone out is that what puts you at risk is predominantly having a preexisting condition. Social determinants are what the federal government uses to measure our health and social determinants are part of what puts many of us, particularly in the minority community, at greater risk. Blacks and Latinos are 2-3x more likely to be infected and also to die from COVID disease, [part of this doesn’t have to do with the notion that we do not take care of our health, part of it has to do with the ways in which structural racism makes us more vulnerable. In a study done by the federal government, particularly the Census Bureau, every week they followed a group of people and they asked them questions about their COVID-19 status as well as questions about these social determinants (eg, economic stability, education, social and community context, health care, neighborhood, etc). The three top things that we can see are related to social determinates of health relative to being at risk for getting infected are what we’re calling the “threats to survival” and “stresses and strains”. People, for example, with income insecurity, people with food insecurity, and people with housing insecurity were more likely to develop COVID-19. In relationship to coming into contact with this infection, it isn’t just whether or not we’re physically healthy, it’s also the ways in which COVID-19 has affected us economically and put us in disarray which has made individuals more vulnerable. When you experience stress, it then becomes a physiological process that throws the body into a state of stress and strain overload which tends to wear the body down physically. We often speak about the concept of how much the body can be worn. In the study, what you can see is that when people are anxious about whether food is available—and this is heartbreakingly so among African Americans—they were saying that during this time of COVID, they did not have enough to eat. So if you want to think about thing you can do, there are a lot of things you can do, even in terms of volunteering. What this also tells us is that policies are important.

What I along with Professor Paul Ong and his team at the Center for Neighborhood Knowledge came up with was a model of the ways in which these social determinants put people at a greater vulnerability to becoming infected when they came into contact with the virus and again what we’re able to see is that pre-existing health conditions are important, but also barriers to accessing services, and not just health services, but services like interpreters/translators, educational opportunities. Other predictors of infection were built environment, which should make sense to us all, some of us have a lot of open space, some of us live in neighborhoods where we can barely walk outside. And then also the social vulnerability index or social risk.

So this is the take home message I want people to be thinking about. Right now we’re very focused, as we should be, on the physical aspects of COVID-19, but on the tail of COVID-19 there is a syndemic, which also occurred with HIV, a mental health syndemic. What we’re seeing because of COVID-19 is an increase in mental health problems, so that means we need to think now about how to set up services, we need to think now about the things that people are experiencing that are causing them to feel the anxiety, depression, etcetera that they are experiencing. [We need to think now] about the increase in suicide, particularly in the Black community, among young men 5-12 years of age. And finally several studies are showing us that when we’re home, we’re drinking just a little bit more, and having more zoom happy hours. But some people are having those happy hours during work hours, all day long and into the evening. So we have a real increase in substance abuse. So some things we need to start thinking about is setting up substance abuse treatment on demand, increasing our suicide prevention efforts, and having much more culturally competent, not just mental health services, but interventions to improve emotional well-being.

Dr Briggs-Malonson: Wow, that was exactly what we needed to hear and very powerful Dr Mays. Putting that all together, as you mentioned, yes there are so many other factors that impact our health. But in particular we need to start thinking about the future. We need to start planning for the syndemic, we need to start preparing to address what we already know will happen in terms of mental health and overall well being. And hopefully try to address these areas, even right now by stopping this pandemic as soon as we can to prevent the worsening of mental health, or suicides, and the substance abuse. As an emergency physician I can tell you it seems that there are a lot more patients coming in complaining of various behavioral health and mental health conditions and it’s definitely heart breaking. We’re all under these stresses and we have to do what we can to try and stop it as soon as possible.

