Tina Warnick, 50, has worked at a gas station in the foothills of northeast Alabama throughout the pandemic. On busy days, she wears a mask during her morning shift as regulars line up for gas and snacks.
But she hasn’t gotten vaccinated, even as cases of COVID-19 race upward across the state.
“I don’t trust it,” Warnick said. “I do not trust it.”
Warnick, a church-going supporter of former President Donald Trump in rural Cherokee County, belongs to one of the groups least likely to be vaccinated: Republicans.
Meka Edwards, 39, of Prattville is not heavy into politics but tends to vote Democratic and also identifies as a Christian. She is Black and works at the Hyundai plant. Even though her politics are different, Edwards also distrusts the COVID-19 vaccine.
“If it was fully approved by the Food and Drug Administration, I probably would take it,” Edwards said. “But since it’s not fully approved and it came out so soon, I’m not quick to get vaccinated.”
Although most adults in the U.S. have gotten at least one dose of the COVID-19 vaccine, rates are lower than average among both Blacks and Republicans. Alabama has large populations of both – confounding efforts to increase uptake as the state battles a wave of cases driven by the delta variant.
Meka Edwards of Prattville has doubts about the COVID-19 vaccine.
According to the U.S. Centers for Disease Control and Prevention, nearly 70 percent of U.S. adults have received at least one dose of the COVID-19 vaccine. Among Black adults, that number drops to 60 percent, according to the Kaiser Family Foundation. Among Republicans, it slips even further, to 52 percent.
About 54 percent of adults in Alabama have received at least one dose of COVID-19 vaccine, according to the CDC. Vaccination rates between Black and white residents of the state are about even – mostly because white vaccination rates in Alabama lag the national average.
Glen Nowak, director of the Center for Health and Risk Communication at the University of Georgia, spent decades working on vaccine and other public health campaigns at the CDC. He said conservatives and Black people tend to distrust vaccines for different reasons.
Conservatives have less trust in government figures and may be particularly wary of mandates, he said. Politicians and government officials have led much of the messaging on COVID-19 and may not be highly trusted among those who vote Republican.
Although there are many historical examples of racism in medical research, Nowak said distrust of medicine among Black patients is more complicated than that.
“They distrust medicine and public health, which in some cases goes back to Tuskegee,” Nowak said. “But probably in more cases goes back to experiences with their own providers.”
It’s unlikely a single message or strategy could sway both groups, Nowak said. Community leaders in Tuskegee have promoted COVID vaccines to Black residents with great success. Conservative patients might be more open to conversations with trusted medical providers than messages from political figures, Nowak said.
Henna Budhwani, a professor in the School of Public Health at UAB, has been researching vaccine hesitation among African Americans in the South. Many of her study subjects said they have concerns about how quickly the vaccine was developed. Dispelling those fears will require different strategies for different groups, Budhwani said.
“We should partner with agencies that Alabama folks trust, such as churches and schools,” she said. “We need to understand that skepticism toward the vaccines is rooted in multiple forces and perspectives, meaning that a single set of messaging will not resonate with everyone.”
For both Edwards and Warnick, the key sticking point is the lack of full approval from the FDA. The agency has granted emergency use authorization to three COVID-19 vaccines used in the United States. Hundreds of millions of doses have been administered, and the companies behind two of the shots – Pfizer and Moderna – have submitted applications for full approval.
Nowak said U.S. officials have never attempted a large-scale vaccine rollout using shots that haven’t been fully approved.
“I’m pleasantly surprised by the number of people overall,” Nowak said. “Nearly 70 percent of adults overall have gotten the vaccine and they’ve gotten it under an emergency use authorization. And we’ve never done that before. I’m not surprised that, having gotten almost 70 percent vaccinated, getting the remain 30 percent vaccinated has been very, very difficult.”
Before the agency granted emergency use authorization, Pfizer studied its vaccine in more than 20,000 people, compared to another 20,000 in the control group, and watched for potential reactions for two months. Since then, hundreds of millions more have received vaccines.
Some rare side effects have emerged. Officials briefly paused the Johnson & Johnson vaccine, which uses a different technology than Pfizer and Moderna, after more than a dozen women under 50 developed a rare clotting disorder and brain bleeds linked to the shot. Other rare cases of heart inflammation called myocarditis, mostly in young men, and Guillain-Barre syndrome, where the body attacks the nerves, have also been reported with the vaccines.
Experts have said such side effects are extremely rare and typically occur within the first few weeks after receiving a shot. Long-term side effects from vaccines are very uncommon, which is why authorities only required two months of follow-up data for the emergency use authorization.
Some states have used lotteries and giveaways to entice more residents to get the vaccines. But Warnick said campaigns to encourage vaccination have only made her more hesitant.
“The government and employers offering free money, lotteries, vacation days, sick pay,” Warnick said. “Here’s $100 from your employer to get a vaccine. I don’t ever recall getting paid to get a vaccine before. And they really pushed it in your face. Here, let’s bribe you to get this vaccine that we know nothing about. It’s too much, to where people don’t trust it.”
While Edwards said she may eventually get her vaccine, she’s in no hurry. And that’s consistent with polling from the Kaiser Family Foundation showing that few Black patients say they will never get the vaccine, but many want to wait and see.
“My opinion might change,” Edwards said. “But for right now, it came so soon. And I’m scared in a couple years you might see a lawsuit on TV saying, ‘If you took the vaccine, you might be entitled to such-and-such.’”
Dr. John Waits, CEO of Cahaba Medical Care, said the clinics and providers in his practice have been heavily involved with distributing the vaccine throughout rural Alabama and particularly to Black residents. They had early success that increased vaccination rates in many Black Belt counties.
Cahaba Medical Care set up mass vaccination sites, but interest waned by early April, he said. Since then, doctors at the clinics have been speaking with patients one-on-one to encourage vaccination.
“The people that remain unvaccinated have some reason,” Waits said. “And that reason almost always boils down to misinformation.”
He said the COVID-19 vaccines have been as well-studied as any on the market. They have now been given hundreds of millions of times with rare cases of serious side effects.
“Vaccines don’t have long-term effects,” Waits said. “Daily medications have long-term effects. If you’re taking a new diabetes medicine every day, it might be five years before we realize, oh, one out of 50,000 have liver failure, it’s a good thing we’re monitoring lab work. That doesn’t happen with vaccines. You just need massive numbers of people to adopt it. We have massive numbers of people now.”
Waits said his Black patients have had some concerns about preventive health care in general. Vaccines are part of that.
Among his white patients, the hesitation stems more from political and religious reasons, Waits said. Messages from public health officials aren’t likely to change their minds, he said.
“It’s going to have to be someone from within,” Waits said. “We create these self-fulfilling prophecies. The right is very freedom-oriented, ‘Don’t give me rules and regulations.’ And evangelical Christians are very suspicious of big government. So, if you have something that’s mandatory, it’s almost an immediate don’t tread on me type of sensibility. It’s intractable.”
Community norms may also influence whether someone wants the shot.
“As more people in particularly rural areas get the shot, word of mouth from the people who got vaccinated and had a positive experience will get out,” Nowak said.
Warnick said most of her family members and customers have not gotten the shot. In Cherokee County, in the hills near the Georgia line, less than a quarter of residents are fully vaccinated, according to the Alabama Department of Public Health.
“I work mornings where a lot of the old-timers come in and people who have been here all their lives and they just come in and start chatting away,” Warnick said. “And we’ve talked about COVID numerous times and they pretty much, most of them will not get vaccinated either. And they follow what’s going on and they pretty much feel the same way I do.”