What Mississippi can learn from Iran

[summer]

I c/p'd the beginning of the article. Click link at the end for full one.

NYTimes

One morning this spring, Claudia Cox, a registered nurse in Jackson, Miss., drove toward the countryside to visit some patients. She often has trouble finding their homes. “The rural people are the worst,” she said. “ ‘Come to the oak tree.’ Well, hell, I’m from the city, I don’t know what no oak tree is. I know magnolia. I know pine trees.” Cox referred to her seven-year-old Ford Freestyle as her “office,” but it had the ambience of an arcade: the ding-ding-ding from her dashboard signaling an unbuckled seat belt, the whir of a phone charger in the cigarette lighter, the phone ringing with the opening of Cheryl Lynn’s disco hit “Got to Be Real.” Cox, a 45-year-old divorced mother of three, juggled phone calls and patients’ charts and cigarettes like some serene octopus, always catching the steering wheel just before the vehicle veered onto the grass. After 20 minutes, she pulled into a pebbly driveway. It was time to find out why Vonda Wells kept going back to the emergency room.

Cox works for an agency called HealthConnect, whose purpose is to reduce admissions to the Central Mississippi Medical Center, a Jackson hospital where people routinely use the emergency room for primary care, sometimes multiple times in a month.

Wells’s large figure filled the door frame of the tiny house. She was jovial despite the oxygen tube that ran to her nose. She held a baby. “Is that yours?” Cox exclaimed.

“That’s my grandbaby!” Wells said and passed the baby off to a teenager who disappeared behind a closed door. The two women sat down in a dark living room cramped with couches.

“All right, Ms. Wells, we come out and check on everybody,” Cox said. “You had pneumonia, right?”

“I went to Florida, and that’s where I first got sick, at the Holy Land.”

“O.K.,” Cox scribbled, and then looked up. “What’s that?”

“It’s an amusement park out there, but it has Jerusalem, it has Noah’s Ark, they did the play the Passion . . .”

“Now there’s another spot for me and my baby to go!” Cox said. They laughed.

Cox doesn’t know oak trees, but she knows how to talk to people. She knows when to ask if someone cannot afford insulin, or is not taking insulin, or is not keeping the insulin cold, or cannot keep the insulin cold because there is no electricity or refrigerator. Not having health insurance is a huge problem in Mississippi, but it isn’t the only one. “So you good with doing your medicines?” Wells made a guilty face. “You oxygen-dependent?” She was.

Wells worked at a Jackson hospital as a certified nursing assistant for five years before she started getting sick with asthma-related illnesses. No one wanted a nurse who needed an oxygen tank, she said, so now she was trying to work a handful of hours a week at a Christian community center. “I stayed in Illinois for 25 years,” she said. “I didn’t really have asthma symptoms till I came down here.”

“There’s something in the house that’s triggering it,” Cox said. “I bet you need to get tested for mold.” She made a note. The house was old, the rug thick, the air damp. “And I’m putting a little check mark down here that you got the basic light, gas and water. Your major problem is the asthma.”

“And congestive heart failure.”

Cox tilted her head. “Have you been taught how to manage your congestive heart failure? Because you should have a scale.” She looked around the house gamely, as if she believed a scale might pop out from behind the TV.

“I need a scale?”

“You need a scale, and you need to do a weight every morning. Because if you get on a scale and there’s a three-pound difference from one day to the next, you’re starting to retain fluid. I see that your legs are already swollen.”

Cox explained why people retain fluid. She then asked whether Wells had checked her blood pressure; her emergency-room chart indicated it had been 212 over 100, which is stroke level. Concerned about Wells’s sodium intake, she asked her how many sodas she was drinking, and told her that some juice has a lot of sodium in it too. “Knowledge is power, O.K.?” Cox said gently. “Cause you’re 40, and you’re oxygen-dependent. We don’t want you goin’ on a date with an oxygen tank!” Wells laughed again.

