NY Primary Health Care: Montefiore Medical CenterBuilding a service to meet the needs

of Latin-American peoples as displaced indigenous peoples

Presentation by: Lanny Smith, MD, MPH, DTM&H

Montefiore Residency Programs in Primary Care and Social Medicine, AECOM

&Doctors for Global Health, DGH

With respectful appreciation to the Kaurna people.

• In Highbridge and Morrisania, the percent of residents living below the poverty level is higher than in the Bronx and NYC overall

• Highbridge and Morrisania have higher proportions of Black and Hispanic residents than the Bronx and NYC overall total number of people living in Highbridgeand Morrisania in 2000: 189,800

0 1

Miles

2

CHCC Service Area

CHFP Service Area

FHC Service Area

WB Service Area

Source: 2000 US Census, 1999 MERRITT

July 3, 2001Department of Family Medicine and Community HealthAlbert Einstein College of Medicine

Co-Owned Service Area

Race/Ethnicity Composition of Population within Montefiore Medical Group Service Area

H.Choi

% Composition of Each Race/Ethnicity0.6855 in. = 370,000 persons

370,000

Hispanic, Any RaceWhiteBlackNative AmericanAsianPacific IslandersOther Ethnicity2 or More Races

Why am I not speaking about Native Americans in

the Bronx?

• Genocide.• When did the United States government

finally recognize Native Americans as U.S. citizens?

• ????

• Cherokees in the state of Georgia, fought their removal in the federal Supreme Court. They thought they had won when Chief Justice John Marshall ruled that the Cherokees were a "domestic dependent nation" that could not be forced by the state of Georgia to give up its land against its will. Unfortunately, President Jackson and the state of Georgia ignored the decision and moved the Native Americans to Indian Territory in Oklahoma. The Cherokees refer to their trip as "The Trail of Tears." 1 October 1838. More than 4K died. “In December 1838, President Van Buren said to Congress:

• It affords sincere pleasure to apprise the Congress of the entire removal of the Cherokee Nation of Indians to their new homes west of the Mississippi. The measures authorized by Congress in its last session have had the happiest effects. [A People’s History of the United States, by Howard Zinn, p.146]

• “Their glory has fled, their spirit broken, their manhood effaced, better they should die than live the miserable wretches that they are.” (one week before Wounded Knee)

• L. Frank Baum, editor of South Dakota's Aberdeen Saturday Pioneer newspaper

• Author of The Wizard of OZ.

Wounded Knee Massacre 12/29/1890

• After most of them had been killed a cry was made that all those who were not killed or wounded should come forth and they would be safe. Little boys who were not wounded came out of their places of refuge, and as soon as they came in sight, a number of soldiers surrounded them and butchered them there... Of course it would have been alright if only the men were killed; we would feel almost grateful for it. But the fact of the killing of the women and more especially of the of the young boys and girls who are to go to make up the future of the Indian people, is the saddest part of the whole affair and we feel it very sorely."

• Mortality• Native American Infant deaths per 1,000

live births: 8.7• Source: Infant Mortality Statistics from

the 2004 Period Linked Birth/Infant Death Data Set, Table 1

• Australia 4.6• United States 6.4• Source: U.S. Census Bureau,

International Database 2007

• Residency Programs in Primary Care and Social Medicine

• AECOM affiliated• 10 new Residents per

year, 3 year program• Plus one PC/SM

Chief (Aaron FoxSara Doorley)

• Dir. Hillary Kunins

Resident Projects

• Citiwide Program• Highbridge Health Promoter CHW• Weight Watchers LIVE program• Research Based Activism and Advocacy

Course (offered yearly in October)• Plan B (“Day After” pill)• Food Security in the Bronx

OPEN IT

• Opportunities Pro-Immigrant, Elderly and Newcomer and International Travel

• Includes Community Health Worker accompaniment

• A door into our Health Center for people who need it (have few resources, have documentation issues, have language issues, have a history of abuse; or are visiting others in the world and want to be safe)

“A clean, well-lighted place.”

