While the vast majority of coronavirus deaths in Framingham have occurred in nursing homes — 82% as of July 13 — infections are disproportionately plaguing the city’s immigrants, people like Aparecida.

FRAMINGHAM — Aparecida first began to notice the symptoms at her bakery job. Her throat was sore. She was so, so tired.

She went home after her shift, took a shower and told her 14-year-old son they needed to go to the hospital. When the pair arrived at MetroWest Medical Center in Framingham, staff tested them for the coronavirus and sent them home with instructions to quarantine.

Three days later, on May 13, Aparecida learned she and her son were positive for COVID-19.

The 45-year-old Framingham resident still cries remembering the crushing weight of the news. A feeling of pure panic set in. She had been watching the rising death toll in her native Brazil. She worried her son would die, or that she would die, leaving him with no one.

It is because of her son that Aparecida moved to Framingham in 2018.

Though he was born in the U.S., he moved back to Brazil with Aparecida when he was 2. As he grew older, Aparecida began to see him struggle in school. When it became clear he had special needs — needs she felt couldn’t be met by the education system in Brazil — she made the painful decision to move away from her community there, a community that included her friends and three older children, to come to the United States.

She dreamed that with an American education, her youngest could become a police officer, though these days he’s more interested in working with computers.

Aparecida got to work building a life in Framingham that she hoped would propel her son to success. She worked hard, she said, careful to emphasize that she never intended to “take” anything from the government.

Aparecida thought she was prepared to provide everything she and her son needed. But then, the little family was diagnosed with the novel coronavirus and their lives turned upside-down.

Aparecida, accustomed to being both a mother and father to her son, as she put it, felt paralyzed. She was already earning less money because of a pandemic-related downturn in business, already late on rent. Her diagnosis now meant she would be out of work for two weeks, with no sick leave to cushion the financial blow.

As she worried about how to feed her son, her symptoms worsened. Soon, the son, who had a more mild case, began to care for his mother. He saw how scared she was. He asked her to stop watching the news.

Though she goes to church, Aparecida hasn’t had much time to build a community in Framingham since moving from Brazil. She felt alone, and desperate.

Eventually, with bills piling up and her symptoms showing no signs of abatement, Aparecida asked her son to reach out to his teacher. They needed help, she told him.

Aparecida doesn’t speak much English. She told her story to the Daily News through Ilma Paixão, a longtime Framingham resident and community activist who volunteered to serve as translator.

Through Paixão, Aparecida said her 14-year-old was reluctant to tell his teacher his family was in dire straits. He was worried about bullies. He knew the coronavirus is something no one wants to have, and he feared that in telling his teacher, word would spread to his classmates.

I understand, Aparecida told him, but you need to study and I can’t help you.

After her son reached out to the teacher, Aparecida was connected with a food pantry that began delivering food to her door, where her son picked it up.

Soon the two-week quarantine stretched into three weeks. Aparecida was still sick, coping with an aching chest and back and a deep lethargy.

It had been four months since she paid rent. She was able to apply for unemployment, but struggled through the process, eventually collecting only a week’s worth of relief. She needed a negative coronavirus test to get back to work.

As a Framingham resident with no car, her only local options for testing were two urgent care clinics, both of which charged for tests at the time she needed them. She couldn’t afford the cost, so she shelled out a smaller amount to pay someone to take her to Lowell, where she got a free test in a parking lot a full two months after she learned she had contracted the virus.

Despite her ongoing symptoms, the test was negative.

Aparecida is now back at her job, though she can only muster the energy to work one day a week. Her body is not the same, she said.

When Aparecida tested positive, she wrote a letter to her landlords explaining that she was unable to work. They never responded, and she hasn’t reached out again. She is scrambling to save up the four months of rent she owes, but her weekly paycheck is barely enough to cover food and utilities.

She dreads the day her landlords call to collect. If she can’t pay, what will happen? Where will she and her son go? Will the pair of mostly well coronavirus victims be able to find a new place to live amid the ongoing pandemic? Will they be able to pay for a security deposit? Moving costs?

