Sophia Easterling was curious about a bus parked across the street from the Mercy clinic, where she works, in Ferguson. Every day, the bus would pull up, park, and sit outside the clinic for stretches of time. Easterling, the clinic’s practice manager, crossed the street to check it out. The driver invited her aboard. What she saw surprised her.
The bus, an Operation Food Search MetroMarket, had been modified to function like a grocery store. The seats were gone. In their place were produce bins overflowing with leafy greens, root vegetables, and colorful fruit—and all of it was affordably priced. “The driver showed me around, and I went grocery shopping on this bus,” Easterling says.
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The MetroMarket is addressing a real need in a community where some residents experience food insecurity and lack healthy options. Access to nutritious food is a social determinant of health, meaning that it affects health outcomes and risks. If you can’t get fresh produce, for example, then you’re less likely to have good nutrition, which, according to the U.S. Department of Health and Human Services, increases your risk of developing heart disease and diabetes. Recent research published in the American Journal of Public Health also suggests that there is a link between food insecurity and forgoing medical care because of cost.
If you’d like to add 10–15 years to your life expectancy, a balanced diet is one place to start and probably a health intervention that comes to mind pretty quickly. You might not think about your job, income, ability to build wealth, education, and access to the internet as health interventions—but they are. The problem? Not everyone in every neighborhood in St. Louis has the same opportunities to get a great job, access a business loan, or connect online.
So Easterling and Mercy saw an opportunity. Together with Operation Food Search and Dierbergs Markets, they have added a new MetroMarket stop, outside the Boys & Girls Clubs Teen Center of Excellence in Ferguson, next to the clinic. Patients who are screened as food insecure will receive vouchers for free produce from the bus. Just like Mercy, other health care systems and organizations are stepping outside the walls of hospitals to start to address these disparities in the name of community health. And they’re getting creative.
“I’ve been saying for several years now that when people think about health, they think about health care in the provision of medical care,” says Jason Purnell, BJC Health care’s vice president of community health improvement. But that care makes up a relatively small part of a person’s overall health, he adds. It’s the larger social, economic, and structural factors that play a part in a person’s life expectancy and whether they suffer from a disease or have a disability.
“We know, for instance, that the life expectancy difference between the top 1 percent of income earners and the bottom 1 percent of income earners is 15 years for men and 10 years for women,” Purnell says. “We’re not going to solve for health equity with just medical care alone.”
Purnell served as the principal investigator for the 2014 For the Sake of All project, which looked at the health and well-being of African Americans in St. Louis. One troubling finding from the report: Residents of certain affluent St. Louis ZIP codes can have up to an 18-year difference in life expectancy than their under-resourced neighbors only a few miles away.
Now, BJC Health care has released a new plan to start to fix health inequities, specifically in the city and North St. Louis County. The health care organization is trying to address the roots of the problem: poverty, education, and housing. It’s also tackling diabetes, access to healthful food, infant and maternal health, and health and wellness in schools. Christian Hospital, for example, is participating in a pilot program with the North Sarah Food Hub to provide prepared meals, meal kits, and nutrition counseling for patients who are either food insecure or financially insecure and also have uncontrolled diabetes. BJC wants to scale this program while continuing to improve access to healthy food. The health care organization is also looking into expanding partnerships with doulas, integrating more doulas into clinical settings, and exploring how Medicaid can help compensate them. “A focus on doulas is really a result of evidence that we have that this kind of continuous support, particularly for Black moms who are delivering babies, results in fewer emergency C-sections, less need for pain medication, and greater satisfaction with the birthing experience,” Purnell says.
Its anchor strategy, however, seeks to leverage its role as the largest employer in the region and purchaser of goods and services to address the wealth and wage gap. In June, BJC opened the Career and Community Hub Connection Center at the Delmar DivINe, Build-A-Bear founder Maxine Clark’s nonprofit hub in the old St. Luke’s Hospital on Delmar. The area to the north of Delmar has historically faced disinvestment; the career center offers the opportunity for people who live there to learn about jobs at BJC. They can also conduct virtual job interviews from the site.
“We understand that employment opportunities and the health of our community are linked,” says Terrie Hart, senior manager of workforce diversity in BJC’s Office of Diversity, Equity, and Inclusion. “There’s lots of data that show that income can have a great impact on your health. By offering these opportunities, and the other experiences to mesh with the community’s needs, we believe that’s the BJC mission of improving the health of the communities we serve. Once you get into successful and sustainable employment, that opens up doors for you.”
One of the most interesting aspects of the plan is BJC financially investing more in the community by leveraging its balance sheet and partnering with Midwest BankCentre. The health care organization is taking a portion of its banking to Midwest BankCentre so that the bank can do more small business lending, real estate lending, and make other loans.
When Midwest BankCentre chairman and CEO Orvin Kimbrough began at the bank, in 2019, he met with BJC president and CEO Rich Liekweg. “[We discussed] Midwest BankCentre’s aspirations to make reasonably priced capital more accessible to more people in the St. Louis region, specifically, low- to moderate-income people,” Kimbrough remembers. “Really just talking about this idea of ‘bank your values.’”
