DIRECTOR, ELEARNING AND TRAINING
November is Transgender Awareness Month, a time to celebrate and honor the trans (transgender and gender diverse) community and bring awareness to issues facing trans people. We interviewed several people involved with TransFORWARD: Texas Transgender Health, a collaboration between Texas Health Institute and Equality Texas Foundation, about barriers to health care for trans adults and how to improve the system for future generations. TransFORWARD aims to improve the lives of trans adults through research, evaluation, education, and dissemination of resources to foster growth in transgender health care and research.
Emmett Schelling serves as the current executive director for Transgender Education Network of Texas (TENT), the statewide trans led and focused policy org in Texas. Madeleine Croll is pursuing a masters in political science while working as graduate teaching assistant and currently serves as vice president of GENTex, Gender Equality Network of Texas. Rocky Lane is a regional co-lead at TransFORWARD and a creative entrepreneur specializing in media and consulting services. Justine Price is completing her doctorate in health sciences and is a former deputy director of a local health department.
Why do you invest time in TF?
Emmett | I’m trans, so I want to see trans health improve. I want to see it improve in Texas, the state with the second largest population of transgender adults. I believe we can not only affect the state, but the rest of the nation, in building a better, more inclusive and healthier world for all of us. The pandemic has opened our eyes, that the most vulnerable people are experiencing greater health concerns.
Madeleine | TransFORWARD allows me to be a conduit for the community, the medical research community, and clinicians. It’s important for them to hear from us directly. I try to compile what the community tells me to say “This is our experience. Now that you are aware of it, what can we do to make it better?” We can understand different cultures and form the bonds we need to move forward. We must collaborate as equals because as much as we appreciate clinicians’ skills, they need to recognize the fact that we have our dignity.
Rocky | I invest my time in TransFORWARD because people I trust invest their time in TransFORWARD: people that I have followed for a long time to understand how things work, how change happens, how advocacy can help build better partnerships to get us to the next level for our community. I was brought here by my mentor, Emmett Schelling from Trans Texas [Transgender Education Network of Texas]. I think Emmett thought because I used to be a health worker that I'd be a great member of this team.
Justine | Because it's really important work for people. The thread that underlies all of the challenges in the transgender community is the unknown. It's a lack of understanding, of data points, of familiarity and being able to relate to people. We don't even really know how many people are trans, how many people identify and on which point of the spectrum. Biology is just starting to join hands with sociology and psychology to understand the spectrum of sex in the same way. A lot more needs to be done to understand the nuances of the transgender population and how we can best tailor treatment.
What are some of the barriers to care for trans people in Texas?
Madeleine | A lot of our barriers [in the Rio Grande Valley] are economic. Our region has severe poverty, including the poorest U.S. county: Starr County. Labs are expensive; insurance is a major barrier. And many people are not competent to provide gender-affirming care, even basic medicine. I’ve heard of providers laughing at patients who “come out” to them. Some clinicians gleefully use their positions of power to render moral judgments against us. Accessibility and transportation are issues, and we are hyper-policed, so if you're undocumented, you're afraid to go out during the day. If you need advanced care, like gender affirmation surgery, there's no place to get it done. Do you go to Monterrey and take your chances trying to come back? And language becomes a barrier. Even within the Latinx community transgender is “transgénero” in Spanish, but across the river, the term is “transexual,” meaning I am taking the step to medically transition, which is a distinctive difference in Spanish.
Rocky | The three buckets identified in our talks with the community were: navigation to affirming resources or clarity of what resources are; access based issues, like cost or access to more complex care; and cisgender people. A lot of the things that we hear from community directly result from cisgender people being a major barrier or the people that trans adults have to get through to get to their services.
Justine | Again, I think it's the unknown. My primary care physician had a hard time understanding my estrogen therapy. She felt it was not safe to be on such a high dose of estrogen, because her medical knowledge was on using hormone replacement therapy for postmenopausal cis women. But that amount would have been ineffectual for trans women. Is our comfort level as a marginalized population such that we can honestly and openly talk about differences between trans people and cis people? I don't think that there's anything wrong or shameful in saying there's a difference. It comes on the basis of fact. If we don't talk about it, we're not going to be able to find the evidence and educate providers so that they even know what to look for or know to make the distinction.
