Note from the Editor: Many health care professionals have expressed an interest in working with the Occupy movement. We prepared the following support guide in early November to provide a general orientation. We anticipate updating the guide in early 2012 and would welcome any feedback. Please send it to Matt Anderson, MD. You can download a PDF copy of the guide here.
Support Guidefor Health Care Personnel Interested in Workingwith the Occupy Wall Street Movement(version 1.0, dated 11/11/11)
Introduction
What is the purpose of this guide?Many health care personnel have expressed an interest in supporting the Occupy Wall Street (OWS) movement but are unsure how they can best participate. The goal of this guide is to synthesize some of the historical experience of physicians working with social movements as well as our own experience with working with Occupy Wall Street in order to provide practical guidance to health care professionals. Anyone can participate in OWS activities as a citizen. This document, however, will discuss bringing professional medical expertise to OWS.This document has been prepared specifically for the US context, but some of the issues may be germane to other countries.Why might health care professionals want to support OWS?Many of us are profoundly dissatisfied with the current health care system. The 2009 health care reform law (P-PACA) essentially turned the health care system over to the insurance industry; many of us see the for-profit insurance industry as part of the problem, not the solution. Perfectly reasonable alternatives – Single Payer, Medicare for All – were simply dismissed by the political elites, forcing many doctors and nurses to resort to civil disobedience to get media attention for these proposals. Many of us feel that true health for the people of the United States cannot happen unless we address the profound social inequalities that are particularly characteristic of the US. We cannot have a healthy people if our environment is polluted, ours schools and communities degraded, and vast sectors of our population tied down in the military industrial and the prison industrial complexes. With the current recession and the political climate in Washington these social inequalities seem only likely to worsen.The Occupy Wall Street movement has shied away from making specific demands. But their emphasis on making the wealthy pay, on direct democracy, and on reducing income inequalities, speaks to many of the issues we are concerned about.
Respectful collaboration
What are the general rules governing working with groups like OWS?First, do no harm. Make sure that you are contributing something that is needed and something you are able to do. Don’t practice outside of your area of expertise. Don’t do things you are not comfortable doing. Don’t do things that are unsafe or illegal. You should not place other individuals at risk, you should not jeopardize your license, and you should be mindful of the reputation of the Occupation.Be respectful and work with the occupiers. They are a diverse group of people working together to build a collective identity, and they are usually the best local experts on what they need. Do not underestimate their skills or make assumptions about their experience. Be patient and learn with them. If you can’t be respectful of the Occupation then you should not be involved.Always identify yourself and have proper ID. As a general rule you should always be willing to show any materials or documents you have (other than confidential patient charts).Know the local laws and regulations governing your professional work. (see below)How are the OWS sites organized?
Different sites are organized differently, but most, if not all, have daily meetings called General Assemblies (GA) to discuss issues and plan events. There are various working groups on logistical and thematic issues, e.g. outreach, direct action, media, sanitation, labor, people of color, health care, … etc. Everyone is welcome to participate in the GA or the working groups, not only the people who are staying there every night or most nights. If you are curious about OWS consider going to one of the GA.
How can you make contact with OWS occupiers?
The best way to communicate and build relationships with OWS occupiers is to make repeated visits to the sites and introduce yourself in person. Join the solidarity marches and participate in the general assemblies. If you’re in a city where health professionals’ groups have already made organized contact with OWS, then go through those groups. Don’t duplicate work that is already being done.
How do you build a relationship with the street medic team?
In the case of occupations, some of the street medic team members are occupiers or otherwise spend most of their time on-site, so they are the local experts with whom you should consistently consult. The street medic model of work is non-hierarchical. Patient communication is key. Since the team can consist of a large and revolving group of people, be prepared to have multiple, repeated discussions with various members. Do not assume one conversation with one person is sufficient. The street medic model also incorporates non-Western traditions, and biomedicine is not assumed to be the solution to many health problems that arise. Be sure to listen and discuss, and be willing to both accept as well as give helpful feedback. Be reliable and consistent, and offer your group or yourself as a resource and ally.What can you offer OWS?
There are a number of things that you can provide the occupiers. Each (except the first) is discussed in more detail below:1. Resources: Check on the OWS websites for a list of items which the sites are requesting. These can range from money to food. If they are asking for it, it’s probably worth providing. See also Peter Rothberg’s article in the Nation: http://www.thenation.com/blog/163749/how-support-occupywallstreet2. Medical accompaniment: The presence of medical personnel (you should be dressed professionally) can sometimes deflect police repression.3. Medical support at demonstrations: This involves knowledge of a specific set of medical problems and the ability to work on the streets.4. Medical care at the occupied sites: Many sites already have active medical tents typically staffed by street medics. In addition to providing care, you can offer to help coordinate a committee that may include street medics, nurses, doctors, public health experts and a lawyer. This committee can draw up protocols, anticipate problems, build connections to ERs and community health resources (including medical vans), and create an efficient structure for medical professionals to volunteer on-site. It can also manage a simple registration process to ensure volunteers are not misrepresenting their training. (PNHP-NY Metro has set up an online registration and scheduling process. Please contact organizing@pnhpnymetro.orgif you’re interested in using a similar system.)5. Establishing longer-term health work in a given community: The current US community health center movement grew out of medical activists working during the civil right era with protesters in the South.
6. Expertise on health policy: You can play a role in helping the occupiers develop their ideas about health policy (as part of a democratic process.) Propose teach-ins to discuss concrete policies aimed to realize the foundation of what many protesters already believe in: health care as a right. Precede or combine teach-ins with speak-outs, to democratize the process and for people with different experiences to learn with each other.
Forms of Medical Solidarity
What is medical accompaniment?
We can provide a general answer to this question by quoting from a 1966 guide written by the Medical Committee for Human Rights for medical personnel participating in the civil rights movement:Just the presence of physicians and other health professional personnel has been found extraordinarily useful in allaying apprehensions about disease and injury in the Civil Rights workers – there is a certain security in knowing that even if they do get hurt, professional help is available. There also seems to be a preventive aspect to medical presence – actual violence seems to occur less often if it is known that medical professionals are present, particularly when Civil Rights workers are visited in jail at the time of imprisonment or thereafter regularly. In addition, medical personnel should anticipate violence in terms of specific projects and localities and to be present at the right place and at the right time. Thus, medical personnel should be in intimate contact with the Civil Rights organizations at all times, and to be aware of any immediate planned activities. Committee members should act mainly as observers who are ready to provide emergency aid at demonstrations. Committee members should strictly avoid getting arrested and going to jail whenever possible. (reference 1)This is a general statement which should be adapted to local needs and circumstances. We would add that to be effective in prevention, health care workers must be dressed professionally (usually white coats or scrubs) and clearly identified. Any accompaniment is best done in collaboration with lawyers; in some protests there are legal observers usually from the National Lawyers Guild (http://www.nlg.org/occupy/). If you plan to provide first aid at a demonstration you should have some preparation (see below). If you are at a demonstration as a medical observer, it does not make sense to get arrested.Documentation of injuries may be important for legal reasons, but is probably best done in an Emergency Room.Who are street medics?The street medic movement arose during anti-globalization protests in the late 1990’s and represents a largely lay response to the specific health problems raised by protests. A great deal of practical experience has been accumulated by street medics. There is an excellent street medic wiki at: http://medic.wikia.com/wiki/Main_Page. See also the following posting by Juliana Grant from which we have excerpted in this document: How to be a Street Medic.
Street medics come from a variety of health care backgrounds including herbalists, nurses, EMTs, NPs, health educators, physicians, medical students, and acupuncturists. In fact, a medical background is not actually necessary to be a street medic as most receive additional training in first aid, the management of activist-specific injuries, and such topics as scene control and pre-hospital assessment.
It is important to emphasize that physicians generally do not have training in pre-hospital medicine. Since you may encounter problems during a demonstration for which you have not received training, you should consider additional instruction, e.g. an EMT or first responders course. Street Medics often arrange training programs.
