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Community Service, Part 1
Humanitarian Healthcare and Homeless Boston: Hidden Heroes and Opportunities
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Among his gossipy notes describing rich friends, John Aubrey (1626-97) mentions Elizabeth Grey, the Countess of Kent, as a skilled physician and apothecary, who “daily fed and cared for more than 70 poor people in her community”(1). These clinical encounters between the Countess and her patients were notable because she provided healthcare beyond the expected women’s role of midwifery and family nursing. Elizabeth Grey was one of many who served “outside the box,” and whose service focused on those in need. Some, like Elizabeth, provided free medical (and surgical) care to “poor” patients by paying for medical supplies and medicinal costs from their own private funds (2). Others funded or served from “free” hospitals.
In 1877, the Vermont native and self-made wealthy Boston restauranteur, Peter Bent Brigham, called such work “the care of sick persons in indigent circumstances.” And such community service is more alive than ever today at BWH, his namesake hospital, with a wide range of innovative ventures in the Department of Medicine alone. Projects on healthcare disparities and opportunities in community medicine continue to inspire research, teaching, and clinical care far beyond “the said County of Suffolk” specified in Brigham's will (3). Our department faculty touch lives not only in rich, poor, urban, and suburban Boston and Mission Hill, but also among New Orleans exiles, Haitian villages, slums in Peru, and prisons in Russia. Internship, residency, and research experiences encourage both trainees and more seasoned physicians to push the traditional boundaries of what it means to practice medicine. Some of these initiatives (such as the work of Drs. Paul Farmer and Jim Kim) get a lot of press. Others find themselves changing the world and their neighborhoods more quietly. Your Medicine Online, inspired though we are by Drs. Farmer and Kim and their teams, decided to take a closer look at some of the other stars in our midst, through a series of occasional articles.
We grouped our interviewees into three categories. First, we turned to clinicians for whom community medicine, as it relates to inequities and human rights, is a fulltime vocation, their primary source of income. Second, we sought out physicians who prefer to be volunteers while maintaining a more traditional medical practice. Finally, we looked at physician-investigators, those who devote a research career to healthcare problems, assessing and addressing social and system factors that influence disparities in healthcare delivery. In this, first, article, we look at the work of Drs. Lynn (Amowitz) Lawry, Director for Evidence-Based Research at the International Medical Corps in Washington and Bruce Levy, who leads the volunteer initiative at the New England Shelter for Vietnam Veterans.
INTERNATIONAL MEDICINE AND HUMAN RIGHTS ADVOCACY
Lynn Lawry, M.D., M.S.P.H., M.Sc.(formerly Amowitz), an Instructor in Medicine at HMS and faculty member in the Division of Women’s Health at BWH, has devoted her career to humanitarian aid, international human rights violations and human rights training, much of it in war-torn areas in Africa and the Middle East. She first realized her interest in international medicine while receiving a Master's degree in public health in parasitology in 1988. “I went to medical school knowing that I was going to do international medicine,” she says. “This was my goal from the start. During my residency at Brown, I convinced my residency director that one of my two renal rotations could be substituted with an international rotation, and I went to a remote area of Kenya to figure out where I fit in the international realm. After that 3-month experience, and with the public health degree, I found myself high on the list of people who could go to international emergency disasters. I was one of the first calls for every disaster from Rwanda on.
“After being in the refugee camps in Zaire and serving as medical director for the International Rescue Committee, I seemed to be treating the same wound—machete wounds—in different countries for different people for all of the same reasons. These reasons always turned out to be human rights issues. I wanted to be more involved in changing policies and the way we respond to emergencies. Lactation consulting, maternal health, and gender violence were some of the big issues that were not being supported by either emergency physicians or by the donors supporting the international agencies involved. During this time, I was a general medicine fellow and then faculty at the Brigham, and I was miserable. I wanted to do international medicine fulltime, not part-time, but it was hard to figure out a way to make that work. I ended up almost serendipitously with Physicians for Human Rights (PHR), through a talk with Howard Hiatt. I made a list of 25 people to talk to about my career. Howard was the twenty-fifth. I said, ‘Howard, I don't know what to do with my life.’ He looked at my CV, picked up the phone, called PHR, and said ‘I have the perfect person to do the studies you want in Afghanistan.’ I was hired that day. I had not thought much about being an academic, but then the research I was doing began to be published in JAMA and other medical journals, and Harvard realized that this was an acceptable career path.”
