Portal de Periódicos da CAPES

Listen to your patients’ ‘why’

2021; Elsevier BV; Volume: 27; Issue: 7 Linguagem: Inglês

10.1016/j.ptdy.2021.06.012

2773-0735

Sonya Collins,

Vaccine Coverage and Hesitancy

More than 150 million Americans have received at least one dose of a COVID-19 vaccine. Pharmacists have played a critical role in the effort it took to get this far. The crucial work of administering the vaccines, which pharmacists have done tirelessly, is just one piece of it. Pharmacists have also spent the last 7 months educating their patients, neighbors, and others about COVID-19 vaccines. They have patiently listened to and addressed the fears and concerns that are very real to the people in their community until, one by one, more and more of their neighbors have decided to get the vaccine. As mass vaccination sites close and demand for vaccines wanes, pharmacists still have a long road ahead. People who haven’t yet gotten the vaccine likely don’t plan to—or they want to wait. That’s why pharmacists must continue to ask each patient who comes into the pharmacy or clinic whether they would like a COVID-19 vaccine. And when the answer is “no,” the next question has to be “why?” Every day may bring a dozen unique answers to the question. “It wasn’t studied long enough.” “There weren’t any Black people in the trial.” “It causes infertility.” “We don’t know about the long-term adverse effects.” “It will change my DNA.” Pharmacy Today spoke with seven pharmacists from around the country who have relentlessly addressed these concerns in their diverse communities to instill vaccine confidence in the vaccine hesitant. Here’s what they said. When RxClinic Pharmacy in Charlotte, NC, received its first shipment of COVID-19 vaccines, staff called patients to schedule their appointments. Patients of the pharmacy represent a cross-section of the city’s diverse population and include Hispanic and Asian immigrants, Burmese refugees, people living with HIV, and folks of various socioeconomic and religious backgrounds. But in phone calls with patients, while many were excited about the vaccine, pharmacy staff got pushback from others. “‘I’m not ready for this. They pushed this through too soon. The government shouldn’t tell me what to put in my body.’ That’s what we were hearing from people,” said Amina Abubakar, PharmD, owner of RxClinic. Abubakar and her team knew they needed a targeted approach tailored to the individual concerns of each group that was pushing back against the vaccine. Fortunately, a customized approach was no problem for the pharmacy because, Abubakar said, “Our pharmacy staff mirrors the local community.” A Vietnamese-speaking pharmacist at RxClinic created an informational video for the Vietnamese community. Spanish-speaking staff did the same while Arabic-speaking staff presented information about the vaccine during community prayer services. They posted the videos on the pharmacy’s social media channels and shared them with other groups that might be relevant to speakers of these languages, such as the Vietnamese Association of Charlotte. The effort has drawn in not only existing patients who saw the videos in their language but people from all over Charlotte who come from those backgrounds. A couple of RxClinic Pharmacies are located inside health care facilities. Abubakar was dismayed when staff at those facilities showed resistance to the vaccine, too. Among administrators, CNAs, medical assistants, and other health workers at various knowledge, training, and responsibility levels, many expressed reluctance to roll up their sleeves and get the vaccine. “We needed to focus on these frontline workers to see where their hesitancy was coming from,” Abubakar said. Her pharmacy staff partnered with clinicians at these health care facilities to produce an educational video that addressed the specific concerns of the health workers, which included how the vaccines work and how they were approved so quickly. To the latter concern, Abubakar explained that the sheer number of COVID-19 cases helped accelerate the process. Almost immediately, there were hundreds of thousands of cases to help researchers study and understand the virus. A vaccine would have taken much longer if fewer people were infected. After the pharmacy presented the frontline workers with an educational video, Abubakar said, “The vaccination rate started going up. People would come to us and say, ‘Thank you. It finally makes sense.’” It wasn’t only pharmacists and other clinicians who helped disseminate information and dispel myths about the COVID-19 vaccine. Abubakar advises all pharmacists to leverage the additional reach of their pharmacy technicians. RxClinic’s technicians shared vaccine information on Facebook Live with their personal networks. One video led to an invitation from the technician’s church to address the congregation about COVID-19 vaccines. Tips▪Pinpoint the reason for the patient’s hesitancy.