Cox said she would try to find a company that would test the house for toxins, and she made an appointment for Wells to visit a medical clinic that HealthConnect operates. Wells got up, the oxygen tube dragging behind her, and walked Cox to the door. Cox paused at one of the photographs on the wall. “You got a beautiful family!” Cox said. She focused on a slim woman. “Now, is that Mama?”

“That’s Grandma,” Wells said. “She was 95 when she passed. I moved down here to help her out.”

One of the people responsible for HealthConnect’s holistic, intensely personal approach is Dr. Aaron Shirley, who three years ago found inspiration for health care reform in an unlikely place: the primary health care system created in the 1980s in the Islamic Republic of Iran. The main issue in Iran back then was “disparities in health between its urban and rural populations,” he told me recently. “In the U.S., these disparities exist. The Iranian model eliminated the geographic disparities, so why couldn’t this same approach be used for racial and geographic disparities in the U.S.?”

Shirley created HealthConnect in 2010 because — and, in part, to prove to others that — poor people in Mississippi still have health problems, even if they have Medicaid or health insurance, even if there are clinics in their communities, even if they get home health services. They don’t get better, and the diseases born of poverty and obesity are not prevented; thousands of people frequent emergency rooms for illnesses that could have been tackled by primary care. They need something more.

Shirley is a civil rights-era hero who for a long time was the only black pediatrician in the state, the type of activist who, he says, wasn’t necessarily of the “nonviolent persuasion” and who, upon hearing that the local Klan was headed to his home, would warn the Police Department that both his boys knew how to shoot. He was the first black resident at the University of Mississippi Medical Center and, in the 1960s, worked at the state’s first community health center, in the Mississippi Delta. He did things that don’t end up in history books, too, like build wells for poor blacks when they didn’t have clean drinking water and travel through the countryside treating malnourished babies. In 1993, the MacArthur Foundation identified him as a “health care leader” when it gave him one of its “genius” awards.

Shirley, now 79, spends his days at the Jackson Medical Mall. For decades, the site was an actual mall, with a JC Penney and a Gayfers, but the area around it began to decline in the 1980s as middle-class families fled to suburbs nearby. Historic downtown Jackson emptied out altogether, and today Capitol Street, the bustling shopping avenue that Medgar Evers boycotted in 1962, looks shuttered and ghostly. The mall, just five minutes from downtown, was well on its way to the same fate, so in the mid-1990s Shirley and others created the Jackson Medical Mall Foundation to buy it and turn it into a center offering various health services for the poor.

Since then, Shirley has observed up close what so many Mississippians point out: millions of dollars pour into the state every year — both public and private funds — but the lives of Mississippians do not improve. “I’ve been coming here for 40 years,” he told me recently, referring to the Mississippi Delta, “and nothing has changed.”

In 2008, Shirley was introduced to a consultant named James Miller by a public health professor at Jackson State University, Mohammad Shahbazi. Miller and his wife live in Oxford, Miss., where they and other family members run a consulting firm and other businesses. In 2004, Miller learned about Iran’s primary-care health system during a meeting in Germany with a delegation from the Iranian government. But it wasn’t until 2007, when a struggling hospital hired Miller’s firm to conduct an assessment of its operations, that Miller fully grasped the extent of Mississippi’s health care crisis — and recognized how much it resembled prerevolutionary Iran.

“When the Iranian system was developed in the 1980s, there were no doctors in rural Iran,” Miller says. “And this is similar to the problem in the delta today.”

The Iranian reforms were relatively inexpensive to implement there. It was the early ’80s, just after the Ayatollah Khomeini’s return and the Iranian revolution, which had promised the country’s rural villagers the kind of social justice that had been lacking under the shah. At the time, more than half the population lived outside major cities, in or around more than 60,000 villages. The Iranians built “health houses” to minister to 1,500 people who lived within at most an hour’s walking distance. Each house is a 1,000-square-foot hut equipped with examination rooms and sleeping quarters and staffed by community health workers — one man and one or more women who have been given basic training in preventive health care. They advise on nutrition and family planning, take blood pressure, keep track of who needs prenatal care, provide immunization and monitor environmental conditions like water quality. Crucially, in order to gain trust, the health workers come from the villages they serve.

