On 10/13/2009 Dr. Jaime Gofin came to Social Medicine Rounds to discuss the gap existing between the teaching and the practice of Community Oriented Primary Care (COPC). His presentation was followed by a discussion during which three New York clinicians presented their current work in the community. Dr. Gofin then explored the relevance of COPC to their specific projects.
Few people in the world today are better qualified to discuss COPC than Dr. Gofin. A native of Uruguay, Dr. Gofin trained under the Karks (who originated the COPC model) and ran a Master’s Program in COPC at the Hadassah Community Health Center of the School of Public Health & Community Medicine in Jerusalem. He is just finishing up a two year appointment at George Washington University in Washington, DC where he set up a COPC certification track within the GWU MPH Program.
What is COPC?
What is now called COPC was developed in South Africa in the 1940’s by Sidney and Emily Kark. The second issue of our online journal Social Medicine includes a classic paper by the Karks entitled A Practice of Social Medicine which sets out the origins of their model. The Kark’s article is accompanied by an introduction written by Dr. Gofin.
During his talk, Dr. Gofin described five principles associated with COPC:
Responsibility for a defined population.
Care based on identified health needs at the population level.
Prioritization of health needs.
Implementation of an intervention program covering all stages of the health/illness continuum and impacting on the prioritized conditions.
Community Involvement.
He further identified four defining features of COPC:
Individual and community care/community medicine.
Integration of individual care & public health.
Provision of care to entire populations – healthy or sick – and based on identified health needs.
Community participation and intersectorial coordination.
Why does such a gap exist? Dr. Gofin cited a number of reasons: lack of infrastructure to implement and sustain COPC, lack of financing for non-clinical approaches to health, difficulties in defining the “community” (especially urban settings), skepticism that COPC can be rigorously evaluated (there are no RCT’s), fragmentation of health care services among multiple payers, lack of models for practice and lack of a supportive community. He expressed frustration that medical schools don’t teach community medicine because there are no clinics where students can practice; yet health services can’t provide community models because they don’t have trained practitioners. He also noted that most owners of health services have a different, non-COPC agenda.
Promoting COPC: Spain, Britain, Uruguay, and the US
Dr. Gofin demonstrated, however, that in several diverse countries he had been able to overcome this gap. He cited four programs which had been developed in very different contexts. Beginning in 1987 he worked with Family Physicians in Spain to integrate COPC principles into community health centers. By 2005 a network of 43 health centers were working with a community orientation. He had collaborated with Primary Health Care Trusts in the British National Health Service to use COPC in GP offices. As a result COPC programs for the very elderly (those over 75) had been established in Camden and Islington. After the recent change of government in Uruguay, he had worked with the Ministry of Health to develop a COPC model in seven provincial health centers. Finally, he had established the COPC certificate program at George Washington, a program that had required developing COPC projects in Washington, DC.
At this point the floor was turned over to three clinicians each of whom presented their community work for Dr. Gofin’s commentary.
Walking in Washington Heights
Dr. Richard Younge of the Family Medicine Division at Columbia discussed a project to encourage walking in the community. The project had started at Alianza Dominicana, a community-based organization in Washington Heights. It was recognized that women participating in their substance abuse programs did not get much exercise. A program was set up to encourage them to walk in the neighborhood on a regular basis as a group. The Family Medicine residency had gotten involved in supporting the program as the initial funding faded. Dr. Younge recognized that this project was an example of service learning and not COPC; the residents promoted it only for the women coming in for care at their clinic. Unfortunately, like many resident-based projects, there was a need for more structure, and the residency program was now looking to partner with another Community-Based Organization. Dr. Younge noted the difficulty of trying to define a community in a setting like contemporary New York City. The Karks, he pointed out, had been able to get out a map and draw a defined area of responsibility around their health centers. This clearly would not work for us.
Bangladeshi Women in the Bronx
Dr. Alison Karasz, a clinical psychologist and researcher with our department, discussed her work with Bangladeshi women in the Bronx. She had partnered with Dr. Jean Berg of the Jacobi Medical Center Family Medicine Program in a study of cultural differences in models of depression. When the study was over she wanted to give something back to the community. Her first impulse was to teach the women how to drive a car. She recounted (with a smile) what it was like to give driving lessons around Yankee Stadium to women attired in full Purdha. This experience had given her “the bug to serve, something researchers rarely have an opportunity to do.”