Dr Garner: Vaccines are based on the idea of protective immunity. When you encounter a virus or bacteria, your immune system fights it off, and when it’s done fighting it off it actually remembers that It fought that particular pathogen. It creates antibodies that move throughout your system so that if you encounter that same bacteria or virus again you fight it off so fast that you don’t experience any symptoms. And so this the concept of protective immunity—if you get sick once, you can’t get sick again from the same thing. Now, that’s a great thing that our immune system does. The challenge is that you must get sick the first time, but what we’re learning through this pandemic is already 400,00 people in the US have succumb to this virus in their first interaction. A vaccine tries to get around this notion by asking the question “can we build protective immunity without actually being exposed to the disease?” There are number of ways to do that and I really want to focus in on how the mRNA vaccine actually does this. One way to create a vaccine is to expose a person to just a small portion of that virus, not the whole virus, but just a small portion that will create that protective immunity. This involves a lot of research, because we have to pick the right piece of the virus to expose somebody to so that they can create those antibodies and be protected. The research has shown with COVID-19 that if a person is exposed to just the spike protein that is on the outside of the virus and helps it infect cells to cause COVID-19, but not the whole virus, the body will make an antibody response to that protein and create a level of protective immunity. This is fantastic, and all of the vaccine products are going to be based on this exposure to the spike protein. The challenge of making that spike protein is very difficult, to be able to inject it and produce the response that you want. So lets get into what the mRNA vaccine is.

A virus is composed of two parts, it has the proteins along the outside that mediate disease, and then it has a genetic code. The genetic code is called RNA, and this RNA is instructions for how to make a whole virus. When a virus infects a cell it releases these instructions and the cell then makes more virus. The mRNA vaccine takes advantage of this. It uses the mRNA code, the genetic instructions just for the spike protein. So when the mRNA vaccine is injected into the arm, the cells in that area of the arm pick up this small piece of genetic code, this small piece of instruction and make the spike protein. So now you have the spike protein being expressed in this area. The immune system sees that, creates antibodies, and then makes this overall level of protective immunity. So it was a novel approach, though it has been in the pipeline for years. We talk about it as novel, but the idea of an mRNA vaccine has actually been pursued for the last ten years. Over time, medical research has shown that this is a way to make a vaccine that’s effective. And you can measure that protective immunity response to show that you get antibodies to that spike protein. But it’s also a way to make it faster. The idea with this pandemic was we needed a cure, we needed a vaccine as quickly as possible. So it was the progression of that medical research that brought us this mRNA vaccine. And I’ll emphasize, it’s only a small portion of the genetic instructions for the virus, about 10% of the overall virus. So when you get that mRNA vaccine it can’t make the entire virus, it can only make the spike protein. So in that setting you can feel confident that the vaccine is not going to result in the COVID disease itself.

Finally, just like many of our successful medical interventions, it was a Black woman who was one of the more important scientists that was involved from the NIH—Dr Corbitt—who put some of the medical research together so we could have this mRNA vaccine.

Dr Norris: A clinical trial is systematic approach to test if a clinical intervention works. The intervention can be a medication such as an antibody, a vaccine such as the COVID vaccine, it can be exercise. We can use clinical trials, for example, to show exercise helps prevent diabetes from going to prediabetes. So these are trials. Trials look at new ways to prevent, protect, control, or treat a disease condition. With a vaccine we’re hoping really to prevent or control the infection so it’s not so bad. The important thing a trial does is to determine whether or not this new test or treatment is safe and effective. So when we do the trials, we want to make sure we have people of different ages, ethnicities, different genders to see how different people respond. Right now, the COVID vaccines are not approved for children. The Pfizer vaccine is approved down to 16 years of age and the Moderna vaccine is approved down to 18 years of age. Studies in children haven’t been done yet so we don’t really know how safe it is and how effective it is.

Dr Briggs-Malonson: Its worth reiterating that these vaccines have gone through the same exact stages as any other medication, as any other vaccine that has ever been approved in this country. And the vaccines, both of them, have been proven to be highly effective at fighting COVID, at preventing hospitalization, and death. COVID causes physical issues, mental health issues, and socioeconomic issues. This is our chance to help stop this.