Emmett | First and foremost is the lack of knowledge, information, education. I think 50% of Texans said they had never even met a transgender person. Which, I giggled a little bit, because there's a very good chance you've met a transgender person and not realized it. The second thing is bias. When you don't know about people, then whatever bias or whatever you've been reading is going to play a part in your understanding or opinions or purview. Texas is a tough state to be trans in, with a limited pool of knowledgeable, informed, and educated health care professionals, and in rural areas, it could be a 3- to 6-hour drive for an appointment. Plus issues of employment and housing, the components along with health that foundationally set up people to be secure and successful. And then we get into other disparities that span across race, ethnicity, ability, and in health care, there is discrimination that can happen.
How do we change the system to ensure future generations don’t face these barriers?
Rocky | One solution is to build something specifically for ourselves and not try to adapt cis systems. So, build trans health care centers, for instance, to take over all training, research and treatments. We need to have community members be a liaison or ambassador, such as a patient navigator. The fact that we have cisgender doctors is not the issue, but that we don't have trans health care workers in any abundance. When I talk about cisgender people as a barrier, it's not something that cisgender people can solve or get out of without trans people. Trans adults want to talk to each other, to have access to each other. Dedicated centers could eliminate variable outcomes and also allow us to outline medical direction and accountability systems in a full regional level.
Justine | First create an environment that's embracing, friendly, and inclusive of trans people so that we can hear from the people that these issues are affecting. Second, with those people as vital stakeholders at the table, continue to build that evidence base and shape projects by identifying priorities and needs, starting with the most critical working towards the ones that are less of an immediate impact on people's lives. And then, combining those two things, we continue to educate providers and build this as a cornerstone, just like any other aspect of medical training, into curricula, something that falls under that umbrella of general care pluralism.
Emmett | Education is a big piece of any change: real permanence and a real shift that helps future generations. One of the things about TransFORWARD that I so appreciated is everyone participating is committed to learning from one another, our collaborative work, research, and different studies. We got honest feedback from the community that has not been heard from, the good, bad, ugly, everything in between. If we don't have that information, and we're not talking to researchers, providers, and community members, then we're not going to effect change for the next generation. We have so many trans adults in this nation that need care, and we need people that are educated and understand from every aspect how to help make them well and make sure they can have successful, happy, healthy lives.
Madeleine | Protective legislation is always a good thing to strive for. It's not something, though, that I expect from my state. A lot of people here, if they have the privilege to do so, will go somewhere else that's more accepting. But a lot of us have talents and skills, and we deprive people of those skills and talents. So, the community has experienced that loss through geography just as much as suicide. We need to address education and the fact that there are queer people, queer families, and you share this state with us. We're not a threat to anybody's way of life. People are going to be themselves, regardless of whatever barriers you put. The only thing you're doing is criminalizing us and putting us in greater danger.
Texas Health Institute (THI) announces that Chief Health Equity Officer Nadia Siddiqui will be stepping down from her role on October 29, 2021. After 12 years, she has made the decision to focus on her children in these unprecedented times, but will remain a close friend, ally, and advisor to our team.
“Nadia’s impact to health equity at the national, state, local and community levels cannot be overstated,” says Executive Director Ankit Sanghavi. “We are thankful for the strong foundation she has laid that will enable THI to expand our footprint on this path towards achieving health equity.”
As Nadia marks her final week with us, we reflect on her journey, wisdom and the impact her work has had on health equity at all levels.
While equity is now a common rallying cry, it was not always a priority in health care and public health. Nadia started at THI as a senior analyst, working alongside Senior Research Scientist Dr. Dennis Andrulis, who brought his expertise in health disparities research to THI in 2010. In particular, their post-Hurricane Katrina work with the Office of Minority Health developed into guidance for integrating diversity and equity into public health preparedness and response. With the passing of the Affordable Care Act, Nadia contributed to over a dozen policy analyses and reports on the law’s opportunities and impact from a health equity lens.
While expanding national partnerships for health equity, Nadia transitioned to Director of Health Equity Programs in 2014 and to THI’s inaugural Chief Health Equity Officer in 2020. Since 2015, THI has worked with the National Collaborative for Health Equity and the Virginia Commonwealth University on the groundbreaking Health Opportunity and Equity (HOPE) Initiative, including an interactive platform with equity data and benchmarks. We also partnered with United Health Foundation and America’s Health Rankings to produce the biennial Health of Those Who Have Served report on veterans’ health since 2016 and their inaugural Health Disparities Report in 2021.
