Friday, June 29, 2012

NYT: Treating the Cause, Not the Illness



In 1965, in an impoverished rural county in the Mississippi Delta, the pioneering physician Jack Geiger helped found one of the nation’s first community health centers. Many of the children Geiger treated were seriously malnourished, so he began writing “prescriptions” for food — stipulating quantities of milk, vegetables, meat, and fruit that could be “filled” at grocery stores, which were instructed to send the bills to the health center, where they were paid out of the pharmacy budget. When word of this reached the Office of Economic Opportunity in Washington, which financed the center, an official was dispatched to Mississippi to reprimand Geiger and make sure he understood that the center’s money could be used only for medical purposes. Geiger replied: “The last time I looked in my textbooks, the specific therapy for malnutrition was food.” The official had nothing to say and returned to Washington.

In some ways, the United States has come a long way since Lyndon Johnson declared the “war on poverty.” But in others, we’re still at square one. We now have a variety of federally-supported nutrition programs, but the health care system remains senselessly disconnected from the “social determinants of health.” In this regard, the United States has fallen behind the rest of the world. If a politician in India announced a public health plan that neglected malnutrition, he would be ridiculed. Here, leaders make this kind of omission all the time. Almost all of the debate about the 2010 Affordable Care Act was consumed with questions about health care access and quality. But if we really want to improve the health of millions of people, we have to address the conditions that make them sick.
A program allows doctors to “prescribe” basic resources like food assistance, housing improvements, or heating fuel subsidies.
One of the most impressive organizations in the country that is developing an approach to do this isHealth Leads, which mobilizes and trains about 1000 volunteers each year who staff resource desks located in the waiting rooms of 23 hospital clinics or health centers in Baltimore, Boston, Chicago, New York, Providence, R.I., and Washington. At these sites, doctors now regularly “prescribe” a wide range of basic resources — like food assistance, housing improvements, or heating fuel subsidies — which Health Leads’ volunteers “fill” — applying their problem solving skills (and tenacity) to identify resources anywhere they may be available.
Health Leads was co-founded by Rebecca Onie in 1996, while she was an undergraduate student at Harvard University. Onie had first witnessed the intimate relationship between poverty and health while volunteering at Greater Boston Legal Services, where she assisted low-income clients who had housing problems. Many lived in dilapidated apartments with leaky pipes, broken windows, rooms full of mold, and walls infested with cockroaches and rats. Often families couldn’t afford to pay for heat. Towards the end of the month, some ran out of food. Onie found herself interviewing mothers whose children came to the office wheezing and coughing from asthma and lung infections — health problems caused or triggered by bad housing. Often, the children had been in and out of hospitals for years; many had fallen far behind in school.
One day, she read a magazine story about Barry Zuckerman, chairman of pediatrics at Boston Medical Center (B.M.C.), who had established the Medical-Legal Partnership for Children, a program that connected doctors with lawyers to assist patients (it has since spread to more than 235 health institutions nationally). Close to 70 percent of the patients at B.M.C. are poor and Zuckerman, like Geiger, had grown tired of treating children, only to see them readmitted to the hospital because nothing was done to address the causes of their illnesses. In some cases — as when a child has chronic asthma attacks because the landlord refuses to clean up mold — a lawyer could be more effective than a doctor.
Doctors are reluctant to inquire about issues in which they feel powerless to intervene.
“I thought bringing lawyers into the hospital was brilliant,” recalled Onie. She called Zuckerman to see how she could help and he invited her to spend six months talking to people in the unit. There Onie found doctors who were “smart, passionate and totally committed to their patients” and yet “stymied in terms of their ability to bring about the health outcomes they wanted.” Some physicians told her they knew they should be asking more about food, housing or social issues, but they were afraid of opening a “pandora’s box.” “I have no idea where to begin to address the problems,” one physician told Onie. “I have 13 minutes with each patient.” (Studies reveal that doctors are reluctant to inquire about issues — domestic violence, for example — when they feel powerless to intervene.)
Onie thought that students could help. With Zuckerman, she founded Health Leads (formerly Project Health) to recruit and train students to provide patients with connections to resources deemed necessary by doctors and other health care providers. “What are college students built to do?” asks Onie. “Track down information!” She adds: “Say your client is a Latina mother working two jobs. She needs food supplements. She has no transportation. Your job is to locate a food pantry within walking distance of her home that’s open after 8:00 p.m. and has a Spanish speaker on staff. That’s a perfect problem for a college student. It’s like a really fancy Google search.”
From the outset, Onie made the decision to work only with students who demonstrated high levels of motivation and commitment. In some of Health Lead’s sites today, as few as 10 percent of students who apply get selected. This has had the effect of attracting serious volunteers. In 2010, the organization reported that in 57 percent of cases its volunteers secured a needed resource within 90 days. This year, Health Leads will serve 9,300 patients and families — not a huge number given the scope of the problem it seeks to address — but the approach is gaining momentum.
One indication is that, where Health Leads works, doctors are changing their behavior. In the Children’s National Medical Center, in Washington, for example, over the past year, there has been a 300 percent increase in doctors “prescribing” Health Leads through the hospital’s Electronic Medical Record. The resources they request for patients include things like exercise or summer meal programs for children or subsidized child care for mothers, so they can find work and afford better food and housing.
Health Leads is also demonstrating that it can improve the efficiency of social workers. In some of the large urban hospitals where the program operates, the ratio of patient visits to social workers is close to 25,000 to 1. Because students can handle basic — but time consuming — cases, social workers can concentrate on what they’re trained for. At The Dimock Center, in Roxbury, Mass., initial data suggests that the program has doubled the time social workers can devote to therapeutic work.
Health Leads is also preparing a pipeline of new health care leaders. Two thirds of its students are either in pre-med tracks or pursuing careers in health, and the exposures they are getting are likely to shape the way they think about health care. As one volunteer said: “When I’m a doctor, I will never prescribe antibiotics that say ‘take with food’ without making sure that the family actually has food in the house.”
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Read previous contributions to this series.
Many health care professionals know that social conditions impact health more than medical care. In a survey conducted by Health Leads at Bellevue Hospital in New York, almost every pediatric primary care provider said the failure to address social and psychological needs “impairs” their ability to treat patients effectively. The vast majority said that the hospital needed a standardized system to screen for these needs on routine well-child visits. But 80 percent said it lacked the capacity to do it.
There is very little money available for this work. Medicaid doesn’t generally reimburse social workers for non-therapeutic tasks. Most of the time, this kind of assistance falls through the cracks. Society then spends oodles of money treating the crises that follow. “There is a tension between what we all know, and agree, needs to be done, and what we are doing,” says Onie. “As a society, we haven’t yet decided that we actually want less emergency room visits.”
Just a year ago, Onie thought that Health Leads’ biggest obstacle would be getting doctors to pay attention to patients’ social needs — given all the demands on their time. Today, the organization is getting so many referrals from doctors, for the first time in its history it has long waiting lists. Five decades after the war on poverty, a work force that can systematically address the social causes of illness is still to be built. Health Leads offers a model of how it might work. A broader system could incorporate students, community health workers, and lay workers. It need not be a perfect solution, nor an expensive one. But something has to be done. And the big challenge is getting health care decision makers to prioritize and pay for it. As Onie says: “How would we ever think that we’re going to secure a return on our health care dollar until we start dealing with these social factors?”

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