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Against All Odds:
City Health Works in New York
with Manmeet Kaur & Prabhjot Singh
Part I

PAUL HOND

 

 

 

Manmeet Kaur and Prabhjot Singh made a commitment to serving their community.

Despite enduring a terrifying act of violence, they haven’t broken it.

When Manmeet Kaur and Prabhjot Singh moved into East Harlem in 2010, the health crisis there had long been dire.

Seven years earlier, the Journal of General Internal Medicine published an article stating, “The toll diabetes takes on residents of communities of color, such as East Harlem, is staggering ... Hospitalizations among persons 65 years and older for diabetes-related amputations in this neighborhood are nearly 5 times those for NYC overall.”

In 2007, the New York State Health Foundation reported that East Harlem residents are hospitalized for diabetes at a rate ten times that of people on the Upper East Side.

In 2006, N. R. Kleinfield of the New York Times, covering diabetes in East Harlem, wrote of “the human behavior that makes dealing with Type 2” -- the common form of diabetes, in which the body cannot produce enough insulin to maintain a normal blood-sugar level -- “often feel so futile - the force of habit, the failure of will, the shrugging defeatism, the urge to salve a hard life by surrendering to small comforts: a piece of cake, a couple of beers, a day off from sticking oneself with needles.”

Despite this attention, the problem only worsened. ‘DIABETES EPIDEMIC’ DECLARED AS NEW YORK CITY DEATHS TIED TO THE DISEASE HIT ALL-TIME HIGH, ran a New York Daily News headline in June 2013.

Around the same time, the New York City Department of Health and Mental Hygiene found that 667,000 New Yorkers have diabetes -- a 33 percent increase from a decade ago. And East Harlem (population 108,000), half Latino, a third African-American, with an influx of professionals, mostly white, filling the new residential buildings -- a neighborhood of high obesity rates and gang activity, where 38 percent of residents live below the poverty line -- is New York’s diabetes epicenter: as many as one in five people here has the disease.

For Manmeet Kaur ’05BC, ’12BUS and Prabhjot Singh, a SIPA (School of International and Public Affairs, Columbia University) professor, this quiet catastrophe points up a fatal failure in the US health-care system.

It also presents a bold opportunity.

*   *   *   *   *

Two women from East Harlem sit facing each other inside a large room with a mirrored wall in a Mount Sinai Medical Center clinic on East 94th Street.

“I had a horrible day,” says the younger woman. “Half the day I was feeling drowsy, irritable, dizzy, confused. I don’t like to check my glucose but once a day, so I didn’t even check it after that.”

“You know that when the doctor prescribes your insulin,” says the older woman, her voice gentle and firm, “he prescribes for you to take it just before you eat.”

A sigh. “I know, but sometimes I get thrown off schedule.”

“Yeah, I understand. We all get busy, and life doesn’t wait for us. But be careful, because there can be a lot of side effects, like you felt last night.”

At a long table, a small group of community-health workers, called coaches, observe the two women, who are also coaches. Led by nutritionist and diabetes educator Jamillah Hoy-Rosas, the coaches are rehearsing for the real-life encounters awaiting them outside.

“I don’t wanna feel like that no more,” says the younger woman. “Is it because I doubled up?”

“Yes, it’s because you doubled up. Then you didn’t eat. When you double up on your insulin you’re gonna feel bad, and it could be dangerous.”

Hoy-Rosas takes notes. She’s the clinical care manager for City Health Works, a nonprofit community-health organization started by Manmeet Kaur. Prabhjot Singh is the lead adviser.

Last September, in the shadows of the impending government shutdown over opposition in Congress to the Patient Protection and Affordable Care Act (“ACA“), City Health Works began a pilot project to demonstrate its approach.

It’s October now. As the shutdown enters its second week, the machinery of health reform cranks forward. The ACA has accelerated a fundamental shift in financial incentives, supporting innovations in payment and delivery that reward quality of care over quantity.

“Traditionally, doctors and hospitals have been paid on a fee-for-service basis,” explains Manmeet Kaur, 30, seated in the City Health Works office at the East 94th Street clinic. “The insurer pays the doctor or clinic for each visit, each test, each screening. But the fee-for-service structure hasn’t improved outcomes or controlled costs.”

The office has peach walls, filing cabinets, carrels, nutrition posters. “Hospitals have never been incentivized to care about wellness and prevent illness,” Manmeet says. “They profit if you’re sicker.” She chuckles. “This is at the heart of why the system is so perverse.”

At City Health Works, Manmeet and Prabhjot have zeroed in on a critical gap in the health-care system: a lack of access to primary care in low-income areas. This gap has always been a reality for patients, but now, for the first time, doctors and hospitals are feeling the financial effects.