Dr Norris: First we have a Preclinical stage, which is where studies may be done in cells like the HeLa cell, it can be done in animals, like mice and rats, or even sometimes primates such as chimpanzees. So there actually had been a lot of work already going on around Coronaviruses, and because of that a lot of information was already known and they were able to quickly get to Phase 1 where they first test to see whether or not the vaccine’s safe and does it have any efficacy. Then the vaccine goes to Phase 2 so we can look at the vaccine in a larger group of people, and then Phase 3 and typically this stage will have a few thousand people. Then the trial results get reviewed by the FDA, it goes out to market and then they continue to do surveillance to see how effective these interventions are and how safe they are. We are just passed the FDA review phase.

Dr Norris: Normally a drug company is not going to make any extra drug until they get FDA review approved. Because they don’t want to put money into making a whole lot of drug and find out it doesn’t get approved and it sits there and they’ve spent a lot of money. But in this case the government, said the vaccine is looking good early on, go ahead and make millions and millions of doses and if it doesn’t work, don’t worry we’re paying for it. So the difference here is all those millions of doses have already been started and that’s why things are moving along as quickly as they are.

Dr Norris: Following the Tuskegee syphilis study, the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research was created and this commission published the Belmont Report which outlines the ethical principles by which research on humans must abide. These principles safeguard all people participating in clinical research but were created in response to the mistreatment of people of color.

The three key principles that underlie the conduct of all research involving human subjects are to have 1) Respect for people; to ensure there’s 2) Beneficence or benefit for people; and that there’s 3) Justice. These principles are all looked at and looked at carefully by institutional review boards. Institutional review boards must approve every clinical trial and are made up of doctors, scientists, and people from the community.

Another safeguard is informed consent. Before joining a clinical trial, study participants are told what to expect and all things that might happen so that they can make an informed decision about whether to participate in study activities. Information is given to the participants so they can look at it and their family members can look at it before deciding to join a study. Larger trials have additional safeguards, they may have, for example, a Data Safety Monitoring Board.

Then if a treatment is going to go to market, it has to go through FDA approval and there’s another board that reviews it. So there are multiple layers of review and approval before these drugs come to market.

Dr Norris: Data from the Moderna vaccine show that it was 94.1% effective overall. A little over 20% of the participants were Hispanic, around 10% were Black. In people of color, it was 97.5% effective, which is really good. Earlier I mentioned there can be 1,000 to 3,000 people in phase 3 of a study. This one had 37,000 people. And with 37,000 people, you can really get a good look at how effective it may be and how safe it may be. Not only was it effective, but no individuals who got the Moderna vaccine ended up with severe COVID, which is also important. 5% or so of vaccinated participants got COVID but they didn’t develop a severe case of COVID. And what we want to do is really prevent people from going to the hospital or from dying, so this is very important.

Similarly, the Pfizer vaccine was 95% effective overall. It was 100% effective in Black persons and 94.4% effective in the Latinx community. This trial had over 37,000 people, around 9% were Black and 28% were Hispanic. Do I think the vaccine will be effective in every Black person who gets it? I don’t. Eventually somebody may get COVID, but it looks like it’s working pretty well. But 95% is really great.

Dr Briggs-Malonson: It’s also good to note that not all vaccines are this effective, there are vaccines around the world that are 50% effective and have other concerns or side effects that are limiting their use. Importantly, they prevent hospitalization and they prevent death. The side effects usually last just a couple of days and they work just as well in people of color. The data look very strong right now and its great to know that right now we do have an intervention that can have a very positive impact, which is extremely important for communities of color, because we are suffering so much more from the ravages of COVID-19.

Dr Norris: The side effects are fairly similar for both vaccines. A lot of people get pain at the injection site. A lot of people, as few as 10% and as many as 60% may have headaches or weakness, muscle aches or chills, nausea. For those of us who are little older, older people have fewer side effects.

In general, the side effects tend to be mild and only last a couple days. For people who have a lot of allergies, we want to be much more cautious and so whenever you go to get your vaccine, they’ll have you wait for 15 minutes to make sure you’re not developing any complications.

