Long before the shooting, Community Health Development, Inc., a federally qualified health center, had been providing medical, dental, and behavioral health services to approximately a third of Uvalde County, Texas.

Then, on May 24, a shooter entered Robb Elementary School in the town of Uvalde, killing 21 people – 19 students and 2 teachers – and injuring 17 others. Nine of the health center’s staff members lost family members in the shooting – and among them were two nurses whose children were killed.

“You never think that this is going to happen to you. We’re not safe anywhere,” said Mayela Castañon, the CEO of Community Health Development, Inc. (CHDI). “There is not a single person in our facility who was not affected…we heard the shots over here.”

The shooting has left community members shattered. “This is not something that is going to go away. This is going to be decades,” Castañon said.

And immediately after, CHDI began a response to the increased need that Castañon knew her community would experience. Staff members worked to meet urgent behavioral health and related issues, while Castañon figured out a long-term plan to improve resilience – and prevent future tragedies.

Following the shooting in Uvalde, Direct Relief provided a $120,000 grant to Community Health Development, Inc. to cover their increased operational costs.

Different symptoms of a common trauma

Within a day, CHDI staff set up a crisis center that included behavioral health provider volunteers who had come to the area in response. They started by treating staff. “My main goal was to get ourselves ready. I wanted to make sure we were in a safe frame of mind to be able to offer services,” Castañon said.

Then, the crisis center opened to the public – not just to CHDI’s patients but to anyone needing care, particularly trauma-informed behavioral health services. Castañon heard initial concerns that local residents – many of them rural and Latino – would be unwilling to seek services due to stigma. The concerns were wrong.

“I am so pleased to know that our community realized that those services were available and that they needed help,” she said. “We seem to be completely booked.”

At first, “everybody was in a state of shock,” said Rebecca Zapata, a licensed professional counselor at West Texas Counseling & Guidance who oversaw providers at the crisis center. “Everybody was hurt. The first few days, people were walking around in a fog…In the next week, a lot of anger started coming out.”

Zapata noticed that many of the people who came to the crisis centers had “past trauma not related to the incident or some generational things that had gone on,” but before the shooting, they hadn’t sought treatment. “They had kind of put their behavioral health on the back burner.”

According to Castañon, many patients came to CHDI with symptoms that weren’t ostensibly related to behavioral health, such as gastrointestinal symptoms or headaches, “not realizing that the headache is [connected to] behavioral health issues.”

Planning for the future

The crisis center was designed to meet the community’s immediate needs, but Castañon doesn’t want to stop there. Long-term interventions are needed in Uvalde and the surrounding areas, and she wants to make sure her health center is prepared to respond.

Among Castañon’s plans is to establish a school-based health clinic for children and their families at a local campus. The goal is in part to meet medical needs in the community, but Castañon has an additional goal in mind: preventing future violent tragedies.

“We’re going to have a professional trained in trauma-informed care,” she said. The stomachaches and headaches children report may be “something else” that a trained provider can identify and treat.

For the shooter, Castañon pointed out, “that idea was brewing in him for weeks, months, maybe years. But we never caught it, we never did anything. But we can do something…and if we don’t do it now, when are we going to do it?”

In addition, she plans to build a multipurpose center close to a local Walmart – “everybody goes to Walmart,” she explained – that can provide medical, dental, and behavioral health care, as well as connecting patients to services like housing, employment, and government-sponsored insurance.

“We’re not going to be the answer to everything, but we can work with other entities” to improve people’s circumstances – and by extension, their health, Castañon said.

That will mean recruiting more providers to CHDI – a challenge at the best of times. The health center worked with volunteers in the aftermath of the shooting because there weren’t enough providers to treat everyone who needed interventions, Castañon said.

But while the area filled with volunteers providing behavioral health and other services in the aftermath of the shooting, Castañon said that now many have gone home.

That won’t be true of CHDI, she said: “We’ve been here for 38 years, and we’re going to continue being here.”

An immediate response

Within an hour of the shooting at a Buffalo Tops Friendly Market, Dr. Takesha Leonard was in the market’s parking lot.

“I needed to know whether any of my patients were in the shooting,” said Leonard, who has a doctorate in health policy and is a family nurse practitioner at Jericho Road Community Health Center, a Buffalo, New York-based safety-net provider and long-term Direct Relief partner.

