When Evidence Fails: Epistemic Injustice and Health Skepticism
By Mitchell Klein
Positionality Statement
Before discussing the complex issues of institutional distrust and healthcare disparities, I acknowledge my position as an outsider to many of the marginalized communities referenced here. While my analysis is grounded in academic research, data, and historical context, it cannot fully capture the lived realities of those affected by systemic racism, epistemic injustice, and mistrust in healthcare. My objective is to contribute to this important discourse by emphasizing the need for patient-centered, inclusive approaches in rebuilding healthcare trust. I encourage readers to engage directly with voices from these communities to deepen their understanding of these experiences and perspectives.
Introduction
Healthcare is an essential human right, yet systemic inequities often undermine trust in healthcare institutions and lead to disparities in health outcomes. For many marginalized populations, interactions with healthcare systems are shaped by histories of discrimination, mistreatment, and neglect, eroding confidence in institutional testimony and exacerbating existing disparities. These dynamics became particularly visible during the COVID-19 pandemic, where vaccine hesitancy emerged as a pressing issue, revealing a complex interplay of institutional distrust, epistemic injustice, and public health decision-making.
Epistemic injustice, as articulated by Miranda Fricker, offers a framework tounderstand how marginalized individuals are wronged in their capacity as knowers. Institutional distrust amplifies the effects of epistemic injustice, as communities with lived experiences of inequity often view institutional testimony with skepticism. This mistrust is not irrational but reflects a pragmatic evaluation of credibility, influenced by both historical injustices and contemporary disparities. The result is a divergence in how testimonial evidence is interpreted, a concept explored in epistemic permissivism, which acknowledges the rationality of differing responses to the same evidence based on individual and communal contexts.
This paper explores the impact of epistemic injustice and institutional distrust in healthcare, using the COVID-19 pandemic as a case study to illustrate these dynamics. Section 1 covers historical and contemporary examples of epistemic injustice in healthcare, from the Tuskegee Syphilis Study to current disparities in pain management. Section 2 posits a sort of epistemic permissivism as being a potentially valuable tool in understanding healthcare interactions and understanding rational divergence. Section 3 then applies these insights to the COVID-19 pandemic, highlighting how systemic mistrust influenced vaccine uptake among marginalized populations and evaluating the effectiveness of institutional versus community-led messaging. Addressing epistemic injustice and institutional distrust is both an ethical imperative and a practical necessity for healthcare institutions and providers that want to most effectively serve everyone. Without systemic reform, healthcare systems will continue to marginalize vulnerable populations, perpetuating disparities and undermining public health efforts. By examining these issues through a philosophical lens, this paper aims to contribute to the ongoing dialogue about creating equitable and inclusive healthcare systems that respect and empower all individuals.
1 Historical and Current Context
Epistemic injustice, a concept introduced by philosopher Miranda Fricker, refers to the ways individuals are wronged in their capacity as knowers. Fricker identifies two primary forms: testimonial injustice, where a speaker's credibility is unfairly diminished due to prejudice, and hermeneutical injustice, where individuals are excluded from shared interpretative frameworks, limiting their ability to make sense of and communicate their experiences.¹ These forms of injustice frequently intersect in healthcare settings, where marginalized populations often face systemic barriers to being heard, believed, or understood. The key testimonial injustice considered in this paper occurs when patients' reports of symptoms or concerns are dismissed, often due to implicit biases related to race, gender, or socioeconomic status. Hermeneutical injustice, meanwhile, arises when the healthcare system lacks the cultural or structural frameworks needed to recognize and validate diverse patient experiences and/or when patients are not given the tools needed to fully understand and participate in healthcare. Together, these injustices erode the trust necessary for effective patient-provider relationships and equitable care. To more fully appreciate the scope and impact of epistemic injustice in healthcare, it is useful to highlight how these injustices can systematically undermine patients’ participation in their own health. When individuals from marginalized groups are consistently met with unjust credibility deficits—where their testimonies about pain, illness, or mistreatment are regarded as less trustworthy—they internalize a sense that their knowledge and lived experiences hold less weight in medical settings. This continuous undermining not only affects the immediate patient-provider interaction but also discourages patients from seeking care in the future. In essence, epistemic injustice is not merely about sporadic incidences of bias or negligence; it is the backdrop against which individuals’ entire healthcare journeys take place, influencing everything from patient-provider communication to broader health outcomes. Recognizing these deeper epistemic harms underscores why rebuilding trust in marginalized communities requires a concerted effort to transform institutional norms and practices that have historically ignored or devalued their voices. This section examines both historical examples—the Tuskegee Syphilis Study and forced sterilizations of Native American women—and contemporary manifestations—racial disparities in pain management and gender bias in cardiovascular care. By exploring these instances, we can understand how epistemic injustice persists in healthcare and contributes to widespread distrust among marginalized communities.