Ms Lucas-Wright: First of all it really is important for the Black community to have access to the vaccine, because it is still true that when the country gets a cold, we get the flu and when the country breaks a fingernail we have a finger amputated. I have been very fortunate to work with a number of partners across community milieus to develop community advisory boards that have representation from the African American, Latinx, Indigenous tribal nations, Pacific Island/Ocean peoples, LGBTQ, and our GenX-ers. So that alongside these multiple segments of the community, we’ve been able to create opportunities to have townhalls. One example is a series of virtual Sabbath Townhalls that occurred right after worship service for Black folk to hear from professionals that they might trust regarding the vaccine. So these opportunities provide a fairly considerable amount of time to have questions answered and to have the perspective of the community considered to shape the narrative and strengthen the narrative for those who are service providers and those who are making decisions about allocation and resource distribution.

I was reading some research literature earlier today, that listed all of these different types of research that African Americans participated in and the percentage of participants that were African Americans in the vast array of these studies was abysmal. The percentage ranged from 12% at the most all the way down to 1%, and the majority of the percentages was well under 5%. So when I see the percentage of participants that were African American in these vaccine clinical trials, while I’m not wild about the percentage, it is better. And I have a feeling it is because there have been so many townhalls and so many convenings that have been set up and established with people that look like the people they are speaking with.

So, when possible, if you are in a position to do it, either create bi-directional learning convenings that are culturally congruent to mitigate medical mistrust and to create an opportunity to voice fears and concerns. Do it often. Or if you don’t have the ability to do that, direct individuals to really good convenings already in the can and already established. It is also good for those of us who are service providers or who because of the kindness of community, are considered leaders in the community to take a picture of yourself getting the vaccine—it goes along way. Finally, redirect folks from the social media platforms that proliferate miseducation and dis-education that send folks down the rabbit hole. It is critical to have those [communities] with you at the table, telling you what they think, what hurts. And I, after all this time listening to a variety of people, think concerns drill down to just two things: 1) are you going to hurt me again, and 2) does it offer hope.

Dr Garner: No, the vaccine will not change your DNA, but it’s a very good question. Some viruses can affect DNA and some of the long term consequences of that are cancers including the HPV virus causing cervical cancer or the EBV virus causing a wide variety of cancers. Why won’t the mRNA vaccine change your DNA? Your DNA, which are the genetic code, or instructions for making all of you, is set aside inside the cell in an area called the nucleus, which is a protected environment. When the mRNA vaccine gets inside the cell to make that spike protein, it never goes anywhere near the nucleus. Because the process of making the spike protein for the vaccine is in a different compartment than the compartment containing your DNA, research shows, that there is no alteration to the DNA so there is no cancer or long term effects because of it.

Dr Garner: Long term complications from vaccines are exceptionally rare. In that setting, while this vaccine and vaccine product feels different, it is actually very similar to other well established vaccines that have been well studied and shown not to have any long term problems.

Dr Briggs-Malonson: Thank you, and if I can add one piece as well—we have actually tracked vaccines and what occurs long term after vaccination for a while, and most of the time if there is any adverse effect, it tends to occur 6-8 weeks following the vaccine administration. We know from the tens of thousands of patients that have already been part of these clinical trials, who’ve now been in these trials for much longer than 8 weeks, that if there were going to be any significant adverse reactions we would have picked up on it by now. So that’s one additional piece as well about the COVID vaccines.

Dr Norris: If you have one of these conditions and get the COVID infection you are much more likely to be hospitalized or die. And there does not appear to be any additional risk of worsening the conditions if you get the vaccine. The vaccine is not like an attenuated vaccine or some other vaccines we do have, where if your immune system isn’t up to speed then you can actually develop the condition. That doesn’t happen here. So if you have these conditions that’s all the more reason to be signing up to get your vaccine.

