Trust and Transformation: Building Health Equity in San Diego

Pastor Clarice Christian gets to know the individuals and families who attend her services at the Immanuel Chapel Christian Church. Some are struggling with a chronic disease. Pastor Christian says a prayer for them. These days, however, she’s doing a whole lot more for them.

Her congregation is one of 21 participating in the Southeastern San Diego Cardiac Disparities Project, which is spearheaded by Elizabeth Bustos of Be There San Diego and the Reverend Gerald W. Brown of United African American Ministerial Action Council, the 2017 Robert Wood Johnson Foundation – National Civic League Health Equity Award winners.

Funded by The Centers for Disease Control and Prevention’s (CDC) Racial and Ethnic Approaches to Community Health initiative, the project is improving the cardiovascular health of African Americans in that community by changing two fundamental systems that can influence their health: faith organizations and health care providers.

The project is focused in the neighborhoods in Southeastern San Diego, the city’s African American hub, because that community has the county’s highest incidence of heart attacks and strokes. The project’s goal is to improve the cardiovascular health of 6,400 African American adults living there.

Led by Bustos and the Rev. Brown, the effort seeks to “transform the individuals and organizations it’s touching, leading to improved health outcomes, helping to achieve health equity and ultimately delivering social justice to a community historically lacking it,” per the award nomination.

The plan must have three components:

• nutrition education
• exercise and health monitoring
• tracking of participants’ blood pressure and weight

The pastors also agreed to come together once a month to learn from one another and share resources. And they agreed to meet with clinicians, particularly doctors, to share their experiences with them. To date, 21 churches and a mosque have full-fledged programs to combat heart disease and strokes, and these are as varied as the faith organizations themselves.

AsBustos and Brown explain, this approach is not simply about creating a heart-healthy intervention. Rather, “it builds a structure for African Americans to improve their health on their terms, relying on their trusted leaders, and controlling the way they interact with other powerful entities. Other communities get to do this naturally because of their race, economic status or other factors.”

Where others might gloss over or ignore the legacy of race and racism in shaping health in African-American communities, Bustos and Brown recognize that these are truths that must be confronted. And that process began with acknowledging that the health of African Americans is inextricably linked to their history. Talking about the legacy of racism, historical disenfranchisement and impacts on the overall health of African Americans became non-negotiables. The project covers an area just east of downtown San Diego made up of a cluster of working-class neighborhoods. The legacy of racist policies has shaped virtually every aspect the residents’ lives there. They struggle against the social barriers of poverty, poorly performing schools, lack of economic opportunities, and an inequitable criminal justice system. They also face the barriers of their physical environment: substandard housing, lack of well-appointed recreational spaces, too many liquor stores and fast-food restaurants, few supermarkets, and a lone pharmacy. Families living there struggle to find places to buy fresh food that are close by and affordable, or nearby safe parks. The top five causes of death there are heart disease, cancer, a cluster of other causes, unintentional injuries and stroke, the highest rates in San Diego County.

This area, then, was a prime magnet for health studies whose stated goal was to improve the community’s health. Ms. Bustos and Rev. Brown were not the first people to approach African American congregations in Southeastern San Diego with the hopes of forming a partnership around health. Over the years, many pastors had opened their congregations to researchers who had “come into the ‘hood” then disappeared. As Senior Pastor William A. Benson explained, “We were concerned about people coming into the community with passion but what they really wanted was our numbers, our data… they would put in for grants and get the money and it never came back to the community. We were tired of being played.”

Rev. Brown pledged to his fellow pastors that, “We’re going to do things differently.” And indeed, they have.

Ms. Bustos and Rev. Brown took the time to listen to these concerns, to acknowledge the community’s history and to build relationships. Work meetings became forums for candid dialogue about the role race, exploitation and neglect had played – and continues to play — in the community.

For example, the pastors demanded that the project be transparent for them to consider joining. They wanted to know what data was going to be collected, who was going to collect it and how it was going to be used. As a result, the partners created a Data Stewardship Agreement that gave the pastors the transparency they wanted and ownership of their data. It took nearly a year of listening, learning and conversations to build the trust necessary to act.

Why partner with churches in the first place? Throughout history the African American church has served a “sacred place of refuge for the afflicted, barren, beaten, discontented and discouraged soul. The church serves as the hub of communication for healing of the body, mind and soul, it serves as the connection to the Divine”, Rev. Brown said.

The pastors are trusted sources of information. “They represent the voice of God, offering correction, encouragement and inspiration to each member of the congregation.” The pastors witness firsthand the arc of congregants’ lives, from birth to youth to midlife and beyond. They see them much more frequently than they see their doctor and can observe their ailments and the toll they take.