▪Listen and share the facts.▪Cultivate trusting relationships.▪Keep the scheduling procedure simple. ▪Pinpoint the reason for the patient’s hesitancy.▪Listen and share the facts.▪Cultivate trusting relationships.▪Keep the scheduling procedure simple. “We converted our technicians into vaccine ambassadors, and that gives us a wider reach.” Abubakar hasn’t relied only on videos to help spread the message about immunizations. She personally searches out remaining pockets of vaccine hesitancy in the community. For example, she or members of her pharmacy staff stop in at international grocery stores, such as Hispanic and Halal supermarkets, to promote the vaccine. Recently, Abubakar visited a Hispanic grocery to let the owner know that vaccines are available at her pharmacy. The conversation led to persuading an employee, who had been on the fence, to get vaccinated. In routine Zoom meetings with the local COVID-19 Task Force, whose health care committee she chairs, Abubakar helps others spread the word about the importance of vaccination to their networks and communities as well. The task force includes medical, business, religious, and community leaders who share challenges they face—such as resistance to masks, social distancing, and vaccines—and then brainstorm ways to overcome them. “Ministers, for example, talk about working this information into their Sunday messaging,” she said. Abubakar is hopeful that the ongoing information and counseling that comes of her staff’s videos, her in-person outreach, and the task force’s efforts will continue to chip away at any remaining vaccine hesitancy in her community. Letoia Clark, PharmD, administered vaccines at one of Kansas City’s first mass vaccination events at Arrowhead Stadium in Kansas City, MO. She saw many people cry tears of joy that day, but one person in particular stood out. The 40-something woman told Clark that she was a florist and that over the last year, her business had been one funeral after another—a reflection of the death toll of COVID-19. “She felt that getting the vaccine was something she could do for all the customers whose stories she’d heard that year, the people who’d had to bury their spouses, their parents, or their siblings.” At KC Care, a federally qualified health center in Kansas City, MO, where Clark is a resident, most patients were equally eager to get their vaccine. But Clark knew that not everyone was going to accept the vaccine right away. So, she launched a study to help clinic staff head vaccine hesitancy off at the pass. “I wanted to find out the reasons that patients in a federally qualified health center might be reluctant or refuse to get the COVID-19 vaccine,” she said. That way clinicians could be prepared for some of the concerns they might hear during encounters with patients. Clark’s survey found three common concerns among this patient population. Some patients worried about immediate and possible long-term adverse effects of the vaccine. Others didn’t understand how the vaccine worked. Some worried about how new the vaccine was. “People weren’t confident about getting the vaccine because, to them, it just kind of came out of nowhere,” Clark explained. The survey also found that White patients were most likely to get vaccinated, Black patients were least likely, and Hispanic patients fell somewhere in the middle. Clark and her colleagues heard around the clinic that some Black patients felt they had been underrepresented in clinical trials of the vaccine. Clark said she feels it’s important to stress to patients who voice this concern that this may happen in clinical trials not because investigators skip over Black people but because they may be less likely to volunteer. KC Care also serves a large population of patients living with HIV. Clark and other clinicians found about a 50/50 split among them in their willingness to get the vaccine. For some, their potentially weakened immune system was all the more reason to roll up their sleeve and get the vaccine. For others, it was a reason to avoid it. Armed with this information, clinic staff set out to lower the barriers to vaccination as much as possible. “Once the vaccine was available, and we knew we were getting it, a team was built specifically to handle and manage vaccine distribution and organization,” Clark said. For starters, they kept the scheduling procedure simple. Rather than navigate an online booking system, eligible patients simply needed to send an e-mail stating their interest in getting the vaccine, and a clinic staff member called them back with an appointment. When patients voiced concerns about the vaccine, Clark said, clinicians listened and shared the facts. In response to concerns about adverse effects, Clark and her colleagues cited data about the effects and pointed out that they were shortlived and similar to those of the flu vaccine. “It’s just our body’s