Introduction

This project represents Step 1 of an ongoing multimedia research project and public presentation being conducted by Nuestra Gente Community Projects, Inc., a 501c(3) nonprofit organization primary serving the Latino community in Toledo, Ohio.

Over the course of several weeks in 2022, we conducted research on the spread of COVID-19 through the Hispanic community in Lucas County; interviewed community members, public health officials, and front-line care workers; compiled data from public information sources; and examined some of the limitations of pandemic care and data gathering in light of the particular challenges facing the Hispanic community.

I. COVID-19 IN LUCAS COUNTY, OHIO

When the novel coronavirus was first surfacing at the end of 2019, few could foresee how far and how quickly it would spread. In what would become a global pandemic claiming more than 6 million lives, Lucas County was not spared, seeing more than 100,000 cases and 1,400 deaths so far. In part due to its status as a port city at the junction of several major interstates and a demographic makeup distinct in the region, the county has faced unique challenges in treating patients, delivering tests and vaccinations, and mobilizing health care forces by combining the effort of public and private institutions.

While this report focuses mainly on the impact on communities of color, specifically Lucas County’s Latino population, it’s instructive to look at the overall picture. By some metrics, Lucas County fared better than the state of Ohio as a whole despite being among the state’s densest population centers. However, limitations of case counting, the intense pressures of mobilizing to face a once-in-a-generation public crisis, and hurdles both cultural and logistic leave our public health officials with at best a low-resolution picture of the virus’ actual spread through the community. Officials and front-line care providers we interviewed for this project all agreed that cases are likely undercounted — perhaps drastically so. What percentage of positive home tests are actually reported? It’s difficult to estimate, but the confirmed positive cases reflected in Ohio’s numbers are no doubt a fraction of the actual infections in the county.

Lucas County Health Commissioner Eric Zgodzinski said the county first got wind of the novel coronavirus when it broke out overseas and started making preparations then. “We had some plans in place — at least we thought we did,” he said. But as the scope of the pandemic began to take shape by March, 2020, the volume of cases began to test officials’ resources.

At first, the understanding of the disease and the tools to fight against it were limited. Eventually, new therapeutics and vaccinations became available. Initially, testing supplies were strained, and officials struggled to keep up with distribution. That presented challenges not only to providing care but to assessing the virus’ spread.

Dr. Anne Ruch, an obstetrician who founded Compassion Health Toledo, a care clinic focusing on maternal and prenatal care, said early on, if patients weren’t very sick, they were encouraged not to come in for treatment. That meant they weren’t being tested or confirmed as positive cases as well. Her clinic administered both tests and later vaccines in one of the county’s most-distressed neighborhoods. She said that limited testing and the incredible strain on the county’s hospital system, which struggled with staffing as care workers became sick or were forced to quarantine, compounded undercounting and at times resulted in tragedy.

“A lot of people died alone,” she said of patients at the height of the onset.

And as the pandemic progressed, the types of challenges health officials faced changed, as well. As tests became more available, many patients picked up home test kits, the results of which often weren’t reported to the state.

“The numbers are way low,” Ruch said of official case counts in Lucas County and beyond.

Early on, availability of testing was a limiting factor to tracking the virus. By the end of the pandemic, a larger percentage of positive cases have gone unreported amid widespread at-home testing.

Zgodzinski said the state had a hard time keeping up with lab reports early on. He noted that Ohio uses a centralized reporting system, where labs report positive cases directly to a state database, and the spread of the virus is reported back to the county health departments.

“Sometimes they didn’t have [access to the database], so we would get a fax, and we would have to upload that. Now, we’re not doing as much of that. At first, we had a hard time keeping up with those lab results,” he said.

With up to 1,200 new infections a day in Lucas County, the existing reporting system wasn’t designed to have that kind of pressure put on it.

Those reporting concerns smoothed out over time, as public health officials got a better picture of both the virus’ behavior and how to respond to it. But new challenges emerged as new COVID variants led to periodic resurgences in the county over the course of the pandemic and the focus of public health efforts shifted from tracking and tracing to distributing vaccines to a skeptical populace.

