Plans to Help Underserved Communities Will Fail Without New Forms of Community Engagement | Opinion

The American health care system, battered by two-plus years of COVID-19, staff burnout and declining public trust, could be forgiven for a period of retrenchment and nostalgia for "the way things used to be." If that happens, however, we will miss the best opportunity in a generation to apply the innovations of the moment to build a better and more just system of care and delivery.

Our pandemic experience reinforced two key points that merit constant repetition. The first is that better engaging with our communities means working with them and actually listening to them. The second is that too much of how our health care payment system is structured gets in the way of how care should actually be delivered.

I come to these discussions with a different perspective from many. I grew up the daughter of a Haitian immigrant living in the shadows of an academic medical center in Philadelphia, where health disparities were a fact of life. Then 40 years later, as a Harvard-trained anesthesiologist working in the shadows of another great academic medical center, I saw that the same health disparities existed here in Boston, and I knew they could not be solved within our hospitals or the current health care system. So, I stepped outside the hospital to look for solutions. Working with the communities of Boston we created a mobile clinic, The Family Van, that has now been in operation for 30 years. This mobile clinic was designed to bring health care services to the community, rather than serving people only if they came to our hospitals or practices.

When my community colleagues and I began, we wanted to tackle the problem of excess infant mortality. We created The Family Van, expecting to mostly serve female patients in the Boston community. We spent two years working with the community to create the program. We intended to offer not just health care resources but also referrals to other agencies and services—including housing, food assistance, and other safety net resources for moms and families

And yet when we proudly launched the program a funny thing happened. Almost all of our patients were men, perhaps desperate for resources provided on their terms and with availability that fit their life.

For two years we had worked with the community to design this program. We all thought we knew what the community needed. It took being in the community to see what they actually wanted. Being mobile and nimble, we adapted quickly, and the program evolved to more broadly serve people of all genders.

This listening, understanding and adapting are foundational to any conception of equity. The stats are well known. Black Americans live fewer years, on average, than white people, are more likely to die from treatable conditions, and are more likely to die during or after pregnancy. Further, Black Americans are also at higher risk for many chronic health conditions, from diabetes to hypertension.

COVID-19 was no different in its effects. People of color experienced higher rates of COVID-19 infection and death compared to white people in the United States. Vaccines remain the best way to prevent the worse outcomes of COVID-19 infections, but making vaccines accessible requires understanding the realities of communities and adapting the delivery system to fit. And making vaccines acceptable to all requires communication that is trusted.

Bridging this gap requires working with and listening to the community. This is why community-based health centers and programs like mobile health clinics are so important to crossing the caretaker-patient divide.

Unfortunately, that returns to the second problem, which is that much of the way care delivery is funded in this country doesn't match these sorts of models.

No one is doing open-heart surgery in the back of a van. What we provide is frontline care and advice that can help people change their lives or catch problems before they get to the stage of needing an ambulance.

This prevention-based model is not how most funding works. Government and private insurers reimburse for procedures and tests, leaving mobile clinics dependent on grants or other non-fee-based mechanisms.

Policymakers need to understand that smaller investments up front will actually save costs on the back end, leading people to healthier lives and ensuring all members of our community have better health outcomes.

Mistrust and fear of our health care system grew greatly during the pandemic. It also increased physical barriers to access in the form of lockdowns and social distancing. Fear of contagion as well as the actual treatments likely affected the willingness of marginalized patient communities to seek out the care they needed.

If U.S. health care providers are to succeed in promoting and encouraging equity and access in health care, many in the provider community will have to get comfortable becoming part of the underserved communities they want to help. Mobile health clinics and other in-community solutions are uniquely situated to improve equity in terms of appropriate care, quality, preventive measures, outcomes and more because of the way they integrate into their communities, building trust and commitment along the way.

Dr. Nancy E. Oriol is faculty associate dean for community engagement in medical education at Harvard Medical School. In this role, her objective is to make the theories of the social determinants of health, structural racism and health equity, actionable. By working with the program in medical education, community programs and student groups she supports both curricular and extracurricular service-learning activities.

Thirty years ago in partnership with Boston communities, she created The Family Van, a mobile health clinic designed to address health disparities. She also co-founded HMS MEDscience, an innovative high school biology curriculum based on mannequin simulation and designed to address the education achievement gap in local high schools. She graduated from Harvard Medical School in 1979 and completed her residency training at Beth Israel Deaconess Medical Center, in the Department of Anesthesia, Critical Care and Pain Management.

The views expressed in this article are the writer's own.