By Enrico Cullen
“Mariluz is such a warm, genuine person that the patients respond beautifully. She has helped many children. I brought my medical residents in to watch Mariluz meet a family. Even if you don’t speak Spanish, you can learn a lot about communication by watching her.”
— Dr. Joshua Needleman, Maimonides Medical Center
The phrase “social determinants of health” is common now and used widely across the health sector. There are descriptive lists (where we live, work, play). There are more meaningful lists (racism, unemployment, housing). And there are efforts to speak positively about improving the serious conditions in which people find themselves (social opportunities). But none seem sufficient when describing the life-altering influences that are all around us and inside of us.
Which brings me to a recent Monday night in Sunset Park, Brooklyn.
A mother whose 3-year-old son had recently had an asthma attack checked-in at a pulmonary clinic associated with Maimonides Medical Center. The clinic is run by Dr. Joshua Needleman, a soft-spoken physician who looks for the best ways to work with patients, not all of them strictly medical. It’s also a place where AIRnyc has embedded Community Health Workers to help families take steps towards better self-directed care.
What was clear on this particular night was that the child has asthma. Beyond being visibly uncomfortable and having difficulty breathing, he scored poorly on his breathing test. Dr. Needleman prescribed controller medications for him. His mother was given instructions in Spanish for how to give the medicine to her toddler on daily basis. These instructions are critical in every single case and yet they often get lost in the normal course of life. Without them, the child’s asthma remains uncontrolled. Consequently, a future emergency department visit or admission becomes all but inevitable. Asthma can also be life threatening without proper controls.
But there’s more. Behind the boy’s frightened face and labored breathing is another story, deeper in the family’s history and potentially toxic for a child of any age, let alone a 3-year-old. The mother’s partner had recently returned from prison. He has been violent towards her, in her home, in front of her child.
What we see emerging is that the stress of home life, mixed with other factors related to poverty, such as incarceration, are creating the conditions in which a 3-year-old is more likely to develop asthma and, in response to an asthma attack, be admitted to the hospital. The child will probably also miss school, fall behind, and return multiple times to the emergency department. To take care of her sick child, the mother will miss days of work and lose income, perhaps lose her job, or even her apartment. This is how health is socially determined. It is almost certain that this mother will return to the hospital with her son in the near future.
Mariluz Garcia, an AIRnyc Community Health Worker, put Monday night’s situation like this:
Everything changed when mom stated that she is a victim of domestic violence and that the child’s father recently was out of prison.
As a CHW, I know that this topic needed to be discussed in private and I told mom that when she finished with Dr. Needleman I would wait for her in the other room. I spoke with the mom while Dr. Needleman and the medical resident were checking the little boy.
I know that discussing domestic violence and scheduling a baseline home visit needed time. First to earn mom’s trust and second because this topic would distract me from asthma.
The delicacy of this situation combined with the sensitivity with which Mariluz addressed it, and her eye on the professional purpose of engaging the mother to help with the child’s asthma, made all the difference.
Dr. Needleman took note.
“I brought my medical residents in to watch Mariluz meet a family,” said Dr. Needleman recently. “Even if you don’t speak Spanish, you can learn a lot about communication by watching her.”
Mariluz meets people with the quiet confidence of someone who is a natural helper, understanding that the family is concerned and may not know exactly what to do to manage a child’s asthma. This is how she can schedule a home visit and guide the child to better health.
“Mariluz has made many vital connections to families here,” Dr. Needleman continued. “ And the children have done so much better because of her. Even families that are reluctant to participate, or have refused in the past, are completely at ease when they meet her.”
Studies estimate that upwards of 80% of what positively or negatively affects our health is non-medical and largely determined by social, environmental and genetic factors. Dr. Needleman has recognized this in the context of his clinical practice and notably is passing this knowledge on to the medical residents under his supervision.
And yet life continues. The mother decided to move to an undisclosed location, a shelter that would keep her safe from her violent partner. She did not even tell Mariluz where she was for fear that he would find her, although they have kept in touch by text and by phone.
Then, last week, Mariluz learned that a second child, an older son, also has asthma. The mother will return again to the clinic in late April with both of her children to try again to keep asthma under control and build a healthier life for her and her children.
Part 2 of this blog entry will appear in May.
Mariluz Garcia joined the AIRnyc as a Community Health Worker in July 2017. She grew up in Tegucigalpa, Honduras, and graduated from Hunter College with a degree in Community Health. Mariluz visits Dr. Needleman’s clinic every Monday and Friday to connect to patients who would benefit from AIRnyc’s home-visiting services.
Dr. Joshua Needleman is a Pediatric Pulmonologist with whom AIRnyc has an established partnership. Dr. Needleman operates an asthma clinic three times a week at the Maimonides Medical Center in Brooklyn.
Enrico Cullen is AIRnyc’s Chief Strategy Officer.