Last Saturday (8/29/2009) at least 3000 people (according to police estimates) gathered in Times Square for the Unity Walk in support of health care reform. Montefiore Residency Program in Social Medicine resident, Cameron Page, and graduates Oni Blackstock, Karen Wang, Manel Silva, Bill Jordan, David Herszenson, Giliane Joseph, and Jonathan Arend all played a large role in organizing the event. There were dozens of students from Einstein, Mt. Sinai, and other NY medical schools.
Here is a list of some of the news coverage of the event:
Dr. Herzenson wrote to us that: “This is a cause that is close to my heart, and unfortunately, there has been a lot of misinformation out there about the current proposals. This site offers an insightful article on what reform means for those who already have insurance: (click here). This site debunks a lot of the myths that have been spread: (click here). Finally, if you want to get more involved, even just by writing an e-mail to your legislator or putting a sign in your window, go to http://www.healthcareforamericanow.org/ This is an umbrella organization that is out there fighting the fight.”
The RPSM participants are all involved with the National Physicians Alliance. The webpage for their local (New York City) NPA group is http://npany.blogspot.com/ Their next meeting will be on Wed, Sept 9th at 7:30 pm, location: TBD
Below is a listing of the Social Medicine Projects (with their abstracts) for the 2009 graduating class of the Residency Program in Social Medicine at Montefiore Medical Center:
Eleanor Bathory, MD and Sharyn Miskovitz, MD: Perceptions about Exercise among Inner-City Adolescent Girls
Funded by a Community Access to Child Health (CATCH) grant, we conducted three focus groups at the South Bronx High School to determine the perceptions about exercise among inner-city adolescent girls. We recruited female high school students to participate in one of three 60-minute focus groups of 10-11 students each. Our objectives were to understand the perceptions of adolescent girls regarding their involvement in exercise, benefits of exercise, barriers to exercise, and factors that would motivate them to participate in an exercise program. The adolescent girls who participated in the focus groups recognized important psychological benefits of exercise and offered critical information on barriers and motivating factors. Based on these results we held three sample exercise classes (step aerobics, kickboxing, and double-dutch jump rope) and asked the participants to complete a survey after each class. The participants enjoyed all of the exercise classes and were enthusiastic to participate in an after-school exercise program.
R. Max Dyksterhouse, MS, MD: Routine opt-out HIV testing in an urban community center
Undiagnosed HIV infection remains a significant public health problem. To address this, the Centers for Disease Control and Prevention revised testing recommendations, calling for routine opt-out HIV screening among adults in health care settings. We examined acceptability of opt-out HIV testing in an urban community health center and factors associated with accepting testing.
Sadiqa Edmonds-Myles, MD: The Impact of Mass Incarceration on Children
The term “Mass Incarceration” has been used to describe extraordinarily high incarceration rates seen in working class communities of color. Despite an estimate of 1.5 to 2 million children affected by parental incarceration, little is known about how mass incarceration affects the health of children or the practice of primary care pediatrics. Previous studies have shown various psychosocial effects of parental incarceration, including PTSD, ADHD, depression, and attachment disorders; however very few have evaluated the breadth of patients in low income urban areas affected by this issue, or the effect of mass incarceration on the health care of children. I participated in two related studies to further evaluate these issues.
The first study was completed during Social Medicine Orientation, and involved a joint effort by Department of Family & Social Medicine residents and faculty to assess the prevalence of arrest and incarceration in patients attending primary care clinics in the Bronx. A card study was completed during a 2.5 week period. 118 cards were completed; one third of which were with parents of pediatric patients. 18% of patients (or parents) currently had a family member in jail. 25% reported having been arrested, and 51% reported they or a family member had spent time in jail. On nearly all variables rates were higher for pediatric visits than for adult visits. Clinicians participating in the study reported positive responses to discussing incarceration.
In order to further evaluate the impact of parental incarceration on the health and health care of children, I am currently working on a qualitative study to evaluate access to a medical home among children of previously incarcerated parents. We have conducted a focus group with the staff of Hour Children, a non-profit organization which assists incarcerated mothers with transition and reunification with their children once released from jail or prison. We are also in the process of conducting in-depth interviews with previously incarcerated mothers to learn more about the effect of incarceration on the health and health care of their children.
James A. Fausto, Jr., MD: Home- and Office-based Buprenorphine Inductions: a qualitative study exploring patients’ experiences with initiation of opioid addiction therapy
Context: Buprenorphine, a partial opioid agonist, is effective in treating opioid dependence in primary care settings. Initiation of buprenorphine treatment (i.e., induction) is challenging because patients typically must be in opioid withdrawal. Although inductions have traditionally occurred in medical settings, home-based inductions have recently emerged as a new treatment strategy. No studies have examined patientsâ experiences with buprenorphine inductions.
Objective: To explore patientsâ experiences with buprenorphine induction.
Design: This qualitative study used semistructured interviews of patients who underwent buprenorphine induction. Interviews were digitally recorded and professionally transcribed. A coding scheme was developed to capture key themes. Each encounter was coded independently by two of three investigators; coded data were entered into NVivo 8® to retrieve thematically-related text.
Setting: A community health center in the Bronx, NY.
Participants: Twenty patients who underwent buprenorphine inductions (10 office-based and 10 home-based inductions).
Results: Narrative themes included: reasons for starting treatment, social supports, health care system engagement, addiction history, and induction experience. Many patients appreciated the anonymity provided by primary care physicians treating their opioid addiction. All patients would recommend buprenorphine treatment to others seeking opioid addiction treatment. Despite a lack of consensus on preferred induction site, all patients valued the potential to customize the induction process to their needs and preferences.
Conclusions: Patients identified that customizing buprenorphine inductions to their needs was important. Incorporating patient-centered strategies with buprenorphine induction appears to be an important for buprenorphine therapy in the primary care settings. These results can help guide buprenorphine treatment in primary care settings.
