We invite you to apply for the third annual Beyond the Biological Basis of Disease: The Social and Economic Causation of Illness, an on-site immersion course in social medicine offered at Lacor Hospital in Gulu, Uganda from January 9, 2012 through February 3, 2012. This intensive course designed for 15 international medical students (clinical years) and 15 Ugandan medical students (3rd-5th year) from Gulu University intersects the study of clinical medicine in a resource-poor setting with social medicine topics such as globalization, war, human rights, and narrative medicine, among others. This highly-interactive course is taught through a combination of lectures, small and large group discussions, films, community field visits, ward rounds, and clinical case discussions. Credit for away-rotations can be arranged.
For more information, we invite you to please see our website at: https://sites.google.com/site/socialmeduganda/. In addition, short videos of our previous courses can be viewed by clicking the desired year: 2010: http://www.youtube.com/watch?v=gLHGpY4EDwg&feature=related and 2011: http://www.youtube.com/watch?v=Z2UCUFcXAas.
If you have any questions or are interested in applying, please email us at social.medicine@yahoo.com. Applications are due July 31, 2011.
Sincerely,
Michael Westerhaus, MD, MA
Julian Jane Atim, MD, MPH
Amy Finnegan, MALD, MA
(course instructors)
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:
Responsibility for a defined population.
Care based on identified health needs at the population level.
Prioritization of health needs.
Implementation of an intervention program covering all stages of the health/illness continuum and impacting on the prioritized conditions.
Community Involvement.
He further identified four defining features of COPC:
Individual and community care/community medicine.
Integration of individual care & public health.
Provision of care to entire populations – healthy or sick – and based on identified health needs.
Community participation and intersectorial coordination.
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.
In late 2006 I saw Dean Allan Rosenfield for the last time, in his office of the Columbia University School of Public Health, where he had served as dean since 1986. Diagnosed with ALS, he was breathing with supplemental oxygen. His presence—always inspiring to me in its lucidity of what is necessary and possible in the struggle for health and social justice—now showed unmistakably a quality which I realize had been there since long before I met him in 1993: the determination to make every minute alive count positively toward the lives of others.
Maternal Mortality—A Neglected Tragedy: Where is the M in MCH?” he shouted in an article in 1985 The Lancet 2 (8446): 83–85, with Deborah Maine startling and shaming a public health world which had since 1980 been reducing primary care to ever more selective programs targeting children and ignoring others, including those who give children birth and all who rear them, young and old. Alas, the question still stings and will until a comprehensive health approach to all humans, including mothers, comes with health acknowledged, planned and effectively funded globally as a basic human right.
According to Maternal Mortality in 2005: Estimates Developed by WHO, UNICEF, UNFPA and The World Bank (http://www.unfpa.org/upload/lib_pub_file/717_filename_mm2005.pdf), the United States has an MMR (Maternal Mortality Rate, i.e. maternal deaths for 100,000 live births) of 11 (11.5 according to the CDC, while for African-American women it is cited as 29.6, see http://www.cdc.gov/od/oc/media/pressrel/r010511.htm), putting the USA at number 41 in the world (the best is Ireland with an MMR of 1). Sierra Leone has an MMR of 2,100, while several other countries in Sub-Saharan Africa have rates above 1000 (examples: Niger 1,800; Angola 1,400; Rwanda 1,300; Burundi 1,100; Malawi 1,100). In short the numbers are atrocious, the realty of pregnancy as a risk for death around the world (even in the USA) evident to anyone who has worked with pregnant women outside the industrialized world and to many who have worked with pregnant women within the USA. The fifth Millennium Development Goal, MDG, is to decrease Maternal Mortality “by 75% by 2015 (starting in 1990).” Alas, even that would leave a terribly high number of women dying preventable deaths. Currently, the lifetime risk of a woman dying in childbirth in Africa is 1:26, with Niger having a lifetime risk of 1:7. (Ireland’s lifetime risk is 1:48,000, a demonstration of what is possible.
It was his characteristic kindness that led Dean Rosenfield to accept my invitation to write the Introduction to Women’s Global Health and Human Rights, WGHHR (http://www.jbpub.com/catalog/9780763756314/), “Global Women’s Health and Human Rights,” together with Caroline Min and Joshua Bardfield. He had always been kind to me, serving at the birth of Doctors for Global Health, DGH on the Advisory Council, and eventually becoming a major donor to DGH through a mechanism that doubled his donations. I have since learned that his kindness as author and co-author spurred many a renowned health professional to publish her or his first paper—one being the Director of the Residency Programs in Primary Care and Social Medicine at Montefiore Medical Center, Dr. Hillary Kunins, co-founder of Medical Students for Choice, MSFC (http://medicalstudentsforchoice.org/), with “Abortion: A Legal and Public Health Perspective” (Annual Review of Public Health, 1991; 12: 361-82).
