After a year of wondering when – or if – it would ever happen, the first people to be vaccinated against Covid-19 in the UK have now received their initial doses. Residents in care homes and their carers are first on the list to receive vaccines, followed by frontline health and social care workers and people aged 80 or over.

By the time healthcare workers get to the bottom of the long list of people who have priority for a Covid-19 vaccine, just under half of the UK population will have received their doses of the vaccine.

But not everyone in the UK will be lining up to get their shot. According to a survey of people in England conducted by the London School of Hygiene & Tropical Medicine and Public Health England, people from BAME backgrounds are almost three times more likely to reject a Covid-19 vaccine than those from white backgrounds.

The same communities that disproportionately felt the worst impacts from Covid-19 are at risk of being left behind again. To reach herd immunity and ensure maximum protection against Covid-19, about 70 per cent of the population will need immunity against the disease, which makes it even more important that no group gets left behind when it comes to vaccines.

There are a number of structural reasons why BAME groups are more likely to encounter the virus. They are more likely to live in densely populated locations and in housing where multiple generations share the same space. To compound the exposure risk, a disproportionate number are employed in public facing roles such as bus and taxi drivers, on the frontline in the NHS and various care home roles.

The structural problems highlighted by the Covid-19 pandemic have not disappeared and could be exacerbated with the roll-out of the vaccine. The events over the summer, particularly the outcry over the killing of George Floyd, the Black Lives Matter movement and even sportspeople taking the knee have created a perception of fundamental societal change. But reversing structural racism cannot be achieved in a few months.

If we are to reach and convince those who are hesitant about a Covid-19 vaccine, we need to understand what is behind their reluctance to get excited by an effective vaccine, even when it is being offered free by the government.

What appears to be scepticism towards taking the new vaccines has some of its roots in structural racism. It is far too simplistic to attribute hesitancy to the influence of the numerous ill informed “anti-vax” campaigns. In a US survey carried out in September, just 32 per cent of Black respondents said they would definitely or probably get a Covid-19 vaccine if it were available at the time – a much lower proportion than white, Hispanic or Asian respondents.

For some, vaccine hesitancy is informed by personal lived experiences leading to a genuine lack of trust in our healthcare systems and providers. In a number of cases what appears to be vaccine hesitancy is actually vaccine ignorance brought about by social exclusion.

People are less likely to hear the public health warnings of the threat from a vaccine-preventable disease if the messages never enter their world. Individuals who do not trust the authorities or who have been denied the education to make an informed choice are equally unlikely to respond to even the best public health messages.

A key government argument for taking the vaccine is that ending the pandemic will return us to the social and economic norms of our pre-pandemic world, this is unlikely to resonate with those who had no stake in the pre-pandemic world and cannot see change coming.

The same structural problems that have made certain groups more likely to be infected and then die from the virus are also likely to prevent effective uptake unless action is taken.

Black people are severely underrepresented in the UK’s database of Covid-19 vaccine clinical trial volunteers, reflecting a similar pattern in the US where Black people are routinely underrepresented even in trials concerning conditions that disproportionately impact Black Americans. Historically vaccine hesitancy is linked to education but in this case it is more about social exclusion and mistrust.

The opportunity to volunteer for any clinical trial is partly through connections, for example being a university student at the type of university where clinical trials are taking place. In many cases volunteering for a clinical trial is well paid, so opportunities may never reach certain excluded communities. Another way to be involved in a trial is to be invited by doctors connected to the trial. Where access to cutting-edge healthcare is limited, such invitations will also be limited.

Although the increased risk from Covid-19 in certain communities is down to social disparities, not genetics, we need clinical trials involving BAME groups to better understand how deprivation, living conditions and comorbidities linked to structural racism will impact on the effectiveness of the vaccine.

Vaccine hesitancy and the lack of BAME people in clinical trials is evidence of social exclusion and structural racism. Unless these underlying factors are changed, the burden of ill health will continue to fall unevenly in our society.

So what can be done? A Public Health England review published in July offers some routes forward. Commissioned after the outcry from Black communities in particular about the disproportionate deaths in the first wave of the pandemic, the report’s chair, Kevin Fenton, made several recommendations around tackling structural racism in medical and public health provision.

Structural problems have meant that too few Black scientists, medical and public health professionals are in positions of influence and power where they can identify problems through research and then communicate solutions.

Such individuals would have greater traction with the hesitant BAME groups. What is worrying is that the government, through the minister for equalities Kemi Badenoch, has been quick to dismiss the role of structural racism in medical outcomes from COVID-19, which is not only wrong but will increase mistrust.