Guest Authors: Shoshanah Brown, CEO and Founder of AIRnyc; Khadra Dualeh, AIRnyc Community Health Worker; Djene Keita, AIRnyc Community Health Worker; Mariluz Garcia, AIRnyc Community Health Worker; Tywan Mata, Director of Care Coordination for AIRnyc
United States of Care continues to be grateful for the work of AIRnyc. The AIRnyc team works with community members to assure that their health needs are met. Its community health workers have a substantial role in the New York City COVID-19 Rapid Response Coalition that was launched in April. The following message is by several members of the team who are devoted to investing in community health.
This past week marks 100 plus days since New York City’s first confirmed case of COVID-19 – 78 days of lockdown, over 21,000 deaths and 500,000 jobs lost due to this disease. New Yorkers, most of us sheltering in small apartments with our families and wearing masks each time we stop out for groceries, are especially eager to recover, reopen and rebuild. And while we may disagree about whether we are yet ready to get back out there, our City has begun to reopen, and we have to talk about the needs of our hardest hit communities as we emerge from our respective bubbles.
While there is still uncertainty around when we will have effective vaccines and treatment for COVID-19, how long the virus lives on surfaces, whether we should fly for summer vacation and if schools can safely reopen in the fall, there is one truth that is absolutely clear regarding transmission dynamics across the nation: Black and Latinx Americans living in low-wealth areas of New York City and throughout U.S. were hit hardest by COVID-19. Black people in New York have died at a rate three times as high as Whites, and continue to be harmed not just from the interlocking health, social, legal and economic impacts of this disease, but also from the longstanding structural racism leading to unjust levels of disparity and inequality ultimately defining who has the opportunity to be healthy and safe. These social, political and economic determinants of health (and/or sickness and death on the flip side) must be addressed, and not as a side show or through “pilot programs”, if we are going to prevent the moral failing that was our preparation for and response to COVID-19.
Fortunately, in the two years leading up to COVID-19, three trends were already converging to drive innovation for addressing the social determinants of health, namely, the emergence of new technologies, the shift to value-based care, and an increasingly sick and aging population. What COVID-19 has shown us in New York City, through a rapid learning cycle, is that no single company, organization, policy or tech solution can bring about the magnitude of change that we need in order to do better for vulnerable people. And that vulnerable people, specifically Black and Latinx people need to be in the room where the ideation, design and implementation of policies and solutions happens if we want to succeed in engaging people and achieving health with and for people who have every reason to distrust the system.
To recover, reopen and rebuild, we need robust investment in both human capital and technology. Most radically, we must collaborate across industries and look beyond our respective short-term interests and bottom lines for the purpose of serving the underserved with a collective impact mindset.
In an April United States of Care telebriefing and a Commonwealth blog, followed by a June 5th blog published by the United Hospital Fund that addressed the challenges of COVID-19 testing and contact tracing in this time of distrust, we have attempted to identify problems and solutions that we in the health, social care delivery and policy-making spaces must consider as we work toward building healthier, more resilient communities, served by systems grounded in anti-racist principles*. Here are a few ways we need to do better for the people we aim to serve as clinicians, service providers, practitioners, entrepreneurs, investors and policymakers:
- Listen. Listen to and invest in Black and Latinx and other marginalized people and communities whose voices have historically been ignored on both the supply and demand sides of the marketplace. Listen for ideas, products and services designed to improve health and access. Even when we believe ourselves to be well-meaning and not elitist or racist, we have a legacy in medicine, public health and government of being overly prescriptive, paternalistic and out-of-touch with what people need and want. We can take a page from other industries that are now driven by consumer demand. Those of us who have the honor and privilege of serving vulnerable people can listen with intention, at close range, and help amplify their voices.
- Integrate. Integrate within and across healthcare, mental healthcare and social care services to make it easier for consumers and suppliers of essential services to meet the prioritized needs of consumers, from their vantage points. Regardless of the setting where people seek care (i.e. in-person, virtual, at-home, ambulatory, in-patient), we have the capabilities to address food insecurity or another social need within the same encounter as a medical need; we should view social and mental health care interventions as buying health just as we do prescribing medications and delivering other clinical care. Let’s commit to really doing, and not just talking about whole-person, integrated health by taking an authentically human-centered, value-generative approach. Heads are connected to bodies, stomachs are connected to brains, children and the frail are connected to caregivers, so let’s stop arbitrarily fragmenting people, conditions, households and solutions.
