Letter from the Chair
With my two-year term as Section chair coming to an end this November, I am feeling a strong sense of transition with so much undone and more to do. With both my tenure at Cook County Hospital and as Medical Care Section chair coming to an end that month, November represents a major change in my professional career and personal life.
Before coming to Medical Care issues (capital M C), I want to talk about what is happening personally with my own medical care work (small m c). Mardge Cohen (my wife) and I will be retiring from work as general internists from Cook County Hospital (now called Stroger Hospital-more on this below) after 31 years of service at Chicago’s only public hospital. The move was precipitated both by my being offered a wonderful opportunity to work at Harvard’s Brigham, as well as a profound crisis — both fiscal and leadership — at our beloved Cook County. The job at Harvard will offer great opportunities to further the work that has brought me into the Medical Care Section of APHA including research, practice and teaching in quality improvement, medication safety and policy, and medical informatics. I will be working in the section of General Internal Medicine at Partners Brigham hospital under David Bates, who is a true national treasure and who heads their Center for Patient Safety Research and Practice for which I will become the associate director. Also exciting for many of my APHA interests will be the opportunity to help teach the annual summer course on clinical effectiveness in the Harvard School of Public Health.
The cutbacks and undermining of services at Cook County are important to share with members of our Section and are receiving insufficient attention from the local and national media. John H. Stroger Jr., [the father who renamed the new hospital that we fought so hard for (and that he initially opposed!) after himself], after being advised by many not to run for re-election as president of the County Board in 2006, did so anyway. However, a few days before the March primary election, he suffered a stroke. He nonetheless narrowly won the primary election, in part because the public was misled about the seriousness of his medical condition and the hospital’s growing fiscal crisis. After not being seen or heard from for months after the primary, his Republican opponent declared “let him show his face at the window to show he is still alive.” The family refused, arguing that this would interfere with his recovery. Instead, at literally the 11th hour in July (in the final hours a replacement candidate could be slated by the Democrats), Todd Stroger (the son, referred to by some as “the toddler”) was picked to replace his father on the November ballot. He won in the election that coincided with the November 2006 APHA meeting.
Many despair that there is no mechanism for impeachment or recall. My patients, unprompted and almost unanimously, enter my exam room voicing their protest. “Why did I ever vote for that man; look what he is doing to the hospital and the clinics.” One of my cancer patients stated, “Cook County is no longer for the patients.” In reality, the problems at County run much deeper than our current misguided and poor leadership. Todd Stroger inherited a $500 million deficit and many of the problems, which have become so much worse in the past half year and have plagued County for decades. What the current leaders are failing to provide are the right diagnosis and solutions for the problems.
The appointment of Robert Simon as head of the hospital and clinics has furthered the undermining of care at the institution. In implementing budget cuts, he argued that County needed to retreat to its “core mission” of treating strokes rather than hypertension, and that some community and public health services represented luxuries we could no longer afford.
Simon and Stroger proposed slashing hundreds of staff positions at the hospital and clinics (the majority of which were doctors and nurses, who lack any union protections), with the most drastic proposed cuts being the closing of more than a third of County’s community clinics. Not only what was being cut, but how the cuts were being made, added to the chaos and demoralization. For example, in one week hundreds of people received pink slips “in error” only to have them rescinded, and another group of hundreds more received pink slips during the following weeks. Physicians with 20 plus years of seniority were fired. The Occupational Medicine Division was eliminated. Those of us remaining asked ourselves who was worse off, the ones laid off or those left behind to care for the patients who had lost their physicians. Of course the answer is that the ones worse off are the patients -- who face more access barriers, discontinuities, longer waits, and most dangerously, a renewed mania to bill patients and turn over unpaid bills to collection agencies.
