Puentes Part I: Steve, the Prenatal Clinic, and the After-School Program
(Written on Feb. 13, 2013)
‘We’re creating a disruptive innovation here.’
Dr. Steve Larson is primarily an ER doctor at the Hospital of the University of Pennsylvania–but if you accused him of this to his face, he’d most certainly tell you otherwise. Larson considers ER doc his day job, just something he’s been doing for the last 20 years to pay the bills
Puentes de Salud, an integrative and interdisciplinary Latino immigrant health clinic, is Larson’s “real” job and his brainchild. He founded the clinic in 2003 with Dr. Jack Ludmir, and the two were joined a year later by Dr. Matthew O’Brien. The clinic’s name means “bridge of health,” a fitting description for a site that works to literally bridge the gap between Philadelphia’s growing Latino immigrant community and the affordable, high-quality health care that this low-income and uninsured population desperately needs.
Larson has worked with the Latino immigrant community in the Philadelphia area since 1991 when he first started working at Project Salud, a migrant health clinic in the mushroom fields of Pennsylvania’s southern Chester County. The clinic was managed by nurses and served a predominantly Mexican labor force in the agricultural region. Larson credits most of what he now knows about health care and the Latino community to the head nurse at Project Salud.
Puentes, however, is more than just a clinic. Yes, there’s a physical health clinic in South Philly that serves the immediate medical and dental needs of the city’s Latino community; but Larson, his colleagues and friends, and the community have created much more than that—they’ve created a comprehensive health care model that addresses the social determinants of health.
Social factors such as education disparity, social inequality, job security, physical environments, access to basic social services, and safety all have an effect on health outcomes within a given community. So, Larson has grown Puentes to include after-school programs, ESL classes, art classes, affordable prenatal care, and much more. And all of these social services, combined with basic health and wellness procedures, are meant to combat the social determinants of health and redefine what health care should look like, Larson says.
“We’re creating a disruptive innovation here,” he says. “We want to completely change the health model.”
‘Have you ever seen a pregnant woman?’
Larson drops me off at the prenatal clinic before his afternoon meeting. The clinic is only open on Tuesdays and Fridays, so I luck out and get to spend a few hours shadowing Dr. Jack Ludmir, cofounder of Puentes de Salud. Ludmir, born in Peru, is an incredibly amiable man with a playful sense of humor and a kind face. When I introduce myself, his first question is, “Have you ever seen a pregnant woman?”
All exams at the clinic are conducted in Spanish. Most of the women who come to the clinic for prenatal care are immigrants, and nearly all of them are uninsured. Ludmir and his staff only charge the women $5 per visit, and if they can’t pay the fee, it’s no big deal—the doctors and nurses want these women to feel like they can come here no matter what, Ludmir tells me.
A basic prenatal exam includes taking a urine sample, checking the mother’s blood pressure, measuring her belly to make sure the baby is growing at a healthy rate, and listening to the baby’s heartbeat. “The baby’s heart beat is much faster than ours,” Ludmir explains.
The urine sample is used to check glucose and protein levels. If a mother has high sugar levels at several, consecutive prenatal visits, it could be a sign of gestational diabetes. However, this type of diabetes usually goes away once the pregnancy ends.
Excess protein in the urine, on the other hand, can be a sign of a urinary tract infection, kidney damage or even preeclampsia, a disorder that causes the blood vessels to constrict. This constriction can cause a spike in blood pressure (which is why doctors will always check the mother’s blood pressure) and can reduce blood flow to vital organs in the mother’s body. The baby can be adversely affected, and in the most extreme cases, the mother can die.
“A character on Dowton Abbey just died of preeclampsia,” Ludmir says matter-of-factly. “You should watch that show.”
After watching a few more prenatal exams, I spend the rest of the time just observing the dynamics of the nurses with the patients. The women are very trusting, and because exams are conducted in Spanish, they are clearly comfortable and unafraid to ask questions about their pregnancy and any discomfort or pain they’re feeling.
A woman with gestational diabetes, however, has the most memorable visit of the afternoon.
The woman comes in for her routine check up—urine sample, blood pressure, belly measurement, ultrasound—and meets with the diabetes counselor on staff. After meeting with a nurse practitioner to end the exam, she emerges from the exam room with three prescriptions. But because she doesn’t have insurance, she seeks out Ludmir to ask which of the prescriptions is the cheapest—she can only afford one.
Ludmir discusses the prescriptions with his colleagues, estimating how much each will cost without insurance coverage. Luckily, none of them are exorbitantly expensive, so the woman walks away with all three.
But these are the kinds of decisions these women have to make every day about their health, and for a moment, I’m self-conscious–because I realize I’ve never had to make any such decisions.
‘Why are these kids getting shot in the first place?’