Being a street medic requires more than just medical knowledge. The ability to work in non-hierarchical affinity groups, value non-western medical knowledge, and work in stressful, and at times dangerous, situations are all equally important to street medic work. For many physicians and nurses, developing these skills will be the focus of their street medic experience.
What are some of the medical issues associated with demonstrations?
It is not possible for us to provide a primer on medical care during demonstrations. Here we can suggest some of the general issues:
Participants in demonstrations can become sick due to dehydration, sun exposure or pre-existing medical problems.
Handcuffs have been associated with nerve injury called Handcuff neuropathy. (reference #2)
Various irritating substances are used to disperse crowds. These include tear gas and Pepper Spray. Tear gas may be composed of several different substances. Among them are phenacyl chloride (“CN gas”, the active component in Mace), 2-chlorobenzalmalononitrile (“CS gas”), and dibenzoxazepine (“CR” gas).
Trauma from weapons: rubber bullets, live bullets, batons.
Dog bites.
Physical trauma due to accidents or beatings. This may take the forms of: burns, cuts, orthopedic injuries.
Difficulty of working in or near the site of a demonstration. Of note, the police may not allow EMS into an area until they declare that it is safe.
There can also be important psychological sequelae of arrests and/or violence (see below).
Problems associated with incarceration; one of the major issues may be lack of medical attention in detention facilities.
While most of the work surrounding these issues has come from lay people, members of the Medical Committee on Human Rights and the District of Columbia Department of Public Health did produce a number of articles documenting their experiences in the late 60’s and early 70’s. These articles are particularly useful since they address the organizational implications of protests for the volunteers, the local health and law enforcement establishments, and for involved communities. (reference #3)
What are the issues involved in working with local jails?
Jails vary greatly based on the locality. People who are arrested often need access to health care because of injuries sustained during a protest or pre-existing medical conditions (such as diabetes or HIV). Mass arrests may overwhelm the facilities of the jail system and lead to unsanitary and unsafe conditions. Lawyers may call upon doctors to visit prisoners and/or document unsafe conditions in the jails.
What are issues involved with working at the occupied sites?
There are important precedents for providing health care services in occupied sites. In early 1968, as part of the Poor People’s Campaign, the National Parks Service allowed 3,000 people to occupy “Resurrection City,” a 15-acre area of the West Potomac Park. Health services were provided there by a coalition called the Health Service Coordinating Committee. (reference #4)
Some of the general issues arising in occupied sites include:
Providing Sub-acute Care: Many Occupy sites have medic groups that have set up an area where participants can seek care. The spectrum of care offered varies substantially among sites and depends a lot on who the medics are. Care offered might only include basic first aid /triage or extend primary health care services. Issues seen at these sites are typical of what one might see in an Emergency: trauma, hypothermia, acute infections (often respiratory), and acute exacerbation of chronic problems. Occupiers may prefer non-traditional medical traditions which are also offered at some site. Lack of health insurance may preclude people from filling prescriptions so you should be aware of local resources for free or low-cost medications.
Disease Prevention and Public Health: Occupy movements bring large numbers of people together in spaces that were not originally designed for an encampment. Disease prevention and public health activities supported by street medics can help keep participants healthy. These might include ensuring that hand sanitizer is available at all food stations and bathroom sites, arranging for free flu shot clinics, and working with logistics to help collect warm clothing for participants.
Mental Health & Substance Abuse: Being a victim of police brutality or misconduct is traumatic. Most of us will experience a heightened level of stress, anxiety or depression after an event. Some individuals might even develop long-term health problems, such as post-traumatic stress disorder. Mental health issues can also arise during regular Occupy activities simply due to the stress of being in a new and rapidly changing environment. Some Occupy participants have pre-existing mental health or substance abuse problems that are exacerbated by stressful situations. Street medics may offer mental health support to activists during or after an event. There is a great need for psychiatrists, and they are highly encouraged to take volunteer shifts at the medical tents. Psychologists and social workers may also be part of the team. Be aware that team members come from very different perspectives and may not all agree on recommendations for a patient. This is particularly important to bear in mind when working in a non-hierarchical context.
Off-site Referral: Occupation sites are not emergency rooms or primary care clinics, so it is important to have knowledge of and access to local health care institutions. Institutions with established outreach programs (as for homeless or SRO’s) may be able to share these resources with demonstrators or occupiers (flu vaccines, rapid HIV testing, counselling, etc.). On the other hand sometimes local facilities (e.g. ER’s) may not welcome protesters; others may have a policy of reporting undocumented workers to the government. Occupiers may have had bad experiences with “safety net” providers and are distrustful of traditional medicine. Sympathetic health care professionals can help build bridges between these two worlds.
How should you work with street medics and other lay health care workers?To quote from the 1966 Medical Committee on Human Rights guidance:When you arrive at the office of the Civil Rights group which will be your base of operation, do not expect to be received with open arms. There may be a brief period of social trial before you are accepted – and this period may be extended indefinitely by any evidence of a paternalistic or authoritarian attitude on your part. Do not make the mistake of telling them how to “run things” on the basis of the experience gathered in your brief stay. It is also important that you seek an appointment with the local people in the Civil Rights groups to discuss how you can repeat and possibly improve upon the services previously provided by the Committee Members who have preceded you. If you are the first one in your area, it is important that the best ways of meeting the prevalent needs within the limitations of what the MCHR offers be worked out in this discussion. Clarity at this point can be extremely helpful later.How should you work with lawyers at the sites or at demonstrations?The National Lawyers Guild has extensive experience working to defend protesters and has set up an infrastructure to help the Occupation Movement (http://www.nlg.org/occupy/). This site provides a hotline (24/7) for 18 major US cities and email addresses for 58 more. You should try to coordinate your work with them or another group of experienced lawyers. You may see NLG or other legal observers at demonstrations or at the occupied sites. Introduce yourself to them and discuss possible collaborations.The Guild encourages protesters who are likely to be arrested to write down the number of a lawyer on their body using indelible ink. If you are at risk for arrest you should consider knowing who you will call and having the number on your body. Generally speaking if you are acting as a professional you will not want to get arrested; the police, however, may not always respect your wish.
How should you work with the local Department of Health?
Depending on the local political context, it may be worthwhile to try to build a positive working relationship with the local DOH. In some cases, however, the relationship may be more defensive than collaborative, especially if the local government is trying to find ways to shut down the occupation. Keep in mind that the mission of a DOH is to protect the health of the public. In Washington DC in the late 1960’s the DOH saw it as part of their mission to protect the health of protesters.Are there long-term implications of providing care to OWS?We believe that there are. Physician involvement in the Civil Rights struggle in Mississippi played a role in the creation of the Mount Bayou community health center which became the model for federally-qualified community health centers in the United States; today there are over 1,000 such centers which provide much needed health care to the working class of the US.Local conditions will clearly dictate what types of possibilities are created by OWS for lasting collaborations. But consider your work with the occupiers within a larger framework.How can you contribute to policy debates within OWS?As with all your collaborations with the OWS movement, be respectful of the existing culture and rules. In cases where there are no agreed-upon rules, or such rules are not well communicated, propose a meeting with the street medics team and discuss. Some team members may feel that “political discussions” should not be mixed in with health care delivery on-site; others may wonder what defines a political position. E.g. “health care as a human right” may be accepted as apolitical, but specific policies, such as single payer, may be considered political.
In New York City, health professionals have played a central role in starting and building up “Healthcare for the 99%,” an official working group of OWS that advocates for universal health care. We have organized teach-ins, speak-outs and marches.
LEGAL MATTERS
What are the legal issues for licensed professionals involved in working with a movement like OWS?This document cannot provide legal advice, which you should get from a lawyer. However, we will mention some of the legal issues involved with medical solidarity. They touch on several different areas of law: mass protest law, physician licensing, health law, public health law, and malpractice.Good Samaritan laws: Good Samaritan laws protect professionals who provide emergency care from medical liability unless they are grossly negligent. The details of these laws vary from state to state so you need to be familiar with local rules. These laws will not prevent you from being sued, although they should protect you from losing the case.Licensure requirements vary by state: Typically states require medical professionals to act within their competency (something you should always do) and maintain adequate records. In New York State you can lose you license for referring a patient for care to someone who is not appropriately licensed.Malpractice: Except for situations where Good Samaritan laws apply, any care provided will be subject to malpractice laws. You should check to see if you malpractice coverage will apply. This is another reason not to provide care outside of your professional expertise.Where can you go for specific legal advice as a health care professional?