In a recent lecture (1 June 2009) for the Global Health Course of Montefiore Medical Center and Albert Einstein College of Medicine, Dr. Joia Mukherjee, Medical Director of Partners in Health (www.pih.org) and an author in WGHHR, made the point that any woman who has had a C-section, received antibiotics or gotten blood during delivery or post-partum would likely have died in most parts of the world and consequently should, along with her partner and anyone else who loves her, be fighting for and demanding access to adequate birth-care for women worldwide as a matter of personal to global solidarity
I am certain that Dean Rosenfield would have affirmed that logic of sharing good fortune. His actions, literally to his dying day, embodied and encouraged such solidarity. In addition to his work promoting women’s health, he dedicated much of his professional life to fighting the AIDS epidemic. His vision extended to health equity for all, health in its largest sense of wellbeing including education—especially for women. “People should have access to the same care in a poor country as in a rich country,” he stated in an interview with Charlie Rose in 2006 (http://www.charlierose.com/view/interview/325), also saying: “I think it’s obscene that in our country 15-18% of people are uninsured.”
Dean Rosenfield enhanced Women’s Global Health and Human Rights, the book and the concept, by direct action throughout his professional life. Alas, the health and human rights reality worldwide for women—and thus for all persons–remains abysmal. In terms of global Maternal Mortality we have Ireland’s example as a target–why not? Equity, not just diminished misery, should be our goal—for women, for every human, anywhere in the world. That goal is Dean Rosenfield’s legacy. Making that goal happen is his challenge for all of us, now.
On Tuesday, March 10th Dr. Kathryn Anastos and Jon Wallen came to Social Medicine Rounds to discuss their work in Rwanda. Dr. Anastos’ story illustrates one answer to the question: “What does a social medicine doctor do?”
Dr. Anastos is an Internist who graduated from the Residency Program in Social Medicine in 1983. She is currently a Professor at Albert Einstein College of Medicine in the Department of Medicine as well the Department of Epidemiology and Population Health. She is known for her pioneering work in the study of HIV in women as principal investigator of the Women’s Interagency HIV Study (WIHS). Jonathan Wallen is a New York photographer who specializes in architectural and landmark photography. Since 2003 they have become increasingly involved in work in Africa, some of which they shared last Tuesday.
Mr. Wallen filled the walls of the third floor conference room with pictures from the Tubeho (“To live again”) Project. Tubeho documents the stories of female victims of the Rwandan genocide and consists of a series of photographs with accompanying stories (see an example at this link). These were disturbing stories. The pictures that accompanied them showed both women in the full bloom of life as well as others whose spirits and bodies seemed broken. Showings of the exhibition have been used to raise funds for the genocide victims as well as to bring attention to the links between gender-based violence and the spread of HIV.
Dr. Anastos framed her work in the context of Community Oriented Primary Care (COPC). She shared her initial skepticism, developed from her work in the Bronx, in COPC as a model of care. Rwanda, however, had changed her point of view.
The couple’s involvement in Rwanda began in 2003. Dr. Anastos had been contacted by Les Veuves (the Widows) a group of genocide survivors, many of whom were infected with HIV. They were incensed that they did not have access to treatment while their victimizers – on trial for genocide – were receiving HIV medicines. Dr. Anastos had worked as an administrator at the Montefiore Medical Group and felt she knew about building an efficient, comprehensive, high quality primary care practice for a chronic disease. As she put it, her credibility was as an HIV expert, but her skill was as a manager. With assistance from the Stephen Lewis Foundation she helped found We-ACTx (Women’s Equity in Access to Care and Treatment) in mid-2004. The goal was to create an HIV treatment program, but this implied first setting up HIV counselling and testing.
