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.

 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.

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.

 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.

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.

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.

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.

[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.

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.

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.

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.

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.

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.

 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.

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.

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.

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.

 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.

 A survey of pregnant Rwandan women’s use of complementary medicine.

Shah M, Edmonds-Myles S, Anderson M, Shapiro ME, Chu C. The Impact of Mass Incarceration on Outpatients in the Bronx: A Card Study. Journal of Health Care for the Poor and Underserved, Volume 20, Number 4, November 2009, pp. 1049-1059.

The  University of Massachusetts’ Commonwealth Medicine division and Nova Southeastern University’s College of Osteopathic Medicine will be sponsoring their 3rd Annual Academic and Health Policy Conference on Correctional Health from December 3rd and 4th, 2009 in Fort Lauderdale, Florida. This conference focuses on collaborations between academic medical centers and correctional institutions.  This link will take you to a listing of the presentations at last conference.

Correctional health is an area of increasing concern to clinicians as more an more Americans find themselves arrested and behind bars.  In fact, so many Americans are arrested that some have spoken of a “plague of prisons.”  This impacts not only on the people who are incarcerated but also on their families and communities.  Interested readers should consult our prior posting on marijuana arrests in the US (Record Marijuana Arrests Feed the Prison Industrial Complex ) and the Pew Charitable Trusts report: One in 100: Behind Bars in America 2008.

The conference will take place at the Hilton Fort Lauderdale Airport Hotel.  A special conference rate of $109/night will be available to conference participants; mention the 3rd Annual Academic and Health Policy Conference on Correctional Health to secure this rate.

The conference website is located at: http://www.umassmed.edu/commed/ch_conference09/index.aspx

Posted by Matt Anderson, MD

courtesy of wespennest on flickr.com

Daphne Eviatar of the The Washington Independent reported last week on a new piece of legislation designed in response to growing awareness about the poor and even dangerous conditions experienced by detainees held by the Immigration and Customs Enforcement (ICE) Agency (see original article here).

New York Senator Kirsten Gillebrand, along with Senators Kennedy (D-MA) and Menendez (D-NJ) introduced the “Protect Citizens from Unlawful Detention Act” and the “Prevent Detainee Deaths and Abuse Act”, which would increase government accountability towards suspected undocumented immigrants and protect those already detained. The article cites the recent work of Amnesty International USA, the InterAmerican Commission on Human Rights, the National Immigration Law Center and others in documenting the abuses experienced by detainees.

Media attention on the subject has grown. Recently, the NY Times reported on the death of a detainee at a detention center in a Monmouth County detention facility.  Ahmad Tanveer, a Pakistani New Yorker died after exhibiting symptoms consistent with a myocardial infarction (or heart attack). His death would have gone unreported were it not for a scrawled note of another detainee sent to a group who regularly correspond with these individuals. It is still unknown as to why Mr. Tanveer was detained in the first place.

In late July, the Times also reported on a series of three-day hunger-strikes being conducted by immigrant detainees in an ICE facility in Louisana. These men are protesting poor conditions: ”’There are rats, mosquitoes, flies, and spiders inside the cell and inside the dorm. The ventilation is terrible,” [one detainee] said. ‘We have tried to complain about all of these problems, and we haven’t gotten anywhere. They tell us, ‘It’s a jail. This is how it is.””

Immigrant detention affects the communities we serve.  I met an elderly women in clinic recently whose symptoms of sleeplessness and anxiety were exacerbated by the recent detention of her oldest son, in his 40s, the father of her five grandchildren. He had been raised in the U.S. since the age of 10 and had been placed in detention after violating parole in relation to an arrest for Marijuana-related drug charges. He was described by his mother as the family’s main support person, both financially and emotionally. Further complicating his detention is a severe acquired hearing deficiency requiring hearing aids for which he had been recently fitted, but had not yet received.

The Social Medicine portal has reported on this subject before (Homer Venters (RPSM IM 2007) On Immigration Detainee Health Care, July 2008; Persistent Concerns over the Health of Immigrant Detainees, April 2009). It is encouraging that the problems outlined in those two articles is being brought to light and addressed by politicians at the national level. Physicians will have to play a role in enforcing new standards of healthcare in ICE facilities.

In the meantime, call your Senators and ask them to support this valuable piece of legislation.