Dr Harawa: I think it’s important to realize there are multiple vaccines and they were made not just by one entity. The US government—NIH—had a role in the mRNA technology for the vaccine and particularly the Moderna vaccine, but this is just one of the vaccines and just one component of the scientific teams that made the vaccine. There are huge numbers of people and players in making these vaccines.

There are multiple companies have been contracted with the US government to develop the vaccine. The question is concerned about experimenting on Black people but the vaccines have been tested on people of all different backgrounds—just about 10% of participants were Black—and they are being rolled out to people of all different backgrounds. So there are two answers to this question, 1) the vaccine wasn’t just made for Black people or is not just being tested on Black people, and 2) the government was just one player in the development of the vaccines and the science behind the vaccines. I’ll just add that Pfizer-BioNTech, which are two companies that are working on the vaccine together, and Moderna are just two of the companies that have been contracted in the US for vaccine development and production, there are actually four others. And BioNTech is actually a German company, not even a US-based company.

Dr Mays: It’s very important for people to think about this concept of ‘you can have something and not look like you’re sick.’ So we try to tell people that you may think you’re healthy and you might actually be healthy, but there are two reasons we wear masks: to protect yourself, and to protect other people.

Likewise, you want to [get the vaccine] if you are healthy so that you stay healthy. We started out with the myth that it was only older people being affected by COVID and what we’re starting to see is that there are younger people who have underlying conditions that sometimes they are aware of, but sometimes they’re not, until they find themselves with severe COVID-19 disease.

[The other reason you want to get the vaccine is once the country decides to stop wearing masks, the people who were not vaccinated are going to still be good hosts to the coronavirus and can pass it on to other individuals who weren’t able to get the vaccine because of an underlying condition or allergy that prevents them from doing so.]

We’re only going to get this under control if we’re all behaviorally doing what we’re asked. Wear a mask. Frequent hand washing. Physically distance. And get vaccinated.

Ms Lucas-Wright: At least we’re hearing that folk are saying that they want to wait, because I can remember a time when you asked about the vaccine and the preponderance of the responses were, in the immortal words of Whitney Houston, “hell to the no”, but folks are now saying I’d rather wait. So here’s the issue, this self-assignment is tantamount to Black folks and or people of color assigning themselves to the back of the bus. So we know some things, we know that the preponderance of these mRNA vaccines are showing success over 94% of the time. We also know that the virus is killing people. When we weigh those two things and reason, then we can understand that we don’t have time to wait. It’s a public health issue if we wait, because that means you have more opportunity to contract the virus and/or pass it on. So the waiting does us absolutely no good and something tells me that if we ran an ad in the paper that said all people of color have to wait until we see if it’s going to work, you’ll get your vaccine later, I have a feeling folk would be very upset about that. So I think we just really need to move away from the notion of waiting. And I thinks its interesting that I have that particular question assigned to me because our second Sabbath Townhall was titled “The Cost of Waiting” and we took quite a look at what that might look like.

Dr Briggs-Malonson: Wonderful and that’s so incredibly important. We have to make sure we’re not preventing ourselves from actually receiving various different treatments and preventative measures to keep ourselves healthy and our communities healthy.

Dr Briggs-Malonson: This is a very important question. And the reason why is because our vaccine distribution process is not just based locally. It comes from the federal government then it goes to the state, then to the county, and then it's distributed. So in terms of the availability of vaccines it’s a much larger process than just the control of a specific clinic or a specific institution. So that’s something to really be aware of and there are certain phases that have been recommended. But what we can talk about is what we’ve been doing on a local level, and specifically at UCLA Health in terms of our vaccine distribution process.

At UCLA Health we absolutely took into account the social vulnerability of all our different communities, both our employees and our patients as well. UCLA Health is taking into account overall occupational risk, overall individual clinical risk, and social vulnerability. One of the ways we did that is a risk score that includes the social vulnerability of where a person lives and that includes the housing density in your environment, who lives in your community, food insecurity, all those factors that Dr Mays mentioned, those social determinants of health that we know are directly linked to actually getting COVID, being hospitalized and dying. We incorporated that so that when we distribute this vaccine it is done in a very fair and equitable way to get it to the people that need the vaccine first. So at least that is something that UCLA Health has already implemented in order to ensure the vaccines get to the right populations and the right individuals as soon as possible.

