Archive for June, 2010

WE ARE REALLY IN CLOUD CUCKOOLAND IF WE ACCEPT THAT NEOLIBERALISM IS A BENIGN SOCIAL IDEA THAT BACKS THE HUMAN RIGHTS FRAMEWORK. (Theodore MacDonald)

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People in a healthy society are mindful of the human rights of all of its members.
1. In neoliberal orthodoxy, certain inalienable laws govern the give-and-take of market forces and to interfere with the self-regulation of markets is to court economic suicide. In that sense, the neoliberal outlook regards market forces as being akin to the great force fields in physics, such as magnetism or thermodynamics. In other words, like these other forces, humans must respond according to the laws of the market or face annihilation. The entire edifice of neoliberla rationality and certainty is thus based purely on the basis of financial considerations.*
*: This outlook is, for sure, not new. It just has had a number of incarnations since the early days of history; we now call it neoliberalism.
2. But to mediate in conflicts between interests and, for sure, to defuse human rights (HR) violations, it is the government that must play the dominant  role…That is why we invented it! Therefore, such ideas as markets being allowed to make major social, political and HR decisions without the mediating influence of the government as a duty bearer are simply nonsense. No wonder democracy is seen as an obstacle, as a barrier by the proponents of orthodox neoberalism. **
**: The keep-government-out-of-economics argument is thus plainly a form of social Darwinism. For neoliberalism, free markets are an article of faith and, in such a naked struggle, the odds operate against community and against the upholding of HR thus undercutting healthy societies that protect the weakest of their members as a measure of their social strength and integrity.
3. Not to be forgotten, though, is the role trade unions have played historically as, over time,  they have protected the HR of workers; we can thus perhaps consider them the first organized claim holders. They were also among the first to consistently confront authorities in an open way with their demands.
4. In modern times, more and more, the HR-based framework has allowed us to jump-start work that directly aims at solving the problems of discrimination and of marginalization coming from a different (or an added) set of principles and standards.
5. Neoliberalism has vigorously promoted mechanisms that remove both wealth and dignity from the bottom of the social ladder and that shift wealth  to the top. It does so by fostering unrestrained competition which ultimately prods and honors inequity –inequity that ends up very fast rewarding the successful to the detriment of the beaten.*** (Makes one really be amazed how the history of civilization has been the cradle of the unequal society).
***: Neoliberalism is a philosophy for the winners, not for whining losers, we are told. Its constituency is only the top 20% of the income scale. It defines anything publicly owned, as opposed to privately owned, as inefficient. It is certainly not the expression of natural human nature. In the case of health, it undercuts physical and mental health and is ever ready to mortgage it for the financial advantage of a few.
6. At the center of neoliberalism is the ownership society, a society that has relentlessly emphasized privatization, deregulation, disregard for HR, living beyond one’s means**** and huge tax cuts for the already wealthy (i.e., the-heroes-of-wealth-creation). Moreover, the proponents of the ownership society have a messianic enthusiasm to change the attitudes of those that do not think like them. (I. Allende) The message is: “you are on your own –your problems are not ours!”.
****: Don’t you think the possession of a credit card, for example, for many, just defers the home-economics-judgment-day for a few months? (The same is true for the printing of more money by central banks).
7. Not to be forgotten either is the fact that in the ownership society the ever-corporate-compliant media keeps people agreeably misinformed, only partly informed and, worse, informed at length and in detail about trivial events and about life styles that require wealth. (Is it true that institutionalized disinformation is the modern means of social control…?)
8. Every now and then, somebody, in the press and elsewhere, keeps calling for ‘market transparency’. But the transparency they call-for is a myth; it promises a politics-fee solution within the confines of the system itself.
9. It is not enough to have a passion for justice and for human rights; one has to look straight in the face of reality and to become acquainted with the laws and with the wheels of politics. (I. Allende)  Unfortunately, in the ownership society, few do so and, worse, the justice system finds guilty people where there are only victims (often of HR violations), and there is no punishment for the rich when guilty. (C. Fuentes)
10. To me, all the above shows that decency rapidly crumbles when faced with greed. If it is all about becoming richer, most proponents of the ownership society will sacrifice their souls….and certainly HR. Historically, it was nothing less than a wholesale change of long cherished social values
that rendered selfishness intellectually respectable. (As an example, you can take, for instance, the promotion of a privatization ethic in Third World countries having become an accepted fait-accompli).
Claudio Schuftan, Ho Chi Minh City
cschuftan@phmovement.org
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Mostly adapted from T.H. MacDonald, Neoliberalism is bad for your health, monograph, summer of 2008.

