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Achebe has headed the Harvard Street Health Center for the past two years.

Meeting Needs

DMS alumnus Chidi Achebe wields powerful weapons—an M.D., an M.P.H., and an M.B.A., plus a can-do spirit—in addressing the health-care disparities and needs of the inner-city populations that he serves as head of a health center in Boston's Dorchester neighborhood.

Text by Amos Esty
 • Photographs by Jon Gilbert Fox

Dr. Chidi Achebe has high expectations—not just of himself and his coworkers, but even of his patients.

As the president and chief executive officer of Harvard Street Neighborhood Health Center in the Dorchester section of Boston, Achebe works hard to bring high-quality care to populations that have long been left out of the nation's health-care system. He is well aware of the enormous gap between the care that's historically been provided in neighborhoods like Dorchester and the world-class care that's available just a few miles away at the medical centers that have made Boston a hub of the health-care industry.

But rather than lament the disparities, Achebe hopes to help bring them to an end by turning Harvard Street into a model of primary care.

Amos Esty is the managing editor of Dartmouth Medicine magazine.

Achebe freely admits that his goals are lofty. But he has always been held to a high standard himself. His father is Chinua Achebe, the renowned Nigerian writer, and his mother, Christie Achebe, is a professor of psychology. Chidi Achebe says that when he completed his undergraduate degree at Bard College, his parents didn't come for his graduation. "Are you kidding me?" he says, smiling. "They weren't impressed." The same was true for his siblings. After all, Achebe points out, having had so many advantages, there was no reason that they should not have finished college.

Mary Bouchard, left, the center's CFO, says that it's the most challenging job she has ever held—but that Achebe, right, is an "inspirational" leader.

Achebe earned his M.D. from DMS in 1996, completed his residency in internal medicine and pediatrics at Texas Medical Center in Houston, and then earned an M.P.H. from Harvard. At the time, he thought he might end up going into international health.

He changed his mind when he got an unexpected offer from Frederica Williams, the CEO of Whittier Street Health Center in Boston's Roxbury neighborhood. She named him medical director of the center. Achebe says that to hire such an inexperienced physician as medical director raised some eyebrows in the medical community, so he tried to prove that he was up to the challenge. "I was so grateful to Frederica that I used to leave the office at 10:00 p.m. daily," he says. "She gave me the chance of a lifetime."

Achebe enjoyed the work, but he felt his education was still lacking something. Every time he was in a meeting and the talk turned to the center's finances, he felt in over his head. As a result, he decided to go back to school once more, this time to Yale to earn an M.B.A. Upon completing that degree in 2008, he took up his current position.

Achebe has had carpeting replaced, walls painted, and furniture donated. He wants patients to be comfortable at the center, even proud of it, because one of the challenges in underserved communities is convincing people to come in for basic care.

Every day, hundreds of patients arrive at Harvard Street Neighborhood Health Center, which sits on a busy street in the diverse community of Dorchester. Most of the neighborhood's residents are members of a racial or ethnic minority, including large populations of blacks, Hispanics, Vietnamese, and Haitians. In many homes, English is not the primary language.

The black men and women of Dorchester and the rest of Boston live, on average, about five years less than the average white Bostonian. The disparity in infant mortality is even starker. More than 12 of every 1,000 live births to black women in Boston end with the death of the child before his or her first birthday—a rate slightly worse than the rate in Russia and Uruguay and just a little better than that in Botswana and Panama. For the city's white women, the infant mortality rate is 4.6 per 1,000. Blacks in Boston are also more likely than whites to die from a host of common diseases, and they are far more likely to contract HIV.

Achebe, right, confers with Dimitry Petion, the center's COO.

It has been clear for decades that there are large differences in the health of whites and minorities in the U.S. The issue began to receive more attention after the Institute of Medicine published a report in 2003 on racial disparities in health care. The report surveyed the research on the issue, producing a damning picture of just how much worse health outcomes were for racial and ethnic minorities than for whites. The problems listed covered virtually every facet of medicine. From heart disease to cancer to diabetes, minority patients were more likely to succumb to the common causes of death and less likely to get the care they needed to stay healthy.

