words by barbara hurley / photography by john emerson
"In a dream, I see a city invincible.”
hat’s the official motto of Camden, NJ. It hardly seems appropriate for a city named America’s poorest, with 44 percent of the city’s population living in poverty, the highest rate in the nation. Progress is defined as moving from #1 on the “most dangerous cities in the country” list to #5. One in four babies is born to a teenage mother. On and on.
For many of the nearly 80,000 people who call Camden home, coping with simple day-to-day survival is daunting. But a corps of dedicated students and professionals is infusing new life into the city. Their determination is invincible. Camden counts for them, and Camden counts on them.
David Unkle and Hope White
The bright yellow walls of the Camden Community Health Center (CCHC) are a welcome, if somewhat surprising, counterpoint to the well-worn, grim façade of its home at 538 Broadway. The building with its ornate molding and its double stone staircase belongs to the Camden County Office of Economic Opportunity, which donates the space to the Center, and is a reminder of a grander past on one of the city’s major thoroughfares. But it is the demands of the present that are the concerns of the staff at the health center: hypertension, diabetes, asthma and emphysema.
Patients can walk in with or without appointments on Wednesdays and Saturdays, when UMDNJ practitioners and students are there to deal with myriad complaints. The CCHC is truly a collaborative effort. Wednesdays are the responsibility of the University’s School of Nursing, while the School of Osteopathic Medicine takes over on Saturdays. On Wednesdays, David Unkle, MSN, RN, APN, FCCM, an advanced practice nurse with faculty appointments at both schools, is the main practitioner. He is a plain talking professional who insists that this center — and he does not use the word clinic, “a perception of a lesser quality of care” — builds relationships that translate into better health and better healthcare for its patients. He may see 15 to 20 people in a day, but he makes the time to get to know them. “I know their good and bad habits,” he explains. “I know if they’ve been taking their medication or not. And I tell it to them like it is.” He believes that this dose of reality is as important as any prescribed medicine.
He sees a critical need for education so that patients can be active participants in their own care. “Our patients often come with a poor understanding of their diseases, of what they are taking medicine for,” he notes, “ but we have the time to spend with patients to avoid the ‘hit and run’ care they may have experienced elsewhere.” It is this educational component that for him is the “value added” of the health center.
Unkle grew up in an upper middle class suburb of Philadelphia. His father, a public service worker in the inner city, told stories of the struggles of those who lived there that made a lasting impression. Unkle found in his training as a nurse a “tremendous opportunity” to understand and experience the disparities in healthcare delivery and to begin his work to correct them. The Center was the vision of Frances Ward, PhD, the School of Nursing’s first dean, and through her Unkle found his place here.
He relates a typical problem. A family comes in with an asthmatic teenager. A prescription for a $250 a month drug will alleviate the asthma. Problem solved? Not quite, since the family breadwinner brings home $200 a week. “But the Center is the right setting for appropriate care,” he insists. “We do have the time to work out solutions.” And he finds great satisfaction in knowing that his clients appreciate these efforts.
His colleague at the nursing school, Hope White, MSN, RN, agrees. “We can get to the bottom of what’s wrong – not just the physical symptoms,” she explains. “Many of our clients are what you’d call the ‘working poor.’ They may have insurance but the co-payment is a deterrent to their getting the care they need. There are so many barriers.” White’s own story is one of overcoming barriers. As an administrator for the Camden Head Start program, she managed a staff that could not afford the out-of-pocket expense of the physicals required for employment. Thus began her friendship with Frances Ward. The Center provided the employment physicals, and Ward provided the inspiration for White’s entry into the nursing profession. Coming full circle, White reports that her students recently provided the physicals for Camden Head Start students.
The challenges remain. But Unkle and White are optimistic about the future of Camden. They see great promise in their students’ commitment to community healthcare. They teach them “to listen to people, to tell them why you’re doing what you’re doing.”
In Camden, diabetics made 48,000 visits to hospital emergency departments during a recent five-year period. “Diabetes is a great lens through which we can examine the medical care we’re providing to low-income urban residents,” says Jeffrey Brenner, MD, an instructor in the Department of Family Medicine at RWJMS in Camden. “If we can improve the care for diabetics, we believe we’ll be able to fix other aspects of healthcare as well.”
Because many of the most seriously ill diabetics in Camden receive only sporadic primary care, their diabetes is not under control. It’s a familiar complaint. “Some of these patients make repeated visits to the emergency department or require hospitalization. They then go home, don’t get follow-up care, and repeat the process.”
Brenner started the Camden Citywide Diabetes Collaborative under the umbrella of the Camden Coalition for Healthcare Providers, a group that he started in 2002 to align the interests of stakeholders in Camden and improve the health of city residents. With a $2 million grant from the Merck Foundation, the Coalition will help 10 primary care practices become certified Patient Centered Medical Homes that use a more organized and systematic approach to the care of patients with chronic illnesses.