She and Dr. Berg received a $50K grant from New York City Council to develop community based activities in this community. They were able to hire a community activist and eventually received funding from the National Institutes of Mental Health to develop a Community-Based Participatory Research (CBPR) Project on managing depression (typically conceptualized as “stress” by the women). This money allowed for the hiring of five community health workers and the development of active discussion groups. Dr. Karasz reviewed some of her own concerns and struggles over how to define a community, how to obtain its participation, and how to establish partnerships. She noted (again with a smile) that many of the women in the community had a finely tuned sense of feminism and were well in touch with the structural causes of their distress.
Green Carts for New York City
Our last presenter was Dr. William Jordan, a graduate of our program and currently a Faculty Development Fellow. He described a several year collaboration with Esperanza del Barrio, an organization of street vendors in New York City. This collaboration had led to his election as President of the organizations’ Board of Directors and an active role as a fundraiser. This work was closely linked to the NYC Department of Health’s Green Carts Initiative which seeks to subsidize mobile food carts selling fresh produce. Dr. Jordan spoke about the difficulties of fund-raising and how, in his role as President of the Board of Directors, he had acquired a panel of uninsured street vendors as patients.
Dr. Gofin comments
Dr. Gofin noted that these projects highlighted the difficulties of identifying a geographically-delimited community in large cities. He suggested that the term “population” might better define the groups we were trying to reach. He noted that it was certainly possible to start initially with a defined group, even a small one, and then to expand it. It was important, however, that this group not just include patients. It needed to include healthy people so that the responsibility of the clinic included the entire population, not just those identified as patients. This, he emphasized, was one of the traits that made COPC different from simply good primary care. He noted that the community-based participatory research (CBPR) model was becoming increasingly popular amongst those interested in community health, but that this was research, not service. Finally, he noted that service learning, even service learning in the community, was also quite different from COPC. He finished by expressing his encouragement to see so much community work going in New York City.
On April 28th, 2009 Social Medicine Rounds hosted four New York City food activists in a session entitled: “Feast or Famine: Building an Oasis in the Food Desert.” This rounds was arranged by Drs. Victoria Mayer and Vanessa Pratomo and is part of a larger series organized by the Public Health Association of New York City (PHANYC). [See our previous posting: Feast and Famine: Obesity, Diabetes and Hunger in New York City.]
Joel Berg, Triada Stampas, Debi Lomax, Zena Nelson, Drs. Mayer & Pratomo
As clinicians we daily see patients whose health is deeply affected by nutrition. Counseling patients on diet often seems a frustrating affair and there is scant evidence that it does much good. We were interested in a better understanding the politics of food and in learning about what local food activists were up to. Our invited panel included Joel Berg of the NYC Coalition Against Hunger, Debi Lomax of the Bronx District Public Health Office, Zena Nelson of the South Bronx Food Coop, and Triada Stampas from the Food Bank for New York City.
The paradoxical link between food insecurity and obesity
Joel Berg is the Executive Director of the New York City Coalition Against Hunger and author of the recently published All You Can Eat: How Hungry is America. He began by emphasizing the lack of nutrition education in medical schools, arguing that nutrition should be the centerpiece of public health. He saw hunger and obesity not as separate problems but rather as “flip sides of the malnutrition coin.” He pointed out that currently 25 million Americans (about 8% of the population) use food pantries and soup kitchens. Here in New York City an estimated 1.3 million people (about 16% of the 8.2 million New Yorkers) are living in food insecure homes. The poor are often accused of not knowing how to budget, shop and cook. But Mr. Berg pointed out that working class people often don’t have access to affordable, good food, a point reiterated by the other three speakers Faced with limited cash, people often choose unhealthier foods because their high fat content. Time constraints – due to work schedules – further limit the ability of working class families to shop and cook.
Mr. Berg argued that good nutrition is a three legged stool based on affordability, proximity and education. The way to make good food more affordable was the increase wages, expand access to WIC and encourage our kids to take advantage of food offered in the schools (breakfasts, lunch, afterschool meals and summer breakfasts). Making sure that school food is healthy is also an area of intense activism. While New York City has recently banned the sale of soda in the schools, highly sugared drinks like Snapple continue to be sold.