Riker's Island

The June 2009 edition of the American Journal of Public Health contains an article entitled: From Public to Private Care The Historical Trajectory of Medical Services in a New York City Jail” written by Noga Shalev, MD. Dr. Shalev is a graduate of the Residency Program in Social Medicine and this work developed from her 2006 Social Medicine Project. The article describes the evolution of health care services at Riker’s Island.

The Riker’s Island Penitentiary sits in New York City’s East River between Queens and the Bronx, just to west of La Guardia Airport.  Riker’s is quite literally an island,  connected to the Borough of Queens by a single bridge. It is one of the world’s largest correctional facilities with an average daily census of about 13,000 prisoners.  Administratively, the facility houses ten jails that sit on the island and the Vernon C. Bain Center, an 800 person facility located on a barge just off of Hunts Point in the Bronx.

Vernon C. Bain Prison Barge

Dr. Shalev divides the history of health care at Rikers into three periods.  From the opening of the prison in 1932 until 1973 medical services were provided by various New York City agencies.    During this period numerous reports documented the poor quality of care provided to inmates.   It seems clear that the Department of Correction’s concern for security trumped attempts to provide medical care to inmates.  As noted in a 1958 report: “The Department of Correction is not now in background, equipment, or personnel capable of giving modern medical care—whether preventative or therapeutic—to the prisoner.”

Attempts to remedy this situation made little progress until the early 1970′s when a series of prison revolts including those at the upstate Attica prison and the Manhattan House of Detention (commonly known as “the Tombs”) led to reforms.   This resulted in the second period of medical care at Rikers.  From 1973 to 1996 Montefiore Medical Center provided health care under an affiliation agreement with the City.  Health care on the island improved and the service was “the first correctional medical program in the country to be accredited by the Joint Commission on Accreditation of Healthcare Organizations” (JCAHO).  However this period also coincided with the HIV epidemic and in its wake a resurgence of tuberculosis; prisoners were particularly affected by these twin epidemics.  Costs for medical care increased substantially and in 1996 the Giuliani Administration decided to turn health care at the island over to a private contactor. The initial agreement with St. Barnabus Hospital was generally recognized as a failure.  Costs did not decrease and there were ongoing concerns about the quality of care.  Currently, care on the island is provided by the private, for-profit Prison Health Service, Incorporated.  Concerns over costs and quality of care remain.  Dr.  Shalev characterizes this final period from 1996 to the present as one of “managed care” and the overarching theme of her paper is that health services at Riker’s have moved from public hands (the city) into private hands (for-profit corporations).

Dr. Shalev’s careful historical research, butressed by interviews with Montefiore staff, tell the story of a particular and certainly unique experience in incarceration.  But the unique story of Riker’s illustrates the larger themes of how corrections have come to be seen as one more commodity on which profit can be made. And this gives powerful players a vested interests in keeping jails full.  The result is a system described by some as a prison-industrial complex, by others as a penal state.

Here is the abstract of Dr. Shalev’s paper:

Over the past 25 years, incarceration rates in the United States have more than tripled. Providing health care services for this growing number of inmates poses immense medical and public health challenges. Focusing on the administrative and financial shifts in health care delivery, I examined the history of medical services in one of the nation’s largest correctional facilities, Rikers Island in New York City. Over time, medical services at Rikers have become increasingly privatized. This trend toward privatization is mirrored nationwide and coincides with the rising prevalence of incarceration.

posted by Matt Anderson, MD

Shortly after the release of these memos, New York Review of Book’s journalist Mark Danzer posted the entire text of the February 2007 report by the International Committee of the Red Cross regarding the interrogration of 14 “high value” detainees by the CIA.  The report was published as part of two excellent articles (“US Torture: Voices from the Black Sites” and “The Red Cross Torture Report: What It Means“) written by Danzer.

The report is of particular interest to health care personnel because it details the alleged roles of medical personnel in the torture of the 14 detainees.  Rather than summarizing the contents of the ICRC report, we excerpt below the entire text of Section 3 entitled:  Health Provision and the Role of Medical Staff.

During the course of their detention, detainees described three principal roles for health personnel whom they encountered. Firstly, there was a direct role in monitoring the ongoing ill-treatment which, in some instances, involved the health personnel directly participating while certain methods were used. Secondly, there was a role in performing a medical check just prior to, and just after, each transfer. Finally, there was the provision of healthcare, to treat both the direct consequences of ill-treatment detailed in previous sections, and to treat any natural ailments that arose during the prolonged periods of detention.

