Omar Neal had every reason to be skeptical.
Here in Tuskegee, Alabama, where roadways are dotted with signs that read “Vaccinate Me. Stop the Spread”, the history of racist medical abuse weighs heavily.
For four decades, between 1932 and 1972, the US government sponsored a biomedical study coercing 600 Black men, all sharecroppers, into a study on the effects of untreated syphilis. The male subjects were not told they were part of the research, and instead were made to believe they were being examined for “bad blood”. Many died. Others spread the disease to family members, partners and their newborn children. None were offered proper treatment.
Neal’s uncle, Freddie Lee Tyson, was one of those men. He grew up in the house next door to his nephew and would occasionally share how it felt when the study was exposed in the early 70s.
“There was shame. And there was disbelief. Disbelief that the government would do that,” Neal recalled. “How could you? How dare you use my humanity for such an egregious activity.”
In 1997, President Bill Clinton apologized for the Tuskegee study, which he described as “clearly racist”. Two decades on, the legacy of what happened here has been routinely cited as a reason many Black Americans remain distrustful of the country’s medical systems and also the Covid-19 vaccine itself.
It is then, perhaps, against expectation that vaccination rates in Macon county, where this city of 8,000 residents is situated, are substantially higher than the state average in Alabama. In Macon county, 36% of residents have now received their first shot compared with only 32% statewide. In this historic region of Black Belt counties, home to large populations of Black residents, some jurisdictions have completed vaccinations at rates of over 40%.
But Alabama and the neighbouring state of Mississippi have for months had the lowest vaccination rates in the country, with vaccine hesitancy underwritten by different forces in various locations across the state. In some areas, political leaders have retreated from public engagement on the issue, while in others, including Tuskegee, local leadership has played a vital role in pushing rates above the state average.
Neal, a radio host and community leader, took his shot almost as soon as it was available. He weighed the heavy history but set aside what he described as instinctive distrust of public health systems after generations of failures.
“Trust is a calculated risk,” he said, pausing for a moment. “Five hundred and eighty-eight thousand people have died because they didn’t get this vaccine. Nobody died that did take it. That’s pretty good odds for me.”
Neal points to years of public health funding cuts and depleted infrastructure not only in Macon county, which lost its two hospitals decades ago, but across the Black Belt that have contributed to greater distrust of medical institutions.
Neal has produced numerous radio segments on the vaccine, urging listeners to get the jab. He filmed himself taking the shot, and broadcast it on social media. “The context of the Tuskegee syphilis study is very different from Covid-19,” he said, as he awaited the injection. “In Covid-19 we are providing the vaccination … it was the Tuskegee study that denied treatment of those men.”
Political leaders in the city of Tuskegee have been on the frontlines throughout the pandemic. Fifty people in this small, rural county of 18,000 people, died from the virus. Other nearby locations in the Black Belt suffered the highest death rates in the state.
The city’s mayor, Lawrence Haygood Jr, created a local Covid-19 taskforce as the pandemic began to rage and a number of elder community leaders died from the virus. It continues to meet virtually every Saturday.
Haygood, a lean, softly spoken man who has lived in Tuskegee most of his life, was also vaccinated live on local television and convened a number of live panel events to dispel myths around the injection.
“More people are looking for a reason to say no than they are yes,” Haygood said, arguing that like countless other areas in the country, the city is also dealing with pervasive misinformation about the vaccine posted on social media. “But I know people who, once they saw me take the vaccine, came and asked: ‘How did it feel?’ ‘What happened to you?’ And the next thing I know they’re getting vaccinated too.”
But still much skepticism remains. Macon county’s 36% rate of first-shot vaccination remains well below the national average, with over half of the country’s adults now fully vaccinated.
Haygood’s approach to this has been to engage with the distrust head on and encourage those who are skeptical to speak publicly about it. His own nephew, a nurse, has declined to be vaccinated. Initially, a handful of members on the taskforce too decided against it. Many have since changed their minds, but one, a retired clinical laboratory scientist named Joyce German, is still resolved against taking it.
“After studying as much as I could study and finding out as much as I could find out, vaccines did not seem to be the answer for me,” German said over the phone. She continues to self-isolate and does not allow visitors into her home. She masks up on the rare occasions she leaves the house.