“Health reform is saying, We’re not going to pay for all these people that are bouncing back over and over again,” says Prabhjot, 31. He notes that the fee-for-service model is being replaced by strategies like global payments, in which hospitals manage the risks of all of their patients with lump sums: if they do it for less, they save money; if they do it for more, they lose money. “So there’s a massive incentive,” he says, “to build this community-health infrastructure.”

Prabhjot is the Director of Systems design at Columbia’s Earth Institute and teaches a course on global health practice at SIPA. He is also a physician at Mount Sinai Medical Center and co-chair of the One Million Community Health Workers campaign, an Earth Institute-based initiative of the African Union and the UN Sustainable Development Solutions Network. (The goal: one million health workers for sub-Saharan Africa by 2015.)

He wears a burgundy turban, a long, black beard, a forest-green pullover, and designer jeans.

“Three or four years ago, the attitude of the New York health systems was, We don’t want to deal with community health. It’s such a money loser in this fee-for-service system,” Prabhjot says. “That flipped immediately” -- he snaps his fingers -- “when health reform kicked in. Now there was a 30-day readmission penalty: if patients came back before 30 days and you treated them, you wouldn’t get new money. Suddenly, doctors said, We’d better build a system to take care of people for 31 days.

“But what about the rest of the year? Why not make a system that takes care of people for 365 days, and not have them just come in and out of the hospital?”

“There’s a need,” says Manmeet, “for a much more intensive community-based layer of the health-care system. Behavior changes are complicated. Socioeconomic factors that cause stress and influence health cannot be solved in a doctor’s appointment.”

Prabhjot can attest. “As a primary-care physician, I know that in my 15-minute visit with a patient, I’m not equipped to give life coaching. And I’m not the guy to do it. So we’ve hired residents of East Harlem who are gifted motivators, trained in motivational interviewing techniques, who help people set goals around diabetes care, around living a healthier life.”

For the moment, the coaches are paid for with grant money from the Robert Wood Johnson Foundation and a service fee from Mount Sinai, New York’s largest private-hospital system. Manmeet and Prabhjot are working with insurance companies so that, over time, insurers will join the hospitals in financing the coaches.

“Our goal for this pilot,” says Prabhjot, “is to get sustainable payments so that we know the pricing for the system. We’re figuring out all the connections, all the costs.”

Prabhjot and Manmeet believe that their model will lower expenses for everyone: patients, hospitals, clinics, and insurers. “As that happens,” Prabhjot says, “then this can spread.”

*   *   *   *   *

It’s about a thirty-minute walk from City Health Works to the high-rise condo at Fifth Avenue and East 120th Street. That path, which traverses the lower half of East Harlem, is checkered with fast-food joints, tenement walkups, and columns of the stark, huddled red-brick towers of the New York City Housing Authority.

Crossing East 96th at Third Avenue on a Friday afternoon, you pass the Mecca-facing domed mosque of the Islamic Cultural Center of New York, toward whose open doors flows a stream of men and boys in caps and tunics. Outside the gates, a South Asian woman in a chicken curry, telling a health-curious customer that meat is a necessity, which prompts a bearded, taqiyah-wearing man to suggest, in a barrio accent, that vegetarianism and bottled water are the way to go (he’s not there yet himself).

Three blocks north, a food stamp-friendly greenmarket offers broccoli ($1.50/lb.), collard greens, snap peas, turnips, kale. Three elderly Puerto Rican women watch a stir-frying demo at an adjacent booth (broccoli and parsnips, olive oil, low-sodium soy sauce). The market, open on Fridays from April to November, is run by Harvest Home, a nutrition-minded nonprofit that receives support from EmblemHealth, New York’s largest private health insurer.

EmblemHealth’s purple-on-white emblem is conspicuous here, and vans bearing the logos of other insurers cruise the area, competing for customers. So it makes a kind of thematic sense that when you turn and look west on East 99th Street, you see, half a mile away on Madison Avenue, looming like an obsidian monolith in a fantasy novel, the 434-foot black edifice of Mount Sinai Medical Center.

On Third Avenue, meanwhile, the food plot thickens: we have, clotted together, McDonald’s, Little Caesar’s, KFC, Burger King, Taco Bell, Dunkin’ Donuts, and, in a few groceries, modest arrays of apples and fresh vegetables that can’t shout like the playroom reds and yellows of the busy fast-food chains that saturate the diabetes epicenter of New York.

Turn left at 110th (Tito Puente Way), walk under the elevated train at Park Avenue, past the Lehman Village Houses to the traffic circle at Fifth Avenue, where the future home of the New Africa Center rises above the northeast corner of Central Park. Below, in the autumn-mellow park, on a green-skinned lake, brown ducks paddle with their bills open, munching the algae-colored, protein-rich duckweed. This is where East 110th Street becomes Central Park North.