Kimbrough has a background in social work—and he sees how economics impacts everything. One of the ways to promote better health in a community, he says, is to make sure that residents have access to traditional banking services, mortgages, and capital to start or scale a small business. “If you think about how you create wealth, it’s homeownership, and it’s having money to start or scale a small business,” he says.
“Sometimes we have financial institutions who may have branches in certain neighborhoods, but they are only taking deposits,” Kimbrough continues. “They’re not necessarily issuing credit. And the reason that they’re not issuing credit is because some communities are viewed as higher risk. Sometimes that higher risk is a symptom of a broader systemic issue—working-class people, living hand to mouth.”
BJC’s deposits mean that Midwest BankCentre can take on a little more risk. “What BJC did was essentially said, ‘We will deposit [this] dollar amount in your low- to moderate-income branches tied to these 20-plus ZIP codes, and we would like for you to do more lending in these 20-plus ZIP codes,’” Kimbrough says.
Can a single loan really improve community health? Amira Jahic, the owner of AJ Wellness Pharmacy on Jefferson Avenue, became a Midwest BankCentre customer before the partnership with BJC. Her story, however, illustrates the kind of transformation that BJC’s deposits could make in the health and vibrancy of a community.
After the pharmacy Jahic worked at closed in March 2021, she decided to open her own. She applied for a loan with a few banks, but she was denied because she didn’t have enough collateral. A friend told her about Midwest BankCentre. “I kind of wanted to give up, but then something in the back of my mind told me to try one more time,” Jahic says. She reached out and began working with a loan officer; six weeks later, Midwest BankCentre approved her. She opened AJ Wellness Pharmacy in July 2021.
Jahic’s model prioritizes personalized care for her customers. She is originally from Bosnia, and her pharmacy staff of six speaks English, Bosnian, Spanish, and Vietnamese to help communicate in patients’ native languages and see that prescription directions are translated correctly and easy to understand. Five times per month, the pharmacy staff visit nursing homes to ensure that residents are taking their medications as prescribed and that they aren’t doubling up on certain meds prescribed by different doctors, which can be dangerous. They also paint, play bingo, or sing karaoke to connect with them outside of the pharmacy setting. Jahic and her staff act as advocates for their patients, many of whom they can recognize by voice over the phone. They can help them navigate the process of signing up for Medicare, which is sometimes complicated.
“If they don’t have good health insurance, we can try to put them in a Medicare Advantage plan,” Jahic says, “so they can get all of those benefits.”
Kristen Sorth, director and CEO of the St. Louis County Library, remembers packed library parking lots during the peak of the COVID-19 pandemic. That’s because people needed free Wi-Fi, and they could access it from the parking lots of county libraries. For years, Sorth says, libraries have been providing computers, Wi-Fi, and printing services to those without them at home. So when they closed to mitigate the spread of the virus, Sorth worried about the people who relied on them to do homework and apply for jobs. One of the first things that the County Library system did was leave the Wi-Fi on 24 hours per day and boost the signal from the buildings so people could use it, distanced and outside, from the parking lot. It wasn’t ideal, Sorth says, but it’s just one of the ways that St. Louisans pivoted to address the digital divide, the gap between those who have access to the internet and computers and those who don’t.
The internet is no longer just a source of entertainment. According to a recent journal article in NPJ Digital Medicine, digital literacy and internet connectivity should be considered “super social determinants of health” because they affect all other social determinants of health—an individual’s access to employment and housing applications, online learning, or assistance programs, for example. Angela Siefer, executive director of the National Digital Inclusion Alliance and one of the article’s authors, points out that whether or not someone is online can even impact one’s experience with COVID-19. “I use my phone to track the rates, so I know when I should be putting my mask back on,” she says. Virtual health technology can improve the efficiency of care and have a positive effect on health—if a patient can use it.
A new report from the St. Louis Community Foundation and the Regional Business Council, prepared by the Center for Civic Research and Innovation and Ernst & Young, makes clear that almost 55 percent of the St. Louis population live in areas that are affected by two facets of the digital divide. Low-income areas often face three or more of these barriers. About 150,000 households in the city and county struggle to afford broadband, and about 90,000 households in the city and county cannot afford the devices they need. The type of device is key. “We’ve all heard people say, ‘Everyone has a cell phone,’” Sorth says. “But it’s not OK to try and do homework on a cell phone. It’s not OK to apply for a job on a cell phone. Online applications are long and complicated.”
The St. Louis Community Foundation and the Regional Business Council are now hoping to use this data to prepare a plan to address the divide. Kathy Osborn, president and CEO of the Regional Business Council, says the solution might not be as simple as distributing more laptops. She points out that once COVID-19 hit, everybody hustled to distribute computers and hotspots to schoolchildren. AT&T offered low-cost broadband to customers who had been economically affected by COVID. “The problem is: How do you provide that month after month, year after year to households that really can’t afford it?” Osborn says. “Even if you say, ‘It’s only $25 a month,’ for many of these families, that’s prohibitive. They can’t do it. It requires a whole rethinking of how we deliver technology services.” With federal money flowing into the state, it’s an unprecedented time to start to make changes. Under the Infrastructure Investment and Jobs Act, Missouri will receive $681 million to invest in broadband in underserved areas.