Thus the pastors were uniquely positioned in the African American community to lead the way to heart health.

At Immanuel Chapel Christian Church, for instance, Pastor Christian developed a plan that calls for monthly meetings on a Saturday morning with her congregants. In her opening prayer at the meetings, she tells them that scripture calls for taking care of one’s body to be able to serve God. Afterward, they take a brisk “Gospel Walk” around the neighborhood, singing an inspirational hymn. They pass businesses, dilapidated houses and empty lots. Each month, they add another block or two to their walk.

Back in the pews, the congregants next hear from a featured speaker – usually an African American health professional. The speaker explains the scientific and medical causes of cardiovascular disease and offer practical, culturally appropriate recommendations.

As morning gives way to noon, the participants enjoy a healthy lunch and fellowship. In a single morning, they’ve nourished their soul, fed their body, participated in group exercise and received disease prevention information from a trusted source in a language they understand paving the way for them to act on that information to protect their health.

This work is not only transforming the way parishioners think about their health, it is shifting pastors’ understanding of their congregation. They discovered that they had doctors, nurses, personal trainers, teachers and healthy cooking aficionados among their congregants. They invited these individuals to form health ministries. These lay leaders implement the church’s heart-healthy plan, which includes monitoring and tracking the blood pressure and weight of congregants. This monitoring alone offers opportunities to engage congregants about their health and to detect problems, and lets them know that they are not alone as they face them. To date, the congregations are tracking around 2,000 people.

It is also shaping pastor’s view of their role in helping to support the health of those in their congregation. In their messages to their flock, the pastors regularly raise awareness of how preventable heart attacks and strokes are with small lifestyle changes. They encourage the congregation to take steps to become healthier. “Don’t forget to stop by to get your blood pressure checked,” “I’m looking for you at next weekend’s health class,” “Remember, no fried food at our monthly reception.” Many publicly announce that they are trying to eat healthier and are struggling to lose weight.

Many of the people who attend these congregations are in their sixties, seventies or older. It’s worth noting, however, that many take care of their grandchildren. The project underscores that prevention begins at an early age, and that these project participants can influence a younger generation.

The legacy of racism and neglect hangs heavily over health discussions in these congregations. Often, the name of the infamous Tuskegee experiment is raised. The pastors acknowledge that their congregants do not trust doctors, and that is a barrier to getting timely medical care and following prescribed treatment.

“There is such a huge trust issue,” Pastor Christian told doctors and other healthcare providers at a regional health summit in 2016. “People are fearful. They remember what happened to their grandmother, to their sister, their next-door neighbor.”

At the same time, the clinicians expressed frustration at having some of their African Americans patients not adhere to their medication regimen, indeed, who follow a relative’s lead instead of what is prescribed.
The project has created safe spaces for clinicians, particularly doctors, to interact with faith leaders, through its annual health summit. The exchanges provided insights not easily gained anywhere else, raising awareness among clinicians of the history and culture of African Americans, with the goal of informing all levels of healthcare, from the treatment of individual patients to how a health system treats a community.

These meetings have already led to tangible results. At one, the ACC/AHA Cardiovascular Risk calculator was introduced to the healthcare providers, many of whom said they were unfamiliar with it. The online calculator estimates the risk of the patient having a heart attack or stroke depending on a variety of factors, including race. African American patients face a significantly higher risk. On the spot, many doctors expressed an interest in beginning to use it. Furthermore, these community-clinical linkages have resulted in doctors volunteering to help the health ministries — doctors are sharing their knowledge in meetings, trainings and other health events organized by the churches.

The project’s data are still being collected, however, the pastors regularly share stories of individuals understanding their risk, losing weight, increasing medication adherence. We believe that the data will show improved health outcomes.

All the churches participating in the project have formed a learning community. Their pastors and their health ministry leaders come together once a month to get an update on the project and to share experiences and best practices.

This is significant because the churches are from various denominations and can have starkly different histories, economic resources, size and type of congregation and leadership. Yet they have come together to help improve their congregants’ health, and are willing to help each other.

The Southeastern San Diego project supports an approach to developing health-enhancing programs, called Community-Based Participatory Research. According to the Institute of Medicine, this approach not only increases the knowledge base for public health but also promises to identify interventions that are ready for dissemination and are sustainable because they have been developed with community engagement – and there is trust.

This project is showing how this approach works and can serve as a national model. Project organizers, led by Ms. Bustos and Rev. Brown, developed a relationship of a key community partner, the faith organizations, and encouraged them to own their heart-healthy plans. As a result, the pastors are raising awareness of cardiovascular disease from the pulpit and the congregants are taking steps to reduce their disease risk. What’s more, the project organizers brought the community together with health practitioners, who become more aware of African Americans’ history and their concerns.