A brief filed by Mississippi Attorney General Lynn Fitch summarized the state’s arguments, writing that Roe and Casey are wrong and outdated, in part because contraception is accessible, affordable and effective, and because today “on a wide scale women gain both professional success and a rich family life.” This argument has been echoed by other proponents of restrictive abortion policies. But what Thomas and her colleagues have seen first-hand in roughly a year of operating their clinic is that many Mississippians do not enjoy easy access to contraception — let alone other basic medical services necessary to plan families and thrive.
Rates of babies who are born underweight, for instance, are very high in the Delta. That’s obviously bad for babies, but it’s also considered a key indicator of the health of mothers, revealing that women in the region experience high levels of stress and poor access to health care. Plus, the state, like many rural areas, has an obstetrician-gynecologist shortage. In more than half of Delta counties, there’s not a single OB-GYN, according to federal data. Plan A has had an insured patient contact them for help getting an IUD, because she couldn’t find an appointment elsewhere for less than three months in the future.
The majority of patients who visit Plan A are uninsured or underinsured, struggling both to afford health care and to physically access it in a sparsely populated region where the nearest hospital or doctor might be an hour’s drive away. Even a health care provider situated a half-hour away can be unreachable without reliable public transit, and telehealth has limitations in the Delta, where many lack broadband access. Patients also might hesitate to seek out care — especially for a sexual health issue — because they feel alienated and judged by a medical system that doesn’t always treat the poor or people of color with dignity. Some rural health providers don’t offer family planning or gynecological exams at all. Meanwhile, the Covid-19 pandemic has pushed many of the state’s beleaguered health care workers out of the industry altogether.
To some extent, Weinberg, who went into public health after completing medical school, anticipated these problems, and figured that a mobile clinic could help address the core issue of geographic isolation. She hoped that making services free, as well as staffing the clinic with people who lived in the Delta and looked like their patients, would build the trust needed to deliver care around sensitive issues such as HIV, STIs and birth control. But, over time, the regional challenges she learned about before the clinic ever saw a single patient have revealed themselves to be much deeper, prompting the organization to expand its services beyond reproductive and sexual health to become a broad-based provider, addressing basic needs such as primary care and vaccinations. It was only Plan A’s second day, for example, when the staff encountered its first medical emergency. The clinic had arrived at a factory in Greenville to offer employees free health screenings when a seemingly healthy woman walked into the truck; she had a blood pressure of 220 over 110 — a life-threatening level. Since then, it’s been a rare week when Plan A doesn’t see someone with blood pressure high enough to warrant a visit to the emergency room.
So far, Plan A’s mobile staff of three — Thomas, nurse practitioner Toria Shaw and another community health worker named Antoinette Roby — has traveled more than 600 miles, visited more than 30 towns and seen about 600 patients. More than half of their patients have received sexual and reproductive health services. Plan A also has given out nearly 200 Covid-19 vaccines.
What’s worked for Plan A over the past year has been cultural sensitivity and individualized care, as well as near-constant assessment of how they can better serve clients and an acute awareness of potential pitfalls. Weinberg knew that, as a white New Yorker, she was “an outsider on every level,” in her words, when she conceived of Plan A, and so she tried to network with anyone who would answer their phone in the Delta — elected officials, health care activists, clergy, nonprofit leaders — to get feedback on her vision, as well as their advice for building trust. “It’s not fair to come into the community and not find out how they feel,” says Jackie Sanders Hawkins, a veteran health outreach worker from the Delta who eventually joined Plan A’s board. “She was able to touch base with all those different stakeholders. Had she not done that in the beginning, then the clinic probably would not have been here.”
Inside the truck, Thomas and her colleagues go out of the way to make patients feel comfortable and do persistently follow up to make sure patients pick up their prescriptions or make it to specialist appointments. Patients, in turn, have told Thomas and her colleagues about a variety of issues that affect their health: relationship problems, infertility worries, sexual abuse and the lingering grief of miscarriage. Many have confided about suffering from chronic pain and heavy bleeding caused by uterine fibroids. Others have talked about relying on tissues to absorb menstrual fluids because tampons and sanitary pads are too expensive. “Some people we touch,” Thomas says. “And they open up to us about certain things in their lives.”
Plan A’s approach has the potential to be replicated, and the organization is working to expand. But its work also underscores the depth of patient need, and demonstrates just how hard it is to serve rural patients well and how many more resources are needed to address race-based and geographic health inequities in a more comprehensive way.
Health and race are inextricably linked in Mississippi. Black and Native American residents, for instance, are far likelier than their white neighbors to die early from treatable conditions. Black women in Mississippi die of cervical cancer at a rate nearly twice the national average. Pregnancy-related deaths for Black Mississippians are nearly three times the rates for white women. Black babies, too, die at nearly twice the rate of white infants in the state.
The state is arguably the most extreme case of the much-discussed national crisis in rural health care, in which policy, geography and demographics translate into bankrupt hospitals, provider shortages and pharmacy deserts. Covid-19, and the speed at which it spread through rural America, shone a bright light on the disparities between urban and rural health systems. Mississippi, whose health system the Commonwealth Fund foundation ranks as the poorest performing in the country, has seen five hospitals close between 2010 and 2019. An additional 27 are classified as vulnerable, according to the National Rural Health Association, a nonprofit membership organization. Mississippi also ranks dead-last among states in physician-to-population ratio.