COVID-19 is indiscriminate. Everyone is susceptible. That’s a message heard consistently from public health officials throughout Appalachia, which includes northern Alabama. Some people are more vulnerable than others: the elderly and those with preexisting health conditions, for example. It’s also true that entire communities are at greater risk: those of color.
This realities were underscored midsummer as the force of the pandemic shifted direction, surging through the Southeast and Western states. The populations of these regions have a higher percentage than the nation as a whole of residents who are Black, Latino and Native American.
Native American adults are almost three times as likely to be diagnosed with diabetes as white adults; Likewise, Latinos more commonly suffer from diabetes. Black adults experience hypertension, diabetes and obesity at higher rates than white adults. These are all conditions that make it more difficult to fight COVID-19.
Members of racial and ethnic minority communities are more likely to work in jobs considered essential, and a return to work places them at greater risk of exposure to the virus. Many minorities work in jobs – in the service industry and construction, for example – in which physical distancing is difficult, if not impossible.
In a Centers for Disease Control and Prevention study, more than a third of Latinos who died from COVID-19 were 65 or younger, nearly three times the rate of whites. The study’s authors noted the nature of their occupations as a potential contributing factor to the higher rate.
The University of Alabama at Birmingham’s Minority Health & Health Disparities Research Center (MHRC) was founded to take a scientific approach to reducing health disparities experienced by vulnerable populations. The center has worked in communities in Birmingham, throughout its region of Appalachia and in the Black Belt to address the social determinants of health.
Responding to the outbreak of COVID-19 is now its primary focus. Doing so requires both proactive and reactive measures – education, testing, immediate care. It also requires, said Cathy Cartagena, an MHRC research specialist and patient navigator, culturally sensitive and respectful interaction and an understanding of a particular community’s day-to-day reality.
Theresa Wallace, program director of the center’s Live HealthSmart Alabama initiative, agrees. Many of those the center is reaching out to, Wallace said, are torn between often-conflicting imperatives: sheltering or working; seeking help or soldiering on. Some, Wallace suggests, “may not see the virus as their biggest threat, because they have so many other pressing needs.”
In countering the disproportionate impact on Black and Latino communities, the MHRC has adopted what Wallace calls a “rapid-response mentality,” while staying mindful of the accelerated urgency of long-term solutions.
Latino communities face some distinctive challenges in confronting COVID-19, language primary among them. Reliable information can be hard to come by. The communities tend to be insular; interaction with the world around them is often minimal.
Fear is another factor – fear of losing a job; fear, for the uninsured, of the cost of seeing a doctor; fear, for the undocumented, of deportation.
Fear is a constant in many Latino households, said Maria Uncein, a native of Venezuela living in Birmingham, and it’s heightened within the pandemic.
People are “scared to go to the doctor,” Uncein said. “They’re scared to even have a conversation about their symptoms, so they’re diagnosing themselves, ‘Oh, no, no; this is just a regular gripe,’” she said.
Rumors abound, say community advocates – for example, that all those who enter the hospital with the virus will die. Or, on the other extreme, that one’s ethnicity makes them immune.
MHRC staff members have worked, Wallace said, “to debunk the myths, providing education and then reinforcing the message that this is real, ‘Yes; you have concerns. Let’s tackle this step by step.’”
No finger pointing
Data compiled by the COVID Tracking Project indicates that while only 4% of Alabama’s population is Latino, they represent 12% of the state’s positive COVID-19 cases.
On a recent afternoon, cars lined up in the parking lot of St. Peter the Apostle Catholic Church in Hoover for drive-up COVID-19 testing. This is one of 15 community sites where testing is provided by MHRC in partnership with the UAB Health System, UAB Medicine and the Jefferson County Health Department.
Hoover is home to many Latino families, some of whom attend St. Peter’s. Roughly half of those queued up today are native Spanish speakers.
The positive rate in this immediate area has been high and testing has been sparse. The church is an ideal location to reach members of the community. Faith leaders tend to be influential voices in marginalized communities, said Tiffany Osborne, MHRC director of community engagement. In times of crisis, they play an invaluable role.
From concept to mobilization, MHRC’s testing program was launched in two weeks. Its patient navigators received training specific to the virus; data systems were linked for scheduling appointments and accessing medical records.“If we can use those voices, those really strong voices in the community to advocate and say, ‘This is a good thing; you need to be a part of this,’ then we’re more apt to have a stronger response from the community than if it were a lay person or a politician,” Osborne said.
Those who test positive are counseled in how they might most-effectively quarantine.
“We educate them about resources if they don’t have a primary care doctor – or even if they don’t have health insurance – for how they can get medical access,” Cartagena said.
