For nearly a century, women have been closing the gender gap in alcohol consumption, binge-drinking and alcohol use disorder.

This article was published on Wednesday, June 9, 2021 in Kaiser Health News.

By Aneri Pattani

Victoria Cooper thought her drinking habits in college were just like everyone else's. Shots at parties. Beers while bowling. Sure, she got more refills than some and missed classes while nursing hangovers, but she couldn't have a problem, she thought.

"Because of what my picture of alcoholism was — old men who brown-bagged it in a parking lot — I thought I was fine," said Cooper, now sober and living in Chapel Hill, North Carolina.

That common image of who is affected by alcohol disorders, echoed throughout pop culture, was misleading over a decade ago when Cooper was in college. And it's even less representative today.

For nearly a century, women have been closing the gender gap in alcohol consumption, binge-drinking and alcohol use disorder. What was previously a 3-1 ratio for risky drinking habits in men versus women is closer to 1-to-1 globally, a 2016 analysis of several studies suggested.

And the latest U.S. data from 2019 shows that women in their teens and early 20s reported drinking and getting drunk at higher rates than their male peers — in some cases for the first time since researchers began measuring such behavior.

This trend parallels the rise in mental health concerns among young women, and researchers worry the long-term effects of the COVID-19 pandemic could amplify both patterns.

"It's not only that we're seeing women drinking more, but that they're really being affected by this physically and mental health-wise," said Dawn Sugarman, a research psychologist at McLean Hospital in Massachusetts who has studied addiction in women.

Research shows women suffer health consequences of alcohol — liver disease, heart disease and cancer — more quickly than men and even at lower levels of consumption.

Perhaps most concerning is that the rising gender equality in alcohol use doesn't extend to the recognition or treatment of alcohol disorders, Sugarman said. So even as some women drink more, they're often less likely to get the help they need.

In Cooper's case, drinking eventually led her to drop out of college at the University of North Carolina-Chapel Hill. She moved back home and was soon taking a shot or two of vodka each morning before heading to the office for her finance job, followed by two at lunch.

When she tried to quit on her own, she was quickly pulled back by the disease.

"That's when I got scared, when I tried to not drink and only made it two days," said Cooper, now 30. "I was drinking for survival, basically."

Drinking to Cope

Although the gender gap in alcohol consumption is narrowing among all ages, the reasons differ. For people over 26, women are increasing their alcohol consumption faster than men. Among teens and young adults, however, there's an overall decline in drinking. The decline is simply slower for women.

That may sound like progress, said Aaron White, a senior scientific adviser at the National Institute on Alcohol Abuse and Alcoholism. But it may indicate larger underlying issues.

"We have a real concern that while there might be fewer people drinking, many of those who are drinking might be doing so specifically to try to cope," White said. "And that is problematic."

Research suggests that people who drink to cope — as opposed to drinking for pleasure — have a higher risk of developing alcohol-use disorder. And while every individual's reasons for drinking are different, studies have found women are more likely to drink to cope than men.

In Cooper's teenage years, alcohol helped her overcome social anxiety, she said. Then she was sexually assaulted, and a new pattern emerged. Drink to deal with trauma. Experience new trauma while drinking. Repeat. "It's hard to get out of that cycle of shame, drinking and abuse," Cooper said.

Women are statistically more likely to experience childhood abuse or sexual assault than men. In recent years, studies have found rates of depression, anxiety, eating disorders and suicide are climbing among teenaged and young adult women. That could be driving their alcohol use, White said.

And the layers of stress, isolation and trauma from COVID could make things worse.

One study that looked at alcohol's effects on college students early in the pandemic found increased alcohol use among those who reported higher levels of stress and anxiety. And several studies found women were more likely to report rises in drinking during the pandemic, especially if they experienced increased stress.

"For us to address issues with alcohol, we also need to address these pervasive issues with mental health," White said. "They are all related."

What's more, despite alcohol's temporary calming properties, it actually increases anxiety, and studies show it causes brain damage and may be lead to depression more quickly in women than in men.

When Gillian Tietz began drinking in graduate school, she found a glass of wine helped ease her stress. But as soon as the glass emptied, her concerns worsened. Within a year, she began drinking daily. Anxiety kept her up at night and she started having suicidal thoughts, she said.

It was only when Tietz took a brief reprieve from alcohol that she noticed the connection. Suddenly, the suicidal thoughts stopped.