- Expand Telehealth. Expand telehealth to vulnerable populations including access to care for the management of chronic conditions (i.e. asthma, diabetes, hypertension, substance use disorders, etc.), and all mental health interventions, particularly trauma-informed mental health services. Social distancing during COVID-19 has shown us that people can and will access telehealth to keep themselves out of the hospital. We should continue to authorize and reimburse for all telehealth modalities that let people effectively self-manage chronic conditions remotely – including simple phone calls with physicians – in order to avoid the risks and costs associated with avoidable hospital use. New York City’s Health and Hospitals, our safety net health system, stood up an incredibly valuable yet low-tech resource during these months of social distancing, one that allowed many vulnerable people to stay home and get care when they needed it through a synchronous phone call with a clinician. Not all conditions lend themselves to remote monitoring and care, but more do than are covered for the Medicaid population, and we should make sure it’s not just the Sweet-Green eating, tech-savvy Peloton and One Medical customers who can virtually engage with clinicians.
- Close the Digital Divide. For telehealth, not to mention distance learning, social connection, and the myriad convening we now do online, people need access to devices and a way to connect to the internet. Broadband / WiFi should be a public utility in 2020, and at the very least, should be available free of charge to the zip codes and communities hardest hit by COVID-19 – proxies for the vulnerability that results in lower levels of formal education, higher prevalence of chronic disease, more exposure to infections diseases, risks of suffering from social isolation, mass incarceration, limited resources for engaging in distance learning and lower wealth in general.
- Establish Interoperability. Of paramount importance for any effort is the need for interoperability and secure data-sharing standards that allow us to coordinate care, catalyze collaboration and mobilize capital within and across our collective institutions across different platforms. We have to be able to safely and securely share data within and across organizations and with consumers themselves, who should be able to easily access their own health records. There are firewalls–literally and metaphorically– put up in the name of protecting peoples’ privacy which really serve to protect corporate profits, and, given the level of injustice and inequality sickening Black and Latinx Americans, it’s time to eliminate the bogus rules so that health, social and medical care providers can use data to better help vulnerable people. We need to expand available SDOH core data for interoperability and accelerate standards-based information exchange by using HL7® FHIR® through a coalition-based approach such as The Gravity Project, which has been building a diverse stakeholder groups in identifying and harmonizing social risk factor data for interoperable electronic health information exchange. We can and should collectively pick up the pace and level of investment in this important endeavor.
- Build the Community Health Workforce. There has never been a stronger case for building the community health workforce in the United States. Specifically, we need legions of Community Health Workers (CHWs) composed of people from the communities not just hardest hit by infectious diseases like COVID-19, but also including those affected by the racism and injustice that make people vulnerable to all chronic disease, including diseases of despair (i.e. drug overdose, alcoholism and suicide) and “lifestyle” diseases associated with lack of access to healthy food options, safe places to exercise and stress. Aside from the return on investment-based arguments for hiring Community Health Workers to address the social determinants of health, CHWs are mission-critical in all of the above five strategies. AIRnyc CHWs have worked to advance all of these strategies prior to COVID-19 and have continued to do so remotely during this pandemic with much higher rates of engagement. Since March 16th, AIRnyc CHWs have engaged nearly 4000 vulnerable New Yorkers by phone, listening to their voices and taking action on everything from facilitating telehealth appointments to prescription refills, food delivery and safe ride services, mental health hotline connections, eviction prevention and finding shelters for domestic violence incidents while also just showing up for people who needed to talk because they were isolated, afraid, lonely, hungry and sick during these harrowing times.
None of these strategies is sufficient on their own, but they are, in concert, part of the roadmap that places the humanity of vulnerable people at the center of our interventions, and will set us off on a more just and equity-enhancing path to recovery, reopening and rebuilding together in health.
As a part of our ongoing #VoicesOfRealLife series, we are connecting with folks across the country to share how COVID-19 is impacting their lives, their work, and their communities.
*Author and historian Ibram X. Kendi claims there’s no such thing as being ‘not racist.’ He explains that even inaction (simply being ‘not racist’) in the face of racism is, in fact, a form of racism. The idea of an innocent bystander is wishful thinking for Kendi; instead, there’s only racism and antiracism: If racism means both racist action and inaction in the face of racism, then antiracism means active participation in combating racism in all forms.