Aparecida also worries about her ongoing pain, her frightening lack of energy. She has a very limited health insurance plan and though she said she’s received care at the Edward M. Kennedy Community Health Center previously, when she called for an appointment with a doctor there, she was told the Framingham clinic was booked, that she would have to go to Worcester.

Kennedy Community Health Center CEO Steve Kerrigan told the Daily News that staff likely told Aparecida to go to Worcester because she came up in the system as a new patient, and wait times are longer for new patients. Kerrigan stressed a referral to Worcester is intended to provide quicker access to medical care, and that the center’s goal is to provide care locally whenever possible.

The Kennedy Center is also working to build capacity so that it can treat more people in Framingham, he said.

Local care is Aparecida’s only option, because without a car, the trip to Worcester is too expensive.

Representing a community

While the vast majority of coronavirus deaths in Framingham have occurred in nursing homes — 82% as of July 13 — infections are disproportionately plaguing the city’s immigrants, people like Aparecida.

Existing health disparities in the city’s Brazilian community, identified as early as 2016 in a community assessment done by the Massachusetts Alliance of Portuguese Speakers, laid the groundwork for a wildfire spread of the virus.

Respondents to MAPS’ 2016 survey cited a range of barriers to important services including health care. Expense. Language barriers. Long waits. Lack of child care during appointments. Lack of transportation. Immigration concerns. Confidentiality concerns. Fear of discrimination.

The pandemic has shown many of those barriers remain.

Brazilian immigrants have been an integral part of the city for decades, but there is still no accurate count of that community in Framingham, or even in the United States. That’s partly because many are undocumented, and partly because Brazilians’ racial identities are far more nuanced than American demographers have traditionally cared to represent.

Brazilians speak Portuguese, not Spanish, so they do not typically identify as Hispanic. They might identify as Latino, a term that usually describes people from any Latin American country, but they could also identify as white or Black, depending on their racial identity in Brazil.

Gisele Bündchen, Tom Brady’s supermodel wife, is one example. She’s Brazilian, but often associated with her German ancestry.

“You’ve got to be careful with Brazilians because they’re diverse,” said Carlos A. O. Pavão, clinical assistant professor at the School of Public Health at Georgia State University. “There’s a large Lebanese population there. There’s a growing Muslim population. I can go on and on.”

Because that complexity doesn’t currently register in the U.S. Census, there could be as many as 2 million Brazilians and as few as 800,000 nationwide, said Pavão, who noted that some Brazilian Americans are now pushing for their own demographic identity.

Incomplete data about Portuguese-speaking communities has serious implications for public health, especially during a pandemic, said Pavão, who is now writing a book on health disparities in Portuguese-speaking communities in Massachusetts.

“If we just envelope them into a larger racial group or ethnic group, then we really don’t know the nature of the issue,” he said.

Pavão, a Brazilian immigrant himself, started his career working as a community organizer in Fall River, where he grew up with a Portuguese mother and a Brazilian father. There, Portuguese speakers feel like the majority, Pavão said, but in writing grants for public health efforts in the city, he realized how little concrete information was available about the community he was trying to help.

“Who’s doing our public health, who’s writing about public health and who is depicting our public health priorities? I realized that data and how our communities are depicted in health data is a problem,” Pavão remembered.

When the city logged its first case of the novel coronavirus on March 11, Public Health Director Sam Wong already had a plan to ensure Framingham had a plan to mitigate that problem. Framingham’s team of contract tracers immediately began asking the people they called — the infected and those in close contact with the infected — about their primary language.

That decision was forward-thinking within the public health sphere, Pavão said.

In breaking down infections by primary language, Framingham had a much better picture than other municipalities of how badly the coronavirus was impacting its Brazilian community.

In neighboring Marlborough, which also has a sizable Brazilian population, COVID-19 data released to the public through the city’s website only shows coronavirus infections by age and gender. The Daily News reached out to Marlborough’s health department to ask if the city collects more data internally, but the director wasn’t available until after the press deadline.

