By Joe Duffy
One after another the questions come from Baltimore City Health Department
caseworker Virginia Walker.
How do you feel?
How much weight have you gained?
Has the baby been kicking?
When is your next prenatal-
Have you heard from your husband?
How is your brother-in-law coping?
Would you like to attend a parenting class?
A young woman named Janet leans forward in a chair, listening in smiling silence to each new query, then turns and locks eyes with second-year Johns Hopkins University School of Nursing student Kitty Poon, awaiting a translation to her native Spanish. Janet is a shy, soft-spoken host during this outreach visit to her well-kept home on the first floor of a rental rowhouse in Southeast Baltimore. Only by leaning in close is Poon able to hear Janet’s replies clearly enough to translate them into English for Walker, who then scribbles notes for her growing file on Janet’s needs.
Slowly, the string of translated answers gives shape to Janet’s situation and its complexities. She, her husband, Francisco, and their 2-year-old son, Francisco Jr. are undocumented immigrants from Mexico. Francisco returned to Mexico earlier this year to deal with a family emergency. They learned Janet was pregnant only after he left. She’s had complicated pregnancies in the past, including at least two spontaneous abortions. Now Francisco is stuck in limbo, unable so far to make his way back across the border to rejoin her.
The baby is due in three short months. Francisco’s brother, who lives upstairs in the same rowhouse, is supporting Janet and little Francisco as best he can, paying the rent and bills in exchange for miscellaneous housework and errands. But he’s got his own family to worry about. There is scant money available for doctors’ visits and medicines, much less essentials like a crib and a car seat. Because of her status as an illegal immigrant, the bulk of assistance programs that might otherwise be available are out of Janet’s reach.
Families like this (Janet requested that her last name be omitted from this article) are finding their way to Baltimore in rapidly growing numbers. Between 1990 and 2000, the U.S. Census Bureau estimates, the city’s Hispanic population rose 80 percent. With an additional increase of nearly 20 percent between 2000 and 2004, the city’s total Hispanic population now numbers around 13,500, according to census figures. (Leaders of Baltimore’s Hispanic community put the current total closer to 40,000 or more.)
More often than not, these immigrants land in the rowhouses that stretch along block after block of the streets of Southeast Baltimore, just below the Hopkins medical campus. There are no reliable numbers on how many of these immigrants are undocumented, but the nonprofit Job Opportunities Task Force has estimated that nearly half of Maryland’s foreign-born immigrants are not yet citizens. Striving to gain a foothold in a new country, they face an imposing array of social, economic, legal, and health challenges.
“Their needs are high, very high,” says Lisa Kelley, a clinical instructor and coordinator of the Caroline Street Free Clinic operated by the School of Nursing under the auspices of the Johns Hopkins Urban Health Institute. “There are some health care resources for people in the Hispanic community, but [many programs] have long waiting lists. And while these places try to make their services affordable, there are many people in the community who can’t afford anything at all.”
Efforts at the School of Nursing to reach out and respond to these needs date back more than a decade. The first step was a small one: In 1993, students and faculty provided translation services during a health fair put on by the Hispanic Apostolate of the local Roman Catholic archdiocese. But that modest beginning marked the start of something big; outreach efforts have grown by leaps and bounds in the years since.
Shortly after that first health fair, the school collaborated with the city Health Department through a Kellogg Foundation program to provide health education and basic clinical care to new immigrants. Then, Lori Edwards and a colleague from the Johns Hopkins School of Medicine helped launch Project HEAL, a venture that sent community health workers into the streets near the medical campus. Edwards also established a federally funded WIC (Women, Infants and Children) program targeted to Hispanics. Along the way, the school developed lasting partnerships with several grassroots community organizations, including the Julie Community Center and St. Michael’s Outreach Center and El Centro de la Comunidad.
In part because of its successful post-Peace Corps fellowship program (led by Edwards), the school attracts many bilingual students. These students have helped develop and translate health information materials. They’ve worked as translators for city agencies, such as the Health Department, and at the two school-operated free clinics that serve Hispanics, the Caroline Street Free Health Clinic and the Wald Community Nursing Center. They’ve administered free flu shots at community centers and coordinated community health fairs. To better understand the growing needs of this community, Edwards also organized graduate nursing students, under the direction of the MSN/MPH program coordinator Joan Kub, to complete assessments of community needs. They pinpointed the medical conditions that disproportionately affect the Hispanic population—diabetes, heart disease, AIDS, communicable diseases, and asthma among them.
