On a recent Sunday afternoon, Flor Amaya and Mass General Brigham health care workers drove a blue bus into the parking lot of Highland Park in Chelsea, Massachusetts. With this mobile clinic, the team aimed to vaccinate some of the Boston suburb’s younger community members and anyone who has had limited access to the COVID-19 vaccines.
“You will find many people from many countries playing soccer at Highland Park on Sunday,” Amaya says. Eastern Europeans, Africans, and Latin Americans—people from countries where soccer is “big”—are known to frequent this field, she says. “That’s part of the reason why we chose that as a location,” says Amaya, who emigrated with her family from El Salvador to Massachusetts when she was nine years old. Now Chelsea’s director of public health, Amaya’s lived in Chelsea ever since.
Parallel to the soccer field, the park’s concession stand advertises $3 horchata, popsicles, and the weekend’s vaccination clinic.
Chelsea is a suburb of Boston “filled with essential workers, hardworking immigrants mostly from Central America,” Boston 25 News reports. About 67% of its residents identify as Hispanic. In 2020, Chelsea had the highest COVID-19 infection rate of any town in the state of Massachusetts, with nearly 4,000 cases per 100,000 people.
“When you’d ask people how many are living in their home, it wasn’t uncommon for them to say, ‘Oh I have nine people living in my home; there are a couple families in one house’,” says Vivek Naranbhai, a clinical fellow at Dana Farber Cancer Institute who conducted pedestrian PCR testing in Chelsea in 2020.
The weekly infection rates have since lowered, with 64% of the Chelsea population fully vaccinated against the coronavirus as of July 15. But the overall toll of COVID-19 on Chelsea—8,905 total cases among a population of just under 40,000 and 228 reported deaths—reflects the disproportionate way the virus has spread among underserved communities, particularly among Hispanics and Latinos.
Amaya now organizes vaccine clinics, using her perspective as a city resident to better approach her community. Having lived in Chelsea for the last 29 years, Amaya has seen “the different chronic health conditions and lifestyle conditions that frequently plague minorities—ethnic communities—whether it is Latinx [or] African Americans,” she says. “I think a lot of us face similar challenges.”
Medical mistrust among African Americans has been documented for more than 30 years, with the legacy of the infamous Tuskegee study serving as the basis for different research surrounding current attitudes toward health care in Black communities. But some cite ongoing discrimination and racism from health care providers and the disproportionately high Black maternal mortality rate—as stronger drivers for medical mistrust today. Though research surrounding medical mistrust in the Latinx community is not as extensive, healthcare providers, religious leaders, and public health officials in majority Hispanic communities have observed hesitancy among those they serve firsthand.
“It seems to be a very gut feeling that people who are resistant to getting the vaccine are experiencing,” Amaya says, “whether it is holding on to ideas of conspiracy theories, whether it is not trusting the government, or not trusting pharmaceutical companies.”
Hosffman Ospino, a minister, professor, and chair of the Department of Religious Education at Boston College, has seen the effects of COVID-19 on his parish in Lawrence, Massachusetts, a city 26 miles north of Boston in which more than 80% of residents identify as Hispanic or Latino. “It’s worrisome,” he says. “We know of a number of parishioners [who] have had the virus, and we know people in [Lawrence] who have died as well.” Because of the long history of mistreatment of people of color under medical care, whether the people Ospino serves hear true stories or myths about it, he says, “there’s a cultural distrust of medicine.”
“We’ve been seeing vaccine hesitancy in general with Black and brown communities, says primary care doctor and Medical Director of MGH Chelsea HealthCare Center Dr. Dean Xerras. “We have always had issues around that in communities like Chelsea. I do see this as a long-term issue with education, engagement, and building trust.
Building trust with our patients in our communities: that’s going to get us through this,” he says.
This need for trust is driving Amaya, Ospino, and Dr. Xerras, and their organizations to both educate and create sensitive public health interventions for the communities most vulnerable to COVID-19.
Barriers to vaccination
Ospino, a Catholic theologian who works as a minister, is helping parishioners understand the nuances of how their religious beliefs intersect with health interests so they can make educated decisions. In December 2020, the Catholic church put out a statement condemning the use of the Johnson & Johnson COVID-19 vaccine due to its use of PER.C6 stem cells, a cell line derived from the retinal tissue of an 18-week-old fetus aborted in the Netherlands in 1985. (Dutch laboratory Crucell—which became Janssen Vaccines after being bought by Johnson & Johnson in 2011—developed the cell line, which has been used in flu, tuberculosis, and malaria vaccines.)