1.1 Historical Injustices
The Tuskegee Syphilis Study (1932–1972) represents a profound example of systemic abuse and epistemic injustice in healthcare. Conducted by the U.S. Public Health Service, the study followed the untreated progression of syphilis in Black men under the pretense of providing free medical care. Participants were deliberately misinformed about their diagnosis and denied access to effective treatment, even after penicillin became the standard of care in the 1940s.² From the perspective of testimonial injustice, the participants' accounts of their symptoms and needs were systematically devalued, in this case rooted in racist assumptions about the Black community. Though, in one regard, the participants’ testimony could be argued to have been taken credibly as evidence of the untreated progression of syphilis, their moral knowledge as members of a larger political community were explicitly disregarded by medical professionals, who pursued their own aims over the participants’ objections. Meanwhile, hermeneutical injustice was evident in the participants' lack of access to the broader interpretative framework necessary to understand and challenge the exploitation they faced. The lack of informed consent underscores how systemic power imbalances can exclude individuals from the processes that shape their healthcare decisions.
Between the 1960s and 1970s, numerous Native American women were subjected to unauthorized sterilizations performed by the Indian Health Service (IHS), often without their informed consent. These procedures were carried out under the guise of population control or routine medical care, targeting women from already marginalized communities. By the mid-1970s, investigations revealed that between 25% and 50% of Native American women of childbearing age had been sterilized—a staggering figure that highlights the scale of this systemic abuse.³ Like above, this instance of abuse has an aspect of testimonial injustice, as the voices of Native American women were routinely dismissed. Healthcare providers failed to take their concerns or objections seriously, perpetuating a power dynamic that disregarded their autonomy and agency. These women simultaneously experienced hermeneutical injustice, as they were excluded from the interpretive frameworks needed to understand and resist these violations. The cultural and structural disparities between the medical institutions and the communities they served meant that Native American women had little recourse to challenge these practices, leaving their experiences underrepresented in public and professional discourses on reproductive rights.
1.2 Contemporary Instances
The legacy of historical injustices like the ones I briefly discussed above are often cited in discussions of institutional mistrust in healthcare, but mistrust is also—and often to a much greater extent—rooted in ongoing lived experiences of neglect, inequity, and mistreatment in healthcare settings. A couple of major contemporary instances of epistemic injustices in healthcare are racial disparities in pain management and gender bias in cardiovascular disease treatment.
Racial disparities in pain management remain a significant issue in modern healthcare. Research shows that Black patients are less likely to receive adequate pain relief compared to White patients, even when presenting with nearly identical symptoms. This disparity is driven by implicit biases among healthcare providers and persistent false beliefs, such as the unfounded idea that Black individuals have higher pain tolerance. These biases contribute to the testimonial injustice of undervaluing of Black patients’ reports of pain, leading to inequitable treatment decisions.⁴ For patients, repeated experiences of having their concerns minimized or dismissed reinforce systemic distrust in healthcare institutions. The consequences of these disparities are far-reaching. Black patients are more likely to suffer from untreated pain, impacting their quality of life and long-term health outcomes. Furthermore, the cumulative effects of these inequities discourage many individuals from seeking care, perpetuating cycles of poor health and limited engagement with healthcare systems.
