There have always been health inequities in certain communities, but the Covid-19 epidemic has exacerbated many of them and brought them to the forefront of the public's mind over the past year.

Why so many Black patients distrust Covid-19 vaccines (and 3 ways to rebuild their trust)

In this episode of Radio Advisory, host Rachel Woods sits down with Fred Cerise, CEO of Parkland Health and Hospital System, and Steve Miff, president and CEO of Parkland's Center for Clinical Innovation, to talk about why the health system stepped in to address inequities in Covid-19 vaccination rates, and how the organization is doing it.

Read a lightly edited version of the interview below, or download the episode to hear the conversation.

Rachel Woods: Over the last year, there has been a real reckoning with the inequities that exist here in the United States, inequities that result in dramatic differences in health outcomes for people of color. As white people continue to receive the majority of lifesaving coronavirus vaccines, there is real potential for the health equity divide to get a lot worse.

So, I wanted to bring an organization to this podcast to talk about its proactive efforts and share what it's doing to reduce inequities, to combat legitimate hesitancy, and to build trust with communities of color. To do that, I've brought two leaders from Parkland Health and Hospital System: the CEO, Fred Cerise, and the president and CEO of Parklands Center for Clinical Innovation, Steve Miff.

Now, I want to start at the high level because there is so much that organizations can do to focus on reducing inequities. What led you and ultimately Parkland to focus on inequities in Covid-19 vaccinations specifically?

Fred Cerise: Inequities is a big part of the work we do with a public hospital, with the public health system in Dallas County. Looking at access to care and outcomes and those types of things, it's part of what we do.

We know that at times of crisis, those disparities become exacerbated. We've seen that happen over and over again. We knew that that was coming. With the onset of Covid-19, whether it was testing or treatment, or now vaccinations, we knew it was something we're going to have to be intentional about focusing on.

Woods: Steve, why vaccines?

Steve Miff: Even from a data perspective, it's part of everything that we do. Leveraging social determinants of health and leveraging data science to understand somebody's life challenges, is basically embedded into how we analyze and look at everything.

With vaccines, it's been equally important to really understand those factors, understand the vulnerability, understand who's at highest risk, and be able to use that to prioritize or target things in a very equitable way.

Woods: Fred, I want to come back to something that you just said—Parkland takes on a public health role in the community. But I don't know that every other health system or hospital leader actually thinks that way. In fact, I've had folks specifically say to me, "That is not our job. Our job is not to do what the public health agencies do." What do you say to that pushback?

Cerise: First of all, Parkland is a little different, because we are the county hospital, and about a third of our budget comes from the county. We do have more of a role there than others. But I would push back to the other hospitals in general and say, health care consumes almost a fifth of the economy in the country, and hospitals are about 30% of that.

There's a lot of investment in our systems, and there's a lot of resources that we have. If you look at the public health system, those things are generally narrowly funded, they're pretty lean, they don't have the capacity to surge the way hospitals, with the scale that we have, can turn things on at times of a crisis.

I would push back and say it is the hospital. We can't ignore the fact that we exist in a bigger ecosystem, and the communities have invested quite a bit of money, trust in our systems. So, I do think we have a responsibility to reach beyond our traditional roles, particularly in a time of crisis.

Woods: When it comes to inequities in vaccination, there's a ton that leaders can do, but my understanding is that Parkland decided to start first on building community trust. Why was that so important?

Cerise: We know we're going to have enough vaccine at some point to vaccinate everybody who wants to be vaccinated. The limiting factor is going to be acceptance of vaccines. If we're going to reach herd immunity, we need 70%, 80% of the people to accept vaccination. We also know that there's a history of mistrust among minority communities, some of that very well founded, understandable.

So the limiting factor is not going to be the availability of vaccine, but it's going to be acceptance of the population. We can't ignore that fact.

On the one hand, if you didn't care about community mistrust in that piece, you still need to do that from a public health perspective to reach herd immunity. We do care about that other piece, and we think it's important that we address the historic mistrust that's well founded.

Woods: I appreciate the fact that you said that this mistrust is legitimate. There are well documented reasons throughout history, up until right now, for why Black, Hispanic, Latino populations would be hesitant to use the health system, period, let alone receive a vaccine that's only gotten emergency use authorization.

Let's talk about what Parkland did. You have described this as a little bit of a push, and a little bit of a poll. What do you mean by that?