Consider contacting the National Lawyers Guild or the legal counsel at your institution.
Who has prepared this guide and how can you help improve it?
This guide was prepared by members of the Montefiore Residency Program in Social Medicine and Physicians for a National Health Program-NY Metro Chapter. This document does not represent the official position of our organizations; they are provided for identification purposes only.
We intend to continue revising this document as we gain more experience with medical solidarity. We welcome your feedback which can be sent to either of the authors.
Matt Anderson
Residency Program in Social Medicine
Montefiore/Einstein Department of Family and Social Medicine
(email: bronxdoc@gmail.com)
Laurie Wen
Physicians for a National Health Program-NY Metro Chapter
(email: laurie@pnhpnymetro.org)
Frank A, Roth J, Wolfe S, Metzger H. Medical problems of civil disorders. Organization of a volunteer group of health professionals to provide medical services in a riot. N Engl J Med 1969 Jan 30;280(5):247-53. Despite it’s unfortunate title this article provides useful insight into MCHR’s approach. For example, they were able to get temporary licenses for physicians who were not licensed in the District of Columbia.
Schneider EL. The organization and delivery of medical care during the Mass Anti-War Demonstration at the Ellipse in Washington, D.C. on May 9, 1970. Am J Public Health 1971 Jul;61(7):1434-42. Available for free at: http://www.ncbi.nlm.nih.gov/pubmed/5563262
Many healthcare professionals see how social factors impact their patients’ health and ability to access health care. They have joined protests over the past weeks in NYC and around the world. Readers of the Portal are invited to participate in the following events organized by the group Healthcare for the 99%, the OWS healthcare working group:
Friday, October 21st 3:30pm, March on Verizon in solidarity with CWA and OWS! A group will meet at ZPark at 3:30 and will march to Verizon HQ at 140 West Street at 4pm to rally.
Sunday, October 23rd at 4pm, Healthcare Teach IN / Speak OUT at ZPARK. Bring your white coats and signs! Check out this powerful video from last week’s speak out at Washington Sq Park. Stay for our usual 5:30pm planning meeting right after.
Yesterday (Saturday, October 15th) saw the largest Occupy Wall Street event to date with estimates of participation running as high as 20,000 in New York City. But New York was just one of many cities across the globe that saw protests yesterday. Encouragingly, the protest movement may finally be taking on an international character which mirrors the international nature of the corporations that dominate our political processes.
It is unfortunate that much of the press coverage has focused on the number of people arrested. This makes it seem that this was some type of sporting contest between the protesters and the police. In fact, the overwhelming message was one of being respectful of the police (in part not to provoke arrests). This reflects the consistent message of non-violence and the broader theme that 99% of the people in this country have a common interest in a new social compact.
Doctors for the 99% has become the name for an informal group of health activists who have set out to support the occupation. We participated in a teach-in of sorts at Washington Square Park that started yesterday around 1PM. Since the use of megaphones or amplification equipment is prohibited in the park, we used the technique of a “human microphone” where the words of a speaker were repeated by the larger group. This lovely video by Jun Mitsumoto will give a sense of the meeting and how the microphone worked:
Meetings of OWS Healthcare for All take place on Wednesdays and Sundays at 5:30 PM at Zuccotti Park/Liberty Plaza “under the Big Red Thing.” (Right across the street from Empire Blue Cross/Blue Shield)
One of the speakers was New York Assemblyman Richard N. Gottfried (seen above) who was gently critical of the slogan Health Care for the 99%. He pointed out that we needed one health care system that would cover 100% of Americans. He also noted that a tax on the wealthiest 1% could pay for health care and for the things that kept people healthy such as housing and education. The OWS health organizer later passed around a petition supporting Assemblyman Gottfried’s proposal for a single payer health care system in New York.
Here is one of his videos from the end of the march in Times Square:
As we arrived in Times Square the massive police presence (dozens of cops walking in the middle of the streets with gloves on and big stacks of plastic hand-cuffs fastened to their belts) felt unnecessarily intimidating. It was also confusing that we were initially sent by the Police down one of the cross-street towards Times Square only to be told to leave (again by the Police). This effectively dismissed us from further involvement in the the protest. But, as noted above, no one wanted a confrontation.
Additional picture are available at this Flickr site.
The long-overdue “occupation” of Wall Street began 23 days ago on September 17th. As it enters its fourth week, there is no sign that the occupation is slowing down. In fact, as of this writing, there are currently “Occupy Together” Meet-ups in 1,112 cities across the US with 83 confirmed occupations across the world.
This week saw significant representation by progressive doctors in the protests on Wednesday, October 5 and Saturday October 8. Many of us were associated either with the Physicians for a National Health Program, the National Physicians Alliance or a Bronx-based residency program in social medicine. [There were far more nurses at the protest largely because far more nurses are unionized.] Here are some pictures and video clips highlighting a protest effort which has come to be called: Doctors for the 99%:
Thursday, October 6:
A gorgeous fall afternoon in New York City. Cameron Paige of New York’s chapter of the National Physician’s Alliance sent out a message early in the day calling on physicians to show up at the afternoon’s rally.
The picture below links to Amy Goodman’s interview with Bronx physicians Dr. Arash Nafisi and Magni Hansel.
Here are some additional photos taken with our cellphones:
Dr Cameron Paige asks: What good is this, if you can't afford your medicines?
Also present on Thursday was one of our local hip hop duos, Rebel Diaz, offering a Bronx-style take on the protests for Amy Goodman’s Democracy Now.
More pictures from the Thursday’s demonstration have been posted on Flickr.
Saturday, October 8, 2011
Some 1,000 protesters moved from Zucotti Park in lower Manhattan to Washington Square Park. Here is the ABC report about the move. It includes a brief interview with Bronx family physician Dr. Daniel O’Connell:
Questions from Reporters (and various answers):
Why are doctors coming to this demonstration?
We are here to express our solidarity with this demonstration, this overwhelmingly peaceful demonstration.
We are here because our patients can’t get access to health care. They can’t afford their medications. And they can’t care for their health if they don’t have insurance and if they don’t have jobs.
Right now there are over 50 million people without health insurance in the United States. Medical costs are a leading cause of personal bankruptcy. Even with the new health care law, we will still have 21 million people without health insurance in 2019.
Health care should be a human right and everyone should have it.
What does Wall Street have to do with health?
There are great income disparities here in New York City. The mean income in the Bronx, it’s $17,000 a year. Here in Manhattan, it’s $64,000 a year. And how much money do the people in these buildings around us make?
These people here need to pay their fair share of taxes and obey the law.
If the economy is not good, people will not be healthy. Our patients need good jobs and benefits.
What is going to happen to these protests?
No one knows the answer. And, of course, the groups leading the protest is inexperienced and not sure what it wants. But this just reflects a political context where only the most conservative, pro-business ideas are allowed to be discussed in the media and in the political world. If progressive ideas are excluded from public debate, it’s inevitable they will burst forth in some spontaneous form.
Final comments
The occupation movement is still developing and we will keep readers of the Portal informed about local participation by health care personnel. Readers who would like us to post more materials can either email me (see below) are post a comment.
It is good that we have two strong local organizations - Physicians for a National Health Program and the National Physicians Alliance - who have spent thankless years organizing progressive doctors. These structures have helped create a cadre of activist physicians who were able to respond to the occupation. If you are not a member of one of these organizations, you should be.
Readers who would like more background on the occupation may consider the following sources:
What is the cutting edge in Social Medicine in 2011, at least in the Bronx?
The 18 social medicine projects completed by the 2011 graduates of Residency Program in Social Medicine offer one perspective. These projects cover a wide variety of topics; three were conducted internationally (Quito Ecuador; Andhra Pradesh, India; and Rwanda). Among the questions addressed were:
1) Are medical schools and residency programs accountable to the broader society?