These and other national partnerships led by Nadia have allowed THI to become more creative, strategic and analytical, paving the way to further health equity work at every level.
While her journey started at the national level, Nadia was driven to bring that work to Texas. “Texas hasn’t done a great job of moving the needle on health,” she says. “We’ve fallen far behind on many measures, with deep and persistent inequities. Closing these longstanding gaps will require moving upstream, working across sectors and with communities to address the root causes of health inequities—including systemic racism and other forms of discrimination built into the fabric of our systems.”
Bringing the work to Texas started with a major opportunity through the Robert Wood Johnson Foundation to understand how nearly two dozen cross-sector community initiatives across Texas work to advance health equity. In Southwest Houston, Nueces County, and other communities nationally, Nadia led efforts to offer new models for engaging communities to co-design and co-implement data initiatives to improve health and well-being.
“Centering communities as the experts is at the heart of the work of health equity,” Nadia says. “Some of my most gratifying work at THI has been with communities, and while we have come a long way, I hope to see THI only further grow in its efforts to authentically engage communities for meaningful and sustained impact.”
“As a public health institute,” Nadia says, “We have the unique and unprecedented opportunity to be a leader in changing the narrative, changing lives, and having a true impact on equity. It starts with us as individuals, as an organization, and bringing other partners along on the journey.”
With so much of public health driven by policy, philanthropy, and health care entities, she hopes THI can be a compass to bring alignment to the disparate initiatives across sectors in Texas. She and Executive Director Ankit Sanghavi have long championed the idea of a Texas Health Equity hub—a statewide network of regional and local cross-sector community health initiatives and leaders that align around a shared vision, metrics, and evidence-informed strategies for achieving health equity.
Nadia also stressed the importance of advancing diversity, equity and inclusion internally. She emphasizes, “I have always wanted THI to walk the talk and become a leader by demonstrating equity principles and being an authentic partner to support other organizations on the same journey.” She helped centralize health equity in our strategic framework and launch initial pieces of an internal health equity assessment of our governance, structures, policies, and practices. “I am confident that THI will carry forward this work from infancy to adulthood and beyond.”
THI is grateful for the legacy Nadia created through her dedication to advancing health equity at all levels. We remain deeply committed to the vision of health equity and are resolved to build on the foundation Nadia has laid and expand it further to drive meaningful change, improving the health of all. We are excited to expand our capacity through new dedicated health equity positions—including a nationwide search for a Chief Health Equity Officer—that we will be announcing in the coming days.
We appreciate the incredible years that Nadia gave us and the people of Texas. We wish Nadia success and happiness with her family and in all her future endeavors.
Thank you, Nadia, for your tireless leadership and dedication to health equity.
National Primary Care Week: October 4-7, 2021 | “Primary Care is Primary” in addressing systemic issues of healthcare inequities, high costs, and lack of access.
CHIEF CONVENING AND EDUCATION OFFICER
Primary care, when prioritized in the health system, results in people living longer lives with more equitable outcomes. Texas Health Institute (THI), as the non-profit, non-partisan public health institute in the state, serves as a trusted, leading voice on public health and health care issues in Texas and the nation. Our expertise, strategies, and nimble approach make us, alongside the Texas Medical Home Initiative (TMHI), integral and essential partners in driving systems change efforts. THI and TMHI have joined forces in creating the Texas Primary Care Consortium (TPCC), with a mission to advance equitable, comprehensive, and sustainable primary care for all Texans.
Primary care is the foundation of a strong and effective health care system. Abundant data shows that people in communities with more primary care practitioners—measured in proportion to the population of the county or city—are overall healthier and live longer. Research has proven the fundamental role of primary care in improved chronic disease management, providing preventive care, ensuring patient engagement, leading care coordination, and delivering person-centered care. Yet, our current healthcare system consistently falls short for everyone involved.
Inequities, high costs, lack of access, and disparities in care and quality lead to frustration and sub-optimal outcomes for not only patients and providers, but communities, businesses, payers, government, and policymakers alike. This is especially true in Texas, where the large number of rural counties, growing health professional shortage, and high rates of uninsured or underinsured residents make access to primary care services difficult. Subsequently, care is frequently obtained later in the course of an illness at higher-cost venues such as emergency departments. Together, these factors are contributing to a growing health care crisis in Texas.
