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The lasting impact of the Tuskegee Syphilis Study: COVID-19 vaccination hesitation among African Americans

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It is widely recognized that African Americans have a higher level of mistrust towards the medical and health sector, which results in insufficient utilization of public health services, low participation in clinical research, and vaccination hesitancy. While the Tuskegee Syphilis Study has been identified as a key factor in this mistrust, its specific influence on COVID-19 vaccination uptake among African Americans remains unexplored. Our paper fills this research gap. Our results suggest that the difference in COVID-19 vaccination rates between communities with low and high proportions of Black residents decreases during the study period, but the gap persists. Notably, counties closer to Tuskegee exhibit a slower rate of progress in reducing the racial disparity in COVID-19 vaccination, indicating that the lingering mistrust stemming from the Tuskegee Study has contributed to unequal vaccination rates between African Americans and the rest of America.

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The author confirms that all data generated or analyzed during this study are included in this published article. Furthermore, primary and secondary sources and data supporting the findings of this study were all publicly available at the time of publication.


  1. Brandt (1978) detailed a thorough summary of the Tuskegee study and racism in medical research.

  2. The paper published the story on the front page on November 16th, 1972, and “dropped a bomb into the laps.” Only 74 study participants were alive then; 128 patients had died of syphilis or its complications, 40 of their wives had been afflicted, and 19 of their children had had congenital syphilis. The digitized version of the article was retrieved from New York Times Achieves, Aide Questioned Syphilis Study.

  3. Survivors of the study later reported that the doctors diagnosed them with “bad blood,” and they thought they were being treated when in fact they were only given the placebo.

  4. When compared with non-Hispanic Whites in the United States, African Americans are three times more likely to get COVID-19 and up to six times more likely to die from it (Yancy 2020). A more recent study by Aburto et al. (2022) found that life expectancy fell more for Black men (3.6 years) compared with White men (1.5 years). Black Americans saw increases in cardiovascular diseases and “deaths of despair” over this period. These changes dramatically increase the already large gap in life expectancy between Black and White people.

  5. According to a National Association for the Advancement of Colored People study in November 2021, only 14% of the Black survey respondents trust the vaccine’s safety, and only 18% trust the vaccine’s safety and plan to get vaccinated. The full report can be retrieved here: Coronavirus Vaccine Hesitancy in Black and Latinx Communities.

  6. Proximity between agents, as described by Tabellini (2010, p. 680), “could refer to geography, but also to social or economic dimensions such as religion, ethnicity, and class.”

  7. The idea behind such an experiment is that if our results are predominantly driven by spillover effects between people, the impacts in less segregated areas (with more social interaction) should be more significant than in highly segregated areas.

  8. The link to CDC COVID-19 Vaccinations in the United States can be found here: COVID-19 Vaccination Tracker.

  9. Counties in Alaska and Hawaii are excluded from the analysis due to missing values. Additionally, CDC vaccine coverage data does not include vaccine coverage rates for some counties in certain weeks. Therefore, our baseline analysis is based on an unbalanced panel.

  10. We classify people into non-Hispanic White, non-Hispanic Black, Hispanic/Latino, non-Hispanic Asian, and others. In addition, we calculate the racial composition by age groups and gender.

  11. We have also depicted the trend for each of the six groups that were present in every possible combination of the categories between Panel (a) and Panel (b). The pattern suggests that vaccination uptake is inversely related to the distance from Tuskegee. The higher the vaccination rate, the further a county is from Tuskegee, regardless of its racial composition. Furthermore, within the “near” and “far” distance groups, counties with a higher proportion of Black people had lower vaccination rates at first but eventually caught up with others. The results are available upon request.

  12. Black people make up 0.00001% of the population in the bottom 1st percentile and 56.15% of the population in the top 99th percentile.

  13. Up to May 2022, at least 257 million people or 78% of the population have received at least one dose. While vaccination coverage has increased, it remains uneven across the country. In five of the six New England states, for example, more than 60% of residents are at least partially vaccinated. In the South, however, Mississippi, Alabama, Arkansas, Georgia, Louisiana, and Tennessee have the lowest rates of residents who have had at least one vaccination in the country.

  14. The link to the full description of the KFF report is Latest Data on COVID-19 Vaccinations by Race/Ethnicity.

  15. The first-order derivative with regard to the share of Black people yields the distance between two counties with the same percentage of Black people. Therefore, it requires ((1.2/0.16)\(\times \)100) miles to close the gap. In terms of magnitude, there are around 1205 counties with a distance greater than 750 miles, making up 38.8% of all counties (3107 counties).

  16. The information of racial segregation can be found here: residential segregation – Black/White. Index of dissimilarity where higher values indicate greater residential segregation between Black and White county residents.

  17. Because around 800 counties do not have a segregation index, we discard them and re-estimate the regression using Eq. 1. After deleting counties with missing segregation index, the point estimates are extremely near to the baseline values, supporting the sample’s representation.

  18. The historical distribution of news was retrieved here: Newpaper. The source does not offer comprehensive or representative coverage of all newspapers, but the selection does give an idea of how quickly the news of the Tuskegee Study traveled across the nation.

  19. The results have barely altered despite the addition of other ratios that were created by gradually extending the 1972–1980 era.

  20. The data source for calculating such population share is from County Intercensal 1970–1972.

  21. We divide the votes for the Democratic (Republican) party by the total votes in that county to get county-level data on support for the Democratic (Republican) party in the 2020 presidential election from the MIT Election Data and Science Lab. Figure A4 shows the county level and vote share results of the 2020 US Presidential Election. The darker the blue, the more Democratic a county voted, and the darker the red, the more Republican a county voted. If a county receives more than half of the Democratic vote, it is classified as Democratic; otherwise, it is coded as Republican.

  22. A mover, in this context, refers to individuals who have changed their place of residence within the past year. Figure  A5 illustrates these migration patterns.

  23. In fact, the US Department of Health and Human Services documented racial/ethnic health disparities almost 35 years ago. As noted in Arias et al. (2021), African people live fewer years, on average, than White people. They are also more likely to die from treatable conditions, more likely to die during or after pregnancy and to suffer serious pregnancy-related complications, and more likely to lose children in infancy.

  24. For the initial 3 months, the HPS survey did not include an “unsure” category in the question related to vaccine probability. However, in the April survey, the HPS survey introduced a modification by adding a new “unsure” category to the scales.

  25. In our data, the average percentage of Black people is 19.4% in Democratic areas and only 8% in Republican areas.

  26. As demonstrated in Fig. A6, the distribution and availability of the COVID-19 vaccine for adults 16 and older vary by state. To alleviate the possibility of endogeneity resulting from vaccine adoption and vaccination behavior across states, we are utilizing the announcement date rather than the state distribution of vaccines.

  27. The report can be found here: COVID-19 Vaccination Coverage and Intent Among Adults Aged 18-39 Years - United States, March-May 2021.

  28. The US cases and the death toll were collected by Johns Hopkins University Coronavirus Resource Center.

  29. New estimates from the World Health Organization show that the full death toll associated directly or indirectly with the COVID-19 pandemic (described as “excess mortality”) was approximately 14.9 million (range 13.3 to 16.6 million) globally. Data source: Department of Economics and Social Affairs, United Nations.


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We thank editor Xi Chen and three reviewers for their helpful comments.

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Hou, X., Jiao, Y., Shen, L. et al. The lasting impact of the Tuskegee Syphilis Study: COVID-19 vaccination hesitation among African Americans. J Popul Econ 37, 41 (2024).

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