What if our healthcare system kept us healthy Rebecca Onie
so my freshman year of college I signed
up for an internship in the housing unit
at greater Boston Legal Services showed
up the first day ready to make coffee
and photocopies but was paired with this
righteous deeply inspired attorney named
Jeff Purcell who thrust me on to the
front lines from the very first day and
over the course of nine months I had the
chance to have dozens of conversations
with low-income families in Boston who
would come in presenting with housing
issues but always had an underlying
health issue so I had a client who came
in about to be evicted because he hasn’t
paid his rent but he hasn’t paid his
rent of course because he’s paying for
his HIV medication and just can’t afford
both we had moms who had come in
daughter has asthma wakes up covered in
cockroaches every morning and one of our
litigation strategies was actually to
send me into the home of these clients
with these large glass bottles and I
would collect the cockroaches hot glue
gun them to this poster board that we
bring to court for our cases and we
always won because the judges were just
so grossed out far more effective I have
to say than anything I later learned in
law school but over the course of these
nine months I grew frustrated with
feeling like we were intervening too far
downstream and the lives of our clients
that by the time they came to us they
were already in crisis and at the end of
my freshman year of college I read an
article about the work that dr. Barry
Zuckerman was doing as chair of
pediatrics at Boston Medical Center and
his first hire was a legal services
attorney to represent the patients so I
called Barry and with his blessing in
October 1995 walked into the waiting
room of the Pediatrics clinic at Boston
Medical Center I’ll never forget the
TV’s played this endless reel of
cartoons and the exhaustion of mothers
who had taken two three sometimes four
buses to bring their child to the doctor
was just palpable the doctors had seen
never really had enough time
for all the patients try as they might
and over the course of six months I
would corner them in the hallway and ask
them a sort of naive but fundamental
question if you had unlimited resources
what’s the one thing you would give your
patients and I heard the same story
again and again a story we’ve heard
hundreds of times since then they said
every day we have patients that come
into the clinic
child has an ear infection I prescribe
antibiotics but the real issue is
there’s no food at home the real issue
is that child is living with 12 other
people in a two-bedroom apartment and I
don’t even ask about those issues
because there’s nothing I can do I have
13 minutes with each patient patients
are piling up in the clinic waiting room
I have no idea where the nearest food
pantry is and I don’t even have any help
in that clinic even today there are two
social workers for 24,000 pediatric
patients which is better than a lot of
the clinics out there so health leads
was born of these conversations a simple
model where doctors and nurses can
prescribe nutritious food heat in the
winter and other basic resources for
their patients the same way they
prescribed medication patients then take
their prescriptions to our desk in the
clinic waiting room where we have a
corps of well-trained college student
advocates who work side by side with
these families to connect them out to
the existing landscape of community
resources so we began with a card table
in the clinic waiting room totally
lemonade stand style but today we have a
thousand college student advocates who
are working to connect nearly nine
thousand patients and their families
with the resources that they need to be
healthy so 18 months ago I got this
email that changed my life and the email
was from dr. Jack Geiger who had written
to congratulate me on hopefully it’s in
to share as he said a bit of historical
context in 1965 dr. Geiger founded one
of the first two community health
centers in this country and a brutally
poor area in the Mississippi Delta and
so many of his patients came in
presenting with malnutrition that he
began prescribing food for the
and they would take these prescriptions
to the local supermarket which would
fill them and then charge the pharmacy
budget of the clinic and when the Office
of Economic Opportunity in Washington DC
which was funding Giger’s clinic found
out about this they were furious and
they sent this bureaucrat down to tell
Geiger that he was expected to use their
dollars for medical care
- which Geiger famously and logically
responded but last time I checked my
textbooks the specific therapy for
malnutrition was food so when I got this
email from dr. Geiger I knew I was
supposed to be proud to be part of this
history but the truth is I was
devastated
here we are 45 years after Geiger has
prescribed food for his patients and I
have doctors telling me on those issues
we practice a Don’t Ask Don’t Tell
policy 45 years after Geiger healthly
it’s has to reinvent the prescription
for basic resources so I have spent
hours upon hours trying to make sense of
this weird Groundhog Day how is it that
if for decades we had a pretty
straightforward tool for keeping
patients and especially low-income
patients healthy that we didn’t use it
if we know what it takes to have a
health care system rather than a sick
care system why don’t we just do it
these questions in my mind are not hard
because the answers are complicated they
are hard because they require that we be
honest with ourselves my belief is that
it’s almost too painful to articulate
our aspirations for our healthcare
system or even admit that we have any at
all because if we did they would be so
removed from our current reality but
that doesn’t change my belief that all
of us deep inside here in this room and
across this country share a similar set
of desires that if we are honest with
ourselves and listen quietly that we all
Harbor one fiercely held aspiration for
our health care that it keep us healthy
this aspiration that our healthcare keep
us healthy is an enormous leap our
–fill and you know the way I think
about this is that health care is like
any other system it’s just a set of
choices that people make what if we
decided to make a different set of
choices what if we decided to take all
the parts of health care that have
drifted away from us and stand firm and
say no these things are ours they will
be used for our purposes they will be
used to realize our aspiration what if
everything we needed to realize our
aspiration for health care was right
there in front of us just waiting to be
claimed so that’s where health leads
began we started with the prescription
pad a very ordinary piece of paper and
we asked not what do patients need to
get healthy antibiotics and inhale or
medication but what do patients need to
be healthy to not get sick in the first
place and we chose to use the
prescription for that purpose so just a
few miles from here our Children’s
National Medical Center when patients
come into the doctor’s office they’re
asked a few questions they’re asked are
you running out of food at the end of
the month
do you have safe housing and when the
doctor begins the visit she knows height
weight is there food at home is the
family living in a shelter and that not
only leads to a better set of clinical