People who become very sick, or require surgical procedures, are referred up through a single, multitiered system: from health house to rural health center to district hospital. The integrated nature of the system is what makes it unique. Today, 17,000 health houses serve 23 million rural Iranians. Health disparities between rural and urban Iranians have narrowed; the Iranians have reduced rural infant mortality by 75 percent and lowered the birthrate. Iran’s reforms won praise from the World Health Organization, which has long advocated preventive, primary care.

To Miller, the model’s great appeal was its simplicity. He approached several academic institutions in Mississippi and told them what he’d learned. Most people looked at him as if he were nuts. The United States and Iran haven’t been on good terms since the hostage crisis in 1979. It is not a country Americans tend to think of collaborating with. But Miller, who loves Persian history and doesn’t disguise his desire to see the United States and Iran mend their fences, spoke to Gail Harrison, a public-health professor at U.C.L.A. She suggested he call a former student of hers: Mohammad Shahbazi, who was not only Iranian but also a professor at Jackson State University, a historically black college right in Mississippi.

Shahbazi moved to the United States in the 1980s for graduate work in cultural anthropology and became fascinated by its health care problems. He recognized the similarities between the conditions in Mississippi and those in Iran, where he grew up as a member of a nomadic tribe, the Qashqai, that was discriminated against under the shah. “We were considered the wild, smelly nomads,” he says. He decided that Mississippi offered the best opportunity for his work on social determinants of health, and settled into a between-worlds existence in Jackson, where he is neither black nor white but privy to racial slights and resentments from both sides. “I consider myself bleached black,” he says.

After joining Jackson State’s public health program, he often wanted to discuss Iran’s health care reforms in wider policy circles, but feared doing so in the post-9/11 climate. Shahbazi, who is animated and friendly and tends to make jokes like “we don’t have pharmacologists, we have harm­acologists,” was once pulled aside by a federal agent at an airport because he thought Shahbazi was on a most-wanted terrorist list. When the agent showed Shahbazi the list, Shahbazi exclaimed, “But I am not Shabaz Mohammad of Pakistan, I am Mohammad Shahbazi of Iran!”

Shahbazi suggested that he and Miller approach Shirley. He arranged for the two men to visit Shiraz, Iran, and meet some of the people responsible for creating and administering the country’s health houses. The two groups decided to establish an official academic partnership between Shiraz University and Jackson State, and Shirley returned to Mississippi a convert. Later that year, several Iranian doctors and administrators and their wives made their own trip to Mississippi. They were surprised by what they saw: “This is America?” they asked. In 2010, the Iranians returned for a month, calculating how many health houses Mississippi would need, as they had done in Iran. Shahbazi began work on a program at Jackson State for the training of community health workers. Using resources from the Medical Mall Foundation, Shirley started HealthConnect to show how interventionist, door-to-door community health workers might save hospitals money and began the process of putting health houses in Jackson schools. Eventually they hope to build the Mississippi Community Health House Network, a pilot version of their project, in the Mississippi Delta.

“We are not saying just trust us,” Shahbazi says. “We are saying give us $10 to $20 million and three years; we’ll implement 15 health houses in the delta, and we will prove two things: We will show you that we are changing the health outcomes, and we will show we can reduce the cost of health care in the state.”

Mississippi has some of the worst health statistics in the country. A Mississippi black man’s life expectancy is lower than the average American’s life expectancy was in 1960. Sixty-nine percent of adult Mississippians are obese or overweight, and a quarter of the state’s households don’t have access to decent, healthful food. Adequate grocery stores can be 30 miles away. In one of the country’s most fertile regions, people sometimes have to shop for their groceries at the gas station. Consequently, Mississippians are dying from diabetes, hypertension, congestive heart failure and asthma. Shirley points out that in the 1960s people starved, and today they die from food.

