HEALTH EQUITY IN ACTION: POPUP VACCINE CLINICS

Dr. Alister Martin

MGH Center for Social Justice and Health Equity; Founder, Get Waivered, VotER and GOTVax

Editor's Note: Since this interview, Dr. Martin has traveled to Washington to serve in the Biden Administration as a White House Fellow in the Office of Vice President Kamala Harris. 

YOU HAVE CREATED THREE GROUNDBREAKING PROGRAMS, ONE CALLED GET WAIVERED, WHICH REVOLUTIONIZED THE ABILITY OF ER DOCTORS TO BE ABLE TO TREAT OPOID ADDICTS FROM THEIR FIRST VISIT TO THE E. ANOTHER, CALLED VOT-ER, WHICH ALLOWS COLLEAGUES AND PATIENTS IN THE ER TO REGISTER TO VOT.  AND MOST RECENTLY GOTVax, WHICH BRINGS VACCINE CLINICS INTO THE NEIGHBORHOODS MOST AFFECTED BY COVID. STEPPING BACK, ARE THERE LESSONS THAT YOU’VE LEARNED THROUGH THOSE PROGRAMS THAT YOU THINK COULD BE APPLIED OVER THE LONG TERM TO REALLY IMPROVE OUTCOMES FOR LOW-INCOME PEOPLE OF COLOR?

No one’s ever asked me that question. Ultimately, I am identifying problems and moving quickly from one to the next, trying to create sustainable solutions to those problems and so I’m always moving so fast, there isn’t time to step back and think about it.

The unifying thread between all of them is a deep compassion for the people we’re trying to serve—and if you really respect the people you are trying to serve, you will go out of your way to build systems and structures and programs that deeply honor the challenges that these folks face. For example, when it comes to the work that we do with opioid addiction in the ER. At the most pure and simple and uncomplicated way, it’s about meeting people where they’re at. I know how hard it can know how hard it can be to navigate the health care system. I do not even have a regular Primary Care Physician. And I’m not alone. So, if that’s the state of being in this country, how do we expect a person with the most difficult addiction possible, an addiction that literally changes the way that your bring fires... How do we expect them to navigate a system that I cannot navigate to get their addiction under control? In a sense, it makes no sense.

So, for instance, with Get Waivered. We know these folks use the ER more often than others. We know that they feel stigmatized from traditional forms of primary care. We know they don’t want to tell their primary care doctor that they’re snorting heroin in between lunch breaks. They come to the ER for a sense of anonymity or for that abscess on their arm or the fact that they didn’t have a place to sleep that night. So, while they’re there, let’s make the barrier area of entry to get into treatment so low that they have to have some intentional reason to not get involved.

Similar, with something like GOTVax. When you are working three jobs and you’re trying to take care of your young family—and you’re also worried about how your immigration status compromises you if you go and get a vaccine. Will this be a way that ICE identifies me? If you have all of these things swirling around in your mind, and you see an invitation to go down to a center that is set up for vaccines, before 5pm, when it closes, how does that solve your problems? So, if we truly respect and honor the folks that we’re trying to serve, you have to create systems, structures, and programs that adapt and meet them where they’re at, right?

Long story short, that is the vision of the work. And I think the framework that animates it is a deep understanding of behavioral science, behavioral economics, right? How can you truly get someone to take an action? You need to design the program or that intervention in a behaviorally sound way. You need to make it easy for them to do. You need to make the action observable if you’re trying to build a new social bond. You need to leverage trusted messengers who have authority. You need to help people with plan-making ahead of time, so they can create the plan and then act it out. So, there are these threads that tie all of the programs together. It really comes down to how you honor, respect the people your serve.

HOW CAN WE MAKE INROADS INTO PROVIDING CARE TO THOSE LEFT OUT OF THE MEDICAL SYSTEM IF EVEN SOMEONE LIKE YOU DOESN’T HAVE A PRIMARY CARE PHYSICIAN? WHAT ARE SOME EFFORTS THAT HAVE WORKED? DO COMMUNITY HEALTH CENTERS HAVE AN IMPORTANT ROLE IN CREATNG SYSTEMIC SOLUTIONS?

