Part Three: "Let’s look at the extent to which racism is embedded in policies and then hold people accountable."
A look at some of the changes needed and, in some cases, already being discussed in a variety of health, economic, and social systems to reduce the health and wellbeing disparities built into our policies and practices over many generations.
Gabriella Chiarenza is managing editor for Invested and Regional & Community Outreach and Steve Osemwenkhae is senior photography and video specialist for Invested and Corporate Communications, both at the Federal Reserve Bank of Boston.
It is hard to pinpoint exactly why this moment feels like it could be the turning point around how we approach racism in America, and how we might finally, permanently untangle the centuries-long threads of racially motivated violence and neglect. It could be because there is stark data showing how much more vulnerable Black people are to being exposed to and facing worse outcomes from COVID-19. It could be that there is growing awareness that those outcomes stem from preexisting health and economic conditions that in turn stem from racist systems. It could be that the brutalizing of Black people by police and others is increasingly being captured in cell phone videos and is harder to ignore. Or it could be that the people in the street and on social media calling for recognition of the value of Black lives are more diverse than in the past. But we have had these moments before—Michael Curry calls them “moments where we take the sheet off America”—and change has been elusive and impermanent. To many, these moments have felt like one step forward, two steps back.
What needs to happen differently this time in order to truly make some progress from here? The people I spoke with for this story underscore the importance of an informed and intentional approach to dismantling systems of power that, in so many cases, run in part on racism. “Moving the ball forward would look like putting Black people in places of power,” Rochelle Levy-Christopher told me. “Period. Full stop.”
Making that change is contingent on Americans acknowledging the origin story and development over time of the imbalanced power structure that feeds many other parts of civic and economic life in America. “I think the first place to start is understanding the history of racism,” Curry said. “People have to know all of these issues in every aspect of our lives, so then they can make the right decisions about policy and make them disruptive.”
Rev. Dr. Gloria White-Hammond believes this awareness requires both introspection into our own biases and behavior, as well as a hard look at the policies that have been in place for so long that those not negatively impacted can too easily ignore the impacts on others. “We’ve seen lots of solidarity statements, and ‘we’re so sorry’ and ‘we’re with you’ and all of that,” White-Hammond said. “But let’s see what it looks like in terms of where we work. Let’s look at the extent to which racism is embedded in policies and then hold people accountable. What is the deeper commitment? You’ve got a leaky faucet and you keep putting the bucket out to collect the water, or you keep mopping up the floor, but the faucet keeps leaking. Now there’s much more of an effort to figure out what’s wrong with the faucet and begin to address it.1 That, for me, is really encouraging.”
In this vein, the pandemic revealed several ways in which our underlying systems of health care and medical communication could be improved. Dr. Cassandra Pierre said that it will be vital for hospitals to leverage trusted community information streams to combat rumors and misinformation in underserved communities of color. “I don’t think that can be overstated. Because people are not looking at the CDC website. They’re not looking at our hospital website for information on how to protect themselves or how to navigate this pandemic and future pandemics. So, we need to ensure that we are partnering with the right people who trust us and whom we trust to carry the message into communities that we do not have admittance to at this point.”
Curry sees a similar awareness of the power of trusted local care centers growing among state and municipal government leaders. Once it became clear that testing needed to be ramped up and that community health clinics were the right facilities to make that happen in many places, Curry said, “everyone turned to health centers and said, what do you need and when do you need it? And now we’ve become that tip of the spear doing testing. I’m hoping that we do sort of a post-op and look back at what happened and make sure that we know what the roles and responsibilities are—hospitals, health centers, behavioral health providers, town managers and mayors, public health departments, and others—because I’m not sure that those lines were clearly defined before, so health centers were caught up in that storm.”
There are also calls to build on newer tools that have been helpful during the pandemic to continue and expand their use in more routine care going forward. Pierre pointed to a successful model that BMC’s pediatric group developed, sending medical vans into underserved neighborhoods to administer vaccines to children during the pandemic. She believes that physically bringing care into neighborhoods and establishing trust and consistency on their own turf could be a way to better serve these historically marginalized communities. “I’ve been thinking that maybe we could do that for flu vaccines,” Pierre said. “Could we think about that as a model—maybe not the vans themselves, but establishing alternative care sites throughout the community that are not necessarily affiliated with being a health care site, such that the threshold for engagement with medical care would be lower, that people would be more assured?”
