Beyond the Clinic

Question 1

Virchow’s findings on the typhus epidemic

Answer 1

“If disease is an expression of individual life under unfavorable conditions, then epidemics must be indicative of mass disturbances of mass life.”

Virchow lay blame primarily upon German landlords, German housing and labor conditions, diet restricted by poor food availability, and the Catholic church. All of these contributed to the malnourishment and lack of sanitation which predisposed the impoverished population to being typhus susceptible.

Question 2

Rudolf Virchow

Answer 2

Father of modern pathology and of social medicine

Same Virchow of Virchow’s triangle

Question 3

The beginnings of primary and specialist care

Answer 3

The ideas were invented in 1919 by Sir Bertrand Dawson in the British Ministry of Health, following a growing political desire for some form of “health care system” rather than simply having sick people brought to doctors.

His ideas would not be implemented for decades, but Dawson effectively invented the model of modern health care, with primary physicians visited regularly for screening, prevention, and education and specialists to which very sick patients were to be referred.

Question 4

League of Nations Health Organization

Answer 4

Founded in the interwar years. Addressed the problem of integrated health and development for rural populations.

Advanced by two major conferences: One in Geneva, Switzerland and one in Bandoeng, Indonesia.

Question 5

Father of revolutionary medicine

Answer 5

Che Guevara

(mantle also carried by Allende)

Question 6

Social medicine only began to take hold in the US during. . .

Answer 6

. . . the Great Depression.

Question 7

Many Farms healthcare experiment

Answer 7

A community health clinic established on the Navajo reservation in the 1950’s-60’s. Trained individuals in a four month curriculum of basic medical interventions and monitoring.

The project was a failure, it did not improve health outcomes, and the conclusion was that a mismatch existed between what medical care could offer and the basic health needs of the community (clean water, healthy food, sanitation, electricity).

Ultimately ended due to IHS bureaucracy: the IHS would not continue to allow the clinic to bring on local health workers after discovering that many had low educational attainment or did not have drivers liscenses or other forms of ID.

Question 8

The Tufts-Delta Program

Answer 8

Set out to provide care to 14,000 people in rural poverty in the Mississippi River delta. The clinic provided health education, prevention, and health care, and sought to develop community partnerships to break the cycle of extreme poverty, ill-health, and unemployment

The program gave medical perscriptions for food to malnourished patients to be filled at the grocery store and billed to the clinic, which was condemned by Mississippi officials as socialism.

Question 9

Peoples Free Medical Clinics

Answer 9

Opened by 13 chapters of the Black Panther Party in 1970’s. Each had to rely on its own expertise, with only some help from white phyiscians and nurses. Some succeeded while others suffered from inadequate resources.

Question 10

1978 WHO Conference in Alma Ata

Answer 10

Famously articulated the progressive vision of health care for all, in hopes that all the world’s population would have access to adequate primary care. Produced the Declaration of Alma Ata:

all signed on to the idea that comprehensive primary health care (Article VII) and community participation (Article VI) would be key drivers of change for a healthier world, and that funding could come from disarmament and diverting military spending towards health care (Article X).

Question 11

Program of Assertive Community Treatment programs

Answer 11

Initially launched in Madison, Wisconsin. Instead of relying on patients to come to the clinic, they brought health care to them. PACT programs soon opened in other cities, and many persist today.

In some versions, there is no clinical space at all, just an administrative office, and doctors, nurses, and social workers provide all of their support within the community.

Question 12

“Accompaniment”

Answer 12

Building health systems that can achieve equity of clinical outcomes for even the lost impoverished and destitute sick:

• If a child is diagnosed with an infectious disease, making a house call and checking on the whole family
• Ensuring personally that patients have access and adhere to antibiotic regimens

Question 13

____ in the US has proven a major barrier to establishing community-based health for at-risk populatons.

Answer 13

The fee-for-service model in the US has proven a major barrier to establishing community-based health for at-risk populatons.

Question 14

Takeaways from CHW for the modern era of medicine

Answer 14

• Focus on supporting those who need you the most
• Distribute care across a team of providers, with a main focus on maintaining health
• Renew the promise of engaging with communities to promote health
• Add non-medical tasks to the medical armamentarium

Question 15

____ is favorable for engaging in community health programs and upstream determinants of health.

Answer 15

The increasingly common ACO model, encouraged by the ACA, is favorable for engaging in community health programs and upstream determinants of health.

Question 16

Today’s VA was etablished by. . .

Answer 16

. . . President Lincoln in the 1860’s.

Question 17

Currently the VA program consists of. . .

Answer 17

. . . 172 medical care centers and 1062 outpatient sites, with over nine million enrolled veterans.

Question 18

Characteristics of the VA population

Answer 18

Tend to be the sicker of the veterans (healthy veterans do not tend to access care). Population is younger, more likely to be non-Hispanic black, and of lower income.

51% of those enrolled in the VA program also have Medicare benefits, 28% also have private insurance, 6.6% have Medicaid, and 20% are otherwise uninsured.

Question 19

To provide proper trauma-informed care to veterans, . . .

Answer 19

. . . you need to have some understanding of military culture and of the unique aspects of each era of service.

Question 20

Treating WWII veterans

Answer 20

WWII veterans often have an enduring sense of pride for having served in WWII, despite gruesome exposures and injuries.

The prototypical injuries of WWII were inflicted by artillery and bombs, making head wounds and traumatic amputations common.