As we highlight National Primary Care Week, TPCC continues to focus on advancing primary care through its framework: educate, activate, and transform.
TPCC’s activities include:
To learn more, register for our upcoming convenings, or join the state’s only multisectoral network focused on primary care in Texas, visit our website: txprimarycareconsortium.org
The Immunization Partnership Staff
August is National Immunization Awareness Month and we are featuring a guest blog from The Immunization Partnership, who distributes resources to promote adult and child vaccinations across the state. Read more below to learn about their efforts and recommendations. As the state’s public health institute, we prioritize sharing both internal and external information that contributes to advancing the health of all.
August provides The Immunization Partnership the opportunity to reach out to parents and the public in general about the importance of keeping current on adult and children vaccines. By combining social media and traditional media messaging for National Immunization Awareness Month and Back to School, we can reach out to Texans in a variety of ways.
We made available to Texas county health districts and public health agencies a NIAM and Back to School proclamation template, which allows customization by inserting the name and title of the proclamation issuer, such as mayor or county judge. We also will provide targeted news releases about NIAM and Back to School, which include quotes from the local public health professional and our interim Executive Director. The local public health person can revise or extend the quote. We use the main news release, which includes only quotes from our interim Executive Director, for the rest of the state.
We are proud to announce the distribution of a series of English/Spanish animated videos we hope will answer COVID-19 vaccination questions and lead to more Texans exercising their right to bare arms and take a shot for Texas. Americagroup Texas funded the project, which The Immunization Partnership produced.
Misinformation, or simply the lack of information, regarding COVID-19 and the authorized vaccines has led to confusion and hesitancy. Hill Powell, our interim Executive Director, is excited about the role these videos can play in reducing the number of COVID-19 cases throughout Texas because they bring the right message at the right time. “The best way to counter relatively common misperceptions and misinformation, such as the belief that vaccines might change a person’s DNA, is through basic information about the vaccines and how they work. And these videos do just that.”
Katy Gore, our Coalitions and Education Program Manager, designed the videos that run about a minute or less. They not only explain the virus and the vaccines in a format we hope will dispel doubts but they also give doctors, nurses, and health professionals an opportunity to answer patients’ questions and concerns about the vaccines. “We want to create comfort with the vaccine among individual Texans, families, and communities,” Katy says.
The videos will run on a loop in the lobbies of Federally Qualified Health Clinics and in reception areas of Texas Community Health Centers members. Coastal Health and Wellness clinics in Galveston County are the first FQHCs to run the videos. We also will share them on social media and with other clinic systems across the state. We have the videos on our COVID-19 webpage. Contact Katy at firstname.lastname@example.org if your organization would like the videos. They’re free!
DIRECTOR, ELEARNING AND TRAINING
August 25th marks the fourth anniversary of Hurricane Harvey slamming into Rockport, Texas- most people will remember the devastating rainfall. The Category 4 hurricane and its 130-mph winds created a path of destruction through the city of 10,000 people as it came ashore. Over 2.5 million cubic yards of debris were removed from Rockport in the five months after the storm. By comparison, Houston, a city 216 times Rockport’s size cleared 3 million cubic yards of debris. A front row seat watching the eye roll across Rockport provides an eye-opening view of Harvey’s force. Cleared cubic yards of debris are not necessarily based on the size of the city.
National Oceanic and Atmospheric Administration (NOAA) predicts another active hurricane season this year, which began June 1st, and forecasters predict multiple major Category 3 to 5 storms. It’s not too early to prepare for a hurricane or tropical storm. The CDC provides excellent guidance including what emergency supplies to stock in your home, planning to evacuate, and protecting older adults and pets. CDC’s practical information and guidance should be bookmarked on your browser. Staying safe after a storm is just as important as preparing for one.
Your mental health and resilience should not be forgotten in planning. THI’s Texas Hurricane Response Hub created eight online courses for public health, first responder, emergency response and preparedness professionals, and healthcare practitioners. Protecting Your Physical and Mental Health Before, During, and After a Disaster provides guidance on how to prepare yourself and your family for a hurricane, both for health professionals and members of the community.