Several people I spoke with for this story highlighted the success of telehealth models during the pandemic as a way to more easily access care and to improve the consistency of engagement with patients. “Telehealth is one of the things that I think is primed, if used well, to increase access in health care to communities of color,” Pierre said. “We’ve seen that our rates have actually improved with telehealth. Part of it may be because people are home, but it’s also because we’ve been scheduling appointments at times that are more convenient for patients and they don’t have to worry about catching two buses or getting a ride to get here. I think if it’s used wisely, telehealth can not only be used for medical appointments, but also by case managers and social workers to level the barriers to the social determinants of health in terms of getting into clinics and getting care.”
Telehealth has also been a major leap forward for mental health care in communities of color in 2020. Curry told me that CHCs are seeing record rates of uptake for behavioral services telehealth appointments, and Pierre said that telehealth options offered by BMC are helping to destigmatize mental health care for people in the Black community who are nervous about being seen in public getting this kind of care. Jackman is pushing for greater access to telehealth and better coverage from insurance companies to facilitate wider use, drawing on recent conversations with others in her field about technology and access to mental health as a social justice issue. “Insurance companies did not have a unified way in which they allowed telehealth services to be provided for their clients,” she said. “Some insurance companies provided it even within insurance plans, so some people got it, some people didn’t. My hope is that there is a recognition that everybody can benefit from telehealth services.”
Of course, these advancements in health care access require complementary changes to other systems related to the social determinants of health, such as employment and insurance. Khori Anderson, a Jamaican actor and activist who immigrated to Boston and a colleague of Levy-Christopher in the BLAC Project, has worked a range of gig jobs in the restaurant and hospitality sector to get by, but these jobs left him without consistent health insurance. He worries that other people of color and immigrants in such jobs are unable to access ongoing preventive care with spotty or no insurance coverage. “My overall experience has been that it’s really hard for Black people particularly to access the level of health care that is required for them to live a sustainable and good quality of life,” he said. “I find it really disheartening that our health care system is an employer-based health care system, which means that if you’re unemployed, you’re without health care.”
With so many people unemployed due to the pandemic, the U.S. is seeing a crisis of health insurance coverage just as Americans need that coverage most to ensure they can be tested or treated for COVID-19. As of July 2020, Black Americans had the highest rate of unemployment (14.6 percent) as compared with white, Asian, and Latinx Americans.2 At the same time, essential workers—many of whom, as previously noted, are Black people and other people of color—may or may not have health insurance coverage through their essential jobs,3 leaving them particularly vulnerable given their heightened exposure to COVID-19 in the course of their work. Even those who have insurance coverage may not have paid sick days or might risk losing their jobs if they have to call out sick. All of these employment-related factors have real impacts on Black health and wellbeing in America, so improvements in consistent coverage and benefits will be crucial to effectively protecting and respecting Black lives.
Then there is the question of how to build trust within Black communities in a health care system associated in too many cases with maltreatment and neglect of Black patients. That trust, I was told, can only come from improved and demonstrated cultural competency among all health care professionals and, vitally, from having more Black health care providers in practice and accessible to Black communities. Yet racism has been a major obstacle to getting more Black students on the path toward medical school. “Too many doctors and clinical providers across this country are white. It’s inherently racist to think that is normal,” Curry said. “We leave talent on the table to think that there aren’t more Black and brown people that are meant to do amazing things that we will never know, because they don’t have a rigorous education, or they have a family structure that’s been diminished by racist systems, or that their families couldn’t get a dynamic job that allowed them to get into the best institutions.” Ahjah Gage agrees. She told me that she feels one powerful way white professionals in medicine can use their privilege to push back against systemic racism in health care is to create space and opportunities in the educational system and the medical professions for more Black students and graduates.
