COVID magnified Fresno County’s racial health disparities. What lessons will be learned?
Health professionals have long recognized a correlation between poverty and health, particularly in rural communities where many residents confront language barriers and a lack of access to medical care, transportation or healthy food.
Over the past year, disadvantaged rural and urban neighborhoods – often areas with larger proportions of racial or ethnic minorities including Black, Latino, Hmong and immigrant populations – have been disproportionately affected by the coronavirus pandemic. At the same time, they are also the areas that generally have the least access to COVID-19 testing and, now, to vaccines intended to bring the pandemic to a close.
“The COVID-19 pandemic has shone a very bright light on health disparities, not only in our state but in our country and around the world, for that matter,” said Dr. John Zweifler, a Fresno physician, author and physician consultant to the Fresno County Department of Public Health. “In some places (there are) really staggeringly high rates of hospitalizations and deaths in minority communities that are very discouraging and need to be addressed at a fundamental level.
Locally, Fresno County’s health department has enlisted the aid of a broad coalition of community-based organizations, working in collaboration with the COVID Equity Project formed by the UCSF Fresno medical education program and other medical providers to bring coronavirus information, personal protective equipment, resources, testing and vaccines into disadvantaged neighborhoods.
In addition to existing connections with trusted neighborhood messengers, they’ve forged a network of 75 trained community health workers – “members of the diverse communities we represent,” said Sandra Celedon, president/CEO of Fresno Building Healthy Communities and one of the coordinators of the Immigrant Refugee Coalition.
Those community health workers, or “promotores de salud” in Spanish, along with program managers, data analysts, administrative clerks and others collectively represent 14 ethnic groups across four races and 16 different languages.
“This is about providing information and resources to folks in the language they’re most comfortable in,” Celedon said.
It’s resulted in what health officials and advocates describe as a new “health infrastructure” for communities that have historically been left behind. And there is optimism that it can serve as a foundation for efforts to ensure greater health equality – if not economic parity – for the most disadvantaged areas of Fresno County long after COVID-19 fades into memory.
Why it matters
Since the first local case of COVID-19 was confirmed in March 2020, almost 101,000 Fresno County residents have been infected with the virus, and almost 1,650 have died.
Racial or ethnic minorities have borne the brunt of the cases – almost two out of every three infections, the county health department reports. Neighborhoods that rank in the bottom 25% of California’s Healthy Places Index also are seeing higher incidence of cases, as a rate per 10,000 residents, than more affluent areas.
More than 70% of Fresno County residents reside in areas that are in that bottom tier of the Healthy Places Index, said Joe Prado, community health manager for the Fresno County Department of Public Health.
Whites account for fewer than 17% of the county’s cases, but have received about 28% of the total COVID-19 vaccine shots administered so far here.
By contrast, nearly half of all of the county’s confirmed coronavirus cases have been among Latino or Hispanic residents, but that population has received less than 37% of vaccine doses administered so far in Fresno County.
Additionally, residents in disadvantaged neighborhoods confront higher rates of poverty, inadequate housing, higher unemployment, less access to health care and other economic disparities that Zweifler refers to as “social determinants of health” that typically result in poorer overall health and lower average life expectancy – conditions and hardships that existed even before the coronavirus pandemic struck.
“Social determinants of health are the conditions into which we are born and live that are shaped by money, power and resources,” Zweifler said. “If you’re from an average white family, you have six to seven times as much money as an average Black family. So you can imagine how your life would be different if you had six times as much money as you have now.”
“We can recognize evidence of the impact of social determinants of health when we identify health disparities,” Zweifler added. “We’ve had the clearest and saddest examples where you see rates of deaths among Blacks (from coronavirus at) three or four times that of whites. It’s unconscionable, really.”
So why did it take something as dramatic as a global pandemic to spur action after years or even decades of neglect for unincorporated rural farming communities and urban neighborhoods of color or poverty?
“It’s important to note that it’s taken this long because we’ve really framed a lot of what we call ‘underserved communities’ as the labor force rather than focus on them as communities to be built up,” Tania Pacheco-Werner, co-director of the Central Valley Health Policy Institute at California State University, Fresno., told The Bee earlier this month.
“We are so interconnected, but it’s usually invisible; I think the pandemic allowed us to see just how interconnected we really are,” she added. “If we move forward in tiers for reopening, or for access to more resources, we really need to think about everybody. … The infection rate in someplace like Caruthers was affecting what people in Clovis could do.”
Low-income and disadvantaged neighborhoods matter to residents anywhere in the county, she added, because many of the people who live in such areas work lower-wage jobs in agriculture, restaurants, recreation and service industries that serve the entire population, whether affluent or not.