Throughout the course of the initial phase of the detention, the ICRC received alle­gations that health personnel were directly involved in monitoring the health effects of ill-treatment. In some cases it was alleged that, based on their assessments, health personnel gave instructions to interrogators to continue, to adjust, or to stop particu­lar methods. As with other personnel within the detention facilities, the health person­nel did not identify themselves, but the detainees presumed from their presence and function that they were either physicians or psychologists.

For certain methods, notably suffocation by water, the health personnel were allegedly directly participating in the infliction of the ill-treatment. In one case, it was alleged that health personnel actively monitored a detainee’s oxygen saturation using what, from the description of the detainee of a device placed over the finger, appeared to be a pulse oxymeter. For example, Mr Khaled Shaik Mohammed alleged that on several occasions the suffocation method was stopped on the intervention of a health person who was present in the room each time this procedure was used.

Other detainees who were shackled in a stress standing position for prolonged peri­ods in their cells were monitored by health personnel who in some instances recom­mended stopping the method of ill-treatment, or recommended its continuation, but with adjustments. For example, Mr Bin Attash (the detainee has had a right-sided below knee amputation) alleged that while being held in a form of stress standing posi­tion with his arms shackled above his head, and his feet touching the floor, had his lower leg measured on a daily basis with a tape measure by a person he assumed to be a doctor for signs of swelling; the health person finally ordered that he be allowed to sit on the floor, albeit with his arms still shackled above his head. Mr Hambali alleged that, after a period of the same form of prolonged stress standing, a health person intervened to prevent further use of the method, but told him that “I look after your body only because we need you for information”.

As well as the monitoring of specific methods of ill-treatment, other health person­nel were alleged to have directly participated in the interrogation process. One detainee, who did not wish his name to be transmitted to the authorities, alleged that a health person threatened that medical care would be conditional upon cooperation with the interrogators.

The second alleged role of the health personnel was to perform a medical check prior to and after each transfer from one detention location to another. The purpose and results of this medical examination appear not to have been divulged to the detainees.

The third alleged role was to provide medical care to detainees, either for injuries resulting directly from the various forms of ill-treatment employed, or treatment for common ailments that arose throughout the course of the detention.

With regard to this third role, when such medical treatment was necessary it appears from the descriptions given that the care was appropriate and satisfactory. In two specific cases, detainees indicated that exceptional lengths were taken to provide very high standards of medical intervention.

Medical ethics are based on a number of principles’ which include the principle of beneficence (a medical practitioner should act in the best interest of the patient—salus aegroti suprema lex), non-malefiance (first do no harm—primum non nocere) and dig­nity (the patient and the person treating the patient have the right to dignity). These principles guide any relationship between a medical doctor and a person whom he or she is relating to as a medical doctor.

There are accepted roles for health professionals working in recognised, official, places of detention such as police stations and prisons wherein the health professionals have the health care and best interests of the detainee as their primary consideration.’ To this end, when a person enters an official detention facility or system, a medical assessment of their medical status is required in order to meet their current and ongo­ing health needs. In the case of a normal, lawful interrogation, a physician may be asked to provide a medical opinion, within the usual bounds of medical confidential­ity, as to whether existing mental or physical health problems would preclude the individual from being questioned. Secondly, a physician may rightly be requested to provide medical treatment to a person suffering a medical emergency during question­ing. This accepted role of the physician, or any other health professional, clearly does not extend to ruling on the permissibility, or not, of any form of physical or psycholog­ical ill-treatment. The physician, and any other health professionals, are expressly pro­hibited from using their scientific knowledge and skills to facilitate such practices in any way. On the contrary, the role of the physician and any other health professional involved in the care of detainees is explicitly to protect them from such ill-treatment and there can be no exceptional circumstances invoked to excuse this obligation.”

With the exceptions detailed in the above paragraph, any interrogation process that requires a health professional to either pronounce on the subject’s fitness to withstand such a procedure, or which requires a health professional to monitor the actual proce­dure, must have inherent health risks. As such, the interrogation process is contrary to international law and the participation of health personnel in such a process is con­trary to international standards of medical ethics. In the case of the alleged participa­tion of health personnel in the detention and interrogation of the fourteen detainees, their primary purpose appears to have been to serve the interrogation process, and not the patient. In so doing the health personnel have condoned, and participated in ill-treatment.