natural response to something being injected into it and trying to build an immune response to it.” As for patients who have HIV, clinicians explained that they were eligible for the vaccine regardless of their viral load and that it would protect people with a potentially weakened immune system—not hurt them. “We stick with information that CDC, WHO, and the vaccine manufacturers provide, and we consistently educate our patients with the most accurate and up-to-date information we have.” Ultimately, the overwhelming majority of patients at KC Care have accepted the COVID-19 vaccine. Clark credits the trusting relationships clinicians cultivate with their patients. And she offers advice for other clinicians who want to foster this type of trust with patients: Listen to their “why.” “It’s important to pinpoint the reason for the reluctance or refusal to vaccinate in the first place,” Clark said. “It’s not enough to ask a patient if they want a COVID-19 vaccine, and if they say no, to move on. Ask why. Once you’re able to identify that concern, you can acknowledge it and offer education, support, and the most accurate research and data so the patient can make the most informed decision.” The state of Alaska has been meticulous about protecting its residents from COVID-19. It was the first state to require a negative test for entry and the first to require a travel declaration, in which untested people entering the state must agree to take a test in the airport on arrival and self-isolate until they receive their results. When the COVID-19 vaccines arrived in Alaska, the Department of Health and Social Services added vaccination to the infrastructure already in place in airports. Eligible people could get the vaccine before they left the building. “This opportunity helps get people for whom convenience was the only barrier,” says Coleman Cutchins, PharmD, clinical pharmacist at the department. Alaska was also the first to open vaccinations to anyone age 16 or older. Cutchins has made it his mission to persuade as many individuals as possible to seize this opportunity. Using real-time vaccination data, Cutchins and his colleagues at the department have developed targeted approaches to address vaccine hesitancy among all remaining holdouts. “Overall, our rural areas are doing much better than urban areas,” Cutchins said. “Most of our urban areas are below the state average.” In general, rural areas have a higher concentration of Alaska natives, while urban centers, such as Anchorage and Fairbanks, are more diverse. Cutchins noted that Alaska natives have a robust tribal health care system as well as several reasons to be eager to get vaccinated. “They have been extremely cut off through the pandemic because of the risks associated with air travel,” he said. The devastation caused by the Spanish flu is also still very much alive in the collective memory of Alaska natives. “A lot of these communities got hit very hard by the Spanish flu. Many elders in the villages grew up without a parent because of that. Those stories are still being told today. So, there’s a clear understanding in some of the villages of how bad this could get.” In the cities, that understanding is less clear, and vaccine hesitancy is pervasive. Compared with some native communities, where nearly all eligible people have gotten the vaccine, in Anchorage just half are vaccinated.In Fairbanks, fewer than a third have rolled up their sleeves. Cutchins and his colleagues have reached many of Alaska’s vaccine hesitant through virtual town halls. Each one targets a specific population, such as industries, including fishing and tourism; public schools, including teachers, parents, students, and school nurses; the medical community, in which the panel prepares other health professionals to counter vaccine hesitancy; and a town hall for the general public that focuses on the science behind the vaccine. In each town hall, Cutchins and several physician panelists counter misinformation, describe the FDA approval process, and explain how vaccines work. Concerns about FDA’s speedy emergency use authorization are among the most common ones voiced during town halls. As a result of explaining FDA’s process so many times, Cutchins has developed a presentation on it. “I explain that with emergency use approval, no one skipped any steps, but that some steps that usually happen one after the other now happen in parallel,” Cutchins said. “But the biggest factor in getting the vaccine to market so fast was that they started manufacturing it before it was approved. If the studies had shown it wasn’t effective, we would have thrown away a lot of drugs.” He uses the Johnson & Johnson (Janssen) vaccine as an example of exactly how the postmarket phase of a clinical trial ought to work. “That’s when we find those one-in-a-million side effects that never show up until the drug makes it to market,” he said. He added that