Cerise: The push piece will come a bit later, actually, and that is people who are already coming to our system, that are accessing services, when they come, we will be able to push the vaccine out as they come in to access clinical services.

Right now, the effort is to pull, and that is doing outreach to people who are not showing up at clinic for an appointment. But we're reaching out to them to say you're at risk, we know you're at risk for these reasons. So, trying to pull them in to our vaccination sites right now.

Woods: The pull, is I'm guessing where it matters a ton to look at data, which Steve is, I think, where you come in.

Miff: That's exactly right. What we've tried to do is really understand the individuals, the neighborhoods, the communities most vulnerable for Covid by combining a number of different data sets—not only the key elements from CDC, such as age comorbidities, but also incorporate into that factors such as mobility and social determinants of health.

By doing that, by understanding who's most vulnerable, we can then target more specifically those neighborhoods and understand the ethnic racial makeup of those communities. So any outreach can be done in a very cultural sensitive way, in a very targeted way.

Woods: Yeah, and Steve, your team put this together as a, I think it's called a vulnerability index, is that right?

Miff: That's correct.

Woods: It gets down to, I want to say it's block by block level data that you can use then for targeted outreach.

Miff: That's exactly right, we've been doing it at the block level to get really hyper localized and very specific. Then for some of the vaccination privatization work, we've actually taken that even to an individual level.

Woods: An individual patient or person level?

Miff: Correct. Because if the data is available, we know the age, the comorbidities based on their medical history. Then we can apply some of the other factors relative to the socio-economic status, and the level of mobility that occurs in their neighborhood, and combine those to be able to get a much more granular understanding of their environment, and also understand they live in an area that is a hotspot at that particular moment in time for Covid.

Woods: I've been curious, as you've built this vulnerability index, you've mentioned a ton of different inputs. Are there any that stick out as ones that maybe other organizations aren't prioritizing right now? The most obvious inputs are things like age, demographic, health status, do you have comorbidities? But because this is so robust, are there any inputs that you want to put on the radar for other clinical leaders to make sure they're incorporating?

Miff: The key learning for us was that incorporating the social determinants of health data—a combination of income level, education, housing situation, transportation needs, food needs, really looking comprehensively at all those factors in aggregate, and using that in a way to understand also vulnerability.

What we've noticed by doing the retrospective analysis is that when you combine all these different factors together, there's an 87% correlation to both infections and Covid-like illness presentation. So, they're very highly correlated, when you combine them.

Woods: High vulnerability index, high risk of disease and ultimately death from Covid-19. So, let's prioritize getting those people the vaccines first.

Miff: That's exactly right. Then one of the other things that we've learned is because as you mentioned earlier, Covid has impacted different racial ethnic groups, some a lot more than others. One of the other things that we wanted to make sure that we do is understand what's driving some of that? The key learning for us has been that by incorporating the social determinants of health, that has been, to some extent, the equalizer across different racial and ethnic groups.

For the point to the need to take that into account, not only particularly now for Covid-19, but a lot of the other clinically related things that we've done in the past and we'll continue to do in the future.

Woods: You used the word equalizer just now, which is, I think, incredibly important in this moment where a lot of people are anxious and eager to get this vaccine, particularly white people, white people who can take time off work, who can sit on their computer ready to refresh the page. I think there is a lot of concern and question about how do you balance appropriate prioritization with playing favorites, or maybe creating downstream effects that you didn't predict? Is that something that Parkland has had to deal with?

Miff: I would say almost daily, because you want to make sure that as you put this information out there, it's first of all, very data driven. It's guided and driven by science. Also, that's very transparent, this cannot be a black box, so you have to be very transparent of how inputs are, what outputs are, so folks at all different levels can understand how it's being done.

Woods: Fred, I wonder if you can give an example of how this kind of daily challenge of balancing appropriate prioritization and playing favorites has actually played out at Parkland.

Cerise: Probably about a month and a half or so ago, we knew that there would be a weekend, where we did not have people scheduled, to a large extent for infections. We're still in our ramp up phase, and we knew the county sites were seeing what you described earlier, and that is a disproportionate number of white individuals who had gotten onto the registration sites early and quick, and were getting vaccinated at the county site.