Yes, the Massachusetts League of Community Health Centers is very important, and CHCs absolutely are part of the solution—and they’re stretched thin. So, we can’t look to CHCs to do uncompensated labor. And so, yes, they are a lynchpin, and so we need to dramatically increase the infrastructure that allows CHCs to exist in the first place. One of the best things we did in regard to voter registration was actually using CHCs to text their patients about the upcoming election in 2020 and offered those folks via text an opportunity to register via text. That was the best thing we did because CHCs are so trusted by the community.

WHEN YOU SEE PEOPLE WHO HAVE BEEN HESITANT ABOUT GETTING THE VACCINE, WHAT ARE THE MAJOR REASONS THEY GIVE YOU?

It varies based on which communities out there we’re helping to get vaccinated. For example, in the Latinx communities we take care of in East Boston or Chelsea, there is a lot of concern around immigration status will be used against them. So, we always have to start the conversation in these neighborhoods by saying, “We don’t care if you’re undocumented or not.” Also, making sure folks understand that there is no catch. This is not going to cost you anything. Because many folks we take care of in Latinx communities feel that the health care system is so expensive and so they’ve had to go without, many of them. So they think this is just another thing they’ll get charged for somehow. So, we have to be sure to say that it’s also free. In African American communities like Mattapan and Dorchester, there is a general mistrust of the health care system and all institutions of power that is another kind of hesitancy. And in those communities, we have to talk about the fact that these vaccines are safe; they’ve got good data on that… But we have found that it’s often better to have neighbors telling their neighbors about their vaccine status—having them persuade each other to get the vaccine—rather than doctors. Sometimes it’s better to have Grandma Jane down the street encouraging people to get vaccinated.

HOW LONG DO YOU THINK THIS VACCINATION EFFORT WILL CONTINUE? WILL IT GO ON FOR YEARS? IS IT SOMETHING THAT WILL HAVE TO BE SUSTAINED SYSTEMICALLY IN SOME WAY?

Great question. We have funding for our program that goes to the end of (September 2021), so that’s the end for us as planned currently. We’ve gotten a lot of funding from the Boston Foundation, which has been great, and also helped to coordinate other funders, like the New Commonwealth Fund, Eastern Bank the Trefler Foundation, and the Life Science Cares Foundation… So, that’s been where the funding has come in. And then there have been some private funders as well. But we’ve been at this since late March, so the team is kind of tired.

It’s been interesting because the campaign has changed so many times. It’s a completely different campaign right now than it was when we were doing this back in April. And it will change going forward, particularly if we have boosters.

HOW COULD WE MAKE THIS A SYSTEMIC RESPONSE OF SOME SORT?

The first answer is, it depends. There has been an expectation that we can take what we’re doing national, right? The quick answer is that, sure, I’d love to do that. Will it be effective? Probably not. Why? Because at the core of what we’re doing here in Boston is community organizing. I have access to networks of people who trust me—and who I trust—who I can call on and say, “I need you.” And that network spans health care providers, funders, CHC directors… It’s a community coming together. All of us seeing the same picture of what’s going to happen. I don’t know anybody in San Francisco. Sure, we can stand something up and call it GOTVax San Francisco, but will it be effective? Not really. You need the organizers in that space to come together and to call each other and come up with a program that is unique for the challenges they have in San Francisco, or Las Vegas…

So, it depends on where this kind of work sits in the future. You can decide that it should sit in community-based organizations, like La Colaborativa in Chelsea that have been sitting in these communities.

HOW LONG DO YOU THINK WE’LL NEED THE VACCINES?

A year? Years? You could build a case that they should sit for a very long time in our public health structure. The Boston Department of Public Health should have some ability to stand something up fairly quickly. But I don’t think we can create a blanket answer to that question because every locality is different—as well as the sources of power and who is in community with whom is different within all of these places. If I were to start over, I would say that the public health infrastructure of cities would be made up of community organizers who are from these communities that are most impacted. That is not what we have right now. We have a gutted public health system that really struggles to do even the basic things. Funding for public health needs to be increased dramatically and we need to make sure that we’re organizing with people who are from the affected communities from day one. Not roll out a policy and then, six months later, say we should have done this through a health equity lens.

TWO OF THE PROGRAMS YOU LAUNCHED HAVE GONE NATIONAL: The ER opioid program and VotER.

