As local health departments across the United States prepare for more domestic cases of Ebola, health equity considerations have arisen, especially in relation to immigrants from West Africa. With nearly 574,000 West African immigrants living in the United States currently, many individuals have faced instances of discrimination and, like many immigrant communities, may be less likely to access the healthcare system if they are ill due to fear of discrimination.
Dr. Aletha Maybank, Associate Commissioner and Director for the Center of Health Equity at the New York City Department of Health and Mental Hygiene (DOHMH), spoke with NACCHO about some of the health equity issues that have emerged in New York City related to Ebola. Dr. Maybank shared how DOHMH has incorporated the needs of New York’s West African population of nearly 71,000 into its Ebola response and how other local health departments can incorporate health equity considerations into their Ebola preparedness plans.
Q: What are some of the health equity issues that have arisen related to Ebola recently, and how has DOHMH responded?
A: Since New York is a “global” city, we understood early on that our West African communities from Sierra Leone, Guinea, and Liberia were potentially most at risk for exposure to the virus if there was travel back and forth from their home country. They may also experience emotional distress due to having close ties to family back home more directly affected by Ebola. In light of this connection, the community was possibly going to be at risk for being discriminated against as a result of stigma and fear around the disease. Unfortunately, this came to be, and we have been hearing of instances of overt discrimination, such as employers telling West African home health aides not to come to work, taxi drivers saying people are afraid to enter their cabs, and children being bullied.
We wanted to address this emerging force head on and acknowledged that, like many immigrant populations, our West African population may be less likely than others in New York City to have the connections, social capital, and resources to elevate their concerns and experience. We were also concerned that our West African communities may avoid seeking healthcare even if ill out of concerns about having to disclose their immigration status or being denied care if they did not have insurance. Before the first case of Ebola emerged in New York City on October 23, DOHMH knew that this was an opportunity for us to reach out to our West African communities to learn more, to ensure that all of our communities received accurate information about Ebola, and to make it easier for our communities to access critical information about Ebola that was both culturally and linguistically appropriate.
Utilizing our agency’s assets, the Center for Health Equity first formalized an internal workgroup of staff of West African descent to help guide our process in engaging the West African communities in New York City. This is group has been a tremendous help in providing consistent feedback on our educational materials, such as our literature and PowerPoint presentations, to ensure that they make cultural and linguistic sense.
We then sought to engage people more broadly in all five boroughs across the city. However, we recognized that we needed to know more about who were the leaders and influencers in the West African communities, especially from the three countries of concern. We started by sending out a mass email to over 500 contacts and conducted follow-up calls to over 200 community-based organizations and faith-based organizations to ask for lists of recommended people to reach out to; the best methods of communication to reach everyone in the community; and their main concerns related to Ebola. We got a great response from the email (which even reached places such as Liberia and Atlanta) and phone call conversations which helped to illuminate answers to the questions we asked. Most commonly, the West African population cited their fear that they would be denied care due to a lack of health insurance and that their immigrant status would affect the quality of care they received. DOHMH has incorporated these concerns into our community outreach strategies and since then has emphasized that insurance and immigration status will not affect care and that anyone feeling ill should seek treatment immediately.
In addition to our direct outreach efforts, DOHMH has also been sharing our message through media of all levels, not just the big stations, but also media channels that reach West African viewers. Next, to further ensure that accurate information is reaching all New Yorkers, DOHMH will be launching a larger subway campaign highlighting the facts on how Ebola is and is not spread. There will also be direct messaging that addresses stigma connected to this campaign.
Q: What are some of the steps that DOHMH has taken to address the stigma West African immigrants are facing related to Ebola?