Gage and Jackman both noted that students in mental health professional tracks are only required to take a single course in cultural competence in most U.S. states (including Massachusetts), which neither woman feels is sufficient to competently and responsibly treat clients of color. “Historically, the field is very white,” Jackman said, “and our training models are very white.” She is hoping to change this by advocating for Massachusetts laws to require regular continuing education throughout mental health professionals’ careers in cultural diversity and competency. As difficult as it can be for Black clients to find a Black mental health care provider, it is that much more important for other providers to be prepared to hear and address cultural concerns or to refer the client to a different provider who is capable of doing so, as Gage points out is their professional obligation. Jackman said Black people have told her, “I don’t want to have to go in and explain myself. I want to work on the issue I have and have the person understand my racial background.”
Even as they appreciate the opportunity of this moment of potential change for the better in health care systems, Black health care providers and students like Gage, Jackman, and Pierre also feel the pressure on them to take advantage of this window of public attention. They are telling more of their own personal stories, reaching out to others in the Black community to help destigmatize the work they do, and finding ways to bring aspects of their own cultures into their care work. “My goal is making our therapists of color visible,” Jackman said. “So, a lot of the community events that I put on are about showcasing therapists talking about their own struggles. There are more therapists of color who are coming in and feeling more empowered to really tap into some of our cultural ways of healing, and putting those out there for people to have access to. I’ve been really energized to see that. We can’t leave our culture at the door when we come to therapy. It has to come in with us.”
Pierre has been working hard to leverage the growing public awareness of health disparities and push for change. Even so, she told me, she is exhausted. With intersecting roles at BMC and at Boston University that involve covering infectious disease prevention planning, caring for her own patients and new patients in the midst of a pandemic, and working on diversity and inclusion strategies for hospital hiring practices, she has felt some guilt and frustration that she cannot do everything. “There’s this dual burden of doing infection prevention and having to do this antiracist work,” she confessed. “I would say that this is certainly true of many of my colleagues of color—that it is very wearying. That there’s this rage, a feeling of déjà vu, and a desire to escape it all. But also, for many of us, there’s a desire to be more resolute at this time, to say, okay, this is the window of opportunity. I now have people’s interest; I have my colleagues behind me. Let’s start making some radical, fundamental changes to strike at the root of systemic racism so that we don’t have to keep having these conversations in the next few years. We don’t want to continue to have these cycles.”
The Black professionals and community members I spoke with for this story are just a few of many who have been doing the work in Boston and beyond in many different ways for generations. In many ways, they told me, their work has become more challenging in 2020, but also more urgent, more powerful, and more meaningful to them in the context of growing momentum around the Black Lives Matter movement and COVID-19. With so many simultaneous threats disproportionately affecting the minds and bodies of Black Americans, there is a renewed sense of solidarity growing across the many dimensions of the Black community. There is an energy drawn from continuing to fight to thrive despite the centuries of trauma that Black people have endured in this country. And there is an unshakable commitment to healing fractured souls and crafting a future free from fear and ripe with opportunities to lead.
“There’s this song we often sing in church called ‘We Need You to Survive,’” White-Hammond told me. “We need you to do the safe distancing. I’m safe distancing because I honor and respect you and because I care about you.” She smiled warmly. “We need you to survive! Not just because we like you, but we need you to survive so you can be on the streets chanting, ‘no justice, no peace!’ We need you to go vote. There are lots of reasons, especially in the wake of all that’s going on and that we’re going through, that we need people to survive. So, to the extent that practicing these COVID mitigation strategies help us survive, yeah, let’s do that—because we’ve got work to do.”
- See: Ibram X. Kendi, How to be an Antiracist,New York: One World, 2019.
- U.S. Bureau of Labor Statistics, Employment Situation Summary, August 7, 2020, https://www.bls.gov/news.release/empsit.nr0.htm.
- Sara Chaganti, Amy Higgins, and Marybeth J. Mattingly, “Health Insurance and Essential Service Workers in New England: Who Lacks Access to Care for COVID-19?” Federal Reserve Bank of Boston, Community Development Issue Briefs, June 11, 2020, https://www.bostonfed.org/publications/community-development-issue-briefs/2020/health-insurance-and-essential-service-workers-in-new-england-who-lacks-access-to-care-for-covid-19.aspx.
The views expressed are not necessarily those of the Federal Reserve Bank of Boston or the Federal Reserve System. Information about organizations, programs, and events is strictly informational and not an endorsement.