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SALLY J. ALTMAN, MPH
Health Care Consultant and Journalist

Illustration by Jon Lezinsky

For many of us, returning to our normal pre-COVID-19 lives is not yet a reality. This is especially true for the most vulnerable among us nationwide, as the pandemic has fallen heaviest on minority and marginalized communities. Although COVID hospitalizations and deaths have diminished and the unemployment rate has fallen, inflation and interest rates are soaring for the first time in decades. Furthermore, affordable housing is now in shorter supply.

Residents in St. Louis' 63106 zip code have felt the impact. It is the sector just northwest of downtown that has long had the most problematic social determinants of health in the metropolitan area. Notably, average life expectancy there is 67, compared to 85 in 63105 in suburban Clayton, the St. Louis County seat, and one of the region's wealthiest communities.

In previous issues of Health Progress, readers were introduced to stories from residents of 63106. This final installment of this publication's 63106 series highlights how families continue to cope with the challenges of staying safe and healthy — physically and mentally — during the pandemic.¹

One of these accounts featured Misha Marshall, a 39-year-old registered medical assistant and mother of two who also serves as a caregiver for her elderly parents and her 37-year-old sister who has cerebral palsy. Marshall aspires to earn a master's degree in nursing and to become an RN — a step forward that could roughly double her income. However, her path to getting there has not been easy. Her experience is just one of many shared by other residents that shines a light on how the nation's patchwork support systems toggle between encouraging and discouraging well-intentioned citizens. Their stories — and those of many others yet untold — point out how efforts toward advancement of racial equity in the region and nationwide is multifaceted, ongoing work in need of systemic reforms.

OVERCOMING NURSING EDUCATION CHALLENGES
St. Louis, the state of Missouri and the nation need more people like Marshall. Vacancies for registered nurses in the St. Louis area increased from 11.2% in 2020 to 20.3% in 2021, according to the Missouri Hospital Association.^{2, 3} Overall, Missouri hospitals reported a staff nurse vacancy rate running at 19.8% — an increase from 12% in 2021.⁴ At that time, Missouri had 33,692 nurses working in hospitals and 8,334 vacant staff nurse positions, according to the data. As the pandemic took its course, nurses suffering from burnout began leaving the profession, taking early retirement and refusing requests to work overtime.

While there are plenty of positions now available, the pipeline is clogged. Nursing schools turned away nearly 1,300 qualified applicants in 2020, in part due to a shortage of teachers.⁵

It would be hard to find anyone more qualified than Marshall to join the ranks. She has worked in clinical settings across the region for more than a decade. Her caregiving has gone beyond patients at work, her family and in one case, a complete stranger.

And for that, she paid a steep price.

On a blizzardy evening in 2019, Marshall, to be safe, hired an Uber to take her from her home near downtown St. Louis to the hospital in the suburbs where she worked.

Not far from the hospital, traffic slowed to a crawl, then stopped. Marshall could see that a driver just ahead had gotten stuck in a snowbank. The driver needed a push. Marshall leaped out of the Uber and made her way to the other car, tapped on the window and told the elderly woman at the wheel she would try to help.

Unfortunately, Marshall slipped on the ice, and immediately knew she had broken her leg. The Uber driver drove her to the hospital, where X-rays confirmed that she had suffered a break in two places in her leg, along with a dislocated ankle.

"From that one night, I was out of work for five months," she recalls. "I was supposed to be living my best life. And here I am, lying in the street with ice and thinking, 'Don't help nobody no more.'"

Her remark made out of frustration, Marshall, of course, wanted to keep helping people by continuing her education to pursue a nursing degree. But then a series of adversities followed. At the time of her fall, she had enrolled in the nursing program at St. Louis Community College. She asked to take a medical leave, which she said had been approved by a school administrator. But then her paperwork got lost. When she reapplied, her request was rejected. Subsequent appeals didn't yield results.

After recovering, Marshall returned to work as a pediatric registered medical assistant at Affinia Healthcare, a clinic not far from her home. But then came more misfortune. Marshall's 75-year-old mother took a fall at home and had to be rushed to the hospital, where she would remain for several weeks. She would be readmitted three more times after suffering further setbacks.

With all that to handle, along with continuing to care for her sister and father, who also was becoming increasingly infirm, Marshall decided to leave her job with Affinia. Her plans to continue her education would also have to wait.