Uriel Felsen, MD, MPH: High rates of clinical factors associated with advanced liver disease in patients with chronic hepatitis C at an urban methadone maintenance program
Background: Chronic hepatitis C (CHC) is a significant cause of morbidity and mortality among injection drug users. While prior studies have demonstrated a high prevalence of CHC among participants of methadone maintenance programs (MMPs), little data exist regarding the clinical factors that impact CHC morbidity and mortality in this population. Mount Sinai Medical Center’s Narcotics Rehabilitation Center (NRC) served approximately 650 patients before closing in 2007. The center offered methadone maintenance, on-site primary care and psychiatric services, and institutional linkages to CHC specialty care. The goals of this study were to elucidate: 1) the CHC-specific healthcare practices at the NRC; 2) the presence of clinical factors associated with advanced liver disease in those with CHC; 3) the presence of co-morbidities complicating or precluding CHC treatment; and 4) the number of patients who accessed CHC specialty services and were treated.
Methods: A chart review of a random sample of active patients was conducted between December 2005 and January 2006. Laboratory data collected included hepatitis C virus (HCV) antibody, HCV viral load, hepatitis A virus (HAV) and hepatitis B virus (HBV) serologies, and HIV status. The CHC-specific healthcare practices reviewed included screening for CHC and vaccinating for HAV and HBV. Clinical factors associated with advanced liver disease included co-infection with HIV or chronic HBV (defined by a positive HBV surface antigen), alcohol abuse/dependence, and duration of infection >/= 20 years. Psychiatric co-morbidity was defined by presence of an axis I diagnosis or a psychiatric medication. Medical co-morbidities complicating or precluding CHC treatment included: malignancy, autoimmune disease, advanced liver disease, renal disease, active alcohol abuse, and other uncontrolled medical conditions. Access of CHC services included being seen by a specialist, undergoing liver biopsy, or having a history of CHC treatment.
Results: 207 charts were reviewed. 98.1% had an HCV antibody test and 99.3% of those that were positive had a confirmatory viral load. Overall, 54.6% (n=113) of participants had CHC. Of those with CHC who were non-immune to HAV, 56.6% were vaccinated for HAV; and 3.1% of those non-immune to HBV were vaccinated for HBV. Of the patients with CHC: 15.0% had HIV, 1.8% had HBV, 41.6% had a history of alcohol abuse, and 70.8% were infected for >/= 20 years. 7.1% of those with CHC actively abused or were dependent on alcohol, 54.9% had a psychiatric co-morbidity, and 22.1% had a medical co-morbidity that impacts CHC treatment. 25.7% of those with CHC accessed specialty services and 12.4% received CHC treatment.
Conclusion: While screening for CHC was successfully integrated into routine care, patients at this MMT would have benefited from a comprehensive vaccination program. Over half of the patients at this MMP were infected with CHC and many of them had clinical factors associated with the development of advanced liver disease, making timely evaluation and treatment even more urgent in this population. Few patients were evaluated for CHC and even fewer received treatment. Targeting on-site psychiatric treatment for those with CHC and strengthening the institutional affiliations with CHC specialty services may have increased the number of patients being treated. As an urban, academically-affiliated MMP, the NRC may be representative of similar MMPs which are well situated to address the current CHC epidemic within their patient population.
Thinh Xuan Ho, MD: Conceptual Models Of Hypertension Among Vietnamese Patients In The Bronx
It is well known that better treatment of hypertension is associated with significant improvement in morbidity and mortality. Lack of adherence to treatment has been postulated as an important reason for poor control of hypertension. Among many underlying causes of low adherence to treatment for hypertension, studies identified misunderstanding about hypertension, perceived efficacy of anti-hypertensive regimen, beliefs concerning the necessity of regular medication and the experience of side-effects, as all serving to discriminate between compliers and non-compliers (13, 14). All of these factors are highly culturally shaped (15).
Although there is no available data about control of hypertension among Vietnamese-Americans, few small studies revealed that the level of awareness of hypertension among this population was even lower than that of the general US population. In order to enhance the level of control of hypertension among Vietnamese-Americans, we conducted a qualitative interview study which investigated personal perspectives of hypertension among Vietnamese-American patients with and without the disease. The ultimate goal of this study was to elicit their understanding about hypertension including prevalence, etiology, symptomatology, possible complications, necessary treatment, as well as its impacts on life.
Sybil Hodgson, MD & Betsy Mathew, MD: Using PhotoVoice to build Self Identity among Preteens
Photovoice is a medium that traditionally uses photography to stimulate grassroots social action by having traditionally underrepresented members of a community take photographs of the environment from their point of view. Internationally, this has been applied to bring forth the voices of refugees, women, or other marginalized populations. There have been attempts to use photovoice with adolescents to help them become active in their communities and learn from their peers.
This program utilized photovoice to develop self identity among preteens through a five session photography-based curriculum emphasizing integrity, communication, self perception and relationships. Each participant created individual portfolios of all of their photographs and narratives. The curriculum will conclude with a gallery session inviting community members and family to view the photographs and narratives compiled by the participants.
Anne Hyson, MD: Evaluation of a directly administered antiretroviral therapy program for HIV-infected people within a community-based harm reduction program
Background and Significance: Ensuring adherence to highly active antiretroviral therapy (HAART) for the treatment of HIV infection is especially challenging among patients who are facing other medical and social challenges, such as active or prior addiction. Studies have demonstrated that adherence is strengthened and outcomes are improved when directly-observed therapy (DOT) is provided for complicated medical regimens through social networks and community-based organizations. Despite this evidence, DOT is not currently a standard of practice to improve adherence and outcomes for HIV therapy. We set out to examine the effectiveness and feasibility of DOT amongst clients who are most at risk of failing HAART because of mental illness or an unstable social situation. Within the drop-in center of a community-based harm reduction organization, we provided specialized DOT called DAART (directly administered antiretroviral therapy) to clients who had been unsuccessful at adhering to antiretroviral therapy on their own. We hypothesized that compared to baseline, six months after enrollment into the DAART program, clients would have a decrease in HIV viral loads and an increase in CD4 counts.