"That made the decision to quit really powerful," said Tietz, 30, who now hosts a podcast called Sober Powered. "I knew exactly what alcohol did to me."

Rising Risks: From Hangovers to Cancer

Until the 1990s, most research on alcohol focused on men. Now, as women approach parity in drinking habits, scientists are uncovering more about the unequal damage alcohol causes to their bodies.

Women generally have less body water, which dissolves alcohol, than men of the same weight. That means the same number of drinks leads to higher concentrations of alcohol in the blood, and their body tissues are exposed to more alcohol per drink.

The result? "From less years of alcohol use, women are getting sicker faster," said Sugarman, of McLean Hospital.

They're at greater risk for hangovers, blackouts, liver disease, alcohol-induced cardiovascular diseases and certain cancers. One study found alcohol-related visits to the emergency room from 2006 to 2014 increased 70% for women, compared with 58% for men. Another paper reported that the rate of alcohol-related cirrhosis rose 50% for women, versus 30% for men, from 2009 to 2015.

Yet when it comes to prevention and treatment of alcohol-related health issues, "that message is not really getting out there," Sugarman said.

As part of a research study, Sugarman and her colleagues gave women struggling with alcohol use information on how alcohol affects women differently than men. Some participants had been in detox 20 times yet had never heard this information, Sugarman said.

Research from Sugarman's colleagues found that women with alcohol use disorder had better outcomes when they were in women-only treatment groups, which included a focus on mental health and trauma, as well as education about gender-specific elements of addiction.

For Cooper, enrolling in a 90-day residential treatment program in 2018 drastically changed her own perception of who is affected by addiction. She found herself surrounded by other women in their 20s who also struggled with alcohol and other drugs. "It was the first time in a very long time that I had not felt alone," she said.

In 2019, she returned to UNC-Chapel Hill and finished her degree in women's and gender studies, even completing a capstone project on the links among sexual violence, trauma and addiction.

Although 12-step programs have helped Cooper stay sober for 3½ years now, she said, a downside to those efforts is that they are often male-dominated. Literature written by men. Advice geared toward men. Examples about men.

Cooper plans to return to school this fall for a master's in social work, with the goal of working to change that.

Aneri Pattani: apattani@kff.org, @aneripattani

A group called Children's Health Defense — prominent in the anti-vaccine movement — is promoting its new film, "Medical Racism: The New Apartheid."

This article was published on Wednesday, June 9, 2021 in Kaiser Health News.

By Will Stone

When a filmmaker asked medical historian Naomi Rogers to appear in a documentary, the Yale professor didn't blink. She had done these "talking head" interviews many times before.

She assumed her comments would end up in a straightforward documentary that addressed some of the most pressing concerns of the pandemic, such as the legacy of racism in medicine and how that plays into current mistrust in some communities of color. The subject of vaccines was also mentioned, but the focus wasn't clear to Rogers.

The director wanted something more polished than a Zoom call, so a well-outfitted camera crew arrived at Rogers' home in Connecticut last fall. They showed up wearing masks and gloves. Before the interview, crew members cleaned the room thoroughly. Then they spent about an hour interviewing Rogers. She discussed her research and in particular controversial figures such as Dr. James Marion Sims, who was influential in the field of gynecology but who performed experimental surgery on enslaved Black women during the 1800s without anesthesia.

"We were talking about issues of racism and experimentation, and they seemed to be handled appropriately," Rogers recalled. At the time, there were few indications that anything was out of the ordinary — except one. During a short break, she asked who else was being interviewed for the film. The producer's response struck Rogers as curiously vague.

"They said, 'Well, there's 'a guy' in New York, and we talked to 'somebody in New Jersey, and California,'" Rogers told NPR. "I thought it's so odd that they wouldn't tell me who these people were."

It wasn't until March that Rogers would stumble upon the answer.

She received an email from a group called Children's Health Defense — prominent in the anti-vaccine movement — promoting its new film, "Medical Racism: The New Apartheid."

When she clicked on the link and began watching the 57-minute film, she was shocked to discover this was the movie she had sat down for back in October.

"I was naive, certainly, in assuming that this was actually a documentary, which I would say it is not. I think that it is an advocacy piece for anti-vaxxers," Rogers said. "I'm still very angry. I feel that I was used."