Dr Mays: With respect to LA County, who is also using our models, because the vaccines require refrigeration in the way that they do there is a team that is looking at where is the place to go in the community and who has a certain amount of space, and who has the ability to do the vaccine distribution. The other thing that was an issue is that some of the community health centers that are what we call “community health center look-a-likes” that aren’t necessarily designated as federally qualified health centers, were left off the list so it took a little longer to get vaccines to them. California has a very robust health system, and they didn’t quite get it right on the federal side in terms of the way in which California labels some of our systems. So there were a lot of things that have been in play at one time. And I don’t have to tell you, there have been politics that have slowed rolled out somewhat. But there is actually a focus on using these vulnerability models to make sure what’s being rolled out is being rolled out for people who need it the most because of that vulnerability, not the privilege but the vulnerability.

Dr Briggs-Malonson: UCLA in general has a true focus on advancing health equity as well as overall equity, diversity, and inclusion throughout the campus. Specifically within the UCLA Health System right now we have a strategy that involves various levels of data analytics, developing interventions to ensure we have equity between our patient populations, and expansion of access to care to our most vulnerable populations that need our help. And so part of the strategy is a reinvigorated, recommitment to advancing health equity and making sure we’re playing our part locally. Anyone who is very interested in this strategy can visit uclahealth.org/hedi, where HEDI stands for Health Equity, Diversity, and Inclusion. In addition there are many efforts going on in the school of medicine, as well as in our School of Public Health in order to ensure that we have the education, we’re training, and we’re also doing the research in order to develop the best interventions possible to continue to promote equity throughout our communities not only here in Los Angeles, but nationwide.

Dr Norris: The first thing the institution had to do, when all these episodes were occurring, was UCLA had to take it look at itself, right, and it recognized it’s not where it needs to be. And so there were a lot of hard conversations with faculty, with staff, and students. And that led to a reassessment, and an increase in the level of acuity and effort for some of the activities that you just heard. First you have to make sure you’re taking care of your own people—we had to take a look at our staff and equity and treatment of the staff, at hiring, and at retention, and to make sure our students are being treated appropriately, and to make sure our faculty are being treated appropriately, and to make sure our patients are being treated appropriately and making sure our patients are getting the type of care they should be getting with the level of respect and the level of attention that they deserve. From there we would be in a better position or place to leverage the brand, per se, of UCLA to have a similar impact on many other institutions in Los Angeles. We have to do some work internally to make sure we have everything operating appropriately, before we could go out and start doing things externally. To have the impact we’d like to have we need to really make sure we’re doing the right thing ourselves.

Dr Mays: I’ll also comment here because what people may not realize is the extent to which UCLA faculty, particularly in the Health System as well as those of us who are doing research, have been involved on a national level of making sure the policies and practices have health equity in them. So for example, there is a member of UCLA Health that is on ACIP, which is the committee that made the decision about 1A, 1B, 1C vaccine rollout, and that person had equity in mind when they came to the table. And what I thought what Dr Norris was actually going to talk about is the funding that he received from NIH to actually, at a state level coordinate not just the UCs but to coordinate the UCs so they are better collaborators with the community. In terms of policies and practices, I actually worked with the Congressional Black Caucus and—some of you may have heard very early on that we were not getting data on race and ethnicity of COVID patients—I happen to be appointed by Nancy Pelosi who sits on the to the federal government’s committee on data, and I helped to write the piece in the CARES Act that required the federal government to do better on its data collection. So we have these day jobs, UCLA people, and we work these day jobs, but we also are giving the knowledge that we learn first here to outside agencies, because we need those policies and practices to represent what we know from being on the ground. So I would say UCLA has actually given a lot of sweat equity in terms of making sure we’re pushing for racial/ethnic equity.

