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Why more coronavirus testing won’t automatically help the hardest hit

Noha Aboelata, the founder of Roots, sits beside groceries delivered to vulnerable people, Oakland.

Noha Aboelata sits in the courtyard of Roots headquarters in Oakland, California.Credit: Roots Community Health Center

Coronavirus testing sites are opening across the United States, but Noha Aboelata, a doctor whose non-profit organization serves people affected by systemic inequity and poverty, says that expanded testing won’t automatically help the communities hit hardest by the coronavirus. Black Americans are dying of COVID-19 at more than twice the rate of white, Asian or Latino Americans. This disparity aligns with a broader trend of communities of colour experiencing higher rates of infant death, asthma and heart disease, among other conditions.

In 2008, Aboelata founded Roots Community Health Center in Oakland, California, to address these health disparities. In parts of Oakland, average life expectancies are around ten years shorter than in San Francisco, a city less than 40 kilometres away. Roots serves an estimated 10,000 people living below the poverty line in Oakland and nearby cities. More than 85% are of African descent.

Nature spoke to Aboelata about what it takes to correct disparities in COVID-19.

Does your work relate to the ongoing Black Lives Matter protests?

We’ve always understood that almost all of the health disparities we see in our community can be traced back to systemic inequities. Roots was created to help address systemic barriers to health care, so it’s really positive that these barriers are being more widely recognized now. But we’re also worried about gatherings, from a transmission standpoint, so we are encouraging our community to get tested if they think they’ve been exposed, and to keep in mind people who might not handle this infection well. We have a lot of families in multigenerational households, and I want everyone to stay vigilant.

How did you respond when there were reports of COVID-19 spreading in California?

We started testing in mid-March at our brick-and-mortar clinics and then at youth shelters we serve. We deployed our street medicine team, which travels to encampments that are in the streets and under freeways in Oakland, in a big, remodelled RV [motorhome]. And we’ve set up walk-up testing sites in Oakland and the nearby city San Jose. We’re partnering with the City of Oakland, and we’re sending samples to six different testing labs that we go to depending on their availability. That was important because results were taking up to seven days, and we need answers faster.

Are you sending people to the drive-up testing sites that are now popping up across California?

No. Drive-up testing won’t work if people don’t have a car. Also, some people don’t feel comfortable accessing services outside of their community. From our work, we’ve seen that trust in the health-care system is a big issue, so operations that just pop up aren’t going to fly. That’s why we decided to attach testing sites to our clinics, which are already anchors in the community, where people can walk up to the site, see a familiar face, and see people who look like them.

Another problem is that most of the new testing sites require people to bring an identification card or enter their e-mail address. People might not have those, and even if they do, a lot of people don’t trust the system enough to hand over this information. Instead, we’ve designed our own testing system and it seems to be working — although it’s labour intensive. But if we want to create more access, it is going to be more expensive and labour intensive.

We’ve tested over 3,200 people so far. Our walk-up site in Oakland has a 14.4% positivity rate.

Why don’t people trust the health system or new testing options?

We think of Tuskegee as the classic example of experimentation on and mistreatment of Black people [from 1932 to 1972, researchers in Tuskegee, Alabama studied the effect of untreated syphilis by enrolling 600 African American men in an unethical experiment in which participants were told they were receiving treatment, but were not]. But there are many other examples. Our communities have had researchers come to them to get information, and then never heard from those folks again. So, there’s a concern about outsiders coming in and taking biological material, who could give the information to third parties. We always have our guard up around these sorts of things, and we know that our community does too. That’s especially true when we’re in an emergency situation where regulations are being relaxed — for good reason. But we do worry about what openings that will create.

In addition, people are mistrustful because of a deluge of conflicting information on COVID itself. People are not sure what to believe, what’s political, what’s scientific, what’s real or not real. People are getting fatigued from information overload, so they’re letting their guard down, or coming up with their own thoughts about what to do because there’s no clear health messaging.

What does Roots do when someone tests positive?

The testing is easy compared to the follow-up. If someone tests positive who doesn’t have a home, we need to track them down. That can be difficult because some people we serve have addiction or mental-health conditions, and don’t want to be found. Sometimes the phone number they gave us doesn’t work. We have managed to find people through our street medical team. Then it can take a lot of talking and coaching to get them to move to one of the isolation hotels that Oakland has provided.

For people who do have homes, we first ask if they can isolate themselves. Some people are living in crowded conditions, such as 12 people in a 2-bedroom apartment. This means that three people isolate in one room, and others are in the remainder of the apartment and quarantining. Quarantine and isolation are also challenging situations because some folks who are losing income are already living day-to-day, hand-to-mouth. So, a lot of what we’ve done is to coordinate delivering food boxes and basic cleaning supplies. Or we make sure that people have a support network who can drop off groceries to them.

Roots has given away food, hygiene supplies, diapers and other things for families for a long time. But we’ve had to really, really scale that up since the pandemic hit — and not just for the people with COVID, but for people who are laid off and lost their income. We’ve at least quadrupled the amount of food distribution that we do.

These are formidable challenges. Are you optimistic?

The work I’m talking about is very labour intensive, but if we don’t think about investing heavily in marginalized populations, there will inevitably be severe disparities in communities of colour. There needs to be an understanding that this will have to look very different from how we deliver care to other populations. We don’t have a template and we need to create one, and now is the time.

doi: https://doi.org/10.1038/d41586-020-01781-z

This interview has been edited for length and clarity.

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