Below I reproduce an essay I sent to the SUNY Downstate MPH program in Brooklyn as part of my application for admission into their program. Enjoy... Feedback welcome.
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Question: HIV and AIDS are on the rise in many immigrant communities. Yet, public health outreach is often diminished because of cultural, language, and socioeconomic barriers. You are the director of a health center in a largely immigrant community (please specify the nationality of the immigrant group). Propose a program for the health center that will enable individuals to understand that the health center provides a wide variety of services including HIV/AIDS screening and treatment.
Improving Clinic-Community Relations for Healthcare Providers in a Haitian-American Neighborhood As a health clinic that neighbors a large Haitian American community, we do not find that many Haitians utilize our programs. This not only suggests that we need to do better outreach, but that we may not be offering the services that seem relevant to the community. By studying other programs in similar communities, I identified three areas of improvement that can increase use of our services by the Haitian American community. 1) The clinic should become more “culturally competent” within the Haitian community. 2) We must make the clinic part of a comprehensive strategy to visibly improve the health and quality of life for AIDS patients. 3) We should involve community members, including our HIV-positive patients, on all levels of the clinic’s operation.
A culturally competent clinic In order to work effectively in the Haitian-American community, we should design our program specifically for them. First of all, we must staff the clinic with Haitian Creole speakers, because many Haitian Americans do not know French [1]. In addition, 75% of Haiti’s population is illiterate, so we cannot rely on written materials as outreach to Haitian immigrant communities [2].
Since Haitians were initially singled out as the only ethnic group “at-risk” for AIDS, we must also be aware of the cultural stigma associated with HIV. Many Haitians are seen as “AIDS carriers” and have suffered firings, evictions, violence, alienation and other discrimination simply because of their national origin [3]. Farmer points out how this stigmatization has even permeated academic literature on the subject [4]. Santana and Dancy add that many Haitian Americans have experienced “visible discrimination” in hospitals, creating distrust within the Haitian American community toward health professionals [5]. To avoid such a situation at our clinic, all of the clinic staff should be taught the popular misconceptions about Haitians and HIV in clinic-sponsored classes.
Moreover, intracommunity stigmatization “can play a major role in diminishing Haitians’ utilization of existing services,” as contracting AIDS is linked to poor morals or otherwise blamed on the patient [2]. We will need to engage community members in an educational process about HIV, AIDS, their causes, prevention strategies, and the lives of survivors in order to address negative popular attitudes. The active involvement of community members in planning and carrying out this process will be necessary to make the clinic more culturally relevant to the Haitian American community.
A comprehensive program that addresses HIV and AIDS in the Haitian community While education and outreach efforts are needed to end stigmatization, Farmer argues that, from his experience in rural Haiti, the recovery and health of HIV-positive patients can very quickly erode the stigma attached to the disease [6]. For example, in the two years after the Clinique Bon Sauveur introduced a Directly Observed Therapy with Highly Active Anti Retroviral Therapy (DOT-HAART) they experienced a 300% increase in the number of voluntary HIV tests [3].
For this reason, our clinic must offer quality HIV treatments including anti-retroviral medication to those who come in for testing and test positive. To encourage more volunteers for the HIV tests, these treatment services should be advertised, especially to vulnerable groups such as pregnant women who might be eligible for pre-natal AZT treatment if they test HIV-positive. Similarly, the clinic must be prepared to offer effective treatment to the common opportunistic infections of AIDS patients, including multi-drug resistant Tuberculosis, to demonstrate the value of the clinic’s services to HIV patients [6]. If we cannot directly offer any of these services, we must be able to partner with other hospitals, government programs, universities or clinics that can guarantee such treatments for our patients.
Furthermore, Farmer argues that poverty and inequality are pathogenic factors in the spread of HIV and opportunistic infections. He offers one example when his patients were not adhering to the medication regimens because they could not afford to buy food and wouldn’t take the medications on an empty stomach [6]. With this in mind, if we cannot provide other services that patients need, we must empower bilingual employees to actively advocate on the patients’ behalf to find housing, food, income, and other necessities. We must also help patients that are drug users to find treatment for their addictions. Moreover, our staff may need to mediate with law enforcement and immigration authorities to allow our patients to continue getting treatment even if they are sent to jail or threatened with deportation [2]. We should advertise these services in order to make the clinic a compelling destination for anyone who is or might be HIV-positive. Since many Haitian American AIDS patients are poor, we have to also find a way to provide these services at little or no cost to the patient [6].
Active involvement of the community The active involvement of the local community members, including the HIV patients, in all levels of our clinic’s operation will improve the services offered by the clinic and encourage participation by other community members.