Methods: The study population included HIV-infected individuals who enrolled in the Montefiore/CitiWide Health Services DAART Program from April 1, 2006 to December 31, 2008. The DAART Program was housed in the larger Montefiore/CitiWide Health Services Program, a collaborative program between an academic medical center and a community-based harm reduction organization that provides comprehensive services to HIV-infected individuals in New York City. The following data were extracted from program logs and medical records: date of enrollment into the DAART Program, socio-demographic information, dates and values of CD4 counts and HIV viral loads, and co-morbid illnesses. We used simple frequencies to describe the clients and program outcomes, defined as change in CD4 count of at least 50 cells/mL, and one log change in viral load (copies/mL).
Results: Thirty-four clients enrolled in the DAART Program. The median age was 48 (range 28-60), and 26 (77%) were men. Fourteen clients (41%) were hispanic, 13 (38%) were black, two (6%) were white, and five (15%) declined to answer. The median CD4 count at baseline was 189 cells/mL (range 4-528), and the median viral load was 8866 copies/mL (range <75 to >500000). Twenty-four clients (71%) were exposed to Hepatitis B, 20 (59%) were exposed to Hepatitis C, and of these, 16 (47%) had been exposed to both Hepatitis B and Hepatitis C. Twelve clients were noted in the chart to be actively using drugs, and 12 were prescribed a psychiatric medicine other than a sleep aid. Seventeen clients (50%) had more than one viral load within six months of beginning the study period. Thirteen clients (76%) had a log decrease in their viral load, three clients (18%) had no change, and one client (6%) had a log increase in their viral load. Nine (53%) achieved an undetectable viral load within the six month period after enrollment in the DAART Program. Ten clients (59%) had a significant increase in their CD4 count, of at least 50 cells/mL. One client (6%) had no change, and six (35%) had decreases in their CD4 counts after starting the program.
Conclusion: Despite a high drop-out rate, our data support the hypothesis that directly administered antiretroviral therapy can be an effective intervention to improve adherence and treatment outcomes among some clients with previous nonadherence to HIV therapy. This evidence could be used to obtain funding for a larger intervention that is designed prospectively, which would enhance data collection and follow-up.
Christine A Lee, MD:Transgender Adolescents: Understanding Their Psychosocial Challenges and Barriers to Healthcare
Transgender (TG) individuals are those who identify with the gender opposite from their genetic and anatomical sex on psychological, sexual, and social levels. Little data exists regarding the health and psychosocial risks and needs of TG individuals, particularly adolescents. My objective was to determine the health and psychosocial challenges and barriers to healthcare access faced by TG adolescents living in New York City. I obtained an Community Access to Child Health (CATCH) grant from The American Academy of Pediatrics to develop a medical home for TG adolescents in NYC. Then I conducted a qualitative study, utilizing structured in-depth interviews. Adolescents were recruited from two community-based organizations providing services to the TG community. First, participants completed an anonymous self-administered survey to collect general information, and those interested consented to a 30-minute structured in-depth interview. TG adolescents in this study cited multiple psychosocial challenges and systemic barriers to obtaining healthcare. This data provides new insight and builds upon the emerging body of research on TG adolescents. The findings were presented at two national conferences to inform and further educate health care providers.
Irina Linetskaya, MD: Montefiore Goes Green: Resident-Led Advocacy for Organizational Change: My recycling project
In January of 2007, Montefiore made an institutional commitment to adopt an environmentally sound waste management strategy aimed to reduce waste and institute recycling. A medical resident attained institutional buy-in from the hospital’s new CEO who committed financial support toward a recycling initiative. The “Montefiore Green Team,â comprising leaders from departments such as engineering, facilities, and public relations, first piloted and evaluated a recycling initiative at CHCC, a satellite clinic in the South Bronx. Lessons learned there shaped the large-scale, Montefiore Medical Center based recycling program. Given the large projected volume of recycling, Montefiore secured lucrative contracts with local recycling contractors to install a free compactor (a savings of $300,000) and haul recycled paper, metal, glass, and oil free of charge, saving rather than costing Montefiore money to divert trash away from landfills.
One year after inception of an institution-wide program, Montefiore has recycled 36 tons of glass, metal, and plastics and 100,000 pounds of white paper. Montefiore’s cafeteria has eliminated the use of 5,000 Styrofoam trays per week, replacing them with recyclable products. Unexpectedly, rather costing money, recycling saves Montefiore over $1000 per week.
Grass-roots activism can catalyze institutional change, dramatically affecting institutional recycling practices. Although medical residents often feel powerless in a hierarchical medical system, they can represent a strong voice for innovation and change.
Sharissa Parker, MD: Perspectives on Culture, Food, Diet and Diabetes Among Jamaican Patients in the Bronx
Diabetes Mellitus is a common, costly condition associated with significant morbidity and mortality. One of the main goals of treating patients with diabetes is to produce near-normal glucose levels to prevent the development of diabetic complications. While pharmacological therapies are clearly effective, diabetes trials have repeatedly shown that adding nutrition and lifestyle approaches can be more effective in delaying the progression of the disease than drugs alone. Diet is an important component of diabetes care, yet full cooperation of patients with dietary regimens can often prove difficult to achieve. In minority ethnic groups, distinct cultural beliefs relating to diet, food and eating need to be understood and appreciated by the health professionals that provide care to these individuals. Our goal was to explore significant questions about health behaviors in general and dietary management, as well as the unique beliefs of food and diet among Jamaicans with diabetes in the Bronx.
