Paul Ambrose Scholar: Emily Starman; University of Iowa School of Dentistry

Community-Based Project Name: Open Heartland: A Pilot Project to Increase Access to Oral Health Care 

The Paul Ambrose Scholars Program prepares public health and clinical health professions students to promote change and be leaders in addressing population health challenges at the national and community level.  Students commit their time and effort to improve health within their communities through the planning and implementation of a community-based project.

This project was to establish a working partnership between the University of Iowa College of Dentistry (COD) and Open Heartland. Open Heartland is a grass roots organization in Iowa City, IA that works with Hispanic, Spanish-speaking immigrant families to provide community resources, including healthcare. I worked with COD administration and faculty to develop a pilot program to refer patients from the UI Mobile Clinic to the COD. Patients were ideally going to see fourth year students in the Family Dentistry clinic for comprehensive exams and radiographs free of cost. A treatment plan could then be developed and completed with a payment plan based on the Iowa Medicaid fee schedule. This was significant since most all adults are not eligible for Medicaid or dental insurance due to their immigration and/or citizenship status. A dental event was held separately from the UI Mobile Clinic at Open Heartland in January 2022 to establish a patient pool for the pilot program. An educational activity for children and educational flip books in Spanish were also used/made. Patients were selected based on evidence of urgent dental needs and desire to be treated at the COD. Seven adult patients were ultimately selected and contacted to make appointments in Family Dentistry with me (Emily Starman, D4) as their clinician. Comprehensive exams, radiographs, and treatment plan formulation was completed for each pilot patient, including extensive oral health education. All appointments were completed using an interpreter over the phone. Patients will then be scheduled with new fourth year students after my graduation to complete treatment in Fall 2022 as necessary.

Project Timeline

• August 2021: Opened Heartland Mobile Clinic #1 in Iowa City, IA
• October 2021: Opened Heartland Mobile Clinic #2
  
• January 2022: Dental Event at Open Heartland
  
• March-May 2022: Saw patients for comprehensive exam, cleanings, and treatment planning.
  
• May 2022: Opened Heartland Mobile Clinic
  
• May- June 2022: Plan for future patient care and pilot programming with mobile clinic patients

Wigdan Farah, MBBS

Mayo Clinic; Preventive Medicine Fellowship

The APTR-AHRQ rotation provided me with a great experience and exposure to the US Preventive Service Task Force work and methodology. During my remote rotation, I was able to work with great and supportive mentors and participate in several projects, AHRQ and Task Force meetings, and educational meetings, including verifying scientific references used in a draft recommendation statement and contributing to drafting questions for the "Putting Prevention into Practice" feature of the American Family Physician journal, in addition to creating a database with the most appropriate Task Force recommendation to address the need of a particular population. I also presented critical 
appraisal for a randomized control trial at journal club, participated in resident rounds, and attended USPSTF meetings.

What were the key concepts you learned during the rotation?
The process of developing evidence based recommendations and learning about the different strategies to tailor the recommendations to address the need of different populations.

Sopan Mohnot, MD

Stony Brook University Hospital  

The APTR-AHRQ rotation was a great experience. During the rotation, I contributed to writing questions for the "Putting Prevention into Practice" feature of the American Family Physician journal. I also assisted in fact checking recommendation statements on a variety of topics. The AHRQ team is very collaborative and they encourage resident input and innovation. I was able to design a database for recommendations based on various needs of the workgroup. I also presented at journal club, participated in resident rounds and attended USPSTF meetings.

What are the initiatives you are tackling in your role at ORR?
As a member of the ORR Administrative Board, I work with residents and fellows from across the country to work across disciplines and bring the trainee perspective to various stakeholders at the AAMC involved in graduate medical education. Most recently during the spring conference of the AAMC Group on Medical Affairs, comprised of national Designated Institutional Officers and heads of Graduate Medical Education Committees, ORR members were key panelists and moderators at breakout sessions. What first attracted you to the specialty of Preventive Medicine? Preventive Medicine allows me to pursue my dual interests in primary care for the underserved and health equity advocacy. I have sought opportunities to improve the health of populations, in particular immigrant and underserved communities. At the individual level, I have been trained to treat patients’ medical and social needs in a primary care setting with a focus on screening and prevention. On the population level, I am learning skills to effect changes through patient safety and quality improvement and research on cultural tailoring of health education.