Ever resourceful, Marshall returned to a small dessert business she started in 2016 to stay financially afloat. Then, finally some good fortune arrived: a friend referred Marshall to Square, the financial services and digital payment company that had recently relocated a few blocks from her home. She was hired and promoted to payroll specialist.

"The company has a structure that supports people who need to be caregivers to loved ones, which really helped," Marshall says. "They never gave me the feeling that I would have to choose between my family and my job."

Even so, Marshall hasn't given up on her dream to earn her nursing degree and has found an ally in her quest: Mimi Hirshberg.

Hirshberg recently retired as a faculty member at the College of Nursing at the University of Missouri–St. Louis, where she was well-known as a mentor for disadvantaged applicants and students, whether providing some preparation for standardized tests, reviewing concepts from texts or negotiating with health care bureaucracies.

After learning about Marshall's situation, Hirshberg placed her with an academic advisor at the university to discuss academic possibilities. Hirshberg believes Marshall can find a path toward fulfilling her dream. "I just want to help her get through all the stages. I think with her experience and intelligence, she could pretty much breeze through (to getting a master's in nursing). It's just a matter of finding the best program."

This past July, Hirshberg noticed that BJC HealthCare in St. Louis announced that it would offer full-tuition scholarships to nursing students at Goldfarb School of Nursing at Barnes-Jewish College who would agree to work for the health system for three years after graduation.⁶ She mentioned to Marshall that perhaps she could qualify.

"I am going to be in school — whatever I have to do," Marshall said. "If that means selling cupcakes, cookies or cake pops, that's what I'm going to do."

Although her dream may be deferred for now, Marshall says it will not be denied.

Photo by Wiley Price Jr./The St. Louis American

In May 2020, Steven Jones was living in St. Louis, but unemployed and struggling with epilepsy near the start of the pandemic. Since then, he has found a path to better health and employment, but his work is in Columbus, Ohio. He hopes to return to St. Louis, where three of his daughters continue to live with their mother.

A PATHWAY TO QUALITY HEALTH CARE
As with Marshall, a personally improving economic picture in the latter part of 2021 and first half of 2022 benefitted Steven Jones, another 63106 resident previously featured in Health Progress. He has found work that is fulfilling, interesting and comes with benefits.

But it came at a cost. Jones is now living in Ohio, hundreds of miles from his daughters.

When Jones' plight was first shared in Health Progress in fall 2020, he was living in a two-bedroom apartment in Preservation Square, a subsidized housing complex just a mile from downtown St. Louis. He had been laid off from his job as a garage custodian downtown due to the pandemic.

Jones' epilepsy disorder prevented him from driving, so his employment options were limited. In the meantime, he was finding it difficult to access and navigate health care through Missouri's Medicaid program. Two clinics were within a manageable commute for Jones, but they were often crowded with people seeking appointments and COVID testing.

But at least while living in St. Louis, Jones regularly saw three of his daughters, who lived nearby with their mom. A fourth daughter, his eldest, lived with her mother in Charlotte, North Carolina, but would visit on occasion.

To save money, Jones decided to move to Columbus, Ohio, in December 2020 to live with his mother. It was then that his luck began to change health and employment-wise.

Under a physician's care in Ohio, Jones' seizures abated. Increasingly he was able to sense when a convulsion was coming and take measures to mitigate its impact, helping him to gain more control of his life. He was then able to find work as a part-time custodian and moved into a place of his own in July 2021. Soon afterwards, he applied for a position as a customer service representative with Spectrum, an internet and cable TV provider, and was hired in April 2022, making $20 an hour and receiving a host of benefits. Living with epilepsy presents distinct disadvantages, but in this instance, Jones' condition provided a hiring incentive: the federal government provides tax credits to businesses that hire people with disabilities under the Work Opportunity Tax Credit program.⁷

Today, Jones sounds buoyant about his prospects. With the new job and improved health care coverage through his employer, it was as if he had found a GPS to guide him through the thicket of government regulations that had stumped him previously.

Also in his favor is an economy that — at least for the time being — has put workers in his field in high demand. It's not lost on Jones that his employer is also looking for customer service reps in St. Louis. "In 90 days, if my metrics are good with my current position, I can ask for a move," he says.

