The Second Front Line: Responding to COVID-19 at a Community Health Center in the South Bronx
Global Health Corps (GHC) alumni Mia Stange and Monica Kavanaugh work for Community Pediatric Programs at Montefiore Medical Center, a Federally Qualified Health Center located in the South Bronx, New York City. In the below interview, GHC’s Advocacy and Communications Manager Brittany Cesarini talks with Monica and Mia about what they’re learning, seeing, and hoping as they battle COVID-19 in the poorest congressional district in the nation.
Brittany: What are your current roles at Community Pediatric Programs (CPP)? How did you wind up where you are now?
Monica: I began at CPP as a Global Health Corps (GHC) fellow in 2016, and have since assumed the role of Grants and Program Administrator. I work on a small team that implements quality improvement, health, and special research initiatives designed to close gaps in health disparities for families served at our Federally Qualified Health Center. In addition, I coordinate the Resiliency Initiative, a series of clinical programs directed at mitigating toxic stress in prenatal and young pediatric patients. We aim to increase parental responsiveness through prenatal and pediatric group care, mother-infant dyadic therapy, and social determinants of health screening and resource follow-up.
Mia: I began as a GHC fellow in 2014, primarily implementing programming for our health center’s Resiliency Initiative, which Monica mentioned above. In 2015 I took on an additional role coordinating Terra Firma, a growing medical-legal partnership program embedded within CPP. Terra Firma provides coordinated and co-located medical, mental health, legal and enrichment services to newly-arrived immigrant youth and families. Over the years, my job grew from a patient-facing case management role to my current position as Terra Firma’s Program Administrator (via an MPH degree at Johns Hopkins), overseeing program operations, grants, and external partnerships.
Brittany: What have the last couple months been like for you at work?
Monica: Each day has looked different, things have changed so quickly. At first, staff and patients were very fearful of the unknown. But gradually we have come to understand more about the virus and our role in the midst of this storm. Policies and procedures have been put in place to keep our families and our staff safe. As a patient-centered medical home in the poorest congressional district in the nation, we are familiar with working to meet the complex health and social needs of our patients. However, this pandemic has challenged us to think creatively to ensure that all of our patients’ needs are met — including non-medical needs that impact health, such as access to food and shelter.
Mia: Primary care plays a critical role in reducing unnecessary hospitalizations and decreasing the burden on emergency departments. The importance of this role in the context of this current epidemic cannot be understated: community health centers are a line of defense to divert patients away from an overwhelmed emergency healthcare system. We assess and triage symptoms, advise precautions, and respond to resource gaps that can lead to increased illness if left unaddressed.
Our health center has pivoted remarkably fast to provide telehealth consultations and expand the infrastructure of emergency food supplies and patient outreach. This crisis has an enormous medical toll but it also has a social one. The aftershocks of both will be felt for a long time. We are trying to mitigate those effects among our patients as early and proactively as possible.
Mia and I have also been working on a team to develop and implement a food pantry that fits the needs of the moment. This has been a clinic-wide effort, spearheaded by CPP’s Director of Nutrition Services Fadhylla Saballos, Dietitians Merced Vega and Zariel Grullón, and Program Specialist Felin Martinez. Each of our program’s staff members, from maintenance to front desk to administrative leadership, have played a part in ensuring the success of this effort.
Monica: In order to do this, our primary care teams have mobilized to conduct targeted telephone outreach to our most vulnerable populations, such as the elderly, families experiencing homelessness, and those with comorbidities. As a result of these outreach efforts, we have been able to prepare our patients with a three-month supply of their prescriptions, medical devices for at-home use such as blood pressure machines, and critical information to protect themselves and their families against COVID-19. In addition, these calls give us a chance to connect with patients on a human level—we ask questions around food insecurity, social support, and emotional capacity.
Mia: In Terra Firma, the program I manage within CPP, our families are particularly vulnerable — almost all are undocumented; many work in service jobs without access to benefits or other safety net programs, and none are eligible to receive the stimulus checks from the federal CARES Act passed earlier this month. Meeting their needs efficiently and sustainably is key, and we are working hard to find funding and tap into resources to support this ongoing effort.
Monica: Across all our patients, one common theme has emerged: our families report experiencing significant food insecurity as a result of the pandemic. Mia and I have been working on a team to develop and implement a food pantry that fits the needs of the moment. Our families are asking for foods practical for a shelter kitchen, cleaning supplies, menstrual products, face masks, infant supplies, and thermometers. We are using our platform as a community health center to order and deliver these essential items directly to families, therefore eliminating travel and possible exposure to coronavirus.
Brittany: Tell us more about the contours of COVID-19 along the lines of the social determinants of health in the South Bronx.
Monica: The existing data reflect the disproportionate impact of the pandemic on low-income, minority communities. COVID-19 deaths per capita are twice as high in the Bronx, which has the highest proportion of racial and ethnic minorities, the most persons living in poverty, and the lowest educational attainment of all the boroughs in New York City. As the pandemic was ramping up, many of our families did not have a choice to work from home, relying on public transit to get to their jobs. Now that we are in a shutdown, many of our families were the first to be laid off.
Mia: Sadly, the COVID-19 pandemic is only serving to more fully illuminate stark disparities that have existed for generations. Communities that have been systematically disenfranchised and underserved have a higher burden of chronic disease, which in turn appears to increase susceptibility to this virus. Healthcare in this country is not a right, and entire segments of our population have been thus far excluded from accessing care and discouraged to do so through harmful policies such as the public charge ruling. This has been shown to limit the likelihood of seeking help when sick and may lead to increased rates of community spread. Lastly, widespread public health messaging has failed to address additional vulnerabilities within the communities we serve. What does it look like to shelter in place when you feel unsafe at home? What does it look like to practice social distancing when you live in a crowded shelter or detention center?