ibuprofen had been on the U.S. market for 31 years before the FDA required a label change in 2015 to include a warning about the risk of GI bleeding and heart attack. He also uses the concept of postmarket surveillance to counter the myth that the COVID-19 vaccine may cause infertility. “If that were truly happening, now that more than 200 million people have been vaccinated, we would have seen it by now,” he said. After one of the sessions in which Cutchins explained the FDA process, he received an e-mail from a participant who thanked him for the clear explanation. When it comes to concerns about adverse effects, Cutchins offers perspective. He tells those who are vaccine hesitant that vaccines are among the safest medications around—safer even than OTC painkillers, which cause more hospitalizations and deaths than vaccines ever have. As for questions about long-term effects, he explains that the vaccine does its job and leaves your system within a few days. The medicine itself doesn’t linger there long term. Most vaccine adverse effects, he explains, happen within 2 weeks of getting the vaccine, but usually just a couple of days. The town halls, in which Cutchins and his colleagues listen to each concern and address it head on, seem to have had the desired effect. “I haven’t done one yet when someone hasn’t messaged me afterward and said, ‘You know what, I wasn’t sure before, but I’m going to get the vaccine now.’” Saad Dinno, BSPharm, has brought COVID-19 vaccines to numerous congregate housing facilities around the Boston area. He and his team have helped vaccinate numerous residents in high-density settings, from group homes for people living with cognitive impairments or physical challenges to low-income housing complexes. “When we vaccinate a whole building, there’s a chance that we are preventing another outbreak,” said Dinno, co-owner of Dinno Health, an independent pharmacy group serving four Massachusetts communities. Dinno runs the business with his brother Ray Dinno, BSPharm. Besides mitigating the heightened risk of community spread in these high-density settings, vaccine clinics in congregate housing also lower barriers to vaccination for many people who might otherwise miss the opportunity. Dinno and his team from Dinno Health have vaccinated people who are blind, paralyzed, and homebound at the 20 or more sites they’ve visited over the last few months. The logistics of transporting some of these patients to off-site vaccine events might have caused major delays. At the sites, patients who were able came to a common area to receive the vaccine. For those who were homebound, Dinno or a member of his team took the vaccine to the patient’s room. After administering the vaccine, the vaccinator waited the requisite 15 or 30 minutes with the patient in case of adverse events. “One patient, who was bedridden, asked, ‘Can I give you a hug? I just can’t believe you came all the way here to see me and give me the vaccine,‘” Dinno recalled. At each clinic, when Dinno arrived an hour early to set up, residents were already lined up to await their turn. Caregiving staff, however, were not as eager. “That was a little discouraging at the beginning,” Dinno said. “We saw a lot of hesitancy.” The most common refrain, Dinno said, was that the mRNA technology used in the Moderna and Pfizer vaccines is too new to trust. To which Dinno replied, “It’s a new avenue for vaccines, but the technology has been around and in use in other disease states for decades.” Others told Dinno that they weren’t completely opposed to the vaccine but that they planned to wait a little longer, in case any new adverse effects or events arose. To this, Dinno explained that the longer they waited, the longer they continued to put themselves at risk. Dinno stresses the importance of listening carefully to people with vaccine hesitancies and thoroughly addressing their concerns with facts. He shares data from the clinical trial with them, which shows that nearly 30,000 people received the vaccine in the study. “This wasn’t just a couple thousand people, I told them. There were many, many thousands of people.” Soon, Dinno began to see a shift. When he returned to those sites to administer second doses, many of those who were hesitant at first came back to get the vaccine. The converts, Dinno found, might turn out to be more ardent proponents of the vaccine than those who had bought in from the start. “What I noticed with those individuals who were hesitant at first, many of whom were immigrants from other countries, was that many of them either recorded or took pictures of themselves getting the vaccine,” Dinno recalled. “They said they were going to send it home to their country to show that the vaccine was safe. That’s a great message coming not from the CDC but from an individual that you know.” Had Dinno not given each of their concerns the time and respect they deserved, they would not have come back a few weeks later to get the vaccine. “It’s important that we give people a chance to discuss their questions and fears with us,” Dinno said. “We can’t ignore the ‘No, I don’t want it.’ We have to come back with ‘May I ask why? Maybe I can help answer some of your questions.’” Community Pharmacy in Springdale, AR, was one of just 12 sites in Washington County to offer COVID-19 vaccines at the beginning of the rollout. Victoria Hennessey, PharmD, the owner, was prepared for high demand. Knowing that her busy pharmacy wasn’t the right venue to meet the demand, she rented a nearby conference space to use as a vaccine clinic location. But, after running the clinic from the rented space, Hennessey realized it wasn’t ideal. “We were only able to vaccinate about 50 people a day in that space, and we just weren’t reaching the numbers that we needed to reach,” Hennessey said. So, she enlisted the help of nearby First Church Springdale, which generously offered her use of their gym, parking lot, and a corps of volunteers. “It was a well-oiled machine,” Hennessey said. “We had repeat volunteers who just showed up and knew what to do. At our peak, we vaccinated 930 people in a day.” The church-based vaccine clinic quickly and efficiently reached those who were eager to be vaccinated, but Hennessey knew she’d have to use a different approach to reach those who were less enthusiastic. Springdale is home to the largest population of Marshall Islanders outside of the Republic of the Marshall Islands. Because of a history of abuses against the Marshallese in their home country by U.S. interests, including internment to study the effects of radiation exposure without their informed consent, Marshall Islanders in the United States harbor a deep distrust of the U.S. health care system. “Even when our Marshallese staff members in the pharmacy have encouraged Marshallese patients to get the vaccine, we have seen hesitancy,” Hennessey said. Hennessey leveraged trusted Marshallese community leaders to help her rise to this challenge. She partnered with the Marshallese Consulate and Sheldon Riklon, MD, one of only two Marshallese physicians in the United States and an associate professor at the University of Arkansas for Medical Sciences, to offer a vaccine clinic. Hennessey disseminated information about the vaccine clinic in Marshallese on Facebook. “For many Marshall Islanders, Facebook is their primary means of communication,” she said. Together, Hennessey and Riklon, with the help of additional interpreters provided by the consulate and University of Arkansas for Medical Sciences, vaccinated Marshallese elders in the consulate’s offices. Many Marshall Islanders in Springdale work at a local poultry plant, which is headquartered there. But when Hennessey administered vaccines on-site at the plant, she was surprised to see that not many Marshallese people were among the hundreds of employees who rolled up their sleeves that day. Again, she leaned on respected community members to help her close this gap. Tyson’s staff nursing assistant, who is Marshallese, was on-site assisting Hennessey with vaccines. When Hennessey asked why they weren’t seeing more Marshallese people, the nurse went inside to find out. She learned that a rumor was circulating among the Marshallese staffers that if they took the vaccine, they would die. The nurse approached the group, listened to their concerns, and respectfully explained that they had already vaccinated hundreds of people that day and no one had died. She also explained that while there was no evidence you could die from the vaccine, there was a serious risk of death from COVID-19, which had already hit the Marshallese community very hard. “Before I knew it, there were 40 Marshallese people lined up outside to get vaccinated,” Hennessey said. “Without [the nursing assistant], I know we would not have been able to vaccinate them.” While fear of death from the vaccine might seem outlandish to clinicians, Hennessey stresses the importance of hearing people’s fears and addressing them directly. This is the same approach she’s taken with people who have expressed concerns that the vaccine causes infertility. “These concerns are very real to the patient,” Hennessey said. “It takes time to look that patient in the eye and say, ‘I recognize and understand your concerns.’ Acknowledgment of the concern is number one. You’re never going to get anywhere with the vaccine hesitant if you don’t acknowledge their concerns.” Now, more than 6 months into the U.S. vaccination effort, large vaccine events, like those at First Church Springdale, the Marshallese Consulate, and the poultry plant, are far less common amid flagging demand. “Those clinics were hard work, but now comes the really hard work,” Hennessey said. “We have to dig our heels in, reach the patients who are hesitant, and figure out why. Every single patient that comes to the pharmacy, we have to ask ‘Have you had your COVID-19 vaccine? If not, can we give it to you today?