• Comprehensive Primary Care Services (med, peds, OB/GYN, opthal, radiology, nutrition, derm)

• Referral services• Sliding scale fee system• Social work for counseling and services• Respectful WELCOME for Undocumented persons• Vaccinations and counsel for travel• Care by physicians who have studied the history, culture,

health statistics and prevalent diseases of their countries of origin

Barriers identified and OutcomeBarrier Example Collaborative Work

1. CHWs contacted the referring CBO a week in advance, obtained the new patient

registration documents, and delivered them to the CHCC registration staff prior to apt. date

OPEN-IT pts had longer registration wait times

secondary to translation needs and a different documentation

process

A complicated registration

process

1.CBO-CHW communication led to a CHW arranged home visit with CHW and MD

Uninsured immigrants unable to attend clinic based medical

care secondary to physical limitations

Physical limitations to health care

access

1. The CBOs and CHWs conducted weekly outreach to taxi garages, construction sites, day

care programs, street vendors etc.

Uninsured immigrants not knowing where they can go to

receive immigrant friendly care

Lack of knowledge regarding available services

1. Referring agency provided a letter verifying name and contact information of the patient2. Monte CHCC director allowed consulate

issued IDs, workplace IDs, and passport pictures as proper form of ID

Pts were being asked to provide a U.S. issued I.D. as

the only form of adequate identification

Inability to produce “proper”

documentation

1. Referring CBO would find a translator to

accompany the immigrant family to the medical apt.

Many of the OPEN-IT patients come from African

countries and speak a myriad of languages

Language

1. CHWs accompanied patients to speak with Lily

Cruz who would then retroactively implement the

sliding scale fee

Referred CBO patients were receiving incorrect bills

from the clinic for services

(sliding scale was not being applied appropriately)

Inability to pay for clinic services

1. CHWs accompanied OPEN-IT patients to the

clinic administrator to have all rx signed in order to

receive them for $5/med.

Uninsured or underinsured patients were having

difficulty accessing the in-place system for low cost rx.

Inability to pay for prescribed medications

1. CHWs accompanied OPEN-IT patients to the first

medical appointment and educated OPEN-IT patients

of various diagnosis potentials

Referred CBO patients were contacted by the CHW.

During the conversation fear of potential negative

diagnosis was expressed (HIV, STI, DM).

Fear of medical diagnosis

Barrier Example Collaborative Work

http://www.tenement.org/immigrantexperience/brourfocus.htm

• The following is a breakdown of the Lation population in the Bronx.*• Population

BronxMexicans 34,377 Puerto Ricans 319,240 Cubans 8,233 Dominicans 133,087 Central Americans 21,408 South Americans 20,782 Other Latinos 107,578 Total Latinos 644,705 Total County Population 1,332,650 Percentage Latino 48%

• *From 2000 Census

El Salvador

• 1932 Massacre, 35,000 Indigenous persons killed in one day

• ARENA party would shout during armed civil conflict: “another ’32, another ’32”

• Nahuatl and other Mayan languages lost

Guatemala

• U.S. sponsored coup in 1954 (Pres. Arbenz)

• U.S. supported military governments since, until 1996

• Over 200,000 Indigenous Guatemalans killed in the 1980’s

vodpod.com/watch/24468-guatemala-nunca-mas

• On Friday, April 24th, 1998, Juan Gerardi, a 75-year-old Guatemalan bishop, presented on national television "Nunca Mas: Guatemala" (Guatemala: Never Again), the final report of the Recovery of the Historic Memory Project ("REMHI Project") of which Gerardi had been director. Nunca Mas contains a clear analysis and strong condemnation of the role of the Guatemalan security forces in planning and systematically committing atrocious political and civil rights violations since 1954.

• Two days later, on Sunday night, April 26th, Gerardi was assassinated.

• December 04, 2006• Guatemala: Menchú forms indigenous political party • Human Rights advocate and 1992 Nobel Peace Prize

winner Rigoberta Menchú Tum today announced during a visit to Costa Rica that she is forming an indigenouspolitical party in Guatemala.

• The goal: win power in the 2012 general elections, and rule Guatemala. Rough translation from Spanish:

• “I will be one of the people involved in the development of this party, which is now at its formative point”, declared Menchú. She assured that the indigenouspeople of Guatemala, who are 60% of Guatemala's 12.2 million inhabitants, will look to emulate the example of Bolivia's president, Evo Morales.