Almost four years later, Rockport is still rebuilding. Crumbling foundations, remains of rusting light posts ripped from their bases, and remnants of a fire extinguishing system all serve as reminders of the devastation the city faced. But, Rockport is resilient, the town is rebuilding, and businesses and tourism are coming back. The COVID-19 pandemic didn't help matters but driving through the town you can see rebuilding and positive changes. A community does what they can with the resources available. Again whether it’s media attention to stay in the public’s and funder’s view or the number of staff to chase down different funding opportunities, size matters.
Rockport and other coastal areas will see storms this year and in the future. There is still work to be done, and doing it correctly will require applying a health equity lens to planning and rebuilding efforts. Hurricane Katrina exposed inequities in racially, ethnically, and linguistically diverse communities across a continuum of preparedness, response, recovery, and mitigation activities. THI's Health Equity team created a body of work post-Katrina that can help local agencies orient and consider the importance of health equity in hurricane planning and recovery. Preparing Racially And Ethnically Diverse Communities For Public Health Emergencies and Guidance For Integrating Culturally Diverse Communities Into Planning For And Responding To Emergencies: A Toolkit are excellent starting points.
“Now is the time for communities along the coastline as well as inland to get prepared for the dangers that hurricanes can bring,” said Secretary of Commerce Gina Raimondo. Regardless of a city’s size, a hurricane can come ashore anywhere along the Texas coastline spanning 15 counties and 3,359 miles. Per the CDC "planning for hurricane season and other potential disasters can be stressful, and because the 2021 hurricane season comes during the coronavirus disease 2019 (COVID-19) pandemic, it may be especially so.
Public health and emergency response professionals have advice to help you safely prepare, evacuate, and shelter for severe storms while protecting yourself and others from COVID-19." Now is the time to prepare for this year’s storms.
Very-low-income people with disabilities can get health coverage through Texas Medicaid. Children, adults in institutions, and a small percentage of adults in the community have a dental benefit. Many people react in disbelief when learning that most adults with disabilities in Medicaid community care do not have access to a dentist. This leads to very bad outcomes, like resorting to an emergency room when in severe dental pain. The treatment there is not dental, only antibiotics and painkillers, often opioids. Some people are in such bad shape they must be hospitalized, and a few actually die from complications. What caused this? Simply, untreated cavities, a treatment that is usually done in a dental clinic. That’s not all. Poor oral health leads to elevated heart disease, diabetes, hypertension, stroke, cancer and more. These facts make a strong argument for adding a dental benefit.
Texas leadership believe in limited government and low services. Texas ranks 49th in community services for people with disabilities and remains among the minority of states not adopting Medicaid Expansion. To succeed, we would need a collective effort. CTD is well positioned in the Capitol and would serve as advocacy lead, including bringing self-advocates, individuals with disabilities. We would need to make the business case, that requires a skilled health research organization. Texas Health Institute filled that role. Influential legislative champions had to be recruited and supported. Our top champions are Senator Lois Kolkhorst and Representative Joe Deshotel. And we needed to show broad support from other groups. That meant putting together a strong list of supporting organizations. Among those would be some obvious groups like the Texas Oral Health Coalition and the Texas Dental Association, but we went beyond and added major trade associations for doctors, hospitals, nurses, health plans and dozens of disability organizations.
It took time. In 2017, we secured a study of the issue. In 2019, we passed a bill to pilot comprehensive dental care. In 2021, after the language passed through five bills, on the last day, a preventive dental benefit was passed. This was the result of many hearings, legislative visits, and organizing. It’s not over as we will continue to monitor the rollout. Yet, the impact is huge. Around 450,000 adults with disabilities, who would have had no dental visits in their adulthood, will now be able to see a dentist every year. The smiles will look very nice indeed.
 United Cerebral Palsy and ANCOR Foundation, The Case For Inclusion Report 2019
ANDY MILLER, MHSE
CHIEF STRATEGY AND IMPACT OFFICER
As you have likely heard by now, Texas will be refiling with the Centers for Medicare and Medicaid Services (CMS) a request to extend the uncompensated care pool part of the Medicaid 1115 waiver for 10 years after the previously approved waiver was rescinded in April. This request will seek billions of dollars to continue reimbursing hospitals that incur costs due to uninsured patients, many utilizing emergency rooms for non-emergency conditions as they are required by law to treat anyone who presents for care. It has long been established that using the emergency room as the primary mechanism for providing health care is expensive, inefficient, and fails to enable people to get preventive services, medications, and effectively manage their chronic conditions.