2) Does the promotion of Zumba dance in the clinic improve the health of diabetics?
3) What are the barriers to reproductive health care among homeless adolescents living in shelters?
4) What is a social medicine doctor?
The abstracts published below represent work by residents in Social Pediatrics, Family Medicine, and Social Internal Medicine/Primary Care. The actual presentations were made during Social Medicine Rounds on May 24, May 31 and June 7, 2011.
Molly Broder, MD, Laura Polizzi, MD, MPH & Ravi Saksena, MDAssessing Sources and Knowledge of Reproductive Health in 14-21 year-olds in the Bronx
The objectives of this study are to obtain information about where teenagers receive their information about sexual health topics, to obtain information about the use of the internet/social networking, and to evaluate adolescent knowledge concerning reproductive health. Male and female adolescents between the ages of 14 and 21 were recruited from two urban clinics in the Bronx. They were asked to complete an anonymous survey which included basic demographic information, internet availability, a knowledge assessment, and questions assessing sources of information and their usefulness. Participants were also asked specifics about websites/social networking resources utilized. Responses to survey questions were tabulated in Excel and descriptive statistics were calculated.
One-hundred and eighty-nine adolescents were surveyed during their clinic visits. The median percent correct on knowledge questions was 64.7%. The most common sources were medical professionals (93%), mothers (85%), friends (86%) and the internet (83%). Information provided by medical professionals was seen as the most useful (92%) followed by mom (81%), boy/girlfriend (79%) and the internet (73%). The most common websites used were Google (74%), Yahoo (26%), and Wikipedia (26%). The top four search terms were sex, condoms, birth control, and HIV.
Elizabeth N. Alt, MD, MPHImplementing Group well child visits as part of a Patient Centered Medical Home at the Family Health CenterTraditionally well-child care occurs with individual providers, either family physicians or pediatricians. Studies suggest that group visits with patients in certain chronic disease management and prenatal care groups can improve overall health and well being, compared to individual visits.
To assess the potential of group visits in comparison to individual visits, a Centering Parenting Model of group well-child care was implemented at a Federally Qualified Health Center in an urban primary care setting designated as Patient-Centered Medical Home.
Study participants are parent-baby dyads and are established patients at the Family Health Center. Centering Parenting groups consisting of 5-10 pairs meet at predefined routine well-child visits to receive routine well baby care in a group setting.
The purpose of this project is to provide group well child care as an alternative to individual provider care with the hope of improving quality outcomes and parent satisfaction.
Cedric Edwards, MDThe Effectiveness of a Mobile Cervical Cancer Screening Program in Andhra Pradesh, India
Background: Cervical cancer is a completely preventable disease. Yet 470,000 new cases of cervical cancer are diagnosed each year and 300,000 women die annually worldwide. The overwhelming majority of these cervical cancer cases occur in the developing world. Pap smears are the main screening test for cervical cancer but many developing countries lack the infrastructure to perform pap smears. To address this need for cervical cancer screening in the developing world, the medical organization Prevention International: No Cervical Cancer (PINCC) developed a mobile service which screens for precancerous cervical cells using direct visual inspection of the cervix with acetic acid (VIA) and immediately removes suspected lesions in a single visit using either cryotherapy or LEEP. This study aims to evaluate the effectiveness of PINCC’s mobile cervical cancer screening program in Andhra Pradesh, India.
Methods: For 12 days in August and in December 2009, PINCC went to a different village each day in Andhra Pradesh, India. Mobile cervical screening using VIA was performed on non-pregnant, non-menstruating women between the ages of 23 and 75 who did not have signs of vaginitis. Pap smears were often performed for VIA-negative lesions, or if the squamocolumnar junction (SCJ) was not fully visualized because it extended into the cervical os. Biopsies were taken of VIA-positive lesions. Cryotherapy was performed if VIA-positive lesions covered less than 75% of the cervix and there was adequate visualization of the SCJ. Women with VIA-positive lesions covering >75% of the cervix received LEEP. PINCC referred all women suspected of having cervical cancer to the local hospital, based on the screening VIA results and biopsy. These women did not undergo cryotherapy or LEEP treatment.
Results: PINCC screened 623 women for cervical cancer during the 24 days that they were in Andhra Pradesh, India. Cervical samples from only 543 women were used in this study since there were missing data for 80 screened patients. Of the 543 women screened, 431 were VIA-negative and 112 were VIA positive. The VIA-negative group included 391 completely normal cervical screening after adequate visualization of the SCJ and 40 women who had to undergo pap smears for inadequate visualization of the SCJ. Precancerous cervical cells were found in 3 of 40 pap smears. Of the 112 participants with positive VIA lesions, 21% had cryotherapy, 27% had LEEP, and 45% were biopsied only without treatment due to either a non-functional cryotherapy or LEEP. Squamous cell carcinoma was found in 1.3% of the screened women. Of all the 112 VIA-positive lesions seen, biopsies found cancer or precancerous cells in 53 women, for a positive predictive value of 47%.
Conclusions: In 24 days, PINCC effectively screened 543 women with the low-cost method of VIA and immediately treated them with cryotherapy or LEEP. The PPV of VIA to detect precancerous cells was similar to other studies involving VIA. Further measures need to be taken to reduce the number of samples with missing data and to ensure operational equipment. A mobile “see and treat” model is a feasible method to address the high cervical cancer rates in the developing world.
Ross MacDonald, MD:Montefiore Transitions Clinic: Reaching the Recently Incarcerated
The Montefiore Transitions Clinic (TC) was established to provide access to primary care, mental health services and social services for recently incarcerated adults. In July, 2009, we established a TC for recently incarcerated adults through partnership with Bronx Parole Board and The Osborne Association, a local prisoner advocacy community based organization (CBO). Initially, referrals to TC were primarily from parole officers and the overall burden of chronic illness was low. Here we report on the impact of a community health worker (CHW) on patient recruitment and disease severity.
To evaluate the impact of the referral source on the disease prevalence seen at TC, we performed a retrospective chart review comparing patients seen before and after the CHW was hired. Data was available for the first 39 TC patients, of whom 38 were referred by the Parole Committee, and the 30 most recent TC patients, 29 of whom were referred by the CBO through the CHW. Our primary measure of interest is prevalence of chronic disease in TC patients, including HIV, hepatitis C, mental illness, opioid dependence and diabetes. Secondary measures include time from correctional facility release to first clinic visit and insurance status.
With the assistance of a CHW, the TC has reached a population of former inmates with a higher burden of chronic illness. Referrals from a CBO, coordinated by a community health worker, identified a population with a high prevalence of chronic diseases including HIV, hepatitis C, mental illness and opioid dependence. system of facilitated referrals, along with access to health centers where barriers to care are minimized, can help bridge gaps in care for the formerly incarcerated population.
Shwetha Iyer, MD:Improving Resident Counseling Competence: Implementing and Evaluating the Impact of a 5A’s skills-based obesity curriculum
Needs and Objectives: Although weight loss can lead to a reduction in diabetes and hypertension and improve health outcomes, only 42% of obese U.S. adults report that their physicians have counseled them about weight loss. Even when weight loss is advised, most physicians do not discuss specific weight loss strategies, indicating that the quality of counseling may be poor. To address this gap, we adapted, implemented, and conducted a pilot evaluation of a previously developed theory-based obesity counseling curriculum for residents using a 5A’s behavioral change model. In this model, residents are trained to assess obesity risk, agree on mutual goals, advise a weight-control program, assist in establishing appropriate intervention, and arrange for follow-up. The objective of our evaluation was to determine the feasibility and impact of a novel obesity counseling curriculum, which incorporates training and practice in obesity counseling skills, on residents’ self-assessed competency in obesity counseling.
Setting and Participants: Our target audience was 28 interns and residents in the Primary Care/Social Internal Medicine Residency Program at Montefiore Medical Center, Bronx, New York.