Commentary on the ICRC Report

Medical participation in torture has been discussed in several articles in the medical literature over the past several years.  Stephen Mile’s 2004 Lancet article entitled “Abu Ghraib: its legacy for military medicine” pointed to multiple ill effects of medical participation in torture. These included damage to the reputation of the US Army and its medical corps as well as “[t]he eroded status of international law has increased the risk to individuals who become detainees of war since Abu Ghraib because it has decreased the credibility of international appeals on their behalf.“  Calls arose the same year for an investigation of doctors who had been involved in torture.

As of today no health care personnel have been prosecuted or lost their license to practice for these breaches not only of basic ethical principles, but also of international law.  Of course, the problem does not reside in a “few bad apples” who did wrong, but rather in the larger system that was designed to torture and abuse.  Medical personnel were one part of that machine.

In a 2003 chapter in the book Military Medical Ethics, Volume 1, Drs. Vic Sidel and Barry Levy argued that the concept of a physician-solider contained an irreconcilible ethical dilemma: that of divided loyalties or dual agency.

The overriding ethical principles of medical practice in our view are “concern for the welfare of the patient” and “primarily do no harm.” As we understand them, the overriding principles of military service are “concern for the effective function of the fighting force” and “obedience to the command structure.” Although there may be rare exceptions to these principles, they have been the fundamental bases of medical practice and military service over the centuries. In our view, the ethical principles of medicine make medical practice under military control fundamentally dysfunctional and unethical.

In making this critique Drs. Sidel and Levy were speaking of primarily physician-soliders who were caring for other soldiers.  But the situation of the medical personnel operating at the CIA “black sites” is the ultimate expression of the problems of dual agency in military medicine.

More on the ICRC

This posting excerpts only a small portion of the ICRC report which is worth reading in full for its careful documentation of the conditions of detention in the CIA black sites.   It is worth pointing out that the ICRC’s involvement in defending prisoners extends far beyond this report. The Committtee’s work can be appreciated on their website.  Finally, the ICRC has provided some background in response to the publication of the report. The ICRC statement concludes with the following:

The ICRC is concerned that any information it divulged about its findings in places of detention could easily be exploited for political purposes. It deplores the fact that confidential information conveyed to the US authorities has been published by the media on a number of occasions in recent years. The ICRC has never given its consent to the publication of such information.

posted by Matt Anderson, MD

Rev. Joseph Danticat died in Immigration Detention. Shown here with his wife & niece Edwidge

In July of last year we wrote about the activites of RPSM alumni Dr. Homer Venters to bring attention to the medical conditions in the detention facilities of Immigration and Customs Enforcement (ICE).  Two reports issued in March – one from Human Rights Watch and the other from the Florida Immigrant Advocacy Center - provide further evidence that ICE is not adequately caring for those in its custody.

A bit of context

To understand the health problems in ICE facilities it is necessary to have some sense of the massive growth in ICE’s detention operations.  In March of this year Amnesty International USA produced a report on ICE entitled Jailed without Justice which notes:

More than 300,000 men, women and children are detained by US immigration authorities each year. They include asylum seekers, torture survivors, victims of human trafficking, longtime lawful permanent residents, and the parents of US citizen children. The use of detention as a tool to combat unauthorized migration falls short of international human rights law, which contains a clear presumption against detention. Everyone has the right to liberty, freedom of movement, and the right not to be arbitrarily detained.

According to the ICE website the average daily number of “detained aliens” in custody rose from 20,838 in 2002-2005 to 31,2345 in 2008 (fiscal years).  By contrast the Amnesty reports notes that as recently as 1996 the immigration system had the capacity to detain only 10,000 people a day.  While the absolute numbers of detainees has increased, ICE has also decreased time each detainee spends in custody.  The result is a massive machine to detain and incarcerate.

It is important to remember that the vast majority of those detained are not criminals.  Those who are in the US without authorization have committed a civil violation not a crime.  In the language of ICE they are “deportable aliens.”  As Human Rights Watch notes it is precisely their status as civil – and not criminal – detainees that deprives them of their right to a lawyer.

