Past And Present Collide As Community Health Centers Strive To Close Rural Care Gaps In The Pandemic
In the 1960s, health care for Black residents in rural Mississippi was practically non-existent. While some hospitals served Black patients, they struggled to stay afloat; most options were segregated. During the height of the civil rights movement, young Black doctors decided to launch a movement of their own.
“Mississippi was third-world and was so bad and so separated. The community health center movement was the conduit for physicians all over this country who believed that all people have a right to health care,” said Dr. Robert Smith.
In 1965, Smith co-founded the Delta Health Center, the country’s first rural community health center, in Mound Bayou, a small town tucked away into the heart of the Mississippi Delta. The center became a national model and is now one of nearly 1,400 across the country. They are a key resource across Mississippi, Louisiana and Alabama, where about 2 in 5 Americans live in rural areas.
These rural health care providers remain under-resourced and the COVID-19 pandemic has only magnified existing challenges, like lack of broadband access and limited public transportation. For much of the vaccine rollout, those barriers have made it difficult for providers, like community health centers, to get shots in the arms of their patients.
“I just assumed that [the vaccine] would flow like water, but we really had to pry open the door to get access to it,” said Smith, who still practices family medicine.
As vaccine demand slows and coronavirus infection rates start to increase, state and federal officials are turning to these health centers to fulfill the mission of making the vaccine available to all Americans. In April, the Biden administration invested $6 billion in community health centers as part of a plan to increase access and awareness in the hardest-hit communities.
Many rural health leaders believe this type of support has been a missing piece in achieving the goal of an equitable rollout and wish community health centers had been prioritized from the beginning.
The Backbone of Care For The Medically Underserved
Walking around Mound Bayou, Miss. today, there’s not much to see: Some small convenience stores, old gas stations and rundown relics of some of the first Black-owned businesses in the state.
The predominantly Black town, founded by formerly enslaved people and settled by farmers, was once a thriving center for Black businesses. Like in many small towns across the rural South, the population has now dwindled.
When the Freedom Riders were registering Black voters in the 1960s, Smith put out a call for physicians who could provide medical care for the civil rights workers. Dr. Jack Geiger, a Harvard-trained physician from New York, traveled to Mississippi to help. He saw first-hand the dire living conditions some communities in the Delta faced: lack of clean drinking water, run-down housing and limited health care options.
“We work from sun to sun,” said Mitch Williams, who grew up on a farm there in Mound Bayou 1930s. “If you would cut yourself, they wouldn’t put no sutures in, no stitches in it. You wrapped it up and kept going.”
Geiger, Smith and others worked to secure federal funding in 1965 to establish the first-ever rural community health center in Mound Bayou. Geiger also established an urban health center in Boston, Mass.
“They were seeing patients in the local churches. They had mobile units. I had never seen that kind of comprehensive care,” said Williams, 85, one of the center’s first patients.
Delta Health staff went beyond just medical care – providing food, helping people insulate their homes and build outhouses. Williams eventually worked at the center and still goes there for primary care. He got his first COVID-19 dose there in late January. He said it’s “frightening” to imagine what the community would have done without it.
Today, there are nearly 1,400 federally-funded urban and rural community health centers, known as federally qualified health centers, across the country. They serve 30 million people in medically underserved urban and rural areas across the country, regardless of their ability to pay.
During the COVID-19 pandemic, rural Black southerners continue to face barriers to health. In April last year, Black residents accounted for nearly half of all deaths in Alabama and over 70% of deaths in Louisiana and Mississippi. Mississippi’s rural counties, which are over 40% Black, have had some of the highest rates of COVID-19 cases.
“We have a lot of chronic health conditions here, particularly concentrated in the Mississippi Delta that lead to higher rates of complications and death with COVID, and it’s been tough,” said Nadia Bethley, a clinical psychologist at Delta Health Center.
Logistical Issues Made Equity ‘A Big Lift’
Despite the higher rates of COVID-19, vaccination sites were missing from Black neighborhoods in the South at the start of the rollout, and rural areas were not prioritized. It is more likely for rural residents to have to go out of their way to travel to get the vaccine.
An NPR analysis of data from Louisiana’s health department shows that between January and April, vaccination sites in rural areas received fewer shipments than ones in urban areas. Urban parishes received enough supply to fully vaccinate 34% of their population, while rural parishes have gotten enough to fully vaccinate 20%.
“Obviously, the department has got work to do. We want to get to every single census tract that needs vaccine,” said Kim Hood, assistant secretary for Louisiana’s department of health. “The vaccine rollout and the infrastructure needed to stand it up in all of these places has been a big lift, I think, in general.”
Hood said the data might not paint a complete picture because of the complexities of vaccine allocation and the fact that updates are not available in real time.
The department declined to provide additional data to clarify where vaccine doses end up. The health department has had to issue guidance in the past to hospital systems to not prioritize their own patients for a vaccine.