Peru

• November 02, 2007• 350,000 indigenous people in Peru say "No FTA"• This week, the Interethnic Association for the

Development of the Peruvian Amazon (AIDESEP) sent a letter to Congress (PDF in both English and Spanish) urging members to oppose the Peru FTA, which currently is scheduled to come up for a floor vote next Wednesday. AIDESEP, "Peru’s largest national organization of Amazonian indigenous communities, representing over 350,000 indigenous persons from 1,350 communities spanning 16 different linguistic groups and six regional organizations

Ecuador, Argentina (PHM)

Mapuche• Location: Southern Chile and Argentina• History: The Mapuche are the only indigenous

group which withstood the attacks of the Inca and were never conquered by them. They are also the only south American indigenous group which was never conquered by the Spaniards. In the late 19th century, the Chilean armies put down a major uprising and finally "pacified" the Mapuche. They were then settled on "reducciones" or reserves. This process continued until 1929 when 3,078 reserves had been created. By 1979, the date of the current law which provides for the division and liquidation of the Mapuche reserves, the amount of land available to the Mapuche had been further reduced.

• Language: Mapuche language is called Mapudungun

• MEXICO: Indigenous People "As Poor as Ever"By Diego Cevallos

MEXICO CITY, Jan 4 2006 (IPS) - Some 13 million indigenous people in Mexico, most of whom are poor, illiterate and work for little to no pay, saw the New Year arrive while listening to yet more government promises that things would improve and watching the start of a unique Zapatista guerrilla campaign in favour of their rights.

• The maternal mortality rate is one of the highest in the world: in Guerrero, 281 indigenous women die for every 100,000 births. Among all indigenous women in Mexico, the average is 151 and for Mexican women in general, 51.

• Lack of medical attention for women in their reproductive years:

• in México, 1 gynecologist attends to 2,414 women in their reproductive years

• in Guerrero, 1 gynecologist attends to 4,132 women• in the Mountains region of Guerrero, 1 gynecologist

attends to 17,654 women (there are 5 gynecologists for 88,277 women)

Doctors for Global Health (DGH)

• Founded in 1995• To promote Health and Human

Rights with Those Whose Voices Have Been Silenced

Doctors for Global Health (DGH)

• Works at the synergy of health, human rights, education and art.

www.socialmedicine.info

• Interview with Victor Toro Ramirez, activist for immigrants in the United States of America, ex-political prisoner of the military dictatorship in Chile, currently in process of being deported by the United States Department of Homeland Security Immigration and Customs Enforcement of the Bush Government.

Victor Toro (1)

• Although by New York law health providers in clinics must offer translational assistance for patients with limited English, 75% of the hospitals in New York City do not give consistent or adequate access to translation. The informal sector of society works in conditions of exploitation with little protection in their labor, and is comprised mostly of persons of color. Of every five immigrants in the city of New York, one is undocumented, and thus forced to work in the informal sector. Ninety-five percent of domestic workers are persons of color, 99% were born outside of the United States and 93% are women. Similar to the above are housing conditions, the application of justice, domestic violence, the Welfare system and the system of wellbeing of the child, the right to vote, etc.

Victor Toro (2)

• Definitely, the centers of Montefiore in the Bronx are a blessing, for the services that they bring to the community in terms of health, attention, remedies and sanitation. Every summer we have Health Fairs in the South Bronx streets, and we have always counted on their help and participation, with orientations, attention, and education of the doctors and medical students, a unique type of contribution to our community, and Montefiore has always been present, this is one mission of the Peña that gets larger every time, because there is much more that we can do in this area which is so important, health.

Victor Toro (3)

• Concerning the encounters, classes and expositions we have had in the School of Medicine Albert Einstein, in the classes with doctors and students it has been my honor to be able to speak about the desires and thoughts of our peoples and our struggle. I believe they have been activities of great use for all (students, doctors, teachers and myself as a community activist). There is always an open ear that will understand that their service and learning should always be with the social world and with the people who need it the most. There have been some initiatives which should multiply at all levels of society, so we can have thousands of doctors like Miguel Enriquez and Ernesto (Che) Guevara.

For More Information on Montefiore and DGH

• PHM www.phmovement.org

• Liberation Medicine, see Doctors for Global Health www.dghonline.org

• Social Medicine, see www.socialmedicine.info

• And Montefiore RPSM www.socialmedicine.org