The navigators assist as needed with transportation and other nonmedical needs.
“We’re totally neutral about all of that,” said Bill Curry of a patient’s immigration status. “We’re not taking any political positions or pointing fingers or anything like that. We’re just saying, ‘Our job is to test people.’ That’s what we’re here to do.” Curry is the UAB Health System’s senior vice president for population health, associate dean of rural and primary care and on-site physician for the testing.
Curry said it is made clear that names are put into a database “so that we can know that we give the right result to the right person” and to track positivity in a given community. The message is reiterated across multiple media: “Nobody is going to use this against you.”
Those tested typically get their results in 24 to 48 hours. With funding through the county from the federal coronavirus relief package, they’re aiming to provide 50,000 tests.
‘If we don’t work, we don’t eat’
Monica Vasquez, a native of Mexico, is the single mother of four grown children. She makes her living doing domestic work but has been self-quarantining out of fear of having been exposed to the virus. She’s been tested and, at the time of a recent Zoom call, was awaiting her results.
“Thank God my daughters are able to work,” she said through an interpreter. But if her results were to come back positive, her daughters would immediately quarantine.
Vasquez found out that her test was negative, but exposure remains a present danger in her life and that of her family.
“If we don’t work,” she said, “we don’t eat.”
A couple of years ago, Vasquez had a severe stroke, spending a month in the hospital and several in rehab. She worries that she’s at heightened risk of contracting the virus. But her biggest concern “is that I don’t have insurance. If something happens, how am I going to pay?”
Cartagena has made her aware of the Hispanic Interest Coalition of Alabama, which offers financial and other services. Churches and nonprofits are offering food and essentials to those in need.
Yeimi Espinoza, also from Mexico, said the stress of the pandemic is taking a toll on her family. She, too, has four children, aged 9 to 19. She’s lost several family members to COVID-19, here and in Mexico.
Espinoza has experienced depression. She’s worried about sending her kids back to school.
“I’m always thinking about what’s going to happen next,” she said through an interpreter.
‘A singular time in our history’
In the midst of the unknown immediate consequences, health care professionals are bracing for the aftermath of COVID-19, aware that preexisting issues will be exacerbated in the long term.
In a video conference with journalists, Margarita Alegria, chief of the Disparities Research Unit at Massachusetts General Hospital and a professor of psychiatry at Harvard Medical School, addressed Latino communities’ critical shortage of access to behavioral health services.
In the midst of the pandemic, a sense of isolation, the anxiety of uncertainty and fear about the future, Alegria said, “are all going to magnify a sense of catastrophe.” She spoke of frustrations that lead to domestic violence and child maltreatment.
Alegria points out that while Latinos have similar or even lower rates of mental health issues as non-Latino whites, “they have greater severity in the consequences of mental illness. We also know that serious psychological distress is more likely to happen in people that are underinsured in a pandemic, and Latinos are the group with the highest (uninsured) rates.”
“We may not have been prepared for COVID-19,” Alegria said, “but we should be prepared for the post-coronavirus aftereffects.”
That means “making sure that we integrate social-science disciplines to understand what’s needed in each local context,” she said, while proactively anticipating the need for health care resources and removing “structural, bureaucratic and attitudinal barriers” to care. It means offering liaison services that operate within community health care facilities.
Further, Alegria said, it will be imperative to “focus on policy innovation to make sure that we address social determinants, and especially institutional racism.”
Richard Besser, CEO of the Robert Wood Johnson Foundation and former acting head of the CDC, offers another remedy: Twelve states, including Alabama, haven’t expanded Medicaid, as allowed for under the Affordable Care Act. This pandemic, Besser argues, has underscored the need to do so.
“This is one of the most stressful periods in our history,” Besser said, “and with that comes the need for mental health and behavioral health services that many people just don’t have the resources to be able to access.”
In expanding Medicaid in all states, he said, “we’d be coming together and saying, ‘This is a singular time in our history, and we need to provide people with as much as we can.’”
The UAB Minority Health & Health Disparities Research Center engages in what it calls “community-based participatory research,” involving the communities in which programs will be initiated upfront. It’s essential, Theresa Wallace asserted, that solutions be forged collaboratively.
In the short term, Maria Uncein said, “I believe that the community has to understand that we’re in this together, and that if we focus on three main areas – education, self-care and social distancing – it really will help everyone.”
“We’re part of the solution,” she said. “It’s in our hands to do better.”
This story was produced by 100 Days in Appalachia, an independent, nonprofit digital news publication incubated at the Media Innovation Center at the West Virginia University Reed College of Media.