Puentes Hacia el Futuro meets from 3 p.m. to 5 p.m. every Monday, Tuesday and Thursday at Southwark Elementary School in South Philly. The after-school program was started three years ago as another branch of Puentes de Salud, and it provides Latino elementary students with one-on-one tutoring with undergraduates, graduate students, or community professionals. Tutors primarily help with English literacy and language skills, but will also help with other homework to make sure the students keep up with their classes.
All of the students in the program are Latino, predominantly Mexican. Francisco, 11, moved to Philadelphia from Mexico one year ago with his family. Today, he works on reading comprehension homework, but when Molly, a volunteer, tries to engage him, he seems a little shy, making jokes and covering his paper so she can’t read the one-sentence response he’s written in English.
Program coordinator Elvis Almanzar has a little bit more luck; when he comes over and asks Francisco (in Spanish) to explain the story, Francisco opens up, explaining (again in Spanish) the story about the reunion of a grandfather and his granddaughter in great detail.
Francisco has quickly become one the program’s best students, Almanzar says. He understands the stories in English, but it takes a little coaxing to get him to talk about it.
Almanzar tells me that the idea for Puentes Hacia el Futuro first sprouted when Larson and his colleagues started hosting community meetings in 2004 to listen to community grievances. Many of the parents at the meetings voiced frustration with the school system and how their children were starting to fall through the cracks.
Southwark was chosen as the site because of the immense need in the school. According to Almanzar, Southwark is considered one of the lowest ranking schools in Philadelphia and has failed the Pennsylvania System of School Assessment (PSSA) tests a number of times. Literacy in particular is a huge problem, with many students reading well below their grade level. The majority of the kids at the school live below the poverty line, and most of them are immigrants, either from a Latino country or Asian countries like Cambodia. (The school also has a large African-American population.)
“And their homework just isn’t getting done at home,” Almanzar asserts.
Most of the parents never had an education past the 6th grade, and if they did, it was in Spanish, he explains. So, they couldn’t help their kids with their work even if they wanted to.
But making sure the kids do their homework, and do it well, is only the immediate concern of Puentes Hacia el Futuro and its volunteers. The real concern is making sure these kids don’t fall through the cracks, settling for low-paying jobs or getting lost in the poverty culture, Almanzar says.
Larson later tells me that his motivation for starting this after-school program was the large amount of teenage Latinos he sees regularly in UPenn’s ER, many suffering from stabbing or gunshot wounds.
“Yeah, I go into biomedical mode when I see them, but my real question is, ‘Why are these kids getting shot in the first place?’” he says.
So the goal of Puentes Hacia el Futuro is to try and reach these kids at an earlier age, before they end up in ER beds in critical condition.
Charlie Silva, a sophomore at Temple University, is studying neuroscience, but he has a special connection to Puentes Hacia el Futuro, where he’s been volunteering for two years.
“I went to Southwark for grade school so I know about the education disparities,” he says. “I want to make an impact in this community.”
Almanzar says the volunteers are certainly making that impact. The after-school program has grown from 15 kids to 60 kids in just threes years, and there’s a waiting list.
The only reason we can’t let those kids on the list into the program at this point is because we don’t have enough volunteers to keep the ratio down, he says. 1:1 is ideal, but right now, it’s more like 1:3, or 1:6 on a day when volunteers are sparse.
We just want to address the literacy issue in the most effective way possible before the state takes over the school and starts cutting funding for the arts and other extracurricular activities, he says.
‘You see how this is all connected, right?’
Once I finish at Southwark, I meet Larson at the Emergency Room at the Hospital of the University of Pennsylvania to watch him in action at his day job. It’s a massive shift in mindset from the after-school program in South Philly to the semi-chaotic ER at one of the country’s major medical institutions.
As I wait for my scrubs, Larson talks to me more about how all of the programming at Puentes is connected.
“A small percentage of the people that come in here [the ER] have things like gunshot wounds and stab wounds,” he says. “The majority is here for the coughs or sniffles, or they’re having some serious discomfort. Or because they are illegal or don’t have insurance.”
The prenatal clinic gives those uninsured Latino women a place to go so they can have a healthy pregnancy. It’s better for them to go there than to come to the ER just when something feels wrong, he says.
And the after-school program is supposed to help the Latino kids in the community with their English and their work habits so they don’t have to settle for low-paying jobs. And of course, it also keeps them safe for those two hours after school, he explains.
It’s about building a knowledge base for health and wellness from childhood, Larson says. If these kids can develop and maintain a good work ethic and are motivated to succeed, maybe they won’t end up in my ER , he says.
“You see how this is all connected, right?” he says. “It’s about a multidisciplinary, holistic approach to health and wellness that is specific to a community’s needs.”