Faculty instructor Lori Edwards is charged with overseeing student participation in such activities and programs. As coordinator for the Community Outreach Program, she teaches the community outreach class required of students before they sign on for the program. At any given time, Edwards says, between 50 and 70 students are putting in significant outreach hours. Many of them earn roughly $11 an hour from the school for some assignments, while others decline the option of taking wages for community work.
“The thing to remember is that we don’t want to just send them off as volunteers,” Edwards says. “We want to do it in a way that provides them with ongoing mentoring so that they’re not just developing language skills. We want them to be developing clinical and nursing skills as well.”
What I’ve learned is that it’s a big deal for these people to let a stranger into their house. I’ve come to see what a privilege it is for me to be let inside. I really feel lucky just to be able to see a bit of their lives.”
Currently, Kitty Poon ranks among the school’s most active student volunteers. In addition to translating for the Health Department, she volunteers at the Caroline Street Free Health Clinic and with Birth Companions, a school-run program that assists pregnant women in need by providing a trained “companion” to help them navigate their pregnancy and delivery.
A native of California, Poon dates her love of Spanish to childhood. The language was one of her two undergraduate majors at the University of California at Davis, and she volunteered at two clinics near that campus that served predominantly Hispanic families.
“I don’t try to go into this work with this attitude of ‘I’m here, so now I’m going to decide how to help you,’” Poon says. “What I’ve learned is that it’s a big deal for these people to let a stranger into their house. I’ve come to see what a privilege it is for me to be let inside. I really feel lucky just to be able to see a bit of their lives.”
Poon and Walker found their way to Janet through Hopkins Bayview Medical Center, where Janet had arranged for a sonogram. Her Bayview caregivers called the quasi-public agency, Baltimore Health Care Access, which in turn alerted the Health Department’s Maternal/Infant Nursing Program. With Baltimore’s growing Hispanic population, such calls are coming more and more frequently.
“The population is growing so fast,” Walker says. “I was saying to Kitty the other day, ‘I’m worried I’m calling on you so much that you’re going to burn out. You’ve got to talk to me if that’s happening, because the last thing I want to do is use you all up.’”
Things have gotten better for Janet since Poon and Walker’s first visit a month ago. She’s gaining weight, and the baby is kicking up a storm. Her husband hopes he might be able to make it back to Baltimore within about six weeks.
As the meeting winds down, Janet turns the tables on her guests and asks a few questions of her own. Can the Health Department arrange for her to get a checkup for little Francisco? He’s been having nosebleeds lately. How about dental care? One of her molars is painfully swollen. Also, she needs to change her phone number. How should she go about making sure the Health Department will still be able to reach her?
To both Walker and Poon, the questions are gratifying; they seem a sure sign that after just two visits Janet has come to trust them. Before they leave, Poon opens a box she’s brought. It contains a utilitarian gift—a child’s toilet seat that might make it easier for Janet to train little Francisco to use the bathroom and get out of diapers.
This one field encounter doesn’t begin to describe the variety of services nursing students deliver through outreach programs to the Hispanic community. Such services run the gamut from simple translation to basic clinical care to complex disease management.
On occasion, the work involves little or no direct contact between students and Baltimore’s Hispanic residents. Alumna Mary Costello, for example, spent much of last year coordinating work on a directory of medical resources that physicians, nurses, and social workers will be able to use as a referral resource in caring for Hispanics. After agreeing to take the project on, Costello issued a call for help via a broadcast e-mail to all nursing, medical, and public health students. Some 15 volunteers signed on to help her take the project to the finish line. A draft version running to nearly 140 pages had been completed by late summer.
“Getting all that help was great, because it was a goal of mine going in, to bring all three schools together on the project,” Costello says by phone from California, where she is now working in the women’s health center at the Stanford Hospital. “The way I think about it, we’re all going to need to work with each other when we get out of school, so why shouldn’t we work together when we’re in school?”
That’s a goal increasingly shared by other outreach programs. At the Caroline Street clinic, Lisa Kelley aims to team medical students with nursing students in ways that build healthy, collegial working relationships.
“One of the things we’re trying to do is to get future nurses and physicians to respect each other early and really learn what the other does,” she says. “Hopefully, they come away with an appreciation of their different roles and an understanding of how those roles overlap and interact.”
Financed in part by a grant from the Johns Hopkins Nurses’ Alumni Association, the resource directory was undertaken in partnership with Baltimore Health Care Access (BHCA). The final product was slated to be posted on the agency’s Web site (http://www.bhca.org) during the fall months. Pamela Brown, coordinator of BHCA’s Hispanic Health Care Project, expects the directory to prove indispensable to caregivers and their patients.
