The Social Medicine Portal

Dr. Jaime Gofin on Community Oriented Primary Care (COPC)

On 10/13/2009 Dr. Jaime Gofin came to Social Medicine Rounds to discuss the gap existing between the teaching and the practice of Community Oriented Primary Care (COPC).  His presentation was followed by a discussion during which three New York clinicians presented their current work in the community. Dr. Gofin then explored the relevance of  COPC to their specific projects.

Few people in the world today are better qualified to discuss COPC than Dr. Gofin.  A native of Uruguay, Dr. Gofin trained under the Karks (who originated the COPC model) and ran a Master’s Program in COPC at the Hadassah Community Health Center of the School of Public Health & Community Medicine in Jerusalem.  He is just finishing up a two year appointment at George Washington University in Washington, DC where he set up a COPC certification track within the GWU MPH Program.

What is COPC?

What is now called COPC was developed in South Africa in the 1940’s by Sidney and Emily Kark.  The second issue of our online journal Social Medicine includes a classic paper by the Karks entitled A Practice of Social Medicine which sets out the origins of their model. The Kark’s article is accompanied by an introduction written by Dr. Gofin.

During his talk, Dr. Gofin described five principles associated with COPC:

1. Responsibility for a defined population.
2. Care based on identified health needs at the population level.
3. Prioritization of health needs.
4. Implementation of an intervention program covering all stages of the health/illness continuum and impacting on the prioritized conditions.
5. Community Involvement.

He further identified four defining features of COPC:

1. Individual and community care/community medicine.
2. Integration of individual care & public health.
3. Provision of care to entire populations – healthy or sick – and based on identified health needs.
4. Community participation and intersectorial coordination.

While Dr. Gofin was able to provide examples from around the world where COPC was implemented (see below), he recognized that in many places there was a “gap” between teaching about COPC and actually carrying it out.  Undoubtedly, there is great interest in COPC within medicine and public health. The November 2002 American Journal of Public Health devoted a special section COPC; it was also the subject of a number of sessions at the APHA 2002 annual meeting. Three years earlier Family Medicine Residency Directors had recommended the incorporation of COPC into FM residency training programs.  Yet a survey done in 2000 revealed that only 7% of doctors in these residency programs actually practiced COPC.  The disparity between interest in COPC and actual practice was highlighted by a 2008 literature review on COPC which found that 60% of the COPC literature was composed of articles on “general theory and education”; only 25% was comprised of “project reports and research.”  As noted by one analyst: “… COPC’s contribution to current health practice remains more symbolic than substantive.”

Why does such a gap exist?  Dr. Gofin cited a number of reasons: lack of infrastructure to implement and sustain COPC, lack of financing for non-clinical approaches to health, difficulties in defining the “community” (especially urban settings), skepticism that COPC can be rigorously evaluated (there are no RCT’s), fragmentation of health care services among multiple payers, lack of models for practice and lack of a supportive community.  He expressed frustration that medical schools don’t teach community medicine because there are no clinics where students can practice; yet health services can’t provide community models because they don’t have trained practitioners. He also noted that most owners of health services have a different, non-COPC agenda.

Promoting COPC: Spain, Britain, Uruguay, and the US

Dr. Gofin demonstrated, however, that in several diverse countries he had been able to overcome this gap.  He cited four programs which had been developed in very different contexts.  Beginning in 1987 he worked with Family Physicians in Spain to integrate COPC principles into community health centers. By 2005 a network of 43 health centers were working with a community orientation. He had collaborated with Primary Health Care Trusts in the British National Health Service to use COPC in GP offices. As a result COPC programs for the very elderly (those over 75) had been established in Camden and Islington. After the recent change of government in Uruguay, he had worked with the Ministry of Health to develop a COPC model in seven provincial health centers. Finally, he had established the COPC certificate program at George Washington, a program that had required developing COPC projects in Washington, DC.

At this point the floor was turned over to three clinicians each of whom presented their community work for Dr. Gofin’s commentary.

Walking in Washington Heights

Dr. Richard Younge of the Family Medicine Division at Columbia discussed a project  to encourage walking in the community. The project had started at Alianza Dominicana, a community-based organization in Washington Heights. It was recognized that women participating in their substance abuse programs did not get much exercise. A program was set up to encourage them to walk in the neighborhood on a regular basis as a group. The Family Medicine residency had gotten involved in supporting the program as the initial funding faded. Dr. Younge recognized that this project was an example of service learning and not COPC; the residents promoted it only for the women coming in for care at their clinic. Unfortunately, like many resident-based projects, there was a need for more structure, and the residency program was now looking to partner with another Community-Based Organization.  Dr. Younge noted the difficulty of trying to define a community in a setting like contemporary New York City. The Karks, he pointed out, had been able to get out a map and draw a defined area of responsibility around their health centers. This clearly would not work for us.

Bangladeshi Women in the Bronx

Dr. Alison Karasz, a clinical psychologist and researcher with our department, discussed her work with Bangladeshi women in the Bronx.  She had partnered with Dr. Jean Berg of the Jacobi Medical Center Family Medicine Program in a study of cultural differences in models of depression.   When the study was over she wanted to give something back to the community.  Her first impulse was to teach the women how to drive a car.  She recounted (with a smile) what it was like to give driving lessons around Yankee Stadium to women attired in full Purdha. This experience had given her “the bug to serve, something researchers rarely have an opportunity to do.”

She and Dr. Berg received a $50K grant from New York City Council to  develop community based activities in this community.   They were able to hire a community activist and eventually received funding from the National Institutes of Mental Health to develop a Community-Based Participatory Research (CBPR) Project on managing depression (typically conceptualized as “stress” by the women).  This money allowed for the hiring of five community health workers and the development of active discussion groups.  Dr. Karasz reviewed some of her own concerns and struggles over how to define a community, how to obtain its participation, and how to establish partnerships.  She noted (again with a smile) that many of the women in the community had a finely tuned sense of feminism and were well in touch with the structural causes of their distress.

Green Carts for New York City

Our last presenter was Dr. William Jordan, a graduate of our program and currently a Faculty Development Fellow.   He described a several year collaboration with Esperanza del Barrio, an organization of street vendors in New York City.   This collaboration had led to his election as President of the organizations’ Board of Directors and an active role as a fundraiser.  This work was closely linked to the NYC Department of Health’s Green Carts Initiative which seeks to subsidize mobile food carts selling fresh produce.  Dr. Jordan spoke about the difficulties of fund-raising and how, in his role as President of the Board of Directors, he had acquired a panel of uninsured street vendors as patients.

Dr. Gofin comments

Dr. Gofin noted that these projects highlighted the difficulties of identifying a geographically-delimited community in large cities.  He suggested that the term “population” might better define the groups we were trying to reach.  He noted that it was certainly possible to start initially with a defined group, even a small one, and then to expand it. It was important, however, that this group not just include patients. It needed to include healthy people so that the responsibility of the clinic included the entire population, not just those identified as patients. This, he emphasized, was one of the traits that made COPC different from simply good primary care.  He noted that the community-based participatory research (CBPR) model was becoming increasingly popular amongst those interested in community health, but that this was research, not service.  Finally, he noted that service learning, even service learning in the community, was also quite different from COPC.  He finished by expressing his encouragement to see so much community work going in New York  City.

posted by Matt Anderson, MD