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Medicine As Social Rehabilitation

In honor of National Primary Care Week 2014, we're running blog posts all week that recognize underserved and marginalized communities and the those who serve them. This piece from our archives first ran in 2012.

By Joe Tobias

Earlier this year I heard Jack Geiger deliver Grand Rounds in the Social Medicine Department of Montefiore Medical Center. A physician well into his 80s, Geiger still travels the country promoting medicine as social rehabilitation—a model he has championed for the past fifty years. In the Mississippi Delta, in the racially divided South of the 1960s, Geiger started the nation’s first community health center. Not only did the center treat North Bolivar County residents’ acute medical problems, it also empowered them to lead better lives: to learn the skills they needed to stay healthy, to obtain the education that poverty had unjustly denied them and to realize their potential.

Variations on Geiger’s model now exist in more than one thousand underserved communities in the United States. On a purely statistical basis, community health centers are impressive: they really do improve the health of 20 million people in the United States each year, 40 percent of whom are insured by Medicaid. But what is perhaps more impressive than their statistics is the philosophy that underlies the model, one that charges primary care physicians with the responsibility of ensuring that patients are leading good lives.
I witnessed this kind of primary care as a social worker in the South Bronx. Like North Bolivar County in the 1960s, the Bronx is a medically underserved area. This means that there are too few primary care doctors to manage the severity of the population’s health problems. In the northernmost borough of New York City, 43 percent of children live below the federal poverty line. And given the link between poverty and disease, it follows that 11 percent of the borough’s 1.4 million people have diabetes (compared to a national average of 8 percent), 30 percent are obese (compared to 26.5 percent nationally) and 16 percent have asthma (compared to 8 percent).
The link between poverty and substance abuse is also strong. As a social worker in the substance use division of the Bronx welfare system, it was my job to help men and women on welfare get treatment for substance abuse. Addiction, especially to heroin, crack and alcohol, is unimaginably difficult to overcome. Yet through group therapy, individual counseling and medication, the welfare system in New York City hopes that substance users will get better. Treatment is therefore a condition of receiving welfare checks. In this directive towards recovery, at once coercive and humane, one of the single most rewarding things I got to do as a social worker was to connect my clients to primary care doctors who share Geiger’s philosophy.
I recall one client in particular whose story demonstrates the power of this philosophy. After twenty years of living as a functional alcoholic, this 45 year-old-man from Georgia ended up homeless on the streets of New York suffering alcohol-induced seizures. At the end of periods of temporary sobriety in inpatient rehabilitation facilities followed by episodes of drinking and homelessness, he became my client.
On welfare and enrolled in a drug treatment program, he met with me each week as I connected him to the medical and social services he needed in order to recover. For primary care, I referred him to the Montefiore Comprehensive Health Care Center. Within several weeks, he had a doctor, a talented woman who referred him to a psychiatrist, social worker, physical therapist and orthopedic specialist. She listened to his complaints of chronic back pain, diagnosed lifelong scoliosis, and more profoundly, recognized the feelings of persistent hopelessness that attend depression.
What is more, she used the power of an MD’s signature to help me do my job. Her signature helped him apply for supportive housing for homeless men in recovery from drug addiction and enrolled him in vocational training in order to ensure that he earns more than a welfare allowance of $68.50 every two weeks. As his primary care doctor, she had a hand in every aspect of his health, which means she had a hand in every aspect of his life.
Of course, she did not do this alone. Between his psychotherapist, drug counselor, various specialists and me, there was a team of people working towards his recovery. Most importantly, all of our efforts would have been meaningless but for his formidable resolve to change his circumstances. “I won’t go back to where I have been,” he used to repeat.
There are two extraordinary parts of this story: the first is my client’s readiness to recover from addiction; the second is the kind of primary medical care he was able to receive at the Montefiore Comprehensive Health Care Center. Like the model of medicine Geiger established in Mississippi, which persists in community health centers across the United States, this was primary care conceived as total responsibility—primary care not only for the physical health of the patient, but for the betterment of his life. And in communities like the Bronx, my client’s experience is proof that, as Geiger promised at Grand Rounds, medicine is very much suited to the task of social rehabilitation.
Hailing from America's friendly neighbo(u)r to the north, Joe Tobias was a 2010 Harvard Center for Public Interest Careers fellow at Montefiore Medical Center in the Bronx. He hopes to join his twin sister in medical school by 2014.

Updated October 10, 2014.  

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Posted by Sonya Collins on Feb 23, 2012 9:37 AM America/New_York
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