For Massachusetts, the state Department of Public Health’s daily coronavirus dashboard breaks infections down by race and ethnicity, but not by language. The dashboard does include Hispanic as an ethnicity, but it does not include Latino, clouding the impact of the virus on the state’s Brazilian communities.

Framingham’s contact tracers — employed by the city, not the state, as is the case in most of Massachusetts — dug even deeper than primary language, hoping to drill down on what risk factors specific communities were coping with. The team asked about housing, work, family.

They learned many people contracting the virus whose primary language isn’t English were essential workers — low-wage health care workers, retail workers, restaurant workers, construction workers. Usually, those residents lived in multi-unit housing complexes, often with multiple generations of family members.

They learned many of those contracting the virus — like Aparecida — have limited access to health care for the same reasons identified in MAPS’ 2016 survey.

For undocumented immigrants, who who are barred from fully participating in a variety of governmental and quasi-governmental systems, including health care, access is even more difficult.

Even an undocumented person’s inability to get a driver’s license has repercussions for public health. Without a driver’s license, a person must rely on others for transportation to a doctor’s office or even a coronavirus test site, yet another barrier that could cause a person to put off finding out if that nagging cough is allergy-related or a product of the coronavirus.

“It is connected,” said District 7 City Councilor Margareth Shepard, who is widely thought to be the first Brazilian immigrant elected to a city council in the United States.

Shepard recently proposed a resolution to the City Council supporting a state bill that would give undocumented immigrants access to driver’s licenses. After a debate in which some councilors suggested the issue didn’t directly pertain to Framingham, the resolution ultimately passed, with Councilors Janet Leombruno and George King abstaining.

Data as a first step

Though efforts to collect more information about the residents contracting coronavirus led to better data than most communities have, Pavão and others interviewed stressed that behind each data point, there is culture and perspective.

For data to be useful, they said, public health officials must also tailor their responses to that culture and perspective.

Pavão gave an example. Most immigrant families operate from a collectivist rather than an individualistic perspective, with each member of the household working toward a shared goal.

That cultural paradigm could impact a person’s willingness to take a coronavirus test that might keep them home from the job that allows them to contribute to the family.

A culturally-competent public health response would take that perspective into account and use it to shape interventions, Pavão said. To learn that perspective in the first place, the health department has to involve the community it is trying to serve in crafting the response, he added.

Two members of the Framingham Health Department’s regular staff speak Portuguese, and one public health nurse working as a contact tracer for the city speaks Portuguese, but amid an onslaught in cases, the city needed more help.

To strengthen the city’s connection with a community that has been traditionally underserved, Framingham used state relief funds distributed by the Department of Public Health to contract with a local organization called the Latino Health Insurance Program, founded by Dr. Milagros Abreu, a member of the state’s COVID-19 Health Equity Task Force.

The Latino Health Insurance Program, on Waverly Street, connects its clients with health care, insurance, food assistance and other resources that can be difficult to access.

Framingham contracted with the organization in May. Now, when the city’s contact tracers know they need to reach someone who speaks Portuguese or Spanish, their first call is often to the Latino Health Insurance Program.

Abreu said her organization has succeeded in bridging the trust gap between the Health Department and some of the city’s immigrants. Many are already clients of the program, she said.

And in partnering with the city, the Latino Health Insurance Program has also helped address the lack of information — or the presence of misinformation — about health care and the coronavirus, an issue cited by several people interviewed for this story.

“Many of them don’t know that there are resources that are available to them in this type of crisis,” Abreau said, adding that residents can contact the Latino Health Insurance Program for help with insurance, food assistance, coronavirus testing and coronavirus treatment.

In partnering with community-based organizations like the Latino Health Insurance Program and the Kennedy Community Health Center, and in speaking regularly with Shepard, Framingham’s health department was able to begin crafting programs aimed at addressing the disparities evident in the coronavirus data.

The city used state and federal funding to launch a program that allows those living in quarters not conducive to isolation to stay at a local hotel while recovering, an effort to protect others in the home from contracting the virus. As of July 8, the program had funded 1,106 nights at the hotel, according to Wong.

In May, after requests from Shepard, the Health Department began working with apartment and condo buildings that had several coronavirus cases — represented on an internal health department “heat map” — to distribute masks among tenants.