Alternatively, expanding health insurance coverage in addition to adequate funding for safety net providers to cover uncompensated care costs for those who are not eligible for affordable insurance coverage could lead to both improved health outcomes for Texans and reduced costs to over time.
The state is holding a public comment period for stakeholder input before sending the application to CMS, which will then hold a second, federal public comment period prior to issuing its decision. CMS specifically cited the lack of a public comment period as its reasoning for rescinding Texas’s previous waiver extension. It is critical that Texans make their voices heard on this issue. The deadline to submit written comments is June 28, 2021.
For more information and to submit written comment, please visit the Texas HHS website.
Daniel Crowe, MD, FACP
TEXAS HEALTH INSTITUTE BOARD OF TRUSTEES
The coronavirus pandemic of 2020-2021 has had a profound impact on the mental health and well-being of Texans, as well as the rest of the US. The pandemic highlighted the need to revitalize the infrastructure of our public health system and to protect it from political influence at all levels. The trauma inflicted by the pandemic has touched all of us. Many have lost family members or friends. Other stresses include loss of employment, insurance coverage, housing, and access to healthcare. Children have lost more than a year of seeing their classmates and friends in person and have had to learn how to learn through a virtual school environment. Many small business owners lost their sole source of income due to restrictions required to minimize the spread of the virus.
The CDC reports that as a result of all of this, there has been a 27% increase in symptoms of anxiety and depression between April 2020 and February 2021. Emergency room visits due to overdoses and suicide attempts were up 36% and 26%, respectively. More than 87,000 Americans died of drug overdoses in the year ending in September 2020, representing a profound increase. Behavioral health service providers reported increased demand at the same time that they were decreasing staff sizes and closing clinics. Although the use of telehealth has risen dramatically, the effect on providing care for those with behavioral health and substance use disorders (SUD) has yet to be determined. The impact of the pandemic has disproportionately affected our communities of color. It has highlighted how a system that prioritizes a law enforcement and criminal justice approach to psychiatric crises often results in unnecessary injuries and deaths.
The health care community has responded rapidly to the new environment created by the pandemic. Some best practices have emerged:
There has also been a significant increase in enrollment in Medicaid and the Healthcare Exchange during the pandemic leading to many gaining or regaining access to health care.
As the public health institute of Texas, Texas Health Institute (THI) is committed to helping Texas overcome the trauma from the pandemic through their continued devotion to advancing the health of all Texans and their communities. THI’s dedicated staff continues to produce outstanding research and translational activities such as the recent work on health equity through the HOPE Initiative that is featured by the New England Journal of Medicine. THI works with the Texas Primary Care Consortium to integrate behavioral health into primary care practices throughout Texas. THI has been a leader in advancing collaborative action on chronic pain, SUD, obesity, oral health, genetic disorders and other topics important to Texans. To quote THI, “We strive to advance the health of all.”
Centering Equity in the COVID-19 Vaccine Rollout: Emerging Strategies for Reaching Communities of Color
Nadia Siddiqui, MPH
CHIEF HEALTH EQUITY OFFICER
April is National Minority Health Month, and this year’s theme sponsored by the HHS Office of Minority Health is #VaccineReady, underscoring the importance and urgency of vaccinating racial and ethnic minorities disproportionately impacted by COVID-19.
As seen across the nation and Texas, Black, Hispanic, and Indigenous populations have faced the brunt of cases, severe illness, death, and economic loss from the pandemic, yet they continue to have lower rates of receiving the COVID-19 vaccine. Local data shed further light into these realities. For example, a new report from the COVID-19 Modeling Consortium finds that areas across Austin with higher social vulnerability and rates of infection, such as the Eastern Crescent, have lower rates of vaccination. Similar gaps in vaccination rates by race and place have also been reported across Harris County, Dallas area, and other parts of the state.
Upending these inequities will require centering equity in the COVID-19 vaccine rollout. What that means is working to ensure the vaccine is accessible to all people—especially to those most at-risk, and not just to those with means to navigate the system. As the supply and availability of vaccines continues to increase, the objective is to work quickly, safely, and effectively to get as many shots in arms as possible, and to take explicit measures to simultaneously reach at-risk low-income and communities of color to minimize preventable infections, severe illness, and death. Doing so will require working authentically with communities and their trusted leaders and partners to learn their concerns, provide accurate and credible information, and access to the vaccination.