Farmers’ Markets in the Bronx
Debbie Lomax, a Program Officer for the South Bronx District Public Health Office of NYC Department of Health, then discussed the DOH Farmers’ Market Program. Quoting their program booklet: “The Farmers’ Market Program encourages fruit and vegetable consumption by promoting farmers’ markets in the South Bronx. There are currently 11 markets in the area. The DPHO publicizes these markets to community residents and health care providers, by giving out “Health Bucks” – $2.00 vouchers redeemable at farmers’ markets for the purchase of fruits and vegetables.”
A complete description of this program and a list of current Farmers’ Markets can be downloaded from this link. More information on Healthy Bucks can be found at this link.
A Food Coop grows in the Bronx
Zeena Nelson is one of the founders of the South Bronx Food Coop. Her interest in food was sparked by her personal difficulties finding good food in her South Bronx community. She had studied business at Fordham University but was unenthusiastic about working for corporate America. She was pushed into food activism when a friend died of complications of massive obesity. What, she wondered, were the economics behind the fact that certain neighborhoods don’t have good food available? She obtained a $20,000 starter grant from Merill-Lynch to set up a small food coop. The coop now has 155 members and operates a small store on Third Avenue Members of the cooperative are a diverse group about ½ of whom are from the South Bronx. The cooperative provides a variety of services including cooking and yoga classes. The Cooperative has plans to create a commercial hydroponic farm inside of a local building.
[For a fascinating look at the world of urban agriculture in New York City, visit Kerry Trueman's Retrovore.com.]
… as do the soup kitchens
Finally, Triada Stampas shared her work at the Food Bank for New York City. The Food Bank started 26 years ago in a big warehouse located in the Hunts Point food market in the South Bronx. The Bank initially supplied food to a handful of sites providing “emergency food.’ Sadly, it currently supplies some 1200 soup kitchens and pantries (yes, that’s 1200 sites) located throughout the City. . Ms. Stampas noted that such a network simply was not needed in the 1970’s.
The food at the bank comes from various sources. The government – federal, state and city – provides some. Feeding America, a national umbrella for food banks, provides food largely donated by corporations. The bank itself raises funds to purchase food. The Bank also conducts research on who uses emergency food. By their estimates there are 4 million New Yorkers (nearly half the population) who have difficulty accessing affordable food. Ms. Stampas noted that the term “emergency food” was really a misnomer. For many people emergency food represented subsistence food. She pointed out, for example, that 80% of families receiving food stamps run out of food before the month is over. She spoke about understanding nutrition as a function of the “food environment.” Bronx residents, according to a recent study by the Marist Institute, have the greatest difficulty finding affordable food in the city.
Ms. Stampas had some specific suggestions for clinicians. She stressed that it was important to talk with patients about what they eat, where they shop for food, and how they afford the food they buy. She pointed us to a food bank locator on the web that could be used when our patients needed food. She signalled the importance of political advocacy to improve food stamp benefits and increase the Earned Income Tax Credit.
Clinicians as advocates
During the question and answer period a number of an additional areas for activism were suggested. Hospitals need to promote healthy eating for staff, patients and visitors. Political support is needed right now for the school meals program and WIC both of which are up for authorization in Congress. In New York State a Healthy Schools Law is being considered in Albany. The speakers highlighted the importance of physician voices in support of these programs.
Tuesday’s talk examined “Corporate Control of Public Health: Case Studies and Call to Action.” Dr. Donohoe has made the slides available on PHSJ. In this posting we wanted to discuss one of his cases studies: Bringing Bad Things to Life: The Alliance between GE Medical Systems and New York Presbyterian Hospital. This case study is available as a slideshow on the PHSJ website or as an article published in the journal Synthesis/Regeneration. (A slightly longer version of the article is also posted on PHSJ.org)
The Agreement
On September 8 , 2003, General Electric and New York-Presbyterian Hospitalannounced “a historic multi-year, several hundred million dollar partnership” between GE Medical Systems and the hospital. As per the GE press release:
An integral aspect of the engagement will have NewYork-Presbyterian Hospital adopting GE’s acclaimed management development and performance improvement methods. This will help build upon NewYork-Presbyterian Hospital’s strong leadership team and employee base to deliver superior patient care well into the future. NewYork-Presbyterian Hospital will implement leading edge tools for improving management, service quality and operational effectiveness. Employees will be trained in GE’s quality and process improvement programs. This balanced approach is comprised of Six Sigma statistical methodologies, change-management strategies (Change Acceleration Process) and team-based problem solving techniques (Work-Out™).