Gender bias significantly impacts the diagnosis and treatment of cardiovascular
diseases. Studies have shown that women experiencing heart attack suffer testimonial injustice because their symptoms are often misdiagnosed or receive delayed care compared to men. Symptoms reported by women are more likely to be dismissed or attributed to non-cardiac causes, such as anxiety or stress. These biases in symptom interpretation and response stem from ingrained stereotypes about gender and health, as well as a medical research gap that historically underrepresented women in clinical studies.⁵ Consequently, diagnostic tools and treatment protocols often fail to address the unique ways cardiovascular diseases manifest in women. This disparity has dire implications for health outcomes. Women are at greater risk of severe complications or death from heart attacks due to delays in receiving appropriate care. These patterns contribute to a broader mistrust of the healthcare system among women, particularly when their experiences and concerns are consistently undervalued in medical settings.⁶
2 The Epistemic Implications of Distrust and Testimonial Evidence
Testimonial evidence—information provided by others, often institutions or experts—is a foundational element of healthcare communication. However, for mar- ginalized populations, trust in such testimony is mediated by a history of systemic inequities and personal experiences of mistreatment. These experiences shape how individuals engage with institutional testimony, often leading to skepticism even when the evidence is robust.⁷ This section examines how institutional distrust influences the evaluation of testimonial evidence, particularly in healthcare contexts. By exploring variability in responses to testimonial evidence and introducing epistemic permissivism, it highlights how lived experiences and systemic factors contribute to divergent yet rational conclusions in public health decision-making.
2.1 The Role of Institutional Distrust in Evaluating Testimonial Evidence
Institutional distrust can fundamentally alter how marginalized populations evaluate testimonial evidence in healthcare. Testimonial evidence, such as guidance from healthcare providers or public health campaigns, is typically seen as credible when issued by institutions with perceived authority. However, for individuals whose lived experiences include neglect, mistreatment, or discrimination from and within these systems, skepticism often becomes a rational response.⁸ Marginalized communities frequently rely on alternative sources of knowledge to navigate healthcare. For example, a Black patient might prioritize anecdotal evidence shared within their community over guidance from a public health agency. This preference is not a rejection of evidence itself but a pragmatic evaluation of credibility. Systemic neglect and inequity foster a sense that institutional testimony may not account for their well-being or address their specific concerns.⁹
Epistemic trust—the belief that a source of information is both competent and benevolent—is a critical factor in how testimonial evidence is received. When institutional trust is undermined, individuals may interpret even well-supported evidence with suspicion. This is particularly evident in public health contexts like vaccination campaigns, where systemic inequities and historical injustices contribute to distrust. Some Native American communities, given their historical experiences with unethical medical practices, may approach institutional claims about vaccine safety with heightened skepticism.¹⁰ This divergence in evaluating testimonial evidence underscores the role of lived experience in shaping epistemic trust. These responses of marginalized populations, while divergent from “mainstream” epistemic norms, often reflect a rational engagement with their social realities.
2.2 Epistemic Permissivism and Rational Divergence
Epistemic permissivism, the philosophical view that individuals may rationally arrive at different conclusions from the same body of evidence, offers a valuable lens for understanding varying reactions to evidence in healthcare contexts. This perspective challenges the idea that a single rational response is required when individuals encounter the same healthcare information/guidance. Permissivism recognizes the role of prior beliefs, social context, and lived experiences in shaping how evidence is interpreted.¹¹ A crucial aspect of epistemic permissivism in this context is that it does not license unwarranted skepticism or reckless dismissal of well-supported medical facts. Rather, it acknowledges that two fully rational agents with the same evidence can justifiably arrive at different conclusions if their background beliefs, experiences, and trust assessments differ. This is particularly relevant in healthcare, where historical patterns of racism, sexism, and other forms of discrimination inform how certain communities weigh present-day institutional claims. Consider a COVID-19 vaccine campaign: the scientific evidence supporting the vaccine’s safety and efficacy is consistent, but marginalized populations may interpret it differently. A person from a historically underserved community might question the benevolence of the institution providing the testimony, while another individual, with no such history of mistreatment, may accept it without hesitation. Both responses can be rational within the framework of epistemic permissivism.