2010 RPSM Social Medicine Projects

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All graduating residents from the Residency Program in Social Medicine complete a social medicine project. This year’s graduates presented their  projects during Social Medicine Rounds on May 25,  June 1, and June 8, 2010.  What follows are the project abstracts:

Drs. Viraj Patel, Vanessa Pratomo, Rahul Wadke, Insung Min, Dana Schonberg and Humberto Jimenez

Adamma Mba-Jonas, MD
Exploring Concomitant Acceptance of Seasonal and H1N1 Influenza Vaccine

The purpose of this study was to explore patient willingness to accept influenza vaccinations during the 2009-2010 influenza season, which was unique due to the concomitant H1N1 pandemic.  It is well documented that many patients, particularly minorities and those of lower socioeconomic status, routinely do not receive seasonal influenza vaccine. This card study sought to investigate patient’s attitudes towards and uptake of the seasonal and H1N1 vaccines, and to determine whether patients acceptance of seasonal influenza vaccination was in some way altered this past season by concerns about H1N1.

Cameron Page, MD
Are Internal Medicine Doctors Serving Our Patients’ Reproductive Health Needs? A cross-sectional survey of the reproductive health needs and preferences of women in an urban Internal Medicine clinic.

Celia Quinn, MD, MPH
Breastfeeding Support in Pediatric Practices

The objective of this project was to identify specific breastfeeding challenges among the CHCC clinic population with the aim to improve educational materials and breastfeeding support in the outpatient setting.  A qualitative study utilizing focus groups and semi-structured interviews was designed to elicit thoughts about breastfeeding support in the hospital, at home, and in the clinic.  Analysis revealed that a key theme was interest in educational materials specific to situation and culture. Participants preferred materials explaining problems they had experienced (e.g., sore nipples). They expressed enthusiasm for scenes of cultural familiarity. Women described lack of support for breastfeeding in the hospital, at home, and in the community. Availability of formula in the hospital contributed to early supplementation. Additionally, lack of understanding among family members about the frequency of breastfeeding was identified as a barrier in the home. Participants also expressed a perceived disapproval with public breastfeeding as a barrier within the community.

Women who choose to breastfeed weigh perceived benefits against the difficulties they face, often with little support. Improving support in the outpatient setting requires messages that acknowledge these challenges and help families to find ways to address them. Materials for breastfeeding promotion should exhibit cultural variety and address specific challenges. Development of educational materials targeting family members should be considered. Qualitative methods can serve to elicit additional information for quality improvement in breastfeeding educational materials.

Margo D. Simon, MD
“PGY-What?”  Towards an integrated residency program in family medicine and psychiatry

People living with mental illness have substantially higher rates of other illnesses, including chronic disease, substance abuse, and HIV/AIDS, as well as poorer health outcomes.  They are among the most marginalized not only within in society at large, but also within our healthcare system.  Obstacles to accessing care in an increasingly specialized and fragmented system are often insurmountable, especially for those with psychosocially disordered lives.  Because of the sociological overlap of these healthcare needs, integration of services benefits not only those with “triple diagnosis,” but also the many living under the complex conditions of urban poverty in the U.S.  Under these conditions where mental health, socioeconomic status, and health outcomes are intimately intertwined, a family practitioner-psychiatrist offers ease of access to multiple integrated levels of care and a uniquely trusted relationship, which are essential to maximize health outcomes and minimize health disparities.  Yet, too few combined residency programs exist to train physicians to address the complex needs of people living with co-morbid medical and mental illness, none of which are in major metropolitan areas.  Therefore, a 5-year training curriculum that independently fulfills the ACGME requirements for each family medicine and psychiatry residency program was developed in an urban, underserved, academic medical center setting.  This case study examined the feasibility, strengths and limitations of such a primary care-based integrated residency curriculum.

