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This is a long but interesting article from the NY Times about how the Iranian rural health care model can solve many of the problems being faced by the poorer regions of the US.
>>>
http://www.nytimes.com/2012/07/29/magazine/what-can-mississippis-health-care-system-learn-from-iran.html?_r=1&pagewanted=all
What Can Mississippi Learn From Iran?
One morning this spring, Claudia Cox, a registered nurse in Jackson, Miss., drove toward the countryside to visit some patients. She often has trouble finding their homes. The rural people are the worst, she said. Come to the oak tree. Well, hell, Im from the city, I dont know what no oak tree is. I know magnolia. I know pine trees. Cox referred to her seven-year-old Ford Freestyle as her office, but it had the ambience of an arcade: the ding-ding-ding from her dashboard signaling an unbuckled seat belt, the whir of a phone charger in the cigarette lighter, the phone ringing with the opening of Cheryl Lynns disco hit Got to Be Real. Cox, a 45-year-old divorced mother of three, juggled phone calls and patients charts and cigarettes like some serene octopus, always catching the steering wheel just before the vehicle veered onto the grass. After 20 minutes, she pulled into a pebbly driveway. It was time to find out why Vonda Wells kept going back to the emergency room.
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Cox works for an agency called HealthConnect, whose purpose is to reduce admissions to the Central Mississippi Medical Center, a Jackson hospital where people routinely use the emergency room for primary care, sometimes multiple times in a month.
Wellss large figure filled the door frame of the tiny house. She was jovial despite the oxygen tube that ran to her nose. She held a baby. Is that yours? Cox exclaimed.
Thats my grandbaby! Wells said and passed the baby off to a teenager who disappeared behind a closed door. The two women sat down in a dark living room cramped with couches.
All right, Ms. Wells, we come out and check on everybody, Cox said. You had pneumonia, right?
I went to Florida, and thats where I first got sick, at the Holy Land.
O.K., Cox scribbled, and then looked up. Whats that?
Its an amusement park out there, but it has Jerusalem, it has Noahs Ark, they did the play the Passion . . .
Now theres another spot for me and my baby to go! Cox said. They laughed.
Cox doesnt know oak trees, but she knows how to talk to people. She knows when to ask if someone cannot afford insulin, or is not taking insulin, or is not keeping the insulin cold, or cannot keep the insulin cold because there is no electricity or refrigerator. Not having health insurance is a huge problem in Mississippi, but it isnt the only one. So you good with doing your medicines? Wells made a guilty face. You oxygen-dependent? She was.
Wells worked at a Jackson hospital as a certified nursing assistant for five years before she started getting sick with asthma-related illnesses. No one wanted a nurse who needed an oxygen tank, she said, so now she was trying to work a handful of hours a week at a Christian community center. I stayed in Illinois for 25 years, she said. I didnt really have asthma symptoms till I came down here.
Theres something in the house thats triggering it, Cox said. I bet you need to get tested for mold. She made a note. The house was old, the rug thick, the air damp. And Im putting a little check mark down here that you got the basic light, gas and water. Your major problem is the asthma.
And congestive heart failure.
Cox tilted her head. Have you been taught how to manage your congestive heart failure? Because you should have a scale. She looked around the house gamely, as if she believed a scale might pop out from behind the TV.
I need a scale?
You need a scale, and you need to do a weight every morning. Because if you get on a scale and theres a three-pound difference from one day to the next, youre starting to retain fluid. I see that your legs are already swollen.
Cox explained why people retain fluid. She then asked whether Wells had checked her blood pressure; her emergency-room chart indicated it had been 212 over 100, which is stroke level. Concerned about Wellss sodium intake, she asked her how many sodas she was drinking, and told her that some juice has a lot of sodium in it too. Knowledge is power, O.K.? Cox said gently. Cause youre 40, and youre oxygen-dependent. We dont want you goin on a date with an oxygen tank! Wells laughed again.
Cox said she would try to find a company that would test the house for toxins, and she made an appointment for Wells to visit a medical clinic that HealthConnect operates. Wells got up, the oxygen tube dragging behind her, and walked Cox to the door. Cox paused at one of the photographs on the wall. You got a beautiful family! Cox said. She focused on a slim woman. Now, is that Mama?
Thats Grandma, Wells said. She was 95 when she passed. I moved down here to help her out.
One of the people responsible for HealthConnects holistic, intensely personal approach is Dr. Aaron Shirley, who three years ago found inspiration for health care reform in an unlikely place: the primary health care system created in the 1980s in the Islamic Republic of Iran. The main issue in Iran back then was disparities in health between its urban and rural populations, he told me recently. In the U.S., these disparities exist. The Iranian model eliminated the geographic disparities, so why couldnt this same approach be used for racial and geographic disparities in the U.S.?
Shirley created HealthConnect in 2010 because and, in part, to prove to others that poor people in Mississippi still have health problems, even if they have Medicaid or health insurance, even if there are clinics in their communities, even if they get home health services. They dont get better, and the diseases born of poverty and obesity are not prevented; thousands of people frequent emergency rooms for illnesses that could have been tackled by primary care. They need something more.
Shirley is a civil rights-era hero who for a long time was the only black pediatrician in the state, the type of activist who, he says, wasnt necessarily of the nonviolent persuasion and who, upon hearing that the local Klan was headed to his home, would warn the Police Department that both his boys knew how to shoot. He was the first black resident at the University of Mississippi Medical Center and, in the 1960s, worked at the states first community health center, in the Mississippi Delta. He did things that dont end up in history books, too, like build wells for poor blacks when they didnt have clean drinking water and travel through the countryside treating malnourished babies. In 1993, the MacArthur Foundation identified him as a health care leader when it gave him one of its genius awards.
Shirley, now 79, spends his days at the Jackson Medical Mall. For decades, the site was an actual mall, with a JC Penney and a Gayfers, but the area around it began to decline in the 1980s as middle-class families fled to suburbs nearby. Historic downtown Jackson emptied out altogether, and today Capitol Street, the bustling shopping avenue that Medgar Evers boycotted in 1962, looks shuttered and ghostly. The mall, just five minutes from downtown, was well on its way to the same fate, so in the mid-1990s Shirley and others created the Jackson Medical Mall Foundation to buy it and turn it into a center offering various health services for the poor.
Since then, Shirley has observed up close what so many Mississippians point out: millions of dollars pour into the state every year both public and private funds but the lives of Mississippians do not improve. Ive been coming here for 40 years, he told me recently, referring to the Mississippi Delta, and nothing has changed.
In 2008, Shirley was introduced to a consultant named James Miller by a public health professor at Jackson State University, Mohammad Shahbazi. Miller and his wife live in Oxford, Miss., where they and other family members run a consulting firm and other businesses. In 2004, Miller learned about Irans primary-care health system during a meeting in Germany with a delegation from the Iranian government. But it wasnt until 2007, when a struggling hospital hired Millers firm to conduct an assessment of its operations, that Miller fully grasped the extent of Mississippis health care crisis and recognized how much it resembled prerevolutionary Iran.