The city has translated applications for economic relief, including relief for rent and utilities, into Portuguese, and pushed information about social distancing and the importance of wearing a mask and getting tested via the Latino Health Insurance Program.

‘Not enough’

Still, Aparecida never got a call from the Framingham Health Department after her diagnosis. She never got a call from the Latino Health Insurance Program.

She didn’t know that the city offers hotel stays for those infected, or that the city had set up a massive food distribution network. She didn’t know that she could be eligible for rent relief.

And because of her limited English skills, she never felt comfortable enough to reach out to the city for help.

“It’s not enough,” Wong acknowledged of the city’s efforts to support its immigrant communities through the pandemic.

With coronavirus cases rising nationwide, Wong is betting the city will get a second chance.

“We’re building our infrastructure right now in anticipation of the second wave,” he said.

Wong is planning to launch two major programs specifically designed to reduce infections in Framingham’s immigrant communities.

The first is building a local test site that would provide COVID-19 tests for free, even for the uninsured. Wong has been asking the state to consider Framingham as a location for a free test site for months, to no avail. The state recently opened a free test site in neighboring Marlborough, but Wong said having a test site there doesn’t address transportation issues Framingham residents face.

With no state-sponsored test site on the horizon, Wong has followed the city of Somerville’s lead. That city partnered with the Cambridge Health Alliance to offer free tests to all Somerville residents. Both Somerville and the health care provider are bearing some of the cost, Wong said.

Wong is now negotiating a similar agreement.

“We’re working with a community partner and also working closely with a commercial lab to try to figure out a way that the cost to us, to the city, is reasonable enough that the city can sponsor it,” Wong said.

A free local test site would also give the Health Department more control over the data collected at the site.

Wong said the city is currently depending on hundreds of disparate test sites to collect the contact information of those being tested. Often, that contact information is wrong. The city has even mailed letters to the addresses listed urging people to call the Health Department, only to have many of those letters returned to sender.

That could explain why Aparecida never heard from the city after testing positive.

With a local test site, Framingham could be more diligent in ensuring contact information is complete and correct, while also making information about available relief resources more widely available to those still not getting the information.

In addition to creating a local option for testing, Wong is working to build a team of in-person contact tracers that would knock on doors of people the city has had ongoing trouble reaching by phone. For the idea to work, Wong said the city needs the help of an organization that has already earned the trust of the city’s immigrants.

Abreau cautioned that a poorly-executed door-knocking effort could end up doing more harm than good. For the team to be successful, the city must first ensure all of its members are trained in health care privacy laws, that they understand the person’s culture, not just their language, and that they have exhausted all options to reach the person by phone.

“It is something that has to be done in collaboration, and if you don’t understand how to do that, you can get in really a lot of trouble in terms of getting that message out,” she said, noting that Framingham’s immigrants are from dozens of countries. “People can perceive the effort differently.”

Wong said the Health Department has still not found a community-based organization willing to put its staff in the position of meeting with people who have the coronavirus in person.

“It is just a fear of getting infected, fear of the disease, which is totally understandable,” Wong said. “We are not pushing, but it will only work when somebody is willing to do that.”

For now, Wong aims to get both the free test site and the underground team up and running this summer, ahead of any potential surge in cases.

At the same time, he’s working to implement an executive order issued by Mayor Yvonne Spicer and the Board of Health in the wake of George Floyd’s death declaring racism a public health crisis.

“To fundamentally address the disparities that have been highlighted by the pandemic, we have to address the underlying root causes,” he said. “That’s the only way. We can come up with a million different interventions to try to address it, but these are all Band-Aids.”

Addressing underlying disparities will not only help Framingham’s most underserved communities, Wong said.

“When we have so many of these population segments getting infected, it affects the entire community. Whether you are white or not, you’re getting affected. So addressing the fundamental root causes is beneficial for all.”

“We have no intention of letting this be another empty promise,” he said.

Jeannette Hinkle is a reporter for the MetroWest Daily News. Reach her at jhinkle@wickedlocal.com.