"If [the vaccine] came out today, I would not take it," said Lonzo Bullie, a retired school principal who has called Tuskegee, Alabama, home for 26 years. "I'm still reluctant … because I do not have enough information on it."
The two FDA-authorized COVID-19 vaccines are more than 95% effective at preventing symptomatic illness, and side effects reported are minor. The trials -- which included more than 30,000 volunteers each -- demonstrated that the vaccines work equally well among people of all races and ethnicities.
But Bullie, who's also president of the Tuskegee-Macon County branch of the NAACP, said that skepticism about the vaccine within the African American community stems from "the history of the United States government experimenting on Black people" and years of "mistreatment."
Tuskegee, where Bullie resides, is ground zero for the infamous 1930s syphilis study. The U.S. Public Health study at the Tuskegee Institute, which recruited 600 Black men, was meant to record the natural progression of syphilis infection, but the researchers did not inform the participants nor did they ask for their consent. The study lasted 40 years and left an indelible mark on the Black community.
Residents in rural communities of color are grappling not only with a pervasive distrust of the vaccines and the health care system, but with multiple obstacles as vaccine distribution begins, including lack of accessibility to medical facilities.
Nearly one in every four rural Alabama residents (24.1%) is Black or Latino, according to the 2018 American Community Survey.
Focus groups across Alabama are meeting to address vaccine hesitancy among communities of color, particularly among African Americans and Latinos, according to Dr. Mona Fouad, director of the University of Alabama at Birmingham's Minority Health and Health Disparities Research Center.
"Tuskegee came back again, and again, and again, in every group we talked about," Fouad told ABC News. "People started to remember Tuskegee."
She said that before the pandemic, outreach groups were gaining traction with "overcoming" distrust of the health care system in communities of color, but now COVID-19 "brought the nerve again about Tuskegee."
"We learned that the mistrust comes from lack of information and transparency," Fouad said.
In a statement provided to ABC News, the Alabama Department of Public Health said: "ADPH has addressed access to testing in rural communities and in communities of color by working with partners including historically black colleges and universities, communities of faith, and housing authorities" in an effort to combat uneasiness over a COVID-19 vaccine.
However, advocates and local leaders said that more inclusion and transparency will be required to increase participation from communities of color.
"As we see more people taking it, people of color, in particular, taking the vaccine, people are going to be more apt to [taking it]," said Benard Simelton, president of the Alabama State Conference of the NAACP.
He also added that explaining the "technical aspects" and providing clearer public messaging about the vaccine will help people living in rural communities have a better understanding of it. In addition, diverse messaging is needed to ensure all communities understand the information.
According to Ana Espino, executive director at the Alabama Coalition for Immigrant Justice, language presents a huge barrier to COVID testing access, too, because people "don't have the information distributed out in any other language other than English."
Engaging local community leaders in rural areas of Alabama to have them reassure vaccine safety and explain it in ways people can relate to is important, Simelton said.
"The key is to develop that trust factor in the community," he added.
Distrust is not the only challenge in providing rural communities vaccines
In parts of rural America, vaccine delivery is set to run into unique health care barriers including understaffed clinics, lack of refrigerated storage units for vaccines and hard-to-reach residents living miles away from major hospitals, experts say. State public health systems, already overextended due to the pandemic, will be responsible for ensuring the day-to-day delivery and accessibility to rural residents.
Geographic isolation and workforce shortage in rural area hospitals across America add to the burden of providing vaccination.
According to a 2018 Pew Research Center survey, rural Americans live an average of 10.5 miles from the nearest hospital and among the quarter of rural Americans traveling the longest to reach an acute care facility, the average travel time is 34 minutes by car.
"Access to hospitals is difficult, because you have folks who don't have transportation or don't have reliable transportation, distance is definitely a barrier," said Espino. "In rural Alabama, Black and brown people would really struggle with accessibility."
According to the Health Resources and Services Administration, 64.6% of the rural counties in Alabama are considered "health professional shortage areas," lacking enough primary care, dental and mental health providers to service residents. Additionally, 55.7% of the rural population in Alabama is without adequate health care services, HRSA said.
When the vaccine becomes available to the general public, people living in rural communities will have to travel far distances to access larger hospitals in cities where doses can be stored properly in refrigerated units, Simelton said.
"There is a significant portion of the community that will not be able to get the vaccine that may want it," said Simelton. "We got to make it available in large enough quantities that everybody in the community will take it."
And in places like rural Alabama, the burden of providing vaccines amid a pandemic is already taking a toll.
In a briefing on Dec. 16, Army General Gustave Perna, the COO of Operation Warp Speed -- the Trump administration's program to accelerate vaccine rollout -- described minor mishaps with delivery in Alabama, including when shipments of the vaccine arrived, but had been stored at the wrong temperature.
Since the impact of storing the vaccine at the wrong temperature is unclear, the vials were not used and were shipped back to Pfizer.
"When COVID came, I felt like we were pushed back another two decades," said Fouad."[COVID] impacted our rural, underserved communities in our cities much more than anybody else."
In addressing the disparities of access to vaccines for rural communities, the Alabama Department of Public Health is "working with rural health clinics, federally qualified health care centers, county health departments, and other providers to provide access to COVID-19 vaccines statewide." according to a statement provided by Chief Medical Officer, Mary G. McIntyre.
Fouad said that lessons learned from the state's oversight during COVID with limited testing access and few quarantine options for underserved rural communities served as a "continuum" in informing state public health leaders' decision-making on vaccine rollout.
"Now that the vaccine is out, we don't want to make the same mistakes," she added.
ABC News' Mark Nichols contributed to this report.