What has been the most rewarding part of your work?
During the COVID-19 pandemic, I was able to apply my academic research on cultural tailoring of public health messaging to real-world resources for immigrant communities. Filipino Americans, like many communities of color, have been deeply affected by the COVID-19 pandemic. Despite comprising only 4% of the nursing workforce in the US, Filipinos are 32% of the nurse deaths due to COVID-19 according to National Nurses United. In response to this need, I was part of a national team to design and implement TayoHelp.com, a culturally-tailored COVID-19 resource for Filipino Americans available in English and Tagalog. Without my training in preventive medicine, I would not have had the skills or the network to help lead this initiative.

How has the training/education in Preventive Medicine positioned you for your current role and function?
At the Cook County Health/Northwestern Feinberg School of Medicine Program in Preventive Medicine, my mentors Dr. Pamela Ganschow and Dr. Juleigh Nowinski-Konchak have created opportunities for me to gain experience and exposure to the complex management of health systems like Cook County Health, an organization that serves as one of the largest healthcare and public health systems for the underserved in the country. Coupled with the excellence in academic scholarship on South Asian health at Northwestern University, with Dr. Namratha Kandula, I have learned valuable skills to utilize data for both research advocacy on behalf of immigrant communities.

What advice would you offer to young professionals who are beginning their journey in Preventive Medicine?
Preventive Medicine is a very diverse field, and your opportunities are only as limited as your passions. Every preventive medicine physician has a unique path, and public health grants additional opportunities to collaborate with non-clinicians who deeply contribute to population health. As physicians, we have entered a profession rooted in service to alleviate suffering, and I hope we may all apply our population-based skills to advocate for community health.

As you reflect on your career, what is the best advice you received that made a difference in the opportunities you explored or the risks that propelled your career?
Interviewing in preventive medicine programs across the country, it was simultaneously inspiring and intimidating to meet accomplished applicants, residents, and faculty with similar interests. Although we all have aspirational career goals, you don’t have to do them all now or all at once. It’s a natural cycle to have different chapters in our careers, whether it be more clinical- or public health-focused. Being open to opportunity, and simultaneously sharing opportunities with others, is both a practice and a skill.

What is the key benefit that a professional association such as APTR can offer an institution or individual?
I highly recommend considering applying for the APTR rotation with AHRQ. During my remote AHRQ rotation during the pandemic, I had the privilege to be exposed to the rigorous methodology used by the USPSTF to develop evidence-based guidelines and how to balance the competing interests of stakeholders ranging from federal agencies, medical specialty societies, and the public. I also encourage others to take advantage of opportunities to attend the national APTR conferences. There you will not only learn from inspiring speakers, but also meet your future colleagues and potential collaborators. Public health is a collective effort, where organizations like APTR serve as our mutual bond.

As the COVID-19 pandemic continues to rage across the country and around the world, its disparate impact on marginalized populations has become increasingly apparent. Two particularly vulnerable groups that are suffering the harms of inadequate protection from the dangers of COVID-19 are migrants currently held in immigration detention facilities and immigrants living in the United States. At a time when many public health scholars have the ear of the nation, it is incumbent upon all of us to advocate for marginalized and excluded non-citizens held in detention at our borders, living in our communities, and working in essential jobs across the nation. The harms being perpetrated by the Trump administration in the name of public health will echo through generations if we do not, as a profession, reject these measures and stand for justice.