While space does not permit a detailed discussion of the financial aspects of this fiscal and billing crisis, it is important to note the obvious. County’s financial crisis does not exist, nor can it be solved, because of failure to send or by sending bills to our poor patients. In fact, it could be argued that the entire $75 million 2005 health care budget shortfall (which set into motion the deficit and cuts for 2006) can be traced to a roughly $75 million cut in federal funding (the so called “intergovernmental transfer” program). Todd Stroger refused to consider tax increases to cover this shortfall. He also burned up the political capital needed to support such an increase by a series of continuing patronage blunders, leading the public to question whether additional funding to support a poorly run operation was worthwhile.
At the three public hearings in February 2007, each attended by more than 1,000 people, the staff and the community mobilized to describe the impact and mistaken logic in these drastic cutbacks. I felt enormous pride in being a County employee as I watched the solidarity and testimony of sheriffs, public defenders, prosecutors, and jail employees (whose jobs and services were also being slashed) raise their voices along with those from the health care community and describe the work they do and how it would be adversely impacted by the proposed cuts.
While some of the cutbacks have been beaten back and Stroger has now inexplicably reversed his position and is calling for a tax increase, uncertainty, chaos, and demoralization are the dominant features of everyday life at County. Worse yet, the leaders appear determined to ignore the experienced and committed voices of those of us who are advocating for our patient and have ideas of how to make County work better. A number of the best physicians and nurses have left or are looking to leave. It is in this context that leaving County at this time of crisis hardly feels like the right decision. But (to paraphrase what Quentin Young said when he left County 25 years ago), County has probably had a maximal dose of what medicine Mardge and I have to offer, with likely diminishing returns on our investments of efforts to make it better. And perhaps (following Quentin’s lead) we can do more for County and the patients in other ways, as we continue our commitment to what County stood for in the past – for accessible high quality services to patients regardless of ability to pay.
The Medical Care Section is one obvious expression of this commitment. My hope is that during the summer and fall we can complete some of the initiatives that I have written about in my earlier newsletter columns. Most important is the continuing effort to improve Section involvement, outreach and communication. There are several initiatives that I hope can advance these aims, and that can be successfully moved towards completion during my remaining months as Section chair. The first is the renewal of our work with the Medical Care journal and its new editors. We have been helping to plan a special issue on the financing and organization of medical care in the United States, and the “call for papers” will appear in the September issue of Medical Care.
But the major initiative I hope to move forward with the help of our summer intern Stacy Liker (first-year student at UIC College of Medicine) is the revamping of our electronic communication structure and processes (hopefully leading to enhanced outcomes during the two-year term of our next chair, Gail Bellamy).
We plan to redesign our communication approach. Many members say they rarely hear from the Section, while others complain of receiving too many e-mails of Section discussion. We will be reaching out to each and every member to solicit your preferences and interests, thereby creating a “profile” of your desired level of communication and topic areas. Your response to the e-mail inquiry you will receive by the end of the summer will populate this profile and allow us to more effectively tailor and target communication to you. It will also permit the option for you to create a personal Web “space” on our Section Web site, where you can post your contact/demographic information, areas of special interest or recommendations for reading, and other desired links.
We will be undertaking this profiling survey effort in conjunction with a retrospective review of Medical Care Section presentations over the past decade, which we hope to cross reference with topics from the Medical Care journal for the same period, thereby creating a taxonomy of Medical Care. While this “taxonomy” project ideally should precede the survey to allow members to then identify interests based on this more rigorous representation of our Section and its areas of interest and influence, for practical reasons (wanted to get the survey going), it will have to proceed in parallel.
I urge each of you reading this newsletter column to thoughtfully respond to the initiative, so we can better know who each of us is in the Section and allow us to better communicate with each other.
In conclusion, and in the spirit of what we will be requesting from you (recommended readings for fellow Section members), I’d like to make my own recommendation of a book worth checking out. It is a remarkable book entitled The Political Economy of Health Care by Julian Tudor Hart (2006, Policy Press). In it, one of my heroes reflects on what is happening in health care in the United Kingdom (and worldwide), which helps put into perspective what we are facing at Cook County, in the United States and what I suspect each of you faces every day in your own work. It is a book that attempts to provide students of health and caring sciences with a “big picture” of our work — a picture that shatters conventional assumptions: “Though this may entail swimming upstream against the tide of fashion….it follows the prevailing winds and currents of history.”