Using qualitative interview techniques, we investigated the cultural beliefs of food and eating among Jamaicans aged 18-75 with diabetes and their reactions to dietary advice given by their health care professional. In recorded interviews of 10 participants, we found that all participants continued to eat at least one traditional food item after migrating to the United States. All participants were told by their physician to change their diet, but only 20% of physicians were familiar with Jamaican cuisine. Dietary advice was not specifically targeted to the foods participants consume. In conclusion, this study is an important reminder to those providing care to Jamaicans, and all ethnic minorities, of the need to make dietary advice culturally sensitive. Patients recognize the importance of healthy eating; they just need the principles of the advice translated into their own cultural food language.
Sharon Phillips Benattabou, MD and Arati Karnik, MD: Perceived Barriers to Contraception in an Underserved Population
More than half of the approximately 6 million yearly pregnancies in the US are unintended. Lack of contraception use and unintended pregnancy are closely related, especially among young, poor women. Homeless women are both an at-risk population for unintended pregnancy and have a greater association of adverse outcomes in pregnancy, such as preterm labor and low birthweight infants. Few studies have been done regarding contraceptive views among homeless women and ways in which to improve access. Contraception is key in this marginalized population which is at high risk both for unintended pregnancy and poor pregnancy outcomes.
Focus groups were conducted with women over the age of 18 at two family shelters located in the South Bronx in hopes of better understanding perceived barriers to contraception for homeless women in New York. Data analysis used narrative theory to extrapolate common themes from transcribed group discussions. Preliminary findings suggest that even sheltered populations with access to on-site clinics and health insurance find lack of patient education, expense, poor clinical rapport with doctors and side effects as some of the limiting factors to using contraception. Continued efforts need to be made to reach this vulnerable population and improved access to reproductive healthcare.
Max E. Quintana, MD: Ay doctor me duele! A typical Presentation of Depression in Latino Men.
It is a clinical chart review determining back pain as an initial complaint of depression in latino men between the ages of 20 and 60yo.
Michael Reid, MD: Approaches to TB screening and diagnosis in people with HIV in resource limited settings
TB is the main cause of morbidity and mortality in people living with HIV/AIDS worldwide. Early diagnosis and treatment is essential to addressing the dual epidemic of TB and HIV. This study involved reviewing the diagnostic tools currently available to diagnose TB among people with HIV/AIDS
Leigh A. Rieper, DO: Implementing a Sustainable Program: Reach Out and Read at Williamsbridge Family Practice
Reach Out and Read trains doctors and nurses to advise parents about the importance of reading aloud and to give books to children at pediatric check-ups from six months to five years of age. Reach Out and Read initiated in September 2007 at Williamsbridge Family Practice. In the first year, over 500 books were distributed during 85.7% of well visits. In order to maintain a sustainable program participation of all providers is needed. Some of the barriers to having 100% participation of providers include time allowance, lack of interest and small pediatric panels.
Amit J Shah, MD: Investigation of Interest Towards Yoga and Meditation in an Inner City Population
Meditation and Yoga are two techniques for wellness that have shown efficacy in multiple medical and psychiatric conditions, such as depression, anxiety, hypertension, fibromyalgia, and lower back pain. The degree of interest towards this complementary modalities in an inner city setting is in question. In this survey study, patients from a general medicine clinic in the South Bronx are interviewed and asked multiple choice and open ended response questions for the purposes of assessing who would be interested in yoga and meditation, as well as factors that may influence this interest. If people show interest, then it may be justifiable to allocate resources towards offering and studying their benefits in this population
Lauren Shapiro, MD: Transition Clinic
The transition clinic is an open-access clinic that will provide health care to previously incarcerated persons upon their release from prison. Recent studies have shown that the adjusted risk of death upon the initial two week period following release was 12.7 times that of other state residents, and 3.5 times greater over a two year period. The leading causes of death were drug overdose, cardiovascular, homicide, and suicide. The challenges of release involve substantial health risks, in addition to the difficulty of finding a doctor to continue their 30 day supply of medicine they leave prison with. The proposed clinic seeks to mitigate the role that absent or unstable medical care may play.
Our transition clinic is modeled after the only other transition program at the University of California, San Francisco and seeks to address the health and social needs of recently released prisoners. We aim to provide four primary functions; acute stabilization and medication renewal, ongoing primary care to those with chronic medical conditions, training for residents, and research opportunities. Through partnership with the Osborne Society, Department of Corrections, parole officers, and a community health worker we plan to open our doors July 11th 2009.
Michele Trela Bowdy, MD: The TRRIP Program: Teens Reducing the Risk of Infections & Pregnancy
The nature of the project was to create & implement a teen peer education program covering the topics of STDs, HIV/AIDS, & pregnancy prevention. Research shows that these programs have great effect on teens’ HIV/AIDS-related knowledge, attitudes/beliefs about risky behaviors, ability to fight negative peer pressure, and time spent helping other youth avoid unprotected sex. The idea stemmed from a similar project that I did as an AmeriCorps*VISTA, while working at a Migrant Health Clinic. I enjoyed the experience I had with the teens then & wanted to do more work in the area of adolescent health. Being that we practice in the Bronx, where we see many teen pregnancies & STDs, I thought it was a much needed program.
The curriculum is meant to promote healthy, responsible choices for teens by giving them information about health topics that will affect them. Through increased knowledge and skill-building sessions, teens will be better prepared to protect themselves against infections and pregnancy. The Program encourages teens to discuss their health concerns with their parents and doctors. We encourage parents to use every chance to discuss health issues with their children. We also encourage parents to help their child learn to access health services provided by physicians and clinics in our community.
On Tuesday, March 10th Dr. Kathryn Anastos and Jon Wallen came to Social Medicine Rounds to discuss their work in Rwanda. Dr. Anastos’ story illustrates one answer to the question: “What does a social medicine doctor do?”
Dr. Anastos is an Internist who graduated from the Residency Program in Social Medicine in 1983. She is currently a Professor at Albert Einstein College of Medicine in the Department of Medicine as well the Department of Epidemiology and Population Health. She is known for her pioneering work in the study of HIV in women as principal investigator of the Women’s Interagency HIV Study (WIHS). Jonathan Wallen is a New York photographer who specializes in architectural and landmark photography. Since 2003 they have become increasingly involved in work in Africa, some of which they shared last Tuesday.
