Medical Care
Section Newsletter
Spring 2011

Letter from the Chair

Dear Colleague,


The events of the last few months have been stunning to watch.

·            The political uprisings in the countries of the Middle East have revealed the oppressive and destructive nature of many of the regimes there, as well as the lack of unifying political philosophy or identity with the power to bring people together. 

·            The 2011 tornado season spawned over 450 tornadoes and ranked the worst in history, serving as a vivid reminder of the awe inspiring power of nature when flows of air, temperature and water interact as a result of the changing climate. 

·            Osama bin Laden is gone despite the deniers who have now so clearly demonstrated their great distrust of media and the United States with their refusal to accept the reality of the assassination. 

·            The steady drumbeat of opposition to President Obama shows us again the manipulative nature of conservative media empires and subsidized propaganda.  This conservative media seeks to push the U.S. population as far to the right as possible, in order to generate support for freewheeling corporations that earn tremendous profits for their executives and deposit U.S. dollars wherever in the world they can return the largest profit with the lowest cost of investment.  Half the dollars that are not collected as U.S. taxes are invested overseas, especially in developing economies.  And yet, the public is often convinced that lower taxes are beneficial to all Americans and higher taxes are an affront to private property.


With this array of trends laid out before us, where does a mere public health professional invest effort to get a reasonable return in better health outcomes?  I would be interested in knowing your views.  You can send letters on this topic for our next Newsletter.  Please send to me ( and I will forward. I look forward to seeing some of you at the Mid-Year Meeting on Health Reform.



Mona Sarfaty MD, MPH, Chair of the Medical Care Section

Quality Improvement to Address Racial Health Disparities: The Chicago Breast Cancer Quality Consortium as a model


Anne Marie Murphy, PhD, Executive Director, Metropolitan Chicago Breast Cancer Task Force


Over the past 20 years, the advent of improved imaging technology and more effective treatments has led to a significant decrease in the overall death rate from breast cancer in the United States.  However, the gains have not been shared equally by all segments of the population.  For example, in Chicago in 1980, the difference in breast cancer mortality between black and white women was nonexistent; this difference has grown steadily since the mid-1990s with the advent of better imaging and treatment.  Currently the breast cancer mortality rate in Chicago among black women is 62 percent higher than for white women[1]. 





Research performed by the Metropolitan Chicago Breast Cancer Task Force showed that black women in Chicago were far less likely to access mammography in an academic medical center, to have their mammograms read by breast imaging specialists, and to have their images taken by a digital machine, all measures which have been found to correlate with better breast health outcomes. Additionally, geographic mapping of approved cancer treatment centers in Chicago showed that with one exception, they were all located outside the high mortality, predominantly minority areas of the city[2]. This research suggests that unequal access to resources that correlate with higher quality health care is a significant driver of health care disparities.  





In an effort to begin addressing the Chicago disparity and many of the factors that likely contribute to it, the Chicago Breast Cancer Quality Consortium was formed in 2008 with generous funding from the Susan G. Komen for the Cure Foundation.  In 2009, it became the first federally designated Patient Safety Organization dedicated exclusively to breast health.  It brings together more than 70 percent of hospital based mammography and treatment providers in Metropolitan Chicago to share breast cancer screening and treatment quality data, with the goal of identifying deficits and implementing solutions that are compatible with the resources of each hospital. This is the largest voluntary collection of breast cancer quality metrics across an entire metropolitan area, and it is unique because participating hospitals cover the entire breadth of facility types (i.e. academic, public, private, and safety-net).  One of the reasons we have been able to work with such a diverse group of hospitals is the technical assistance provided directly by staff at the Task Force for hospitals with few resources.


Data-sharing in a confidentiality protected manner is available to Patient Safety Organizations, and has allowed us to compare data across all types of hospitals, gaining a better picture of what is happening throughout Metropolitan Chicago.  Furthermore, we believe this approach will actively drive improvement across the area and in particular will provide targeted assistance to providers serving minorities and underserved populations in order to integrate quality improvement more broadly and raise the boat for all. 


For more information on this project, please visit our website <> under quality consortium.  All data collection tools are available to the public for replication of this project in other areas.