‘” When Rossi Pharmacy in the Ocean Hill neighborhood of Brooklyn, NY, started receiving shipments of the COVID-19 vaccine, Ambar Keluskar, PharmD, supervising pharmacist, wanted to ensure that members of the community had first dibs on the long-awaited vaccines. So, he promoted the vaccine and offered it to any eligible people around the working-class neighborhood. “At the beginning, some people acted like I was offering them poison,” Keluskar recalled. They’d counter the community pharmacist’s offer with tales of horrific vaccine adverse effects they’d read about on Facebook. Those who were slightly less averse to the vaccine said they planned to wait until more people received the vaccine, and then they would get it. Some expressed concerns that the vaccine was developed too quickly. Others in the predominantly Black and Hispanic patient population said the clinical trials didn’t include enough people who looked like them. Some complained it was too hard to get an appointment or that the lines were too long. Over the last 6 months, Keluskar has slowly chipped away at vaccine hesitancy in his community. “You don’t have to make the hard sell right then and there,” he explained. “You’re their local neighborhood pharmacist. You see them 12 times a year—more than their doctor. So, you have all these micro-opportunities to whittle away at the hesitancy and the rumors. You just keep making the gentle offer.” While Keluskar continues to make the gentle offer to every unvaccinated patient who approaches the pharmacy counter, he has also stepped out from behind the counter to host and coordinate vaccination events in the area. He started with local housing complexes. That was a way to reach older adults with mobility issues that kept them from going off-site to get the vaccine. These residential events also allowed Keluskar to harness those whom he believes to be the most effective vaccine advocates. “The strongest vaccine advocates are your neighbors,” he said. “That’s why, especially early on, any time we vaccinated someone in the community, we asked them to spread the word as much as possible. It was really quite effective and caused a snowball effect.” That approach is particularly effective when people get the vaccine in their apartment building, where they can immediately send their neighbors downstairs to do the same. Thus far, Keluskar and his pharmacist colleagues at Rossi have done about 15 first-dose clinics and 15 second-dose clinics. At their peak, they vaccinated 350 people in a day. Rossi Pharmacy also partnered with UJA-Federation of New York, a Jewish philanthropic organization, to bring the vaccine to Jewish community centers. There, rabbis joined forces with the pharmacists to address people’s concerns and get the message out about the importance of vaccination. The UJA-Federation provided volunteers from the local Jewish community, whose presence went a long way to reassure those who might be hesitant. “We even saw some of the volunteers hold the patients’ hands while they got vaccinated,” Keluskar said. The UJA-sponsored events included a pop-up vaccine clinic at the Hatzalah Ambulance dispatch in Brooklyn’s Borough Park neighborhood. Hatzalah ambulances serve predominantly Jewish neighborhoods throughout greater New York. Borough Park is home to the largest Orthodox Jewish population outside of Israel. Keluskar also called on UJA to help him use a windfall of doses the pharmacist suddenly came into when a hospital in the Bronx had received more doses than they could use in the next 7 days. They got word of the extra doses on a Monday and worked quickly with UJA to organize a series of events through which they vaccinated 1,200 people over the next week. “Our flexibility and ability to leverage technology rapidly was key to being able to meet this challenge,” he said. “But vaccinating is only half the battle. There’s still a fairly significant amount of work to enter them into the system and report the immunization.” Now, more than 6 months into the U.S. vaccination effort, big vaccine events are no longer the most effective way to reach those last holdouts. Those who are most likely to show up at such an event have received the vaccine by now. “We’re currently in talks with the rabbi [at one of the UJA vaccination sites] about how to pivot our efforts now that it’s no longer really about these mass vaccine sites. It’s now more about reassuring people about the vaccines.” Back at Rossi Pharmacy, Keluskar’s focus remains on that gentle offer. The pharmacy has removed any barriers to vaccination. Rather than organize off-site events, the pharmacy allows patients to walk up and get the vaccine at any time without an appointment. “This is possible because New York State is now prioritizing not missing vaccination opportunities over not wasting small