The GE/NYP deal raised concerns about the corporatization of medicine that were voiced in 2004 in the New England Journal of Medicine by Dr. A. M. Garber(Business and Medicine: Corporate Treatment for the Ills of Academic Medicine). Garber noted the agreement – said to last ten years and involve $500 million dollars – offered a series of discounts and financing for GE products that would create an effective lock-in for GE medical equipment. While noting potentially positive aspects of this relationship, Gerber questioned the wisdom of such a lock-in. He also noted the potential conflicts of interest arising from GE’s dual role as management consultant and provider of equipment. Finally Dr. Garber raised concerns about the multiple ways in which corporate consultants might deal with economic pressures facing hospitals. He painted an elegant picture of the ways in which corporate thinking can undermine the social mission of the hospital:
But any consultant could also help a hospital’s financial performance by pursuing strategies that do not benefit the public. Many academic hospitals could improve their bottom lines by cutting the amount of uncompensated care they provide and eliminating unprofitable services. They might also promote excessive use of high-margin services. For example, to the extent that physicians induce demand, any hospital that owns a scanner — and any physician who earns fees by interpreting scans — can raise revenues by performing scans for less critical or even dubious indications. Similarly, well-reported phenomena such as “DRG creep,” “upcoding,” and “unbundling” can increase health care expenditures without benefiting patients. Such practices may seem innocuous from the individual patient’s point of view, if they merely raise health expenditures generally. But a physician or hospital that takes advantage of reimbursement anomalies can also jeopardize patients’ health. Physicians and hospitals can be reimbursed more if a candidate for the placement of multiple coronary stents has the procedure divided among two or more hospital admissions than if they are placed as part of a single complex procedure. Is it plausible that clinical needs alone explain why so many patients have stents placed as part of multiple admissions?
IMAGINE a small town where one person not only owns the hardware store, but is also the banker and the doctor’s most trusted adviser. In a sense, General Electric is trying to play such a role in the nation’s $2 trillion health care industry.
The New York Times article discussed the possibility that the agreement would foster the use of expensive technology, a major factor in rising health care costs. As noted by Gerber above, expensive diagnostic machines often generate their own demand.
New York Presyterian’s Dr. Herbert Pardes responded to the Garber article in a two paragraph Letter to the Editor (published in February 2005). Pardes stated: “Our collaboration with GE Medical Systems is based on having access to business skills and cutting-edge equipment that, in our judgment, will benefit our patients and increase our ability to provide cost-effective, high-quality care. We purchase from GE only technology that the hospital deems to be in the best interest of its patients. We will never delegate to a third party any decisions regarding our patients and the manner or method of our delivery of health care.”
Swimming with Sharks
Dr. Pardes’ reassurances ring far less convincing when we know a bit more about General Electric; this is the main topic of Dr. Donohoe’s article. General Electric is the world’s largest company by market share. In 2007 it had revenues of $168 billion and profits of $21 billion. For a bit of perspective GE’s revenues are larger than the GDP of over 2/3 of the UN member states. The corporation is built upon a diverse set of products and services including media (NBC, Universal Studios, Telemundo), consumer appliances, power, aircraft engines, insurance, transportation, business systems, and medical services/equipment (see the Columbia Journalism Review website). Through GE Power, the company is a major force in nuclear power.
General Electric does not have a stellar history as a corporate citizen. GE’s history of corporate malfesance is discussed Dr. Donohoe’s article and also in a 2001 article in The Multinational Monitor entitled “GE: Decades of Misdeeds and Wrongdoing.”
Rather than review this history in detail, we will focus on one of these misdeeds that is particularly close to our home: the pollution of the Hudson River with 1.3 million pounds of polychlorinated biphenyls (PCBs). These PCB’s were released between 1947 and 1977 from two of GE capacitor manufacturing plants and became a major focus of organizing along the river (discussed in a slideshow from Clearwater and a series of FAQ from Riverkeeper). Thanks to GE, two hundred miles of the Hudson River are now the EPA’ largest Superfund site (see http://www.epa.gov/hudson/). Of note this is just of of several GE superfund sites.
PCB’s are good neither for the environment, nor for health. The EPA states: “PCBs are considered probable human carcinogens and are linked to other adverse health effects such as low birth weight, thyroid disease, and learning, memory, and immune system disorders.“ General Electric has devoted tremendous resources into evading responsibility for the cleanup (see Richard Pollock’s Is GE Mightier Than the Hudson?) For GI’s side of this story, see their website.