If you turn right on Fifth Avenue, you’ll pass the Harlem Academy; the Martin Luther King Jr. Towers; the fire-engine-red garage doors of Engine 58/Ladder 26, where a banner reads, Proud home of FF. Mike Corrigan, currently on active military duty with the US Army in Afghanistan. Freedom is not Free; and low-rise residential buildings and storefront churches that march up to the schist outcropping at 120th Street, which marks Marcus Garvey Park (called, before 1973, Mount Morris Park, the name preferred by today’s realtors).

Manmeet and Prabhjot live across from Marcus Garvey Park with their one-year-old son, Hukam Singh. They have lived there for three years.

*   *   *   *   *

“I hear it every day,” says Leny Rivera, a Honduran-born New Yorker who lives on East 109th Street. “Neighbors talking about struggling with diabetes.”

Rivera was the first coach hired by City Health Works. Like the newer trainees, she has learned a counseling technique called motivational interviewing, in which, Manmeet says, “you don’t tell people what to do, but guide them into identifying their motivation and their sources of ambivalence.”

“The biggest challenge,” says Rivera, “is food. Our parents raised us on certain foods, and we got accustomed. The members” -- members being the term for people in the City Health Works network -- “are mostly Puerto Rican and Mexican. They eat a lot of deep-fried foods. So instead of cutting things out entirely, we minimize: try it for a week and see how you feel. We’ve had some success, but it goes back and forth.”

Once a week, Rivera walks to the food pantry at Madison Avenue and East 109th to meet with members one-on-one. She has six members, all diabetic, all older, all from the neighborhood.

“You hear a lot of life stories,” she says. “People don’t have a lot of support. Low income. No insurance. They’re not being treated and have nowhere to go. When they hear about a program to help them, they are very grateful.”

Rivera emphasizes diet and physical activity, and encourages members with untreated ailments to see a doctor before the problems get bigger and more expensive.

“Hospitals have never been incentivized to care about wellness and prevent illness,” Manmeet says. “They profit if you’re sicker.”

Prabhjot puts it this way: “You go to the doctor one day out of the year. Where’s the health-care system for 99 percent of your life? That’s what’s missing, and that’s what we’re feeling. Clinical care accounts for only 20 percent of health outcomes. Thirty percent comes from health behaviors, 40 percent from your socio-economic circumstances, and 10 percent from your physical environment. Yet we spend trillions on that first 20 percent. We’ve bet the farm on this hospital-heavy model. It’s like a sinkhole: you have to get bad enough to warrant medical care. But the time between when you feel a symptom and when you get really sick can be pretty long. And you’re kind of left to the wolves.”

This, says Prabhjot, is where we can learn from other systems -- for instance, the notion that entrusted people from neighborhoods can play an important role in people’s health, as he found in sub-Saharan Africa.

There, community-health workers, strongly supervised and equipped with mobile phones, deliver items like anti-malarial and anti-diarrheal treatments.

“At a time in the US when we’re worried about costs,” says Prabhjot, “when we’re not delivering high-quality care, when we’re not reaching vulnerable populations, there’s much we can learn from those systems abroad, and bring it to places like Harlem.”

*   *   *   *   *

On Saturday, September 21, 2013, members of the Somalia-based Islamist group al-Shabaab carried out an assault-rifle attack on the Westgate Mall in Nairobi, Kenya.

For Prabhjot Singh, this was no far-flung event. He had spent his early childhood in Nairobi, part of a relatively prosperous and cohesive Sikh and Indian community of 70,000 that, between the British colonizers and the black African majority, had always lived a little uneasily in Kenya.

Prabhjot had been busy that day finding out if his relatives, who lived minutes from Westgate, were OK. They were.

That evening, in New York, at sundown, Prabhjot and a friend took an after-dinner stroll along Central Park North. Minutes earlier, Prabhjot had dropped off his wife and son at home. Now, walking on the park side of the street, he approached the T-intersection at Malcolm X Boulevard, with the park on his left and Central Harlem fanning out to his right. It was a mild night; people were about; Prabhjot saw a family walking ahead of him.

“Osama!” came a voice from behind. “Terrorist!”

A hand grabbed Prabhjot’s beard. A fist caught his jaw. Prabhjot stumbled and ran.

He ran, and behind him he saw bicycles. Fifteen or twenty bicycles, ridden by what looked like teenagers. “Osama!” “Get him!”

The bikes quickly overtook Prabhjot. More fists flew at him. Prabhjot fell to the ground, and was surrounded.

To be continued tomorrow …


[Courtesy: Columbia Magazine. Edited for sikhchic.com]
February 15, 2014



Photos
Prabhjot-Manmeet
ManmeetKaur-NY
Prabhjot-NY

Conversation about this article

1: Baldev Singh (Bradford, United Kingdom), February 15, 2014, 9:03 AM.

As Sikhs we are sending out a message through our identity and uniform that we are 'Saint-Warriors', like a lion is recognizable by its mane and demeanour.

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City Health Works in New York
with Manmeet Kaur & Prabhjot Singh
Part I "









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