Since the publication of that report, researchers have continued to document ongoing disparities. In 2006, the average life expectancy for black men was 69.7; for white men it was 75.7. The rate of new cases of HIV/AIDS for blacks in 2006 was 60.3 per 100,000; for whites it was only 6.4 per 100,000. There is a long list of common diseases that are more prevalent among blacks—and more likely to result in death. There are even differences in the rate of procedures such as knee replacements, with black men only 36% as likely as white men to get a knee implant.

About 60% of the health center's patients are covered by Medicaid, but reimbursements rarely cover the cost of their care.

Dr. John Rich, a 1980 graduate of Dartmouth College, has spent a lot of time investigating these kinds of disparities, including as medical director of the Boston Public Health Commission from 1998 to 2005. Many such disparities present more questions than answers. He says the infant-mortality gap, for example, doesn't seem to be explained by differences in behaviors during pregnancy, such as smoking.

Instead, researchers are increasingly looking at how a woman's health prior to her pregnancy might affect her baby's health, as well as at the links between race and income. "There's evidence that the stresses associated with being poor and the stresses associated with facing discrimination and racism across one's life take a toll on the body in terms of stress," Rich says. For example, stress has been shown to weaken the immune system.

A dental student works on a patient in the center's dental clinic.

To address disparities successfully, Rich points out, it's important to take into account more than the health care system. "You have to look at what happens in the community," he says.

A case in point is the fact that in Dorchester, as in other Boston neighborhoods that are home to large minority populations, fast food is easy to find but healthy options are limited. Overall, blacks in Boston are less likely than whites to get regular exercise and more likely to be overweight or obese.

Violence is another problem for the neighborhood surrounding Harvard Street. The murder rate in Dorchester is one of the highest of any Boston neighborhood. In March, there was a fatal shooting just a few blocks from the health center.

In short, the history of racial disparities in health care and the problems facing Dorchester could seem overwhelming. But Achebe believes the care provided at Harvard Street can be as good as care anywhere. That means thinking about everything from waiting rooms to gang violence.

Since his arrival, Achebe has had carpeting replaced, walls painted, and furniture donated. He wants patients to be comfortable at the center and even to feel proud of it. He believes that it's particularly important for health centers in areas like Dorchester to be welcoming environments, because one of the major challenges providers face in underserved communities is convincing people to come in for basic care.

Achebe isn't just an administrator—he also still sees patients regularly. He wishes he could get more men to come to the center for care, however.

Achebe first encountered this problem at Whittier Street. He noticed that a lot of women and children came to the clinic, but very few men. In such communities, he says, "men do not go to see the doctor unless their foot is falling off." So he turned to what he calls "shock therapy." He went to churches, barber shops, and other gathering places and talked to people about the neighborhood's dire health statistics, trying to scare men into getting a check-up. As a result, the number of men seeking care eventually quadrupled.

"If you lose men out of the health-care system at about 18, you don't see them again until they're 40, for the most part," agrees Rich. "And then you've had no opportunity to prevent smoking, to address high blood pressure, to address early diabetes."

The same problem exists at Harvard Street. Dr. Stephen Wright, a physician there, says that when he sees patients, he has to assume that they haven't been to a doctor in years and may not return for follow-up care. He agrees that men are particularly problematic. "Men want to be tough," he says. "They don't want to admit there's anything wrong with them." Even if they're willing to see a doctor, they may have trouble getting time off from work to go to an appointment. And although almost all Massachusetts residents now have insurance, deductibles and copayments still present barriers to care, according to Wright. "It's not unusual that my patients come in and say, 'Dr. Wright, my blood pressure is high. I couldn't afford the medication. Can I borrow $10?' This is a real scenario. We see this every day," he says.

