Building trust during challenging times, Part II
Dr. Anthony Vavasis on how mobile clinics connect underserved communities with the care they need.
For Part Two of our series on building trust, we sat down with Dr. Anthony Vavasis, co-founder of Mobile Health Map and the Mobile Healthcare Association, and former Managing Director of Medicine at Callen-Lorde Community Health Center in New York. Dr. Vavasis spoke about advancing health equity and providing culturally-competent care for members of the LGBTQ+ community, and how mobile clinics fill a much-needed gap in America’s health care system. Here’s what he had to say, in his own words.
Mollie: The Mobile Health Map team has been monitoring a trend around deferred healthcare – specifically, that people in urban, suburban and rural areas still aren’t getting up to speed on preventive screenings post-COVID. Speaking broadly, are you seeing this in New York? And, if so, what are the root causes?
Anthony: Yes, we are seeing this in New York. And I think the root causes are multifactorial. As a society, we don’t put enough focus on prevention. So, I don’t think patients are always aware of what they need. And then COVID affected that dramatically, and even when people knew what they needed, they deferred a lot of tests because they didn’t want to travel or they were isolated. And then all the access issues that we know about for specific populations still persist, such as lack of adequate transportation or health insurance, proximity to care – all of those I think influence how people do or don’t get preventive care.
Mollie: You have served the LGBTQ+ community for many years. A recent study from OutCare and Healthgrades showed that LGBTQ+ patients are two times more likely to delay care because of a past negative experience with doctors. How do you find, serve and build trust with those who’ve experienced medical trauma, or those who have other reasons for avoiding medical systems or institutions?
Anthony: That’s a really good question and it’s a hard one to answer. At Callen-Lorde… we did a study on those who were referred for colonoscopy. In that patient population, if you looked at patients who identify as trans or gender diverse, the rate of their completion of colonoscopy was 10% of the overall Callen-Lorde rate, which was already lower than the national average. So, exceedingly low.
When we asked them why, it was all the things that you might expect. Medical trauma; being disrespected or not validated for one’s identity; the thought of being under sedation for the procedure felt threatening given a prior history of trauma. And then I would add specifically for transgender patients that oftentimes … they don’t feel safe in a specialist’s exam room if they are “dead named” – that is, using their old name versus their preferred name.
But I think more generally speaking that healthcare is super heteronormative. People get asked questions all the time that are irrelevant to their actual life. And that reinforces a pattern of behavior that most people have experienced historically of not being acknowledged for who they are. So it’s a structural lack of safety. Or you might call it structural homophobia or transphobia where basic life experiences are not factored into health care systems. An example of this is medical records and patient registration forms that aren’t inclusive.
So, to answer your question about how we make it better: It’s to make the patient experience more inclusive … and to start training staff. Helping people to understand the experience of patients who identify with the LGBTQ community. And then I also think creating spaces that are affirming of all identities is helpful to at least signal non-verbally to patients that they are welcome. But it’s a long process.
Mollie: What do mobile clinics offer to underserved or marginalized communities that bricks-and-mortar hospitals can’t?
Anthony: So many things. First of all, proximity. And by that I mean that [in both] rural and urban populations, oftentimes the most marginalized people are least able to transport themselves. They’re reliant on either long travel times on public transportation; or, in rural places, there is no public transportation. Or their car may not work. So, mobile can actually bring care to people and dramatically reduce the barrier of transportation.
I also think marginalized populations are more likely to move and gentrification [can also displace them] in an urban environment. For example, you can build a clinic, but then if [the neighborhood] gets gentrified and nobody lives around that clinic, then they have to transport themselves back to where they used to go. And consequently, you get right back to transportation barriers.
Mobile clinics can move and can follow people. And again, thinking rural, this [helps clinics serve] migrant farm worker populations. I also think the opportunities [to connect] are greater with mobile. You can literally park and [hand out snacks] so that people will come and check the place out. That creates safety. If the first time you step on a van … is to just to see what it looks like or meet the staff, that experience can dramatically affect the likelihood of [you seeking care there when you need it].
Mollie: Mobile clinics clearly fill a gap in modern medicine. How do they fit into the future of health care?
Anthony: I think the key there is that they don’t replace anything. They augment everything. I forgot to say this earlier, but appointments don’t work for a lot of people. And again, the more marginalized you are, the less likely they are to make an appointment. And so creating different models of access is really important.
Where I see mobile fitting into [the future of care] is in all those spaces where there are people who are not getting any attention and have no access. [Health care organizations of all types] have to figure out, for example, who has never had a mammogram and how are we going to get them a mammogram knowing that they probably not only need one, but for whatever reason aren’t going to come to us.
And more broadly, with regard to population health and value-based care, healthcare entities are becoming more and more responsible for the entire population. I think they don’t know how to reach people who don’t come to them; it’s embedded in the structure. [There’s this notion that you] have to come to us because we’re a building and you have to walk through our front doors to get care. So, for all the people who never walk through those doors, there’s no [big solution] right now. But one answer could be mobile. So, big picture, the future is all about getting out to the people who never come in, as it were, to the system.
Mollie Williams, MPH, DrPH is Executive Director of The Family Van and Mobile Health Map and Lecturer of Global Health and Social Medicine at Harvard Medical School. In her free time, she enjoys spending time with her family, traveling, and textile arts.