The Coalition also uses a primary care outreach team to target hospital “super users”— individuals who frequently turn to hospital emergency departments for primary care. “Data indicates that 50 percent of Camden residents use the emergency department in a given year,” says Brenner. “That’s twice the national rate. It’s bad for patients and a tremendous waste of resources. If these patients won’t come to us, we’ll go to them, into their homes if necessary.”
Brenner, an RWJMS alumnus, also advises the medical student outreach program, the Urban Health Initiative in Camden. Students operate three free clinics at a local charter school, the LEAP Academy, in the evening and run patient education programs in the city.
Bernadette West, PhD, the School of Public Health’s assistant dean for the Stratford/Camden campus and associate professor for community health, “absolutely has a lot of hope for Camden” — literally and figuratively.
Project Hope, for example. The overpass for Interstate 676 shades the 40 or 50 tents that make up Camden’s tent city. The project, an initiative of Our Lady of Lourdes Medical Center, engages students from four of the schools on the Stratford campus — SPH, SOM, GSBS, SHRP — with the homeless people who find some structure in a makeshift life there that includes rules, regulations, and even a “mayor.” The students are participants in UMDNJ’s summer community service program, Bridging the Gaps in Camden. As they distribute food, water, clothing, and health information, they learn that good health is not just about healthcare delivery, but about delivering the basics of life as well.
West is also working with Hope Community Outreach Center, which is based in the Whitman Park neighborhood of Camden, a “devastated area” according to West. Recently she and MPH/PA student Sarah Nezworksi teamed up with the Center and children who lived nearby for a project that opened many eyes. Nezworski was joined by two other students — one from SOM, the other from SPH — to teach the children how to use digital cameras and to assign them to photograph “something that you love about where you live; or something you are proud of; or something you want to change.” The children were encouraged to talk about what they had photographed, and Nezworski is planning follow up to assess just how empowering this effort was for them. The photos, which West describes as “incredible,” were exhibited on UMDNJ’s Stratford campus and at the Stedman Gallery at Rutgers in Camden.
West has been deeply involved in working toward a healthier future for the city. She came to UMDNJ from a career as a health planner for the state and worked on the Camden Healthy Futures Committee, which was started by UMDNJ. While participating on a health assessment of the city, she made the connection between Camden’s many needs and the “young, energetic students” at the University.
West’s hope is to create a “cadre of students to work in the inner city.” Her students write journals about their experiences. “Working in Camden is humbling,” she notes. “The community has a great deal to teach them.”
Lesly D’Ambola and Christopher Myers
North Camden is a neighborhood of row houses. Along the main street, some are getting new windows and fresh paint. But on the side streets, many stand boarded up and covered with graffiti. Drugs are openly sold on its street corners, according to Christopher Myers, APN, a nurse practitioner who with Lesly D’Ambola, DO, provides care to a largely Latino population at Saint Luke’s Catholic Medical Services. This is a neighborhood with all the typical problems of the inner city. But St. Luke’s and the people who run it are far from typical.
D’Ambola is an SOM alumna who completed her training in internal medicine at St. Michael’s Medical Center in Newark. She and Myers both came to the inner city from participation in the Jesuit Volunteer Service Corps. Myers, a New Jersey native, traveled to Oregon to work with migrant workers there. D’Ambola volunteered for two years in San Jose, California, working with chronic adult psychiatric patients. “The skills I learned as a Jesuit volunteer are what I now use as an attending physician,” she notes. She has been at St. Luke’s since SOM negotiated a formal affiliation with the medical center in 2000. Both have faculty appointments at the medical school.
That they both gravitated to a career serving an inner city neighborhood under the auspices of Catholic Charities is not surprising. In fact, St. Luke’s is a partnership between UMDNJ and the Catholic diocese of Camden. D’Ambola is medical director of the center, which had nearly 8,000 patient visits last year. “Our vision is to bring exceptional healthcare to those in need through a private medical practice concept,” she explains. “We spend time with our patients, addressing their medical, psychosocial and spiritual needs.” Unlike in clinics, patients need appointments for care and usually see the same doctor each time. Unlike in other private practices, however, the modest fee is $25 for an office visit and some Thursdays are devoted to home visits for patients who can’t get out. And since St. Luke’s participates in the city-wide diabetes initiative — the Camden Coalition for Healthcare Providers where D’Ambola serves as a board member — diabetes education sessions are also offered.
The needs of the patients are familiar: diabetes, hypertension, lack of primary care. But these are complicated by communications issues; even though the staff is largely bi-lingual, educational limitations and cultural differences create special difficulties. On a positive note, D’Ambola was recently recognized for mentoring medical students and for helping them to become compassionate, culturally competent physicians.