Lessons, promising strategies, and guidance are emerging on how to more equitably rollout the vaccine. Kaiser Family Foundation released a summary of promising state-level actions for addressing racial equity in COVID-19 vaccine efforts, and Johns Hopkins produced detailed guidance for working with communities of color to ensure equity in COVID-19 vaccination. Leading public health experts Dr. Faith Fletcher and Dr. Aletha Maybank recently penned 5 Ways to Make the Vaccine Rollout More Equitable, and Dr. Kingsley Okafor with Kaiser Permanente highlighted steps for getting to vaccine equity by addressing health equity. Our own work in the wake of the H1N1 pandemic 10 years ago with the HHS Office of Minority Health provides important guidance and steps on engaging communities of color in public health crises, also offering equity lessons from the H1N1 vaccination and response efforts.
Taken together, the following are highlights of what we have learned and what is emerging as strategies for ensuring all communities and people across Texas have access to information, resources, and the COVID-19 vaccine to be #VaccineReady.
Building Equity in COVID-19 Vaccine Outreach, Education and Communication
Work with trusted community partners to get to know communities, particularly in terms of the longstanding structural and social injustices that may serve as barriers to vaccine uptake—from the effects of systemic racism to the digital divide. See for example, our pre-pandemic survey work with community partners in Southwest Houston.
Identify and work with trusted community messengers for the vaccine to develop, test, and deliver clear, accurate, and culturally appropriate information in multiple languages. Trusted messengers and sources of information will vary by community and may include community and faith leaders, community health centers, ethnic media, and friends and family. In particular, partnerships with faith-based organizations are proving effective all across Texas, from El Paso to Fort Worth and the Rio Grande Valley.
Provide safe venues such as virtual townhalls or webinars for community members to interact with diverse experts they trust to share and have their concerns and questions answered in culturally and linguistically appropriate ways. See for example, NAACP’s Unmasked COVID-19 Town Hall Series, or Waco’s Spanish language virtual town hall.
Building Equity in COVID-19 Vaccine Access and Distribution
Prioritize vaccine distribution to ZIP codes most severely affected by COVID-19 and also facing greater social vulnerabilities, such as measured by the CDC Social Vulnerability Index. Harris County’s COVID-19 Vaccine Equity Strategy provides an example of prioritizing vaccine distribution to ZIP codes most severely affected.
Complement vaccination mega sites with targeted vaccination equity clinics and fairs in trusted community settings, such as community health centers, community clinics, mobile clinics, houses of worship, schools, social service sites and neighborhood centers. See for example the unique partnership between Baylor St. Luke’s and Texas Southern University to locate a vaccine site in the heart of the city’s historically Black Third Ward neighborhood.
Expand distribution to individuals facing mobility, transportation, or other barriers to reach homebound individuals. For example, Corpus Christi rolled out a promising initiative with the Fire Department and Meals on Wheels to reach homebound seniors, providing a statewide model. Austin is working to provide door-to-door COVID vaccines in east Austin neighborhoods.
Provide accessible hours of operation to vaccine clinics including after hours, late-night hours, and 24 hours.
Expand access points for registering beyond online, such as providing hotlines, call centers, and in-person registration through community and social service partners. Some localities are removing online registration altogether.
Hashtags: #VaccineReady #NMHM2021
Dr. Philip Huang, Director and Health Authority for the Dallas County Health and Human Services Department, recently spoke with Texas Health Institute about the continued need for preventive measures against COVID-19, current status of vaccination efforts, and what to expect moving forward in Texas.
Q: Why is it important for people to continue wearing masks in public at this stage of the pandemic, especially as millions of people have been immunized at this point?
A: It’s very encouraging all of the vaccination efforts that we’re having and the improvements in some of the indicators we are seeing, but it’s still too early to relax these measures. In Dallas County, as of March 24th, we’ve vaccinated over 532,000 persons, but that’s still only a fraction of the population. Approximately 26% of eligible persons have received one dose, and 13% have completed the full two doses, but that still leaves about three fourths of the population of adults who have haven’t received the vaccination. So there’s a significant percentage of the population that has not been vaccinated and it’s still very important for people to do the other preventive measures that we know are very effective.