“Things sometimes changed a couple times a day. There’s a couple things we definitely did learn for the next pandemic,” Zgodzinski said.

To that end, Ohio has started upgrading its reporting system and migrating COVID data to a new database, although officials we spoke to offered no timeframe for the project.

Zgodzinski emphasized that greater uniformity in software and reporting systems and improved remote access to the servers through devices like phones and tablets are key to mobilizing against potential future pandemics. Early, fast, accurate reporting are vital to an effective public response and could potentially prevent a future pandemic from taking hold.

But the virus is only part of the picture. The general health and economic well-being of communities also play big roles in outcomes, especially when public health measures include quarantine and closures.

“People living paycheck to paycheck, they got hit hard not just from the virus but from all the things associated with it. Even into March [2020], those populations were already being impacted,” Zgodzinski said.

Our examination of public health data and Census demographic breakdowns reveal some interesting correlations among the effects of the virus on various communities in the counts. The correlation between age and COVID deaths is immediately apparent, exemplified by the ZIP code 43547, comprising the village of Neapolis, with 35% of its population ages 65 and older. The tiny village saw by far the county’s highest death rate. Another good example is the city of Oregon, which saw a relatively high COVID toll for its stastistically older but more prosperous population. Age discrepancies can explain why some of the county’s poorest neighborhoods saw comparitavely low case and death rates.

Clear correlations can likewise be drawn between posperity and vaccination uptake, notably among heavily Hispanic neighborhoods, a fact we will examine more closely in the next section.

II. COVID-19 AND LUCAS COUNTY’S HISPANIC COMMUNITY

By some metrics, the county’s Hispanic residents fared relatively well, with death and hospitalization rates below their share of the population. But our discussions with health officials and front-line care workers revealed both challenges and advantages unique to the community.

Dr. Richard Paat, clinical professor of medicine at University of Toledo, was among the leaders in Lucas County in reaching out to local underserved communities and to migrant camps in surrounding counties. He witnessed firsthand how the virus impacted Latino families and communities in Lucas County and was among the leaders in working to distribute tests and vaccines in those neighborhoods.

As one of the few official vaccine providers offering free clinics in the nation, Dr. Paat and volunteer medical students distributed nearly 7,000 vaccines. At the height of the vaccination effort, they were operating 5 bilingual clinics a week, including at Escuela Smart School in South Toledo.

At the request of the state, he also partnered with the Farm Labor Organizing Committee to lead bilingual teams into surrounding migrant communities. His experiences on the front lines of the virus response offer insight into how Lucas County was both uniquely challenged but also uniquely prepared to deal with an unprecedented health emergency.

• INVISIBLE TO THE DATA

Rampant undercounting — acknowledged by every expert we spoke to for this project — is only one of the ways that the true burden of the virus on the county’s resources can’t be seen in officially reported numbers.

One of the themes that emerged in our research was the unique challenge the county faced in serving migrant populations. The Ohio Department of Agriculture estimates there are 5,600 migrant farm workers at licensed camps in the state.

As the urban center in the middle of a large agricultural region, officials in Lucas County and Toledo in particular lead efforts to serve camps in surrounding areas, and hospitals in the county saw scores of migrant workers seek treatment.

Dr. Luis Jauregui, head of the division of infectious disease at Mercy Health St. Vincent Medical Center, not only played a key role in developing much of Mercy’s infrastructure for pandemic response, but he is also a frontline care worker who saw the toll of the virus firsthand.

“I’ve taken care of over 1,200 patients personally, and in the beginning it was like the Wild West,” he said. “All we had was a face-mask and a gown.”

While testing and treatment have vastly improved over time, severe COVID is still a complex disease to treat. Because of that — and because resources and talent are concentrated in the urban center — Lucas County was well-positioned for effective virus response and led treatment efforts for the entire region, including surrounding migrant communities.

He offered a particular example of an undocumented mom from Mexico who became very ill with COVID after delivering her baby. Care providers took a special interest in the case were able to get approval to fly her to Chicago for a lung transplant. She was able to get extraordinary care despite having no documentation or financial resources.