“It is so, so important for professionals to have a resource like this and for it to be accurate and up to date,” Brown says.
Other students get deeply involved in the lives of Baltimore’s Hispanic families. Each fall and spring, several students are assigned to St. Michael’s Outreach Center, where their work is coordinated by senior case manager Blanca Picazo. Each student works with an individual family, meeting with them at least once a week for two to three months in order to deliver public health and disease management education and facilitate their access to health care professionals and public services.
“The experience has been really positive for both sides,” Picazo says. “The [Hopkins] students that I’ve gotten to know so far, they’re just incredible people who have been really good for the families they work with. Some of them, they almost become a part of the family.”
Many Hispanics migrating to Baltimore arrive unaware of longstanding problems with lead paint in the city’s older housing stock. In one case, Picazo recalls, a student went to incredible lengths to find a new, lead-safe home for a family of eight that had an income of almost zero. In another case, a student assigned to help a young mother learn to deal with the dietary issues surrounding her diabetes arrived with a slew of brochures and pamphlets, only to learn that her client was illiterate in both English and Spanish. So the student tossed the brochures aside and spent her outreach time at the woman’s side while she shopped and cooked.
Clinical instructor Carm Dorsey has supervised students in such outreach assignments for the past 10 years. She regards the opportunities as critical to the development of top-flight nurses because it gives them a chance to see health care through the broader lens of economic status and social circumstances.
“It’s so important for the students to have this opportunity out in the field to reflect on what they’re learning in classes,” Dorsey says. “This really shows them up close the root causes of health disparities that they’re going to be dealing with in their careers.”
As coordinator for the Community Outreach Program, Lori Edwards decides how best to place students in this diverse mix of independent programs. In recent months, she has launched a concerted effort to coordinate all the offerings under a single new banner, Programa Salud (salud means “health” in Spanish) at the School of Nursing.
“This came about simply because of the way this outreach came together, with all these different programs getting started on their own,” says Edwards, who is coordinator of the new effort. “Programa Salud is about trying to formalize and coordinate what we’ve been doing. And it’s about giving us a chance to target those services in more efficient ways.”
It’s also designed to provide a stronger framework for the future expansion of outreach efforts. Edwards, Kelley, and Dorsey all agree that the work is hampered by a short supply of free medicines in clinics and by a lack of funds to support faculty time spent coordinating outreach programs and mentoring students in the field.
“It’s a constant challenge,” Dorsey says, “but it’s something that we have to keep after. Certainly, there must be donors out there who are interested in reducing the disparities we see in this population. They might think about funding the time that frees a faculty nurse to work in a clinic or developing a fund for medications so that people could get their insulin supplies and the other medicines they need.”
The Programa Salud name actually originated at Hopkins on the Homewood campus, where students four years ago launched their own outreach program to the Hispanic community. Now, both the School of Nursing and the School of Medicine have launched their own independent Salud chapters, opening the possibility for coordination among all three schools.
“The experience has been really positive for both sides…The [Hopkins] students that I’ve gotten to know so far, they’re just incredible people who have been
really good for the families they work with.”
At Nursing, the transition was led by Lynn Desrosiers before she graduated this past July (she began working in September at the cardiac progressive care unit of Hopkins Hospital). Desrosiers worked under the mentorship of Edwards. Her goal for the project was to help give a sense of cohesiveness and continuity to the outreach work students perform. She herself volunteered at the Wald Center and at several community health fairs.
“There are just so many different places where you can work now, so many different clinics and events,” she says. “A lot of the people who work on these things don’t really have a sense of how all this fits together—they’re all just off doing their own thing.”
With a promised Johns Hopkins Nurses’ Alumni Association grant, Desrosiers set out to develop a Web site and curriculum materials that would give students a clear sense of how each individual project fits into the whole of Hispanic outreach across all the Programa Salud chapters at Hopkins. The grant also financed the development of a logo, a banner, and T-shirts designed to build a sense of camaraderie.
In addition, her project is designed to build a stronger identity for the School of Nursing out in the community.
“Students come and go so quickly in nursing,” Desrosiers says. “We want to make it so that it doesn’t feel like we go out into the community for a year and then we graduate and leave the community hanging. We’re trying to make it so that even though the faces of the students are changing, the community will know that the School of Nursing will always be there for them, as it has been over the past 12 years.”
Jim Duffy writes from Cambridge, Maryland. He is a frequent contributor to this magazine.