"We're such a medicalized nation," Achebe says. "We would like to . . . begin to move away from 'Here's another aspirin, here's another Lipitor tablet' to 'What is it that I can do to keep you healthy and make you maybe get off some of these meds?' "

Of course, another key to caring for the community is ensuring that Harvard Street remains financially viable. As at many community health centers, that's a constant challenge. About 60% of the center's patients are covered by Medicaid, but reimbursements rarely cover the cost of providing care. The remaining medical payments come from a mix of private insurers and Medicare, both of which generally reimburse at higher rates than Medicaid. The center also gets funding from government grants. Mary Bouchard, the center's chief financial officer, calls her position "the most challenging job I've ever had. The dreams are big here, but the realities are a little more constraining."

Dimitry Petion, Harvard Street's chief operating officer, says the staff is constantly looking for ways to be more efficient. "One of the main challenges is how do you do more with less," he says. For example, he explains that the center's electronic medical records system has made keeping track of the care of diabetes patients easier by reminding physicians when patients are due for certain tests.

Dr. Wha-ja Woo, the chief of pediatrics, examines a patient.

People with chronic diseases such as diabetes make up much of the patient population. Wright trained as a general surgeon, but he now spends most of his time providing primary care. And much of that care is for patients with chronic diseases. "Almost every week I identify three or four new diabetic cases," he says. A nutritionist advises diabetes patients about healthy eating, and the clinicians try to ensure that they get the tests they need to effectively manage their disease.

Nationwide, diabetes is one of many conditions for which outcomes for black patients lag behind those for white patients. Blacks with diabetes are more than four times as likely as whites to have a leg amputated, a complication that can result when the disease is not well controlled. But thanks to the center's diabetes clinic, Achebe says, some patients have been able to reduce their hemoglobin A1c, which is used as a measure of blood-sugar levels, from out-of-control to within the normal range for diabetes patients. This greatly reduces their risk of complications, such as amputation.

Achebe is less interested in race than in disparities. "It cannot be about race," he says. "I'm interested in who are the needy, and let's take care of them."

By improving the care available to people in Dorchester, Achebe hopes to show that racial disparities in health are neither inevitable, nor even necessarily about race.

The prevailing view of the causes of racial disparities in health care has been that individual patients are treated differently, with whites tending to receive better care than minority patients. Dartmouth graduate John Rich says studies have shown that the treatment patients receive can be affected by their race or ethnicity. "Providers are like anybody else," he says. "They hold biases, they hold stereotypes."

For example, a study of patient-physician encounters showed that doctors considered black patients more difficult, less likely to follow treatment plans, and less intelligent than white patients, even after adjusting for their income and education.

Shown is lab assistant Sharon King; the center has its own lab and pharmacy.

But other studies have shown that race isn't necessarily the only or even the most important factor in what seem to be large racial disparities in health care. Rather, as Dartmouth economist Jonathan Skinner has found, hospitals that provide lower-quality care tend to serve a larger proportion of minority patients. So perhaps disparities can be explained, for the most part, by the overall quality of hospitals, not by how individual patients are treated at the same hospital. Therefore, Skinner says, if you target lower-quality hospitals for improvement, you'd automatically address racial disparities because lower-quality hospitals serve a disproportionate number of minority patients.

In one study, Skinner examined outcomes after a heart attack for Medicare beneficiaries (cardiovascular care is one area with a long history of racial disparities). He divided hospitals into 10 groups based on the percentage of black patients treated there for a heart attack. Hospitals in the lowest group didn't have a single black patient. In the highest group, about a third of patients were black. Black patients tended to be clustered into a relatively small number of hospitals—21% of hospitals treated 69% of all black heart attack patients on Medicare. The hospital group with the highest percentage of black patients had the highest mortality rate for both blacks and whites. And within each hospital group, outcomes for blacks and whites showed little difference.