But her case was an outlier, and outcomes for many patients were worse. He said many of the Latino patients he treated were migrant workers — often with severe cases.

“We only saw them when they had no options left,” he said.

Migrants — many undocumented — were often reticent to seek care due to fear of arrest, lacked access to early treatment, and at times were actively prevented from getting tested.

Dr. Paat said a lot of growers didn’t want their workers tested, for fear that quarantine would keep them out of the fields during key times of the growing season. Ironically, he said, many of those same growers actively encouraged his later vaccination efforts for the same reason.

When the teams were able to administer widespread testing, they found the virus was spreading quickly in migrant communities, finding 55 positives out 80 migrants at one camp.

As to the fear of deportation, Dr. Paat said migrant workers were guaranteed by health departments that nobody would be arrested for seeking care or getting vaccinated.

“We didn’t care who you were as far as getting service,” Health Commissioner Zdgozinski said. “All we had to do was keep people healthy and keep them out of the hospital.”

“We have mission to take care of everybody,” Dr. Jauregui said of care providers in the Mercy Health system. “There has never been at any time any hint of discrimination.”

Nevertheless, the fear of deportation or arrest was a real factor in keeping undocumented immigrants from seeking testing, care, or vaccination, especially early during the pandemic and in a political climate where immigration issues were being hotly debated.

• CULTURAL AND POLITICAL HURDLES TO CARE

Lydia Finch, a medical assistant at Compassion Health Toledo, which serves poor communities in South Toledo in a part of town with a large Hispanic population, pointed to four key issues facing Lucas County’s Hispanic community that created barriers to treatment and vaccination: money, access to transportation, lack of documentation, and cultural barriers.

She estimated 15% of the patients at the clinic don’t speak English.

“It’s hard in Toledo because there’s so few practitioners who speak Spanish,” she said.

Other care providers we spoke to echoed that assessment.

• LANGUAGE BARRIERS

Dr. Jauregui, the infectious disease expert, emphasized consistent communication and dispelling misinformation as vital to mobilizing against a pandemic.

Language barriers break down even that most basic effort to get care, but also stymie patients at every level of the process, from access to routine examinations to understanding how to prevent the virus’ spread or seek treatment.

Being able to communicate clearly is needed to build trust, and that trust gets patients to follow the advice of doctors and leads to better outcomes.

While teams of bilingual care providers went into Hispanic neighborhoods, hospitals in Lucas County tackled the issue in part using the STRATA system for translation, which allows doctors to communicate across language barriers using remote live translators for multiple languages.

“It’s like a Zoom meeting with a live translator, but it’s not the same as being in person,” Dr. Jauregui said.

He said being a native Spanish speaker helped him build trust, which is the biggest factor in early intervention and testing.

Dr. Paat and Dr. Ruch echoed that conclusion. While systems like STRATA aid with front-line care, having established relationships with communities is the only way to build the trust needed.

“I see people who are already here, so we have a good relationship with the Latino patients,” Dr. Ruch said. But that isn’t always the cases in areas where bilingual services are not well established.

Dr. Paat said he couldn’t have done the work he did if he hadn’t already been working to establish strong relationships with underserved communities.

“It’s a trust that we’ve developed in the community,” he said. “It’s not something that could be done if you didn’t have a long-term relationship.”

• CULTURAL ATTITUDES

General distrust of institutions and health officials for various reasons was a recurring theme in our discussions. While undocumented patients may shy from care due to fear of arrest, others have historical, personal, or political reasons to resist testing or vaccination.

Care workers said that reticence was particularly strong in the Black community and in rural and poor white communities, especially early on.

Dr. Jauregui told the story of a woman from a rural town:

“I recall one conversation I had with a sick lady, and she declined treatment. And her husband called angry. I explained that we had a chance to decrease the chance of progression. She couldn’t explain why she was afraid. And her husband said her kids wanted to approve anything she would take. I asked, ‘I presume you love your wife, by making this decision, and me being a specialist telling you it’s wrong, your decision could cause the death of your wife.’ So he agreed to support whatever decision she made. She never did take the treatment — she was 81. Her risk of dying was 35%. But she wanted to go home. So that’s what she did.”