While the CDC has instructed residents of the United States to wash their hands, wear masks, and practice social distancing, migrants in detention facilities run by Immigration and Customs Enforcement (ICE) and Customs and Border Protection (CBP) have no control over their ability to engage in any of these practices. As a result, cases of COVID-19 have skyrocketed in immigration detention, with ICE’s own numbers indicating that over 1700 migrants have tested positive for COVID-19, and at least two migrants and four guards have died from the disease. The public health community has for years decried the unsanitary and unsafe conditions in detention facilities in the United States and the inhumane treatment of migrants, particularly women and children, seeking to enter the U.S., but in the midst of a nationwide communicable disease outbreak, the plight of migrants is at risk of being overlooked.

Consider the parallel between immigration detention and the U.S. prison system. At the urging of public health experts and advocates, some prisons and correctional facilities across the country have begun releasing inmates accused of nonviolent crimes in order to reduce the chances of widespread outbreaks. Despite this small step towards progress in the wider carceral system, immigration detention facilities are still holding thousands of migrants and asylum seekers, the overwhelming majority of whom did not commit violent crimes. According to the non-partisan Center for Migration Studies, ICE still held over 4,000 asylum seekers determined to have a “credible fear” of persecution or violence in their home countries, even several months into the pandemic. Meanwhile, COVID-19 cases continue to rise as ICE shuffles detained migrants between facilities.

In addition to continuing to detain some migrants and asylum seekers in unsafe conditions, the Trump administration is also using COVID-19 as an excuse to ramp up immigration enforcement and deterrence strategies. Border Patrol agents have been instructed to expel people apprehended at the border without following legal requirements to determine if a migrant has a valid asylum claim. In the name of public health, hundreds of minors have been sent to Mexico, where they face the dangerous conditions experienced by people subject to the Migrant Protection Protocols (MPP, also known as “Remain in Mexico”), including rampant kidnapping, sexual assault, and murder.

The COVID-19 crisis does not only affect asylum-seekers and migrants in detention. Immigrants who live in the United States, with or without legal status, are also disproportionately harmed by the fatal intersection of anti-immigrant policy and inadequate public health measures. When the Trump administration changed the public charge rule in 2019 to discourage legally residing immigrants from using social services like Medicaid and SNAP, tens of thousands of commenters wrote to oppose the changes. Some who wrote in opposition argued that the policy would be bad for the health of immigrants and American citizens alike, citing the communicability of disease outbreaks and the dangers of discouraging vulnerable people from seeking health care. They could not have known how prescient those concerns were, as we can now see the effect the public charge rule has had on immigrants’ willingness to seek care for COVID-19. 

In addition to the damaging public charge rule, the U.S. government has doubled down on the harm to undocumented immigrants by excluding them from the 2 trillion dollar Coronavirus Aid, Relief, and Economic Security (CARES) Act. Although many undocumented immigrants are essential workers, they are not entitled to relief under the CARES Act, and even the U.S. citizen children of undocumented immigrants are unable to access the benefits of the program. Most undocumented immigrant adults are ineligible for publicly funded insurance, and their children are only eligible if they are citizens or reside in one of the few states that provide coverage to undocumented children. These exclusions from social safety-net programs, while clearly unjust even during non-pandemic times, seem downright cruel and counter-productive to the goals of public health in the midst of a dangerous pandemic disease outbreak.

The injustice of this moment, directed against some of the most marginalized members of society, presents a unique challenge to public health scholars and practitioners. As COVID-19 continues to ravage communities of color and tear through immigration detention facilities, it is incumbent upon all of us, as members of the public health community, to use our collective voice, power, and privilege to call for immediate and long-term change. This crisis has demonstrated the moral and practical dangers of excluding some populations from the benefits of publicly funded health care and denying the humanity of non-citizens seeking to make a better life for themselves and their families. We must meet this moment with persistent advocacy for justice in all of the systems that perpetuate health disparities, including a reimagining of both our health care and immigration systems. If we truly believe that the “public” in public health includes all of us, there is no other alternative. 

Rachel Fabi, PhD