We did some outreach to some of the communities that we know are heavily represented by minorities, that we know were not getting vaccinated at the county sites. Did some outreach to churches and did some outreach to community centers and whatnot, and said, "Listen, we're going to have some walk-up availability on Saturday and Sunday from these hours."

Well, I got blowback from people almost immediately about having a secret vaccination event

There was nothing secret about it, it was all over social media. We had a line of people, probably four blocks long before five o'clock in the morning. So, it was definitely not a secret. But just by trying to do some targeted outreach to some areas that we knew were not getting in, generated that sort of backlash. Now, we're trying to get people registered at a site, and then with that registration, apply the criteria that Steve's group has been able to develop, to prioritize once people get on the site.

I'm maybe the 100,000th person to register on a site, but based on my risk, I'm going to get an invitation to get a vaccine in the next week, because by objective criteria, I'm a higher-risk person.

Woods: This is really important. Everyone that I know personally, and professionally has an online registration system for vaccines. That's where you hear the stories of more affluent people with more control over their schedule, blocking their calendar so they can just refresh the page over and over again.

That doesn't even account for access to broadband issues, and do you have a computer and things like that. Have you stuck with this online registration system, or have you pivoted to other ways of registering more vulnerable populations for the vaccine?

Cerise: It's both. We have stuck with you online, but recognizing what you just said, we've had to do more outreach so that we can help people sign up, we can help people that don't have access to computers, partnering with community organizations that then can get people in and enroll people.

Once they get on the registration list, then you can apply prioritization, based on objective criteria, but it is a challenge to get on that list. We've had to do a lot of individual outreach that doesn't involve being able to refresh, refresh, to get them top of the list.

Woods: There's of course the challenge of prioritizing the people who you want to engage. But now there are a heck of a lot more vaccines on the market. We've got Johnson & Johnson's (J&J) one dose vaccine. We've got Pfizer, we've got Moderna. Have you made a decision as an organization about how you will prioritize specific vaccines for specific communities?

Cerise: We're in the midst of that right now, as you know, because the J&J vaccine just got released. So, we expect to get some of that this week. We're doing like a lot of organizations, you're looking at your populations that may be tougher to track to get back for a second dose, and that's who we're going to target with our J&J vaccines initially.

We have a homeless health care program. That program will take the vaccines to homeless shelters into the sites that they visit around town. We have a jail health program, we'll take that vaccine to the jail to administer that way.

One of the things that, I think everybody's looking at there, and you hear the conversation now is, okay, are you going to give a better vaccine to this group or that group?

We just don't have the data to say we have a better vaccine. That's the honest truth.

Woods: Is that something people understand? Because there's a difference between reality and perception. We started off this conversation by talking about inequities more broadly, we haven't even talked about things like access and how difficult it can be to get somebody into health care, period, if they're working two jobs or don't have transportation, et cetera, which is a huge benefit of the J&J vaccine.

The thing that keeps me up at night is, would those same vulnerable populations, those largely minority populations think, I'm getting the short end of the stick here. How do you combat that?

Cerise: It's a real issue. We've struggled with that too, as we're developing our strategy. But the truth of the matter is, we don't know that one is better than the other, they have not been tested head-to-head at the same time. You've got the J&J that's been tested later, where you've got varying strains, you're not taking into account how many people will show up for the second dose or miss the second dose, and what the impact of that's going to be.

With the best data we have, and listening to the experts that dedicate their lives to this, you got people like Dr. Anthony Fauci who are saying, take the vaccine that's in front of you, and then I really not the science to say one is better than the other right now.

Woods: I couldn't agree more. I'm thinking if I'm spending my time arguing with my friends over Zoom happy hours and telling them, "No, you've got to get any vaccine you can." I can only imagine how difficult it is when you extrapolate that out to the rest of the population.

Steve, you spend a ton of time on building out this robust data set, this process, this ultra-specialized way of prioritizing folks for the vaccine. I have to imagine that it hasn't always been a perfect process. What are some of the big hiccups or barriers that you've hit, and what did you learn from that, that you want to make sure our listeners know about?

Miff: You're absolutely right, it's a learning process, and the best we can do is adapt. I think there are two key things that come to mind. One is the amount of time and energy that we spend every day cleaning the data and making that actionable. What I mean by that is something that you actually alluded to earlier on folks registering again, and again and again, because if I do it 50 times, chances are maybe better than I'm going to get higher on the list. So, you have a lot of duplications of registrations.