He doesn’t know if she survived her fight with COVID, but he distinctly remembers the fear and apprehension and said such reactions created a real obstacle to virus response, especially vaccination.

“Challenges were different for different communities, and everyone was so afraid,” Dr. Ruch said.

Terez Siggers, a social worker at Compassion Health Toledo put it succinctly: “People just don’t want to be told what to do.”

Much like a virus, these cultural attitudes spread among neighborhoods, friends, and relatives.

“They didn’t have anyone in their circle who had the vaccine,” she said.

Nancy Elzinga, also a social worker at Compassion Health, noted that most of the obstetrics patients were still unvaccinated at the time of the interview. Many of the patients told her that making the decision for their unborn child added an extra level of responsibility and risk for those who had concerns about the vaccine.

That points again to a need for consistent and accurate communication in at-risk communities. It’s having established, trusting relationships with patients that cuts through that type of reticence, and the more that people seek treatment and vaccination in a community, others become emboldened to do so as well.

In fact, Dr. Jauregui said the Black community lagged behind in testing at first, but that has equaled out over time. “In fact, now they’re ahead.”

He gave an anecdote of a young Black man who was very sick.

“We offered him plasma, and he declined,” Jauregui said. “His aunt happened to work here, so I kept insisting, so he called his aunt, so the aunt told him to do it. When it came down to it, it was the type of reluctance and acceptance that we did see.”

Simply put, people take advice from others they know and trust, so fostering greater trust in public health efforts is vital to any pandemic response.

• TRANSPORTATION

Access to vehicles became a big concern during the pandemic and complicated efforts to test, treat, trace, and vaccinate against COVID.

Early on, residents without access to private vehicles could be all but cut off from testing or care.

“Unless you had a car or could take a bus, you weren’t getting tested, and would you want to get on a bus if you aren’t feeling well?” Zgodzinski asked.

So health officials and care organizers took the testing and vaccine effort to underserved communities directly.

Dr. Paat targeted his bilingual clinics in largely Hispanic neighborhoods.

“That’s why we chose to go to those communities,” he said. “You could walk to those sites in the Old South End and East Side.”

TARTA designated a bus specifically to go into struggling communities and administer vaccines.

Dr. Paat said that, at first, vaccines were difficult to get, and teams would sometimes go door-to-door to make sure that limited vaccines supplies were used. Takers could be hard to find.

“When we were out the beating the bush, there was a lot of resistance to it. There was lots of crazy misinformation out there. We did do outreach. If you have 5 extra shots, you don’t want to waste them. So we’d drive around to local communities, go door-to-door. Sometimes it was hard to get rid of that last vaccine. It was sometimes hard to find that last person to give the last shot to.”

• VACCINATIONS

Data comparisons show a clear correlation between poverty, ethnicity, and vaccination uptake in Hispanic neighborhoods, a fact that health officials noted early on.

“When we realized there was a discrepancy in vaccination rates, we reached out to hospitals. They allocated about 20% of vaccines for vulnerable populations,” Dr. Paat said.

They partnered with the V-Project in a combined effort to vaccinate 70% of Toledo residents. That goal has not yet been reached.

Providers noticed a bell curve in vaccination efforts. At first, it was difficult to distribute vaccines because of constrained supplies and widespread fear of the shot. Over time, as mitigation efforts ramped up, there was a surge in vaccinations. But now, interest has again waned, possibly due to resignation about the virus or a general desire to return to pre-pandemic life.

“The numbers initially were up to 200 people a night, and they’d be lining up outside,” Dr. Paat said. “By the end — November or December –- you were lucky if they were vaccinating 5 or 6 people.”

Their most recent clinic at St. Peter and Paul Catholic Church, which holds Spanish-language Masses, saw fewer than 50 people register for vaccination. Only half actually showed up.

Dr. Jauregui cited misinformation as a continued problem. At first, the misinformation centered around the real risks of the virus and an inflated belief around the risks of the vaccines. Now, much of that misinformation is simply the belief that the pandemic is over.