"Now I'd like to talk to a lawyer to see if I can get a driver's license. Then, I can move on my own. I will have a stable income and a good work history when I come back to St. Louis."

Photo by Brian Munoz/St. Louis Public Radio

Kim Daniel details how she wants to decorate her new St. Louis apartment on Feb. 17, 2022. After years of waiting for Section 8 assistance, she finally moved into a residence in a safer neighborhood.

PURSUIT FOR A SAFE FOUNDATION
Just as Jones was finding a path to a brighter future, one of his former neighbors, Kim Daniel, found herself on the brink of homelessness.

At the time Jones departed his apartment in Preservation Square, violent crime was becoming an increasing problem in his neighborhood. It weighed even more on Daniel, who lived alone in a second-floor unit. In the spring of 2020, a neighbor's boyfriend fired shots that penetrated the wall of her apartment, an account she shared previously in Health Progress. Last summer, a youth she had mentored was murdered in a drive-by shooting down the street. She could see the makeshift memorial friends and family placed at the spot from her balcony.

Daniel became increasingly desperate to find a way out.

Her hopes rested on a slender reed. More than a decade ago, Daniel had applied for a Section 8 voucher that would provide a subsidy to cover three quarters of her rent, along with allowing her to find a unit in another part of town.

The Section 8 system, established in 1978 by Congress and administered by the U.S. Department of Housing and Urban Development (HUD), has been chronically underfunded.⁸ So it was no surprise that Daniel had to wait so long in the queue. "I got to the point where I didn't think it ever was going to happen," she recalls.

But last summer, the St. Louis Housing Authority notified her that her wait was over and issued her a voucher. Weeks later, she located a lovely two-bedroom unit in a complex located near the Lafayette Square neighborhood just south of downtown, the apartment within walking distance to a park, restaurants and most importantly, a full-service grocery with fresh food.

But at the end of that autumn, just 10 days ahead of her move-in date, Daniel collapsed with blood clots in her abdomen, legs and upper left ventricle — essentially a stroke. She would spend the next two months in the hospital and a rehabilitation facility and could no longer get around without a walker or a wheelchair. She now needed an accessible apartment.

The complex near Lafayette Square had such a unit and agreed to put it on hold for Daniel until she was released from a rehab facility. But the unit was more expensive, and the Housing Authority and HUD would need to approve a larger subsidy.

Initially, her request was denied. The Housing Authority told Daniel her situation no longer fit the government's formula for Section 8 support. Daniel's sister, Kenvee Daniel, was in disbelief.

To help her sister return to health and crusade for her increased housing benefit, Kenvee took an unpaid leave of absence from her job in Hawaii. The two moved to a wheelchair-accessible hotel room (at nearly $100 a night) in St. Louis County as Kenvee mounted a full-court press in support of her sister.

On a near daily basis, she sent polite but demanding emails to the Housing Authority and HUD to grant Daniel a larger housing voucher to cover the rent at the Lafayette Square complex. She also got in touch with Niya Foster, a fair housing specialist with the Metropolitan St. Louis Equal Housing and Opportunity Council. Foster pointed out to the Housing Authority that its own rules allowed for a "reasonable accommodation request" that would permit the agency to relax its payment standards.

Daniel's situation soon caught media attention, and her story was shared on St. Louis Public Radio in February.⁹ Later that day, a representative from the Housing Authority told Daniel that the path had been cleared for her to move into the Lafayette Square complex. Three days later, she signed a lease, and, with assistance from her family, she moved into her handicapped-accessible unit the following day. For the first time in three-and-a-half months, she had a place to call home.

Not lost on Daniel nor those involved in helping her were all the extraordinary measures and people it took to find housing for a deserving, resourceful citizen with health issues. "I would have been lost in the system without them," she says.

ENABLING POSITIVE CHANGE FOR STRUGGLING YOUTH
When the FDA approved use of the first COVID vaccine in December 2020,¹⁰ many Americans greeted the news with joy and relief. However, for Beverly Jones — and many other residents in 63106 — this development did not bring a sense of comfort. Many Blacks do not trust the health care system and were skeptical that a safe and effective vaccine could be developed so quickly.¹¹

Jones had contracted the illness a few months earlier and battled it for two weeks at home. She was perhaps lucky to have survived it, given that she suffers from lupus, fibromyalgia, osteoarthritis and chronic obstructive pulmonary disease.