In fact, many of those detained are victims of crime themselves.  In July of last year our journal, Social Medicine, published an interview with Victor Toro, an immigration activist in the Bronx.  Victor, who had been severely tortured in Pinochet’s Chile, described his experience with ICE detention:

On 6 July of 2007, when I was traveling from California to New York in an Amtrak train, when we had just passed the city of Buffalo, in one of the stations, the Immigration service entered the train with dogs producing great alarm and upsetting the English-speaking passengers, asking for papers from everyone and acting especially rude and hateful toward the persons who had Hispanic features or looked as if they were from some other part of the world than the USA. I was among these persons, among them I was traveling and had lived nearly 25 years in this country. Without many questions I was hand-cuffed and forced with blows from the train, then handcuffed to the others and taken to the regional immigration offices, afterwards to the Cayuga jail, where I was stripped and forced to wear the orange prison jump-suits, which are the same that everyone in the world saw on the prisoners tortured and tied-up in Guantanamo and Abu Ghraib. This squeezed and cramped all the fibers and vibrations of my body, it took me immediately to sessions of torture and mistreatment that I lived through in Chile, in the torture centers and the concentration camps of Pinochet. It was horrible, I cannot even talk about it and just thinking about and seeing the photos of the prisoners in Guantanamo converted into animals by the authorities of the United States, this has no name. It is pure savageness, a total lack of humanity.

Concerns about immigrant health care

Given the rapid expansion of the ICE facilities it is not surprising that health problems have arisen. Indeed the Inspector General of the Department of Homeland Security had issued a report in December of 2006 noting “instances of non-compliance at four of the five detention facilities, including timely initial and responsive medical care.” Among other concerns the Inspector noted that procedures did not exist for detainees to report abuse or human rights violations.

During May of 2008 the poor care provided in ICE facilities was highlighted in a series of articles in the Washington Post entitled: Careless Detention:  Medical Care in Immigrant Prisons.  This report drew an angry response from ICE and a careful rebutal by the Washington Post’s Ombudsman.

In November of last year the ICE issued a fact sheet on Detainee Health Care which stated that detainees received care for both acute and chronic medical conditions in accordance with community standards.  Further ICE claimed that health care in its facilities was evaluated using “applicable health care standards from the American Correctional Association (ACA), the National Commission on Correctional Health Care (NCCHC), the Joint Commission, and the ICE National Detention Standards to evaluate the care provided to detainees.”

The reports by Human Rights Watch and the Florida Immigrant Advocacy Center paint a very different picture.

Detained and Dismissed

Commentary

posted by Matt Anderson, MD

]]> http://www.socialmedicine.org/2009/04/03/prison-health/persistent-concerns-over-the-health-of-immigration-detainees/feed/ 2 http://www.socialmedicine.org/2008/11/20/community-health/residency-program-in-social-medicine-orientation-month-2008/ http://www.socialmedicine.org/2008/11/20/community-health/residency-program-in-social-medicine-orientation-month-2008/#comments Thu, 20 Nov 2008 05:54:02 +0000 Matthew Anderson http://www.socialmedicine.org/?p=620

US Incarceration Rates Stratified by Race

Each October our Residency Program in Social Medicine does something rather unusual.  We take our interns off the hospital wards to participate in “Orientation Month.”  For four weeks they learn about social medicine and the Bronx, the place in which they are practicing medicine.  They are introduced to the philosophy, theoretical framework, and practice of Social Medicine through a curriculum of didactic and experiential learning. The month emphasizes a biopsychosocial perspective that integrates patients, their communities, and the medical system into a holistic view of health problems. At the conclusion of the month residents present a synopsis of the clinical problem they have studied and  develop a proposal to address its social determinants.

This year the overall theme of the Orientation month was The Impact of Violence on Clinical Practice. We explored this through three cases: one involved a patient who had been incarcerated, the second a case of domestic violence and the third an immigrant. These cases were tightly integrated into a series of activities that included visits to prisons (Riker’s Island and Sing Sing), community organizations, community centers (e.g. the Bronx Community Pride Center), local businesses (such as botanicas) and Bronx institutions such as the Botanical Gardens and the Bronx Museum.  The interns also learned practical skills such as how to perform a medical evaluation of an ayslum seeker and how to do community organizing (a workshop taught by Steve Max of the Midwest Academy).

On Tuesday, November 18th the interns presented their work as part of our regularly scheduled Social Medicine Rounds.  A standing room only crowd listened as they shared what they had learned and made a a variety of project proposals. Their presentation can be downloaded as a Powerpoint. While the Powerpoint does not capture the richness of their actual presentation, it suggests the themes they explored and learned about.

Posted by Matt Anderson, MD

Robert Greifinger, an RPSM graduate in Social Pediatrics in 1976, has been extensively involved in examining the prison system from a public health point of view. Last year, he published Public Health Behind Bars: From Prisons to Communities, the title of which suggests his social conception of the problem of prisons and health. He is currently an adjunct Professor at the John Jay College of Criminal Justice. Previously, he was the Chief Medical Officer for the New York State of Correctional Services, which was responsible for the health care of 68,000 inmates.