When the Iranian system was developed in the 1980s, there were no doctors in rural Iran, Miller says. And this is similar to the problem in the delta today.
The Iranian reforms were relatively inexpensive to implement there. It was the early 80s, just after the Ayatollah Khomeinis return and the Iranian revolution, which had promised the countrys rural villagers the kind of social justice that had been lacking under the shah. At the time, more than half the population lived outside major cities, in or around more than 60,000 villages. The Iranians built health houses to minister to 1,500 people who lived within at most an hours walking distance. Each house is a 1,000-square-foot hut equipped with examination rooms and sleeping quarters and staffed by community health workers one man and one or more women who have been given basic training in preventive health care. They advise on nutrition and family planning, take blood pressure, keep track of who needs prenatal care, provide immunization and monitor environmental conditions like water quality. Crucially, in order to gain trust, the health workers come from the villages they serve.
People who become very sick, or require surgical procedures, are referred up through a single, multitiered system: from health house to rural health center to district hospital. The integrated nature of the system is what makes it unique. Today, 17,000 health houses serve 23 million rural Iranians. Health disparities between rural and urban Iranians have narrowed; the Iranians have reduced rural infant mortality by 75 percent and lowered the birthrate. Irans reforms won praise from the World Health Organization, which has long advocated preventive, primary care.
To Miller, the models great appeal was its simplicity. He approached several academic institutions in Mississippi and told them what hed learned. Most people looked at him as if he were nuts. The United States and Iran havent been on good terms since the hostage crisis in 1979. It is not a country Americans tend to think of collaborating with. But Miller, who loves Persian history and doesnt disguise his desire to see the United States and Iran mend their fences, spoke to Gail Harrison, a public-health professor at U.C.L.A. She suggested he call a former student of hers: Mohammad Shahbazi, who was not only Iranian but also a professor at Jackson State University, a historically black college right in Mississippi.
Shahbazi moved to the United States in the 1980s for graduate work in cultural anthropology and became fascinated by its health care problems. He recognized the similarities between the conditions in Mississippi and those in Iran, where he grew up as a member of a nomadic tribe, the Qashqai, that was discriminated against under the shah. We were considered the wild, smelly nomads, he says. He decided that Mississippi offered the best opportunity for his work on social determinants of health, and settled into a between-worlds existence in Jackson, where he is neither black nor white but privy to racial slights and resentments from both sides. I consider myself bleached black, he says.
After joining Jackson States public health program, he often wanted to discuss Irans health care reforms in wider policy circles, but feared doing so in the post-9/11 climate. Shahbazi, who is animated and friendly and tends to make jokes like we dont have pharmacologists, we have harm*acologists, was once pulled aside by a federal agent at an airport because he thought Shahbazi was on a most-wanted terrorist list. When the agent showed Shahbazi the list, Shahbazi exclaimed, But I am not Shabaz Mohammad of Pakistan, I am Mohammad Shahbazi of Iran!
Shahbazi suggested that he and Miller approach Shirley. He arranged for the two men to visit Shiraz, Iran, and meet some of the people responsible for creating and administering the countrys health houses. The two groups decided to establish an official academic partnership between Shiraz University and Jackson State, and Shirley returned to Mississippi a convert. Later that year, several Iranian doctors and administrators and their wives made their own trip to Mississippi. They were surprised by what they saw: This is America? they asked. In 2010, the Iranians returned for a month, calculating how many health houses Mississippi would need, as they had done in Iran. Shahbazi began work on a program at Jackson State for the training of community health workers. Using resources from the Medical Mall Foundation, Shirley started HealthConnect to show how interventionist, door-to-door community health workers might save hospitals money and began the process of putting health houses in Jackson schools. Eventually they hope to build the Mississippi Community Health House Network, a pilot version of their project, in the Mississippi Delta.
We are not saying just trust us, Shahbazi says. We are saying give us $10 to $20 million and three years; well implement 15 health houses in the delta, and we will prove two things: We will show you that we are changing the health outcomes, and we will show we can reduce the cost of health care in the state.
Mississippi has some of the worst health statistics in the country. A Mississippi black mans life expectancy is lower than the average Americans life expectancy was in 1960. Sixty-nine percent of adult Mississippians are obese or overweight, and a quarter of the states households dont have access to decent, healthful food. Adequate grocery stores can be 30 miles away. In one of the countrys most fertile regions, people sometimes have to shop for their groceries at the gas station. Consequently, Mississippians are dying from diabetes, hypertension, congestive heart failure and asthma. Shirley points out that in the 1960s people starved, and today they die from food.
The state has the highest rate of teen births in the nation. Currently there is one abortion clinic in Mississippi, and Gov. Phil Bryant, a former deputy sheriff, is working hard to render it inoperable. Until this year, schools taught abstinence. In the United States, the black infant mortality rate is more than twice that of white infants, so Mississippi, which is 37 percent black, has huge neonatal intensive care units. Caring for the thousands of premature babies (weighing between one and four pounds) costs millions of dollars. According to Dr. Glen Graves of the University of Mississippi Medical Center, these tiny, deprived babies grow up to be plagued with chronic illnesses.
Human Rights Watch calls the Deep South the epicenter of the H.I.V. epidemic in the United States, with more people living and dying of AIDS than in any region in the country. Blacks in Mississippi are dying from AIDS at a rate 64 percent higher than the nations average. In the delta, which stretches north and west of Jackson and is home to 560,000 people, H.I.V./AIDS is an immense but silent crisis. The state Department of Health estimates that half of H.I.V.-positive Mississippians currently dont receive treatment.
Many delta hospitals complain that their emergency rooms are overrun with nonpaying patients. Dr. James Keeton, the vice chancellor for health affairs at the University of Mississippi Medical Center, says that 14 percent of the centers patients are uninsured, or self-pay, and the hospital recovers only a small part of what they owe. Now, I say to you as a businessperson: How would you like to work at an auto company and give away . . . cars before even opening your doors?
Of the states population of nearly three million, 550,000 are uninsured. At the moment, Governor Bryant is claiming that the state might not accept federal money to expand Medicaid under the Affordable Care Act. But even if it does, there wont be enough doctors to see all the Mississippians who need them; the state has 176 doctors per 100,000 people, the lowest such number in the country.
Sixty years ago, Mississippi, the countrys poorest and most racially divided state, was the standard by which this nations commitment to social justice would be measured, the historian John Dittmer wrote. Talk to those in Mississippis health care community, and they all whisper the same thing: Its not rocket science; we all know what needs to be done. In short, as one Mississippian put it to me, hand-to-hand combat hiring folks whose sole job is to ameliorate the problems in poor peoples lives and a tremendous amount of money could change the situation. But the political will does not exist. So the status quo endures: generations of people who cant afford fresh tomatoes, and who dont understand that when a doctor says take this pill three times a day, he doesnt mean all at once.