Still, some differences did remain within each group, with outcomes for blacks consistently slightly worse than those for whites. And that, Skinner says, is where other factors might be playing a role. "We certainly do not deny that there are differences between how black and white patients are treated within a hospital," Skinner says. But, he adds, blacks tend to get care at hospitals where "they provide equal-opportunity poor-quality care."

Wright adds that despite the frustrations, financial and societal, there are significant rewards from serving the center's patient population. "We recognize that our community is in trouble," he says, "and we also recognize that we can make a difference."

Tracy Onega, an assistant professor of community and family medicine at Dartmouth, supports Skinner's findings. She investigated mortality rates for four types of cancer, comparing outcomes in patients treated at cancer centers designated by the National Cancer Institute to outcomes at cancer centers without the NCI designation. Onega found that at NCI centers—which she used as a measure of high-quality care—outcomes were better for both blacks and whites.

When comparing three-year mortality, she found that blacks were 23% more likely to die within three years of diagnosis regardless of where they were treated, and that there were even more significant disparities in outcomes among those treated at non-NCI centers. But there was no difference in the likelihood of death for whites and blacks treated at NCI cancer centers; both blacks and whites fared better at such centers. "If you attend these similar facilities, then you will have similar outcomes," she says, "which suggests that a lot of what we see with the racial differences in mortality might be due at least in part, a significant part, just to how people distribute among facility types."

Dr. Stephen Wright checks a patient as physician assistant Diego Neira, left, and Achebe look on. Wright says many patients can't afford their drugs.

Achebe is likewise less interested in race than in disparities. "It cannot be about race," he says. "I'm not interested. I'm interested in who are the needy, and let's take care of them." He says he'd be just as comfortable running a health center in rural Oklahoma, for example, as in the inner city. "The people may be different, but the mission would be the same: to take care of people who don't have insurance or the kind of health care that they deserve."

Achebe recognizes the factors that have long contributed to worse health among minorities. If those obstacles are removed, he says, there will no longer be any excuse for people not to do more to improve their own health. That's where his high expectations of patients come in. He points out that across the street from the center is a large park with walking paths, tennis courts, a golf course, and other recreational facilities. "Why aren't you walking in the park if you're obese?" he wonders about his patients. "Why are you not jogging?" He thinks that Harvard Street can help change the focus from health care to health. "The point is, how can we get our community to use the natural resources, this beautiful forested park, . . . to keep fit and keep them healthy?" he asks.

But there's a problem with that mindset. Achebe would much rather help people stay healthy than prescribe drugs or other treatments. However, the center makes more money if patients come in for care than if they stay healthy and no longer require regular care. "We're such a medicalized nation," Achebe says. "One of the things that we would like to do is to begin to move away from 'Here's another aspirin, here's another Lipitor tablet' to 'What is it that I can do to keep you healthy and make you maybe get off some of these meds?' "

Achebe says his goal "is to arm and empower that same group of people that we're calling vulnerable." It doesn't work to rely on "do-gooders" to save people, he adds. "They're human beings—they can save themselves. Give them the tools to do that."

Part of getting there, he believes, is up to health-care providers and part is up to individuals. "We have to start talking about individual responsibility, and the way to get there is to provide them with a certain equal standard of facilities," he says. That might mean finding ways to provide more fresh fruits and vegetables in areas that do not have them. Once the structural needs of the community are met, then it's up to members of the community to take care of themselves. "I don't want to get to a point where we're perpetually lamenting the inner city," he says. "We need to move away from that. We need to move to a new realm where you're American, you get a certain standard of care, period, wherever you are. Now, tell me, why are you still not fit?"

Achebe wants Harvard Street to offer other services in addition to health care, including educational classes in the evenings, day care for both young and old, and spaces where people can gather. He says the center already holds community meetings where staff try to educate the community about chronic diseases and explain how people can get help.

Medical assistant Wilda Rosado greets a patient at Harvard Street's family medicine department. Access is a complex issue in such communities.