The state has the highest rate of teen births in the nation. Currently there is one abortion clinic in Mississippi, and Gov. Phil Bryant, a former deputy sheriff, is working hard to render it inoperable. Until this year, schools taught abstinence. In the United States, the black infant mortality rate is more than twice that of white infants, so Mississippi, which is 37 percent black, has huge neonatal intensive care units. Caring for the thousands of premature babies (weighing between one and four pounds) costs millions of dollars. According to Dr. Glen Graves of the University of Mississippi Medical Center, these tiny, deprived babies grow up to be plagued with chronic illnesses.

Human Rights Watch calls the Deep South “the epicenter of the H.I.V. epidemic in the United States, with more people living and dying of AIDS than in any region in the country.” Blacks in Mississippi are dying from AIDS at a rate 64 percent higher than the nation’s average. In the delta, which stretches north and west of Jackson and is home to 560,000 people, H.I.V./AIDS is an immense but silent crisis. The state Department of Health estimates that half of H.I.V.-positive Mississippians currently don’t receive treatment.

Many delta hospitals complain that their emergency rooms are overrun with nonpaying patients. Dr. James Keeton, the vice chancellor for health affairs at the University of Mississippi Medical Center, says that 14 percent of the center’s patients are uninsured, or “self-pay,” and the hospital recovers only a small part of what they owe. “Now, I say to you as a businessperson: How would you like to work at an auto company and give away . . . cars before even opening your doors?”

Of the state’s population of nearly three million, 550,000 are uninsured. At the moment, Governor Bryant is claiming that the state might not accept federal money to expand Medicaid under the Affordable Care Act. But even if it does, there won’t be enough doctors to see all the Mississippians who need them; the state has 176 doctors per 100,000 people, the lowest such number in the country.

Sixty years ago, Mississippi, the country’s poorest and most racially divided state, was “the standard by which this nation’s commitment to social justice would be measured,” the historian John Dittmer wrote. Talk to those in Mississippi’s health care community, and they all whisper the same thing: It’s not rocket science; we all know what needs to be done. In short, as one Mississippian put it to me, “hand-to-hand combat” — hiring folks whose sole job is to ameliorate the problems in poor people’s lives — and a tremendous amount of money could change the situation. But the political will does not exist. So the status quo endures: generations of people who can’t afford fresh tomatoes, and who don’t understand that when a doctor says take this pill three times a day, he doesn’t mean all at once.

In May, Shirley, Shahbazi and a black pediatrician named Eva Henderson-Camara piled into Shahbazi’s car and headed to the delta to talk to two nurses at a small hospital in Belzoni, more than an hour north of Jackson. The first thing you notice on entering the delta, especially when you’re expecting to find poverty, is that you don’t see many people. The farms are vast and empty. So much of the area is bucolic and sun-dappled that it doesn’t seem poor. When I said as much to Claudia Cox about Mississippi in general, she replied sternly: “That’s because poverty in America doesn’t look like what y’all think. It used to be bare feet, now it’s Nikes. If I miss two months of work because I get sick, well, guess what? I’m in poverty. This is the new poverty.” Yet in delta towns like Louise and Midnight, the poverty is impossible to miss: desolate commercial streets in the shadow of a rotting mill, shotgun houses wilting on one side of railroad tracks, houses almost buried under possessions on the porch and in the yard.

Henderson-Camara, now 60, grew up on the plantation her grandfather owned. Children at the time worked much of the school year as part of the sharecropper system, which lasted until the ’70s, as corporations bought and mechanized the farms. (“Imagine waking up every morning and this is all you see,” Henderson-Camara said, looking out the window at the flat fields stretching to the sky. “And you think, Should I shoot myself now or later?”) Thousands of displaced workers found jobs at the Jockey factory, or the Schwinn plant, or on catfish farms, but those shut down in the early ’90s. Henderson-Camara got out by winning a scholarship for a fifth year of high school at Yale. Today she lives in Jackson and works in HealthConnect’s medical clinic.

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www.nytimes.com/2012/07/29/magazine/what-can-mississippis-health-care-system-learn-from-iran.html?pagewanted=all