Dr. Lawry served PHR from 1999 to 2004, in Kosovo, Pakistan, Afghanistan, Sierra Leone, and Nigeria. She then began to focus more on research, evaluating, documenting and advocating for changes in health and human rights inequalities, especially for women worldwide. Projects included human rights training of Kosovar physicians, developing a standardized assessment tool for documenting sexual violence among refugee women, addressing gender issues in the HIV/AIDS pandemic in Africa, and a maternal mortality survey of women in Afghanistan (available online at http://www.phrusa.org/research/afghanistan/maternal_mortality.html). The media began to profile her, and she found herself featured in places as diverse as the Oprah Winfrey Show, National Geographic, and Fresh Air on NPR.
Recently Dr. Lawry returned to the humanitarian aid realm, where she is now Director for Evidence-Based Research for International Medical Corps (IMC) in Washington, D.C. (www.imcworldwide.org) She focuses on “rights-based programming, or making sure that programming meets international standards of care,” particularly for women. This “silent diplomacy” includes meetings with the State Department and other agencies, along with occasional international travel, to ensure that humanitarian data that is collected effectively benefits women's issues, and that care for women meets international human rights standards and is adequately funded. She continues to serve BWH from her Washington office in her role as the Director for the Initiative in Global Women's Health in the BWH Division of Women's Health, training medical students and fellows who are eager to find their place in international medicine. She recently published a detailed study on women's health needs in Sudanese refugee camps. Data from that study will enable her to lobby the State Department and the United Nations to address issues of gender violence. “Over the years it has become very clear that you have a better chance of making policy changes if you have statistics, not just stories,” she says. “For instance, for the study we did in Sierra Leone, we could say, ‘One hundred women were raped and here are their stories.’ But because we had the data, we could also say, ‘These are only a subset of the 64,000 women who are at risk or have experienced sexual violence, and we need programming money for 64,000, not just these 100 heartbreaking stories.’
“And I have seen government responses change because of our data,” she adds. “For instance, when I was at PHR, the U.S. Agency for International Development (USAID) had decided not to support traditional birth attendants training, but their decision was based on outdated and poorly done studies. When I showed them data that 99% of Afghan women were delivering with untrained birth attendants, or alone without any attendants, and that there would be a 10- to- 15-year lag to educate women enough to train for the midwifery or Ob/Gyn work USAID might support, I could say why not at least train the traditional birth attendant so women don't, for example, bleed to death after delivery? USAID saw our point, and we were able to lobby Congress for $5 million for women’s health, which included money for traditional birth attendants training programs.”
Cost and the need for continuity influence her advice to those who might want to do an international rotation, or offer their services as potential volunteers. “In the early 90s, I would originally go to an area, set up the program, and leave,” she says. “But what is needed these days is long-term programming, and local capacity-building. Even at IMC we require a three-month commitment from our volunteers. It is hard for agencies to implement one- or two-week experiences when war-risk insurance alone costs between $3000 and $5000 a week, and that’s money that could be used for the program. Most of our programs are set up so it is the local physicians who do the work, not us. We support, and train, and serve as intermediaries between governments, including their own, where they may not be able to get funding.”
So what would she tell those who care about similar issues and want to make a difference? “It completely depends,” she replies. “There are so many different ways to work internationally; you can do human rights; you can do humanitarian aid, that is, direct care; or you can do policy; there are many different paths. Short-term experiences are easier if you’re a surgeon or an anesthesiologist; you can go in, do a service, and come home. But to implement long-term programming, you need to do the diplomacy. You need to become known and trusted. Does going just to “feel good” or to help as an individual really help overall? I’m not sure. It really only helps if you have something to offer to those who are in need; the experience cannot be all about you. I try to help the students I work with find out where they fit. And things are always changing. For example, military involvement opens the need for civil-military discussions on how to deal with these issues. And the humanitarian response is always acting in concert with policy, international affairs, and international law, for example. I am going to be very busy until I retire!”
If she were teaching a course on her work, what books would she use? “Chris Beyrer is editing a public health text with Johns Hopkins University Press; that should be coming out soon,” she says. “And there is Eric Noji’s book, The Public Health Consequences of Disasters , and Jonathan Mann’s Health and Human Rights: A Reader . For intellectual discussions about the on-the-ground issues, there is The Bookseller of Kabul by the journalist, Åsne Seierstad; Khaled Hosseini’s The Kite Runner ; and Between Two Worlds, the autobiography of Zainab Salbi, who founded Women for Women. These books expose you to some of the things you’d have to deal with in programming.”