Hood said equity has always been the goal across Louisiana, but logistical issues have made it challenging. At the beginning of the rollout, she said, the Louisiana Health Department relied on large hospital systems and pharmacies to get vaccines out to rural areas. Some rural providers didn’t have the staff or infrastructure, like refrigeration to handle the vaccine.
An NPR analysis of vaccination rates shows Louisiana has one of the largest gaps between rural and urban vaccination rates in the country, second only to Florida.
NPR analyzed CDC data on vaccine administration and found that as of April 18, 17% of people living in rural parishes have been fully vaccinated, while urban parishes have fully vaccinated 23% of residents.
Some health officials also point to vaccine hesitancy, saying providers receive a smaller supply due to shrinking demand, but, without clearer data, it’s impossible to know whether hesitancy or convenience is behind the low demand.
Vaccine supply increased for all Louisiana providers, including community health centers, at the beginning of March. The department has started offering targeted mass vaccination events and launched a campaign called Bring Back Louisiana to “meet people where they are.”
Alan Morgan, the president of the National Rural Health Association, said the low level of allocation to rural health clinics and community health centers early on was a “mistake.”
“It’s going to cost lives,” Morgan said. “With hospitalizations and mortality much higher in rural communities, these states need to focus on the hot spots, which in many cases are these small towns.”
A Preexisting Condition
Health officials often point to the challenges of distributing vaccines in areas with little health care infrastructure, but this divide in access is just one of many preexisting conditions in America that has been exacerbated by the pandemic.
“COVID has just shown a spotlight on underlying lack of access for good medical care for people in rural communities,” said Dr. William Curry, a rural health expert at the University of Alabama at Birmingham. He said in Alabama rural providers have been among the last to get the vaccine.
Officials at the Alabama Department of Health rejected several requests for data but said they are “focused on an equitable response.”
Smith, one of the founders of the community health center movement, sees the challenge of getting health care to rural communities of color as “an example of systemic racism that continues.”
In Mississippi, the vaccine rollout – and really, the entire pandemic response – has gotten political. Rep. Bennie Thompson, a Democrat, represents some of the most low-income and rural parts of the state. He said many areas he serves have asked for large-scale vaccination sites, and he’s made those requests as well.
“But that is a decision that has to go through the governor’s office. And the majority of people don’t have any confidence that the governor is interested in providing those kinds of services in the minority community,” Thompson said.
The office of Mississippi Gov. Tate Reeves declined an interview request but touted the state’s high vaccination rate for Black residents. The Gulf States Newsroom requested vaccine allocation data from the state’s health department to back this up, but the invoice for the request was more than $1,000. A spokesperson said the high cost was tied to the request for racial demographics.
A spokesperson from the state’s health department said they are “committed to providing vaccines to rural areas, but given the rurality of [Mississippi] it is a real challenge.”
“If the governor’s office, working through the health department, don’t have facilities set up in communities where those individuals live, there’s a great probability that we’ll miss them,” Thompson said. “Thank God for community health centers. You’d think they’d be a natural ally.”
‘The Infrastructure That’s Already In Place’
The Delta Health Center, founded in Mound Bayou, Miss., has 17 clinics across five counties in the state and provides a safety net of care for 16,000 patients annually across the Delta. At the beginning of the rollout, the center only had a few hundred doses per week, according to CEO John Fairman. As supply increased across the state and nationally, it got more doses and has managed to vaccinate around 5,000 people, most of them Black.
In late March, the Biden Administration announced an investment of more than $6 billion from the American Rescue Plan toward community health centers to expand vaccinations and operating resources. Seventy-three health centers across Mississippi, Louisiana and Alabama were collectively awarded over $260 million. As of April 7, more than 600 centers nationally signed up to receive direct shipments of vaccines from the federal government to add to their supply and have given out over a million doses.
About two-thirds of the shots administered by health centers receiving vaccines from the Biden Administration program have gone to racial and ethnic minority patients.
A new report from the Kaiser Family Foundation finds the people of color made up the majority of people vaccinated at community health centers, and the centers seem to be vaccinating people at similar or higher rates than their share of the total population. The report adds that “ramping up health centers’ involvement in vaccination efforts at the federal, state and local levels,” could be a meaningful step in ”advancing equity on a larger scale.”
Some worry that setbacks with the one-dose Johnson and Johnson vaccine could complicate ongoing efforts.
The Mississippi State Department of Health has been trying to tap into health centers’ network of trust and, in early April, asked for more partnerships with these centers.
Health departments in Alabama and Louisiana are using targeted methods to reach rural and underserved populations – like mobile clinics and church events. These are strategies that have been baked into the community health center model for decades.
“My strong recommendation would be to use the infrastructure that’s already in place, use the infrastructure that has community trust,” said Fairman, also acknowledging other rural providers, like clinics and urgent care centers. “I really think many states would be much further ahead had they utilized community health centers from the very beginning.”
Additional reporting by NPR’s Austin Fast. This story was produced by the Gulf States Newsroom, a collaboration between WBHM in Birmingham, Alabama, Mississippi Public Broadcasting, WWNO in New Orleans and NPR.