Yes, and in those areas there are sustainable infrastructures that we can tap into. In that sense, it’s a little bit more like a playbook. “Here’s what we recommend. Here’s how we would do it.” I can work with the folks at those hospitals or clinics to create something that fits well enough. If I were to try to do that with GOTVax in San Francisco, I wouldn’t know where to start. The closest approximation to a nationalization of this type of work is a presidential campaign, believe it or not. Where every locality has a campaign director—an Arizona State Director or a Pennsylvania State Director—who knows that area really, really well. We would send money their way and get them press coverage, but in large part, they would run their own show, because they know their place better than I do. That would be the way to do it.

CAN ADVOCACY AND PHILANTHROPY AND BUSINESSES PLAY A ROLE IN IMPROVING THE PUBLIC HEALTH INFRASTRUCTURE?

Yes. That’s a great question. I think everyone has a role to play there is absolute utility and value in advocating for specific policies, greater funding, public policy interventions that make it easier to do this work of health equity. For philanthropy, I would say, “You need to have a plan for each of the following three spheres. One is advocacy where there are clear policy victories and interventions mobilizing the network to convert these interventions into wins, from a political perspective. The second area is actually community organizing. The philanthropic community doesn’t necessarily have to be doing the community organizing; but they need to be supporting individuals, groups and organizations that are out there building people. Building people. We don’t build people. The easy win nowadays is to put up a webinar and say that we’ve done the good work and we’re done. Building people takes investment and time and takes patience. If we truly want what’s best for East Boston and Chelsea, I promise you what we need to do is build the people—the leaders—of East Boston and Chelsea.

What it looks like is having a community-based program in community-based organizations that are led by folks from those communities. So that, when something bad happens, you have a network that you can tap into. The owner of the bodega who can pull together a neighborhood meeting just like that.

The last is mobilizing. While the work of community organizing takes time, mobilizing is a muscle that the more you use it, the better it gets. When something happens, quickly pulling together a response and an action that can meet the needs of the moment. You’re not making transformational asks of people, but one ask of someone that you need someone to do right now. I’ll give you an example. When the Crisis Level of Care came out back in 2020, when COVID was really bad, we had a person come to our department, set up in a room and say, “Here’s the deal: We’re going to run out of ventilators. We’re now going to move to a new crisis standard of care, which is a lower standard of care, because we can’t give a ventilator to everybody. So, now we’re going to start scoring people and if they have a lot of points, you don’t get a ventilator. How do you get points? You get points by having diseases. That’s a humongous problem. Why? Because Black and brown people are more likely to have the same diseases that are on this list of points—heart disease, kidney disease, liver disease, diabetes… Long story short, that was a huge problem. So that policy needed to be changed ASAP. And so what I and a few other organizers and physicians did here in the Boston area was we started circulating a petition. All I needed was for physicians to sign on and say, “This is not okay. We can’t do this.” And we got 3,000 physicians to sign this thing. That’s a mobilizing effort. That carries weight that I can then bring to City Council, like we did, and the Department of Public Health, like we did… And that policy was changed. So, long story short, I think that the philanthropic community can help in those three ways: certainly funding advocacy; second building people in community and, when possible, being a part of the solution when it comes to mobilizing folks to take action on a specific issue.

The business community can stop talking and do more work. There’s a lot of Black Lives Matter emails that go around from the CEOs of corporations, who say that it’s important to stand for Black Lives Matter or it’s important to be for voter rights. But what are you doing? I don’t want to see another email; I want to see who’s on your board. Who’s in the C Suite? What do the people look like?

We need less optical allyship and more concrete interventions.

ONE FINAL QUESTION: HOW DO YOU STAY OPTIMISTIC? THE PROBLEMS WE’VE BEEN DISCUSSING ARE SO MASSIVE. IS IT A DAY-TO-DAY KIND OF THING FOR YOU?

I don’t think there is any role for pessimism. It’s either I want to do this work or I don’t want to do it. And if I want to be part of the solution, I need to be optimistic that the efforts and the work that I’m doing, that others are doing, the work that I’m mobilizing people to care about will mean something in the end. And I think history has shown us is that’s all you need: a couple of people who are crazy enough to believe that we can create a better world. That’s all you need. I’m a realist, in the sense that the programs and interventions have to be done tactfully and thoughtfully—and you can’t just assume everything’s going to work out. But if you do it right and are strategic, I think we can fix so many of these problems—and I think we will.