Mr. Wallen filled the walls of the third floor conference room with pictures from the Tubeho (“To live again”) Project. Tubeho documents the stories of female victims of the Rwandan genocide and consists of a series of photographs with accompanying stories (see an example at this link). These were disturbing stories. The pictures that accompanied them showed both women in the full bloom of life as well as others whose spirits and bodies seemed broken. Showings of the exhibition have been used to raise funds for the genocide victims as well as to bring attention to the links between gender-based violence and the spread of HIV.
Dr. Anastos framed her work in the context of Community Oriented Primary Care (COPC). She shared her initial skepticism, developed from her work in the Bronx, in COPC as a model of care. Rwanda, however, had changed her point of view.
The couple’s involvement in Rwanda began in 2003. Dr. Anastos had been contacted by Les Veuves (the Widows) a group of genocide survivors, many of whom were infected with HIV. They were incensed that they did not have access to treatment while their victimizers – on trial for genocide – were receiving HIV medicines. Dr. Anastos had worked as an administrator at the Montefiore Medical Group and felt she knew about building an efficient, comprehensive, high quality primary care practice for a chronic disease. As she put it, her credibility was as an HIV expert, but her skill was as a manager. With assistance from the Stephen Lewis Foundation she helped found We-ACTx (Women’s Equity in Access to Care and Treatment) in mid-2004. The goal was to create an HIV treatment program, but this implied first setting up HIV counselling and testing.
One of the lessons of this experience was to ” first, provide the services people ask for, not just those professionals think they need”. This, she felt, was the essence of COPC. And what people wanted was wanted medical care (to prevent dying and promote health), HIV testing, medical care for their children, food, income, and – a top priority - education for their children. The local women rejected the idea of going out “into the bush” to provide care. They wanted it done through existing infrastructure and using local nurses and clinics. By knitting together multiple small grants an HIV testing program was implemented in September of 2005 and has by now performed over 50,000 tests. In January of 2006 anti-retroviral care was introduced and there are currently 2,400 people on ART, essentially “everyone who needs it, gets it”. The program is implemented in coordination with 24 community partners and is staffed by 2 physicians, and 12 nurses. She feels that the necessary skills to run the program exist locally (“if we left now, the program would continue”) but that the local staff continues to need salary support.
For a beautiful look at the WE-ACTx progam in action, you can see pictures in the linked slideshow.
Because of the focus on meeting people’s expressed needs, several “off mission” programs had been created. “Just because I think it is not health service related, doesn’t mean we don’t have to find a way to provide it.” These off mission programs included the provision of food supplements, creation of income generating activities (originally doll making, now bag making, see Ineza), community based education, and a program to help with school fees.More recent activities are a cohort study (requested by the community) and programs to address cervical cancer. Cervical cancer, an essentially preventable disease is the number one cancer killer in Rwanda.
In considering the successes of their work (and of the COPC model) Dr. Anastos pointed to the strong sense of community in Rwanda. “There is no cult of the individual. It is always my family, my community, my country.”
A friend recently brought to our attention the film, A Right to Health, Neighborhood Health Centers in Profile, made by the Office of Health Affairs of the Office of Economic Opportunity (OEO) apparently in the early to mid-1970’s. This 33 minute film highlights the work of diverse Community Health Centers in the US, beginning with Montefiore’s Martin Luther King Health Center in the South Bronx.
We have also posted Out in the Rural, a film about one of the first two OEO community health centers, the Tufts-Delta Health Center of North Bolivar County, Mississippi. See our media page for a link to this film and the following link for an introduction to Out in the Rural.
A Right to Health is made in the overly somber, paternalistic style of old public service announcements. Nonetheless, the voice and feeling of the communities manages to emerge. Dr. Roger O. Egeberg, then Dean of USC School of Medicne, introduces the movie stating that it “describes new ways of providing health care for the poor.” But this is a bit deceptive. The film describes ways of organizing health care services – community care, comprehensive care, team care, the use of community health workers – that suggest a broader vision of clinical care than just “poor care.” In fact, the title “A Right to Health” expresses a universal ideal that we have yet to achieve in the US.
On Tuesday January 20, 2009 Dr. David Kindig offered the second annual Harold Wise lecture as part of our Social Medicine Rounds series. The Wise lecture is organized the Residency Program in Social Medicine Alumni Committee. His talk was entitled: To: President Obama, From: Harold Wise, MD, RPSM Founder, Re: Beyond Health Care Reform. Dr. Kindig has kindly given us permission to post his presentation which can be downloaded here. It should not be reproduced without his consent.
Dr. Kindig began with some memories of Harold Wise, a Canadian physician born in Hamilton Ontario in 1937. After receiving his MD degree at the University of Toronto in 1961, Dr. Wise completed an Internal Medicine internship at the Kaiser Permanente Foundation Hospital. In 1964 he moved to Bronx and completed his Medicine residency at Montefiore. He then served as Director of Ambulatory Services and Home Care at Morrisania City Hospital, a New York City hospital affiliated at the time with Montefiore. In 1969 he became the director of the Dr. Martin Luther King Jr. Health Center, one of the first OEO (Office of Economic Opportunity) Community Health Centers in the US. Faced with the problem of finding well-trained clinicians interested in working in underserved areas, Dr. Wise created the Residency Program in Social Medicine. He passed away in 1998.
Dr. Kindig then discussed his own path to the Bronx. As a pediatrics resident at the University of Chicago he had been told that spending a month working at a community health center was “not a legitimate PGY-2 activity.” He was becoming increasingly politically active at the time and became interested in pursuing other paths in medicine. He met up with Harold Wise who convinced him to come to the Bronx and develop a “Social Pediatrics” residency program. Dr. Kindig moved from Chicago to the Bronx both creating the residency program and becoming its first graduate in 1971. He went on to have a distinguished career in academics and government service. He is currently Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin-Madison, School of Medicine. He also serves as Senior Advisor to the Wisconsin Public Health and Health Policy Institute.
