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As coronavirus disease 2019 (COVID-19) surged last spring, pediatric surgeon Ala Stanford, MD, heard from Black residents in her hometown of Philadelphia, Pennsylvania, who had symptoms but were hitting roadblocks in getting tested.
Some lacked a physician’s referral. Others were turned away because they didn’t arrive in a car or didn’t meet criteria for testing. Testing sites were clustered in affluent White areas. Black residents, who were dying in disproportionate numbers, couldn’t find testing in their own neighborhoods.
In April, Stanford launched the Black Doctors COVID-19 Consortium to provide free tests at walk-up locations such as church parking lots during convenient hours for working people. By early December, the group had tested more than 17 000 people. Stanford, who also serves on the city’s advisory board for vaccination planning, was the physician of record for each person tested.
In a recent interview, she said the mobile unit continues to attract long lines. The day before she spoke with JAMA, 300 people arrived during a rainstorm—evidence, she said, of “something missing” in our health care system. “There's no reason why I should still be in business,” she said. The following is an edited version of that conversation (Video).
JAMA:What alerted you to the fact that in some areas of Philadelphia, people not only were getting sick and dying from the novel coronavirus at very high rates but they had a particularly hard time getting tested?
Dr Stanford:Many friends were calling saying, “Ala, can you write me a script? I really don't feel well. I'm trying to get tested for coronavirus but when I show up, I keep getting turned away and told to stay at home.” These were African American friends and friends of friends, with health insurance.I called local, state, and federal folks to say, “So, what's happening? It's affecting African Americans more, but yet I don't see anything in place. How can I help?” I got a lot of, “Everyone's concerned. We share your thoughts.” But there really was not anything in place. Everyone was still focused on having traveled to China, being a nursing home resident, being a health care worker, being over the age of 65, and having comorbid conditions. If you didn't meet those criteria, you couldn't get tested.
JAMA:How did you come up with the idea of a mobile testing unit as a way to address the access problem?
Dr Stanford:I went on the website, Philadelphia.gov, and it put every zip code where the positivity rates were the highest, and then you could concurrently overlay and see where the testing locations were. There were no testing sites in the areas where the positivity rates were the highest. All the testing sites were primarily in affluent areas that were predominantly White and the reduced number of testing sites were in all the poor neighborhoods or middle-class neighborhoods that were predominantly Black. We had to go to all the zip codes throughout the city where the positivity rates were the greatest. So, that's where the mobile unit came from. I have an office, and I could have just said, “Hey, if you need a test, come to my office.” But you really needed to go to where the people were. In the beginning, we drove house to house for every person who preregistered, and we tested them. The problem with that was we spent more time in the car than we did testing folks.Talking to my pastor, I said, “We’ve got to go to a place that people trust.” In the African American community that is largely the church. We basically built a triage unit or a small hospital in every parking lot that we went to.I was intentional about the consortium’s name. I wanted the Black population to know that we as Black health care professionals are coming to your neighborhood to take care of you. I got on Zoom with all of my friends who were doctors, doctors who were mentors for medical students, nurses. We had 30 people on the Zoom. I said, “Listen, I’ve got a van. I have testing kits. I have PPE [personal protective equipment] because I'm a surgeon. And I've got a dozen people to test tomorrow. Who can do it?” That’s how we started.
JAMA:With a dozen patients?
Dr Stanford:The first day, April 16, we drove door to door and we tested about 12 people. By Saturday, April 18, we tested 140 people in a church parking lot. By Monday, April 20, we tested 400 people in a church parking lot. It was cold and windy and rainy. When I pulled up, there were cars lined up around the block. We didn't even have enough testing kits. But I'll never forget because of the 400 people we tested, 100 were positive. That's still our hottest zip code.
JAMA:How was this received by the medical professionals and the communities you were serving?
Dr Stanford:From the institutional medical profession—meaning the city health commissioner and different hospitals—I think they thought we were just going to be here temporarily, that this was a great PR stunt. We got a lot of skepticism.What we brought that they didn't was a level of trust and empathy. We did not require you to have an appointment. We did not require you to have a referral from your doctor. We did not require a state-issued ID. You did not have to be over 65. You needed to have symptoms and to have been exposed to someone who was positive or presumed positive. And you had to be someone who was in direct contact with the public. So, if you were a police officer or delivering mail or bagging groceries, we tested anyone that had jobs like that. Because in my mind, that constituted high risk.Remember, the testing kits were hard to get back then. Some [in the medical community] wanted to know, how did I get testing kits? Well, I'm a private practice doc. I have an account with LabCorp and Quest like any other, but as a surgeon you only were allocated 5 testing kits. You didn't get a lot. But all the primary care doctors' offices were closed. So, I went to my friends and said, “Hey, you guys aren't testing anybody, your offices are closed, can I have your testing kit?” And I drove around and picked up the testing kits from my colleagues and those were the ones I would use.The response from the community—it still gives me chills. Older folks, like 90 years old, telling me how proud they were of me. Some people had no symptoms at all but sat in a line in the car with their daughter or son because they had never seen a Black doctor.
JAMA:What do you see as the root cause of these testing barriers?