In May, Shirley, Shahbazi and a black pediatrician named Eva Henderson-Camara piled into Shahbazis car and headed to the delta to talk to two nurses at a small hospital in Belzoni, more than an hour north of Jackson. The first thing you notice on entering the delta, especially when youre expecting to find poverty, is that you dont see many people. The farms are vast and empty. So much of the area is bucolic and sun-dappled that it doesnt seem poor. When I said as much to Claudia Cox about Mississippi in general, she replied sternly: Thats because poverty in America doesnt look like what yall think. It used to be bare feet, now its Nikes. If I miss two months of work because I get sick, well, guess what? Im in poverty. This is the new poverty. Yet in delta towns like Louise and Midnight, the poverty is impossible to miss: desolate commercial streets in the shadow of a rotting mill, shotgun houses wilting on one side of railroad tracks, houses almost buried under possessions on the porch and in the yard.
Henderson-Camara, now 60, grew up on the plantation her grandfather owned. Children at the time worked much of the school year as part of the sharecropper system, which lasted until the 70s, as corporations bought and mechanized the farms. (Imagine waking up every morning and this is all you see, Henderson-Camara said, looking out the window at the flat fields stretching to the sky. And you think, Should I shoot myself now or later?) Thousands of displaced workers found jobs at the Jockey factory, or the Schwinn plant, or on catfish farms, but those shut down in the early 90s. Henderson-Camara got out by winning a scholarship for a fifth year of high school at Yale. Today she lives in Jackson and works in HealthConnects medical clinic.
In Belzoni, everyone sat down at a rectangular table, and the director of nursing, Dee Ann Brown, recounted the hospitals troubles: emergency-room readmissions, obesity, inadequate insurance. Shirley then explained the role of community health workers and asked Brown if she thought that service might be helpful.
What you are describing is home health, isnt it? Brown said.
Home-health agencies dispatch nurses to do clinical work in patients homes. But they are not obligated to take your phone calls at midnight or steer you away from eating fried food and you have to have insurance to get their care. Often for-profit services, they are also the hedge funds of the health care community: potentially lucrative, largely unregulated, producing bad results as often as good. Sanjay Basu, a physician and policy expert at the University of California, San Francisco, says that while he has seen some remarkable and devoted home-health agencies, if youre in it for a buck, you could have a terrible home agency and make a ton of money. Many towns in the delta have them yet the deltas problems persist. Why? Shirley offered that the hospitals need a third party trained to discern what exactly will help a patient, and that party must come from the patients world: talk the same, share similar fears and frustrations and life experiences.
Most home-health nurses build great relationships with their patients, Brown said.
But theres a lot of distrust, Henderson-Camara said, leaning forward. We dont trust people who dont look like us. Having grown up in a very segregated community, I know this for a fact. You may think that youre in with that patient, but when you walk out that door, they will laugh and say, I just told her that so shell stop asking me questions. But if you live in that community and sister Edna tells you something, you say, Now, Edna, and she will say, O.K., you got me. And shell tell you the truth. People do not trust people who do not look like them.
I dont feel thats a problem here, said Brown, who happens to be white. I may be way smoozed.
I think youre smoozed.
The friction between them highlighted a problem beyond a distrust of outsiders: the fractured nature of American health care. It was easy to dismiss, or misconstrue, the health-house network as just another addition to a market glutted with for-profit businesses and nonprofit services looking to patch up the holes in or take advantage of the health care system. What Shirley and his colleagues saw the need for was something holistic and aggressive that would take root in the community, get into homes and alter the course of future generations, before obesity, say, or diabetes sets in. The Iranian system they admire is a preventive health care system. American health care is not preventive, and its not a system.
The practice of community health workers going door to door has been applied everywhere from China to Mexico. According to Carl H. Rush of the University of Texas Institute of Health Policy, in the United States, community health workers have been used on a small scale for decades. More recently, he says, hospitals around the country are realizing the potential for community health workers to lower their costs.
The Iranian health houses, too, resemble the original mission of Americas community health centers. When Dr. H. Jack Geiger founded the countrys first federally qualified health center in 1967 in Mound Bayou, a small town in the delta, the goal was to confront the many aspects of peoples lives that were contributing to their ill health. We built wells and privies and housing and started a 500-acre vegetable farm, says Geiger, whose work was inspired by what he saw in South Africa in the late 50s, and that probably had a bigger impact on the health of the population than what we were doing as doctors. The indigenous people we trained were among the most useful people on staff.
Today there are 8,300 centers serving 20 million people throughout the country. Over the years, however, community health centers, needing to compete in the marketplace, have evolved into more conventional medical businesses, focused on the delivery of personal health services rather than the social and environmental determinants of overall health.
To help them return to the original mission, the Affordable Care Act will give $11 billion to community health centers, a sum that will double the numbers and capacity of centers nationwide. It would be effective if community health centers were given the budget to return to the interventions that characterized almost all of the first health centers of the 1960s and 1970s, Geiger says. Every health care provider in this country is under pressure, because of the incentives in the system, to churn out patients as fast as you can, because you get paid for visits. That just doesnt work for people with the kind of complex problems you probably saw in Mississippi. You cant fix these problems in 10 minutes.
Shirley says he believes that the problems of the American poor living conditions, deficient education, harmful behaviors and the lack of family support and access to healthful lifestyles demand house calls. This approach was used by groups in Atlantic City and Camden, N.J., profiled by Atul Gawande in The New Yorker last year, which identified the worst offenders of emergency-room readmission and deployed social workers and nurses to figure out the myriad sources of ill health. What was clear above all else from Gawandes account is that what these people needed was constant attention. Because one stumble an unpaid electricity bill, for example can lead to cascading health setbacks.
The Iranian model goes a step further by making the community health workers responsible for their villagers well-being from birth. Its an approach very much at odds with the American ethos of self-reliance. But in Iran, the seeming intrusiveness is required, according to Dr. Kamel Shadpour, one of the architects of the Iranian system. If you go to one of these community health workers and ask him or her how many people they cover, they wont tell you around 2,000, Shadpour says. They will tell you exactly 1,829 people. If you take out the family file with the No. 62, he or she will know which family that is, and she will tell you that the father is this old, and they have five children, their ages, their vaccinations, how they were doing family planning, everything.
The Iranian model also differs from many others because of its integrated delivery network: the way a patient is referred up through a chain of hospitals according to their needs. The overall system is the key, says Miller, the Oxford consultant, not just community health workers.
The American government has been moving toward more comprehensive solutions. The Affordable Care Act has created accountable care organizations that include doctors, social workers, nurses and pharmacists working together to serve patients. Since May, also as part of health care reform, the Centers for Medicare and Medicaid Services announced more than 100 multimillion-dollar grants to organizations that proposed new ways to prevent illness and save money. Its Innovation Center awarded grants to a large number of experimental programs that involve community health workers.
Theres a renewed interest in them, in part because of the nations increased focus on prevention, says Dr. Richard J. Gilfillan, the director of the Center for Medicare and Medicaid Innovation. Eighty-four percent of our health care dollar is spent on managing people with chronic conditions. . . . We know preventing obesity can help prevent other illnesses such as diabetes, hypertension and kidney disease so how can we prevent these conditions from occurring in the first place? Likely not with more procedures and X-rays. Some of the winners programs harken back to the way health care was delivered long ago. The things we learn by going into someones home tell us so much about the patients life and how they manage their own diseases.