The free online film is the latest effort by Robert F. Kennedy Jr., the founder of Children's Health Defense. (He's a son of former U.S. Attorney General Robert "Bobby" Kennedy and nephew of President John F. Kennedy.) With this film, Kennedy and his allies in the anti-vaccine movement resurface and promote disproven claims about the dangers of vaccines, while aiming squarely at a specific demographic: Black Americans.

The film draws a line from the real and disturbing history of racism and atrocities in the medical field — such as the Tuskegee syphilis study — to interviews with anti-vaccine activists who warn communities of color to be suspicious of modern-day vaccines.

At one point in "Medical Racism," viewers are warned that "in Black communities something is very sinister" and "the same thing that happened in the 1930s during the eugenics movement" is happening again.

There is a lengthy discussion of the thoroughly disproven link between autism and vaccines. For example, the film references a study from the Centers for Disease Control and Prevention about the measles, mumps and rubella vaccine and autism rates as evidence that African American children are being particularly harmed, but in reality the study did not conclude that African Americans are at increased risk of autism because of vaccination.

The movie then displays a chart claiming to use that same CDC data — obtained through a Freedom of Information Act request — to make a connection between vaccinating Black children and autism risk. The findings in the chart closely resemble another study sometimes mentioned by anti-vaccine activists, but the medical journal later retracted the study, because of "undeclared competing interests on the part of the author" and "concerns about the validity of the methods and statistical analysis." (That study's author was a paid independent contractor for Kennedy's group as of 2020 and sits on its board of directors.)

The film also brings up a 2014 study from the Mayo Clinic that showed Somali Americans and African Americans have a more robust immune response to the rubella vaccine than Caucasians and Hispanic Americans. One of those interviewed in Kennedy's film then asks, "So if you have that process that could be caused by vaccines, why wouldn't there be a link between vaccines and developmental delays?"

But the study's author, leading vaccine researcher Dr. Gregory Poland, said this conjecture is not accurate.

According to a statement provided to NPR by the Mayo Clinic, the study demonstrated "higher protective immune responses in African-American subjects with no evidence of increased vaccine side effects," and any claim of "'increased vulnerability' among African-Americans who receive the rubella vaccine is simply not supported by either this study or the science."

For her part, Rogers, the Yale professor, appears for only about 14 seconds in the film. Her quotes are accurate. But her remarks are embedded in a wider narrative that she has "enormous problems with" — namely that the anti-vaccine movement is heroically engaged in a new civil rights campaign, one meant to stop experimentation on the Black community.

Rogers said the film uses many ideas she holds "passionately, like health disparities, fighting racism in health, working against discrimination, and it's been twisted for the purposes of this anti-vax movement."

Another credible expert from mainstream medicine also appears in the film: Dr. Oliver Brooks, the immediate past president of the National Medical Association. The group is the largest organization representing African American physicians in the United States.

Brooks said he agreed to be in the film because he wanted to provide balance, but after seeing it he regrets doing the interview.

"The crux of the documentary is generally 'Don't get vaccinated,'" Brooks told NPR in a recent interview. "There is an understandable concern in the African American community regarding vaccines — however, in the end, my position is you look past those, have an understanding of those and still get vaccinated. … That nuance was not felt or presented in the documentary."

Kennedy's group released the film in early March, just as the COVID-19 vaccine was becoming widely available to the American public.

"The film basically wants people to recognize this history that leads right into the present, and especially when they're facing decisions about whether they should take any vaccine, including COVID," said Curtis Cost, one of the film's co-producers and a longtime anti-vaccine activist.

Cost said the film does not explicitly tell people to refuse the COVID vaccine, but it "goes all the way to the present experimentations and bad things have been done by the medical establishment in America and in Africa and other parts of the world."

In an emailed statement, a spokesperson for Children's Health Defense denied that the film is misinformation and said it contains "peer reviewed science and historical data."

But the movie is "a classic example of the anti-vaccine industry with a highly targeted message using sophisticated marketing techniques and building alliances with affiliate organizations," said Imran Ahmed, CEO of the nonprofit Center for Countering Digital Hate, which has extensively researched figures such as Kennedy.

"They've seen the opportunity to target a specifically African American audience," he said, during a particular moment of heightened national attention on racial injustices and health disparities.

Black Americans have twice the risk of dying of COVID compared with white Americans. Racial disparities in vaccination uptake persist across the United States.