Then the second one is to be able to actually proactively know if somebody on the list has already received the vaccine, because it's not always easy or convenient for somebody who is on the list to call back and say, "By the way, take me off the list because I received the vaccine."

Woods: Steve, I got to tell you, my parents literally went through that themselves, where my mom was able to get a vaccine appointment, my dad wasn't. They ended up going to the same appointment anyway, saying, "Please, please, can he get a dose?" He was able to get a dose, and then my mom spent two hours on the phone trying to cancel his appointment for the following week.

Miff: No, that's exactly right, and it's a very dynamic process. So, you'd have to do this daily. Because then once you provide the outreach teams with that list, their success rate for contact with somebody registering, you want it to be as high as possible. If too many folks have even multiple times on the list, and they're calling the same people if they've already received somewhere else, it's a little bit of a waste of their time.

One of them is really just that blocking and tackling to make sure that you use the information that's most curated and accurate. But the second one, you also alluded to, and there was a miss.

When I think back, it's like, boy, it makes so much sense, why do we miss this? But we've described, we use this very data-driven, scientific way to rank folks based on their risk.

Well, by doing that, what we've noticed is that you end up having families in which one spouse might be 65 with no comorbidity and somebody else who is 74 with a comorbidity, and they might end up several hundred spots away from each other on the list, and hence, they're being scheduled at different times to different locations, which is not that convenient for them by any stretch.

Key lesson was, as we create these lists, let's make sure that we identify if you have folks who are together within the same criteria and categories, but bring them in a way that they can be scheduled at the same time.

Woods: So far, we've been talking about the pull part of your strategy, the proactive data-driven outreach that health systems can do to engage the communities who are in the most need of protection, not even the communities, the people, down to that very, very specific level. But the other side of the initiative that you described is more of a push. What does that entail?

Cerise: The push is more for the people who are coming to the doctor for other things, but you're taking advantage of that opportunity to get the vaccine to them. As we think about the mistrust that we talked about earlier, the one place that is consistently ranked highest among people in further source of medical information is their physician's office. They trust their doctor to give them a message. We want to take advantage of that.

Also, from a convenience standpoint, a lot of the patients who we see, a day to the doctors means a day off of work, it may involve child care and transportation challenges. To the extent that we can push that vaccine at the time that we have people in the office, it's going to be a big advantage to us and to the people that we take care of.

Right now, what we're doing is routing down from the office, because it's not a disseminated vaccination site strategy at this point, you're still in hubs.

We're capturing the office and then directing them to the vaccination site. But what we hope at some point, when we have a more disseminated strategy is to catch everybody when they're coming through the office and do their education there. While their visit for whatever, they're going to get the vaccine at the same time.

Woods: I love this comment, because it's such an easy thing to do. Even if you don't have the data and analytics to build this robust index, what you can easily do is make sure every time patients are showing up for their doctor's appointment anyways, that you're assessing their risk, addressing their concerns, and pushing them to an immunization. Ideally, that moment that they've already taken off work and etc., if you can. I love that approach.

Cerise: So much of what we do is structured around the health system and the convenience of the health system. As we look for more opportunities to be more patient centric, how can we make things easier for the patients? That's just one small example of that.

Woods: We were just talking about using existing appointments as an opportunity to address concerns about the vaccine. This is another area where I will admit, I start to feel uneasy very quickly, because I hear a lot of well-intentioned folks focusing on education, and I'm afraid they might be missing the point.

They're talking about how we need to educate people of color; we need to educate Black communities about the benefits of the vaccine, etc. But that assumes that these groups are uninformed and uneducated, when, in my experience, they're actually ultra-informed about the history of medical abuse and experimentation on their people. Again, that gets back to legitimate mistrust.

When it comes to community outreach and this kind of push, how do you see the difference between education and a campaign aimed at building trust?

Cerise: I think that is a great distinction, because like you said, a lot of times the problem is not education, but sometimes it is. I think the approach has to be both.

I'll give you an example, I talked to one of our housekeepers at the hospital a few months ago, and asked her if she had gotten vaccinated, she had not. I asked her what her concern was? She said she was afraid she would get Covid-19 from the vaccine.

In fact, when you look at the data, about half of Blacks who are vaccine hesitant list that as one of their concerns that you actually get Covid-19. There's a pretty straightforward educational opportunity there around how the vaccine works.