And how does being a woman--and mother of a 5- and 9-year old—influence Dr. Lawry’s work? Being a woman leader in Arab countries has not been a major problem, she says. “I spend a lot of time observing, to learn to avoid faux pas. I use local intermediaries in policy work, but I never had a problem getting to the people I needed, even in Taliban-controlled Afghanistan. As a physician you have a different status. And if you're a human rights expert, it's your status as a physician that will get you to the higher level. That's what I use to get to what I need for the people on the ground who have no voice.” And as a mother? She pauses. “I look at what the needs are at the moment,” she says, “and it changes. I don’t have to be in the field as much now because I’m becoming more a mentor than a researcher, and can be home more. But the kids know that what mommy does is to go away to disasters. My son said the other day, ‘Mom, how come you haven’t gone away in a while?’ So we had a long discussion. And he said, ‘That’s okay, Mom. When you’re away we get more McDonald’s!’”
VOLUNTEERING LOCALLY: HEALTHCARE TO HOMELESS VETERANS
As an undergraduate at the University of Pennsylvania during the Reagan administration, Bruce D. Levy, M.D. got his first glimpse of something he’d never seen while growing up in St. Louis: homeless people, lying like garbage on subway grates in the sidewalk, where the warm air blew by with each passing train. What was going on? It bothered him. He wanted to understand it. He wanted to do something about it. Now, twenty years later, Dr. Levy coordinates a volunteer team of BWH Medicine physicians who provide medical care at the New England Shelter for Homeless Veterans (NESHV) (www.neshv.org). The third largest shelter in Boston (after Pine Street Inn and the Long Island Shelter), the NESHV was founded as part of the Vietnam Veterans’ Workshop (VVW), and provides homeless veterans (both men and women) with shelter, food, a place to sleep, and an array of social services. All Shelter residents must be sober and working or enrolled in a job training program. Dr. Levy got involved as a fellow, shortly after the Shelter first opened in 1991. He became the volunteer medical director in 1993. Since that time, physician-volunteers have provided healthcare at a walk-in “First Aid and Referral Service” at the Shelter every Wednesday night.
“The cohort of attendings who work at the Shelter now have been doing this for a long time, and they are real stars, real troopers,” he says. They include Drs. Wendy Chen, Kathryn Cunningham, Joseph Dorsey, Kathleen Finn, Michael Fischer, Nancy Keating, and Richard Lee. “I’ve been going for about five years,” says Dr. Fischer who, like many of the volunteers, started during his residency. “Bruce does a great job of coordinating. It’s a good setting for HMS students to learn since there are no tests or prior records to fall back on.” And Dr. Lee says, “For me, personally, it’s a nice reminder that I went into medicine to take care of people—and that it doesn’t matter whether the setting is a plush examining room or a homeless shelter.” “It’s the veterans themselves who keep me going back,” says Dr. Keating. And Dr. Finn, who had volunteered in homeless shelters and soup kitchens in college and graduate school, began to volunteer again “when the news got to me. Listening to news reports about inequalities, politics, and the health care system just got to me. I had started to believe people were more fundamentally bad than good. The veterans’ appreciation and attempts to turn their lives around help me to believe in the ‘goodness’ of people. They make me a better physician.”
“We saw early that you need to go to them,” says Dr. Levy. “In addition to financial barriers to care, there are substantial non-financial barriers that relate to feeling alone, not trusting others. You have to work to generate trust, because there is a strong social disaffiliation in this population. They don’t trust institutions, especially big institutions like the Brigham. If you spend time connecting with them as people, then if it’s necessary they will follow you into large hospitals for specialty care. It’s a very rewarding experience for a health care provider. We see whoever walks in, sometimes just a couple of people, sometimes as many as 10 or 12 in an evening.”
Psychiatric illness is prevalent and leads to homelessness, but even more commonly, the combination of homelessness, social isolation and the stress of poverty lead to psychiatric illness. Homeless people frequently feel quite alone. If you ask about their next-of-kin, the most frequent reply is “nobody.” “The first time a physician meets a homeless patient they are often unwilling to talk to the physician. So when they come to see us,” says Dr. Levy, “the nurses have learned that you put their feet in a warm foot soak with some Betadine, give them a warm cup of tea or coffee, and have them sit there and relax. It’s very different from providing care at BIMA, where the patient walks in because he wants to see you. When you provide care to a homeless person at a shelter, you’re going to their home, making a house call. Sometimes it might take two or three visits just to get them to take off their hat so you can look at the lesion on their head. If you ask an open-ended question, you’re often rewarded with a story. Once the trust is there, they are very eager for companionship, to tell you their story.” Those who care for homeless patients say that this type of clinical practice has, ironically, some of the same rewarding parallels that a medical “concierge practice” might have, he notes; “When these patients end up in the emergency department, the first person they ask for is the person they developed a relationship with in the shelter.