There is some nuance to the Church’s statement: Because Catholics have a moral obligation to pursue the common good (which is, during a pandemic, to get vaccinated), they can take the Johnson & Johnson vaccine when no others are available. Still, there could be fear of “cooperating in an abortion” among Catholics nationwide, 38% to 40% of which self-identify as Hispanic. “Many people are confused,” says Ospino, adding that the vaccine “does not imply direct collaboration with abortions.” He says that a lack of Spanish-language resources about the stem cells contributes to a misunderstanding of the Johnson & Johnson vaccine.
And then in mid-April, the use of Johnson & Johnson’s vaccine was paused due to rare but severe blood clots in six patients. Amaya and her colleagues had been planning a Johnson & Johnson vaccine clinic at a church in Chelsea just before the distribution pause. Many people from local congregations had signed up for the clinic, Amaya says, and while she and the faith leaders were planning it, the use of PER.C6 stem cells in developing the vaccine did not come into question.
Amaya has noticed some hesitation in her Chelsea community toward the Johnson & Johnson vaccine. But most people, she says, cite a fear of developing blood clots, not religious conviction. “It’s really hard to override those beliefs,” Amaya says. “We’re trying to figure out what it’s going to take right now to motivate people. We’re trying different modes of vaccine delivery. And for some people, it might just require time.”
In Chelsea, where religious leaders and healthcare providers alike are working to improve their community’s health, access to vaccination may be a greater issue than hesitancy and trust. Ospino says of the Catholic church’s recommendations, “most people actually will simply either ignore or somehow look at those issues and not understand them and then move on.”
Among undocumented members in his community, Ospino sees fear of the legal system as a vaccination barrier. “In order to register, you have to give your name. Sometimes they ask for your address,” he says. Ospino recalls his own vaccination appointment at Boston’s Hynes Convention Center—a massive event center turned into a large-scale vaccination clinic. “When I went…what’s the first thing I see at the door? The military; the police and the military. So people are saying, ‘No way, I’m not going there!’” he says. “We need safe spaces for the immigrant community, spaces that are not threatening.”
Meeting patients “where they’re at”
To create these safe spaces, Dr. Xerras believes it’s important to “meet patients where they’re at,” whether that be at churches, apartment buildings, or parks. And the ways the intersection of equity and health care is studied may also need to change, suggests Dr. John Iafrate, a pathologist at Massachusetts General Hospital. Researchers and health care providers, he and Dana Farber Cancer Institute clinical fellow Naranbhai explains, may shy away from creating tailored public health interventions in fear of being patronizing. “Many people don’t do these kinds of studies because they’re afraid to hurt the community or cause more mistrust,” says Dr. Iafrate, who with Naranbhai in 2020 set up a COVID-19 antibody testing site on the street in Chelsea in order to track the level of infection in the city.
Even as outsiders, Dr. Iafrate and Naranbhai were able to “meet a balance” to best serve the population and “tried hard to do it right,” Dr. Iafrate says. Their study included providers that spoke Spanish and represented members of the community, but most importantly, made participants feel safe, they say: The study did not collect information that could make participants feel like they would be tracked later, a key aspect of making a population where some people may have undocumented family members—or be undocumented themselves—feel comfortable.
At the vaccination clinics she operates, Amaya pushes to have “people that represent the fabric of the community here in Chelsea,” she says. Her FEMA-supported vaccination clinic, based out of the Chelsea Senior Center, works with the nonprofit volunteer organization Chelsea Black Community to manage lines, registration, and other outdoor operations at the clinic. “We are multilingual, so we have Spanish speakers there to help with the consenting process,” she says. “We understand that a lot of people cannot read or write in their own native language, so we have the staff to verbally ask some of the screening questions and provide that support that people need.”
Amaya and her team’s community savvy helps the Department of Public Health and Mass General Brigham employ approaches that state government and faith-based organizations might overlook, including Chelsea’s Highland Park vaccination van.
As community members start queuing up for their vaccine, Mass General Brigham site contact Damien Leach offers free personal protective equipment care kits and information about vaccination to them. People are very responsive to the care kits, Leach says, because the materials inside make navigating the pandemic—and adhering to state and CDC guidelines—easier. “I’ve had people try to give me $10 bills for these care kits,” he says. “We try to think about what the community needs and give it to them.”
Inside the vaccination van, one health care provider draws up doses of the Pfizer vaccine, and Mass General Kraft Center medical director Dr. Priya Sarin Gupta vaccinates patients. She receives a vaccine syringe from the staff member inside the van, and in the blink of an eye, her patient—the first person in line at Highland Park that day—gets his first dose. Behind him, people play basketball, while just a few yards away, a crowd of spectators cheers loudly for their soccer team’s goal.
“Could you make sure he knows he has to come back for a second shot?” Dr. Sarin Gupta asks her colleague, Eddie Taborda. Taborda steps out of the van and lets the patient know, in Spanish, to return for a second dose.
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