For Partners In Health, Vaccination Equity Starts in the Community
With each passing day, national and local healthcare leaders are understanding more about COVID-19 vaccination equity, and have been coming up with strategies to help mitigate the disproportionate impact the virus has on underserved communities.
As part of this approach, the Biden Administration has recognized the importance of supporting community-based healthcare organizations’ (CBOs) response to the pandemic, as these stakeholders are seen as vital to equitable vaccine distribution in areas of the country that need it the most.
For instance, late last month, thanks to the American Rescue Plan, the U.S. Department of Health and Human Services (HHS) announced nearly $150 million in funding to community-based healthcare providers to aid their response to the crisis. The investments, according to officials, will support approximately 100 Health Center Program lookalikes to respond to and mitigate the spread of COVID-19, strengthen vaccination efforts, and enhance healthcare services and infrastructure in communities across the country. “Health center lookalikes (LALs) are community-based healthcare providers that provide essential primary care services to underserved communities and vulnerable populations but are not Health Center Program grantees,” officials explained.
In 2019, Health Resources and Services Administration (HRSA) Health Center Program LALs served more than half a million patients. Currently, more than 89 percent of LAL patients live at or below 200 percent of the federal poverty guidelines, and more than 63 percent are racial or ethnic minorities, according to HHS data. As such, federal health leaders believe that this funding opportunity is critical to supporting LALs in serving medically underserved populations who rely on LALs for access to care.
COVID-19 data continues to show that Black and Hispanic individuals are receiving smaller shares of vaccinations compared to their shares of cases and deaths, and compared to their shares of the total population in most states. For example, in Colorado, 10 percent of vaccinations have gone to Hispanic people, while they account for 41 percent of cases, 25 percent of deaths, and 22 percent of the total population in the state, according to updated data from the Kaiser Family Foundation, which also shows that White people have received a higher share of vaccinations compared to their share of cases and deaths, and their share of the total population in most states reporting data. It's also been reported that in some states, affluent ZIP codes are more likely to be vaccinated than lower-income ones.
One example of the type of community-based healthcare that this new federal funding can support can be found in Montgomery, Ala., where community health workers visit church congregations, barbershops, low-income housing units, and neighborhoods disproportionately affected by poverty to provide information about COVID vaccines and resources available through in-person conversations.
Supporting community healthcare providers is something that Partners In Health (PIH)—a global organization headquartered in Boston, Mass., whose aim is to ensure quality healthcare is available in some of the world's most vulnerable communities—has been doing since the crisis began. PIH has been teaming up with community-based providers across the country, including in Montgomery, a city whose population does not fully trust the federal government’s promise of a groundbreaking COVID-19 vaccine to protect them and stop the pandemic.
In Alabama, mistrust runs deep, according to previous PIH research. Indeed, only about one in six Black and Latino individuals from across the state told researchers they’d be willing to get a COVID-19 vaccine. “I didn’t expect that [mistrust] would be that deep and across the board,” Mona Fouad, M.D., director of the University of Alabama’s Minority Health & Health Disparities Research Center, said in a January article published by the outlet AL.com.
A separate article from Partners In Health in February dug deep into some of the reasons behind Montgomery residents’ distrust, referencing the “exploitation suffered by Black residents of this region,” pointing to “a statue of J. Marion Sims, the gynecologist who practiced his surgical techniques on enslaved Black women without using anesthesia. Just about half an hour away, as residents are quick to point out, is Tuskegee, site of the U.S. government’s decades-long medical experiment conducted on impoverished Black men with syphilis who were intentionally left untreated as they grew sicker and died.” Said one community organizer in that piece, ““People don’t want to be experimented on, especially if they’re Black. They don’t want to feel like they’re being tested like a guinea pig.”