Humberto Jimenez, MD
Will existing recommendations to improve LGBT patient comfort be applicable in diverse health centers? Thoughts from the MSM population at Family Health Center–a needs assessment.

The objective of the project was to assess the level of LGBT patient comfort at Family Health Center and identify areas of improvement.  Since the recommendations published from the Gay and Lesbian Medial Association was extracted from work at Fenway, Mass., at an exclusively LGBT clinic, the applicability of such recommendations is questionable.  We sought to extract ideas from our patients about which of these strategies might work at FHC and asked them about other ways LGBT patient comfort could be improved. Patients were key informants identified by FHC providers.

Viraj Patel, MD
A Community Based Health Needs assessment of Bangladeshi Immigrants in the Bronx

South Asian immigrants, and particularly Bangladeshi immigrants in the Bronx is a rapidly growing community. The limited data that exists on this community show high rates of cardiovascular disease. However, little else is known about the health needs of this population. To address this lack of information and address the health and social concerns of this group through a social justice platform,  we formed a community-academic partnership (Westchester Square Partnership). Community Health Promoters have been recruited and trained to help administer a variety of programs. They have also conducted a community mapping project and a health needs assessment. The project continues to grow and more programs are being developed to address the needs of this community

Vanessa Pratomo, MD
Conceptualizing patient centered care in the context of social medicine

This was a qualitative study looking at how family medicine residents  conceptualize their practice of patient centered care, learned patient  centered care and view the relationship between patient centered care  and social medicine. This study consisted of interviews of nine RPSM  family medicine residents from the class of 2009.  In identifying  common themes, we hoped to identify areas for future study, better  understand how residents learn to be patient centered, and discover  possibilities for improving the psychosocial curriculum.

Rahul Wadke, MD
Psychosocial barriers to care in patients with diabetic foot ulcers.

Patients with diabetic foot ulcers have identifiable psychosocial barriers to care that delay initial presentation and impede treatment adherence. The study aims (using  qualitative analysis of patient narratives) to identify barriers to care from psychological, educational, social, disability-related, and financial sources and to explore the perceived role of health care providers in overcoming those barriers.

InSung Min, MD & Dana Schonberg, MD
Introducing Training in Correctional Health to Residents

This project aimed to expand correctional health training in medical education. A card study performed at a number of Montefiore clinics found that a significant portion of our patients and communities were involved with the criminal justice system. Involvement in the criminal justice system is associated with numerous complex medical and psychosocial issues yet traditional medical education fails to adequately train health professionals to work with this population.

In response, we conducted a literature review of existing training programs in correctional health. This was followed by the creation of a Marginalized Populations Elective during which residents rotate through the intake center of Riker’s Jail. The final part of the project took steps towards creating a standard national curriculum in correctional health to train health professionals to effectively treat those involved in the criminal justice system.

Mary Foote, MD
Medical Advocacy for Immigrant Detainees

For my project I performed medical reviews for clients being held in immigration detention facilities.  Clients were referred by a lawyer for a medical record review to address various issues pertaining to the medical care that clients had received while in detention.  Reviews were performed for various reasons including: 1) to help assess and improve care pertaining to a specific medical complaint. 2) to assess cases for potential medical parole. 3) to review cases to determine the causes of poor outcomes.  Upon review of the records, a summary was compiled with a focus on potential issues with medical management and included a summary of accepted standard of care for the given condition.  The client and lawyer were then able to use the summary as a tool to advocate for improved medical care within the immigration detention system.

