Building Pipelines to Health Care Equity - The University of Miami AHEC
by Rick Docksai
As a family physician in Miami, Arthur Fournier knows firsthand the disparities in U.S. health care. He’s seen how doctors overwhelmingly set up shop in wealthier jurisdictions while avoiding poorer locales. “Go to the ritzy part of town, and there are no shortages of doctors,” he says of Miami. “Go to the next ZIP code, and you have no doctors.”
He is striving to correct the imbalance. As director of the University of Miami’s Area Health Education Center (AHEC), he leads the raising up of new, homegrown medical services in historically underserved communities—rural towns, African-American neighborhoods, homeless shelters, and communities of Latino and Creole immigrants—of the Florida Keys and Miami-Dade County.
Those new medical services include personnel from those very same communities. Dr. Fournier and his group teach residents of all ages about career opportunities in health care. Then they help those who are interested to find health-care training programs and, upon completion, to practice their professions in the neighborhoods where they had grown up. “What we need is more learning by and with the poor, not learning on the poor,” he says.
Dr. Fournier’s AHEC is a “pipeline” program, the term given to initiatives that direct students and career seekers to train for medical careers and to practice medicine in their home communities. In his experience, pipeline programs are the difference between many communities getting the medical care they need and not getting care at all. “If you didn’t have a pipeline mechanism, medical schools wouldn’t produce people who are willing to work in underserved communities,” he says.
Miami-Dade and the Florida Keys have many working poor whose menial-pay jobs do not offer health benefits. Standard hospitals are not an option for them. Federally sponsored clinics treat some, but there are not enough federal clinics to go around. So Dr. Fournier and his colleagues fill in the gaps. At AHEC-affiliated sites within the communities, program faculty and students collaboratively diagnose and treat more than 50,000 at-need residents a year.
Local schools are among their areas of operation. He and his team set up “model health teaching clinics” at eight schools. Each one offers students ear exams, checkups, and other services. Students are healthier, and as a side benefit, classrooms function better. “We hope that in addition to improving their health, we can improve their school performance,” he says.
The teaching clinics’ nurses and staff include medical students working for credit. They are gaining experience in primary care, which to Dr. Fournier is hugely important: Some may decide to take up primary care as a profession and thereby help relieve the country’s worsening shortage of primary doctors. “We have way too many specialists, because specialists make a lot of money. The result is we’re going to run out of primary care doctors,” he says.
Community residents get instruction, too. AHEC faculty and students hold educational health fairs and programs on such topics as how to respond to a natural disaster. They also train adult volunteers to promote better health practices within their schools, clinics, churches, and civic associations.
For local youths, they maintain Health Career Pipeline programs that encourage disadvantaged young people to pursue medical education. Dr. Fournier says that he would love to go a step further and provide them scholarships to the University of Miami. “The schools have these wonderfully deserving kids,” he says.
Culturally Competent Care
Dr. Fournier says that problems in translation often arise when doctors see patients from other countries and cultures. A doctor needs to truly understand a patient’s mindset and background, not just the patient’s physical symptoms. “You have to have some sort of bond between the provider and the community,” Dr. Fournier says. And who better to form such a bond than a doctor from that patient’s own community?
Dr. Fournier’s faculty team includes three Haitian-American physicians, two African-American nurse practitioners, and a Puerto Rican doctor. Each works directly with his or her respective communities. The Puerto Rican doctor, for instance, looks after migrant Hispanic farm workers in Miami’s South Bay area. “I've come to learn how important cultural competency is. When you don’t have culturally competent physicians, health-care quality goes down and costs go up,” he said.
Dr. Fournier creates opportunities for all his students, who hail from myriad backgrounds, to work with communities of their own and other backgrounds. Every now and then, a student and community truly click. “We now have a wonderful program where we visit Haiti. We have three or four Haitian-American students that come through our school every year. You should see them blossom when we go down to Haiti,” he said. “And while you can’t assume that just because someone is from Haiti they’ll be dedicated to serving the Haitian community, it’s like panning for gold in the stream. Keep panning often enough and you’ll hit a nugget.”
Tough Fiscal Climate
Dr. Fournier worries that in difficult economic times such as now, government support will wane. It’s already happened in Florida: The legislature slashed funding in half last year. But recessions are when pipeline programs are needed the most, he warns. When unemployment goes up, the number of uninsured goes up, and so the cost of care goes up. To roll back pipeline programs is to exacerbate an already-worsening health situation. “It’s a negative feedback loop,” he says.
Fournier’s University of Miami AHEC is just one of the more than 300 AHECs affiliated under the National Area Health Education Center Organization (NAO). The Health Occupation Students Association (HOSA) is also a pipeline network. Its 3,200 university/college chapters and 47 chartered State Associations form a 120,000-strong membership. More medical schools additionally have pipeline programs of their own.
These many programs share the same goal: building up a health-care work force that is large enough to serve the whole country yet localized enough to respond to each community’s unique needs. It is a tall order, but Dr. Fournier and others carry it out day by day.