Anne Marie Murphy, PhD, is executive director of the Metropolitan Chicago Breast Cancer Task Force.  She can be reached at

[1] Sinai Urban Health Institute.  Black and White Breast Cancer Mortality Chicago, 1980-2007. 2010, unpublished data.

[2] Ansell D, Grabler P, Whitman S, et al.  A community effort to reduce the black/white breast cancer mortality disparity in Chicago. 2009 Nov; 20(9):1681-8.

Equine Assisted Learning for At-risk, Urban Youth: The fastest way out of town might be on the back of a horse

Ruth L. Schemm, Elisabeth Ervin-Blankenheim, and Lezlie Hiner


Polo is not commonly classified as a sport of interest to urban youth.  However, recent media coverage of the winners of the 2011 Polo Association National Championship featured three African American youth from the Philadelphia team, Work to Ride, holding high the ornate trophy.  Raised in impoverished communities, these athletes were drawn to the excitement and challenge of polo, “the sport of kings.” How can horse and barn chores foster incentives to: compete in a taxing sport; extend friendship to individuals from different backgrounds; attend school and obtain good grades; negotiate and resolve conflicts; regard set-backs with eloquence and resilience; and lead and perform under pressure?  Can ideas learned from the success of the Work To Ride program be translated to other out of time, after school programs, clubs or anti-violence organizations? Insight might be gleaned from Csikszentmihalyi[1] , a psychologist and researcher, who described enjoyment as the balance between boredom and anxiety.


Pairing the “just-right challenge” with the interested child requires planning for both routine and challenge.  After school programs provide constructive outlets for urban youth during 3 p.m. to 6 p.m., a vulnerable time, when a significant number of children’s delinquent activities take place.  At Work To Ride, horses, competition, training and horse and barn chores are part of the required weekly eight-hour minimum routine for riders.  African Americans are the target audience of this socially supportive program designed to use horses and polo as the “carrots” to promote personal responsibility, school success, career aspirations, healthy competition, leadership and achievement.  The program is designed to create a “home away from home” for 20 riders. 


Homicide is the leading cause of death for African American men aged 15-34 years, and in 2006 2,946 black males aged 15-24 were victims of homicide.  After-school programs are an invaluable resource to encourage resilience and improve quality of life. Based on initial information gathered in 2009-10, school performance, goals, roles, and routines of 19 Work To Ride riders aged 7-19 years were studied.  Findings indicate that riders categorized Work To Ride staff, riders and volunteers as “family” and expressed short term goals such as “get good grades” and long term goals including  “attend college” or “become a pilot or lawyer.”  Responses to a quality of life questionnaire were skewed to the positive, except in the areas of neighborhood and environment. Interestingly, some riders expressed concern about their classmates, school or street, describing how they avoided danger. Robust daily routines and the social support of other riders, staff and program alumni were valued.  Sometimes the “fastest way out of town is on the back of a horse.”



Ruth L. Schemm is Professor Health Policy/Public Health at the University of the Sciences in Philadephia.  Elisabeth Ervin-Blankenheim is Director of Institutional Research at Delaware Valley College.  Lezlie Hiner is Executive Director of Work to Ride. 


[1] Csikszentmihalyi, M.  “Flow” (p 52). 1990 HarperPerenniel

Cultural Competency Gains Consensus

Cheri C. Wilson, MA, MHS, CPHQ


The U.S. Census Bureau projects that the United States will become a minority-majority between 2042 and 2050, meaning that today’s minorities will numerically outnumber non-Hispanic whites.  Four states (Hawaii, New Mexico, California and Texas) plus the District of Columbia are already minority-majorities.  At the same time that the country is becoming increasingly diverse, health care organizations struggle to provide culturally and linguistically appropriate services.  These issues have been brought to the forefront by the following external legislative and regulatory pressures:


·         Title VI of the Civil Rights Act of 1964;

·         2001 CLAS Standards, which are currently under review by the U.S. Department of Health and Human Services, Office of Minority Health;

·         The Joint Commission Standards on Effective Communication, Cultural Competence, and Patient-Centered Care;

·         NCQA Multicultural Health Standards Distinction Program;

·         Meaningful Use of Electronic Health Records; and

·         Provisions of the Affordable Care Act.