His talk focused on the need to move beyond simply reforming health care in the United States. Insuring all Americans and providing them with health care are two necessary and important steps for the new Administration in Washington. But they are not enough. True health reform would require addressing the multiple social determinants of health. He discussed how the book Why Are Some People Healthy and Others Not? The Determinants of Health of Populations had been an epiphany for him. He had come to see that curative medical services were of limited value in addressing social disparities and that spending more on such services might actually reduce the overall health of the population. He briefly reviewed some of the recent evolution of thinking on population health and spoke about his own work in conceptualizing reimbursement systems that would pay for population health. His concepts are outlined in his book Purchasing Population Health (available on Google Books) and in a 2006 JAMA article A pay-for-population health performance system.
Currently, Dr. Kindig is active in the Robert Wood Johnson Health & Society Scholars Program and the Population Health Initiative at the University of Wisconsin. At the Population Health Institute he leads an initiative to make Wisconsin the healthiest state and he shared some of that work with us. The project produces an annual report card on Wisconsin health. The 2007 report card noted that while health in Wisconsin was improving it was not improving as fast as other states. The state was graded B- overall for health and D for addressing health disparities. The program is moving beyond merely grading the state to better understanding the determinants of health and then to suggesting specific evidence-based actions to address each one. The work of the program seemed embued with a very political sense of making health statistics understandable to the people who could actually influence public policy.
It is impossible to comment on the talk without mentioning the spirit of optimism generated by the inauguration earlier in the day of Barack Obama. Rounds took place at the Cherkasky auditorium where some five hours earlier hospital employees had watched President Obama sworn in. It in words of Montefiore President Steven Safyer it was a moment of Jungian synchronicity.
Our colleague, Dr. Rebecca Williams, has set up a website exploring Family Centered Maternity Care (FCMC). Family Centered Maternity Care, as she explains it, is “a philosophical approach to prenatal care and delivery providing care to the pregnant woman in the context of her family. FCMC is prenatal care that considers, includes, and fosters the development of families. Historically, practitioners have also promoted natural childbirth.” While the site is primarily towards the teaching and clinical needs of our Family Practice residents, Dr. Williams updates it on a regular basis, making it a valuable resource.
The movement for Family Centered Maternity Care is several decades old. Interested readers may want to consult Celeste R. Phillips‘ book Family-Centered Maternity Care some of which can be read on Google Books. Phillips, a pioneer in the field, defines FCMC as “a way of providing care for women and their families that integrates pregnancy, childbirth, postpartum, and infant care into the continuum of the family life cycle as normal, healthy life events.” She developed the following 10 principles for FCMC:
Principle No.1: Childbirth is seen as wellness, not illness. Care is directed to maintaining labor, birth, postpartum, and newborn care as a normal life event involving dynamic emotional, social and physical change.
Principle No. 2: Prenatal care is personalized according to the individual psychosocial, educational, physical, spiritual and cultural needs of each woman and her family.
Principle No. 3: A comprehensive program of perinatal education prepares families for active participation throughoutthe evolving process of preconception, pregnancy, childbirth and parenting.
Principle No. 4: The hospital team helps the family make informed choices for their care during pregnancy, labor, birth, postpartum and newborn care, and strives to provide them with the experience they desire.
Principle No. 5: The father and/or other supportive persons of the mother’s choice are actively involved in the educational process, labor, birth, postpartum and newborn care.
Principle No. 6: Whenever the mother wishes, family and friends are encouraged to be present during the entire hospital stay including labor and birth.
Principle No. 7: Each woman’s labor and birth care are provided in the same location unless a Cesarean birth is necessary. When possible, postpartum and newborn care are also given in the same location and by the same caregivers.
Principle No. 8: Mothers are encouraged to keep their babies in their rooms at all times. Nursing care focuses on teaching and role modeling while providing safe, quality care for the mother and baby together.
Principle No. 9: When Mother-Baby care is implemented, the same person cares for the mother and baby couplet as a single-family unit, integrating the whole family into the care.
Principle No. 10: Parents have access to their high-risk newborns at all times and are included in the care of their infants to the extent possible given the newborn’s condition.
Dr. Phillips currently runs a healthcare consulting company, Phillips + Fenwick, which assists hospitals in implemented FCMC programs. The company website – www.panf.com – has some resources on FCMC, such as a short reading list. Of particular interest, is her 1999 article Family-Centered Maternity Care: Past, Present, Future which discusses the history and current of FCMC.Readers may also wish to consult the WHO’s document on Care in normal birth, although this document is now 12 years old.
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.
What does a Social Medicine doctor do? Here is Bill Jordan’s current answer:
I graduated from RPSM Family Medicine in 2007, and I’m currently finishing my MPH and serving as Chief Resident in Preventive Medicine at Mount Sinai School of Medicine in New York City.
While a resident at Monte, I built on community psychiatry experience from medical school, launching an HIV prevention workshop at Geel Clubhouse, a day program for people with mental illness in the South Bronx. In addition to a recent report on this work in the journal Psychiatric Services, the workshops lived on after I left Monte, led by medical students under the stewardship of Dr. Alice Fornari.
As a preventive medicine resident, I have continued my longstanding commitment to immigrant health. I volunteer with Doctors of the World, writing medical affidavits for asylum seekers, and I regularly see new refugees at my primary care clinic in Harlem, the Barbee Family Health Center. I am also spearheading the NYC DOHMH pilot program to address cervical cancer screening disparities among female immigrants.