Dr Stanford:The root cause of why the testing is not widely available is a myriad of things. For the hospitals, a lot of them did drive-up [testing] because I believe they felt it was a layer of protection for the health care worker if a person was in their car. But in a commuter city like Philadelphia, the majority of the residents take the bus or train or subway. Because the testing sites were not in Black neighborhoods, to travel to the suburbs or a predominantly White neighborhood by bus or train and then walk to the site, only to be turned away [if you weren’t in a car], was very disheartening—especially if you were symptomatic.Then there was the component of the haves and have-nots. It's been around since forever, and when you don't have a note from your doctor or a referral, you get turned away. You don't have a scheduled appointment, and mind you, most of the appointments were during working hours 9 to 5, they weren't nighttime hours. They were not weekend hours which is when we test.The other root of the problem is that the health care system for African Americans has been untrustworthy. I'm very purposeful with that choice of words because the narrative is that African Americans don't trust the health care system. When you do it that way, then you can easily say, “If they don't trust us, that's on them.”But when you say the health care system has been untrustworthy to African Americans, it's different. It means, as a health care institution, you have to assume the responsibility for the fact that the health care industry in general has been untrustworthy. We know that [19th-century surgeon] J. Marion Sims was performing obstetrical procedures on slave women without anesthesia, without their consent, doing procedures over and over and over until he perfected the operation. As a surgeon, that was painful for me to learn about. Then, of course, there is Tuskegee [the syphilis study] and everyone talks about that.If you ask most African Americans about their experience with the health care system, they may not be able to point to the historical perspective. But they might know, “I just don't trust the doctor.”
JAMA:The consortium has received funding from sources including the City of Philadelphia, private charities, and individuals. A GoFundMe page is about a third of the way toward a $1 million fundraising goal. Have you been surprised by the support?
Dr Stanford:I wish I could tell you I sat down over a week and I came up with this master plan, but it wasn't that at all. As we started testing people, folks started saying, “Well, we want to donate.” I said, “Oh, I guess I never thought about that.” [My brother] set up the GoFundMe.Then there were the people who said, “Hey, I want to give you a little something,” and put $10 in my pocket when we were testing. There was lots of that.
JAMA:Can you talk about what you're doing to educate people about the virus and how they can keep themselves and their families safe?
Dr Stanford:On March 5, I posted my first video on social media. I couldn't continue to be on the phone 24 hours a day, 7 days a week, so I started posting snippets about what was known about coronavirus and how you contract it. I did a lot of Facebook Live and Instagram Live with young folks, with radio personalities. I had a spot on [R&B radio station] WHUR in Washington, DC, once a week, where I would do an update.We give an information sheet to every person we interact with about how to keep yourself quarantined until your results come back, how to isolate if you find out you're positive, and contact numbers [for contact tracing and help in obtaining a location to quarantine or isolate]. Working with the Philadelphia Department of Public Health, we now have a great contact tracing program.
JAMA:When you started COVID-19 testing more than 6 months ago, did you imagine that you would still be at it?
Dr Stanford:No, not at all. And I'm tired. To see the positivity rates going back up, it almost feels like PTSD [posttraumatic stress disorder], because I remember what April and May felt like. I remember seeing sick people in line getting tested, and you would call to tell them their results the next day or the day after, and they were inpatients in the hospital.
JAMA:What are your expectations regarding the consortium’s role in distributing a vaccine?
Dr Stanford:I and many of the other health care professionals on the [city’s vaccination planning] board have said it will require transparency in terms of seeing the data—the side effects, how African Americans were represented in the phase 3 trials, how much immunity was conferred from the vaccine, how many people had the disease and received the vaccine. I appreciate being on the board and them seeking out my insight. So the short answer is, yes, I see us having a role, but for me the transparency is key.I should mention that the Black Doctors Consortium created a survey measuring confidence and security, your belief in the government, and attitudes and beliefs about receiving a coronavirus vaccine. We had about 600 respondents, and we are analyzing that data right now.
JAMA:What do you think it will take for Black Americans to embrace a vaccine?
Dr Stanford:I believe it will take trusted leaders to impart the safety, the efficacy, and the importance. It won't be your president, your surgeon general, your secretary of health because the messages have been so mixed from the beginning.I personally think it's going to take me, or someone like me, receiving the vaccine live and following me…to see how I'm doing and measuring my antibody response. For some, that still won't be enough. There are lots of folks that are like, “No, I'll just wear a mask and stay socially isolated.” So, we have our work cut out for us.
JAMA:What can physicians do to address trust issues and other needs in their own communities?
Dr Stanford:The majority of physicians are not in private practice like myself. They belong to health care entities. So, what can hospitals and academic institutions do? I think they have to start with acknowledging the barriers to health care that have been in place. That's going to come from asking a patient who doesn't look like the majority, “How easy was it for you to be seen here,” or someone who isn't seen in your hospital, “Why can't you come here?”The [city] health commissioner and I, we've spoken to all the CEOs at the major hospitals and said, “You’ve got to widen your ability to test people. Someone should be able to walk into your hospital 24 hours a day, 7 days a week and get a coronavirus test.” I've heard all sorts of bureaucratic things. But honestly, there's no reason why I should still be in business with all of the hospitals, all the medical schools, all of the health care entities that exist in this city.As [for] the individual, we all have implicit biases. It's your job to identify and work on it, just like if your HbA1c [hemoglobin A1c] was high, and you wanted to lower it so you decreased your chance of having complications from diabetes. You might change your diet; you might exercise more. We have to first identify what our biases are and then make a conscious effort every single day to work against it.
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Jaklevic MC. Surgeon Fills COVID-19 Testing Gap in Philadelphia’s Black Neighborhoods. JAMA. 2021;325(1):14–16. doi:10.1001/jama.2020.22796
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