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Bridging the Gap
He was known as a “frequent flyer,” a regular visitor to emergency departments and urgent care clinics who consistently failed to manage his diabetes. Living in Boston, he had access to some of the best medical care anywhere, but his illness remained out of control.
Monica Bharel, Harvard Medical School instructor in medicine at Massachusetts General Hospital and commissioner of the Massachusetts Department of Public Health, was recalling a patient she met early in her career.
At first, the patient’s repeated bouts of illness mystified her, but as she learned more about the man’s life, the mystery was solved. One key issue was the fact that he was homeless.
“People’s stories matter,” Bharel said. “We know so much about the pathophysiology of diseases, but we know so much less about where a man should store his insulin when he sleeps under a bridge.”
Bharel, who went on to serve as chief medical officer for the Boston Health Care for the Homeless Program was speaking about the challenges of caring for the most vulnerable patients at a seminar hosted by the Center for Primary Care at Harvard Medical School and the HMS Department of Global Health and Social Medicine. The crowded auditorium at the Joseph B. Martin conference center was filled with clinicians, researchers, advocates and medical students.
“Caring for poor people—whether they are in another country or living within the shadows of this campus—is a challenge requiring great creativity. That’s the real work of places like HMS.” —James O'Connell
She was joined by James O'Connell, HMS assistant professor of medicine and founder and president of the Boston Health Care for the Homeless Program, and Paul Farmer, the Kolokotrones University Professor of Global Health and Social Medicine, head of the HMS Department of Global Health and Social Medicine, and founder of Partners In Health, an organization that delivers world class health care in places such as Haiti, Rwanda and Peru by collaborating with local communities and national governments.
The speakers shared stories from their work and discussed what they said were the few differences and many similarities between work in resource-limited settings internationally and work with vulnerable populations in Massachusetts.
Community Health Care
All three agreed that building personal relationships with individuals and communities is the foundation for providing excellent care.
“It’s about learning who you are serving and what they want,” O’Connell said, noting that homeless programs around the country all look different because different communities have different needs.
From Sierra Leone to Back Bay, where and how a patient lives has a huge impact on her health, the speakers said.
Bharrel noted a study that found the chances of having diabetes were more than three times higher for riders who take the MBTA to the economically challenged Dudley Square neighborhood in Boston than for the riders who take the MBTA to more affluent Arlington station. Yet the two mass transit stops are less than two miles apart.
Bharrel said non-clinical factors, including economic status, racism and lifestyle, have a much bigger impact on health in Massachusetts than clinical care.
“There are endemic health disparities that are all of our responsibility to address together,” Bharrel said. “Soaring health care costs won’t go down unless we do something about the social determinants of health.”
Farmer said that this was one difference between health care work in places like Boston and work in nations without existing health care systems, where spending on health and education are near zero.
Investing in Health
“The first thing we need to do there is let costs soar,” Farmer said, not only because money is needed to deliver better health, but because investments in health and education yield immense dividends in economic growth.
He also noted that even some countries that are struggling to build functioning health systems have managed to achieve levels of progress delivering certain kinds of care that richer nations have not been able to attain.
Rwanda has better HIV statistics than the United States—higher survival rates, lower transmission rates and greater adherence to medication plans—because they have robust systems of community health workers who can meet patients where they live and make sure their long-term medical needs are met, Farmer said.
“We can’t deliver good care for chronic illness without community health workers,” Farmer said. “But we also need hospitals. If I get hit by a car, I don’t want community based orthopedics; I want a hospital and a surgeon.”
The speakers expressed their shared feeling that the work of treating vulnerable patients was not only morally necessary but richly rewarding, providing complex medical and scientific challenges and opportunities to work with outstanding people, both within the communities served, on clinical teams, and in collaborations with researchers, educators, advocates and policy makers.
“Caring for poor people—whether they are in another country or living within the shadows of this campus—is a challenge requiring great creativity,” O’Connell said. “That’s the real work of places like HMS.”