Sharonica Hardin-Bartley, superintendent of the School District of University City, sees firsthand how the digital divide impacts students. Some live in areas where high-speed broadband isn’t available. For others, it’s an issue of lack of devices. The school district leveraged partnerships to be able to provide hotspots and devices to families—but it can’t run wire. If neighborhoods don’t have the infrastructure for high-speed internet, the school district can only do so much.
“What I see with my families is that they want to be connected, they want upward mobility, they want to be vibrant members and contribute and to be engaged in the workforce,” Hardin-Bartley says. “I think that some of our communities are just so far behind from an equity perspective that it is a bigger issue.”
Ray Harter doesn’t like the term “food desert.” A desert is natural. The regional director for mission integration at SSM Health prefers the phrase “food apartheid” because the term underscores that this disparity is human-made. And in the communities around SSM Health DePaul Hospital in Bridgeton, 25 to 30 percent of the population struggles with food insecurity.
Just like Mercy, SSM Health is trying to solve for this challenge. To address the need in the community, the health care system looked back 150 years, to when its founding sister, Mother Mary Odilia Berger, walked around the city with a basket of food for the hungry. “That’s always been core to our work: How do we be an advocate for the poor and vulnerable in our community?” Harter says. “Having a commitment to that allows us to understand that our service and our healing presence goes beyond the brick-and-mortar of our hospitals. It needs to go out in the community and be present there.”
To continue its work beyond the hospital walls, SSM Health has launched a clinically integrated food pantry called the Bread Basket for inpatients who are screened as food insecure at DePaul Hospital.
Those patients meet with a nutritionist and social worker during their stay at DePaul Hospital, and when they’re discharged, they’re sent home with a basket of food—a nod to the nun—to feed themselves and any family members for a couple of days. Twenty-four hours from discharge, they receive a call from a caseworker at a local food pantry, so they can continue to access healthy food. DePaul Hospital staff then follows up with patients 30, 60, and 90 days after discharge to help ensure patients’ needs are taken care of, too.
DePaul Hospital has also hosted four drive-through food distribution events in partnership with St. Louis Area Foodbank and Operation Food Search. Because food insecurity is sometimes layered with behavioral health challenges, DePaul Hospital invites members of its behavioral health team to talk to anyone at the event who might need those services.
“People go to hospitals because they’re at a point of vulnerability,” Harter says. “At these events, there’s a gathering of people who may or may not be aware of the other resources in our community. We think about how we can, in their time of vulnerability, not only heal them in the best physical way, but also bring these resources to them from a social aspect. We have to get to the root of the issue.”
Sophia Easterling, the practice manager at the Mercy clinic in Ferguson, also helps run another clinic, this one at The Hub, a community resource center in North City that serves residents in the Jeff-Vander-Lou, The Ville, and Greater Ville neighborhoods. It’s an area with few urgent cares, especially ones within walking distance. Three days per week, Mercy’s clinic offers appointments with a practitioner whose background is in urgent care. There is another employee available five days per week to answer questions and schedule appointments.
But the Mercy clinic at The Hub also offers patients the option to work with Arial Collins, a certified community health worker. Besides being a fixture in the community and doing outreach to let residents know that the clinic is there, Collins connects patients with different services at Catholic Charities’ Pathway to Progress or The T, a nonprofit focused on reducing the impact of trauma.
If a patient can’t afford a medication because they have to pay utilities that month, Collins will help them fill out a utility assistance application and look into whether the medication’s manufacturer offers any kind of help. Often, patients come away with assistance for both.
Knowing the challenges that a community is facing is crucial, Easterling says. However, people won’t necessarily volunteer the information that they, say, missed their last appointment because they couldn’t find a babysitter or couldn’t get time off work. One patient at the clinic is a single father of five. One of his daughters has diabetes. “Trying to get a juvenile to take care of diabetes can be difficult,” Easterling says. “But trying to get him to bring her in is difficult, too. So what can we do? Sometimes if you tell a patient what you think, they’ll end up admitting it. ‘Are you having a hard time getting off work? Well, let’s see if you can do FMLA.’”
In the same way that the clinic is breaking down barriers to health care, it’s also changing the narrative of who works in the health care field. In May, children from the Boys & Girls Club came to visit the clinic. One girl commented that she had never had a Black doctor before, Easterling says. “We were here to inspire her and tell her, ‘You can do it. We’re here, and this is the road that you take to get there.’”
Collins adds: “When you see someone of your ethnicity doing what you thought wasn’t possible in certain neighborhoods, you think, Oh, I can do that, too. It lights a fire inside.”
