When the pandemic hit St. Louis last March, it soon became clear that the majority of COVID hospital patients were coming from north St. Louis — where the state’s largest Black population is.
“That is concerning,” Dr. Alex Garza, the incident commander of the St. Louis Metropolitan Pandemic Task Force, said in April. “That shows the disease does disproportionately affect those that are disadvantaged in society.”
Black residents were being infected at a rate four times higher than white residents, according to St. Louis County’s calculation in early April. And in St. Louis city, the first 12 COVID-related deaths were all Black residents.
Despite this revelation, north St. Louis continued to lack access to COVID-19 testing for months following the onset of the pandemic.
Health centers that serve the area sounded the alarm on the need for a steady supply of COVID tests from local and state agencies.
“Our patients were coming in, some were showing symptoms, and we were sending them to the emergency rooms,” said Angela Clabon, CEO of CareSTL Health, a Federally Qualified Health Center (FQHC) that provides affordable healthcare to underserved communities in north St. Louis city.
One year from the state’s first reported COVID-19 infection on March 7, 2020, the same dynamic is now playing out with vaccinations.
Black Missourians have contracted and died of COVID at rates higher than their share of the population. Yet, only 5.2 percent of Black residents have received their first COVID vaccine dose, compared to 13.5 percent of white residents, according to the state’s dashboard as of Saturday.
Analyses have found that the largest “vaccine deserts” — or areas with little to no access to the vaccine — are in the city centers, the areas with some of the most vulnerable populations and where Black populations are the highest.
It’s emblematic of how inequity is built into the system, said Serena Muhammad, the managing director of the COVID-19 Regional Response Team, which is tasked with addressing structural inequities in the pandemic response in the greater St. Louis region.
“Everything favors folks who have transportation, insurance, money — whatever that privilege category is — and everybody else is left out and scrambling. That’s across the board, across time,” Muhammad said. “So the fact that we are as unprepared as we are, is really an indication that we’ve never really intended to fix it.”
It’s a point Kansas City Mayor Quinton Lucas recently echoed in a letter last week requesting the federal government establish mass vaccination sites in the city.
“Under the current Missouri plan, urban access to vaccination is also predicated on association with a hospital,” he wrote, “which provides disproportionate access to those with social or professional connections to vaccine opportunities.”
In the St. Louis and Kansas City metros, areas with little to no access to the vaccine expanded from late December to Jan. 18, according to an analysis by a consulting firm hired by the state.
For both cities, the analysis pointed to the regions being made up of “predominantly lower socioeconomic communities with higher than state average minority populations.”
An initial analysis in late December, which was provided to The Independent through an open records request, found that in Kansas City there were no easily accessible vaccine providers along the I-435 corridor.
Then nearly two-and-a-half weeks later, the areas in both cities had grown, according to a subsequent analysis obtained by The Independent through a records request. Specifically in St. Louis city, the study suggested that there is, “growing inequity in vaccine center access.”
In St. Louis, the initial analysis identified CareSTL and Affinia Healthcare, two FQHCs, as providers that could help close the “vaccine desert” in the city.Missouri HealthPrism_Vaccine Desert Analysis 2.0_020221
Local budget-strapped public health departments and FQHCs — not the hospitals — are primarily responsible for vaccinating the state’s most vulnerable populations, who often don’t have primary care providers.
“Even if they were firing on all four cylinders,” Muhammad said of the public health departments and FQHCs, “their capacity is a fraction of what the hospital systems have. Their resources are a fraction of what the hospital systems have.”
During a Feb. 18 meeting, St. Louis County Council members pressed the area’s four major hospital systems on how they would reach vulnerable residents where they are.
Out of BJC HealthCare, SSM Health, Mercy and St. Luke’s, only BJC said they had a mobile unit at the time. While discussions were underway, they hadn’t yet used it for vaccinations, Clay Dunagan, BJC HealthCare’s senior vice president and chief clinical officer, said.
“We’re ready and willing to play any role we can,” Dunagan told council members, “but the public health services have a long history of reaching communities that are hard to reach. They’re familiar, and they are well accepted.”
For Jannette Berkley-Patton, a professor at UMKC School of Medicine’s Department of Biomedical and Health Informatics, the areas identified as having little to no access to the vaccine in Kansas City were not surprising.
“These are areas where we see some of the lowest life expectancy in the Kansas City metro area,” Berkley-Patton said. “I probably could have drawn this map — especially the map that goes down inner city Kansas City from north to south… without even looking at this, unfortunately.”
At KC CARE Health Center, an FQHC in Kansas City, they’ve taken on administering vaccine on top of providing community COVID testing and their regular services, just like many FQHCs across the state.
Patricia Neubauer, chief clinical officer for KC CARE, said they hope to have an outreach team just focused on going into neighborhoods to do vaccinations — but that can be difficult when they’re still trying to staff testing events at the same time.
“A lot is being asked for them,” Joe Pierle, CEO of the Missouri Primary Care Association, said of FQHCs. “But as we’ve always done, they’ve really stepped up to meet the call.”
The state and local response
The state has since acknowledged gaps in access and has dedicated targeted vaccination events supported by the Missouri National Guard to reach vulnerable communities.