Dr Morrison: Thank you for that Dr Mays, because that’s a reminder that Dr Briggs-Malonson is leading a physician cohort in lobbying for a racial equity bill that has been introduced in congress. So again, some of the things we’re trying to do above and beyond our day jobs.

Dr Norris: As of right now there are no known adverse effects in women who are pregnant and it is recommended that it can be used. Similar to other medical conditions, although pregnancy isn’t a disease, there are more things going on in the body than normal, but right now it is recommended that the vaccine can or should be offered to women who are pregnant or thinking of becoming pregnant.

Dr Garner: Just an addition to that, because I’ve been asked this question a lot: COVID-19 is very dangerous to pregnant women and COVID-10 disease is very dangerous to women who are delivering babies. And so in that setting of risk-benefit analysis, I think that’s important. Another thing is, we don’t know when a vaccine is going to be available for children and we don’t know if it’s going to be available for babies at all. But the protective immunity the mother gets from the vaccine actually can transfer to the baby and protect the baby from COVID-19 disease as well.

Dr Briggs-Malonson: Yes, the nutshell of it is yes please speak to your doctors if you have any additional questions, but we highly recommend it for both yourself as well as the baby.

Dr Harawa: I really appreciate this question. I think it’s really important for everybody to understand that they have a roll and one of the things I appreciate about the dialogue that’s occurred since George Floyd is increased dialogue around not just learning to be not racist, but anti-racist. And there are a lot of tools available where people can engage with and understand both any implicit bias that they may have. We all grew up in a society with racism, sexism, homophobia, so none of us is immune from absorbing some of those messages, so I think part of the [work] involves personal reflection. And, another piece of it is understanding the history of how it is that racism has manifested in the medical enterprise, and I have mentioned just a few of those things. And another piece is looking at your own institutional setting, whether you’re in a small practice or a larger setting and seeing ways in which there may be inequities in which treatment is occurring and being active about trying to address that so that you create a more welcoming and equitable environment for people to come in.

I’ll just give one basic example, and this is an example that an African American provider gave, but it was about another ethnic and racial group. So she worked serving pregnant women in a study of predominantly immigrant and Latino women. And in this particular study they wouldn’t give people appointments, they literally would tell people show up at the beginning of the day if you want to be seen by your provider and we’ll serve you whenever it is that we have time to get around to you. So she advocated that these women’s time is just as valuable as anyone else’s time, for whatever reason we might think that it’s not but this is not an appropriate way for you to be treating your patients. This is an egregious example, but there’s plenty in multiple institutional settings.

So I think it’s really important that we understand what’s going on internally, we understand what’s going on within our setting, and that we also keep in mind that history so that when we have patients that come in and are extremely guarded, providers are then creating a bigger gap because they feel uncomfortable and their patient feels uncomfortable, instead they’re able to sit in non-judgement, be able to get that patient to open up and hopefully then start that process of building trust.

Dr Briggs-Malonson: That’s wonderful. So seeing that person for who they are, understanding and just really spending that time with them.

Ms Lucas-Wright: Dr Harawa did an amazing job covering this. I would just say that—and it’s true, my birthday is next week and so I am just full of wisdom—people don’t care what you know until they know that you care. My favorite doctor would turn her chair and face me and lean into me and talk to me and that meant so much to me—I don’t care if she was pretending, I bought it—because she did everything she needed to do in order to let me know that it’s not necessarily what’s on the screen, I want to look at you, I want to know how you feel, I want to know what’s going on in your life. And I told her far more things than I probably would have told anybody else, so if you want all the information to move the needle on good outcomes try to act like you care about your patients. And when you have a patient that is of a different race or ethnicity, find out if a medication is really good for them—I just got prescribed another medication, cause that’s what happens when you get old, and I asked her, “well how do Black women do with it?” and I really wanted her ahead of time to know this kind of thing—find out, turn the page, get another book to learn specifics and the individualized kind of information that you need to have for your patients.