Joy Hao, MD
Patient Characteristics Associated with Physician-Delivered Smoking Cessation Counseling in a South Bronx Community Clinic

This study seeks to determine patient-level characteristics associated with the receipt of smoking cessation counseling at CHCC, and to evaluate whether patients’ beliefs and attitudes regarding the importance and efficacy of smoking cessation counseling are associated with receipt of smoking cessation counseling.

Stephanie Lovinsky, MD
Managing Pediatric Asthma Medications: The Transition from ED to Clinic Care

Two projects developed from related concerns. Are our children receiving treatment for chronic symptoms of asthma in the face of an acute exacerbation in the ED?  And if so, how is that information reaching the primary care providers? I performed a retrospective chart review of patients evaluated in the pediatric ED for asthma and quantified controller medication prescriptions. I then designed an Asthma Health Passport to bridge the gap between providers in the ED and primary care clinics.

Victoria Mayer, MD
A Community-based partnership for residency education in obesity and nutrition

The obesity epidemic in the United States is disproportionately prevalent in indigent communities, where access to healthy food is problematic. For resident physicians to become effective in reducing this health disparity, they must develop culturally competent knowledge and skills to address obesity and nutrition.  We have developed a partnership between a community organization, the South Bronx Food Cooperative, and our primary care residency program with the goals of supporting a local effort to improve access to healthy food while fulfilling a need to train residents in nutrition and obesity.

Lysette Ramos, MD
Nonresident Fathers and Fatherhood: A Needs Assessment

Research has shown that a father’s involvement in a child’s life impacts every domain in their functioning, from birth through adolescence.  However, 24 million children in the United States (34 percent) do not live with their biological father.  In 2000, the Bronx was one of the five counties in the US with the highest percentage of single mother households (> 30%). This trend has been more pronounced for African American children, with 50% living in single mother homes in 2007. This study’s objective was to obtain data on the parenting experience of nonresident fathers by exploring their perceived roles, learning processes, challenges, and supports.

A qualitative study was undertaken using semi-structured interviews (n=5) with nonresident fathers recruited from CHCC and a focus group (n=11) with a community organization in the Bronx that serves nonresident fathers. Themes identified are presented to increase awareness of the unique challenges and perspectives of nonresident fatherhood in order to provide appropriate education, support, and anticipatory guidance.

Jennifer Reckrey, MD
Surrogate Decision Making:  Residents’ Perspectives

There is a substantial literature about what it is like for health care proxies, families, and other surrogates to make health care decisions. Less is known, however, about what residents bring to the table.  What do residents experience as they try to help surrogates make decisions?  How do they learn to do this? What do they think their role in the process should be, and how do they decide when to give surrogates recommendations or advice?

To explore these questions, I conducted 45 minute semi-structured interviews with second and third year family medicine residents at Montefiore, Jamaica, and Beth Israel hospitals.  Interviews were transcribed, a coding scheme was developed, and these codes were applied to all interviews.  Preliminary analysis of the data suggests that residents receive little formal education about how to help surrogates make decisions despite the significant emotional burden of these interactions.  Residents adopt a broad range of roles when interacting with surrogates, including advice-giving.  Yet residents uniformly express concern that recommendations may negatively impact patient and surrogate autonomy.  This concern adds to the emotional burden of the interactions.

Miriam Shiferaw, MD
Global Health Training in Pediatric Residency: Interest, Needs and Barriers to Participation

I performed a cross-sectional survey of the pediatric residents at the Children’s Hospital at Montefiore to assess residents’ previous global health experiences, satisfaction level with their current global health training, interest in having increased exposure to global health education and also their perceived barriers to participating in an international global health elective.  The goal of this project is to use the needs assessment as a framework to inform the development of a global health curriculum for the pediatric residents over the next two years.

Marianna Borkovskaya Shimelfarb, MD & Guido Grasso-Knight, MD, MPH
Taking a Step Towards a Healthier Workplace

As part of our Departmental Social Medicine Project we drafted a survey to assess physical activity among Montefiore employees and also provider views on healthy lifestyle. We made the survey available online through “surveymonkey.com” and through notices in the Montefiore Bulletin. Our goal is to contribute to the broader efforts to improve the healthiness of our workplace for our staff and patients.