choices but the doctor can also
prescribe those resource for the patient
using health leads like any other
subspecialty referral the problem is
once you get a taste of what it’s like
to realize your aspiration for health
care you want more so we thought okay if
we can get individual doctors to
prescribe these basic resources for
their patients could we get an entire
healthcare system to shift its
presumption and we gave it a shot so now
at Harlem Hospital Center when patients
come in with an elevated body mass index
the electronic medical record
automatically generates a prescription
for health leads and our volunteers can
then work with them to connect patients
to healthy food and exercise programs in
their communities we’ve created a
presumption that if you’re a patient at
that hospital with an elevated BMI
the four walls of the doctor’s office
probably aren’t going to give you
everything you need to be healthy you
need more so on the one hand this is
just a basic recoding of the electronic
medical record and on the other hand
it’s a radical transformation of the
electronic medical record from a static
repository of diagnostic information to
a health promotion tool in the private
sector when you squeeze that kind of
additional value out of a fixed cost
investment it’s called a billion dollar
company but in my world it’s called
reduced obesity and diabetes
it’s called health care a system where
doctors can prescribe solutions to
improve health not just manage disease
same thing in the clinic waiting room so
every day in this country
three million patients pass through
about 150,000 clinic waiting rooms in
this country and what do they do when
they’re there they said they watch the
goldfish in the fish tank they read
extremely old copies of Good
Housekeeping magazine but mostly we all
just sit there forever waiting how did
we get here where we devote hundreds of
acres in thousands of hours to waiting
what if we had a waiting room where you
don’t just sit when you’re sick but
where you go to get healthy if airports
can become shopping malls and McDonald’s
can become playgrounds surely we can
reinvent the clinic waiting room and
that’s what health leads has tried to do
to reclaim that real estate and that
time and to use it as a gateway to
connect patients to the resources they
need to be healthy so it’s a brutal
winter in the Northeast your kid has
asthma or he just got turned off and of
course you’re in the waiting room of the
ER because the cold air triggered your
child’s asthma but what if instead of
waiting for hours anxiously the waiting
room became the place where health leads
turned your heat back on and of course
all of this requires a broader workforce
but if we’re creative we already have
that too we know that our doctors and
nurses and even social workers aren’t
enough that the ticking minutes of
healthcare are too constraining health
just takes more time it requires a
non-clinical army of community
health workers and case managers and
many others what if a small part of that
next healthcare workforce were the 11
million college students in this country
unencumbered by clinical
responsibilities unwilling to take no
from an answer from those bureaucracies
that tend to crush patients and with an
unparalleled ability for information
retrieval honed through years of using
Google now lest you think it improbable
that a college volunteer can make this
kind of commitment I have two words for
you March Madness the average NCAA
division 1 men’s basketball player
dedicates 39 hours a week to his sport
now we may think that’s good or bad but
either case it’s real and health leads
is based on the presumption that for too
long we have asked too little of our
college students when it comes to real
impact in vulnerable communities college
sports teams say we’re gonna take dozens
of hours at some field across campus at
some ungodly hour of the morning and
we’re gonna measure your performance and
your team’s performance and if you don’t
measure up or you don’t show up we’re
gonna cut you off the team but we’ll
make huge investments in your training
and development and we’ll give you an
extraordinary community of peers and
people lined up out the door just for
the chance to be part of it so our
feeling is if it’s good enough for the
rugby team it’s good enough for health
and poverty health leads to recruits
competitively trains intensively coaches
professionally demand significant time
builds a cohesive team and measures
results I kind of Teach for America for
health care now in the top ten cities in
the US with the largest number of
Medicaid patients each of those has at
least 20,000 college students New York
alone has half a million college
students and this isn’t just a sort of
short-term work force to connect
patients to basic resources it’s a next
generation health care leadership
pipeline who have spent two three four
years in the clinic waiting room talking
to patients about their most basic
health needs and they leave with the
conviction the ability and the efficacy
to realize our most be
SiC aspirations for healthcare and the
thing is there’s thousands of these
folks already out there so me lazada is
chief resident of internal medicine at
UCSF Medical Center but for three years
as an undergraduate she was a health
leads volunteer in the clinic waiting
room at Boston Medical Center Mia says
when my classmates write a prescription
they think their work is done when I
write a prescription I think can the
family read the prescription do they
have transportation to the pharmacy do
they have food to take with the
prescription do they have insurance to
fill the prescription those are the
questions I learned at healthly it’s not
in medical school now none of these
solutions the prescription pad the
electronic medical record the waiting
room the army of college students are
perfect but they are ours for the taking
simple examples of the vast
underutilized healthcare resources that
if we reclaimed and redeployed could
realize our most vast basic aspiration
of health care so I had been at legal
services for about nine months when this
idea of healthy had started perking in
my mind and I knew I had to tell Jeff
Purcell that my attorney that I needed
to leave and I was so nervous because I
thought he was going to be disappointed
in me for abandoning our clients for
some crazy idea and I sat down with him
and I said Jeff I have this idea that we
could mobilize college students to
address patients most basic health needs
and I’ll be honest all I wanted was for
him to not be angry at me but he said
this Rebecca when you have a vision you
have an obligation to realize that
vision you must pursue that vision and I
have to say I was like whoa that’s a lot
of pressure I just wanted a blessing I
didn’t want some kind of mandate but the
truth is I’ve spent every waking minute
nearly since then chasing that vision I
believe that we all have a vision for
healthcare in this country I believe
that at the end of the day when we
measure our healthcare it will not be by
the diseases cured but by the diseases
prevented
it will not be by the excellence of our
technologies or the sophistication of
our specialists but by how rarely we
needed them and most of all I believe
that when we measure healthcare it will
be not by what the system was but by
what we chose it to be thank you
you