One morning last spring, Shirley took me to see one of his new health-house facilities at Blackburn Middle School, which is on the edge of Jackson State Universitys campus and across the street from where Shirley grew up. Walking with him through the neighborhood, or stopping in with him at the Penguin, a nice restaurant on the Jackson State campus, is like being with the mayor. Over lunch, the people who came to shake his hand included the states new director of Medicaid and the president of the Mississippi NAACP.
Shirley reasoned that opening health houses in the schools was a natural way to gain access to families. Many public schools in Mississippi dont have full-time nurses, and Blackburn Middle School is attended almost entirely by students who live in poverty, so it welcomed the chance to have health care on the premises.
One community health worker on the staff at Blackburn was Tiara, a single mother on Temporary Assistance for Needy Families I first met almost nine months earlier. A not-so-obvious benefit of training community health workers is that doing so creates jobs for unemployed people; advanced degrees are unnecessary. In our first interview, Tiara told me how much she loved her job. At Blackburn, she seemed quieter as we talked about how she counseled young girls about sex. As someone who had a child at 17, I am so against it, she told us. (She is now 22.) You have so much potential.
As a HealthConnect employee, Tiara also made house calls before being transferred to work in the school. Her life is a kind of full-time HealthConnect anyway. I had she said, counting six people in my apartment last night. Because they dont have electricity. And one was a real bad diabetic who cant see how to pull her insulin, cant see anything.
These are the sorts of stories you hear repeatedly in Mississippi. During five days driving around with Cox, I saw what health workers were up against, and what they were capable of. Cox comes from a middle-class family, the product of a stable home. She went to college, became a funeral director and then decided to go to nursing school, using public assistance to make her way through it. Cox had worked as a nurse for 20 years Shirley and the Central Mississippi Medical Center decided to use licensed nurses at HealthConnect until their community health workers are trained and she could intuit that a patients life might be crumbling in surprising ways.
There was Regina Huggins, who had been in the hospital 20 times in eight months since her heart attack. She was a smoker with chronic obstructive pulmonary disease who lacked energy and had lost 50 pounds. One of the reasons she kept calling ambulances to go to the E.R. seemed to be that she had no transportation; she couldnt even afford a taxi. She did not qualify for Medicaid. Without insurance, she couldnt get an oxygen tank or inhalers or fill her prescriptions. She had $300,000 in medical bills.
There was Mamie Marshall, who was dying of bone cancer in the back room of her house. None of her doctors had put her in hospice care, and she said she had been told that no one could do anything for her. She was a licensed beautician and had worked for Packard Electric, a subsidiary of General Motors, and as a public-school bus driver and as a nanny. I worked, she said.
And there were Carolyn Brewster and Melvin McGee, 29-year-olds whose baby, Justin, was born prematurely, most likely because Brewster had high blood pressure and pre-eclampsia. Both Brewster and McGee have learning disabilities, but they had jobs and had earnestly embraced parenthood, paying $450 a month for a two-room apartment in a motel-like apartment complex where everyone seemed to be under 30. When we called on them, Cox decided to take Brewsters blood pressure and discovered that it was 149 over 100. Brewster wasnt doing anything to reduce it except taking vinegar, a common home remedy. Cox made an appointment for her at the medical clinic later that day, told her how to catch the bus and which pharmacy to go to and emphasized that she needed to go right away. You are only 29, and you are going to end up on dialysis, she said.
On our way out, Cox said she wanted to stop by to see Tiara, who lives in the same apartment complex. She had just had her second child.
Shirley, Shahbazi and Miller havent had an easy time getting large-scale financing for their health-house network. They enlisted a Mississippi congressman, Bennie Thompson, to write a letter to Kathleen Sebelius, the secretary of Health and Human Services. They applied for (but did not receive) one of those grants awarded by the Innovation Center; Jack Geiger wrote the recommendation letter. They talked it up in Mississippi.
The three men and many Mississippians I spoke to complain that a lot of federal and grant money goes to research, not actual services. The delta people have been studied to death, Shirley says. Also, as they point out, funding rarely goes to entire systems. But the group is hoping that the idea of Iranian-style health houses in the United States might inspire good will between the two countries.
If they can get the resources, then why not give it a try? said Shadpour, the architect of the Iranian system, when I called him in Tehran. The situation is not worse than Iran. To the contrary, it is much better in many ways. The infrastructure is there.
Until someone finances the pilot for 15 health houses, Shirley will establish them in 11 schools where there are already rooms, electricity, water. To keep the houses running, Shirley says, they are staffed with certified nurse practitioners whose services can be billed to Medicaid. So the revenue that the nurse generates will go to paying her and the community health workers, too. We say, O.K., how much money is already out there?
The only outside money that weve gotten to contribute to our project has been $75,000 from United Healthcare, the insurance company, because they see the potential to save them money, he continued.
His methods are scrappy and scattershot, but Shirley is used to working around the system. After 60 years, perhaps the main reason hes turning to an Iranian model is because, unlike everything else in Mississippi, it worked. In one year, HealthConnect cut the rate of readmissions to the Central Mississippi Medical Center by 15 percent.
Meanwhile, Miller is trying to find yet another way to generate money. With support from Jackson State doctors and advice from their counterparts at Shiraz University, he has begun discussing the idea of Americans and Iranians working together to implement the Iranian model in other needy countries. He hopes that a major international aid project might be a way to get financing for Mississippi.
A few weeks after her first visit, Claudia Cox returned to Vonda Wellss house. Wells, who is now 41, hadnt returned to the emergency room, but she seemed sadder. She hadnt been paid the $5 a day she was supposed to get for working at the Christian community center, but despite doing all her paperwork and leaving messages for her caseworker, she had not heard back.
And because Medicaid limits the number of doctor visits in a year, she couldnt see one now.
How you going to follow up with your pulmonologist and cardiologist? Cox asked.
I had to cancel, Wells said. I already have a bill in there for $240 I have to pay.
She couldnt keep up with her medicines. Medicaid cant pay for it, and I cant pay for the medicines, not at $90 a pop, she said. I try to wean myself off of medicine. If I feel good, I dont take them.
But Wells spoke of positive things. Her 19-year-old daughter, who played in the next room with Wellss grandchild, was talented enough to be a fashion designer, she said. Her youngest daughter, 16, wanted to join the military to see the world. Her mother helped out with the bills at times. And her uncle had offered to come by and do some repairs, rip up the carpet, fix the kitchen. In many ways, Wells was rare among Coxs patients: she still had family.
In fact, the house had been her grandmothers, and she had spent some of her childhood there. She was lucky to have a rent-free home full of so many memories. But Wells would have to wait to learn whether that house was giving her asthma problems.
We couldnt find anybody to examine the house that was affordable, Cox said. It was $1,300 for one day just to test. Just to come out here and pull a couple of pieces from the attic.
Suzy Hansen last wrote for the magazine about the art scene in Istanbul, where she lives.