After outrage following unused doses at multiple vaccine clinics in rural areas, Gov. Mike Parson vowed more mass vaccination teams — who support the mass vaccination events — will be transitioning to the Kansas City and St. Louis areas by April 1.
The St. Louis region will have three teams and the Kansas City region will have two. Meanwhile, the northern and southeast corners of the state will be covered by one team each, “based on our saturation in the marketplace there,” said Adam Crumbliss, the director of DHSS’ Division of Community and Public Health.
It wasn’t until the first week of February that the state announced local public health departments and FQHCs would each begin to regularly receive about 8 percent of Missouri’s weekly allocation of vaccine — with over half of the state’s allocation going toward select “high throughput” hospital systems.
Dr. Matifadza Hlatshwayo Davis, who sits on St. Louis’ health advisory board, said the city had been strategizing ways to distribute the vaccine equitably for months. But the lack of doses to the public health department and FQHCs essentially made those plans moot.
“It’s difficult for local governments and jurisdictions to enact some of those thoughtful plans when they have so little vaccine product up front,” said Davis, who is an infectious diseases physician at the John Cochran VA Medical Center.
Local health departments have made do with what they have, holding invitation-only clinics and partnering with churches to ensure they reach Black residents. And they’re working to take vaccine directly to residents, like those in independent living facilities.
That supply is expected to soon increase, after Parson announced Thursday that going forward both groups are slated to receive about 15 percent of the state’s allocation each week.
In addition, the federal government announced select FQHCs will begin to receive direct shipments from the federal government. In Missouri, Advocates for A Healthy Community, Inc. in Springfield was chosen to participate.
An underutilized resource to help close the vaccine gap is partnering with trusted community leaders, like churches, neighborhood groups and businesses, said Berkley-Patton, who also serves as the director of the UMKC Health Equity Institute.
She’s doing just that with a grant from the National Institutes of Health to work with the Kansas City Health Department and Black churches to increase COVID testing in underserved communities and also study the factors that influence whether someone will get tested.
One of those faith leaders is the Rev. Eric Williams, the pastor of the Calvary Temple Baptist Church.
Williams has been working to tackle inequities in healthcare since the early 90s through groups like the Calvary Community Outreach Network and Clergy Response Network, where his work first started around the HIV epidemic.
“It’s almost as if we are the forgotten people amidst climates politically that seem to care about others more than us,” Williams said of the government’s handling of the pandemic. “It’s those things, I think, that lead to distrust and fear and then sometimes apathy: ‘Why get tested if I’m not going to get vaccine anyway?’”
Clabon, the CEO of CareSTL Health, said many residents she’s spoken with who are eligible to receive the vaccine — based on their age or chronic health conditions — aren’t even aware they qualify.
It’s made Clabon even more concerned about getting clear information out to Black residents in St. Louis city, and that includes having more points of access for them to seek out a vaccine, Clabon said.
“The message is actually not getting out to them,” Clabon said. “And if they qualify, they have nowhere to go. So that’s the other issue.”
The Champion Program
— Elizabeth M. George (@ElizabethG_SLCF) August 8, 2020
Nearly every day for the past year, Muhammad has worked alongside Rebeccah Bennett, managing director for the COVID-19 education campaign Prepare STL, to address inequities in the region’s pandemic response.
And that work has only increased with the vaccine rollout.
In September, they started to get lots of requests from their medical and health partners asking for their help in convincing the minority community to get vaccinated.
“We took a step back and said, ‘Well, that doesn’t sound like a direction that we want to head in,’” Muhammad said.
And there were many reasons for that.
“One of the reasons why many African Americans are not leaning in is because of historic racism, continuing racism, a history of medical experimentation and experiences of medical trauma,” Bennett said.
In all those instances, African Americans’ agency to make their own choices was compromised, Bennett said. So the organizations decided to focus their message on choice and general health wellness.
“We really wanted to hold a space for sharing factual information, for having safe conversations, where people can ask questions, and they could trust that we were providing neutral information,” Muhammad said about the vaccine.
The pandemic has impacted every aspect of people’s lives, so Bennett and Muhammad realized they needed to “draw a wider frame.” Having a conversation about whether to take the vaccine also required talking about the ways COVID is undermining overall wellbeing.
“Even if you got a vaccine, chances are issues around economic stability, issues around housing security, issues around food security, issues around trauma and loss — all those things don’t magically go away because you get a shot,” Bennett said.
PrepareSTL and the Regional Response Team have teamed up to work to give residents’ agency in making that decision in a peer-to-peer outreach program.
Their model is to hire 300 “community health champions,” provide training and pay them $200 each to have conversations with 20 people each — facilitating at least 6,000 conversations.
“People are experiencing this crisis for real, so we are really redistributing money in ways that support our community members,” Bennett said.
It’s a proven model they’ve already used to facilitate education about COVID and to distribute masks and protective equipment. To date, they’ve already distributed $150,000 in stipends to community members.
What Bennett and Muhammad found most successful throughout the year is hiring people from the community who have relationships with those most vulnerable.
“We got a whole bunch of healthcare experts who want to get to vulnerable Black folks and brown folks, but they don’t have relationship,” Bennett said. “They have knowledge, but they don’t have proximity often. And even if they have proximity, they may not have trust.”