Bridging Healthcare Gaps in Underserved Boston Communities: An Interview with Dr. Mollie Williams

interview by beier nelson

HUHPR Senior Editor Beier Nelson interviewed Dr. Mollie Williams, Dr.P.H. Dr. Williams is the executive director of The Family Van, a mobile clinic that utilizes a community- oriented approach to provide free preventative care screenings to Boston’s underserved, neighborhoods. Dr. Williams is also a lecturer on Global Health and Social Medicine at Harvard Medical School.

Beier Nelson (BN): Thank you for your time today, Dr. Williams. Can you give a brief introduction to your background and interests in social medicine and your journey that led you to become the Executive Director of the Family Van?

Dr. Mollie Williams (MW): I started in the field of public health around 25 years ago in response to the injustices I saw in how people with HIV and AIDS were treated. So this was during the 80s and 90s, and it lit in me a passion for social justice, particularly around health. I noticed that people who use drugs or were sex workers, or were gay, were demonized in the media and by healthcare professionals and politicians. I knew that it was wrong, and it made me want to do something to change that. So I decided to study public health, and then have had a series of different roles for 25 years now, working primarily in the social justice health arena.

BN: In many communities in Boston, language barriers, lack of access to culturally-competent care, and other social determinants of health (SDOHs) such as food, housing, and job insecurity have contributed to negative health outcomes. How have you seen The Family Van make an impact on these communities?

MW: The Family Van goes directly to communities that are often excluded from their traditional health care system—immigrants, people of color, people without insurance, people who are low income—it's difficult for them to get care. Even in a city that has as many health resources as Boston, there are a lot of barriers, such as transportation or the ability to pay. But there's also a really important barrier: a lack of trust. What we see is that people come to The Family Van and talk to the community health workers who operate the van in a way that they don't feel comfortable talking to their primary care provider about. So they come to us for information, guidance, and counseling, and we can direct them to where they can get the support and care they need.

We also educate our clients about how to work with their primary care provider to improve their health. For example, people often come to us with an issue around a chronic disease like diabetes or high blood pressure, and we always ask: “have you been prescribed medication for this? And if yes, have you taken that medication?” And a lot of people say no, or “I don't remember,” or “Well, sometimes, but I don't like the way it makes me feel.” So it's important that they're able to go back to their provider and say, “This medication isn't working for me” or “I can't afford this medication.” But that's not easy to do, especially when there's a language or trust barrier or you have to admit that you can’t afford it. We are helping those folks who really need that care get what they need from our healthcare system and do it with compassion, understanding, and patience.

BN: Why do you think there is a gap of distrust between the primary care providers and the community?

MW: It goes back centuries and generations, if we think about even just say sixty or seventy years ago, health care in many parts of the country was segregated. If you were African American in the South, and probably many places in the North as well, you went to a different hospital. It was separate care, and it certainly wasn't equal care. These disparities still continue in the present day, often in de facto segregation. For instance, depending on what kind of insurance you have, you may go to one healthcare provider versus the other, with levels of care are still not equal.

For example, here’s a story from my own experience. I had my son at a very well-respected hospital in New York City. He came early, so I wasn't supposed to deliver there, but I developed a complication and had to go to the hospital for an ultrasound to see what was going on. They rolled me into this room on the first floor of this busy, well-respected hospital. The room was jam-packed with people. Most of the people in the room were people of color, and there were lots of different languages being spoken. Finally, a staff member yells out my name and asks, “public or private?” And I said, “what do you mean, public or private?” They asked me what type of insurance I had. “Oh, I have Cigna, or Aetna, or something.” They said, “Oh! Well, you're in the wrong place. Take her up.” They wheeled me out from this overcrowded room where everybody was waiting for a long time and took me up the elevator right into the exam room—and there's no wait whatsoever. In fact, no one is even up there, and I get my ultrasound in minutes.

That's still segregated care. We like to think that it doesn't happen anymore, but it happens every day, even in the best hospitals in this country, including hospitals in Boston. Segregation in healthcare comes out through interpersonal racism in the exam room, via language barriers, in structural racism, and from generational experiences. If your parents or grandparents went someplace and they were treated poorly — even if that was 50 years ago—you're still going to hear about that. You're not going to want to go back there for care, let alone if you've had your own negative experiences at that institution. So that's just one part of why I think this distrust exists. It is the legacy and continuation of racism and segregation, perpetuating the problem of separate and unequal care.