Question 21

Treating Korean War Patients

Answer 21

Began in 1950 and lasted 37 months, ending in a truce. Sometimes described as the “Forgotten War.” As it took place in the shadow of WWII during the “baby boom” in the US, it was little studied. What was termed a “police action” by President Truman was not congressionally recognized as a “war” until 1998.

“There were no celebrations in Times Square–or anywhere else. The Washington Post noted, ‘Washington greeted news of the Korean truce yesterday with a matter-of-fact attitude–quietly, without evident jubilation….’ It was peace without a clear victory”

Combat was often brutal and injuries from extreme cold and radiation were common.

Question 22

Much of our modern understanding of trauma and PTSD comes from. . .

Answer 22

. . . the Vietnam War.

Question 23

Treating Vietnam War Patients

Answer 23

Vietnam was the first televised war, as well as the first true US guerilla war, and possibly the best documented in history.

Unlike WWII and Korea where the enemy had a defined uniform and battle lines were clear, Vietnam had unclear conflict zones and boundaries which created unprecedented challenges for soldiers. The soldiers also did not receive any sense of gratitude from the South Vietnamese they were supposed to be fighting for.

Upon return, soldiers were discouraged from sharing their horrific narratives. Additionally, medical advances meant that severely disabled soldiers survived and made it back to America with chronic disabilities.

Question 24

Irrespective of conflict, ___ is a frequent comorbidity of post-traumatic stress disorder.

Answer 24

Irrespective of conflict, substance use disorder is a frequent comorbidity of post-traumatic stress disorder.

Question 25

Gulf War I

Answer 25

In 1990, sparked by the invasion of Kuwait by Iraq. The US got involved and Kuwait was liberated rapidly, allowing troups to return home in about a year’s time.

Veterans of this brief conflict experienced multiple environmental toxins, burning petrochemicals and other substances, as well as radiation exposure to depleted uranium. Respiratory problems and amyotrophic lateral sclerosis (ALS) are also recognized as being linked to exposures during this conflict

Many Veterans returned with diffuse pain, fibromyalgia, memory loss, and other multisystem symptoms, now known as “Gulf War Syndrome”

Question 26

War on Terror

Answer 26

Began with 9/11. The following month, US troops were deployed to Afghanistan, Iraq, and Syria.

Due to the overall length of these conflicts, and the volunteer nature of the armed forces, many have served multiple tours and deployments, which is unprecedented in the history of US warfare. Overall about 40% of current military service members have been deployed more than once. Tours were also lengthened and periods of time at home shortened.

Service members survived blasts that would have been lethal previously, and rates of traumatic brain injury (TBI) are unprecedented. War-related trauma has resulted in an increasing number of suicides and self-injury among Veterans

Question 27

Treating Women Veterans

Answer 27

Women have served in the US military throughout history, but were only allowed to serve in combat since 1948. Since September 11, the population of women joining the military is at an all-time high. They are the fastest-growing segment of the Veteran population.

Despite this, women do not always self-identify as Veterans; for this reason, VA recommends that providers ask patients: “Have you served in the military?”

Women Veterans, in particular, are a commonly trauma-exposed population and often enter the military with significant histories of child abuse, sexual assault, and intimate partner violence (IPV). These exposures may be compounded by combat exposure and military sexual trauma (MST).

Question 28

When compared to non-Veterans, Veterans consistently report higher levels of ___ across studies.

Answer 28

When compared to non-Veterans, Veterans consistently report higher levels of adverse childhood experiences (ACEs) across studies.

Question 29

“PTSD Coach”

Answer 29

An app that helps PTSD patients (regardless of source of traumatic stress) manage their illness. Has been impltemented across 74 separate countries and is evidence-based.

Question 30

Military sexual trauma

Answer 30

38 US Code Sec. 1720D as “physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the Veteran was serving on active duty or active duty for training.”

MST is considered a duty-related hazard, and an electronic health record prompt for screening occurs once for each Veteran. It is experienced by both male and female service members (1 in 4 women, 1 in 100 men).

MST, like other interpersonal traumas, is underreported in part due to military culture in which toughness and unit cohesion are emphasized. Often service members who disclose MST are met with disbelief or dismissal or—at worst—reprisal

Question 31

Male Veterans are less likely than women to receive MST care even though . . .

Answer 31

Male Veterans are less likely than women to receive MST care even though the overall number of men reporting MST is similar to that for women because the Veteran population is mostly male

Question 32

MST prevalence among at-risk population

Answer 32

15.7% of military personnel and Veterans report any MST (3.9% of men, 38.4% of women)

Question 33

When questions about MST are reworded to explicitely indicate that harassment is included, . . .

Answer 33

31.2% report MST (8.9% of men, 52.5% of women)

Question 34

While Veterans make up approximately __% of the US population, they represent more than __% of the homeless adult population

Answer 34

While Veterans make up approximately 7% of the US population, they represent more than 12% of the homeless adult population

Question 35

___ are common in the homeless population and often precede housing loss

Answer 35

Trauma and PTSD are common in the homeless population and often precede housing loss

Question 36

Routinely asking all homeless persons about prior military service is recommended in order to . . .

Answer 36

Routinely asking all homeless persons about prior military service is recommended in order to connect them with Veteran-specific housing benefits and programs

Question 37

Providing trauma-informed care to veterans

Answer 37

• Providing privacy when asking veterans to fill out sensitive forms related to trauma and mental health
• reducing “noise pollution,” including all loud, startling sounds like doors slamming
• Allow veterans to decide whether to sit in the exam room or a consultation room
• Avoid sudden and potentially startling movements during a physical exam, especially anything that involves approaching a veteran from behind
• Always inquire about military service and the conditions unique to your patient’s particular service