It is becoming clear that in urban centers across the country, Black and Latinx people are dying at disproportionately higher rates than their White counterparts. This crisis is shining a light on systems that have failed many in this country for a long time. Just as Hurricane Katrina was much more than a natural disaster, this is much more than a disease outbreak. The communities that suffer most are those who have been allocated less power and fewer resources over time — long before the spread of COVID-19.
Monica: At CPP, I’ve seen these disparities most reflected in families experiencing homelessness, who make up more than two-thirds of the shelter population in NYC. The conditions in the shelters are particularly conducive to the spread of disease — families live in tight quarters, with many required to share rooms and bathrooms with those they do not know. There is little control over air quality and shared spaces are not routinely cleaned. Most families are responsible for purchasing their own cleaning supplies, hygiene products, and face masks. Shelter sites are isolated in remote areas, making it nearly impossible for families to access food, medical care, and basic necessities. In addition, there is a tremendous amount of displacement in the shelters, with families getting moved around from one week to the next. I’ve heard from many families that they are fearful of going outside or taking public transit to access available resources.
Mia: I fear that we will also see a widening of these disparities in the wake of the initial crisis. Many families with school-aged children are struggling to navigate remote learning, particularly those whose primary language is not English. Lack of support in this transition can set children back on their educational trajectory and widen the achievement gap. Other long-term impacts remain to be seen, but the economic implications for low-wage workers and those in the informal economy will be devastating. Our role in this crisis is not only to address those needs to the extent possible, but to share what we are learning so that other health centers, neighborhoods, policymakers and community members can see what is happening on the ground and can work to implement larger-scale solutions.
Brittany: You’ve been working in intense, front line roles throughout the pandemic. Why does community matter to you at a time like this?
Mia: This moment has given me a lot of time to pause and reflect on the different communities of which I am a part. At CPP, our Medical Director has taken to leading daily relaxation exercises to close out a team call that often discusses patient illness and death. At my MPH alma mater Johns Hopkins, faculty and students have jumped in to track data and analyze global trends in real time. At GHC, I participated on a video call recently with the group of seven women with whom I lived during our incoming training in 2014. GHC was a foundational community and established the importance of finding others who have different experiences, backgrounds, and skill sets but a shared dedication to the principles of human rights and social justice. It is telling to me that six years after my fellowship year I am still in such close communication with a global network of friends and colleagues, and I believe it is a testament to the program’s ability to cultivate leadership and vulnerability in equal measure.
On a larger scale, it has been heartening to see so much community solidarity in NYC and across the country in unexpected and powerful ways. Grassroots organizations and mutual aid groups are mobilizing to fill in the gaps that top-down approaches have not yet managed to address. It is also important to acknowledge that this is not new work — many groups have been providing these critical services for years without as much fanfare or collective involvement. The unique global impact of this crisis has stopped us in our tracks, but the way that people are showing up for each other, in big and small ways, gives me a sense of hope as we all chart a new and uncertain path forward.
Brittany: It’s still early, but what is this crisis teaching you about leadership?
Monica: This moment of collective vulnerability has exposed leadership in a new light for me. It has been so remarkable to see leaders emerge at all levels, and at different times, of the pandemic. As the reality of the depth and duration of this pandemic sets in, I am now seeing the value of the different kinds of leadership to bring about shared impact. Each leader is invaluable in their own way and for their unique contributions.
In the first few weeks the bureaucratic leaders surfaced, laying the structure and setting the direction for the work ahead. As the reality of the pandemic hit, the more democratic leaders came forth, asking for input and adapting the status quo to more accurately fit the needs of the moment. Now, as we are in week eight of the lockdown in NYC, the servant leaders are mobilizing to boost morale, reiterate our mission, and offer light in an increasingly dark time. When the clouds eventually clear, I imagine we will more clearly see where our own leadership fit into the whole, in retrospect.
Brittany: What’s your motivation for doing this work?
Monica: I am particularly inspired by the resilient and unwavering medical leadership at our clinic, who continue to remain fiercely devoted advocates for families in our community. While in the office the other day, I overheard one doctor on the phone, offering to personally walk a thermometer to their elder patient’s apartment. These complex, unprecedented times require innovative and out of the box solutions. I am continually inspired by our clinicians resolve to combat the status quo.
Mia: In this moment I find inspiration in the individuals and programs that have shifted to sustain community in this new and jarring context. Teachers who are supporting the multiplying needs of their students from afar, local businesses fighting to stay open, neighbors checking in on each other and offering food and resources, and the clinicians and patients Monica mentioned. In a fundamental sense, it reflects why I became interested in health equity — we are only as strong as the sum of our communal efforts, a truth made more stark in emergencies like this.
Mia Stange was a 2014–2015 Global Health Corps fellow and Monica Kavanaugh was a 2016–2017 Global Health Corps fellow at Children’s Health Fund (of which Community Pediatric Programs at Montefiore Medical Center is a flagship program) in The Bronx, New York City.
Brittany Cesarini is Advocacy and Communications Manager at Global Health Corps.
Global Health Corps (GHC) is a leadership development organization building the next generation of health equity leaders around the world. All GHC fellows, partners, and supporters are united in a common belief: health is a human right. There is a role for everyone in the movement for health equity. To learn more, visit our website and connect with us on Twitter/Instagram/Facebook.