Crade to Grave Care?
Dr. Donohoe closes his article on GE with the following reflection:
It is abhorrent to imagine GE profiting from New York-Presbyterian Hospital requiring that a patient’s developmental anomaly or environmentally-induced cancer (a result of exposure to GE toxins) be diagnosed by a GE scanner and treated with GE-manufactured therapeutic devices. This is a macabre twist on the concept of cradle-to-grave health care.
The question then is whether we should be looking to or partnering with corporations like GE for models on how to run health care.
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.”
Tuesday February 24th’s Social Medicine Rounds brought Dr. Siobhan Dolan to the Residency Program. Dr. Dolan is double-boarded (Obstetrics and Gynecology, Clinical Genetics) as well as having an MPH. She currently works in the Montefiore/AECOM clinical genetics testing service.
Dr. Dolan began by discussing the difference between traditional clinical genetics and the current field of genomics. Genetics was originally concerned with single gene defects, usually associated with rare diseases. These mutations were usually of high penetrance (i.e. having the genetic mutation usually caused you to be sick) and caused conditions (like Down’s syndrome) in which environment played a relatively minor role. Genomics, on the other hand, typically involves multiple (often interacting) genetic variants that are associated with common conditions. These genetic variants often confer only a modestly increased risk of the disease. The diseases in question are ones (such as lung cancer) in which the environment plays a large role. (For more on this distinction, see the article by Alan E. Guttmacher, M.D., and Francis S. Collins, M.D., Ph.D. in the November 7, 2002 issue of the New England Journal of Medicine entitled: Genomic Medicine: A Primer).
Genomic medicine promised to make genetics relevant to everyone. In a 1994 article in the American Journal of Human Genetics, Dr. Eric Hoffman predicted “[t]he day of the personal DNA profile provided at birth, complete with calculated risks of various cancers, heart disease, and many other conditions could be actuality by the time that current first-year medical students begin to practice medicine.” While this prediction proved premature, a few years later genomics entered the mass market with internet-based direct-to-consumer advertising.
Dr. Dolan expressed considerable skepticism regarding the value of many genetic tests. In order to assess their clinical validity she recommended use of the ACCE criteria developed by the Foundation for Blood Research for the CDC. These criteria evaluate:
Analytic validity: Does the test actually measure the genetic variation it is supposed to measure? (“ability to accurately and reliably measure the genotype of interest. “)
Clinical validity: Is the genetic variation actually predictive to the disorder of interest? (“ability to detect or predict the associated disorder (phenotype)”)
Clinical utility: What are the risks and benefits of introducing the test into clinical practice?
Ethical, Legal and Social Consequences of the Test
The ACCE criteria suggest 44 specific questions that should be answered in considering a given genetic test.
Several genetic tests have not lived up to their initial promise. For example, Roche’s AmpliChip CYP450 test was touted as a breakthrough that would allow individualized dosing, particularly of psychiatric medications. But the clinical utility of the test has been questioned (The Medical Letter, 47(1215/1216), August 15/29, 2005). In 2007 the Evaluation of Genomic Applications in Practice and Prevention (EGAPP) Working Group writing in Genetics in Medicine concluded that: No evidence was available showing that the results of CYP450 testing influenced SSRI choice or dose and improved patient outcomes, or was useful in medical, personal, or public health decision-making.” [SSRI's are a common class of anti-depressant drugs].
Similar concerns have been raised about pharmacogenetic testing for warfarin. Reviewing commercial tests for CYP450 polymorphisms associated with differences in warfarin metabolism, The Medical Letter concluded in May of 2008 that: “Currently available data are probably insufficient to recommend pharmacogenetic testing just yet for all patients taking warfarin, but these tests may be helpful, especially in selecting an initial dose and in some patients with unexpected therapeutic responses to the drug. Whether they improve clinical outcomes remains to be established.” (The Medical Letter, 50(1286), May 19, 2008)
Regardless of these cautions genomics has now entered the world of direct to consumer advertising and Dr. Dolan reviewed the major categories of this fascinating “brave new world”. [Please note, we are not endorsing the use of any of these websites.]
1. Determining Paternity. DNA Lab Centers features a smiling baby on the home page with the caption: “Does he really have your eyes?” Results can be used to “provide Maternity, Paternity, Immigration, Grandparent and Sibling Testing/Verification.” The use of DNA for immigration cases is, apparently, a growing field.