Editor: Dean Robinson
>>>
http://www.nytimes.com/2012/07/29/magazine/what-can-mississippis-health-care-system-learn-from-iran.html?_r=1&pagewanted=all
What Can Mississippi Learn From Iran?
One morning this spring, Claudia Cox, a registered nurse in Jackson, Miss., drove toward the countryside to visit some patients. She often has trouble finding their homes. The rural people are the worst, she said. Come to the oak tree. Well, hell, Im from the city, I dont know what no oak tree is. I know magnolia. I know pine trees. Cox referred to her seven-year-old Ford Freestyle as her office, but it had the ambience of an arcade: the ding-ding-ding from her dashboard signaling an unbuckled seat belt, the whir of a phone charger in the cigarette lighter, the phone ringing with the opening of Cheryl Lynns disco hit Got to Be Real. Cox, a 45-year-old divorced mother of three, juggled phone calls and patients charts and cigarettes like some serene octopus, always catching the steering wheel just before the vehicle veered onto the grass. After 20 minutes, she pulled into a pebbly driveway. It was time to find out why Vonda Wells kept going back to the emergency room.
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Cox works for an agency called HealthConnect, whose purpose is to reduce admissions to the Central Mississippi Medical Center, a Jackson hospital where people routinely use the emergency room for primary care, sometimes multiple times in a month.
Wellss large figure filled the door frame of the tiny house. She was jovial despite the oxygen tube that ran to her nose. She held a baby. Is that yours? Cox exclaimed.
Thats my grandbaby! Wells said and passed the baby off to a teenager who disappeared behind a closed door. The two women sat down in a dark living room cramped with couches.
All right, Ms. Wells, we come out and check on everybody, Cox said. You had pneumonia, right?
I went to Florida, and thats where I first got sick, at the Holy Land.
O.K., Cox scribbled, and then looked up. Whats that?
Its an amusement park out there, but it has Jerusalem, it has Noahs Ark, they did the play the Passion . . .
Now theres another spot for me and my baby to go! Cox said. They laughed.
Cox doesnt know oak trees, but she knows how to talk to people. She knows when to ask if someone cannot afford insulin, or is not taking insulin, or is not keeping the insulin cold, or cannot keep the insulin cold because there is no electricity or refrigerator. Not having health insurance is a huge problem in Mississippi, but it isnt the only one. So you good with doing your medicines? Wells made a guilty face. You oxygen-dependent? She was.
Wells worked at a Jackson hospital as a certified nursing assistant for five years before she started getting sick with asthma-related illnesses. No one wanted a nurse who needed an oxygen tank, she said, so now she was trying to work a handful of hours a week at a Christian community center. I stayed in Illinois for 25 years, she said. I didnt really have asthma symptoms till I came down here.
Theres something in the house thats triggering it, Cox said. I bet you need to get tested for mold. She made a note. The house was old, the rug thick, the air damp. And Im putting a little check mark down here that you got the basic light, gas and water. Your major problem is the asthma.
And congestive heart failure.
Cox tilted her head. Have you been taught how to manage your congestive heart failure? Because you should have a scale. She looked around the house gamely, as if she believed a scale might pop out from behind the TV.
I need a scale?
You need a scale, and you need to do a weight every morning. Because if you get on a scale and theres a three-pound difference from one day to the next, youre starting to retain fluid. I see that your legs are already swollen.
Cox explained why people retain fluid. She then asked whether Wells had checked her blood pressure; her emergency-room chart indicated it had been 212 over 100, which is stroke level. Concerned about Wellss sodium intake, she asked her how many sodas she was drinking, and told her that some juice has a lot of sodium in it too. Knowledge is power, O.K.? Cox said gently. Cause youre 40, and youre oxygen-dependent. We dont want you goin on a date with an oxygen tank! Wells laughed again.
Cox said she would try to find a company that would test the house for toxins, and she made an appointment for Wells to visit a medical clinic that HealthConnect operates. Wells got up, the oxygen tube dragging behind her, and walked Cox to the door. Cox paused at one of the photographs on the wall. You got a beautiful family! Cox said. She focused on a slim woman. Now, is that Mama?
Thats Grandma, Wells said. She was 95 when she passed. I moved down here to help her out.
One of the people responsible for HealthConnects holistic, intensely personal approach is Dr. Aaron Shirley, who three years ago found inspiration for health care reform in an unlikely place: the primary health care system created in the 1980s in the Islamic Republic of Iran. The main issue in Iran back then was disparities in health between its urban and rural populations, he told me recently. In the U.S., these disparities exist. The Iranian model eliminated the geographic disparities, so why couldnt this same approach be used for racial and geographic disparities in the U.S.?
Shirley created HealthConnect in 2010 because and, in part, to prove to others that poor people in Mississippi still have health problems, even if they have Medicaid or health insurance, even if there are clinics in their communities, even if they get home health services. They dont get better, and the diseases born of poverty and obesity are not prevented; thousands of people frequent emergency rooms for illnesses that could have been tackled by primary care. They need something more.
Shirley is a civil rights-era hero who for a long time was the only black pediatrician in the state, the type of activist who, he says, wasnt necessarily of the nonviolent persuasion and who, upon hearing that the local Klan was headed to his home, would warn the Police Department that both his boys knew how to shoot. He was the first black resident at the University of Mississippi Medical Center and, in the 1960s, worked at the states first community health center, in the Mississippi Delta. He did things that dont end up in history books, too, like build wells for poor blacks when they didnt have clean drinking water and travel through the countryside treating malnourished babies. In 1993, the MacArthur Foundation identified him as a health care leader when it gave him one of its genius awards.
Shirley, now 79, spends his days at the Jackson Medical Mall. For decades, the site was an actual mall, with a JC Penney and a Gayfers, but the area around it began to decline in the 1980s as middle-class families fled to suburbs nearby. Historic downtown Jackson emptied out altogether, and today Capitol Street, the bustling shopping avenue that Medgar Evers boycotted in 1962, looks shuttered and ghostly. The mall, just five minutes from downtown, was well on its way to the same fate, so in the mid-1990s Shirley and others created the Jackson Medical Mall Foundation to buy it and turn it into a center offering various health services for the poor.
Since then, Shirley has observed up close what so many Mississippians point out: millions of dollars pour into the state every year both public and private funds but the lives of Mississippians do not improve. Ive been coming here for 40 years, he told me recently, referring to the Mississippi Delta, and nothing has changed.
In 2008, Shirley was introduced to a consultant named James Miller by a public health professor at Jackson State University, Mohammad Shahbazi. Miller and his wife live in Oxford, Miss., where they and other family members run a consulting firm and other businesses. In 2004, Miller learned about Irans primary-care health system during a meeting in Germany with a delegation from the Iranian government. But it wasnt until 2007, when a struggling hospital hired Millers firm to conduct an assessment of its operations, that Miller fully grasped the extent of Mississippis health care crisis and recognized how much it resembled prerevolutionary Iran.
When the Iranian system was developed in the 1980s, there were no doctors in rural Iran, Miller says. And this is similar to the problem in the delta today.