On May 14, a shooter motivated by racism and white supremacy murdered 10 Black people at the Tops Friendly Market, choosing a food store and pharmacy on which many in the primarily Black neighborhood relied. An additional three people were injured.

After hours of waiting in the parking lot with people desperately hoping for information on family and friends, Leonard decided to order pizza so that people could eat. Jericho Road’s CEO, Dr. Myron Glick, sent her his credit card information, and she ordered “boxes and boxes of pizza.”

At the end of the day, “none of them were my patients, but I stayed there. I stayed there all night,” Leonard said. “I went to all of the vigils and all of the ceremonies.”

Immediately, Leonard – along with the rest of Jericho Road’s staff – prepared to respond, calling vulnerable patients to check in on their mental and physical health, and increasing their behavioral health services to meet a drastically growing need. Behavioral health providers offered support to fellow staff members as well as patients.

Tragedy strikes a traumatized community

One patient posted on Jericho Road’s Facebook page, asking staff members to tell Leonard that “’I am not OK,’” Leonard recalled. The patient’s daughter had been at Tops at the time of the shooting. “The next morning at 7:30 in the morning, I got up and I called that lady.”

In offering increased behavioral health services to the larger community, Jericho Road’s behavioral health providers knew that they were dealing with a population already dealing with a history of segregation, violence, and other sources of trauma.

“If you are from the east side of Buffalo, you hear gunshots,” said Amanda Budwine, a licensed clinical social worker at Jericho Road. “We are all trained as trauma therapists…and because we are trauma therapists, our approach has always been patient-centered and trauma informed. We are continuing to do what we’ve always done.”

But the shooting at Tops, Leonard said, was utterly devastating. “I’m angry, and [my family is] angry, and the community is angry,” she said. “It just ripped the soul out of us.”

A history of service

Jericho Road’s staff is used to meeting community needs, especially when conventional channels aren’t working. The community health center offers specialized services to refugees and other vulnerable groups; trains doulas to help patients deliver their babies; and has a parent-child home program in which volunteers provide toys and books, and model reading and play to support families.

“We’re very intentional about looking at some of the non-medical factors that influence a person’s health,” Glick said.

Leonard offered as an example Jericho Road’s response to the Covid-19 pandemic, in the days when testing required a doctor’s order. Many of her patients didn’t have access to the Internet or transportation. “It wasn’t that Black people didn’t want to get tested. It’s that you put so many barriers in place that they can’t access the testing,” even as Black patients were being disproportionately affected by Covid-19, she explained.

At Leonard’s suggestion, Glik secured Covid-19 tests for his patients, with no further requirement than simply showing up. “On the east side, it’s word of mouth,” Leonard said. “Within that day, we had 100 people show up, when they knew they could get tested.”

Preparing for the long term

In the wake of the Tops shooting, more than behavioral health care was needed. The supermarket wasn’t just a place to buy food – the store’s pharmacy was also where many people in the community got medications for chronic diseases and other medical issues.

“Nobody was thinking that they don’t have their medications,” Leonard said. “People are coming into my office and they’re stressed, and their blood pressure’s elevated…and then they can’t take their medication.” A number of patients with diabetes or hypertension worsened.

Jericho Road responded by delivering medications from their in-house pharmacy directly to patients.

“Our being integrated into the community is lifesaving for folks. It’s what we’re supposed to be doing,” Glick explained. The high level of trust Jericho Road has earned among community members has made it possible for the health center to do more good, more effectively.

Glick is well aware that the shooting will have long-term implications for the Buffalo community. “This is all still very acute, but I think we’re going to be seeing the ripple effects for awhile,” he said. “When something like this happens and folks have already experienced trauma in their lives, it just reignites that feeling and that can cascade into depression or anxiety, or just not taking care of yourself.”

For many of Jericho Road’s patients, a long history of racism and segregation in the city of Buffalo directly affects them today, Glick said. He explained that approximately 85% of Black residents of Buffalo live on the city’s more dangerous east side. “That reflects hundreds of years of decision-making that have caused folks to be segregated,” he said. The shooter “chose Buffalo and he chose the east side of Buffalo and he chose that Tops because that’s where he would find, in his mind, the greatest concentration of Black folks.”

But Leonard is optimistic that that things may get better. She noted that government officials are seeking out Jericho Road’s input, along with that of other important community members like local pastors, to help them more effectively provide services to Buffalo residents.

“We’re at that table,” she said.