Description: The curriculum was delivered 4 times over a 6 month period to groups of 5 to 10 residents during ambulatory medicine blocks. One week prior to curriculum participation, residents completed a previously validated survey with 9 items measuring self-assessed obesity counseling competence, based on the 5A’s model. Each question used a 4-point likert scale. The 3-hour 5A’s Obesity Curriculum included a 2-hour didactic and discussion session on the epidemiology of obesity, 5A’s obesity counseling framework and practical tools for its implementation. Case-based discussions of treatment modalities included behavior change, medication, and surgical options for weight loss. The final hour involved reviewing motivational interviewing (MI) and practicing with a standardized patient. Two months after participation, residents completed a post-intervention survey, and gave general feedback. Preliminary analyses compared median scores before and after curriculum participation using the Wilcoxin test.
Evaluation: To date, 16 residents have completed the curriculum and surveys, with another 10 scheduled to participate. Residents reported their counseling competence in: 1) assessing patients’ stage of change, 2) diet and 3) current level of physical activity; 4) agreeing on mutual goals for weight loss; 5) assisting patients in goal setting for weight loss; 6) responding to patients’ questions about behavior change; 7) offering medication and 8 ) surgical weight loss options; and 9) using MI techniques to change behavior. After the curriculum, there was a significant increase in the median scores from 2 to 3 (2=somewhat able to perform, 3=able to perform adequately) in residents’ report of assessing stage of change, assisting in goal setting, discussing treatment options and using MI techniques. There were no differences in the remaining domains. On qualitative questions, residents reported a high degree of satisfaction with the curriculum and requested additional skills practice sessions in MI.
Discussion: We developed and implemented a novel curriculum for residents to address strategies for weight loss using the 5A’s behavior change model, which incorporated obesity counseling skills practice. Preliminary pre and post curricular analyses showed improvements in several areas of residents’ obesity counseling competence. Implementing this three hour curriculum in a residency program was feasible. Post curricular questionnaires indicated that residents were satisfied with the curriculum, and were eager for additional sessions for continued practice and refinement of obesity counseling using MI skills. Further evaluation, with additional learners, and direct observation of counseling skills is needed to fully elucidate the impact of the curriculum in promoting effective obesity counseling skills.
Preetha Iyengar, MD:Effectiveness of a Brief Health Education Intervention to Address Chronic Malnutrition in Quito, Ecuador
Chronic malnutrition is associated with childhood mortality and affects up to a quarter of children in Ecuador. In southern Quito, lack of knowledge and poor diet diversification are contributing factors. Existing research has shown health education is a critical component in influencing behavioral changes and local collaborators, such as the Ecuadorian Ministry of Health and community physicians, have identified health education as an area that merits further investigation in their patient population. Hence, the objective of our study was to assess the effectiveness of a health education intervention given at a government-run clinic in Quito, Ecuador.
A 20-minute workshop and pictogram handouts were developed to provide education on the effects of protein malnutrition and highlight locally available protein sources. The workshop was offered daily over a 4-week period and the handout was distributed to a subset of patients after the workshop. Oral questionnaires were developed to assess protein nutrition knowledge, confidence in participant’s own knowledge, and protein intake pre- and post-workshop and at home visits three weeks later. A total of 98 participants completed pre- and post-workshop questionnaires and 57 completed home visit questionnaires. We found that knowledge and confidence increased after protein education workshops with retention at home visits. The utilization of pictogram handouts in educational sessions improved protein intake. These findings support continuing to work with Ecuadorian collaborators to further develop one-time, concise educational interventions to improve dietary behavior.
Anjani Reddy, MD: Exploring GME Social Accountability
[This presentation won the Daniel Leicht Social Medicine Award and the Chairman's Research Award.]
Purpose: Seen as a public good, graduate medical education (GME) was financed by Medicare 1965, expecting that this responsibility would continue “until the community bears the cost in some other way”. Over 40 years later, Medicare is still bearing the brunt of GME financing, spending $9.5 billion last year. Many have suggested that academic health centers have become dependent on such financing. We sought to better understand the perceived responsibility of GME institutions in addressing the needs of the nation, and the utility of and most likely methods to measure and compare the social impact of GME institutions.
Method: Eighteen informants were interviewed via semi-structured interviews done by phone and in-person. Key informants were chosen from salient national agencies/associations after developing a sampling matrix to ensure appropriate breadth of perspectives. Snowballing technique was employed, and informant interviews were continued until saturation of themes was achieved and confirmed via search for disconfirming data.
Results: Seventeen of eighteen informants noted that GME institutions have a responsibility to be socially accountable. Informants’ definitions of social accountability included: training of future physicians, addressing workforce shortages and providing service to the institution’s community. Multiple informants noted barriers to measuring social accountability, though many informants suggested possible tools for measurement of social accountability.
Conclusions: GME is largely seen as a public good, and multiple informants noted that recipients of GME funding should be responsible to their communities. However, time constraints, financial limitations, and curriculum overload limit GME institutions’ ability to be socially accountable. Financial incentives, accreditation requirements and maintenance of mission values can address GME institutions’ responsibility to medical education, workforce shortages and community service.
Irene Hwang, MD: Development of a Longitudinal Curriculum in Correctional Health at RPSM
Prison release rates in New York City correlate directly with poverty rates, and a disproportionate number of prisoners are returning to the Bronx. Recently released individuals attempting to reintegrate into the community are among the most marginalized of populations and have grave health outcomes. RPSM residents provide care for many of these patients who are directly or indirectly impacted by incarceration. The goal of this project was to develop a longitudinal training program in correctional health for family and internal medicine residents. Methods included reviewing existing correctional health training programs, interviews with medical and academic directors, rotations and site visits to correctional facilities and transitions clinics in San Francisco and New York City.
The proposal for a longitudinal correctional health curriculum is comprised of required clinical and didactic components: Transitions Clinic sessions at FHC and CHCC during elective blocks throughout residency as the foundation; health education workshops, targeted outreach and discharge planning at Rikers Island and VCBC; buprenorphine training and case-based discussions with a substance abuse specialist; and cross-track conferences to discuss syllabus readings. Residents interviewed unanimously support a longitudinal model of learning and this proposed curriculum provides an example of a rigorous training program to meet their educational needs.
Ari Kriegsman, MD & Allison Stark, MD, MBA: A resident-driven approach to systems-based practice education and innovation at a primary care medicine ambulatory teaching clinic
Description: During the academic year 2010 – 2011 we initiated an iterative educational process to engage residents in a dialogue about SBP. An anonymous web-based survey was sent to all 19 PGY2 and 3 residents asking them how they would handle four common clinical scenarios that occur when the resident is not in clinic or between patients’ clinic visits: (1) following up of critical lab values; (2) scheduling non-routine follow-up appointments; (3) handling urgent care situations when patients call from home; and (4) titrating medications. Each scenario was derived from our clinical experience and piloted with colleagues prior to survey distribution. Results were analyzed and a set of best practices was created. At a program-wide retreat attended by approximately 25 residents and faculty we moderated a two-hour discussion on the survey results, best practices and other SBP topics identified. A second anonymous survey was sent to the same 19 residents assessing the value of monthly SBP meetings.
Evaluation: Seventy-four percent (14/19) of residents responded to the initial survey, with up to 5 solutions given for each scenario. Responses varied by the skill level of the clinic staff member asked to assist with the task, the number of phone calls, emails, and hand-offs required, and the time needed for task completion. Given the heterogeneity of responses a set of best practices, emphasizing non-physician resources, was created and disseminated. Our second survey used a 5-point Likert scale (5=Quite Valuable, 1=No Value) to quantify the value of monthly SBP discussions. One hundred percent (14/14) of responders reported that sessions would be valuables or quite valuable. We then initiated monthly discussions (60-75 minutes) during ambulatory blocks (4-8 residents/month). To date we have held two sessions. Prior to each session we solicit SBP topics and distribute a resident derived agenda. Afterwards, we email key takeaway points and post updates on our program’s searchable website.
Bonnie Stahl, MD: Routine Gonorrhea and Chlamydia Screening for Women entering Methadone Mainteance Treatment: Is it worth it?