The Iranian reforms were relatively inexpensive to implement there. It was the early 80s, just after the Ayatollah Khomeinis return and the Iranian revolution, which had promised the countrys rural villagers the kind of social justice that had been lacking under the shah. At the time, more than half the population lived outside major cities, in or around more than 60,000 villages. The Iranians built health houses to minister to 1,500 people who lived within at most an hours walking distance. Each house is a 1,000-square-foot hut equipped with examination rooms and sleeping quarters and staffed by community health workers one man and one or more women who have been given basic training in preventive health care. They advise on nutrition and family planning, take blood pressure, keep track of who needs prenatal care, provide immunization and monitor environmental conditions like water quality. Crucially, in order to gain trust, the health workers come from the villages they serve.
People who become very sick, or require surgical procedures, are referred up through a single, multitiered system: from health house to rural health center to district hospital. The integrated nature of the system is what makes it unique. Today, 17,000 health houses serve 23 million rural Iranians. Health disparities between rural and urban Iranians have narrowed; the Iranians have reduced rural infant mortality by 75 percent and lowered the birthrate. Irans reforms won praise from the World Health Organization, which has long advocated preventive, primary care.
To Miller, the models great appeal was its simplicity. He approached several academic institutions in Mississippi and told them what hed learned. Most people looked at him as if he were nuts. The United States and Iran havent been on good terms since the hostage crisis in 1979. It is not a country Americans tend to think of collaborating with. But Miller, who loves Persian history and doesnt disguise his desire to see the United States and Iran mend their fences, spoke to Gail Harrison, a public-health professor at U.C.L.A. She suggested he call a former student of hers: Mohammad Shahbazi, who was not only Iranian but also a professor at Jackson State University, a historically black college right in Mississippi.
Shahbazi moved to the United States in the 1980s for graduate work in cultural anthropology and became fascinated by its health care problems. He recognized the similarities between the conditions in Mississippi and those in Iran, where he grew up as a member of a nomadic tribe, the Qashqai, that was discriminated against under the shah. We were considered the wild, smelly nomads, he says. He decided that Mississippi offered the best opportunity for his work on social determinants of health, and settled into a between-worlds existence in Jackson, where he is neither black nor white but privy to racial slights and resentments from both sides. I consider myself bleached black, he says.
After joining Jackson States public health program, he often wanted to discuss Irans health care reforms in wider policy circles, but feared doing so in the post-9/11 climate. Shahbazi, who is animated and friendly and tends to make jokes like we dont have pharmacologists, we have harm*acologists, was once pulled aside by a federal agent at an airport because he thought Shahbazi was on a most-wanted terrorist list. When the agent showed Shahbazi the list, Shahbazi exclaimed, But I am not Shabaz Mohammad of Pakistan, I am Mohammad Shahbazi of Iran!
Shahbazi suggested that he and Miller approach Shirley. He arranged for the two men to visit Shiraz, Iran, and meet some of the people responsible for creating and administering the countrys health houses. The two groups decided to establish an official academic partnership between Shiraz University and Jackson State, and Shirley returned to Mississippi a convert. Later that year, several Iranian doctors and administrators and their wives made their own trip to Mississippi. They were surprised by what they saw: This is America? they asked. In 2010, the Iranians returned for a month, calculating how many health houses Mississippi would need, as they had done in Iran. Shahbazi began work on a program at Jackson State for the training of community health workers. Using resources from the Medical Mall Foundation, Shirley started HealthConnect to show how interventionist, door-to-door community health workers might save hospitals money and began the process of putting health houses in Jackson schools. Eventually they hope to build the Mississippi Community Health House Network, a pilot version of their project, in the Mississippi Delta.
We are not saying just trust us, Shahbazi says. We are saying give us $10 to $20 million and three years; well implement 15 health houses in the delta, and we will prove two things: We will show you that we are changing the health outcomes, and we will show we can reduce the cost of health care in the state.
Mississippi has some of the worst health statistics in the country. A Mississippi black mans life expectancy is lower than the average Americans life expectancy was in 1960. Sixty-nine percent of adult Mississippians are obese or overweight, and a quarter of the states households dont have access to decent, healthful food. Adequate grocery stores can be 30 miles away. In one of the countrys most fertile regions, people sometimes have to shop for their groceries at the gas station. Consequently, Mississippians are dying from diabetes, hypertension, congestive heart failure and asthma. Shirley points out that in the 1960s people starved, and today they die from food.
The state has the highest rate of teen births in the nation. Currently there is one abortion clinic in Mississippi, and Gov. Phil Bryant, a former deputy sheriff, is working hard to render it inoperable. Until this year, schools taught abstinence. In the United States, the black infant mortality rate is more than twice that of white infants, so Mississippi, which is 37 percent black, has huge neonatal intensive care units. Caring for the thousands of premature babies (weighing between one and four pounds) costs millions of dollars. According to Dr. Glen Graves of the University of Mississippi Medical Center, these tiny, deprived babies grow up to be plagued with chronic illnesses.
Human Rights Watch calls the Deep South the epicenter of the H.I.V. epidemic in the United States, with more people living and dying of AIDS than in any region in the country. Blacks in Mississippi are dying from AIDS at a rate 64 percent higher than the nations average. In the delta, which stretches north and west of Jackson and is home to 560,000 people, H.I.V./AIDS is an immense but silent crisis. The state Department of Health estimates that half of H.I.V.-positive Mississippians currently dont receive treatment.
Many delta hospitals complain that their emergency rooms are overrun with nonpaying patients. Dr. James Keeton, the vice chancellor for health affairs at the University of Mississippi Medical Center, says that 14 percent of the centers patients are uninsured, or self-pay, and the hospital recovers only a small part of what they owe. Now, I say to you as a businessperson: How would you like to work at an auto company and give away . . . cars before even opening your doors?
Of the states population of nearly three million, 550,000 are uninsured. At the moment, Governor Bryant is claiming that the state might not accept federal money to expand Medicaid under the Affordable Care Act. But even if it does, there wont be enough doctors to see all the Mississippians who need them; the state has 176 doctors per 100,000 people, the lowest such number in the country.
Sixty years ago, Mississippi, the countrys poorest and most racially divided state, was the standard by which this nations commitment to social justice would be measured, the historian John Dittmer wrote. Talk to those in Mississippis health care community, and they all whisper the same thing: Its not rocket science; we all know what needs to be done. In short, as one Mississippian put it to me, hand-to-hand combat hiring folks whose sole job is to ameliorate the problems in poor peoples lives and a tremendous amount of money could change the situation. But the political will does not exist. So the status quo endures: generations of people who cant afford fresh tomatoes, and who dont understand that when a doctor says take this pill three times a day, he doesnt mean all at once.
