Abt Conversations: Beyond Health—How Health Centers are Fighting Human Trafficking, Racism & More

Dr. Kimberly S.G. Chang: Thank you for the question and thanks for the invitation to be on this podcast. When I think, and I reflect upon how I ended up in community health centers and how I ended up here in this leadership role, if you will, I just think about the patients that we see and the history of the movement of community health centers. And so when I finished residency in a certain year that will not be named, I started trying out different practices. I tried private practices, I tried a large HMO here in the Bay Area, and at the same time, I was also working at Asian Health Services, which is a community health center here in Oakland, California, serving predominantly Asian immigrants and refugees. Through those experiences, I quickly realized that my purpose in being in medicine was to care for the underserved or to be a part of the community, trying to lift up our communities and our patients, and I quickly gravitated to Asian Health Services and became a regular provider here over 20 years ago.

When I started working at Asian Health Services and seeing the patients that we see, as well as talking to the leadership here at our health center and learning about the history of the community health center movement, it became very clear that this is what I wanted to do as a career, how I wanted to spend my time, how I wanted to contribute to society, how I wanted to invest in our local communities and the people all around us, who sometimes we don't see when you're in a “professional” setting. Patients who are in food service or in agriculture or domestic help services or in-home support services, other hospitality services or people who may not be able to be employed.

A lot of the work that we do isn't just contained within the four clinical walls, within the interaction that I have with a patient. A lot of it is outreach, community involvement, making sure that the systems of care and protection are being able to be accessed by the patients that we see and the communities that we see, and so that they're not left out by the systems of care in our communities. So that really inspired me. I could do my clinical practice and I could also, through being in community and being on a team, be involved in lifting up and helping our communities to raise their voices and be better.

Ann: Thanks, Kim. Can you tell me a little bit about why this health center movement, why does that resonate with you so much?

Kim: Well, it resonates with me because I'm not interested in doing charity work. I'm not interested in giving people services that just keep them in the same situation that create vulnerabilities to illness, disease, victimization. I'm not interested in just keeping people in the same place of where they're at. I'm interested in changing policies and systems so that the people that we care for can actually be fully present and participatory in our democracy, in our communities, to have civic engagement, to have the same opportunities that you or I or any of my professional colleagues have. We need to be involving our patients in civic engagement in whatever ways that means, whether it's voter engagement, whether it's getting involved in the redesign of their streets and urban development, whether it's the environmental issues, all of these things have health impacts, and all of these things show up in our exam rooms whether we realize it or not.

And so policies are important, policies determine who's included or excluded, policies determine who's affected or not affected, who's harmed and who's not harmed. And so I want to be able to make sure that our society, our local, our state, our federal systems and policies have open access to everyone wherever you start in terms of your socioeconomic class, or the color of your skin, or your gender, or your gender expression, whatever it is, or your ability, your physical ability or mental health abilities. I want people to be able to live full productive lives and have community and be engaged.

Ann: Yeah, love that. Especially when you think about systems that perpetuate dependency rather than lift up and support independence and the ability to have agency in your own life.

Kim: Absolutely. Agency is the term that we use. We want people to have agency and control and autonomy. In many ways, that's a very conservative principle but ... “and,” not “but”: and at the same time, you need to have systems that encourage participation, that don't shut people out based on the policies and the lines and the rules that we draw in society. And so that's what I'm interested in, and I think health centers really do that very well. We provide services so that people can be healthy in their bodies and their minds, and we are trying to level the playing field so that people can access these systems and access care and protection in many different ways, in many different venues, not just in the healthcare system. And when you're working in a community health center and it's hard, and then you see a lot of how society as a whole values different things, and then how our patients bear the brunt of those big value systems—capitalism, different kinds of things like that—you realize that, wow, this is a hard road for some of our communities and the people that we serve.

Ann: Yeah. Well, when you think about Asian Health Services and empowering the community to be engaged, the Asian-American community in particular had some additional pointed and disturbing challenges throughout the COVID pandemic. When we think about all the social factors that came to a head with COVID, what do you think the role of addressing the vital conditions of inclusion, belonging, and civic muscle look like for health centers?

Kim: I think what health centers should be doing is what we're already doing, paying attention to our communities, paying attention to our patient boards. Because we have the 51 percent governing board that our patients of our center, that means we are absolutely accountable to and responsible to the issues facing our community. And so when you asked me about addressing the vital conditions of inclusion, belonging, and civic muscle look like for health centers, I'll give you an example. So at Asian Health Services, when the COVID pandemic started early 2020?

Ann: Yeah. That's when we were told about it.

Kim: Yeah. January, 2020, I think the public health emergency was March in 2020. Actually, for us at Asian Health Services, we started hearing about this kind of virus thing that was coming from China in late December from our patients, from different media outlets, ethnic media outlets. And our experience with SARS from Hong Kong, the first SARS epidemic, our CMO at the time was also the CMO during that SARS epidemic and he was following that very carefully. We were prepared. We did trainings on PPE, so he started ordering PPE right away so that we would be ready if this became a pandemic, which it ultimately did. At the time, there was no public messaging, there was no content in media, in any Asian languages. And so we at Asian Health knew that we had to get it out to our patients, plus our patients were hearing it from their family members and community back over in Asia. And so they were asking us questions, so we needed to respond. We needed to give them answers as well, what were we going to do about it?

So we developed a lot of multilingual materials to respond in terms of the vaccine or in terms of testing. Our community health centers weren't going to be getting the vaccines, but NAC and other health centers across the country raised their voices and said, "Hey, absolutely not. If you don't give health centers the vaccine, all these people are going to be harmed." And then in terms of the vaccine, BPHC, the Bureau of Primary Health Care, started collecting data on language. And if you look at the COVID vaccine data, the majority of health center patients who got the vaccines through us were people who didn't speak English or had English as a second language or limited English proficiency. So when you talk about health equity, that's us, that's health centers that are doing it.