Our clinic can achieve this effect by hiring community “health promoters.” These members of the community are better connected to community institutions and better prepared to identify the pathogenic factors that are widespread within their community but not openly discussed - such as drug use, unprotected sex, domestic violence, crowded living situations, or chronic malnourishment. In addition to doing outreach and advocacy work, promoters can also teach other clinic staff about the community and help the staff craft strategies that work best in the local context.
Such health promoters at the Partners In Health (PIH) program in Boston were able to quickly recognize the poor AIDS treatment response rate of a certain subpopulation of patients. They responded by creating a supportive Directly Observed Anti-Retroviral Treatment to insure that patients adhered to the treatment regimens despite difficulties [3]. In another example, the Center for Community Health, Education and Research, Inc. (CCHER) created a program of “psychosocial educational counseling” in Creole for community members. This community-based counseling was able to uncover a hidden problem of alcohol and drug abuse in the Haitian community of Boston that had not adequately been described previously. They then developed “interventions from a community-level approach” to address problems discovered by the counselors [2].
Promoters can also run creative outreach initiatives such as the “Volunteer Health Educators” program of CCHER. This program trains “community members, affected family members, and consumers” to organize small group presentations on HIV/AIDS prevention, on services in the clinic and on other issues related to illness and recovery [2]. Since the advocates and/or health promoters will be community members, they can help identify other appropriate methods of outreach and information dissemination.
Effective outreach will require extensive networking with other community institutions, taking advantage of the networks that have already been created. Our bilingual staff should be empowered to create alliances with churches, schools, community organizations, affordable housing advocates, prisoner and immigrants’ rights groups, local radio stations, artists and music groups. These networks can help create new spaces where HIV/AIDS education, prevention, testing, treatment, and other services can be made accessible to many different parts of the community. For example, CCHER’s promoters ran a regular radio show at a popular and supportive radio station to talk about HIV and AIDS, to advertise services at the clinic and to answer callers’ questions in Haitian Creole [2].
Meanwhile, our health professionals should create and/or strengthen connections with local Universities, hospitals, social workers, relevant government programs, NGO’s, and foundations. These institutional contacts can help give the clinic access to more resources, funding, and complementary services. We should also build working relationships with successful programs like CCHER and PIH so that we can jointly work toward common goals and learn from each other’s experiences.
Conclusion
In order to make our clinic a more integral part of the community, our staff must respect and try to understand the difficulties that our patients face. Furthermore, bilingual members of the community must be integrated both as staff and volunteers into all levels of the clinic’s operation including outreach efforts, decision-making, and case management.
Since the AIDS epidemic among Haitian and Haitian American patients is so widespread and so intricately linked to issues of poverty, the services offered should be part of a systematic strategy to confront and stop the transmission of AIDS and the suffering of AIDS patients. The bilingual health promoters can ensure that our efforts are effective by interpreting, advocating and counseling for the patients. Their feedback will then be crucial in adapting the clinic to the community’s needs.
Health promoters, along with patients, family, community leaders and others can then reach out to the rest of the community as colleagues and make the clinic’s services an accessible and compelling part of our neighbors’ lives. Collaboration with community organizations and other relevant institutions will be instrumental in allowing this work to expand and one day end the local AIDS epidemic.
Selected Bibliography1. Boyd-Franklin, Nancy, et al. “Cultural Sensitivity and Competence: African-
American, Latino and Haitian Families with HIV/AIDS.”
Children, Families and HIV/AIDS: Psychosocial and Therapeutic Issues. Eds. Nancy Boyd-Franklin et al. New York: Guilford Press, 1995. 53-77.
2. Jean-Louis, Eustache, et al. “Drug and Alcohol Use among Boston’s Haitian Community: A Hidden Problem Unveiled by CCHER’s Enhanced Innovated Case Management Program.”
Drugs and Society. 16 (2000): 107-125.
3. Farmer, Paul, et al. “Community Based Treatment of Advanced HIV Disease: Introducing DOT-HAART (Directly Observed Therapy with Highly Active Anti-Retroviral Therapy).”
Bulletin of the World Health Organization. 29 (2001): 1145-1152.
4. Farmer, Paul. “New Myths for Old.”
The Uses of Haiti. Monroe, Maine: Common Courage Press, 1994. 345-374.
5. Santana, Marie-Anne, and Barbara C. Dancy. “The Stigma of Being Named AIDS Carriers in Haitian American Women.”
Health Care for Women International. 21.3 (2000): 161-172.
6. Farmer, Paul. “From Despair to Health Care.” Bloomberg School of Public Health. Johns Hopkins University, Baltimore. 22 September 2005.