One of the lessons of this experience was to ” first, provide the services people ask for, not just those professionals think they need”. This, she felt, was the essence of COPC. And what people wanted was wanted medical care (to prevent dying and promote health), HIV testing, medical care for their children, food, income, and – a top priority - education for their children. The local women rejected the idea of going out “into the bush” to provide care. They wanted it done through existing infrastructure and using local nurses and clinics. By knitting together multiple small grants an HIV testing program was implemented in September of 2005 and has by now performed over 50,000 tests. In January of 2006 anti-retroviral care was introduced and there are currently 2,400 people on ART, essentially “everyone who needs it, gets it”. The program is implemented in coordination with 24 community partners and is staffed by 2 physicians, and 12 nurses. She feels that the necessary skills to run the program exist locally (“if we left now, the program would continue”) but that the local staff continues to need salary support.
For a beautiful look at the WE-ACTx progam in action, you can see pictures in the linked slideshow.
Because of the focus on meeting people’s expressed needs, several “off mission” programs had been created. “Just because I think it is not health service related, doesn’t mean we don’t have to find a way to provide it.” These off mission programs included the provision of food supplements, creation of income generating activities (originally doll making, now bag making, see Ineza), community based education, and a program to help with school fees.More recent activities are a cohort study (requested by the community) and programs to address cervical cancer. Cervical cancer, an essentially preventable disease is the number one cancer killer in Rwanda.
In considering the successes of their work (and of the COPC model) Dr. Anastos pointed to the strong sense of community in Rwanda. “There is no cult of the individual. It is always my family, my community, my country.”
As one of many activities marking the 30th anniversary of the 1978 Alma Ata Conference, the Institute of Tropical Medicine in Antwerp Belgium sponsored a conference on “Primary Health Care in Times of Globalization: Alma Ata, Back to the Future ” [11/26 - 11/27/2008]. The presentations and background material for this conference have now been posted on the web. The different presentations – available as powerpoints – provide a quick snapshot of current international thinking regarding Primary Health Care (PHC).
Monique Van Dormael of the ITM began with a presentation suggesting that the publication in 2008 of three reports – the Report of the WHO Commission on the Social Determinants of Health, the WHO World Health Report and the second Global Health Watch – were all hopeful signs for PHC. Her presentation explored some of the ways in which PHC (and the language of Alma Ata) might and might not be relevant in the world today. She made the distinction that health problems were not complicated – meaning “systems that experts can fix if they get the right technology” – but rather were complex – meaning “systems driven by social actors who cannot be controlled like robots.” This was, she felt, a key insight of the Alma Ata conference that had been lost in the last 30 years.
A number of experiences with constructing primary care systems – in the Democratic Republic of the Congo, in Eduador, in Mexico City and in Belgium were presented. There was a discussion of new modalities of “aid” and human resources development. Each of the three reports mentioned in the introduction – the WHO World Health Report, the Report of the Commission on the Social Determinants of Health, and the second Global Health Watch – was also the subject of a presentation.
Community Participationwas highlighted in presentations from Cuba, Venezuela, and Belgium. In Ghent, Belgium a Community Oriented Primary Care (COPC) model has been adopted to involve the community in the solution of health problems. A presentation by Wim De Ceukelaire examined some of the political questions concerning community participation. Quoting Wallerstein, he emphasized that true community participation must involve “capacity to challenge non-responsive or oppressive institutions and to redress power imbalances.” This might be done, he suggested through People’s Organizations, Health committees and Community health workers. On the second day of the conference an international panel offered suggestions on how to go about promoting community participation.
The conclusions and preliminary recommendations of the conference are summarized in the final powerpoint, available at this link.
Reflecting on these presentations from New York City, one wonders if the US really sits on the same planet everyone else lives on. We struggle here just to get everyone covered by the health care system. But this is only one (necessary) step towards building a real system of care and of building a real system of primary care. The very idea of community participation in the development and management of a health care system seems entirely foreign to our corporate model. In a health care market “consumers” are limited to the “choice” of which plan (i.e. which commodity) is most economically rational for them.
But the US does sit on planet Earth. Seeing what is happening in other countries reminds us another world is possible. And even what it might look like and how to go about building it.
In 1999 the Kark’s published Promoting Community Health: From Pholela to Jerusalem, a book summarizing their work in Community Oriented Primary Care.
A detailed discussion of their principles can be found in “A Practice of Social Medicine” a chapter authored by them in the early 1960’s. It was republished in 2006 in the online journal Social Medicine.
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Doctors for the 99%: Medical Solidarity with Occupy Wall Street
On 10/13/2009 Dr. Jaime Gofin came to 
On Tuesday, March 10th 
As one of many activities marking the 30th anniversary of the 1978 Alma Ata Conference, the 