Finally, I helped build the coalition supporting this year’s introduction of Green Carts in New York City. The new permits allow vendors to sell fresh fruits and vegetables in neighborhoods with limited economic opportunity and low availability of healthy food. I promoted adoption of the permits with a local community-based organization representing Spanish-speaking street vendors, Esperanza del Barrio, and was recently elected to the board of directors. I am currently exploring the possibility of real-time cell-phone based mapping of vendor locations as a tool for promoting microlending to vendors and healthy food consumption by local residents. After finishing residency, I hope to continue working on the intersection of economic development and nutrition as a way of addressing health disparities.
A Brief History of the Residency Program in Social Medicine (RPSM) & the Department of Family and Social Medicine:
Montefiore Medical Center / Albert Einstein College of Medicine
The Residency Program in Social Medicine (RPSM) of the Montefiore Medical Center (MMC) was founded in 1970 by Drs. Harold Wise and David Kindig, who sought to develop residency training in pediatrics and internal medicine that emphasized primary care for the underserved. In 1973 family practice was added as a third track. Residents worked in partnerships and maintained their continuity practices at the Dr. Martin Luther King, Jr. Health Center (MLK), which Dr. Wise had begun in 1968. The RSPM was their response to the difficulty of recruiting physicians to MLK who could work effectively with the community and other members of the health care team. At the time MLK was the flagship of the neighborhood health center movement of the Office of Economic Opportunity.
In 1973 Dr. Jo Ivey Boufford, one of the RPSM’s first pediatric graduates, became the director of the RPSM and began developing the social medicine curriculum which all three disciplines shared. This included health systems skills, such as medical care organization and economics; community and organizational skills, such as medical anthropology, Spanish and community-based projects; research and evaluation skills, such as epidemiology, biostatistics, and health services research; and educational and teaching skills, including patient education and curriculum development.
In 1977 the family practice track moved its continuity practice from MLK to North Central Bronx Hospital and in 1978 Dr. Robert Massad, already a national leader in his discipline, became chairman of Montefiore’s Department of Family Medicine. Under his leadership in 1980 the Montefiore Family Health Center (FHC) was opened and became the primary site for residency training and faculty practice in family medicine.
In 1982 Dr. Boufford left the RPSM to become a Vice President of New York City’s Health and Hospitals Corporation and Dr. Massad assumed her responsibilities. That year the RPSM offered its first month-long “Core Curriculum” rotations in Medical Spanish; Understanding the Health System; and Epidemiology and Community Assessment. Because of MLK’s fiscal problems, the pediatrics and internal medicine tracks moved to St. Barnabus Hospital in 1986. In 1990 several independent community health centers affiliated with MMC were organized into the Montefiore Ambulatory Care Network (MACN) under Dr. Massad. In 1991 pediatrics and internal medicine moved to MACN, now divided between the Comprehensive Health Care Center (CHCC) in the South Bronx and the Comprehensive Family Care Center (CFCC) near the Albert Einstein College of Medicine (AECOM) campus in the East Bronx. In 1997, when CHCC moved into a newly constructed facility, the social internal medicine and pediatrics tracks were again consolidated there. CHCC, CFCC, and FHC are all federally-funded community health centers (Section 330).
In 1992 the Department of Family Medicine at Montefiore, which administers the RPSM, became a full academic department at AECOM with a Division of Research, a required third year clerkship for medical students, and its first geographic inpatient ward on Rosenthal D. Dr. Massad became the first Unified Chairman of Family Medicine at AECOM with affiliated residencies at Bronx-Lebanon Hospital Center. In 1993 Dr. Massad received national recognition awards from both the National Association of Community Health Centers and the Society of Teachers of Family Medicine. In 1995 the RPSM itself became the first organization to receive the National Primary Care Achievement Award in Education from the Pew Charitable Trust (in collaboration with the U.S. Public Health Service, the Pew Health Professions Commission, and the Primary Care Organizations Network). The award cited RPSM’s success in having more than two-thirds of its graduates enter practice in underserved communities.
In 1996 MACN was merged with the older Montefiore Medical Group and a former RPSM graduate, Dr. Kathryn Anastos, was recruited as its first Medical Director. Family practice residents began work at Castle Hill and Valentine Lane Family Practices, where medical students had been rotating since 1993.
In 1998 Dr. Massad announced his retirement, and in 1999 he was succeeded by another RPSM graduate, Dr. Peter Selwyn, as Chair of the Department of Family Medicine and Community Health. Dr. Selwyn extended the Research Division and initiated a Palliative Care Service, including hospice beds on Rosenthal D.
In 2000 the Valentine Lane Family Practice was transferred to the St. John’s Riverside Hospital System in Yonkers, and half of the family practice residency moved to the Williamsbridge Family Practice. In 2001 member of the department established the first Hispanic Center of Excellence in New York State at the medical school. In 2003 the department established the Bronx Center to Reduce and Eliminate Ethnic and Racial Health Disparities, the first and only such NIH Center of Excellence in a department of family medicine. After the AECOM Department of Epidemiology and Social Medicine became the Department of Epidemiology and Population Health in 2004, we became the Department of Family and Social Medicine in 2005.
This brief history was written by Dr. Hal Strelnick for the 2005 RPSM Alumni Reunion. Posted by Matt Anderson, MD
On Tuesday, July 22nd we had the pleasure of hearing Dr. Roberto Belmar, the current Director of Santiago Chile’s Public Health Zone, speak at the RPSM. Dr. Belmar has a special relationship with our Department. In the 1970’s he came to Montefiore as a political refugee and worked for many years in the Social Medicine Department. His personal story is quite compelling, although his talk on Tuesday was devoted to his current work as a public health Official.
In the 1960’s and 1970’s Dr. Belmar was a Professor of Community Medicine in Chile. President Salvador Allende named him as the Director of a primary health care network of 45 health centers providing care to more than 3 million Santiago residents. Following the military coup of 9/11/1973, Dr. Belmar fled Chile in the face of a military order to execute him if he attempted to enter a hospital.