Even after all she endured from COVID, she told a reporter, "I ain't in no big hurry to get it," when the vaccine became widely available.¹²

Since then, Jones, 59, has been vaccinated and boosted. She is not one bit happy about it, but the St. Louis Job Corps Center — a residential education and job training program for youth and young adults where she works as an adviser — had made COVID vaccinations a requirement. Jones never wanted to lose her connection to the center's young people, so she complied.

"It was either get the shot or I can't work," she says. "That's the way the world works sometimes. We're being forced to do things we don't want to do."

Later, the federal courts would step in and issue a block against the vaccine mandate for federal workers,¹³ so Jones could stop taking the shots. But she said, "I'm just going to go ahead and get it, because it makes no sense not to now." (To date, Jones has suffered no side effects from the vaccine.)

Jones says authorities would be better advised to lay off the mandates and focus on the health of young people who are at turning points in their lives. She speaks of the need for "second-chance employment."

"A lot of people have convictions on their records for nonviolent crimes, but that doesn't mean we should throw them away. We need a program that is easily accessible to help them get their records expunged," she says.

Jones was once in that category. She had a drug addiction and is in recovery, with a felony on her record. It took her years to get her life back together. But she earned an associate degree in human services and a certificate of proficiency in criminal justice at St. Louis Community College in 2003. She went on to earn a bachelor's degree at Fontbonne University in 2006, then three years later, earned a master's degree in business management at Fontbonne. During that time, she accumulated an exemplary work record, earning the praise of her supervisors.

Jones said that in her town and in today's environment, she feels like the exception that proves the rule. Although it wasn't easy for her, she would like to make it easier for others to get their lives on the right track.

Photo by Aisha Sultan

Tyra Johnson holds her youngest child, Mason, while helping her older children prepare to go back to school in January 2022.

OVERCOMING ROADBLOCKS
At the start of summer 2022, life was looking a little brighter for Tyra Johnson, a single mother of three whose experiences during the pandemic were last shared in the spring 2021 issue of Health Progress. In 2020, Johnson lost her job; and her eldest children, Meegale, now 8, and Madison, 6, missed more than a year of in-person school. Fortunately, she was able to bring her youngest, Mason, into the world without complications.

Like Kim Daniel and Steven Jones, her former neighbors, Johnson moved out of the crime-ridden Preservation Square neighborhood. Last year, she found an apartment across the Mississippi River in East St. Louis, Illinois. Though the city has a national reputation for crime, Johnson felt the new complex would be safer than Preservation Square where, like Daniel, bullets had been fired into her unit. Her new quarters also were closer to her mother who could help babysit her kids.

Then, just months later, Johnson landed a job at a Walmart in Granite City, Illinois, a 15-minute drive from her home. As an overnight shift worker, she would earn $19 an hour and among the benefits was a program that would help her earn her GED. Johnson had never made more money in her life and felt fortunate.

But only weeks later, Johnson's car broke down, requiring expensive automotive work. After being repaired, her vehicle was stolen, and she was unable to cover the loss.

Johnson would begin taking the bus to work, but it took more than an hour each way. Ever resourceful, she found a 24-hour day care that offered subsidized support. Still, just getting the kids there on public transportation would take a couple of hours. She also relied on the unsustainable option of having her mom watch her children overnight.

To compound her stress, Johnson was dealing with a traffic ticket for driving without a license. To get it dismissed, though, she needed to get a license, and she was unable to do so without a car.

"I need transportation. I need day care. I can't do this anymore," she said in a St. Louis Post-Dispatch article.¹⁴ After Johnson's story appeared this past July, a reader created a GoFundMe site on Johnson's behalf. By the end of August, more than 100 people had donated more than $15,000. Two local Muslim organizations also purchased a car to replace her stolen vehicle.

Now with a car, Johnson's quest to provide a stable life for her kids and to advance her education are within her grasp. Although a natural optimist, Johnson remains cautious, never really knowing what might lie ahead.

The same is true for many residents in 63106 and marginalized communities nationwide. COVID has tested their resilience and taken its toll. Perhaps the pandemic will finally abate. But unless and until more privileged communities find common cause with their neighbors, as things continue to change, the more they will remain the same.

This article includes additional reporting from DENISE HOLLINSHED, LEYLA FERN KING, AISHA SULTAN and RICHARD H. WEISS.