3. Dating and Social Networking: Sites like Gene Partner and Scientific Match claim to match people based on genetics. Gene Partner bases its system on HLA matching and the site provides references to 11 scientific publications. Four of these were non-human studies and three of the studies are listed twice (ouch!). Of the remaining four studies three relate to female preferences for different male odors and only one associates HLA types with romantic involvement, a study involving 48 couples. Not a particularly strong evidence base. Scientific Match seems also to use the HLA types, but the site is less explicit.
4. Sites looking for specific medical disorders: Sites like DNA Direct and 23 and me provide comprehensive genetic testing services include whole genome tests. Again, the clinical utility of most of these tests has yet to be demonstrated.
It is a shame that the development of genomics in the United States is being left to the marketplace. The British are rightly proud of their National Institute for Health and Clinical Excellence (NICE) which evaluates new drugs and devices prior to their adoption by the National Health Service. NICE’s decisions has been controversial at times, but this is to be expected given the nature of the decisions it makes. The new Federal stimulus bill sets aside $ 1.1 billion dollars for effectiveness research. This is a welcome move and long overdue.
Concluding thoughts:
Maybe major histocompatibility genes truly explain romance. But in the market, let the buyer beware.
I prefer poetry and will close with the thoughts of Edmund Spenser:
Amoretti XXX: My Love is like to ice, and I to fire
My Love is like to ice, and I to fire:
How comes it then that this her cold so great
Is not dissolved through my so hot desire,
But harder grows the more I her entreat?
Or how comes it that my exceeding heat
Is not allayed by her heart-frozen cold,
But that I burn much more in boiling sweat,
And feel my flames augmented manifold?
What more miraculous thing may be told,
That fire, which all things melts, should harden ice,
And ice, which is congeal’d with senseless cold,
Should kindle fire by wonderful device?
Such is the power of love in gentle mind,
That it can alter all the course of kind.
Anyone who has driven across the Whitestone Bridge more than once or twice has probably noticed the large brick building located just east of the highway on the Bronx side. This is the home of the St. Joseph’s School for the Deaf, a school founded in 1869 and which moved to its 10-acre campus in the Bronx in 1913. St. Joseph’s is is one of eleven New York State 4201 schools which are supported by the state to provide educational services to children who are deaf, blind or physically challenged. Social Medicine Rounds last Tuesday (2/10/2009) took us to the School to learn something about deaf culture.
We were greeted by Patricia Martin, Noreen Collins and Roxana Aguilo who were gracious enough to spend nearly 90 minutes talking to us about the school and about the meaning of deafness. Dr. Martin is the Executive Director of St. Joseph’s and has been with the school for seventeen years. Ms. Collins in responsible for pupil personnel services and is the person to call (718.828.9000) for assistance with referrals . Ms. Aguilo is a former student at the school who works there now as a teacher’s assistant. Since she is deaf, she participated in the Rounds through the able translating abilities of Dr. Martin and Ms. Collins.
Dr. Martin began by distinguishing two definitions of deafness. Deafness can be seen as a pathology; this is what we could the “medical model.” In this model the important questions are why it occurred, how severe it is and how it can be fixed. But deafness can also be seen as a culture. From this perspective to have deafness is not to be dis-abled, but rather to be differently abled. To emphasize the reality of deaf culture, Dr. Martin read a poem entitled “Being Deaf” by Dianne Kinnee:
“What is it like to be deaf?”
People have asked me.
Deaf? Oh, hmm… how do I explain that?
Simple: I can’t hear.
No, wait… it is much more than that.
It is similar to a goldfish in a bowl,
Always observing things going on.
People talking at all times.
It is like a man on his own island
Among foreigners.
Isolation is no stranger to me.
Relatives say hi and bye
But I sit for 5 hours among them
Taking great pleasure at amusing babies
Or being amused by TV.
Reading books, resting, helping out with food.
Natural curiosity perks up
Upon seeing great laughter, crying, anger.
Inquiring only to meet with a “Never mind” or
“Oh, it’s not important”.
Getting a summarized statement
Of the whole day.
I’m supposed to smile to show my happiness.
Little do they know how truly miserable I am.
People are in control of language usage,
I am at loss and really uncomfortable!