Dr. Belmar took political asylum at the USA with support from Montefiore Hospital, Dr. Victor Sidel, Dr. Jack Geiger and the APHA; see, for example, the APHA’s 1977 report on the Chilean Health Care system. Dr. Belmar led the Chilean exile community in the US, creating the “Emergency Committee to Help the Chilean Health Workers.” The Committee was supported by more than 10,000 physicians and health workers in the US.
Dr. Belmar returned to Chile with his family in 1985 to help organize resistance to the military dictatorship. In 1989 Patricio Alwyns became the first democratically-elected President of the post-coup period. Dr. Belmar was named the Chief of a newly created Department of Primary Care. In 1990 he was instrumental in establishing a “Statute of Primary Care” which secured free primary care for all Chileans. He later developed the Division of Environmental Health (1995-2000) which is the Chilean equivalent of CDC, FDA, OSHA & NIH. He was instrumental in creating the regulatory bodies for foods, occupational and workplace regulation, air quality, water quality, industrial waste, home and city waste, and mine industry sanitation.
Dr. Belmar now serves as the Health Officer of Santiago Health Zone. In this role he is responsible for overseeing the health care and public health of the (now) 6 million residents of the Chile’s capital city, Santiago. During his talk Dr. Belmar emphasized a broad conception of public health. To take the single example of air quality, his office was involved at the community level, where it worked to upgrade wood-burning stoves in individual homes; at the city level, where his greatest dream was to put a cap on the number of cars in Santiago; and at the national level, where he negotiated with large corporations to get cleaner burning woods and fuels. He told us, with a rueful smile, that he was the only one in the government who liked the idea of a cap on cars, “even the President is against it.”
His conception of public health also involved community participation. He had recruited retired people to work as community inspectors. They would issue sanitary warnings modeled on the red and yellow penalty card system in soccer. Occupational health was supervised by joint factory committees made up of workers and management. “We are lucky to have an increasingly strong Union movement to work with,” he noted in a comment that would seemed unthinkable for a US public official.
He spoke about the clinical programs run by the public health service and told a particularly poignant story about their program for the survivors of torture. During his exile, Dr. Belmar had come to know Senator Edward Kennedy. Senator Kennedy had queried him regarding how much money the US had spent overthrowing Allende. This was estimated to be about $10 million dollars. Kennedy made sure that the US allocated $10 million in aid for a Chilean program to treat survivors of torture. (For Kennedy’s role in combating torture, see the Torture Victim Protection Act of 1989).
Dr. Belmar is an active teacher and innovator in medical school teaching, participating in the Introduction to Community Medicine, Behavioral Sciences in Medical Schools, the Summer Field Work in Chile, a Rural medicine clerkship, The Evening School of Medicine for workers, and the Sophie Davies School of Biomedical Education at CUNY.
Tuesday, March 9th: NO SOCIAL MEDICINE ROUNDS ON THIS DATE. POSTPONED UNTIL SUNDAY 3/14.
Wednesday, March 10, 5:30-6:30 PM: AECOM Student-run Social Medicine Course: "Separate and Unequal: Medical Apartheid" Neil Calman, MD and Nisha Agarwal, JD, Forcheimer Auditorium
Sunday, March 14, Social Medicine Rounds in the Community: Noon to 2PM: Visit to the Chua Kien Buddhist Temple, 2011 Clinton Avenue, Bronx, NY. Noon: Discussion, 1PM: Lunch
Tuesday, March 16, 5PM-6PM: Global Health Center: Nicholas Kristoff, co-author Half the Sky: Turning Oppression into Opportunity for Women Worldwide. Robbins Auditorium.
Tuesday, March 16, 7:15 PM: AECOM Student-run Social Medicine Course: "Liberation Medicine" Lanny Smith, MD, MPH Forcheimer Auditorium. NOTE THIS EVENT WILL BE HELD ON A TUESDAY AND AT 7:15PM
Wednesday, March 17, 5:30-6:30 PM: AECOM Student-run Social Medicine Course: "Rentry: Old Fears, New Hopes" Meekaelle Joseph, Forcheimer Auditorium
Tuesday, March 23, 4:30-6:00 PM: Social Medicine Rounds: "Street Medicine" Jim Withers MD, 3rd Floor Conference Room, 3544 Jerome Avenue.
Wednesday, March 24, 5:30-6:30 PM: AECOM Student-run Social Medicine Course: "Street Medicine" Jim Withers MD, Forcheimer Auditorium
Wednesday, April 7, 5:30-6:30 PM: AECOM Student-run Social Medicine Course: "The History & Practice of Community Psychiatry" Thomas Betzler, Forcheimer Auditorium
Wednesday, April 14, 5:30-6:30 PM: AECOM Student-run Social Medicine Course: "Nyaya Health: A Case Study in Developing a Healthcare NGO" Ryan Schwarz and Bijay Acharya, MD, Forcheimer Auditorium
Wednesday, April 21, 5:30-6:30 PM: AECOM Student-run Social Medicine Course: "Refugee and Asylee care: Human Rights for Torture Survivors" Nicole Sirotin, MD, Forcheimer Auditorium
Wednesday, April 28, 5:30-6:30 PM: AECOM Student-run Social Medicine Course: "Ayurvedic Medicine" ∙Bhaswati Bhattacharya, MD, PhD, Forcheimer Auditorium
The views and opinions expressed on this site do not necessarily reflect the views of Montefiore Medical Center, Albert Einstein College of Medicine, Yeshiva University or the Social Medicine Publishing Group.
Last Saturday (8/29/2009) at least 3000 people (according to police estimates) gathered in Times Square for the Unity Walk in support of health care reform. Montefiore Residency Program in Social Medicine resident, Cameron Page, and graduates Oni Blackstock, Karen Wang, Manel Silva, Bill Jordan, David Herszenson, Giliane Joseph, and Jonathan Arend all played a large role in organizing the event. There were dozens of students from Einstein, Mt. Sinai, and other NY medical schools.
On Tuesday, March 10th 
Our colleague, 