While there are efforts to improve access to the vaccine, media coverage has also focused heavily on historical reasons for vaccine skepticism — too much, some scholars argue, when the focus should be on how Black Americans experience the impact of systemic racism in healthcare today — and how to fix those problems and improve trust.

"We're in this moment where we're having some necessary discussions about health equity," said Victor Agbafe, a medical student at the University of Michigan. "It's not a good thing to sort of exploit that as a means to undermine trust in the vaccine today, instead of focusing on how we can make the vaccine more accessible for all communities."

Agbafe, who helps lead his school's Black medical student association, was surprised to get an email from Children's Health Defense asking him to promote the movie among his peers.

When it was released, the film did not seem to gain much traction on major social media platforms such as Twitter, although tracking how often this kind of video is being shared privately can be difficult, said Kolina Koltai, a University of Washington researcher who studies the anti-vaccine movement online.

But Kennedy's anti-vaccine activities during the pandemic involve more than this movie.

In February, he was banned from Instagram for posting misinformation on vaccines, but he still has a home on Facebook and Twitter. Ahmed's organization has labeled Kennedy one of the "disinformation dozen" — a group of people responsible for 65% of the shares of anti-vaccine misinformation on social media platforms.

In a recent webinar about the film, Kennedy said those who agree with the film need to use "the tools of advocacy that Martin Luther King Jr. talked about" and promote it "guerrilla-style" against the "darkening cloud of totalitarianism."

Although more than half of American adults have gotten a COVID vaccine, demand is falling fast, and polls show almost one-third of adults still either want to "wait and see" or do not want to get the shot. When asked why, many say the vaccine is unsafe, based on false conspiracy theories.

"I see the downstream ripple effects of disinformation every day in practice, every day in the patients' lives I treat," said Dr. Atul Nakhasi with the Los Angeles County Department of Health Services and co-founder of the online campaign #ThisIsOurShot, which aims to encourage trust in the COVID vaccines.

"We know people have uncertainties, and we need to acknowledge that and have humble, respectful conversations, but for someone to actively subvert that trust is unconscionable," Nakhasi said.

According to the Center for Countering Digital Hate, the ideal strategy for stopping the spread of online misinformation is to cut it off at the source: meaning "deplatform" the most notorious spreaders of that information so they can't gain a following on social media in the first place. But Ahmed said that all too often tech companies don't take those steps themselves. In that case, the next best tactic is to try to "inoculate" people against false and misleading claims.

"You tell people in advance, 'Hey, something terrible is happening. Be careful — they're targeting you,'" Ahmed said.

This story is from a reporting partnership between NPR and KHN.

Black patients are about four times as likely to have kidney failure as white Americans, and who make up more than 35% of people on dialysis but just 13% of the U.S. population.

This article was published on Tuesday, June 8, 2021 in Kaiser Health News.

By Rae Ellen Bichell and Cara Anthony   

Alphonso Harried recently came across a newspaper clipping about his grandfather receiving his 1,000th dialysis treatment. His grandfather later died — at a dialysis center — as did his uncle, both from kidney disease.

"And that comes in my mind, on my weak days: 'Are you going to pass away just like they did?'" said Harried, 46, who also has the disease.

He doesn't like to dwell on that. He has gigs to play as a musician, a ministry to run with his wife and kids to protect as a school security guard.

Yet he must juggle all that around three trips each week to a dialysis center in Alton, Illinois, about 20 miles from his home in St. Louis, to clean his blood of the impurities his kidneys can no longer flush out. He's waiting for a transplant, just as his uncle did before him.

"It's just frustrating," Harried said. "I'm stuck in the same pattern."

Thousands of other Americans with failing kidneys are also stuck, going to dialysis as they await new kidneys that may never come. That's especially true of Black patients, like Harried, who are about four times as likely to have kidney failure as white Americans, and who make up more than 35% of people on dialysis but just 13% of the U.S. population. They're also less likely to get on the waitlist for a kidney transplant, and less likely to receive a transplant once on the list.

An algorithm doctors use may help perpetuate such disparities. It uses race as a factor in evaluating all stages of kidney disease care: diagnosis, dialysis and transplantation.

It's a simple metric that uses a blood test, plus the patient's age and sex and whether they're Black. It makes Black patients appear to have healthier kidneys than non-Black patients, even when their blood measurements are identical.

"It is as close to stereotyping a particular group of people as it can be," said Dr. Rajnish Mehrotra, a nephrologist with the University of Washington School of Medicine.