The Cultural Competency Organizational Assessment-360 (COA360) was developed by Dr. Thomas LaVeist, professor and director of the Hopkins Center for Health Disparities Solutions, a research center within the Johns Hopkins Bloomberg School of Public Health (, which has been designated a “National Center of Excellence” by the National Institutes of Health’s National Institute on Minority Health and Health Disparities.


The COA360 is a multilevel, evidence-based, web-based cultural competency tool that dynamically evaluates the readiness of a healthcare organization or clinical unit to meet the needs of a rapidly diversifying U.S. population. The COA360 is designed to assess the cultural competency of health care organizations, rather than individuals. It is a multi-dimensional tool providing a "360-degree view" of an organizational unit from the perspective of health care administrators, providers, non-provider staff and clients/patients. The measure was designed for use in hospital organizational sub-units, such as clinical departments, hospital inpatient service units, or outpatient units, and is adaptable to the unique configuration of diversity within an organization's service area (i.e. nationality, ethnicity, language, tribal affiliation or religion).  The COA360 is the only organizational cultural competency tool with a validation study published in a peer-reviewed journal[1].   The COA360 received the 2008 Innovation Award from the National Institutes of Health, National Center on Minority Health and Health Disparities. The COA360 recently underwent substantial revision, and the new version was launched at the DiversityRx Conference on Health Care for Culturally Diverse Populations in October 2010.


Your organization could benefit from a COA360 assessment to achieve the following:

·         Document adherence to CLAS standards.

·         Gain a competitive advantage with diverse patient populations.

·         Learn how to best allocate resources for language services.

·         Determine where enhanced services for culturally and linguistically diverse patients are needed.

·         Facilitate patient-provider communication.

·         Improve patient safety and health care quality with the goal of reducing health disparities for culturally and linguistically diverse patients


The Culture-Quality-Collaborative (CQC) ( is a network of leading health care organizations that is working in conjunction with Hopkins Center for Health Disparities Solutions faculty to share ideas, experiences, and solutions to real world problems arising from cross-cultural interactions that hinder the elimination of disparities in health care settings.  These problems include:

·         How do you determine what cultural competency means within your unique organizational context?

·         How do you introduce cultural competency to your organization?

·         How do you encourage others to think outside the box and accept new ideas? and

·         How do we create an evidence base for determining bestpractices in cultural competency? 


CQC member organizations participate in monthly webinars, attend an annual in-person conference, and have access to the members-only section of the CQC website.  The webinars provide members with the opportunity to learn, network and share experiences as we develop and deploy the various interventions.  Each webinar features an expert on cultural competency who will present on a topic about which the CQC founding members have expressed an interesting in learning.  In addition, a brief case study of a success or challenge associated with the topic is presented by one of the CQC founding members.


Prior to developing and deploying interventions, each of the CQC founding members completes the cultural COA360 for several units or departments within their respective healthcare organizations.  These assessments will establish a baseline of performance.  Following the implementation of interventions, the same units or departments will be reassessed to determine the effectiveness of the intervention.  Once the effectiveness of the interventions has been determined, the interventions will be included in an online interventions database.


Ten health care organizations currently have agreed to participate. These founding members serve as the Coordinating Council for the CQC.  The founding member organizations are:

1)    Catholic Health East (Newtown Square, Pa.);

2)    Catholic Health East – Holy Cross Hospital (Fort Lauderdale, Fla.);

3)    Catholic Health East – Mercy Philadelphia Hospital (Philadelphia);

4)    Catholic Health East – Saint Francis Hospital (Wilmington, Del.);

5)    Catholic Health East – Saint Mary Medical Center (Langhorne, Pa.);

6)    Henry Ford Health System (Detroit);

7)    The Johns Hopkins Hospital (Baltimore);

8)    Johns Hopkins Bayview Medical Center (Baltimore);

9)    Saint Elizabeth Regional Medical Center  (Lincoln, Neb.);and

10) Sinai Hospital (Baltimore). 


We are seeking to expand the CQC membership. 


If you would like additional information about the COA360 or CQC, please contact Cheri Wilson, Faculty Research Associate, COA360 Administrator, and CQC Program Director, at:, (443) 287-0305.

[1] LaVeist TA, Relosa R, Sawaya N. (2008) “The COA360: a tool for assessing cultural competency of Healthcare Organizations” Journal of Healthcare Management 53:4 July/August.