Background: Chlamydia and gonorrhea (GC) screening in specific populations, including substance users, is recommended. Entry into methadone maintenance treatment presents an opportunity to screen a high risk population, yet the prevalence of Chlamydia and GC infection in this population has not been well-defined. To address this gap, we began to routinely offer screening to women admitted to our Bronx methadone maintenance treatment program (MMTP).
Methods: A chart review of consecutively admitted adult female patients from June 1, 2010 is underway. Using a structured chart review instrument, we abstracted sociodemographics (age, race, income), substance type, injection use, trauma and incarceration history; HIV antibody status, syphilis titer, and urine GC and Chlamydia results.
Results: Forty-nine women were entered treatment between June and December 21, 2010. Eleven (22%) self-identified as Black, 32(65%) as Hispanic. Their mean age was 40 All had heroin dependence. Thirty-one (63%) reported cocaine use. Twenty-two (45%) had injected. Eleven (22%) had experienced domestic violence and 30(61%) had been incarcerated. Nine (18%) were HIV positive, and five (10%) had serologic evidence of syphilis infection. None of the 46 (94%) women tested for GC and Chlamydia were positive.
Conclusions: Although women entering MMTP are typically considered at high risk for sexually transmitted diseases, routine testing GC and Chlamydia testing did not identify any infections. The HIV and syphilis infection rates we found warrant routine screening, but the absence of GC and Chlamydia in this population does not thus far support routine screening with drug use as a sole risk factor.
Asiya S. Tschannerl, MD, MPH, MSc: What is a Social Medicine Doctor?
Purpose: It is clear that social conditions contribute to ill health. This was described as early as the 19th century by Rudolf Virchow, generally considered the founder of social medicine. Yet, medical training continues to center on the molecular basis of disease. In efforts to create a different model of physician training, the Residency Program in Social Medicine (RPSM) of Montefiore Hospital was founded in 1970 to train a cadre of socially-minded physicians dedicated to providing care for the underserved. The RPSM is a holistic curriculum that encompasses an understanding of social problems affecting the health of individuals and communities and strategies for addressing these issues, while training in community health centers. This study investigates what encompasses a social medicine physician today, and how their practice differs from other primary care doctors.
Methods: All current residents, faculty and alumni of the Residency Program were eligible to participate in the survey, which was emailed in March 2009. A survey monkey questionnaire was used, and emailed to current department members and an alumni list-serve. The complete survey had seven items that included status (resident, faculty, or alumni); specialty (Family Medicine, Internal Medicine, Pediatrics); questions about the role of social medicine in regards to their practice, how it differs from other primary care doctors, and questions regarding the RPSM curriculum. Demographic data describing the participants was tabulated, and comments were grouped into themes and investigated via textual and qualitative analysis.
Results: The survey was completed by 173 participants. Forty-seven percent were in the field of Family Medicine, 30% in Internal Medicine, and 24% in Pediatrics. Fifty-six percent were alumni, 26% were faculty, and 21% were current residents. There were three main themes that were common to most responses, which were that social medicine doctors 1) have a broad knowledge of the social determinants of health, 2) have the ability to translate this broad knowledge of health into a specific treatment plan, and 3) promote social justice. Within each theme were various sub-themes which provided a richer description of social medicine concepts and its practice contrasted with the practice other primary care physicians.
Conclusions: Social conditions are not separate from medical conditions, an integral concept of social medicine and RPSM. Although this study was limited in that not all potential subjects responded and responses varied greatly in length and description, the concepts of social medicine are clearly central to their practice of medicine. Social medicine is thought to be valuable and essential in the treatment of individuals and communities, and an opportunity for social change. This model of medicine was viewed as fundamentally different from the practice of other primary care physicians. Further research in the practice of social medicine on patient outcomes, and perspectives of patients treated by social medicine doctors could be helpful in substantiating our findings and expanding the number of social medicine residency programs nation-wide.
Feyisara Akanki, MD & Scott Ikeda, MD, MPH:Staff perceptions of Patient Centered Medical Home implementation in two urban clinics
The Patient Centered Medical Home (PCMH) has received attention as a cost-effective way to address the myriad problems facing the US primary care system. As more practices become PCMH’s, staff must carry out this change, however their perceptions of the PCMH and the change process may not be congruent. We will compare staff opinions of the PCMH transformation at two primary care clinics in the Bronx, NY, using focus groups consisting of providers and support staff, and analyze recorded transcripts for themes. We anticipate the analysis will yield insight into perceptions of the PCMH and the capacities of the clinics to carry out their transformations that will be useful to other practices as they begin their own transformation processes.
Richard Gil, MD:Screening, brief intervention and referral to treatment (SBIRT) for opioid abuse in an urban hospitalized population: a pilot study
Numerous studies demonstrate the deleterious health outcomes associated with substance abuse and dependence. To intervene early in the course of substance use, Screening, Brief Intervention, and Referral to Treatment (SBIRT) has been advocated by many.Few studies have examined the feasibility of or outcomes associated with conducting SBIRT in hospitalized patients. Although data regarding SBIRT for drug use has been sparse, with the rise in opioid use, abuse, and dependence, many advocate for SBIRT specifically for drug use. We sought to test the feasibility of conducting SBIRT for problematic opioid use targeting patients hospitalized on the medical wards of a large urban academic medical center.
We identified adult patients who were admitted floors of the medical wards and administered audio computer-assisted self-interviews assessing theirof problematic opioid use using the WHO ASSISTscreening tool.Patients were categorized as having no opioid use, or low, moderate, or high risk of problematic opioid use. Those who had moderate or high risk problematic opioid use received a brief computer-based intervention. We found that 42 (56.0%) reported no opioid use, 4 (5.3%) low risk, 26 (34.7%) moderate risk, and 3 (4.0%) high risk of problematic opioid use. Of the 29 patients with moderate or high risk, 19 (65.5%) were interested in referral to treatment and 27 (93.1%) reported that the brief computerized intervention was useful. We question whether our model of conducting SBIRT-with a dedicated person outside of the team delivering health care-is feasible. However, this urban inpatient population seems at significant risk thus more research is warranted on how to best use SBIRT to intervene on problematic opioid users in the inpatient setting.
Harini Kumar, MDMaking Exercise a Reality: Zumba Bronx
Zumba Bronx is a reproducible and sustainable form of dance exercise that is built on one of the strengths of an underserved community, the passion to dance. Dance aerobic exercise has been shown to improve participants’ s BMI. The 2010 ADA noted that a 5-10% decrease in weight translates into a decrease in HbA1c. The literature review indicated that successful programs for weight loss have consolidated exercise, diet, and behavior modification plans. In addition, studies have illustrated the utilization of pedometers as a useful tool to motivate diabetic patients to increase physical activity and maintain these efforts. The goal of this social medicine project is to promote physical activity for patients with diabetes at the Williamsbridge Family Practice. The study will utilize this culturally appropriate, and cost-effective form of dance exercise, Zumba, coupled with pedometers, and develop patient centered support that can be incorporated into the FHC and CHCC health centers in the future. The objective of this project is to provide diabetic patients with the tools to develop and maintain a healthy lifestyle.
Anna E. Jackson, MDRetention and Screening of Immigrant Patients in the South Bronx
The purpose of this study was to evaluate whether a dedicated immigrant health session within a larger primary care practice can achieve retention in and quality of health care for immigrants. This was a retrospective cohort study with medical record review of all new patients seen at the OPEN-IT clinic at CHCC from October 1, 2007 to September 30, 2009. The primary outcome was retention in care, defined as at least one follow-up visit within one year after the initial visit. Secondary outcomes included rates of age-appropriate cancer screenings and results of specific screening tests as recommended by the CDC for refugee populations, including Hepatitis B surface antigen, tuberculin skin test, complete blood count, and ova and parasites in stool. Results showed that 79% of patients were retained in care, with no detected difference in retention based on age, gender, length of time in US, or presence of chronic illness. Rates of mammography and cervical cancer screening were 82% and 79% respectively, but the rate of age-appropriate colorectal cancer screening was only 24%. We also found that over a quarter of patients screened had evidence of latent tuberculosis, anemia, and intestinal parasites, although our numbers were small. Our results support the need for clear recommendations regarding immigrant-specific screening. Further work needs to be done to improve rates of colorectal cancer screening within our model and to better understand which diseases need to be screened for in the immigrant population.