"I think part of it is to arm and empower that same group of people that we're calling vulnerable," Achebe says. It doesn't work to rely on "do-gooders" to save people, he adds. "They're human beings—they can save themselves. Give them the tools to do that."

To that end, Achebe has expanded the services available at Harvard Street, often by forming partnerships with larger organizations. The health center's lab is run by the University of Massachusetts, for example, and its dental clinic is staffed in part by students from local dental schools. He hopes to soon expand into a large building across the street from the existing center, which would allow Harvard Street to provide additional services and serve more patients.

Achebe's vision of what a community health center can be is part of what makes it possible to get through the daily grind of working in such a difficult environment, says CFO Mary Bouchard. "He's very inspirational," she says. "And he's extremely dedicated to the mission of preserving and growing and building this health center into a sustainable, viable entity."

Wright adds that despite the frustrations, there are significant rewards to the work. "We recognize that our community is in trouble, and we also recognize that we can make a difference. . . . We come in every day, and we're taking care of our community, and that's a good feeling to have."

Achebe understands that an important part of his job is to keep everyone focused on the long-term goals, to keep their expectations as high as his own. "For me, it's almost a spiritual journey," he says. "There's a lot of work, and you can't give up."

Students, too, get "up close and personal" with disparities

Meaghan Kennedy makes science real for these reservation grade-schoolers.

Over spring break, about a dozen DMS students in the Rural Health Scholars and Urban Health Scholars programs—plus several Dartmouth undergraduates—had a chance to get a first-hand look at health disparities.

Christopher Worsham and five other Urban Health Scholars, together with five undergrads, spent some time in Washington, D.C., where they worked at Bread for the City, a center that provides basic health care and other services to underserved D.C. residents. Among other activities, the students talked to patients, eliciting personal stories that could be used in grant applications. Worsham says that having the chance to talk to patients provided a different kind of medical education. "Part of why I want to go into medicine, or why I think a lot of my classmates want to go into medicine, is to tackle health disparities," he says. And he thinks DMS provides a lot of opportunities to examine such issues. He says that Dartmouth can seem removed from urban issues, given its rural location, "but that doesn't mean that it's something that we ignore here."

Meaghan Kennedy is also a first-year student. Over spring break, she and eight other first-years in the Rural Health Scholars program, plus several Dartmouth premeds, traveled to Minnesota to volunteer on two Native American reservations. They presented health education lessons at elementary schools—making models of lungs out of soda bottles, for example—and talked to students about career opportunities in health care. They also helped out at community health education events, including a night of diabetes bingo. Numbers on the bingo cards were replaced with pictures and words related to diabetes, and health educators explained risks and symptoms of diabetes as the game progressed. "Bingo is really popular in the community, and they have high rates of diabetes, so they're trying to teach about diabetes in a way that the community would enjoy," Kennedy says. One group of students offered basic health screening at a casino. Others helped with HIV education programs. They also shadowed physicians, nurse practitioners, and other providers to see what it takes to provide care in an underserved community.

"It's a different type of learning," Kennedy says of the spring trip. "We spend a lot of time in the classroom, which is obviously valuable, but to really get out in the community and see these things firsthand . . . is . . . really wonderful."

"We just learned a lot by talking to people," Kennedy says. "It's a different type of learning. We spend a lot of time in the classroom, which is obviously valuable, but to really get out in the community and see these things firsthand . . . is a really wonderful experience."

Both Kennedy and Worsham are considering trying to work in a underserved area when they finish their medical education. But there are barriers that make such a commitment difficult—especially the large amount of debt that many students take on over the course of their education. Dr. Joseph O'Donnell, the senior advising dean at DMS and the advisor to the Urban Health Scholars program, thinks that more could be done to encourage newly minted M.D.'s to work in underserved areas, such as loan-forgiveness programs. He believes it's vital for students to learn about these issues while they're in medical school—for the nation's future doctors "to really know what health disparities mean, up close and personal," he says, "rather than in the abstract in a lecture."

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