Public Health Behind Bars: From Prisons to Communities was favorably reviewed in the New England Journal of Medicine in May and in the Journal of Urban Health in April.  It will be reviewed in the July issue of the Journal of Correctional Health Care [14(1) July 2008 pp. 232-235].

The health of prisoners and the impact of mass incarceration on the communities we serve is an area of very interest in the DFSM.

Here is the description of the book from the publisher’s website:

• Prisoner reentry is a topic of current interest in correctional and public health
• Coverage includes both health care and topics in law and public policy
• Contributors are experts from such fields as public health and correctional health

Projecting correctional facility-based health care into the community arena, Public Health Behind Bars: From Prisons to Communities examines the burden of illness in the growing prison population, and analyzes the considerable impact on public health as prisoners are released. More than forty practitioners, researchers, and scholars in correctional health, mental health, law, and public policy make a timely case for correctional health care that is humane for those incarcerated and beneficial to the communities they reenter. These authors offer affirmative recommendations toward that evolutionary step.

Chapter authors identify the most compelling health problems behind bars (including communicable disease, mental illness, addiction, and suicide), pinpoint systemic barriers to care, and explain how correctional medicine can shift from emergency or crisis care to primary care and prevention. In addition, strategies are outlined that link community health resources to correctional facilities so that prisoners can transition to the community without unnecessarily taxing public resources or falling through the cracks. Between the authors’ research findings and practical suggestions, readers will find realistic answers to these and similar questions:

• Can transmission of HIV, tuberculosis, and other communicable diseases be reduced and prevented among prisoners?
• How can correctional facilities treat addiction more effectively?
• What can be done to improve diagnosis and treatment of psychiatric disorders?
• Can correctional care benefit from quality management and performance measurement?
• How can care be coordinated between correctional and community health care providers?
• What are the health risks to communities if action is not taken?

Public Health Behind Bars: From Prisons to Communities is a challenge of immediate interest to readers in correctional health and medicine, public and community health, health care administration and policy, and civil rights.

posted by:Matt Anderson

Dr. Homer Venters, a 2007 RSPM Internal Medicine Graduate, is currently working as an Attending Physician at the Bellevue/NYU Program for Survivors of Torture and is a Public Health Fellow, New York University. During his residency at Montefiore, Dr. Venters worked with Bronx Defenders, a legal aid organization in the Bronx, helping to get people involved in the criminal justice system into primary care. This work resulted in the publication of an article about the tragic case of Scott Ortiz in the Harm Reduction Journal. His work as a resident was awarded the Dan Leight Social Medicine Award.

On June 4 2008, Dr. Venters testified in front of the House Judiciary Committee’s Subcommittee on Immigration, Citizenship, Refugees, Border Security, and International Law. He discussed problems with the medical care provided to Immigration and Customs Enforcement (ICE) detainees. It is clear to people working in the field that ICE detainees are not accorded the same medical care provided to other US prisoners. Dr. Venters outlined some of the reasons why. Specifically he pointed out that the ICE medical system is designed to care for acute problems; it is not set up for persons with chronic medical issues. To quote from his testimony:

“This institutional aversion to caring for detainees with chronic disease is evidenced in recent detainee deaths. One year ago, a 23 year old transgender woman, Victoria Arellano was detained by ICE. Ms. Arellano had AIDS and was taking a life saving medicine to prevent opportunistic infections that could quickly cause pneumonia and death were she to stop. These medicines are essential for people with AIDS and even a brief interruption risks sickness and death for a patient. Despite reporting her medical history and her medication when detained (and throughout her detention), Ms. Arellano was refused her medicine. Over the following weeks, Ms. Arellano developed a cough and fever, which should have prompted hospitalization and evaluation. Instead, Ms. Arellano was given an inappropriate antibiotic by the detention center medical staff, was still refused her needed medication, and returned to her cell. By the time Ms. Arellano’s cellmates staged a protest to draw attention to her deteriorating condition, she had become very ill and died soon thereafter, comatose and shackled to her bed. Faced with a common chronic disease, ICE medical staff withheld the correct medicines, gave inappropriate medicines and failed to seek more competent care for Ms. Arellano. The care that Ms. Arellano required would be routine in almost any medical clinic or hospital in the United States.”

The full testimony is available here.

Posted by Matt Anderson