This race coefficient has recently come under fire for being imprecise, leading to potentially worse outcomes for Black patients and less chance of receiving a new kidney. A national task force of kidney experts and patients is studying how to replace it. Some institutions have already stopped using it.

But how best to assess a patient's kidney function remains uncertain, and some medical experts say fixing this equation is only one step in creating more equitable care, a process complicated by factors far deeper than a math problem.

"There are so many inequities in kidney disease that stem from broader structural racism," said Dr. Deidra Crews, a nephrologist and the associate director for research development at the Johns Hopkins Center for Health Equity. "It is just a sliver of what the broader set of issues are when it comes to both disparities and inequities in who gets kidney disease in the first place, and then in the care processes."

Why Race Has Been Part of the Equation

Kidneys filter about 40 gallons of blood a day, like a Brita filter for the body. They keep in the good stuff and send out the bad through urine. But unlike other organs, kidneys don't easily repair themselves.

"There's a point of no return," said Dr. Cynthia Delgado, a University of California-San Francisco nephrologist who is leading the task force working on the national recommendation to ditch the racial part of the equation.

Furthermore, it's hard to gauge whether kidneys are working properly. Gold-standard tests involve a chemical infusion and hours of collecting blood and urine to see how quickly the kidneys flush the chemical out. An algorithm is much more efficient.

Buoyed by activism around structural racism, those seeking equity in healthcare have recently been calling out the algorithm as an example of the racism baked into American medicine. Researchers writing in the New England Journal of Medicine last year included kidney equations in a laundry list of race-adjusted algorithms used to evaluate parts of the body — from heart and lungs to bones and breasts. Such equations, they wrote, can "perpetuate or even amplify race-based health inequities."

In March, ahead of the national task force's upcoming formal recommendation, leaders in kidney care said race modifiers should be removed. And Fresenius Medical Care, one of the two largest U.S. dialysis companies, said the race component is "problematic."

Until the late 1990s, doctors primarily used the Cockcroft-Gault equation. It didn't ask for race, but used age, weight and the blood level of creatinine — a chemical that's basically the trash left after muscles move. A high level of creatinine in the blood signals that kidneys are not doing their job of disposing of it. But the equation was based on a study of just 249 white men.

Then, researchers wrapping up a study on how to slow down kidney disease realized they were sitting on a mother lode of data that could rewrite that equation: gold-standard kidney function measurements from about 1,600 patients, 12% of whom were Black. They evaluated 16 variables, including age, sex, diabetes diagnosis and blood pressure.

They landed on something that accurately predicted the kidney function of patients better than the old equation. Except it made the kidneys of Black participants appear to be sicker than the gold-standard test showed they were.

The authors reasoned it might be caused by muscle mass. Participants with more muscle mass would likely have more creatinine in their blood, not because their kidneys were failing to remove it, but because they just had more muscles producing more waste. So they "corrected" Black patients' results for that difference.

Dr. Andrew S. Levey, a professor at Tufts University School of Medicine who led the study, said it doesn't make intuitive sense to include race — now widely considered a social construct — in an equation about biology.

Still, in 1999, he and others published the race equation, then updated it a decade later. Though other equations exist that don't involve race, Levey's latest version, often referred to as the "CKD-EPI" equation, is recommended for clinical use. It shows a Black patient's kidneys functioning 16% better than those of a non-Black patient with the same blood work.

Removing the Race Number

Many patients don't know about this equation and how their race has factored into their care.

"I really wish someone would have mentioned it," Harried said.

He said it burned him up "knowing that this one little test that I didn't know anything about could keep me from — or prolong me — getting a kidney."

Glenda V. Roberts curbed her kidney disease with a vegan diet and by conducting meetings as an IT executive while walking. But after more than 40 years of slow decline, her kidney function finally reached the cutoff required to get on the transplant waitlist. When it did, the decline was swift — a pattern researchers have noted in Black patients. "It really makes you wonder what the benefit is of having an equation that will cause people who look like me — Black people — to get referrals later, to have to wait longer before you can get on the transplant list, but then have your disease progress more rapidly," she said.

Roberts, who is now the director of external relations at the University of Washington's Kidney Research Institute in Seattle and on the national task force, said a genetic test added to her feeling that a "Black/non-Black" option in an equation was a charade.