Therein lies a significant and complex issue that must be resolved to defeat the current COVID-19 crisis: the virus disproportionately affects some of the very same people who are skeptical to get the vaccine due to historical inequities throughout the medical community. In Montgomery, 60 percent of the population is Black, and 20 percent live below the federal poverty line. According to updated data from Alabama’s state COVID-19 dashboard hub, about 69,000 Montgomery residents have received at least one dose of the vaccine; the city has about 200,000 residents, meaning approximately two-thirds have not yet gotten a single dose. So, leaders at PIH believe that understanding residents’ concerns at a fundamental level will be a critical step in getting vaccination uptake.
To accomplish this, it’s critical that there is a strong community ecosystem in place to support disenfranchised neighborhoods, says Sheila Davis, DNP, CEO of Partners In Health. Davis describes PIH as a non-governmental social justice and healthcare organization that aims to combat injustice by providing quality healthcare in the most vulnerable neighborhoods, communities, and countries around the world. PIH operates in 11 countries, and Davis says there have been lessons learned globally from PIH’s previous work to help support those areas impacted by outbreaks such as Ebola, HIV and Cholera.
“Our model, regardless of geography, is focused on the idea that care should be grounded in the community and connected to quality facilities and hospitals,” says Davis. But importantly, she adds, PIH does not work with U.S. hospitals, and while there are many “phenomenal hospitals here, we [recognized] there was a gap centered around community care. So that’s what we have really focused on.”
Davis asserts there needs to be community engagement from the very beginning [of any healthcare crisis], with targeted interventions for communities that are the most impacted, even preferentially going to communities that have disproportionally impacted by COVID-19. “Having community engagement as part of the planning and implementation of every rollout is critical. To add people later on [in the process], rather than in the beginning, is a mistake that I believe was made in the U.S. across the whole COVID response,” Davis contends.
For example, even before vaccinations began, it was important to address specific social determinants of health (SDOH) issues, such as making sure people had access to a safe space to isolate, or had adequate access to food and primary care. “Connecting people to the services they needed was critical from the beginning, first to build trust, but also to see where the gaps were. That is a piece we have been infusing in our full response, from testing to tracing to vaccinating, in that it has to be really grounded in what other needs people have.”
On the vaccination front specifically, Davis reports the new federal funding is already being leveraged in a few key areas. One is by working with the mayor’s office in Montgomery to hire community health workers, who she describes as “a cadre of people we work with who speak the same language of the people from this communities, and are from the same background. They know that context so well. The community health workers are knocking on doors, connecting people to get rides to vaccine [appointments], are even helping people make the appointments themselves, and are getting people connected with food and housing services, etc. These are people who are embedded in those communities already,” she says.
What’s more, in Montgomery, PIH is also working on appointing community “vaccine ambassadors”—similarly, people who are from the same neighborhoods as those they are helping. These are individuals who are passionate about the vaccines, who are working with CBOs to make sure folks on the ground are learning the right facts about the vaccines, and then assisting where needed to make the vaccine shot a reality. “When there are people who have questions, being able to answer those and have someone who is a known, trusted community member talking to people about what their fears are, is the best way we will combat this,” Davis says.
Ultimately, she believes, communities need to make things around the vaccination process much more convenient. “We need to go into peoples’ homes rather than expect them to navigate complex scheduling systems. I don’t think we have made things accessible in a way that fits into peoples’ busy lives. If we look at the many things folks battle with every day, it’s connecting with primary care for chronic disease, it’s food, and it’s housing. So vaccinations might just be lower on their priority list.”
While the American Rescue Plan funding will help cities hire community health workers and vaccine ambassadors in the short term, Davis believes that keeping them on for the long haul to address other healthcare issues will prove beneficial when the next crisis comes around, in addition to getting vaccination rates high in the present. “We have to use this moment and this inflection point to realize that our healthcare system is so skewed to really good hospitals—which we 100 percent need—but the best time to build a long-term public health system is now. And we need to keep it going instead of just flipping in and out of communities.” She adds, “If we can use this opportunity to rethink our healthcare system in the U.S., and not just use this money for emergencies, that will be a silver lining of what’s come out of this devastation in the past year and a half.”