Melissa Berlin, MD & Lisa Lapman, MD
Zumba: The Effect of Dance on Quality of Life in Community Dwelling Seniors in the Bronx

Our project investigated the effects of dance on quality of life and vitality in seniors. At the RAIN Senior Center, we taught a 12 week Zumba class (a Salsa Dance Exercise class) and conducted pre and post-class surveys using the Vitality Plus Scale (VPS) and a modified version of the SF36. We also collected demographic data and followed attendance rates. Although our study design did not have enough power to achieve statistical significance, we did find a definite trend towards improvement in the VPS. We hope that this data can be utilized in a larger study to quantify the effects of Zumba on Vitality in Seniors in the Bronx.

In health care as elsewhere, cheaper is not always better.

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So the dirty little secret has come to light. As it appears, in health care, cheaper is not always better. The “pioneering” research produced by the Dartmouth group, propagating the belief that many areas of the country spend more in health care than others, while providing no better, and sometimes worse, care (the study used comparisons within Medicare) because in these regions doctors are simply “wasteful”, may have been based on faulty research after all.

At least this much was admitted in a recent article in the New York Times, even as the very New York Times editorial board, and key reporters such as David Leonhardt, have been all along major supporter of the science and philosophy underlying Dartmouth and of the many “cost-saving and quality improving” measures that will be implemented under the new law, the “Patient Protection and Affordable Care Act”. One key measure is to reduce “superfluous” services to Medicare patients, and thus “rein on waste, fraud and abuse“.  Somehow, this will not undermine, but rather improve, the quality of care provided to them, or so says the law.

Indeed, for New York Times editors one key problem in our health care system has been all along the “profligate” behavior of doctors. If we can tame this behavior, our collective savings will be extraordinary, the Times and its health reporters have asserted repeatedly, and will enable us to eventually provide health care to all Americans at lower costs. Promoting this view, The Cost Conundrum, by Atul Gawande, a Harvard-affiliate doctor and author, became “required reading” in the White House, and turned its author into a Washington star virtually overnight.

But as it turns out, the research may have been faulty.

Just so as not to clog cyberspace with redundancies, here an excellent analysis of what the Dartmouth study really showed (you guessed it: correlation is not causation), and what may have been the motivations of researchers who  promoted the study (you guessed it: money!).

Single payer anyone?

SOCIAL MEDICINE AS A PRAXIS IS PROFOUNDLY LINKED TO THE PRAXIS OF EMANCIPATORY HUMAN RIGHTS.

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Food for an emancipatory thought

Human Rights Reader 242

Time was when we could; we’ve come to the time we can; we do not want to come to a time when we’re out of options. (adapted from Haiku #1533, J. Koenig).

1. As HR activists working in health, we face a double challenge. We must work for fundamental economic, social and political changes underlying what we know as the social determinant of health and, at the same time, we must work on changes in the specific field of health where additional localized resistance (often by doctors) is to be reckoned with. We thus need to set-up networks –not forgetting the health workers, organized or not– to integrate our health and our human rights (HR) aims in what will inevitably become a political challenge. (As this Reader has repeatedly said, HR are a powerful idea which should be spread, starting with concerted efforts to launch more and more HR learning activities).

2. Actually, it is the HR-based framework that contains the powerful ideas; ideas that are at odds and counter neoliberal ideology, ideas that are a counter-power to the prevailing market forces –and, let’s face it,  that is why the spreading of the HR idea is opposed. The powers-that-be fear HR as they entail an emancipatory praxis, a praxis that eventually is a counter-hegemonic force against globalization. The HR-based framework legitimizes power in the hands of claim holders, away from male, adult, middle and upper-class property owners. In so doing, the HR framework confers on rights holders a legitimate claim on the resources necessary to fulfill specific HR –and that is feared. HR are ultimately the legal expression of a collective will –and that is feared. Moreover, the HR-based framework prioritizes dignity and solidarity over accumulation, over competition, and over the market, as well as the inclusion of environmental rights –and that is feared. (I think I am not being harsh in my analysis here; I am just calling a spade, a spade).