German, who described herself as “naturopathic”, expressed concerns about the long-term effects of the vaccine and pointed to the under-representation of Black Americans in certain vaccine trials and in senior medical research positions. “Racism is entrenched in these United States,” she said, explaining it was not simply the Tuskegee study that contributed to her skepticism but rather the pervasive racial disparities in American healthcare more broadly.
“I would be more comfortable with research that came from institutions that I know are geared towards the health and safety of people of color,” she said, acknowledging she would reconsider her position in the future and was not against vaccination more broadly.
Alabama’s low rate of vaccination had initially been attributed to slow rollout efforts. But, said Dr Michael Saag, a leading infectious diseases researcher at the University of Alabama at Birmingham, widespread hesitancy appears to have become the major reason for the lagging numbers.
Following a national trend, many counties with the lowest rates of vaccination in Alabama, a deep red, Republican state, tend to be more conservative, leaning heavily toward Donald Trump at the last election.
“I think what it is boiling down to now is the political resistance,” said Dr Saag.
Although Trump recently encouraged his supporters to get vaccinated during an appearance on Fox News, the former president’s outreach on the issue has been minimal. He was never vaccinated in public and has declined to record a commercial encouraging his supporters to do so. He also thrust disinformation on Covid-19 into the centre of his presidency and pushed the issue of mask wearing into America’s culture wars, which played out in various locations around the state.
Alabama’s Republican governor, Kay Ivey, has sent mixed messages. On the one hand she openly encouraged vaccinations. But on the other hand, last week she signed a law that prohibits businesses and public institutions from requiring vaccine passports to access services or stopping those without a vaccine from entry.
“I can’t think of a single public health or medical reason to prohibit ‘passports’,” said Dr Saag.
The Alabama department of public health did not make an official available for interview, despite requests.
In the town of Florala, with a population of 1,500 in rural Covington county, which is 120 miles south of Tuskegee, vaccine conspiracy theories and deep hesitancy tied to individual choice were easy to find. An overwhelming 84% of the county voted for Trump in 2020. Covington is 84% white, and during interviews with almost a dozen residents, only one told the Guardian they had taken the vaccine. According to state health data just 24% of residents in the county have taken their first shot.
Donna Battin, a hairdresser at the local barber, Cobb’s, said she had moved back to town from Tucson, Arizona, after her employers there had told her to get vaccinated. “It’s against my constitutional rights,” she said. “I’m not a sheep. I do what I want to. And I just don’t want to dive into something brand new.”
Her colleague, Myra Radney, was bed-bound for six weeks after contracting the virus in January. For a time she struggled to breathe and feared she might die. But she felt the same as Battin. “I just don’t believe in it [the vaccine],” she said, as she trimmed a customer’s hair – neither of them wearing face masks. “It’s just another way to control people, I think.”
Across the street at Florala’s City Hall, the sentiment was the same. Gina Hendriks, the city clerk, said she had long distrusted vaccinations. “I feel like we’re guinea pigs,” she said. “I’m a cancer survivor and I do not want to put anything in my system that I don’t know what it is.”
Multiple calls to the mayor of Florala, Terry Holley, were not returned. But Gregory White, chairman of the Covington county commission, acknowledged the county had not held public forums to engage with vaccine hesitancy directly, although it had promoted vaccine clinics during a commission meeting.
“Maybe we need to be a bit more public in our stance,” White, who has been vaccinated but not in public, said. “I’d be glad to do it [speak directly to hesitant constituents], but I haven’t been given the opportunity.”
He argued that the low rates of vaccination in his county could be partially attributed to slow early rollout but acknowledged: “There is a little tendency to distrust government at the federal level here. I think that’s pretty much inherent in any rural, conservative community. And ours is certainly that.”
Dr Saag remains alarmed by the low rates of vaccination and the ongoing politicization of the pandemic and cautioned it could lead to further outbreaks and more deaths in the future.
“This infection is not going to disappear, it’s going to be with us, I would say, as a global entity for the next decade, probably presenting itself as hot pockets of infection, like wildfire. And I think these communities in Alabama, should they become exposed to especially more contagious variants, there will be an endemic, mini-outbreak.
“Some people will get sick. Some people will die, because they refuse to get vaccinated,” he said. “That is a tragedy. It’s a preventable death.”