“It’s a tough atmosphere, a challenge at times,” Myers acknowledges. D’Ambola agrees, but her hope is that St. Luke’s will inspire students to continue working with urban underserved populations.
As director of the New Jersey AHEC — area health education centers — program, Elyse Perweiler has her eye not only on Camden but beyond the city limits as well. “Our state has three AHECs and they’re all in South Jersey,” she explains, and she has oversight of all three. The federal program that created AHECs required a connection to a medical school, and the primary care focus of SOM seemed a good fit with the AHEC mission. The relationship strengthened as the AHECs evolved into a liaison between academic health centers, local healthcare providers, and the communities they serve.
AHECs are also pipeline programs designed to improve the supply, distribution and diversity of healthcare providers. The medical students who participate in the various projects to deliver care to underserved communities become role models themselves. “Some of what these students have done is just amazing,” Perweiler says. One group created a model “smoker” where the chest lifted off so that the Camden elementary school audience could see the effects of smoking on the lungs and heart. Another developed an English/Spanish language “myth buster” brochure about HIV/ AIDS for the Hispanic population in Atlantic City. A third team
fostered healthy eating by showing shoppers in three Cumberland county supermarkets how to read food labels.
Although Tom Jones now has statewide responsibilities in his position as UMDNJ’s Director of Community Affairs, his roots and his heart are in South Jersey. He has watched the Camden area grapple with the “big three”: unemployment, crime and health disparities. He is convinced that the people who live there, while well aware of the problems, see the University as “a help to find solutions.” UMDNJ has been an anchor on projects ranging from a higher education task force to improving the commercial neighborhood adjacent to its Camden campus.
Take Camden City Health Futures Committee, for example. Our school founded the group in 2000 to develop and maintain a sustainable system of healthcare planning, program development and implementation. Its activity led to a recent health needs assessment that updated one done more than a decade ago and a series of public health features on cable TV.
“The University is actively involved in Camden’s revitalization and in addressing key public health issues,” Jones notes. “UMDNJ and its schools have created collaborations that have made the seemingly impossible actually happen.”
The Power of Community
"Middle school is prime time in Camden,” notes Farhad Modarai, one of the SOM students who have gathered to talk informally about their vision for Camden’s future and the part they hope to play in shaping it. “Prime time to become runners for the drug dealers,” he adds. His classmate Hyun Ouk Hong shares another disturbing statistic: 10 - 12-year-olds in Camden can look ahead to a threefold increase in juvenile arrests by the time they turn 13. So the two decided that something needed to be done, and that they would do it. Their target would be the youth of Camden.
Modarai knows Camden; he did his undergraduate work at Rutgers-Camden with a major in urban studies and biology and he was a mentor at a Camden school. Hong was president of the student council at Stevens Institute and has a long-standing interest in community outreach. They put their heads — and their passions — together, and Project REACH (Revitalizing Education and Advancing Camden’s Health) was created.
With a little research, the duo discovered that while community service was technically a requirement for Camden middle school students, the schools were often at a loss as to how to go about it. They designed Project REACH to fill this gap. “We will go to the students and say, ‘you take control,’” Modarai explains. They plan to have the Camden students become project leaders and the UMDNJ students the “team members.” The goal is to “create grass roots leaders,” Hong says, “to teach them how to organize their own projects.” Both are firm believers in “the power of community.”
Both young men have a highly developed social consciousness. Modarai attends city hall meetings to be sure that the city “treats the locals fairly” amid the rush to build luxury townhouses. The two recall a visit to a Camden farmers’ market to do blood pressure screening only to find a greater need to treat the infected arms of IV drug users. Their enthusiasm has built a REACH club, now with 55 members, open to all UMDNJ students in South Jersey.
The first REACH projects will be built around four areas: hypertension, teen pregnancy and HIV awareness, smoking and alcohol, and nutrition. The student group works under the guidance of SOM’s Department of Family Medicine. The department chair, Carmen Ciervo, DO, will serve as the project’s administrative officer and medical reviewer for the learning modules.
Modarai and Hong are modest — yet proud — about their own role in this ambitious undertaking. Both received Albert Schweitzer Fellowships, a program that supports emerging professionals in translating their idealism into action. The project also earned a 2009 Caring for Community grant from the Association of American Medical Colleges. They laughingly recount how they put together a budget itemizing everything from paperclips to post-it notes. They’re sure that it was obvious the grant applications were student-initiated and this turned out to be their strength. “I waited two years before I started medical school,” Modarai says. “But I came because I believe that physicians have powerful voices that should be raised to combat social injustice and advocate for the underserved.” He hopes to increase the volume.