I was able to have that conversation because I know the person and we already have a rapport, and she ultimately got vaccinated. But at a community level, that's probably a message that may be difficult for me to deliver, and it's going to be better received from somebody who has established trust in the community.

One of the things that we're working with is, who are those community members whom people know and trust, and how can they help us deliver not just some of the FAQs, the educational pieces, but also, deliver a message, from a trusted person perspective, that the vaccine is safe and effective?

Woods: Who are those people whom you've maybe identified in the community?

Cerise: We've had a series of calls with community leaders, city councilmen, commissioners, church leaders, leaders of community-based organizations, and one of the cool things our team has done is— when one of those individuals will come to the drive thru to get vaccinated, they'll do a video and capture the vaccination on video, that person can deliver a message, and then they will get a package, an educational package, a toolkit that's got their video in it, and it's got FAQs, and information about the vaccine that they can then take to say their congregation and use that to educate people about it. They'll get their little education pack, and then they go on and they're ambassadors for the vaccine.

Woods: I love that term, ambassadors for the vaccine, and your role, the role of the health system is to provide the material to make it easier for them to be an ambassador in their community.

Cerise: Well put, it's exactly what we're trying to do. We try to establish trust, and it comes by showing up over and over and over again.

But the reality is, there are people who are embedded in those communities who have been there forever, and people know them, they trust them, and they're going to be a better messenger than somebody from the hospital.

Woods: Yeah, exactly. You two have been at the forefront of creating this really robust campaign. We've talked about the proactive, data-driven outreach, making sure that you're connecting patients to vaccinations when they're already interacting with the health system, and then using community ambassadors to establish some trust in the community. What's the next step for this campaign?

Cerise: One of the things that we were working on before Covid that really has applicability now, as well, and particularly as the vaccine becomes more widely available, is working through community groups that again, already have some established trust to help us get those health messages out. We have a group of high school students who have an interest in health care, that we've been working with as health ambassadors.

During flu season, they helped us create a flu message that was done in English and in Spanish, was promoted in their school areas, and were able to get, one day and a half over the weekend, between 1,500 and 2,000 people vaccinated for the flu, many of whom had never been vaccinated for the flu before.

So to try to create some momentum there, building on programs like that, where we're using the community assets to help provide some information, and then they can carry that message forward in their own community.

Woods: I love that example, because I think it's obvious to look towards ambassadors who are leaders in the community; the religious leaders, the City Council people, etc. But what you're talking about is the fact that you can establish some trust and you can create ambassadors with kids, with trusted kids in the community, in the high school.

Cerise: It was great too. Our high school student workers, they were able to deliver a message on Spanish-speaking radio, so they became famous among their peers because they were on radio, and they were giving a message of why the flu shot's important. People in the community were hearing from people they knew, and it pulls people in, again that may have an interest in public health and gets at an early age shows what an impact they can make.

Miff: Rachel, what I will add here from more of a blocking and tackling perspective—we're tracking the administration of the vaccines at a very granular level, to really understand where and who's getting the vaccines. Are they coming back for that second dose?

Because while we look across the whole county, across the whole city, it's how this plays out within certain neighborhoods. So, make sure that as we track those elements, we're able to target better or better understand where the uptick is lower, etc., because we're only going to get there by bringing the whole community up together.

Some communities, and some neighborhoods are falling behind, we then can understand why and double down there to make sure that we're able to elevate them concurrently.

Woods: You're also right, that some of the most important work that you can do is not the sexy stuff. It is the blocking and tackling and continuously going back to the data and figuring out what works and what didn't and fill the gaps, that really is going to make a difference here.

Fred, I want to ask you sort of a personal question, before we close out. You are the CEO and the leader of Parkland, you are also a white man. What did you see as your specific role in this initiative, the thing that you didn't want to or knew that you couldn't delegate or pass on to anyone else?

Cerise: It's not a specific task, but it was the direction to say we're going to lean into this thing, and bring the full force of the resources we have in the health system to address not only things like testing and treatment and vaccinations, but to do it in a way that addresses, what I anticipated we would see, and that is the inequities that have played out across the country.

To set the idea that, when the county was talking about doing testing for Covid-19, that we would bring our resources, and we would bring our resources to focus on the underserved areas of town, and make sure that those individuals are going to have access to testing.

Then we have a team that just goes crazy. Once you point them in the right direction, and give them t