And then, for us at Asian Health Services, there was a lot of political rhetoric around the virus being from China, and then a lot of negative ramifications from that, a lot of anti-Asian hate incidents due to some of this political rhetoric. And that put our patients in a very fearful state. A lot of our patients didn't want to leave the house, they didn't want to come out to the clinic, they were basically trapped in their own homes because they were scared. They were scared about the virus, but more importantly, they were scared about being attacked and being blamed for it. We had patients who talked about being harassed on the bus, rocks thrown at some other patients because they were Asian and were being blamed for the pandemic.

I also had a particular patient who actually just died last year. She was afraid of leaving her house, and she wasn't that old, either. She was in her mid-50s and she was afraid of leaving her house. So we would do telemedicine visits, which by the way is a great way to reach out to your patients, but sometimes you actually need them to come in. So this particular patient also had some mental health challenges, but she was functional, she was doing well, she was happy, but she wouldn't come to the clinic or to her mental health appointments because she was afraid of leaving. So we did telehealth, we were checking in.

Turns out she developed acute trouble breathing. She had swollen legs, this is what I heard from her family member, and she hadn't been leaving the house for three years. And so my take on it is she probably had a pulmonary embolism because she wasn't moving her body around. I attribute it especially to the anti-Asian sentiment and anti-Asian rhetoric, because she didn't want to leave the house, and she was terrified of being attacked. That's something I think about. It's something that I still think about.

Ann: Yeah. I'm going to change topics just a little bit. A lot of the people who experience extreme social determinants of health in a negative way, people who aren't necessarily seen day-to-day in our community, they're more vulnerable to human trafficking. And human trafficking is such a big part of your work, but it's not something that people immediately think of when they think of health centers, even though health centers serve a lot of people who are in those situations and help them. Why is this such a critical issue to address these days, especially in health centers? How can health centers play a leadership role on this critical issue?

Kim: Health centers are seeing people who are made vulnerable to being exploited and trafficked. Period. Full stop. We often didn't have the language or the words to identify or to really understand this issue until the year 2000 when the Trafficking Victims Protection Act was passed. Now, in this act, it was legislation, federal legislation that defined human trafficking and defined human trafficking from a criminal justice standpoint. This was important because that means that people who fall into the eligibility criteria of being trafficked under this TVPA—Trafficking Victims Protection Act of 2000—could then get access to different protective measures. They could be protected under the criminal justice system. Now, that's an important legislation. And at the same time, I will say that not everybody who is trafficked, not everybody who is exploited, is eligible to be labeled as a human trafficking victim. Not everybody gets access to the criminal justice protections. How many people who have been a victim of a crime often get access to criminal justice protections, prosecution of perpetrators, et cetera, restitution, justice?

And so when I talk about human trafficking, we talk about it more broadly as exploitation. That's a broader category. Exploitation, sexual exploitation, sexual violence, sex trafficking, labor exploitation, wage and labor violations, labor trafficking. We see patients every day, day in and day out, people who are made vulnerable to being exploited either sexually or through labor. Why? The reason is that these people are the same people that we see. Period. People who are made vulnerable to being trafficked or exploited, or people who are poor, who don't speak English well, who have differential classes of immigration or citizenship status. Because that immigration or citizenship status or visa status confers what benefits or protections you're able to access in our society. So differential classes of benefits and protections.

Ann: You're right. And so ...And often those levels or those different categories of protections create the context in which you can even live. Your economy is different depending on where you fall.

Kim: Absolutely. Absolutely. You think about our undocumented brothers and sisters in community with us. What can they get in terms of healthcare access? What can they get in terms of criminal justice access? What can they get in terms of employment, access to employment opportunities? Yet they're here living amongst us, with us, part of a local economy, part of our community of people, of humanity that we coexist with and interact with, yet we don't know and they don't get access. So when you think about that, it's clear health centers have a role to play, not just in providing healthcare when they come in, abused, harmed, financially exploited, overuse injuries from work or injuries at work. These different kinds of things are certainly within our wheelhouse. And I will say it is also in our wheelhouse to advocate for policies that increase their access to systems and care and protection. I keep saying that. Increasing access to systems of care and protection and opportunity in our society. That's where health centers excel. We do direct services and we do advocacy.

And I know we've often, in the more recent years, thought about advocacy in terms of getting our base payments, base grant reauthorized to be able to get different participation in ACOs or different kind of healthcare financing mechanisms. And to me, that's really, really important. And it also goes to the issue of what do we use these operating margins for? Well, we use it for that so that we can create the ground level partnerships so that our people who we are in community with—who have differential access to healthcare, to education, to economic opportunity—so that we can help them get those opportunities and access, to level the playing field so that they're not made more vulnerable to exploitation and trafficking and abuse and violence and trauma.

Ann: So in that way, they can play a leadership role in addressing human trafficking because they're influencing the systems that support it and perpetuate it sometimes.

Kim: That's right. And when you think about advocacy, what is the most important advocacy? How is it done? Well, it's done by the knowing what people are experiencing. And so that's the role health centers play. We see it. Our professional staff, our medical staff, our outreach workers, we see and we hear the stories of people living in this way, and how do we use our platform, our position, our prestige, our privilege to elevate those voices so that policymakers can hear that?

Ann: Thank you, Kim. This has been an incredible honor to speak with you and get your insights and all the things you do as a clinician, as a health center leader, as someone who continues to elevate the voices of people who are disenfranchised from our current healthcare system as it is today. So we applaud your work and are so grateful for your time that you took today to speak with me. Thank you.

Kim: Thank you for having me. Appreciate it.