BN: Thank you for sharing that story. The Family Van was founded in 1992 by former Harvard Medical School Dean for students Nancy Oriol and Cheryl Dorsey, who was a medical student at the time. Have the health needs of these communities shifted since The Family Van’s founding and how has the care offered by The Family Van evolved to meet these changing needs?

MW: The services and the needs in the community in many ways have not changed at all and, in other ways, have really evolved. When The Family Van started, Dr. Oriol had this vision of addressing the problem of maternal and infant mortality, especially among African American women. When I say things haven't really changed, there’s still significant disparities surrounding maternal mortality. Dr. Oriol was—and still is—an OB anesthesiologist at Beth Israel, and she noticed this disparity that it was often black women from Roxbury and Dorchester who had prenatal care, but they didn't have the kind of support and education and access that other people did. So, she and Dr. Dorsey worked with the community for over two years to identify really what was going on and what the community thought the solution might be. The solution didn’t come from Dr. Oriol or Dr. Dorsey but from the community.

Once the Family Van hit the streets, however, the understanding of the community’s needs became much clearer; it was much more than access to prenatal care. Maternal mortality isn't just about those nine months, it is about that person's entire lifespan. Before children are even born, their experience in utero can influence their birth outcomes. The solution had to evolve, now including helping people identify and manage chronic conditions like diabetes and hypertension. We work especially hard to detect undiagnosed hypertension or high blood pressure. Hypertension is called “the silent killer” because many people are unaware that they have had high blood pressure for years and it damages their blood vessels, their brains, and their hearts, and dramatically increases their risk of heart disease and stroke. So, our efforts surrounding maternal and child health evolved to deal with chronic disease, and we are currently evolving to integrate mental health into that work.

BN: The Family Van utilizes multilingual and multicultural healthcare providers to offer free preventive care services such as screenings for blood pressure, cholesterol, and HIV, as well as health referrals. Why is it so crucial to provide culturally competent care?

MW: Trust is central to any well-functioning healthcare relationship, and understanding and accepting someone else's culture and life experiences is foundational for building trust. To address the problem of trust, first we need to be culturally competent. And that term, I think, is limiting, as is another term, which I like: cultural humility. The Family Van is operated by community health workers from the communities that we serve. There are no doctors or licensed medical professionals on the van. People often ask us why we don’t have doctors, and I like to tell them that there's a doctor on every corner in Boston, but for some reason, people are still not getting the care they need. The Family Van acts as the bridge, and we have staff who come from and understand and respect the cultures, life experiences, and wisdom of the people who are seeking care. It's a matter of respecting the other person's dignity and you have to do that if you want to improve someone's condition.

BN: The Family Van is an invaluable way to bring care to underserved communities, but the ongoing need for this service suggests that there is still a structural lack of accessible and culturally-appropriate care options for these communities, despite Boston housing such robust institutions for healthcare and research. What are some possible long-term solutions and health policy implementations to ensure that communities are able to access the appropriate care they need?

MW: I completely agree there are structural issues at the root of the problems that I've mentioned, and mobile clinics like The Family Van are just one part of that solution. There’s around three thousand mobile clinics in the United States, and that number is increasing rapidly because more and more people recognize that health care can and should be delivered outside of the walls of a hospital. This kind of growth needs to continue, and there's many policy interventions that could help. So, looking at issues of reimbursement of resource allocation for these mobile clinics. Medicaid and Medicaid expansion are really key to the success of not just mobile clinics but any sort of effort to address disparities, as the disparities are the greatest, mostly in states that didn't expand Medicaid.

During the pandemic, hundreds of cities and counties across the country declared racism as a public health crisis. Mobile clinics are one very visible, tangible way that cities can respond to that crisis, but it's not the only way. I know everybody's talking about it, but we need to focus on the social determinants of health. We can't artificially separate health from the other components of our lives. To me, that's all social determinants are: it's the rest of our lives, and that influences who is healthy, who has the opportunity to be healthy, and who is not. So structural solutions around education, transportation, and housing that seek to create equity, and ameliorate racism, and make reparations — those kinds of policy changes and commitment to equity is what's needed everywhere.