This article is part of Harvard Medical School’s continuing coverage of medicine, biomedical research, medical education, and policy related to the SARS-CoV-2 pandemic and the disease COVID-19.
The severe pain and lengthy hospital stay could have been avoided, said Angela, an undocumented immigrant from Colombia, if only the application she had submitted to receive Charity Care in New Jersey two months earlier had been approved, or if just one of the nearly 70 follow-up calls she made had been returned.
“Maybe I wouldn’t have spent so much time suffering and wouldn’t have ended up with a severe kidney infection, as well as severe anemia and months without work,” she said.
Instead, Angela, who did not want her last name used for this article, was hospitalized for 13 days in late 2020 to clear the infection and replace a stent that had been inserted in May for kidney stones.
Undocumented immigrants in the U.S. have lower rates of health insurance and receive lower quality of care than people born in the country, according to the Robert Wood Johnson Foundation. During the COVID-19 pandemic, the challenges for undocumented immigrants in getting access to health care have only intensified, widening existing inequalities and increasing the spread of the disease.
Filling a void
But Angela is now one of the more than 600 undocumented immigrants being served by Quetzales de Salud (Quetzals of Health), formed by Harvard Medical School students in the spring of 2020. The organization is geared toward improving access to medical care for uninsured immigrants while assisting them with costs related to medication, outpatient clinic visits, or specialty care.
The founders—third-year MD student Lianet (Lia) Vazquez, third-year MD-PhD student Silvia Huerta Lopez, and second-year MD student Brendan Eappen—initially came together through an HMS student initiative to make COVID-19 resources accessible to immigrant and non-English speaking communities.
The founder’s new goal was to screen undocumented immigrants for COVID-19 symptoms and connect them to existing services, such as testing sites, primary care, or emergency medical care.
For Vazquez, Huerta Lopez, and Eappen, combating misinformation, empowering the community with knowledge of their legal right to receive medical care, and advocating on their behalf when such care was denied are critically important.
“There was a real information gap,” Vazquez added, “and fear that the medical system would not take good care of the undocumented community.”
“There are so few services and supports for our undocumented friends and neighbors,” said Margaret Sullivan, a postdoctoral fellow at the FXB Center for Health and Human Rights at Harvard, who is advising the students. “The scarce resources that do exist aren’t well-known in the communities that need them the most.”
When HMS went to remote learning last March, Huerta Lopez, who is undocumented, returned home to New Jersey to find COVID-19 devastating her community.
“There was a solid week where my family’s coworkers were dying, my family’s friends were dying … every other day,” she said.
Roots of the problem
According to a study of U.S. patients published Oct. 7 in the New England Journal of Medicine, 42.6 percent of Latinx patients tested for SARS-CoV-2 had positive results, compared to 17.6 percent of non-Hispanic Black patients and 8.8 percent of non-Hispanic white patients.
Besides not having access to health insurance or unemployment benefits, undocumented immigrants were excluded from coronavirus relief packages, with only a handful of states providing emergency economic assistance to immigrant communities during the health and economic crisis caused by the pandemic. Not only were people in these communities at higher risk of contracting COVID-19, but many were forced to grapple with the decision to go to work despite having symptoms.
An April 8 Health Affairs article states that undocumented immigrants face multiple obstacles to obtaining testing and treatment for COVID-19 because of existing fears of immigration enforcement, a lack of health insurance, and a federal policy that went into effect in February 2020 that can penalize immigrants who use Medicaid by jeopardizing their immigration status. There are also financial, cultural, and language barriers to getting adequate care.
“These barriers have been there before COVID got here,” said Huerta Lopez, who added that she came to HMS with an awareness and sense of responsibility to work to achieve better health care for others in her community.
“It’s not just coincidence that the people from my community are dying and other communities are faring much better,” she said.
From the beginning, the HMS students who formed Quetzales de Salud worked closely with Cosecha, a national grassroots network of volunteers working for permanent protection for undocumented immigrants, and which Huerta Lopez had worked with in her home state. The volunteers initially attempted to contact undocumented people with an online request form. When this didn’t elicit enough responses, either because people could not access the technology or because they were uncomfortable with making contact online, the students worked with Cosecha to engage in direct outreach.
In New Jersey, Cosecha had been providing mutual aid to people affected financially by the pandemic, but its organizers did not have experience connecting people to health care resources.
“We were really scrambling around to find programs and places that we can send our community to because they were dying,” said Carlos Castaneda, a volunteer community organizer with Cosecha.
“Then Silvia and Lia and their team created this program to start connecting people from our community to the right places and people to get the help they needed,” he said.