In May, Shirley, Shahbazi and a black pediatrician named Eva Henderson-Camara piled into Shahbazis car and headed to the delta to talk to two nurses at a small hospital in Belzoni, more than an hour north of Jackson. The first thing you notice on entering the delta, especially when youre expecting to find poverty, is that you dont see many people. The farms are vast and empty. So much of the area is bucolic and sun-dappled that it doesnt seem poor. When I said as much to Claudia Cox about Mississippi in general, she replied sternly: Thats because poverty in America doesnt look like what yall think. It used to be bare feet, now its Nikes. If I miss two months of work because I get sick, well, guess what? Im in poverty. This is the new poverty. Yet in delta towns like Louise and Midnight, the poverty is impossible to miss: desolate commercial streets in the shadow of a rotting mill, shotgun houses wilting on one side of railroad tracks, houses almost buried under possessions on the porch and in the yard.
Henderson-Camara, now 60, grew up on the plantation her grandfather owned. Children at the time worked much of the school year as part of the sharecropper system, which lasted until the 70s, as corporations bought and mechanized the farms. (Imagine waking up every morning and this is all you see, Henderson-Camara said, looking out the window at the flat fields stretching to the sky. And you think, Should I shoot myself now or later?) Thousands of displaced workers found jobs at the Jockey factory, or the Schwinn plant, or on catfish farms, but those shut down in the early 90s. Henderson-Camara got out by winning a scholarship for a fifth year of high school at Yale. Today she lives in Jackson and works in HealthConnects medical clinic.
In Belzoni, everyone sat down at a rectangular table, and the director of nursing, Dee Ann Brown, recounted the hospitals troubles: emergency-room readmissions, obesity, inadequate insurance. Shirley then explained the role of community health workers and asked Brown if she thought that service might be helpful.
What you are describing is home health, isnt it? Brown said.
Home-health agencies dispatch nurses to do clinical work in patients homes. But they are not obligated to take your phone calls at midnight or steer you away from eating fried food and you have to have insurance to get their care. Often for-profit services, they are also the hedge funds of the health care community: potentially lucrative, largely unregulated, producing bad results as often as good. Sanjay Basu, a physician and policy expert at the University of California, San Francisco, says that while he has seen some remarkable and devoted home-health agencies, if youre in it for a buck, you could have a terrible home agency and make a ton of money. Many towns in the delta have them yet the deltas problems persist. Why? Shirley offered that the hospitals need a third party trained to discern what exactly will help a patient, and that party must come from the patients world: talk the same, share similar fears and frustrations and life experiences.
Most home-health nurses build great relationships with their patients, Brown said.
But theres a lot of distrust, Henderson-Camara said, leaning forward. We dont trust people who dont look like us. Having grown up in a very segregated community, I know this for a fact. You may think that youre in with that patient, but when you walk out that door, they will laugh and say, I just told her that so shell stop asking me questions. But if you live in that community and sister Edna tells you something, you say, Now, Edna, and she will say, O.K., you got me. And shell tell you the truth. People do not trust people who do not look like them.
I dont feel thats a problem here, said Brown, who happens to be white. I may be way smoozed.
I think youre smoozed.
The friction between them highlighted a problem beyond a distrust of outsiders: the fractured nature of American health care. It was easy to dismiss, or misconstrue, the health-house network as just another addition to a market glutted with for-profit businesses and nonprofit services looking to patch up the holes in or take advantage of the health care system. What Shirley and his colleagues saw the need for was something holistic and aggressive that would take root in the community, get into homes and alter the course of future generations, before obesity, say, or diabetes sets in. The Iranian system they admire is a preventive health care system. American health care is not preventive, and its not a system.
The practice of community health workers going door to door has been applied everywhere from China to Mexico. According to Carl H. Rush of the University of Texas Institute of Health Policy, in the United States, community health workers have been used on a small scale for decades. More recently, he says, hospitals around the country are realizing the potential for community health workers to lower their costs.
The Iranian health houses, too, resemble the original mission of Americas community health centers. When Dr. H. Jack Geiger founded the countrys first federally qualified health center in 1967 in Mound Bayou, a small town in the delta, the goal was to confront the many aspects of peoples lives that were contributing to their ill health. We built wells and privies and housing and started a 500-acre vegetable farm, says Geiger, whose work was inspired by what he saw in South Africa in the late 50s, and that probably had a bigger impact on the health of the population than what we were doing as doctors. The indigenous people we trained were among the most useful people on staff.
Today there are 8,300 centers serving 20 million people throughout the country. Over the years, however, community health centers, needing to compete in the marketplace, have evolved into more conventional medical businesses, focused on the delivery of personal health services rather than the social and environmental determinants of overall health.
To help them return to the original mission, the Affordable Care Act will give $11 billion to community health centers, a sum that will double the numbers and capacity of centers nationwide. It would be effective if community health centers were given the budget to return to the interventions that characterized almost all of the first health centers of the 1960s and 1970s, Geiger says. Every health care provider in this country is under pressure, because of the incentives in the system, to churn out patients as fast as you can, because you get paid for visits. That just doesnt work for people with the kind of complex problems you probably saw in Mississippi. You cant fix these problems in 10 minutes.
Shirley says he believes that the problems of the American poor living conditions, deficient education, harmful behaviors and the lack of family support and access to healthful lifestyles demand house calls. This approach was used by groups in Atlantic City and Camden, N.J., profiled by Atul Gawande in The New Yorker last year, which identified the worst offenders of emergency-room readmission and deployed social workers and nurses to figure out the myriad sources of ill health. What was clear above all else from Gawandes account is that what these people needed was constant attention. Because one stumble an unpaid electricity bill, for example can lead to cascading health setbacks.
The Iranian model goes a step further by making the community health workers responsible for their villagers well-being from birth. Its an approach very much at odds with the American ethos of self-reliance. But in Iran, the seeming intrusiveness is required, according to Dr. Kamel Shadpour, one of the architects of the Iranian system. If you go to one of these community health workers and ask him or her how many people they cover, they wont tell you around 2,000, Shadpour says. They will tell you exactly 1,829 people. If you take out the family file with the No. 62, he or she will know which family that is, and she will tell you that the father is this old, and they have five children, their ages, their vaccinations, how they were doing family planning, everything.
The Iranian model also differs from many others because of its integrated delivery network: the way a patient is referred up through a chain of hospitals according to their needs. The overall system is the key, says Miller, the Oxford consultant, not just community health workers.
The American government has been moving toward more comprehensive solutions. The Affordable Care Act has created accountable care organizations that include doctors, social workers, nurses and pharmacists working together to serve patients. Since May, also as part of health care reform, the Centers for Medicare and Medicaid Services announced more than 100 multimillion-dollar grants to organizations that proposed new ways to prevent illness and save money. Its Innovation Center awarded grants to a large number of experimental programs that involve community health workers.
Theres a renewed interest in them, in part because of the nations increased focus on prevention, says Dr. Richard J. Gilfillan, the director of the Center for Medicare and Medicaid Innovation. Eighty-four percent of our health care dollar is spent on managing people with chronic conditions. . . . We know preventing obesity can help prevent other illnesses such as diabetes, hypertension and kidney disease so how can we prevent these conditions from occurring in the first place? Likely not with more procedures and X-rays. Some of the winners programs harken back to the way health care was delivered long ago. The things we learn by going into someones home tell us so much about the patients life and how they manage their own diseases.