Always feeling like an outsider
Among the hearing people,
Even though it was not their intention.
Always assuming that I am part of them
By my physical presence, not understanding
The importance of communication.
Facing the choice between Deaf Event weekend
or a family reunion.
Facing the choice between the family commitment
And Deaf friends.
I must make the choices constantly,
Any wonder why I choose Deaf friends???
I get such great pleasure at the Deaf clubs,
Before I realize it, it is already 2:00 am,
Whereas I anxiously look at the clock
Every few minutes at the Family Reunion.
With Deaf people, I feel so normal,
Our communication flows back and forth.
Catch up with little trivials, our daily life,
Our frustration in the bigger world,
Seeking the mutual understanding,
Contented smiles and laughter are musical.
So magical to me,
So attuned to each other’s feelings.
True happiness is so important.
I feel more at home with Deaf people
Of various color, religion, short or tall.
Than I do among my own hearing relatives.
And you wonder why?
Our language is common.
We understand each other.
Being at loss of control
Of the environment that is communication,
People panic and retreat to avoid
Deaf people like the plague.
But Deaf people are still human beings
With dreams, desires, and needs
To belong, just like everyone else.
–Dianne Kinnee (Switras)
Dr. Martin went on to describe their work in the school. She pointed out that about 95%of deaf children are born into hearing families. If hearing parents don’t learn sign language, as often happens, this can be very isolating for the deaf child. This is a particular problem in Bronx where many parents don’t speak English. For immigrant parents learning American Sign Language involves communicating in a doubly foreign language. [A universal sign language does not exist; each spoken language has its own way of signing]. The result of this is that even when deafness is identified early on deaf children may not receive a great deal of language stimulation at home.
The school has responded to this challenge by providing programs in which parents can bring their children to the school as early as 8 months of age. Children come to the school on their own starting at age 3 and stay through the 8th grade. The school also offers a 10 session class on Thursday evenings for people interested in learning how to sign. The cost is $50.
Ms. Aguilo then spoke at length about her personal experience. She had been born in the Dominican Republic where there were no services for the deaf. Her mother brought her to the Bronx and she had been diagnosed as deaf at Jacobi Hospital. This was a great blow for her mother. Fortunately, they had a Spanish-speaking counselor at Jacobi who was able to explain the situation in a language her mother could understand. Her mother found learning sign language difficult and so Ms. Aguilo had great difficulty in communicating with her Mom. Ms. Collins mentioned that often parents came to the school requesting that the school tell children about the death of relative or a pet. In these cases the school asked the parent to come in and the school provided translation services.
Ms. Aguilo had been a student at St. Joseph’s and later enrolled at Rochester Institute of Technology where she majored in fashion design. But she was homesick for the Bronx and returned after only a year and a half. Now she was working as a teacher’s assistant. She has three children of her own (“and all of them hear”) and has taught them ASL. Her kids are tri-lingual, speaking English, Spanish (with the abuela) and ASL (with Mom).
The topic of kids lead to a discussion of their use as interpreters. Ms. Aguilo spoke in forceful terms that the American Disability Act gives deaf people a right to a translator and this right should be respected. “Don’t write”, she said. “Don’t ignore our rights. It only makes us angry.” The use of children as interpreter has also been an issue with our southeast Asian patients. For a list of translation resources, see the end of this post. Ms. Aguil0 also spoke about the coverage limitations imposed by SSI particularly in terms of cost-sharing for hearing aids.
Ms. Aguilo noted to us that deaf people can drive cars. Deaf persons had initially experienced difficulty getting auto insurance so they formed their own company. Accident rates are lower for deaf drivers than for hearing drivers.
Finally we touched on the controversy surrounding cochlear implants. A 2005 Scientific American Frontiers program provides an introduction to this topic. The program included a fascinating website that allows one the hear the evolution of CI technology.
To some cochlear implants are the latest medical miracle. But many in the deaf community see it as an attempt by the medical community to eradicate deaf culture. Ms. Aguilo was blunt: “I like being deaf. And cochlear implants say to me that I am not ok.” She did not think they were appropriate for children born deaf. But they were an option for hearing people who were becoming deaf. Dr. Martin stated that the school was neutral with respect to implants.