"In fact, I am not predominantly of African ancestry. I'm 25% Native American. I'm Swedish and English and French," said Roberts. "But I am also 48% from countries that are on the continent of Africa."

The Black/non-Black question also doesn't make sense to Delgado, the University of California nephrologist. "I would probably for some people qualify as being non-Black," said Delgado, who is Puerto Rican. "But for others, I would qualify as Black."

So, theoretically, if Delgado were to visit two doctors on the same day, and they guessed her race instead of asking, she could come away with two different readings of how well her kidneys are working.

Researchers found that the race factor doesn't work for Black Europeans or patients in West Africa. Australian researchers found using the race coefficient led them to overestimate the kidney function of Indigenous Australians.

But in the U.S., Levey and other researchers seeking to replace the race option with physical measurements, such as height and weight, hit a dead end.

To Crews, the Johns Hopkins nephrologist who is also on the national taskforce, the focus on one equation is myopic. The algorithm suggests that something about Black people's bodies affects their kidneys. Crews thinks that's the wrong approach to addressing disparities: The issue is not what's unique about the inner workings of Black bodies, but instead what's going on around them.

"I really wish we could measure that instead of using race as a variable in the estimating equations," she said on the "Freely Filtered" podcast. "I don't think it's ancestry. I don't think it's muscle mass."

It might not be that Black bodies are more likely to have more creatinine in the blood, but that Americans who experience housing insecurity and barriers to healthy food, quality medical care and timely referrals are more likely to have creatinine in their blood — and that many of them happen to be Black.

Systemic health disparities help explain why Black patients have unusually high rates of kidney failure, since communities of color have less access to regular primary care. One of the most serious consequences of poorly controlled diabetes and hypertension is failure of the organ.

Direct discrimination — intentional or not — from providers may also affect outcomes, said Roberts. She recalled a social worker categorizing her as unable to afford the post-transplant drugs required to keep a transplanted organ healthy, which could have delayed her getting a new organ. Roberts has held executive roles at several multimillion-dollar companies.

Delgado and Levey agree that removing race from the formula might feel better on the surface, but it isn't clear the move would actually help people.

Studies recently published in the Journal of the American Medical Association and the Journal of the American Society of Nephrology noted that removing the race factor could lead to some Black patients being disqualified from using beneficial medications because their kidneys might appear unable to handle them. It could also disqualify some Black people from donating a kidney.

"Fiddling with the algorithms is an imperfect way to achieve equity," Levey said.

As researchers debate the math problem and broader societal ones, patients such as Harried, the St. Louis minister and security guard, are still stuck navigating dialysis.

"One of things that keeps me going is knowing that soon they may call me for a kidney," Harried said.

He doesn't know how long his name will be on the transplant waitlist — or whether the race coefficient has prolonged the wait — but he keeps a hospital bag under his bed to be ready.

Rae Ellen Bichell: rbichell@kff.org, @raelnb

Cara Anthony: canthony@kff.org, @CaraRAnthony

States that were slow to use health centers in the vaccine rollout made a mistake that has made it difficult to get a handle on COVID in the most vulnerable communities.

This article was published on Tuesday, June 8, 2021 in Kaiser Health News.

By Shalina Chatlani, WWNO

In the 1960s, healthcare across the Mississippi Delta was sparse and much of it was segregated. Some hospitals were dedicated to Black patients, but they often struggled to stay afloat. At the height of the civil rights movement, young Black doctors launched a movement of their own to address the care disparity.

"Mississippi was third-world and was so bad and so separated," said Dr. Robert Smith. "The community health center movement was the conduit for physicians all over this country who believed that all people have a right to healthcare."

In 1967, Smith helped start Delta Health Center, the country's first rural community health center. They put the clinic in Mound Bayou, a small town in the heart of the Delta, in northwestern Mississippi. The center became a national model and is now one of nearly 1,400 such clinics across the country. These clinics, called federally qualified health centers, are a key resource in Mississippi, Louisiana and Alabama, where about 2 in 5 people live in rural areas. Throughout the U.S., about 1 in 5 people live in rural areas.

The COVID-19 pandemic has only exacerbated the challenges facing rural healthcare, such as lack of broadband internet access and limited public transportation. For much of the vaccine rollout, those barriers have made it difficult for providers, like community health centers, to get shots into the arms of their patients.

"I just assumed that [the vaccine] would flow like water, but we really had to pry open the door to get access to it," said Smith, who still practices family medicine in Mississippi.