Justin Sanders, MD, MScMeanings in Methadone:Perceptions About Methadone Doses Among Individuals in Methadone Maintenance Treatment.
Medicines have meaning and these meanings affect both their efficacy and their perception of it. Perceptions about efficacy affect adherence to and retention in treatment. Observations by substance abuse clinicians suggest that patients in methadone maintenance treatment(MMT)hold perceptions about methadone and methadone doses that may not reflect current medical understanding about methadone, including about interactions and adverse effects. Literature about the experience of patients in MMT is sparse, and this study aims to understand the experience with and perceptions about methadone among patients in an urban methadone clinic. Individuals in substance abuse treatment are a marginalized population. It is anticipated that a better understanding of their experience in a particularly stigmatized realm of medical treatment will allow clinicians to better understand their needs, their response to treatments with potential for interaction to methadone, and thereby improve the adherence to and retention in methadone treatment.
April Wilson , MD & Lin-Fan Wang, MDPerspectives on reproductive healthcare access among homeless female adolescents living in family shelters in the Bronx
Homeless adolescents experience multiple barriers to contraceptive use and they have high rates of unintended pregnancy and poor birth outcomes. The goal is to conduct semi-structured interviews with homeless female adolescents ages 14-18 at family shelters in the Bronx and to have teen educational seminars at a homeless family shelter. Interviews include questions on demographic data and open-ended questions regarding beliefs about contraception, experiences with accessing reproductive healthcare, future plans, and specific barriers to accessing reproductive healthcare as an adolescent living in a family shelter. Teen seminars focus on pregnancy, sex, and STDs. The purpose of our study is to 1) describe the experience of unintended pregnancy, abortion, and contraceptive use; 2) identify barriers to reproductive healthcare access including contraception; and 3) describe preferences for reproductive healthcare access in homeless teens. This data will generate data for targeted changes in services.
Jason Beste, MDThe Use of Traditional Botanicals among Pregnant Women in Rwanda
A survey of pregnant Rwandan women’s use of complementary medicine.
IT IS THE GRASSROOTS ‘PULL’ THAT IS MISSING, AND WE ARE NOT PUSHING GRASSROOTS MOBILISATION STRONGLY, AS WE SHOULD.
All lower-income countries need new generations of leaders in public health and in nutrition, with a new vision and energy. What about the even younger generation, of students who are already committed, perhaps passionately, to what they believe public health nutrition stands for, and who are planning a career – maybe a lifetime – in our profession? This column is addressed to them, in the form of a letter to a student. So:
Dear candidate,
So you want to join our guild of public health nutritionists. Good! I hope you will now allow me to give you a few words of advice, some of warning, some of encouragement.
I start with an issue that has worried public health nutrition workers for many years now, namely how we have been doing professionally in the international arena. Over the years, many of us have shared this concern. Before you embark on your professional journey, you need to see this and other issues. What we have experienced can help you better to judge what you are most probably going to get involved with, in your future career. That is why I am writing you this letter.
I am one of those who do not share the feeling that international public health nutrition is much healthier today than it was ten years ago. The academic training we are giving our new graduates in public health nutrition still often is of limited relevance. This is perhaps more so for students from the South, especially when trained in universities in the North, where they have to go through core curricula that include courses of no relevance to them.
In judging the most important advances in nutrition in the last ten years, many of our colleagues think these have been greatest in preventing and treating micronutrient deficiencies. This comes as no surprise. Most nutritionists still like ‘silver bullet’ fixes. These are ‘technical’, and the technical realm is the one in which they feel more at home, and more in command.
The main issues are structural
But malnutrition is really a political problem. It is the biological manifestation of a social disease. Some other colleagues think that advances in our field in the last ten years have included greater community involvement in nutrition programmes, and increased attention to care practices addressing women and children. This is so, up to a point. But I feel most colleagues do not really have a better, action-oriented understanding of the causes of malnutrition now, than they had in the 1990s. This was the decade in which we agreed that the correct conceptual framework of the causality of malnutrition is one that considers malnutrition as an outcome of different levels of causality. These are basic and underlying as well as immediate, and social, economic and environmental as well as behavioural and biological. All these levels and dimensions need to be addressed at the same time.
For the same period, colleagues have said that we have not come up with comprehensive designs for a better management of nutrition interventions. For them, this explains why we have not been effective in addressing protein-energy malnutrition. But design and management are not the main shortcomings of the last decade, or even the last thirty years. The main problem is the top-down, often curative and palliative thrust of the interventions. Also, it still amazes me that some colleagues even think that failures can be attributed to insufficient attention having been paid to the importance of nutrition counselling. This just shows their ethnocentric bias. ‘Counselling’ does not begin to address the basic problems of impoverishment and inequity that are at the root of malnutrition the world over.
The same bias can be found when colleagues think that reduced funding for nutrition projects is the major problem or constraint to achieving better results in the battle against hunger and malnutrition. Let us face it: If additional funding is used for the wrong priorities and types of intervention, we might as well not have it!
I further disagree with colleagues who think the issue of lack of coordination among United Nations and other aid and development agencies providing nutrition services is central to our non-success in our work. The causes of this confusion or even conflict are ultimately related to issues of control, egos, and ‘old boy networks’, although there are also a number of genuine points of contention among agencies, some clearly ideological in nature. Yes, the non-coordination exists, and it is a disappointment. But it is not the main obstacle to faster progress.
Lack of commitment by governments to meaningful nutrition interventions is another excuse that is made too often, as a blanket statement, almost as a slogan. This said, I do accept that bureaucratic obstacles are a great burden. I know this after working for six years in ministries of health in Kenya and Vietnam, the latter a country where the politics are right, but where it takes a long time to get anything done.
But taken together, I cannot agree with the reasons given above as to why public health nutrition is ineffective. The major negative factors are structural, and are to do with the basic causes of malnutrition. Most of what remains undone ultimately relates to matters of empowerment of those whose right to nutrition is being violated, every day of their lives.
The main issues are political
One of the real issues at stake is the genuine empowerment of claim holders, the people who are suffering from malnutrition. In the years to come, it will take a more sustained (and sustainable) bottom-up activism to reduce malnutrition on the scale that is needed. It is the grass-roots pull that is missing and, as professionals, we are not pushing grass-roots mobilisation strongly, as we should. Will this be covered in your curricula? I am a skeptic.
On UN and other aid and development agencies, the big issue is that there are just no real good role models. Interagency competition and rivalry is often disguised as technical, but is actually political and ideological. My experience is that none of these agencies is really engaged in making empowering and sustainable changes with a potential to win the battle over malnutrition. Your generation, dear candidate, will have to give these agencies new, bolder directions. They are not immune to the political discourse. Some need to be challenged, even confronted, for as long as they keep to their conservative, outdated positions.
Very few of your future professors, dear candidate, are sold on the position I present to you here. They tend to be dogmatic and conservative, sticking to outdated or obsolete concepts, and a paradigm I think is fading. This is a challenge for you as well as for them. Take your stand. We take political stands based on adopting a consistent overall philosophy, which is to say, an ideology. This puts us in opposition to those with different ideologies. It is best not to adhere to our positions as the ‘only’ ones, but as those we stand for. It is good to believe you are right, when you enter into a discussion on the deep-rooted problems of hunger and malnutrition, even when you later come to see that you need to shift your position, just as long as your revised position remains consistent. Dialectics is about change. This includes recognising and amending your own mistakes.
By now, dear candidate, I hope you can sense that politics are at the very centre of international public health nutrition. This means that you cannot escape the responsibility of taking a political stand on nutrition yourself. This will help you to question your own current and future education, as well as all that you will see out there in the job market that is waiting for you shortly. What this points to dramatically is the almost taboo question, so rarely addressed, asked or answered: ‘How would you classify yourself politically?’ Why is this not asked in the first place?