One morning last spring, Shirley took me to see one of his new health-house facilities at Blackburn Middle School, which is on the edge of Jackson State Universitys campus and across the street from where Shirley grew up. Walking with him through the neighborhood, or stopping in with him at the Penguin, a nice restaurant on the Jackson State campus, is like being with the mayor. Over lunch, the people who came to shake his hand included the states new director of Medicaid and the president of the Mississippi NAACP.
Shirley reasoned that opening health houses in the schools was a natural way to gain access to families. Many public schools in Mississippi dont have full-time nurses, and Blackburn Middle School is attended almost entirely by students who live in poverty, so it welcomed the chance to have health care on the premises.
One community health worker on the staff at Blackburn was Tiara, a single mother on Temporary Assistance for Needy Families I first met almost nine months earlier. A not-so-obvious benefit of training community health workers is that doing so creates jobs for unemployed people; advanced degrees are unnecessary. In our first interview, Tiara told me how much she loved her job. At Blackburn, she seemed quieter as we talked about how she counseled young girls about sex. As someone who had a child at 17, I am so against it, she told us. (She is now 22.) You have so much potential.
As a HealthConnect employee, Tiara also made house calls before being transferred to work in the school. Her life is a kind of full-time HealthConnect anyway. I had she said, counting six people in my apartment last night. Because they dont have electricity. And one was a real bad diabetic who cant see how to pull her insulin, cant see anything.
These are the sorts of stories you hear repeatedly in Mississippi. During five days driving around with Cox, I saw what health workers were up against, and what they were capable of. Cox comes from a middle-class family, the product of a stable home. She went to college, became a funeral director and then decided to go to nursing school, using public assistance to make her way through it. Cox had worked as a nurse for 20 years Shirley and the Central Mississippi Medical Center decided to use licensed nurses at HealthConnect until their community health workers are trained and she could intuit that a patients life might be crumbling in surprising ways.
There was Regina Huggins, who had been in the hospital 20 times in eight months since her heart attack. She was a smoker with chronic obstructive pulmonary disease who lacked energy and had lost 50 pounds. One of the reasons she kept calling ambulances to go to the E.R. seemed to be that she had no transportation; she couldnt even afford a taxi. She did not qualify for Medicaid. Without insurance, she couldnt get an oxygen tank or inhalers or fill her prescriptions. She had $300,000 in medical bills.
There was Mamie Marshall, who was dying of bone cancer in the back room of her house. None of her doctors had put her in hospice care, and she said she had been told that no one could do anything for her. She was a licensed beautician and had worked for Packard Electric, a subsidiary of General Motors, and as a public-school bus driver and as a nanny. I worked, she said.
And there were Carolyn Brewster and Melvin McGee, 29-year-olds whose baby, Justin, was born prematurely, most likely because Brewster had high blood pressure and pre-eclampsia. Both Brewster and McGee have learning disabilities, but they had jobs and had earnestly embraced parenthood, paying $450 a month for a two-room apartment in a motel-like apartment complex where everyone seemed to be under 30. When we called on them, Cox decided to take Brewsters blood pressure and discovered that it was 149 over 100. Brewster wasnt doing anything to reduce it except taking vinegar, a common home remedy. Cox made an appointment for her at the medical clinic later that day, told her how to catch the bus and which pharmacy to go to and emphasized that she needed to go right away. You are only 29, and you are going to end up on dialysis, she said.
On our way out, Cox said she wanted to stop by to see Tiara, who lives in the same apartment complex. She had just had her second child.
Shirley, Shahbazi and Miller havent had an easy time getting large-scale financing for their health-house network. They enlisted a Mississippi congressman, Bennie Thompson, to write a letter to Kathleen Sebelius, the secretary of Health and Human Services. They applied for (but did not receive) one of those grants awarded by the Innovation Center; Jack Geiger wrote the recommendation letter. They talked it up in Mississippi.
The three men and many Mississippians I spoke to complain that a lot of federal and grant money goes to research, not actual services. The delta people have been studied to death, Shirley says. Also, as they point out, funding rarely goes to entire systems. But the group is hoping that the idea of Iranian-style health houses in the United States might inspire good will between the two countries.
If they can get the resources, then why not give it a try? said Shadpour, the architect of the Iranian system, when I called him in Tehran. The situation is not worse than Iran. To the contrary, it is much better in many ways. The infrastructure is there.
Until someone finances the pilot for 15 health houses, Shirley will establish them in 11 schools where there are already rooms, electricity, water. To keep the houses running, Shirley says, they are staffed with certified nurse practitioners whose services can be billed to Medicaid. So the revenue that the nurse generates will go to paying her and the community health workers, too. We say, O.K., how much money is already out there?
The only outside money that weve gotten to contribute to our project has been $75,000 from United Healthcare, the insurance company, because they see the potential to save them money, he continued.
His methods are scrappy and scattershot, but Shirley is used to working around the system. After 60 years, perhaps the main reason hes turning to an Iranian model is because, unlike everything else in Mississippi, it worked. In one year, HealthConnect cut the rate of readmissions to the Central Mississippi Medical Center by 15 percent.
Meanwhile, Miller is trying to find yet another way to generate money. With support from Jackson State doctors and advice from their counterparts at Shiraz University, he has begun discussing the idea of Americans and Iranians working together to implement the Iranian model in other needy countries. He hopes that a major international aid project might be a way to get financing for Mississippi.
A few weeks after her first visit, Claudia Cox returned to Vonda Wellss house. Wells, who is now 41, hadnt returned to the emergency room, but she seemed sadder. She hadnt been paid the $5 a day she was supposed to get for working at the Christian community center, but despite doing all her paperwork and leaving messages for her caseworker, she had not heard back.
And because Medicaid limits the number of doctor visits in a year, she couldnt see one now.
How you going to follow up with your pulmonologist and cardiologist? Cox asked.
I had to cancel, Wells said. I already have a bill in there for $240 I have to pay.
She couldnt keep up with her medicines. Medicaid cant pay for it, and I cant pay for the medicines, not at $90 a pop, she said. I try to wean myself off of medicine. If I feel good, I dont take them.
But Wells spoke of positive things. Her 19-year-old daughter, who played in the next room with Wellss grandchild, was talented enough to be a fashion designer, she said. Her youngest daughter, 16, wanted to join the military to see the world. Her mother helped out with the bills at times. And her uncle had offered to come by and do some repairs, rip up the carpet, fix the kitchen. In many ways, Wells was rare among Coxs patients: she still had family.
In fact, the house had been her grandmothers, and she had spent some of her childhood there. She was lucky to have a rent-free home full of so many memories. But Wells would have to wait to learn whether that house was giving her asthma problems.
We couldnt find anybody to examine the house that was affordable, Cox said. It was $1,300 for one day just to test. Just to come out here and pull a couple of pieces from the attic.
Suzy Hansen last wrote for the magazine about the art scene in Istanbul, where she lives.
Editor: Dean Robinson