“The people that we’re serving are the people who are waitressing in north Fresno,” Pacheco-Werner told reporters in a Zoom video discussion earlier this month. “If we’re serving someone in Selma, maybe they go to work in Fresno. We’re thinking about serving the ones in most need, to help our entire community be healthy.”
The pandemic “made those who don’t often have to care about how interconnected we are really see that these are communities that need some attention, too,” Pacheco-Werner told The Bee in a separate phone interview. “A lot of it is this shift in how we treat people in these unincorporated areas as your neighbors, (as) worthy people to invest infrastructure in.”
The collaborations in the current response to COVID-19 didn’t simply happen overnight, however; there’s been about a decade of gestation as different organizations advocated for more community resources, infrastructure investment and health services for their constituents.
“This concept of equity has already been in our community; we’ve been brewing this for a while – community-based organizations, academics, we have all been talking about this,” said Prado, the county’s community health manager. “But this (pandemic) really threw it out in the forefront to immediately build the infrastructure overnight. It has been extremely effective.”
The organizations that are part of the Immigrant Refugee Coalition, including Fresno Building Healthy Communities, Jakara Movement, Reading and Beyond, Cultiva la Salud and Fresno Interdenominational Refugee Ministries, “have been working together for the last 10 years” with Latino, Punjabi and Asian communities, Celedon said. “So when the COVID pandemic started, we quickly shifted to function as a COVID-19 response team specifically for immigrant and refugee communities.”
“We’ve been leveraging the relationships that our organizations have nurtured over the years to connect with folks and support the county’s efforts” in education outreach, contact tracing, testing and vaccinations, Celedon added.
Pacheco-Werner told The Bee that another factor was the passage of the Affordable Care Act during the Obama administration, which expanded MediCal to not only provide health insurance coverage to more people, but also made it more economically feasible for a larger number of community health clinics to open in Fresno County.
What’s the lesson? And will we forget?
The costs of the pandemic over the past 13 months – the economic ruin of lost commerce and lost jobs, medical expenses for thousands of patients requiring hospitalization and others who were forced to quarantine or isolate themselves, and the human toll of lives lost – offer a harsh lesson.
“We get opportunities to learn these lessons time and time again,” Pacheco-Werner said. “We saw it in the freeze of the 1990s, that we have to rally around these (agricultural) communities, and then we left again. … Every generation gets an opportunity to learn the lesson; we either choose to or not to.”
The tricky part will be maintaining the momentum of the broader health-equity effort into the future, rather than returning to complacency and longstanding patterns of neglecting or ignoring disadvantaged neighborhoods once the COVID-19 crisis has passed.
Lasting change will require community-wide shifts in attitude “and finding the common things that people want everyone to have,” Pacheco-Werner said. “People in north Fresno, for example, want and care about people having good jobs. If we can think about that in a way that really extends to the county as a whole, then everyone should have good jobs.”
“If we have a little more expanded definition of ‘community,’ that can help,” she added.
What’s been unique about the pandemic is that it has forced some unlikely partnerships, Pacheco-Werner said. That includes a county Board of Supervisors with majority members who lean conservative politically and community-based organizations that are decidedly progressive on the political spectrum.
For organizations like Fresno Building Healthy Communities and others to have a contract with Fresno County for COVID-19 response and outreach “really shows progress,” Pacheco-Werner said. “It shows hope that we can be talking about different sides of the aisle politically, but we all have the same goal.”
“How do we keep those common visions working together, and be willing to keep having hard conversations?” she added. “None of this has been easy. But I’m hopeful because communication lines have opened that had not before.”
The broader problems surrounding social determinants of health are too big for government, or community organizations, or health-care systems to tackle on their own, said David Luchini, assistant director of the Fresno County Department of Public Health.
“It’s a lot of work; this is why partnerships are so crucial. No one entity or government agency is going to handle this,” Luchini said. “It takes everyone working together to build and improve the social determinants so that no matter where you live in Fresno County, you have an equal access to making a healthy decision. And that’s not the case (now) in large parts of our county.”
The actual structure of the collaboration, and particularly the establishment and training of the web of community health workers or promotores de salud who are able to communicate with and relate to residents in the diverse neighborhoods, provide a model for the future, as well as an example for other counties.
“These lessons learned are so important during these times of COVID, but it also lays the groundwork for what we can do in our community in the months and years ahead addressing social determinants of health in a collaborative manner,” Zweifler said of the partnerships that have emerged.
“There’s an opportunity for us to build on these lessons learned, build a strong information infrastructure and use the promotores model to make sure the people who need the care are getting the care they need (and) addressing health care needs in a much more holistic manner.”
“I think we’re really at a critical point where we can make a real difference in the long term,” Zweifler added. “Actually I’m optimistic that we will be in a much better place in the coming years in having an effective system of addressing social determinants of health and health disparities.”
This story was originally published April 25, 2021 at 5:00 AM.
