As many countries around the world implement their vaccination programmes, they face questions of priority and uptake. In this timely blog post, Ben Kasstan examines the issues around vaccination in ethnic and religious minority communities. Building on research with Jewish communities, Kasstan explores issues of trust and authority as it relates to the vaccination rollout.
Against a backdrop of disproportionate morbidity and mortality from COVID-19, the need to prioritise and protect ethnic and religious minorities as part of the UK’s new vaccine programme has been the focus of recent media, public health and government attention. My question is who is considered a ‘priority’ and how can public health bodies engage productively and sensitively with ethnic and religious minorities.
The production of current evidence and debates in the pandemic is a useful place to start addressing this question. The Scientific Pandemic Insights Group – B (SPI-B) is specifically tasked with providing ‘advice aimed at anticipating and helping people adhere to interventions that are recommended by medical or epidemiological experts.’ It provides ‘expert behavioural science advice’ to the Scientific Advisory Group for Emergencies (SAGE), which, in turn, advises government ministers on appropriate interventions. The ethnicity sub-group ‘advises on COVID-19 risks and impacts for minority ethnic groups.’ A recent output prepared by the ethnicity subgroup of SAGE (15 January 2021) noted that ‘within previous national vaccination programmes in the UK, vaccine uptake has been lower in areas with a higher proportion of minority ethnic populations. There is a significant risk that vaccine uptake for COVID-19 will also be lower among ethnic minority groups.’ The paper specifically outlines concerns of lower-vaccination uptake among Black African and Black Caribbean minorities due to mistrust, a group that was also disproportionately affected by the pandemic. While this point is not in dispute, my concern is with the plurality of minorities and their public health relationships.
The report led to calls in the media to prioritise minority groups for vaccination. In one recent Guardian article, Dr Habib Naqvi, director of the NHS Race and Health Observatory, said that the vaccine is endorsed by religious leaders and councils and people should be reassured that the vaccine contains ‘no pork.’ Yet, the issue of vaccines and minorities is much more complex than pork – and I would argue that this discourse is essentializing.
When I contacted an editor to pitch an article on vaccination and ethnic and religious minority groups based on my long-term interest in vaccine decision-making among Orthodox Jewish families, I was told that if they were to commission a comment on this issue then the focus would need to be on Black British and Asian minorities. Their response struck me as not only unfortunate but part of a larger issue of who is considered a “deserving” minority and the implications for the vaccine roll-out. The response signaled a tendency in the public imagination to view Jews only as a White or religious minority – or ‘Other’ – and not an ethnic minority.
The default position towards Jews in the public imagination is a stereotype of class mobility, communal wealth and resources. Yet, as Nigerian author Chimamanda Ngozi Adichie has argued, ‘the problem with stereotypes is not that they are untrue, but that they are incomplete.’ Many families, especially in Haredi neighbourhoods in Hackney and Salford, tend to live in overcrowded homes and experience socio-economic marginality. Haredi families, too, have much higher total fertility rates, estimated to be three times that of the UK population. This results in particular welfare needs, as well as considerations as part of family health and vaccination services.
What characterizes Haredi Jewish minorities is a general pursuit of self-protection, of immunity, from external influence, which is raising current tensions around education but also has implications for engagement with healthcare services. Orthodox and especially Haredi Jews (commonly and inaccurately referred to as ultra-Orthodox) in the UK and Israel have experienced lower-level vaccination coverage leading to persistent outbreaks of vaccine preventable-disease, especially measles. In 2018-19, measles cases were identified in New York’s Haredi Jewish neighbourhoods, leading to the largest measles epidemic in a quarter-century in the US and Israel. The reasons for lower-level vaccination coverage are complex and include challenges around convenience, complacency and confidence, and in my own research I have observed a circulation of non-vaccination rhetoric between Haredi neighbourhoods in the UK, North America and Israel.
Jewish and Haredi Jewish neighbourhoods in the UK, Israel and the US were disproportionately affected by the COVID-19 pandemic, with Haredim especially facing situated challenges with regards to structural inequalities and were also represented as the image and definition of ‘non-compliance’ in media. There is, then, a need to consider the plurality of minorities who should be considered a priority and how to learn from past and situated issues around vaccine services and public health relations.
In my research with Orthodox and Haredi Jews in Manchester and Jerusalem, I found that parents generally did not view vaccination as a ‘religious issue’ that would require the intervention or advice of religious authorities. This was the case among parents that accepted vaccinations and among parents who felt that a rabbi would attempt to sway their decision towards vaccination – or if they perceived rabbis as uncritically accepting the information presented by healthcare professionals. To quote one parent, ‘even if a rabbi said “you have to vaccinate,” we wouldn’t.’
Vaccine ‘hesitancy’ (which places an emphasis on parents or the person making a decision) often reflected concerns around statutory services and healthcare providers – a lingering concern with safety that stems from the MMR controversy. Vaccine decisions, then, reflected the concerns of parents in the broader White British population. The legacy of the MMR is crucial to consider, especially amidst controversial plans (in extraordinary circumstances) to allow ‘mixing and matching’ vaccines – before any clinical trials have been completed to confirm efficacy or safety. If parents and people do not feel safety is considered to be the absolute priority by the Government and public health services, then a dilemma of protection will arise (to vaccinate or not), which will compound the issues of mistrust that the SAGE ethnicity subgroup identified.
To think that endorsement of vaccines by a religious authority will encourage uptake does not really reflect the full and diverse reality of vaccine decision-making among ethnic and religious minorities. Parents who are religiously observant may also not consider synagogues and mosques to be the most appropriate place to be vaccinated. Relationships built with healthcare providers over many years may make clinics the most convenient and trusted setting to receive vaccinations.
The construction of evidence and discourse shapes how minorities are included and excluded in the definition of priority and the (in)visibility of their needs and expectations. Getting the national vaccination programme right requires reflection on past issues in public health relationships and thorough engagement with minorities – not only religious leaders but parents and people making decisions around their own health. With the possibility that vaccination will be a long-term project, monitoring and evaluation should be constant and qualitative researchers should explore processes of vaccine decision-making across the UK population. Communication surrounding the national vaccination programme must reflect the full range of population diversity, and providers need to be supported with their task of protecting the health of minority groups. Lastly, despite vaccination offering a potential exit route from the pandemic, vaccines will not protect minorities from the structural injustices that underlies the disproportionate morbidity and mortality from COVID-19.
Note: This piece gives the views of the author, and not the position of the LSE Religion and Global Society blog, nor of the London School of Economics.