Chagas’ Disease: The South Comes North

Paul J. Edelson, MD


For nearly a century, since its recognition in 1909, Chagas’ disease, or American trypanosomiasis, was strictly a disease of the Latin America rural poor. The organism, Trypanosoma cruzi, which causes Chagas’ disease, is transmitted by triatomine bugs that pass the parasite in their feces; the bug feces can contaminate a skin puncture, allowing a transmission of the parasite.  Untreated Chagas’ disease leads to life-long infection with a prolonged asymptomatic period which may progress, in approximately 20-30 percent of cases, to serious cardiac or gastrointestinal disease. The cardiac form of the disease is typically characterized by potentially life-threatening arrhythmias and cardiomyopathy, and may result in sudden death, heart failure requiring cardiac transplantation, or stroke attributable to embolization of left ventricular thrombi.


Although vector-borne transmission (that is, disease organisms carried by an insect) of Chagas’ disease continues to be limited almost entirely to countries south of the U.S.-Mexico border, the disease can also be transmitted by blood transfusion, by organ and tissue transplantation, or congenitally from an infected mother to baby.  In the United States, several cases of local vector-borne transmission have been reported, but risk is considered low.  Transmissions by organ transplantation and blood transfusion have also been documented in the United States. Congenital transmission has been reported in other non-endemic countries with large immigrant populations from Latin American and may occur undetected in the United States.


Control efforts principally include spraying insecticide in areas where the vector has infected houses made from plant materials, or from stone with fractures or cavities where the insects can hide.  These control efforts have reduced the number of infected persons from an estimated 16 million between 1975 and 1985 to 7.5 to 12 million currently. To help reduce transmission by contaminated blood transfusions, many countries, including the United States, now screen blood donors for Chagas’ infection.


Mexico, the principal country of origin of Latino immigrants to the United States, has made only limited efforts to control Chagas’ disease.  Caryn Bern and Susan P. Montgomery, of the U.S. Centers for Disease Control and Prevention, estimated that about 300,000 persons with T.cruzi infection lived in the United States in 2005, resulting in approximately 30,000-45,000 cases of cardiomyopathy and an annual incidence of 63-315 congenital infections[1]. Two drugs are currently available to treat Chagas’ infection -- benznidazole and nifurtimox. These drugs are not FDA-approved but are available from the CDC for treatment of patients under investigational protocols in the United States.  Treatment has been shown to be effective in early, acute infection such as congenital infection, and a consensus is growing on the benefits of treatment of asymptomatic chronic disease, and even in the early stages of cardiac disease in an effort to slow or stop disease progression[2].


Unfortunately, few physicians in this country are familiar with Chagas’ disease, its management, or even its occurrence in the United States. In a recent survey of obstetricians, Verani  and her colleagues found that only about 9 percent were aware that Chagas’ can cause congenital infection and the majority of respondents (77.9 percent) reported that they “never” considered the diagnosis, even among patients from endemic countries[3].


Given the importance of Chagas’ disease as a cause of heart disease and premature death, physicians in the United States should be aware of the importance of this often silent infection in the Latino population.   Public health and clinical medical professionals should work together to increase awareness in Latino communities and to reduce the burden of premature deaths and disability among the 50 million Latinos living in the United States.


More information on Chagas’ disease is available at, including a free online CME/CNE course titled “Chagas’ disease: what U.S. clinicians need to know.”



Paul J. Edelson, MD. works for the Centers for Disease Control and Prevention in Jamaica, N.Y. and can be reached at

[1] Bern C, Montgomery SP. An estimate of the burden of Chagas’ disease in the United States. Clin Infect Dis. 2009 Sep 1;49(5):e52-4

[2] Bern C, Montgomery SP, Herwaldt BL, Rassi A, Jr., Marin-Neto JA, Dantas RO, et al. Evaluation and treatment of Chagas’ disease in the United States: a systematic review. JAMA 2007 Nov 14;298(18):2171-81.

[3] Verani JR, Montgomery SP, Schulkin J, Anderson B, Jones JL. Survey of Obstetrician-Gynecologists in the United States About Chagas’ Disease. Am J Trop Med Hyg. 2010 October 5, 2010;83(4):891-5.