Permissivism also underscores the importance of context in shaping rational responses. For marginalized groups, distrust in institutional testimony often reflects the reasonable prioritization of alternative sources, such as community leaders or anecdotal evidence, that align more closely with their lived experiences. This divergence does not indicate a failure of rationality but highlights how epistemic trust is informed by historical and social realities. By accommodating this divergence as rational via permissivism, we can better understand the seemingly paradoxical phenomenon of medically robust guidance being met with persistent skepticism among marginalized populations. It moves the analysis away from labeling these communities as “anti-science” or “irrational” and toward recognizing how their beliefs may reflect a reasonable position grounded in lived experience and complex social realities.
3 COVID-19 Vaccine Hesitancy
Vaccine hesitancy—the reluctance or refusal to vaccinate despite the availability of vaccines—emerged as a critical challenge during the COVID-19 pandemic. While public health efforts successfully vaccinated billions worldwide, substantial pockets of resistance highlighted the complex interplay of trust, cultural context, and epistemic divergence in healthcare decision-making. This hesitancy was particularly pronounced in marginalized populations, where historical injustices and ongoing inequities shaped responses to public health initiatives. As such, the COVID-19 pandemic serves as an interesting case study for using epistemic permissivism to more accurately understand the epistemic dynamics of institutional distrust. For many, skepticism of vaccines did not stem from ignorance but from lived experiences of mistreatment or exclusion from healthcare systems. By examining vaccine hesitancy in marginalized communities, this section explores how the previously discussed systemic distrust, testimonial evidence, and epistemic divergence intersected to shape public health outcomes. The same evidence can lead to different rational beliefs based on how evidence is presented and how previously formed beliefs were supported or challenged by healthcare institutions historically.
3.1 Vaccine Hesitancy Instances
Vaccine hesitancy in Black communities during the COVID-19 pandemic reflected a deep-rooted distrust of medical institutions. Studies showed that Black Americans were less likely to trust government and healthcare authorities, leading to lower vaccination rates compared to White Americans. This hesitancy often reflected a rational response to perceived systemic failings. For example, unequal access to vaccines in early distribution phases reinforced concerns about institutional priorities. Moreover, conflicting messaging from public health agencies during the pandemic exacerbated pre-existing skepticism, making it difficult for institutional testimony to be universally accepted.¹² Efforts to address vaccine hesitancy in Black communities highlighted the importance of community-led initiatives. Campaigns led by trusted local figures, including faith leaders and community organizations, were more successful in increasing vaccine uptake than top-down institutional messaging.¹³ These efforts underscored the role of epistemic trust in shaping health behaviors and demonstrated the need for culturally relevant approaches to public health.
Native American communities also experienced significant vaccine hesitancy during the COVID-19 pandemic, likely driven by both historical trauma and contemporary healthcare inequities. These concerns were compounded by systemic underfunding and limited access to healthcare in many Indigenous communities.¹⁴ However, initial hesitancy in these communities was not universal. Many tribal nations quickly launched their own vaccination campaigns, emphasizing cultural values of collective responsibility and community health. By relying on trusted tribal leaders and culturally tailored messaging, some tribes achieved remarkably high vaccination rates. These efforts illustrate how reframing the otherwise-identical testimonial evidence within a trusted cultural context can effectively counteract institutional distrust.¹⁵
3.2 Institutional vs Community-Based Messaging
During the COVID-19 pandemic, public health messaging faced significant obstacles in engaging diverse communities. One major challenge was the need to adapt communication strategies quickly in response to evolving scientific knowledge, such as updates on vaccine efficacy or new variants. While this adaptability was essential, it often created confusion among the public, particularly in populations already skeptical of institutional authority. The gap between institutional messaging and lived experiences was a critical factor in vaccine hesitancy. Marginalized groups often viewed generic public health campaigns as detached from their specific realities, reinforcing a perception of institutional indifference. For example, messages encouraging early vaccination often failed to address logistical barriers like transportation issues or access to clinics, making the guidance seem impractical. These oversights not only alienated individuals but also diminished the credibility of these institutions as reliable sources of knowledge going forward. Moreover, misinformation on social media platforms capitalized on these gaps, spreading tailored narratives that resonated more effectively with certain audiences than official campaigns. This digital misinformation further fragmented public perceptions of vaccine safety, creating a complex web of competing testimonial evidence that public health officials struggled to navigate.¹⁶˒ ¹⁷