Hart presents an extremely optimistic picture of what was the basis and early achievements of the much maligned British National Health Service. The NHS is now succumbing to costly privatization efforts ideologically driven by “those without personal responsibility for giving health care or substantial personal experience of receiving it." He shows how we can, via imaginative efforts based on shared understandings, confidently make a better world by “thoughtful human decision rather than the tidal waves of avarice released by market forces,” convincingly arguing for a “world that is planned and shared rather than plotted and grabbed.” In such a world, decisions will be made not on where life and labor are the cheapest but will be based on identified needs, knowledge and learning.
I look forward to working with you through Medical Care to help promote such a world and ensure that the organization and practice of medicine reflect these values and opportunities.
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Action Board Update
The Action Board activities in the past several months have focused, from my perspective, on two main areas: 1) advocacy, and 2) archiving.
A recent meeting in Washington included visits by Action Board members to elected representatives on Capitol Hill on behalf of APHA. Included in the discussions was enhanced funding for the SCHIP program (State Children's Health Insurance Program) which is critical to many projects APHA and the MC Section hold dear. Also likely discussed were issues related to universal health care.
The important topics discussed the weekend of the Action Board meeting and visits to the capital will be delivered to you in a subsequent e-mail or in the next newsletter. APHA had provided very helpful Web links to allow for easier communication with Washington using www.capwiz.com.
Policy archiving was initiated and promoted by the Action Board. I believe, while the immediacy of doing this is less critical than some of the above activities, archiving is an important and potentially useful activity for all APHA members. This year, the topics chosen to focus on, namely, rural health, children's health, public health work force issues, and health care policy, have relevance to everyone on some level. Streamlining the policies in the review process could allow for a more efficient use of those very policies. I am not sure what the outcome was, but I would greatly appreciate some feedback, if any exists, from the MC Section regarding use or non-use of this process. The process of policy review may be slightly tedious initially, but it rapidly becomes quite rewarding as a result of the significant knowledge gained about our policies and the process involved in making policies.
Please look for a more detailed, nuanced report for the next newsletter.
By Simon Piller
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Avian Flu: Not The Best Issue for APHA
What are the problems with focusing on avian flu as the APHA’s primary action issue? To summarize a longer essay that many have already received:
· Avian flu has infected only about 250 people worldwide, and it is by no means sure that this H5N1 bird flu will cause the next pandemic.
· The last pandemic in 1918 killed 40-100 million people, but the deaths were much higher among the poor, both in the United States and worldwide. The same disparities in underlying health, health care and public health infrastructure exist today. Without an attack on these disparities, no effort to limit the harm from a flu epidemic will be very useful.
· Even in the United States, social distancing and the means to guarantee that people can remain out of school and work while maintaining nutrition and access to medical care is the most important epidemic control measure. Our lack of a social safety net, health insurance, public health and medical care cuts make this unfeasible.
· The main prevention needed is support of poor nations where bird epidemics take hold, with compensation to farmers, assurances of equal access to vaccines, and assistance with research, all of which is vastly underfunded.
· The U.S. government’s main plan for epidemic control is militarily enforced quarantines, which is of medically limited use, but useful to continue the militarization of public health and many other aspects of our society.
· During the last epidemic during WWI, the priority given to war over U.S. or world health was largely responsible for the spread and the severity of the illness. The current war in Iraq and likely future wars against Iran and China make this scenario likely again.
The way for APHA to fight epidemics of flu or any other health problem is to continue the fight for universal coverage, expand the public health infrastructure, fight racism and health disparities, and oppose war and the militarization of our public life. We should demand more of our organization on these fronts and not permit these emphases to be lost.
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APHA Student Assembly Alumni Database
This year, the APHA Student Assembly Opportunities Committee provided more resources to students regarding scholarships, conferences, job postings, potential employers and fellowships/internships. In addition to these endeavors, the committee revamped the Student Assembly Alumni Database. The Alumni Database is meant to not only allow the Student Assembly to keep track of their past members, but it also provides current and potential students access to learn about possible careers in the public health field.