SALLY J. ALTMAN has devoted her career in public health to working with key stakeholders on health access issues as a health care administrator and a journalist. DENISE HOLLINSHED served as a crime and urban affairs reporter for the St. Louis Post-Dispatch for 21 years and is now a freelance writer. LEYLA FERN KING is a Wells Scholar at Indiana University and a reporter for Before Ferguson Beyond Ferguson. AISHA SULTAN is a nationally syndicated newspaper columnist, award-winning filmmaker and features writer. RICHARD H. WEISS is co-founder and executive editor of Before Ferguson Beyond Ferguson, a nonprofit racial equity storytelling project.

Previous articles about the 63106 Project appear in the Fall 2020 and Spring 2021 issues of Health Progress.

NOTES

1. Sally J. Altman, "Two Zip Codes, A World Apart," Health Progress 101, no. 4 (Fall 2020): 44-50, https://www.chausa.org/publications/health-progress/archives/issues/nurses/two-zip-codes-a-world-apart; Sally J. Altman, "The COVID Conundrum," Health Progress 102, no. 2 (Spring 2021): 51-56, https://www.chausa.org/publications/health-progress/archives/issues/spring-2021/the-covid-conundrum.
2. "2021 MHA Workforce Report: St. Louis Region Profile," Missouri Hospital Association, https://www.mhanet.com/mhaimages/Workforce/2021/STL_2021_WF_Report.pdf.
3. "2022 MHA Workforce Report: St. Louis Region Profile," Missouri Hospital Association, https://www.mhanet.com/mhaimages/workforce/2022/STL_Region_2022_WF.pdf.
4. "2022 Workforce Report," Missouri Hospital Association, May 25, 2022, https://web.mhanet.com/media-library/2022-workforce-report/.
5. "2022 Workforce Report," Missouri Hospital Association.
6. "Scholarship Programs," Goldfarb School of Nursing at Barnes-Jewish College, https://www.barnesjewishcollege.edu/Financial-Aid/Scholarship.
7. "Work Opportunity Tax Credit," U.S. Department of Labor, https://www.dol.gov/agencies/eta/wotc/.
8. Sonya Acosta and Erik Gartland, "Families Wait Years for Housing Vouchers Due to Inadequate Funding," Center on Budget and Policy Priorities, July 22, 2021, https://www.cbpp.org/research/housing/families-wait-years-for-housing-vouchers-due-to-inadequate-funding.
9. Richard H. Weiss, "A St. Louis Woman's Dream of Better Housing Is Lost to Illness, Crippling Bureaucracy," St. Louis Public Radio, February 14, 2022, https://news.stlpublicradio.org/health-science-environment/2022-02-14/a-st-louis-womans-dream-of-better-housing-is-lost-to-illness-crippling-bureaucracy.
10. "FDA Takes Key Action in Fight against COVID-19 By Issuing Emergency Use Authorization for First COVID-19 Vaccine," U.S. Food and Drug Administration, December 11, 2020, https://www.fda.gov/news-events/press-announcements/fda-takes-key-action-fight-against-covid-19-issuing-emergency-use-authorization-first-covid-19.
11. Altman, "Two Zip Codes"; Altman, "The COVID Conundrum."
12. Denise Hollinshed, "A Grieving Reporter Rushes to Get Vaccinated as Her Subject Resists," Riverfront Times, May 10, 2021, https://www.riverfronttimes.com/news/a-grieving-reporter-rushes-to-get-vaccinated-as-her-subject-resists-35497492.
13. Alison Durkee, "Biden Vaccine Mandate For Federal Employees Blocked Again as Appeals Court Dissolves Earlier Ruling," Forbes, June 27, 2022, https://www.forbes.com/sites/alisondurkee/2022/06/27/biden-vaccine-mandate-for-federal-employees-blocked-again-as-appeals-court-dissolves-earlier-ruling/?sh=91975d62ebba.
14. Aisha Sultan, "Sultan: How a Stolen Car Could Ruin an Entire Family," St. Louis Post-Dispatch, July 15, 2022, https://www.stltoday.com/lifestyles/parenting/aisha-sultan/sultan-how-a-stolen-car-could-ruin-an-entire-family/article_4814ffef-abdb-559c-b95a-dfb5f85e4d55.html.