It is said that, on micronutrients and breastfeeding, more concrete achievements are possible. This is precisely the silver-bullet type option many of our colleagues choose. Why should addressing tougher underlying and basic intersectoral issues be seen as impossibly difficult? These are what will ultimately lead to sustained improvements in public health –if we all put our hearts and minds to the task. Nutritionists in your generation need to face the more difficult choices and challenges in the battle against malnutrition and its real causes.
Properly understood, public health nutrition is part of the larger development perspective. I see it as being our point of entry to the big picture where it rightfully belongs, according to the integrated conceptual framework of the causes of malnutrition. Nutrition will keep its rightful identity in such an approach. To be taken seriously, our discipline has to be engaged with all aspects of development; if it stays territorial, it will remain only marginally relevant.
Are the impediments to public health nutrition too great?
Dear candidate, the current condition of international public health nutrition will continue to pose increasing frustrations and challenges for you. My acute concern is seeing how politically uninterested so many of your generation, particularly in North America and Western Europe, have become.
Those who say that international public health nutrition was just one fashion that now has had its day might be right, after all. If so, this is because our vocation may have turned out to be irreversibly irrelevant in global terms in addressing malnutrition, the rates of which are now rising again. It is just tough trying to beat the gigantic odds of inhumane and often outrageous economic globalisation, structural adjustment, and expanding ‘market economies’, that have no room for the problems of impoverished people.
But international public health nutrition must not and cannot be a passing fashion! We invite you to join in. If leaders and citizens turn their back on problems like these, they are part of a movement towards an inhumane, unjust and unsustainable world that will have gone wrong, for ever.
Yes, you can make a difference
In closing, dear candidate, I convey to you my confidence and optimism that our work has the ability to make a difference. The question is, what difference, and what for. Routine, pat solutions will not do. It is not a matter of an increasing number of activities in international public health nutrition starting to take place again in low-income countries. It is a matter of what kind or type of activities. Issues of inequality and of the right to nutrition are at the base of the problems at hand. And if nutrition is used as a way to revert such inequalities, I will be an optimist. But we need your upcoming generation, dear candidate, to get the job done. Perhaps you can start by questioning the curriculum you will be exposed to.
I have worked in many places on most continents, and this, in my experience, is what awaits you if you decide to join us. I see your role as a potential agent of change. I hope that, by now, you have a sense of what motivates us, the older workers who keep going as best we can, and of what we stand for. Principles include those that are ethical and social. Motivation can include romantic approaches such as those of charity and the desire to help the needy, but what’s most needed are political approaches that attempt to fight inequalities and injustice by empowering people to fight for their own rights.
Unfortunaytely, many of our commitments and energies wane as we get older, dear candidate. Do what is bold, now that you are young. Reach for the stars.
A call for documentaries or films developed by the IPHU-2011 participants, resulted in an amazing response! It was obvious that each participant had his/her own special story to share, which ofcourse, was pertinent to their field of interest. Sharing one’s work in their setting or country, is a rich experience in itself. It was rewarding to see the enthusiasm of the participants as they queried to get more information from the presenters. It was interesting to listen to participants share their knowledge on Human Rights and not just stop there…but express a strong conviction to stand up and raise their voice for a community at large. The plethora of knowledge and experience shared was simply indelible! Each participant unfolded their experience by way of sharing their documentaries and webpages. They were keen to learn strategies to direct their momentum to achieve ‘ Health For All’, one that would be sustainable.
Participants and faculty who shared their field work were Bryan Parras, Bharath Rathod, Rosalia Guerrero, Pauline Dinakar, John Sullivan.
BRYAN PARRAS, a Houston filmmaker who specializes in documentation of environmental and social justice movement stories, shared his work: www.youtube.com/hightechaztecHe has presented with John Sullivan at numerous U.S. EPA Community Involvement conferences, the Alaska Environmental Forum, and the Pedagogy & Theatre of the Oppressed annual conference (Chapel Hill NC 2006).
BHARATH RATHOD, a community activist for manual scavengers introduced a documentary on the lives of manual scavengers and their children. The documentary is called ‘I am dalit, how are you?’,
ROSALIA GUERRERO, a Community Liaison for Air Alliance Houston, a non-profit education and advocacy environmental organization, shares her rich experience on Facebook. Her mission is to fight for clean air in the Houston region and surrounding areas of non-attainment or under environmental threat. In addition to working with local neighborhoods, she has also been working towards organizing several communities along the Gulf Coast of Texas facing similar environmental and public health challenges. You could search for “Texas Port Communities Network’ on Facebook available on this link: http://www.facebook.com/home.php#!/pages/Texas-Port-Communities-Network/211344255542581
JOHN SULLIVAN, faculty member in the Department of Preventive Medicine & Community Health, an adjunct faculty member within the Institute for Medical Humanities, and is Co-Director of Public Forum & Toxics Assistance through the Sealy Center for Environmental Health & Medi-cine / NIEHS Center at the University of Texas Medical Branch in Galveston. He takes a creative approach to address environmental and social issues, which is very engaging and interesting. He is an artist who has worked as a writer, playwright, director, poet, performance artist and arts educator. He conveys key ideas of health activism around specific health concerns by way of organizing Forum Theatres. Two of the documentaries introduced for reference are the following:-
1. Behind the Fence: Forum Theatre on Lupus, Lead Poisoning & Environmental Justice:
PAULINE DINAKAR, currently a Research Assistant at the National Black Leadership Commission on AIDS in New York, works on a federal project rolled out by the Office of Minority Health. Pauline Dinakar is also an activist highlighting the needs of the substance abusers in India. She is the president of the TULIP New Life Trust in India, which provides holistic health-care to HIV infected substance abusers in India. This holistic health-care regimen includes rehabilitation, spiritual outreach and medical-nutrition therapy. The need to create drop-in clinics is currently under strategic planning for effective follow-up. A quick overview of her work among the substance abusers which led to the development of the TULIP New Life Trust is
HRIPSIME KALANDARIAN and LANA O’SON, students of the Lebanese American University (LAU) medical school, are active members of the Social Medicine Society. They work in unison with the Social Medicine Society to raise awareness about common medical conditions in Lebanon. Their current project is to provide primary health care to the Palestine refugees living in Byblos. Their aim is to educate people about the importance of primary care; provide yearly health check-ups for early detection and prevention; educate people about self medication and its consequences (which are highly prevalent in Lebanon). Hripsime and Lana O’Son have shared some pictures of the health campaigns and field work, in which they are actively involved: https://picasaweb.google.com/104148248662063813890/IPHUBronx2011?feat=directlink#
The first People’s Health Movement USA National Meeting will be held July 28-29, 2011, at Loyola Marymount University, Los Angeles CA, in conjunction with the annual assembly of Doctors for Global Health. We invite those who endorse the People’s Charter for Health to participate in identifying our medium-term goals and developing a plan to reach them. This is an opportunity for you to get more involved with the international movement that has set the people’s agenda for global health for the last 12 years.
The People’s Health Movement is a global network of people’s organizations, civil society organizations, NGOs, social activists, health professionals, academics and researchers who believe we can provide health for all by tackling the social and economic underpinnings of health status, and providing community based comprehensive primary health care. PHM in the United States has been working in solidarity with health activists around the world, and promoting solutions emerging internationally as a result of local research and action for health.
We have many challenges both domestically and internationally. At this first national meeting we need your input to make decisions about where to focus our energy and how to take advantage of upcoming opportunities. One of those is the 3rd People’s Health Assembly in Cape Town, South Africa next July. If you have thought about attending the PHA3, you should participate in this meeting.
Soon we will send out a pre-meeting survey to hear from as many people as possible as we develop the agenda.
If you would like to participate but are unable to travel to LA, we will be setting up some kind of virtual participation connection for part of the meeting. Please email phm@hesperian.org if you would like to participate virtually.
Discussion, learning, and action across organizations, disciplines, race and class is needed to build the movement to demand for health for all in the US and globally. We will lay a foundation July 28-29 in Los Angeles.
In Solidarity,
People’s Health Movement–USA National Meeting Organizing Committee
Sri Shamasunder
Sarah Shannon
Laura Turiano
Jyoti Puvvula
Linda Sharp
Lily Walkover
Evan Lyon