A: We know that fear, miscommunication, and misinformation can perpetuate the spread of Ebola. DOHMH has recognized that stigma has emerged as a result of fear of the virus, so we’ve repeatedly messaged that Ebola is a human tragedy, it doesn’t have biases, it doesn’t have a passport, it is not a country, and it can affect us all. We’ve been transparent about how DOHMH has been working to prepare for and respond to cases of Ebola in New York City and that the risk of contracting Ebola is still low; our messaging has really been focused on calming fears by sharing consistent and accurate information. We’ve also partnered with the Mayor’s Office, the New York City Human Rights Commission, and 311 to help further our outreach efforts and reinforce these messages. New York City has great top-level leadership and spokespeople in Mayor Bill de Blasio and the Health Commissioner, Dr. Mary Bassett, whose actions and statements have helped to calm our residents’ fears.
DOHMH has also recognized the important role that healthcare workers play in perpetuating or reducing the stigma of the Ebola virus. Many healthcare workers have shown that they also have fears about the Ebola virus and the people they are treating. DOHMH has taken direct steps to educate healthcare workers in multiple settings to assist healthcare organizations in filling communication gaps. In remembering that our staff is one of our greatest assets in sharing accurate information with family and friends, we hosted multiple “Ebola 101″ trainings for all DOHMH staff during lunch hours to provide opportunities to answer their questions and address their concerns.
To further educate our local residents, we created a Speaker’s Bureau made of DOHMH physicians and mobilized and trained 250 of our 7,000 Medical Reserve Corps volunteers to give community presentations about Ebola and to pass out “Am I at Risk?” palm cards during community events such as the annual West African Day Parade in early October. We also partnered with West African groups, elected officials, local hospitals, and other city agencies, such as the Mayor’s Office of Immigrant Affairs and the Office of Emergency Management, to host town halls entitled, “Understanding Ebola,” in each borough in the communities with the largest West African populations. This allowed for the opportunity for folks to hear firsthand what we were doing to prepare for and respond to Ebola and to ask their most pressing questions. Also to our advantage, our Press Office did a great job at promoting the events and bringing media to provide coverage on many of the major local news stations. DOHMH staff street teams were activated and gave over 40,000 palm cards to New Yorkers on the streets, at subway stations, and to taxi-Livery cab stations at JFK airport.
Q: What are steps that other local health departments can take to integrate health equity considerations into their Ebola preparedness plans?
A: Local health departments should be aware of the diversity in their jurisdictions and understand how an emergent Ebola case will cause different experiences across communities. DOHMH also found it helpful to develop targeted messaging based on the audience and make sure that the messaging is culturally and linguistically appropriate. Another key aspect of messaging related to Ebola is to make sure that it is accurate and calms the public’s fears.
Forming partnerships in the community will also help your local health department to be ready address health equity issues that may arise. It is important for the local health department to have identified who the trusted local leaders are and form a strong relationship with them since many people will trust what these leaders say. It is also critical to have a good partnership with your local media outlets to ensure that they can get your message out.
We’ve also integrated an explicit community outreach strategy into our ICS structure. Before the case of Ebola emerged in New York City, DOHMH’s preparedness plans, while considered robust and top-notch, were limited in providing a formal structure for community engagement. We’ve since built in a framework, based on the CDC’s Second Edition of Principles of Community Engagement, and strategies that will engage different communities, by sectors, into our preparedness and response plans for now and in the future. We are confident that our partnerships and communication with the many diverse communities, community-based organizations, faith-based organizations, businesses, media, New York City agencies, and healthcare institutions have helped to bring down hysteria and panic and provide accurate information to all New Yorkers about Ebola.
View NACCHO’s Health Equity and Social Justice eLearning series to learn more about the root causes of health inequity and how local health departments can tackle these causes through public health practice.
1. Immigration Policy Center. (2014). African immigrants in America: A demographic overview. Retrieved Oct. 31, 2014 from http://immigrationpolicy.org/just-facts/african-immigrants-america-demographic-overview.
2. Melissa Harris Perry on MSNBC. (Oct. 18, 2014). Discrimination mounting on immigrants. Retrieved Oct. 31, 2014 from http://www.msnbc.com/melissa-harris-perry/watch/discrimination-mounting-on-immigrants-344641091574.