Mound Bayou was founded by formerly enslaved people, many of whom became farmers.

The once-thriving downtown was home to some of the first Black-owned businesses in the state. Today the town is dotted with shuttered or rundown banks, hotels and gas stations.

Mitch Williams grew up on a Mound Bayou farm in the 1930s and '40s and spent long days working the soil.

"If you would cut yourself, they wouldn't put no sutures in, no stitches in it. You wrapped it up and kept going," Williams said.

When Delta Health Center started operations in 1967, it was explicitly for all residents of all races — and free to those who needed financial help.

Williams, 85, was one of its first patients.

"They were seeing patients in the local churches. They had mobile units. I had never seen that kind of comprehensive care," he said.

Residents really needed it. In the 1960s, many people in Mound Bayou and the surrounding area didn't have clean drinking water or indoor plumbing.

At the time, the 12,000 Black residents of northern Bolivar County, which includes Mound Bayou, faced unemployment rates as high as 75% and lived on a median annual income of just $900 (around $7,500 in today's dollars), according to a congressional report. The infant mortality rate was close to 60 for every 1,000 live births — four times the rate for affluent Americans.

Delta Health Center employees helped people insulate their homes. They built outhouses and provided food and sometimes even traveled to patients' homes to offer care, if someone didn't have transportation. Staffers believed these factors affected health outcomes, too.

Williams, who later worked for Delta Health, said he's not sure where the community would be today if the center didn't exist.

"It's frightening to think of it," he said.

Half a century later, the Delta Health Center continues to provide accessible and affordable care in and around Mound Bayou.

Black Southerners still face barriers to health. In April 2020, early in the pandemic, Black residents accounted for nearly half of COVID deaths in Alabama and over 70% in Louisiana and Mississippi.

Public health data from last month shows that Black residents of those states have consistently been more likely to die of COVID than residents of other races.

"We have a lot of chronic health conditions here, particularly concentrated in the Mississippi Delta, that lead to higher rates of complications and death with COVID," said Nadia Bethley, a clinical psychologist at the center. "It's been tough."

Delta Health Center has grown over the decades, from a few trailers in Mound Bayou to a chain of 18 clinics across five counties. It's managed to vaccinate over 5,500 people against COVID. The majority have been Black.

"We don't have the National Guard, you know, lining up out here, running our site. It's the people who work here," Bethley said.

The Mississippi State Department of Health said it has prioritized health centers since the beginning of the rollout. But said the center was receiving only a couple of hundred doses a week in January and February. The supply became more consistent around early March, center officials said.

"Many states would be much further ahead had they utilized community health centers from the very beginning," Fairman said. Fairman said his center saw success with vaccinations because of its long-standing relationships with the local communities.

"Use the infrastructure that's already in place, that has community trust," said Fairman.

That was the entire point of the health center movement in the first place, said Smith. He said states that were slow to use health centers in the vaccine rollout made a mistake that has made it difficult to get a handle on COVID in the most vulnerable communities.

Smith called the slow dispersal of vaccines to rural health centers "an example of systemic racism that continues."

A spokesperson for Mississippi's health department said it is "committed to providing vaccines to rural areas but, given the rurality of Mississippi, it is a real challenge."

Alan Morgan, CEO of the National Rural Health Association, said the low dose allocation to rural health clinics and community health centers early on is "going to cost lives."

"With hospitalizations and mortality much higher in rural communities, these states need to focus on the hot spots, which in many cases are these small towns," Morgan said of the vaccine efforts in Mississippi, Louisiana and Alabama.

A report from KFF found that people of color made up the majority of people vaccinated at community health centers and that the centers seem to be vaccinating people at rates similar to or higher than their share of the population. (The KHN newsroom, which collaborated to produce this story, is an editorially independent program of KFF.)

The report added that "ramping up health centers' involvement in vaccination efforts at the federal, state and local levels" could be a meaningful step in "advancing equity on a larger scale."

Equal access to care in rural communities is necessary to reach the most vulnerable populations and is just as critical during this global health crisis as it was in the 1960s, according to Smith.

"When healthcare improves for Blacks, it will improve for all Americans," Smith said.

This story is from a partnership that includes NPR, KHN and the three stations that make up the Gulf States Newsroom: Mississippi Public Broadcasting; WBHM in Birmingham, Alabama; and WWNO in New Orleans.