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Alma Burrell was worried. The patients at her health center, Roots Community Health Center in California’s Bay Area, weren’t getting tested for Covid-19 – even though they wanted to.
“A lot of the testing around this area was all drive-through, so if you didn’t have a car you couldn’t be tested,” said Burrell, the regional director of Roots’ South Bay clinic.
That was true of many of the South Bay clinic’s patients. Overwhelmingly communities of color – “probably 99% of the folks we serve are people of color,” Burrell said – with many unhoused and a high number of chronic conditions, Roots’ patients were particularly at risk.
They knew it. And they wanted to be tested. Burrell was receiving frequent calls from patients who had symptoms or were worried about exposure. Some wanted to bring in family members who weren’t already patients.
And while the clinic was doing some testing in the parking lot – “the nurse practitioner would run out the door with the medical assistant in PPE” – it wasn’t a permanent solution.
Under the surface
The experience Burrell described – of already-vulnerable patients not able to easily access Covid-19 testing – wouldn’t surprise Dr. Georges Benjamin, director of the American Public Health Association.
Not much information on the equity of Covid-19 testing access is available. However, Dr. Benjamin said, “we’ve always had challenges getting to some communities – the poorer, the more underserved communities.”
Still, as testing materials have become more available and the parameters of who is eligible have broadened, Dr. Benjamin said, those groups are at risk of being left out again. Testing sites “often did not result in convenience, particularly in communities with fewer resources,” he said.
Drive-through testing doesn’t work for people who don’t have a car, Dr. Benjamin explained. Testing site hours may not be convenient for people doing public-facing work.
Health workers staff a San Jose, California temporary testing site. (Photo courtesy of Roots Community Health Center)
And in addition, “I think when people have to set up a site, they may look around where they may tend to get the best land, where the most traffic is. That does not tend to be in the inner city.”
“We don’t know a whole lot about testing inequities, but we sort of presume that they’re there,” said Dr. Jennifer Nuzzo, a professor of environmental health and epidemiology at the Johns Hopkins Bloomberg School of Public Health. “We obviously see very obvious disparities…in our case numbers, our hospitalizations, and our deaths.”
Dr. Nuzzo explained that most states are only reporting on testing numbers at the state level, so it’s hard to get a good sense of where testing is taking place – and who’s getting tested. Only four states are currently providing data on Covid-19 testing by race, according to the Johns Hopkins Coronavirus Resource Center.
In addition, Dr. Nuzzo said, many states are only reporting the number of tests given – not the number of people tested.
While Dr. Nuzzo said that the number of positive tests provides a somewhat better picture of how much Covid-19 infection is really present, “positivity is not a perfect metric, because you could have a low positivity if you test all the wrong people.”
That has real consequences.
“We are now making decisions of policy and practice that depend on having an accurate case count,” Dr. Nuzzo said. “If we’re not collecting the right data, if we’re missing important pieces of data, then we’re not going to have the right answer.”
Mobile solutions
For Roots, the solution came in the form of a temporary testing site, coordinated with the local public health department, in the parking lot of San Jose’s Antioch Baptist Church.
“We were looking for a place that was really well known and that would be in the community,” she explained.
The church – a local historical landmark – was conveniently located for patients and highly recognizable.
To make the experience more appealing, staff workers use bright-colored tents and a circular setup. “It almost looks like a big fair,” Burrell said. “It’s kind of colorful, kind of pretty, but then you see all of us folks in PPE.”
A Roots Community Health Center staff member checks people in to be tested. (Photo courtesy of Roots Community Health Center)
Ann Langston, senior director of strategic partnerships at Church Health in Memphis, Tennessee, reported an experience similar to Burrell’s.
“We have testing sites all over town that people can go to for free. They are woefully underutilized,” she said. “We need to go where people need to be tested.”
Working with other local clinics, Church Health has begun using a mobile medical unit to offer pop-up testing sites. Like Roots, they focus on bright colors and a festive atmosphere, “which sounds weird to be a testing site, but it has worked,” Langston said.
Langston described testing one family who arrived at a testing site to find that everyone – including a child present with the group. “That’s what we want to stop, because that family then could infect how many others?” she said. “Whereas if they could just stay home…that would make a huge difference.”
In addition, Church Health has partnered with the local food bank to distribute boxes of food – and fresh produce – to people who show up at testing sites.
Care in the community
Their success likely wouldn’t surprise Dr. Benjamin, who explained that health care organizations and public health departments have long employed mobile units as a way to provide care – including breast and cervical cancer screenings, vaccinations, and other essential health interventions – to harder-to-access communities.
“The point is you’re providing the testing close to the community, so the community can get the test,” he explained.
In particular, mobile units have been shown to be a costly but “from a clinical perspective, very efficacious” way to bring health care to vulnerable communities.
And health centers and clinics across the country are using mobile units and temporary testing sites to offer Covid-19 testing to seniors, agricultural workers, and homeless communities.
“Being able to take the mobile unit to different locations, different communities, makes us able to reach out further than what one clinic can do,” said Francisco Alemán, chief medical officer at Northwest Health Services in Missouri, which has provided testing to all three groups.
Gail Jackson-Blount, the chief development and communications officer at Harvard Street Neighborhood Health Center in Massachusetts, explained that her health center hasn’t yet been able to offer mobile testing.
Thanks to a grant from Direct Relief and the Abbott Fund (the foundation of the global healthcare company Abbott), that’s about to change.
“We feel it’s extremely important right now, because, in particular, a majority of the people we serve…are those who are considered in that high-risk category,” Jackson-Blount said.
Harvard Street plans to offer mobile testing three days per week – more, if demand requires it.
According to Jackson-Blount: “That will help us to reach many more people.”
To support health centers working to expand access to coronavirus testing and treatment — primarily in diverse, under-resourced communities across the U.S. that are affected disproportionately by COVID-19 — Direct Relief and the Abbott Fund established the Direct Relief + Abbott Fund COVID-19 Community Grant Program. The program helps health centers safely and effectively screen, test, triage and treat COVID-19 cases and provide clinical education to patients.
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