Cosecha provided the HMS students with contact information for 600 community members who had requested information or mutual aid during the pandemic.
Now, only months later, Quetzales de Salud has a nationwide network of more than 70 medical student volunteers who have contacted all 600 individuals and have made more than 1,500 phone calls to them.
A resource gathering team of students has identified and compiled a database of COVID-19 testing sites and federally qualified community health centers in New Jersey that will accept new patients and that do not discriminate based on immigration or insurance status.
Another team is made up of bilingual medical students who call community members to conduct screenings using the COVID-19 symptom self-checker tool from the U.S. Centers for Disease Control and Prevention. The volunteer callers are screened in advance for their proficiency in Spanish and English and trained to provide COVID-19 health information based on national guidelines.
Based on the answers to COVID-19 screening questions, the student callers provide information on how to get tested, how to connect to primary care, or how to go to an emergency room for urgent treatment. The volunteers develop lasting relationships through follow-up calls to ensure that members have received the care they need in the language they speak and to assess whether new needs have emerged.
The student organizers said the initiative has naturally expanded to provide access to psychoeducation groups on stress management and trauma, referrals for primary care, and assistance in navigating specialty care.
“The work we’re doing really is an accompaniment model. It’s a care coordination and community support effort,” Eappen said.
Beyond immediate concerns about COVID-19, the callers discuss other issues with members and provide information about resources, asking them how they are managing isolation or job loss, how their families are doing, whether they have been able to fill prescriptions or make medical appointments, whether they can afford office-visit fees and prescription costs, and other factors that affect their physical and mental well-being.
“By and large, the people that we’re calling are in touch with the same [student] volunteer every two or three weeks,” said Eappen. “Some of the most impactful support we’ve been able to provide has been in the subsequent weeks, where that trust has been built,” he said.
“The strong collaboration with a trusted grassroots organization has also been key in the success of our direct outreach and health navigation model,” said Huerta Lopez. “Well-meaning health centers seeking to improve immigrant health should partner with trusted local organizations and engage in direct outreach to close the information gap and repair decades of mistrust,” she added.
A question of incentives
Angela came to the U.S. in November 2019 for factory work and began experiencing problems with kidney stones after her tourist visa expired in May 2020.
In May, she arrived in an emergency room with severe pain and bleeding, which led to a stent placement and a four-day hospitalization. While hospitalized, she was encouraged to apply for New Jersey Charity Care, the state’s payment assistance program for inpatient and outpatient services for acute care. The stent was to be removed after two weeks, but Angela’s Charity Care application had been misplaced. She was told she would either need to reapply or pay a high out-of-pocket fee.
Her inability to pay for the services and her difficulties reapplying for the payment program meant she could not get timely medical attention. Her appointments were repeatedly rescheduled and canceled. She continued to have severe pain and bleeding, and the stent became infected.
“At that point, I was in a very fragile state,” said Angela. “I was very frustrated, scared, and didn’t know what was going to happen with me and my health.”
“Access to health care has a lot to do with state policy,” Eappen said, and the student volunteers are educated to “understand the opportunities and limitations” of such policies.
“For people who have been granted Charity Care status, and those without it, cost is a major barrier,” Eappen added.
After Angela became hospitalized a second time, a Charity Care team met her in her hospital room to expedite approval. “Such swift action in anticipation of a large, potentially unpaid hospital bill stands in stark contrast with months of seeming indifference and neglect,” said Vazquez, who advocated on Angela’s behalf. “It goes to show that the incentives for securing reimbursement are not always aligned with providing quality care to those in need,” she added.
Native to Central America, the quetzal, a colorful neotropical bird, is associated with strength and beauty, qualities that “are abundant in the uninsured, undocumented community,” said Vazquez.
“We chose the image of a bird to signify that we strive to overcome whatever barriers exist, just as birds fly across seemingly endless distances and over steep mountains,” she said.
The students plan to expand the services of Quetzales de Salud beyond New Jersey by connecting to Cosecha and similar organizations that work with the undocumented community in other states.
“Lia, Silvia, and Brendan have leveraged an opportunity created by COVID-19 to provide a vital service that has long been needed—connecting undocumented individuals with trusted health information and health care,” said Sullivan. “Their careful decision making, individualized approach, and creative scaling of this project have been truly remarkable. They are stepping into a void and bridging a gap with their minds and hearts.”
“Both the people we try to serve, and the team of volunteers who partake in this effort, are quetzals in our eyes,” Vazquez said. “Together we will continue to fight in the struggle for equity, justice, and access to health care.”