To access the Alumni Database, students can visit www.aphastudents.org and click on the Opportunities Committee link. Here students can look at job positions currently held by public health professionals in the field. Prospective public health students could access this database and view jobs held by people with public health degrees to gain a better understanding of the wide variety of career paths available to them. Alumni range from recent graduates working in fellowships or entry-level positions to seasoned health professionals with well-established research agendas.
The Student Assembly Opportunities Committee co-chairs are working to increase participation of Student Assembly alumni in the Alumni Database. Anyone who at one time was a member of the Student Assembly (previously entitled Public Health Student Caucus) can visit the Web site, complete the form available on the Opportunities Committee page at www.aphastudents.org/phso_alumni_db.php and return it to email@example.com. This endeavor depends on the cooperation of alumni. With APHA Student Assembly alumni support, the Alumni Database can become a wonderful resource for the next generation of public health students. We hope you will consider taking a few moments to add yourself to the Alumni Database.
If you have any questions or want more information, please feel free to contact Jennifer Cremeens or Anna Pollack, the Opportunities Committee co-chairs, at firstname.lastname@example.org.
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Community Health Centers: A Movement and the People Who Made It Happen
Rutgers University Press, 2007 by Bonnie Lefkowitz
This new contribution in the series “Critical Issues in Health and Medicine” (edited by Rima D. Apple of the University of Wisconsin-Madison and Janet Golden of Rutgers University) from a veteran staff member of both the federal Bureau of Primary Health Care and the National Association of Community Health Centers provides juicy historical detail informed by decades of personal and professional relationships with a cast of characters still serving in the trenches of the U.S. community health center movement.
This welcome volume builds on a literature that is only now beginning to be written but is deserving of many more chapters. It picks up on Alice Sardell’s wonderful PhD dissertation, “The U.S. Experiment in Social Medicine: the Community Health Center Program, 1965-1986,” which chronicled the movement’s origins and subsequent political agility in successfully facing down the Reagan administration’s efforts to do away with the program through block granting.
Many of the health center founders interviewed extensively in this book are movers and shakers who now possess three to four decades of experience and who remain ensconced in their roles at community health centers across the country. A remarkable theme of grit, political skill and grassroots mobilization shines through the narrative. Lefkowitz makes the observation of a male predominance in those who run the health centers, but, speaking as a mid-career founder of one of the younger health centers (my own health center saw its first patient 10 years ago), I am struck by the large number of senior female health center executives who are as experienced and grounded in social justice movements as are the men.
Lefkowitz organizes the book into five major sections, each with its unique geo-cultural expression of the health center movement, and each home today to many thriving health center sites: Mississippi, Boston, South Carolina, New York City, and the Rio Grande Valley of Texas.
Health centers started in Mississippi and Boston, fueled directly by the Civil Rights movement from which they were initially indistinguishable (they were initially started as the health care arm of the Civil Rights movement). To this day, national health center meetings are strikingly diverse and multicultural. According to my conversation with historian John Dittmer, author of the classic “Local People: The Struggle for Civil Rights in Mississippi,” the Medical Committee for Civil Rights preceded the Medical Committee for Human Rights (MCHR) with the planning process for freedom summer, in 1963.
According to Dittmer, “Dr. Bob Smith of SNCC in Jackson sent out the call for medical support. Over a thousand [non-medical] volunteers were expected in Mississippi that summer, yet there were very few black doctors and very few white doctors willing to care for them.”
Interviewed by Lefkowitz in Chapter Two (“Mississippi: Where It All Began”), Smith estimates that, for the entire black population of 800,000 Mississippi residents, there were at that time only 25 to 30 black physicians in private practice. Smith recalls, “This place was sweltering in anger” following the June 1963 murder of Medgar Evers. Then as Dittmer has chronicled, “the murder of the three civil rights workers, including two young New Yorkers took place after the first MCHR planning meeting, and this totally galvanized the effort.”