“Patients are very grateful,” says Dr. Levy. “And they’re generally extremely motivated. As an example, they’ve just gotten a new job. It’s their ticket out of the Shelter. If they sprain their ankle, they will come to us saying, ‘Fix me up so I don’t have to miss tomorrow’s work.’ If they lose that job, it is not only a major setback to their journey out of shelter living, but it could be a disaster: a 1994 study in Philadelphia, for example, showed that homelessness carried an age-adjusted mortality rate nearly four times that of Philadelphia’s general population (4).
“Caring for this population, it’s medically interesting,” Dr. Levy continues. “Almost all homeless adults have several medical illnesses that they are largely ignoring, whether it’s diabetes or hypertension, heart disease, or chronic lung disease, they’re ignoring these conditions. If they have a health concern, it’s usually regarding their eyes, teeth or feet. So it’s common for us to identify several neglected medical illnesses that we then can help address.”
Community services rely on networking, and medical care to the homeless is no different. Dr. Levy first learned of the shelter from colleagues at the Harvard Vanguard Alliance for the Homeless, a charitable arm of Harvard Vanguard Medical Associates that helps provide medical, podiatry, dental and nursing services and some donated medications to the Shelter. Additional valuable support comes through the Partners Community Benefits Office, thanks to people like Matt Fishman and Lee Chelminiak, and there are private donations as well. The New England College of Optometry also helps provide volunteer services and donated items, including optometry exams and glasses. Some shelter residents without “honorable discharge” veteran status do not qualify for VA benefits. But even for those who do, it’s still a matter of getting them hooked up and back into the system.The BWH volunteer providers also work closely with full-time health care providers from Boston Healthcare for the Homeless (5), a city-wide program that provides vital health services to Boston’s homeless persons. This licensed “clinic without walls” was started over 15 years ago by Dr. James J. O’Connell as a Robert Wood Johnson Foundation project. One innovative aspect of the program is the Barbara McInnis House in Jamaica Plain. A respite unit, the McInnis House accepts many BWH homeless patients for transitional health services, providing beds for homeless persons who are not ready to be back in shelters or on the streets at the time of hospital discharge. While the patients recover from their acute illness or injury, the Boston Health Care for the Homeless Program providers work with them to deal with their personal issues as well.
The medical services at the NESHV are also a teaching experience for HMS medical students and BWH interns and residents. “A resident is often with us on Wednesday evening,” says Dr. Levy, “And students in the (joint MIT/HMS) Health Sciences and Technology program all rotate through the Shelter as part of their Introduction to Clinical Medicine course.”
The number of homeless in Boston and around the country continues to grow, and their healthcare needs continue to grow. With increasing fiscal constraints on the healthcare system, especially in academic medical centers, public hospitals, and Boston Health Care for the Homeless Program sites, where the majority of our city’s poor get their healthcare, our society faces some tough questions. How can we help address the problem of healthcare for the homeless in Boston? Dr. Levy believes that, “In this population, the health needs are coupled with social services needs. Boston has many outstanding resources, but we can’t let financial pressures erode our ability – or willingness – to provide these services. BWH is leading the way, with Elizabeth Glaser, Vice President for Clinical Services, heading a task force on caring for those without health insurance to be certain they continue to receive outstanding care in our system.
“Paul Farmer and Jim Y. Kim have taught all of us to care for the poor one patient at a time,” concludes Dr. Levy, “and Francis Peabody simply stated that the secret to caring for the patient is to care for the patient. Through volunteer activity, BWH providers and administration are contributing to the care of Boston’s poor – homeless Veterans at the NESHV.”
Shelter photos in this article are from the NESHV website “tour”; to see more, click here
(1) cited in Lynette Hunter and Sarah Hutton, eds., Women, Science and Medicine 1500-1700 (Phoenix Mill, UK: Sutton Publishing Ltd, 1997), 91.
(2) A less well known example is that of Lady Catherine Springett, whose granddaughter married the Quaker, William Penn. Lady Catherine was a wealthy English widow who used her servants (and “half her income”) to prepare “medicinal” products for doctoring the poor who regularly came to the house. Her daughter-in-law records that Lady Catherine was an expert at removing cataracts and treating “many desperate burns, cuts, dangerous sores, and broken limbs,” regularly seeing up to twenty patients a day.
(3) Information about Peter Bent Brigham and quotes from his 1877 will are taken from David McCord, The Fabrick of Man: Fifty Years of the Peter Bent Brigham Boston: Published for the Hospital by the Fiftieth Anniverary Celebration Committee, 1963, p. 14.
(4) Hibbs JR, Benner L, Klugman L, Spencer R, Macchia I, Mellinger AK, Fife D. “Mortality in a Cohort of Homeless Adults in Philadelphia,” NEJM 1994; 331:304-309.
(5) see Levy BD and O’Connell JJ, “Health Care for Homeless Persons,” NEJM 2004;350:2329-32.
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