In response to the limitations of institutional messaging, community-led efforts emerged as a vital tool for rebuilding trust and addressing vaccine hesitancy. Unlike large-scale campaigns, which often lacked cultural nuance, community-led initiatives focused on engaging individuals within their social and cultural contexts. These initiatives prioritized direct interaction and emphasized the relational aspect of epistemic trust. For instance, grassroots organizations in urban Black communities delivered tailored messaging that aligned with cultural values, such as protecting family and community. These efforts often included vaccine clinics held in familiar, trusted spaces like churches and community centers. By directly addressing practical concerns—such as clarifying vaccine side effects or countering misinformation—these campaigns succeeded in ways that institutional efforts could not.¹⁸
In Native American communities, tribal health officials utilized storytelling and cultural narratives to encourage vaccination. By framing vaccines as tools for safe-guarding collective well-being—a value deeply ingrained in many Indigenous cultures—tribal leaders fostered a sense of ownership over public health efforts. This localized approach demonstrated the effectiveness of situating testimonial evidence within a trusted framework.¹⁹
Similarly (but distinctly), in some rural communities, skepticism toward government-led campaigns reflected broader ideological beliefs, including a strong emphasis on personal autonomy. Here, vaccine hesitancy was less about historical injustices and more about perceived encroachments on individual freedoms. In Black communities, skepticism was often shaped by a combination of personal mistrust in healthcare systems and perceptions that vaccines were developed too quickly without adequate testing for diverse populations. In rural communities, however, mistrust often revolved around perceived overreach by government agencies rather than systemic healthcare inequities. In these communities, campaigns that emphasized personal choice or were delivered by locally trusted figures, such as clergy, were more effective. Unlike urban campaigns or the campaigns led by tribal leaders, these efforts refrained from leveraging collective responsibility as a central theme, recognizing that his narrative conflicted with the region’s cultural values.²⁰
These community-led campaigns highlight the importance of relational trust and localized approaches in public health. By meeting people where they are—in their physical states and epistemic states—they provide a blueprint for addressing systemic mistrust in future public health crises. This underscores a critical epistemic point: trust in institutional testimony depends not only on the credibility of the message but also on the perceived alignment of the institution’s values and priorities with the audience’s lived realities.
Integrating epistemic injustice and epistemic permissivism provides a nuanced understanding of why vaccine hesitancy flourished in certain communities during the COVID-19 pandemic. In many cases, marginalized groups encountered a form of testimonial injustice where their historical grievances and concerns about new medical interventions were not taken seriously by mainstream institutions. At the same time, epistemic permissivism explains why these communities’ skepticism can be understood as rationally permissible, given a background of consistent mistreatment. Rather than reducing vaccine hesitancy to a simple lack of information, this lens reveals it to be a complex interplay between entrenched distrust of institutions and alternative frameworks of credibility (e.g., trusting local elders or community leaders). Consequently, effective interventions must do more than just relay factual data; they must also engage the deeper epistemic needs and concerns of marginalized populations, building trust through culturally responsive communication and genuine structural reforms.
3.3 Addressing Institutional Mistrust
The COVID-19 pandemic highlighted the urgent need for structural changes to address systemic mistrust in healthcare. Institutional distrust, as evidenced by vaccine hesitancy among marginalized populations, is not a temporary phenomenon but a symptom of long-standing inequities in healthcare access, treatment, and outcomes. Addressing this mistrust requires a comprehensive approach that prioritizes equity and inclusion at every level of public health policy.