Nassau County’s ‘Health Checks’ Program Hosts Inaugural Event

Lawrence Eisenstein


A new community health screening program was recently initiated in Nassau County, N.Y.  The Nassau County Department of Health, in partnership with NuHealth, County Executive Edward Mangano, Nassau County Legislator Ciotti, and many local community leaders, held the first installment of the new “Health Checks” program. The event was held at Elmont Public Library, with a goal to link local residents with continuing care at the nearby Elmont Community Health Center.  

The event consisted of medical screenings -- including blood pressure, BMI and dental screening --  and counseling sessions by the medical staff of the Elmont Health center. Facilitated enrollment was provided by multiple agencies, and people previously without doctors left the event with follow-up appointments at the Health Center. A mobile mammography van provided mammograms to people with and without appointments, as well as follow-up appointments when necessary. Dental services were provided by the new Stony Brook University Dental Van. Exercise classes, gardening, and healthy eating discussions were popular. Medical Reserve Corp participation was vital, and a Medical Reserve Corp pharmacy table helped answer questions about the medications residents take, including interactions. Tables supporting seniors’ health, fall prevention, and pandemic influenza were onsite. Bicycle helmets were donated and raffled off, and Island Harvest provided bags of food to those in need.

This is the first such event, and the hope is to continue to ensure linkage to care at Elmont Health Center, and other Nassau County Community Health Centers.

Lawrence Eisenstein can be reached at

We’re Number Thirty-Seven!

Melvin H Kirschner, BA, BS, MPH, MD


The many shortcomings of the health care arena in the United States have left millions of people with limited health care or no care at all. The United States is rated 37th in the world regarding access,

quality and amount of health care that many of its residents receive. Insurance companies are known to select people who are least likely to need care. Need and quality of care are minimized, and company profits are maximized.


Many uninsured, low income people use the emergency room as their doctor, because they know that they cannot be required to pay for the services.  Emergency rooms have become so jammed with non-emergency patients that truly critical patients may be unable to receive the timely, intense care that they need.


The pharmaceutical industry has been reported to pay generic drug manufacturers to not produce a drug whose patent has expired. That allows them additional years of exclusive production and higher prices than the generics would charge for the same medicine. That was not the intent of the FDA 100 years ago, when it limited the length of time that the original manufacturer would be the sole producer of a new medication.


I agree with the 18,000 Physicians for a National Health Program. They advocate for single-payer, not-for-profit health coverage, Health Care for All.


We are the most advanced industrial country in the world. Our medical technology is the most innovative in the world. Our people should expect to be provided with the top-ranked medical services in the world, not the 37th.


My book, "All Medicines Are Poison!" sets out to remove the fog of confusion that clouds the landscape that the American people must navigate in their search for health care today. The book describes the risks and benefits associated with the use of medicines, and explores the validity of other treatment modalities such as complimentary and alternative care.  It discusses the failings and back room dealings by the pharmaceutical and insurance industries, and highlights possible solutions to many of these current concerns.


The provocative title of the book is not just a "come-on". It's a fact that every physician is aware of. The job of the physician is to decide that prescribing the medicine is less harmful than the untreated illness. All physicians are also aware that every medicine has side-effects which could potentially afflict some patients. But if the patient is dying, they must be willing to risk the side effects that the life-saving medication is capable of causing.


Melvin Kirschner can be reached at

Public Health and Transportation

These are exciting times when considering the many ways our transportation systems impact health and equity in our communities. Congress extended the current federal surface transportation bill until Sept. 30, 2011, and Congressional committees are aiming to draft a new transportation bill before this latest extension ends.

Want to learn more about the connections between transportation, equity and health? View our archived webinar series, subscribe to the monthly transportation and health eNewsletter that offers an array of new events and updates, and download the newly-released online public health and transportation toolkit and accompanying resources today.

We also invite you to send a message to your members of Congress urging that they ensure that strong public health provisions are included in the federal surface transportation reauthorization. For more information, visit

APHA Annual Meeting

Registration is now open for the APHA 139th Annual Meeting and Exposition in Washington, D.C., Oct. 29 - Nov. 2, 2011.  More than 1,000 cutting edge scientific sessions will be presented by public health researchers, academicians, policy-makers and practitioners on the most current public health issues facing the nation today. For registration and more information about the Annual Meeting, visit


The Medical Care Section will have a strong presence at the meeting. View the sessions sponsored by the MC Section in the interactive Online Program.  Search the program using keyword, author name or date. Don’t forget to visit the Section and SPIG pavilion in the Public Health Expo next to Everything APHA to speak to a Section representative.