amounts of vaccine,” Keluskar said. “We’re leaning on the trust our patients have in our pharmacy. Through the convenience of the walk-up model and reminders that we have the COVID-19 vaccine at checkout, we’re consistently vaccinating about 8 to 10 people per day.” From the moment Powell Pharmacy in Powell, OH, began offering COVID-19 vaccines, owner Emlah Tubuo, PharmD, MS, found herself fielding questions all day long. “Do you trust the vaccine? Do you think it was studied enough? How long has this mRNA technology been around? Does mRNA change my DNA?” Rather than answer the same questions again and again, Tubuo decided to record a video that plays on loop in her pharmacy and on the store’s Facebook page, where it’s been shared more than 50 times. In the video, Tubuo stands before a whiteboard, where she has drawn diagrams of the COVID-19 virus and mRNA, and she explains how mRNA triggers the immune system to create antibodies against spike proteins. Wearing a t-shirt that reads “Choose kindness always,” she closes by saying that getting the vaccine is an act of kindness to yourself and to everyone around you. After seeing Tubuo’s video on Facebook, people who’ve never been to her pharmacy have come in to ask questions about the vaccine. “I tell them that our rule at the pharmacy is not just to give vaccines,” Tubuo said, “but to educate people about them.” Tubuo has put great effort into educating people about the COVID-19 vaccines, from how they were studied to how they work and what adverse effects people can expect. Powell, OH, is a predominantly White community, so Tubuo actively seeks out Black people to spread the word about the vaccine and to counter hesitancy. Many Black people she encounters question whether Black people were sufficiently represented in the vaccine trials. In clinical trials in general, Black people tend to be grossly underrepresented. But the Pfizer and Moderna trials showed improvement in this area. When patients bring these concerns to Tubuo, she acknowledges this very valid worry. “Yes, this is a part of our history, but now we have to move forward with science. We have to participate in the studies and make sure that we understand the technology,” she said. She then gives them a copy of the demographics of the trial cohorts. While the proportion of Black participants in the Pfizer and Moderna trials was slightly smaller (9.8% and 9.7%, respectively) than the proportion of the general population that is Black (12.3%), both Pfizer and Moderna enrolled far more diverse cohorts of patients than many other drug trials do. Tubuo also mentions that, at one point, Moderna stalled enrollment to ensure diversity among participants. In a further effort to represent Black people, she tells patients, Moderna enlisted all four of the country’s historically black medical schools—Meharry Medical College, Howard University College of Medicine, Morehouse School of Medicine, and Charles R. Drew University of Medicine and Science—as trial sites. “That tells you that they wanted to include us in this study,” Tubuo said. “This isn’t something that they’re only testing in other people and then trying to give to us. We are included in this study, too.” It often takes many encounters with a patient before they decide to get the vaccine. “If they say no, just keep trying. Give them time, hold their hand, and explain how the vaccine works in language that they can understand.” While Tubuo gives time to patients in the store, she doesn’t want to waste time distributing vaccines. She has partnered with numerous organizations to offer clinics, including homeless shelters, churches, free clinics, workplaces, and minority-owned businesses. “That’s important because a lot of hesitancy is coming from minority communities,” she said. But, she adds, “My efforts are as broad as can be because vaccine hesitancy is beyond race. We have a lot of vaccine hesitancy in the White community as well.” Tubuo and her staff vaccinated people who are homeless or undocumented on a walk-in basis for several days across several weeks at free clinics. She has also vaccinated congregants at a local church after Saturday and Sunday mass. “Vaccines don’t belong in the fridge at my pharmacy,” she said. “Vaccines belong in people’s arms.” This project was funded in part by a collaborative agreement with CDC (CoAg number 1 NU50CK000576-01-00). CDC is an agency within the U.S. Department of Health and Human Services (HHS). The contents of this resource do not necessarily represent CDC or HHS and should not be considered an endorsement by the federal government. This project was funded in part by a collaborative agreement with CDC (CoAg number 1 NU50CK000576-01-00). CDC is an agency within the U.S. Department of Health and Human Services (HHS). The contents of this resource do not necessarily represent CDC or HHS and should not be considered an endorsement by the federal government.