3. A ‘decent minimum’ cannot be set on inalienable human rights. There is thus no such a thing as ‘basic rights’ or ‘low intensity human rights’ (the latter seeming to be what is, at most, acceptable to the powers-that-be as they relentlessly foster the process of globalization with its ‘low intensity democracies’ the world over). (B. de Souza)*

*: Fact: Strong democracies encourage claim holders and shield them from drastic reprisals. (T. Schrecker)

4. “Things have a price,” says Emmanuel Kant, “but man, in contrast, has dignity”. Things that have a price are interchangeable, can be sold, and/or can be used as tools. Human dignity, on the other hand, implies that human life is an end in itself, irreplaceable and never exchangeable; it cannot be made into an object or thing, and it cannot serve as an instrument or a commodity. Dignity is violated when something associated with life acquires commodity status and becomes –either directly or indirectly– an object of profit; we see this all the time in processes that subordinate life (and nature) to the interests of accumulation: health is regrettably no exception.

5. Capitalism has made health too much into an economic concern. The right to maintain and restore health (mostly the latter) thus became dependent on a business, and a new corresponding morality came into being with it –and for HR, as much as for social medicine, this has become a nemesis, an issue central to their respective raisons d’etre.

6. Some feel that the emphasis on individual rights (as sanctioned by UN human rights treaties) has created an obstacle for social medicine which is all about collective or community rights. **

**: Allow me an unorthodox metaphor here. Conventional wisdom would suggest that ‘In HR work, the I is a We or it is not at all; united, we are part of a choir; outside it, our music is atonal’. (C. Fuentes)  But then, conventional wisdom can sometimes be wrong…

7. In the unequal societies of Capitalism, health policies have medicalized health problems; we all know that much. The human right to health (RTH) presupposes a right to the non-medicalization of life –since medicalization is inherent to the commodification of health. (That has made health a topic of what has become known as bio-politics). The RTH arose within the context of the social welfare state, true; so it is, in principle, since then that the RTH fell in the realm of bio-politics. But real action to defuse the many violations of this right and to start staking claims against pertinent duty bearers took a good 40 or more years to gain momentum.

8. Take, for instance, the 1993 World Bank’s World Report which was devoted to health; it has guided most of the neoliberal reforms we find today all over the world –and it was conspicuously silent-on and did not even mention the RTH. Instead, we got DALYs. DALYs legitimized the denial of access to services essential for survival to those unable to pay for them. We were thus left with the damage and with the social exclusion that has resulted from our planners using this neoliberal WB indicator to measure progress.

9. But back to social medicine as a praxis linked to the praxis of human rights: Its strong egalitarian emphasis is one of the most important reasons to consider HR as central to efforts to advance health equity. (T. Schrecker) In other words, HR-based action on health is essential for health equity. Yet, still today, this action is more often talked about than practiced.

10. Since changes in health will only come about by collective action (M. Marmot),  at the community level –given appropriate and ample HR learning opportunities– the HR-based approach creates the prospect to innovate and to implement new ways of addressing the-processes-of-health-disease-and-care in a collective, mutually supportive manner. Therefore, as borrowed from the concept of food sovereignty, health sovereignty has come to mean communities themselves deciding what they need and want.

11. Bottom line, the introduction of HR not only preordains how public health work is to be done (i.e., processes), but also what its ultimate outcome should be in terms of dignity and solidarity. (D. Tarantola)

Claudio Schuftan, Ho Chi Minh City

cschuftan@phmovement.org

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Mostly adapted from A. Stolkiner, Human rights and the right to health in Latinamerica: the two faces of one powerful idea, Social Medicine, 5:1, 2010.




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