Q: What is the optimal percentage of individuals that we would like to be vaccinated before we reach a place where we could see relaxation of masks and social distancing protocols?
The estimate that’s out there is 75-80% of the population need to be protected. That might include some that have had natural illness and protection, but we do not know how long that protection lasts. So, it’s really difficult to set an exact number on that, but the thought is 75-80% of people being protected. Ideally, [that would mean 75-80% vaccinated]. CDC released additional guidance regarding recommendations for people who are fully vaccinated, which, moving forward, provides some guidance and hope for what people can do safely after being fully vaccinated.
Q: If someone has been immunized, do they need to continue to wear masks and avoid crowded spaces where maintaining social distance isn't possible?
A: The new CDC guidance has some specific recommendations. When you are visiting with other fully vaccinated persons indoors, these people are within a single household and no one is at high risk for severe illness, then it is safe to not wear masks and not physically distance. However, if it’s with people from more than one household or persons that are at high risk for severe illness, then continue to practice masking and physical distancing. There is specific guidance in the new CDC recommendations. Also, in medium and larger public settings continue to practice masking and physical distancing. You still want to avoid crowds as much as you can.
Q: Now that there are several vaccine types available from different manufacturers, should people be concerned over which vaccine they receive?
A: All three of the vaccines that have been approved are really very effective. They have been almost 100% effective at preventing death and have very high effectiveness at preventing severe illness. There is still limited vaccine availability, so we strongly recommend that you take the first vaccine that becomes available to you. They are all very good vaccines. These [vaccines] are amazing scientific breakthroughs.
Q: What is one best piece of advice you would give to someone who continues to be concerned or confused about what preventative actions they should be taking?
A: I think we all want to get back to normal as soon as possible. We all want everyone to be able to receive the vaccine as quickly as possible, but we’re still not there yet. There’s still limits on the availability of the vaccine. There is still a large percentage of the population that is not vaccinated. Continue to do the preventive measures that we’ve been doing that have been very effective. We have shown that we can slow this down. Continue masking. Continue to avoid crowds. Continue to stay 6 feet physically distant. Continue to wash your hands. If you are fully vaccinated there are some settings where CDC has recognized it is very low risk and you can relax some of the guidance. But, in general it is still good to continue to be vigilant. We really want to slow this down. We are very concerned about these variants that are out there, the UK variant, South Africa, and Brazil, that have been shown to be able to be spread more easily and may have some resistance to the vaccine. Although, still thus far it is showing there is efficacy from the vaccine. But these genetic variances, and other variables out there make it clear we need to continue to be vigilant.
Q: Any closing thoughts or additional comments you would like to add?
A: We are all very excited about the availability of vaccines. We’re doing everything we can to get everyone vaccinated as quickly as possible. We would love for everyone to be priority. Unfortunately, right now there is still limited vaccine availability, but hopefully that will be changing over the short term with more vaccines becoming available. Let’s keep doing the common sense preventive measures and not let up because it would be very easy that we could see some backsliding on this if we let our guard down.
Philip Huang, MD, MPH
Dr. Huang has been the Director and Health Authority for the Dallas County Health and Human Services Department since February 2019. Prior to this he had served as Medical Director and Health Authority for the Austin Public Health Department, and as Chief of the Bureau of Chronic Disease & Tobacco Prevention at the Texas Department of State Health Services. He received his undergraduate degree in Civil Engineering from Rice University, his MD from the University of Texas Southwestern Medical School, and his Master's in Public Health from Harvard with a concentration in Health Policy and Management. While at Harvard, he led the successful movement to divest of their tobacco stocks. Dr. Huang completed his residency training in Family Medicine at Brackenridge Hospital in Austin, and served two years as an Epidemic Intelligence Service (EIS) officer with the Centers for Disease Control and Prevention assigned to the Illinois Department of Public Health where he conducted epidemiologic studies in chronic disease and infectious disease outbreak investigations. He is currently an Assistant Professor with the University of Texas at Austin, Dell Medical School, and an Adjunct Assistant Professor with the University of Texas School of Public Health, Austin Campus. He has served as Principal Investigator for numerous CDC and State-funded public health cooperative agreements.