Interpreting Services
New York Society for the Deaf: 212 366-0075 (9AM-5PM)
Mill Neck Manor School for Deaf Children: 516 512-6222
Deaf & Hard of Hearing Interpreting Services, Inc.: 212 647-1092 (8AM – 5PM, requests for interpreting by appointment; call same number after 5PM for emergency interpreting)
Video Relay Service (VRS): Sorenson VRS 866 327-8877. You need to have either the video number or the IP address for the Deaf person to call in addition to calling VRS.
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.
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.
On Tuesday, September 11, Dr. Jean-Silver Isenstadt, the founding Executive Director of the National Physicians Alliance spoke at Social Medicine Rounds about the work of the NPA since its formation in 2005.
She began her presentation with Broken Covenant, a short film which captures the issues and events surrounding the birth of the NPA; it is available on the NPA website. The Alliance developed from a core group of AMSA (American Medical Student Association) ex-presidents who wanted to create an “AMSA beyond AMSA,” i.e. a physician’s organization that could better express the values animating AMSA. These core values, as identified by NPA’s founders, were: service, integrity and advocacy.
Core Issues
The core issues identified by the new organization were:
The Secure Health Care for All campaign has chosen not to endorse a specific plan, but rather endorses the Institute of Medicine’s general principles for health care reform:
1. Health care coverage should be universal.
2. Health care coverage should be continuous.
3. Health care coverage should be affordable to individuals and families.
4. The health insurance strategy should be affordable and sustainable for society.
5. Health insurance should enhance health and well-being by promoting access to high-quality care that is effective, efficient, safe, timely, patient-centered, and equitable.
This campaign has been undertaken in alliance with a number of groups including HCAN, Health Care for America Now. HCAN calls for a plan which guarantees affordable coverage and allows people to: “keep your current private insurance plan, pick a new private insurance plan, or join a public health insurance plan.” It appears this plan has been controversial within the NPA, some seeing it as too left, others as not left enough. (For a recent critique of HCAN from Physicians for a Naitonal Health Plan, see the PNHP blog). The campaign also offers NPA’s report card on the health plans of the current presidential candidates.
The NPA lays great importance on the role of physicians as advocates. Dr. Silver-Isenstadt stated: “Patient advocacy is a responsibility of the profession.” And their website offers many opportunities for physicians to work as advocates. In addition, NPA has a blog and a facebook page.
From the NPA website: “Jean Silver-Isenstadt holds a doctorate in the history and sociology of medicine from the University of Pennsylvania, a medical degree from the University of Maryland, and a master’s degree in nonfiction and science writing from the Johns Hopkins University. Her doctoral work focused on 19th-century American health reform. She is the author of Shameless: The Visionary Life of Mary Gove Nichols (Baltimore: Johns Hopkins University Press, 2002), a biography of the infamous and influential health advocate and social reformer best known for her leadership of the water-cure movement and for her scandalous public lectures to women on anatomy and physiology.”
After her talk, Dr. Silver-Isenstadt reminded me that the Social Medicine Portal was one of the first sites to give publicity to the NPA in 2005.
Last Tuesday (7/8/2008) brought Dr. Jonathan Tobin from Yeshiva University’s Institute for Public Health Sciences to Social Medicine Rounds. He came to lead a showing and discussion of the PBS documentary Unnatural Causes: Is Inequality Making Us Sick? Dr. Tobin is well-known in the public health community for his work as head of the Clinical Directors Network, Inc (CDN). CDN is a“not-for-profit network that supports community-based health centers, including their patients, practitioners and organizations.” The CDN website is full of clinical resources relevant to the work of Community Health Centers in the US.
Dr. Tobin’s visit was an opportunity for us to learn something about Yeshiva’s Institute for Public Health Sciences. The Institute is currently awaiting certification from New York State to offer a Master’s level degree in Public Health as well as a Certification of Public Health training. At the present time they are sponsoring educational activities, which have included a public health grand rounds series and a 14-session course on public health approaches to obesity. In September of 2007, they hosted a two day conference on Diversity & Disparity in Health and they are interested in forming academic think-tanks to look at particular health problems in a multi-disciplinary way. These activities are all posted on their website.
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.
On 10/13/2009 Dr. Jaime Gofin came to Social Medicine Rounds to discuss the gap existing between the teaching and the practice of Community Oriented Primary Care (COPC). His presentation was followed by a discussion during which three New York clinicians presented their current work in the community. Dr. Gofin then explored the relevance of COPC to their specific projects.
On Tuesday, March 10th 
Tuesday February 24th’s 