Dr. Jack Geiger, who became the founder with Dr. Count Gibson of the first U.S. health centers, recalls that some of the north-south professional relationships forged during freedom summer continued with a much smaller number of northern physicians. “In December 1964, there was a meeting in Greenville of a bunch of us left-over civil rights types, the Delta Ministry of the National Council of Churches, a number of the Mississippi Headstart people, etc. It was at that meeting that I remembered my community health center experiences and training in South Africa and suggested that we try it here. Dr. Des Callan (a New York physician), Dr. Robert Smith of Jackson, the black physician who was the local linchpin of MCHR, and others, grasped the idea and offered suggestions and comments. At this time it was just a pipe dream; there were no federal grant programs for this at HEW or at OEO. I didn't contact OEO until January or February 1965, and ultimately it got funded as a research and demonstration project, the only way it could be.”
Geiger, at the time a member of the Tufts Medical School faculty, became the founder, with Dr. Count Gibson, of the first two community health centers in Mississippi and Boston. An interesting note is that Geiger acknowledges the Boston center was proposed only because Tufts would probably have refused to permit a project involving only a Southern site. At the Mississippi site, medical care was started alongside cooperatively-run education, transportation, farming and public health projects in which local residents were not only the passive recipients of government benefits, but were actively involved in restructuring their community around multiple basic human needs.
The health center program was written into law in the early 1970s, in order to protect it from the Nixon administration. The comprehensive health center program survived its second major political attack during the Reagan administration, ironically to become the darling of the Bush administration two decades later.
Today, the health center program has grown to serve more than 7 million Americans with medical, dental, mental health and substance abuse and pharmaceutical programs. As a unique favorite of the Bush administration, it has enjoyed increasing appropriations in the range of $200 million per year, while simultaneously undergoing (along with other federal health and human service programs) many corporatizing pressures. During the same period, increasingly restrictive coverage under many state Medicaid programs (the major revenue source for most health centers) and the new federal prohibition on Medicaid reimbursement for the care of undocumented patients have presented new sets of challenges for health centers.
An implication of reading Lefkowitz’s book is that continuity in the committed leadership of the overall movement and within individual health centers have played a critical role in maintaining the community orientation of health centers. As many discuss in moving and personal accounts, the life-changing commitment of many health center founders to the social justice movements of the 1960s and 70s carries them forward to this day. Political linkage between the health center institutions and the people they serve is a strong theme of the book, with many examples of the soul-searching struggles to maintain ethical, good-faith connections with the underserved populations and communities who have no other source for dignified health care. Some of these struggles are lost, but a surprising number continue to be won on both large and small scales.
Currently, defense of the community-based governance board requirement is an active project for many in the health center movement. Historically, Lefkowitz describes how this battle was previously fought and won; now it must be re-fought. Last year, the program failed to win Congressional reauthorization for the first time due to a proposal to allow demonstration projects by organizations that would be free of the longstanding program requirement for 51 percent controlling interest by actual patients on the governing board of each community health center. This effort was led by Catholic hospital organizations and quickly joined by other nonprofit and faith-based organizations serving large numbers of uninsured people but unwilling or unable to accept the rigorous community accountability that has always been a part of the foundation of health center governance.
Unwilling to accept this chink in the armor of health centers’ basic identity, the compromise was rejected and health centers have now entered a precarious phase of annual appropriation without authorization. In this, they have joined the ranks of other federal programs that resist restructuring of their basic mission (including federal family planning program and the National Health Service Corps). Health centers’ rejection of the “compromise” deal was made possible only by the political staunchness and numbers of the health center movement itself.
We should hope that Lefkowitz’s well-crafted book will be followed by many more to eventually recount all the stories of a feisty, durable American movement and a large and remarkable group of mostly unsung heroes, characterized by the same courage and resilience as the communities from which they draw their daily strength.
Sarah Kemble, MD, MPH
Desmond Callan Community Health Center
Turners Falls, MA
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