Need-Based Scholarships Available for Students to Attend Annual Meeting

APHA is proud to announce the availability of need-based scholarships, sponsored by External Medical Affairs, Pfizer Inc., for student members to attend the 139th Annual Meeting and Exposition in Washington, D.C., from Oct. 29-Nov. 2, 2011.  Twelve students will be granted registration and up to a $500 stipend to use toward food, lodging and transportation.  An additional four students will be given Annual Meeting registration only.  Recipients of the scholarships will be chosen based on financial need and essay.  As part of the award, students will be strongly encouraged to attend at least one Section business meeting.  Please inform the student members of your Section about this unique opportunity!  Visit: for complete details and application.  Please contact Pooja Bhandari at with any questions. 

Update on APHA Book Publications – June 2011

I am very pleased to announce that there are a number of books in production as well as a number of proposals for books that have been accepted with work under way.  Furthermore, several authors of current products will be available to sign their books at the Fall APHA Annual Meeting in Washington, D.C.


APHA members of all Sections are encouraged to using existing, new and emerging products in their academic courses. These resources are also very relevant to policy, prevention, advocacy and client care initiatives. Please encourage your colleagues to use these timely and evidence-based resources.  Go to the APHA website to find out more: 


We are also looking for new proposals for books. If you have an idea for a book, please send a few paragraphs describing the idea, intended audience and your qualifications to Nina Tristani, Director of Publications, APHA,

Thank you for supporting APHA Books and promoting these products.


Norman Giesbrecht, PhD, Chair, APHA Publications Board




·         Environmental Health and Racial Equity in the United States, Authors: Robert D. Bullard, PhD; Glenn S. Johnson, PhD; and Angel O. Torres, MCP,

Books at Printer in June

·         Megacities and Public Health, Omar Khan, MD, MHS

·         Public Health Management of Disasters, 3rd edition, Linda Landesman

Books Currently in Production

·         Injury Prevention for Children and Adolescents: Research Practice, and Advocacy, 2nd edition, Karen D. Liller, PhD

·         School–Based Health Care, Terri Wright, MPH and Jeanita Richardson, PhD

Books in Development

·         Control of Communicable Diseases Manual, 20th Edition

·         Control of Communicable Diseases Lab Book

·         Compendium of Methods for the Examination of Foods, 5th Edition

·         Caring for Our Children, 3rd edition

·         Standard Methods for the Examination of Water and Wastewater, 22nd edition


·         Communicating Public Health Information Effectively is now on Kindle.

Co-sponsored Books

·         Jossey-Bass: Emerging Infectious Diseases published in April 2011.


Jones and Bartlett Learning books to be published before the 2011 Annual Meeting:

Essentials of Biostatistics in Public Health, Essential Case Studies in Public Health: Putting Public Health into Practice, Global Health 101, Field Epidemiology in Public Health Practice, Epidemiology in Women's Health, Essentials of Health, Culture and Diversity, Epidemiology of Chronic Disease, Introduction to Air Pollution Science, and Essentials of Program Planning and Evaluation.


APHA and Wiley are co-publishing Designing Healthy Communities by Richard Jackson.  The book is a companion to a PBS series to air this fall.



We Want to Hear From You!

What's going on in your work?  Do you know someone who is doing something that would be of interest to the MC Section?  We welcome articles or ideas for articles for upcoming issues of our newsletter. Short pieces (300-500 words) work great, but longer ones are okay, too.

We'd love to hear your news, announcements, "pro/con" opinion pieces, analysis of meetings and conferences, advocacy information, summaries of papers or reports, personal features, student activities, local news, book reviews, motivational pieces and job opportunities. 

Please respond directly to me at, and let me know your proposed topic, and whether you can have something ready by early August 2011, or whether you’d like to write something in a later issue.  If you already have something written, even better.

Thanks in advance for sharing your knowledge with the Section.

Sara Teppema, FSA, MAAA, MC Section Newsletter Editor