One essential step is the recognition and acknowledgment of past and ongoing injustices. Transparency about systemic failures can help institutions begin to rebuild trust with communities that have been historically marginalized. Public health policies must also focus on improving accessibility by addressing logistical barriers such as clinic locations, hours, and affordability, which disproportionately impact low-income and minority groups. Additionally, public health agencies must actively include representatives from marginalized communities in the decision-making process. Representation ensures that policies reflect the needs and priorities of those most affected by healthcare disparities. Programs designed with direct input from these communities are more likely to resonate and foster trust, as they align with the lived experiences and concerns of their target populations.²¹˒ ²²
Cultural competence within healthcare systems is another essential for reducing mistrust and addressing vaccine hesitancy. Training healthcare providers to recognize and respect cultural differences can improve patient-provider interactions and foster relational trust. This includes understanding how historical and systemic inequities influence individual decisions and tailoring care to accommodate diverse needs. Healthcare systems should also invest in community partnerships to deliver culturally relevant care and messaging. Programs led by trusted local figures can bridge the gap between institutional testimony and individual skepticism. By committing to cultural competence and inclusive policies, healthcare institutions can create environments that encourage engagement and reduce disparities. Such efforts are not only ethical imperatives but also necessary for improving public health outcomes in future crises.
Conclusion
The challenges of epistemic injustice and institutional distrust in healthcare, as illuminated throughout this essay, underscore the urgency of transforming not only the content of medical guidance but also the manner in which that guidance is communicated. From historical abuses such as the Tuskegee Syphilis Study and the forced sterilizations of Native American women, to persistent disparities in pain management and cardiovascular care, the evidence points to a deeply ingrained pattern of discrediting and disregarding the testimonies of marginalized populations. The COVID-19 pandemic brought these tensions into sharp relief, with vaccine hesitancy serving as a prominent example of how systemic neglect and mistreatment can lead communities to rationally question even well-supported medical evidence.
In recognizing how reasonable skepticism can arise from lived experiences of discrimination, epistemic permissivism emerges as a critical philosophical tool. Permissivism allows space for multiple rational responses to the same set of data, acknowledging that historical and social contexts fundamentally shape how individuals interpret institutional testimony. Rather than framing such skepticism as inherently irrational or anti-science, a permissivist stance in healthcare messaging challenges practitioners and policymakers to address the root causes of distrust. This approach involves not only improving factual transparency but also engaging more sincerely with the narratives, needs, and values of communities whose experiences have long been discounted.
Ultimately, adopting a measure of epistemic permissivism in healthcare can foster more inclusive and effective public health strategies. Permissivism does not mean abandoning scientific rigor or condoning misinformation. Instead, it entails a commitment to contextual, culturally competent communication that validates community knowledge, acknowledges legitimate grievances, and actively seeks to build or rebuild trust. By affirming that different interpretive stances can still be rational, healthcare institutions position themselves to collaborate with, rather than lecture to, marginalized populations. Such a shift is essential for moving beyond superficial solutions and working toward a healthcare system that empowers all individuals—even those who, for very justifiable reasons, have hesitated to trust the institutions meant to serve them. explosion presents.
¹ Fricker, Epistemic Injustice.
² Kiple and Jones, “The Tuskegee Syphilis Experiment.”
³ Lawrence, “Sterilization of Native American Women.”
⁴ Hoffman et al., “Racial Bias.”
⁵ Lichtman et al., “Sex Differences.”
⁶ Lichtman et al.
⁷ Fricker, Epistemic Injustice.
⁸ Medina, “Epistemology of Resistance.”
⁹ Kidd et al., “Introduction.”
¹⁰ Fricker, Epistemic Injustice.
¹¹ Schoenfield, “Permission to Believe.”
¹² Laurencin, “Addressing Justified Vaccine Hesitancy.”
¹³ Laurencin.
¹⁴ Haroz et al., “Nurturing Innovation at the Roots.”
¹⁵ Haroz et al.
¹⁶ Johnson et al., “The Online Competition.”
¹⁷ Larson, “Viral Misinformation.”
¹⁸ Laurencin, “Addressing Justified Vaccine Hesitancy.”
¹⁹ Haroz et al., “Nurturing Innovation at the Roots.”
²⁰ Koskan et al., “Rural Americans’ COVID-19 Vaccine Perceptions.”
²¹ Baier, “Trust and Antitrust.”
²² Kidd et al., “Introduction.”
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