I know that the US Task Force is always sort of giving out these recommendations about when certain kinds of screenings are to happen. Well find out for the Black community, the Latino community, the Pacific Islander community, find out if in fact that recommendation holds true for that community. There are so many cancers that we were getting a whole lot earlier than age 50. I did a research project in the faith community and it was based upon the US Health Task Force recommendation of age 50, and that did not work so well because every church had a litany of names of people who developed cancer much earlier and died by the time they got to 50. So really have to take the time to do a little more work to have an individualized approach to those that you are treating.

Dr Briggs-Malonson: That’s incredibly important and the fact that you just said—treat your patients with care—okay, like that’s huge, that’s really the core of it.

Dr Norris: So I t’s not really known. There has been one or two people in the trials that have developed Bell’s Palsy, but Bell’s Palsy occurs in the general population anyway at a certain rate, right? And right now it doesn’t appear that it’s happening any more frequently than it’s happening in the general population. But we can’t say absolutely that it’s not. But at least right now it doesn’t appear to be any more common than in the general population. So you have to think, when you have 37,000 people going into these clinical trials going on for months, life happens to them to. All the other diseases or problems you can get don’t stop and say “oh, you’re in trial, I’m not going to happen to you.” All those things can keep happening and do keep happening. And so that’s what we know about Bell’s Palsy. Clearly that stands out more than having headaches or aches and pains for a couple of days, but usually like in the general population it’s self-limiting and goes away after a couple of weeks.

Dr Harawa: I think all of our institutions need to hire and up-level the voices of people like ourselves--members of the communities who know those communities and can speak to the particular needs of the communities in a way that maybe other individuals can’t.

Dr Mays: I’m going to say, almost along the lines of what Nina was saying, that we need more of you. You, Dr Briggs-Malonson, for example area an individual that has been given the mantle of diversity, equity, and inclusion, and as Nina said, it’s the concept of—and you actually used the phrase— “lead and serve”. If we are put in the positions to be able to do that, like I’m the special advisor the chancellor on Black life, you can begin to see the transformation that’s happens. We are in the community, of the community, and many of us haven’t forgotten our roots in the community so I really agree with what Dr Harawa said, “lead and serve” but with us.

We need more individuals from these communities in positions of leadership. When we do this we empower individuals from these communities to initiate institutional transformation through leadership and service. We are in the community and of the community and many of us haven’t forgotten our roots in the community. Lead and serve, but with us.

Dr Norris: I agree with that absolutely, lead and serve and we want everyone in this together, and to be in it together you need to be alive. Right? So think about taking the vaccine today so you can be here to fight mistrust and mistreatment tomorrow.

Dr Garner: For me, building medical trust in the Black community, it’s about mentoring. So if you find yourself as a Black medical professional, reach out to your community mentor youth be there for youth whether it’s high school age, college age, or in the medical training. That individual mentoring is really what’s going to build our overall numbers that really allow us to address and fix some of the institutional challenges that we see in the medical community, because until those challenges are fixed or actively being addressed, we haven’t earned the trust of the Black community. So this is work we have to do.

Ms Lukas-Wright: Try to be as transparent and as honest as you can, serve with humility, and remember that your patient is a living soul worthy of respect, and—I think we all learned this when we were little—do unto others as you would have them do unto you. Very simple. And finally I will certainly intone the bible “To whom much is given, much is required.” (Luke 12:48).

Dr Briggs-Malonson: Thank you. And of course I have to include one item too. And what I would say is serve with courage and lead with courage. And what that means is that I think that its really important for those of us within the healthcare field no matter what professional role that we play, that we address each person as the individual they are and that we address their needs as if they are our family because they are our family. And then also for those of us that are in the community just knowing that it is a new time, find the other doctors, nurses, the other clinics that you feel comfortable with and make sure that you’re not holding yourself back from having the healthiest life possible.