At the third and probably last community meeting being held by the Rhode Island Department of Health (RIDOH) to discuss the potential closing of the Memorial Hospital Birthing Center, well over a hundred people turned out to speak. Since the massive protest outside Care New England’s offices last week the movement to keep the birthing center seems to have grown. One speaker at this community meeting drove over an hour to speak her piece about the closing, because the birth of her child at Memorial four years ago was such a positive experience and so important to her.

Care New England announced the closing on March 2, RIDOH Director Dr. Nicole Alexander-Scott scheduled three hearings because under the law, RIDOH must approve any such closing. The process is called a Reverse Certificate of Need and there are procedures connected to the process that Care New England seems to have skipped when announcing the closing of the birthing center. The process is “intended to ensure access to quality health services and healthcare throughout Rhode Island.” Dr. Alexander-Scott has ruled that she must approve or deny the facility’s proposal within 90 days.

Chris Callaci, an attorney representing the nurses who will lose their jobs if the facility closes, pointed out that Care New England has not actually filed a plan for closing the birthing center, as required by law. The public, he says, is being forced to comment on a plan without any of the details of the plan. Further, he says that scheduling the hearings with barely a week’s notice may be a violation of the law. Calico claims that the first meetings must be scheduled no earlier than thirty days after Care New England has submitted a complete plan.

Because of the vagaries of RI public hearing law, the officials in attendance do not comment or answer questions from the public. So Dr. Alexander-Scott, Executive Director Ana Novais and Chief Legal Council Kenny Alston sat silently as patients, medical professionals and community members spoke out against the birthing center’s closure.

Many who live in Pawtucket and surrounding areas object to having their inpatient obstetrics services moved at the 11th hour to Women & Infants or Kent County Memorial Hospital. To interrupt pregnancy care for women who plan to deliver in April and May is a terrible physical and emotional inconvenience for mothers and families, never mind the increased travel time and the last minute loss of a doula.

One woman who is due in early May said that the only information she has received on the closing of the Memorial Hospital Birthing Center has been from those advocating against the closing. Official communication from Care New England has been scant.

Central Falls Mayor James Diossa said he is very concerned about the interruption of services at the birthing center. But he stopped short of calling on Care New England to change their plan. He simply wishes to be involved as a community partner to make the transition as safe as possible for the residents of Central Falls and Pawtucket. This is similar to the position staked out by Governor Gina Raimondo, who has announced no plan to intervene in the closing but who says she understands the pain being caused “as a mother.”

A doula testified that despite Care New England’s promise that all providers would be credentialed at Women & Infants or Kent, there is no process in place for her to be credentialed. In fact, Women & Infants requires an OB/GYN be present during the process. Since Memorial functions as a community service provider, there is no way most people who use Memorial Birthing Center can afford to have two providers present during the birth of their child.

This has the effect of medicalizing birth, something many women who wish to deliver their children object to.

“If Memorial closes,” said a mother planning to deliver in June, “my choices will be to have a home birth, which I do not want, or go to Cambridge. There is no other place offering the options I want.”

The Good Samaritan Act was passed in the RI Senate last week on the second legislative day of the season and the enthusiastic support the Act has received from Governor Gina Raimondo and Speaker Nicholas Mattiello gave advocates hope that the bill might be on the fast track. Those hopes were dashed last night when the vice chair of the House Judiciary Committee, Representative Doreen M. Costa (R District 31 Exeter, North Kingstown) motioned to hold the bill for further study.

Larry Berman, communications director for the Office of the Speaker, explained that, “It is customary to hold almost all bills of substance after the first hearing.  The exceptions are for minor bills such as marriages.  This enables the committee members and staff to review the testimony and many times there are changes made after listening to the testimony.”

The bill exempts “from liability any person who administers an opioid antagonist to another person to prevent a drug overdose. It would further provide immunity from certain drug charges and for related violations of probation and/or parole for those persons who in good faith, seek medical assistance for a person experiencing a drug overdose.”

The bill under consideration in the House is identical to the one that passed in the Senate and it seemed all the members of the House Judiciary Committee were on board with the bill, or at least anxious to be seen sitting in support of it. I have never attended a committee meeting where every member was present when role was called. Even Committee Chair Cale P. Keable (D District 47 Burrillville, Glocester) noted that having no absentees at a committee meeting “hasn’t happened in a long time.”

“Overdoses represent a public health crisis,” said Dr. Nicole Alexander-Scott, director of the Rhode Island Department of Health, in her testimony before the committee, “that is as urgent as any crisis we have ever confronted in Rhode Island in the past.” Both Director Alexander-Scott and Maria Montanaro, director of the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals presented evidence that the law saves lives.

Jonathan Goyer, who is in recovery and works as an advocate combating drug addiction and overdose told the committee, “No pressure, but as I’m sitting in the back of the room, there’s a good chance that as we all sat in here, that we just lost another life… and I don’t think we need to wait until next week, I think it needs to pass today.”

But the bill did not pass, and will not pass this week.

Larry Berman told me the Good Samaritan Act, “is tentatively scheduled to be posted for a vote at the next Judiciary Committee meeting, Tuesday, January 19, and then it could be brought to the floor for a potential vote by the full House on Thursday, January 21.”

No pressure, House of Representatives, but people are dying.

You can watch all the testimony in the video below.

And you can watch Jonathan Goyer explain how Narcan helps save lives here:

A lesson in the use of Narcan

Dr. Nicole Alexander-Scott, director of the Rhode Island Department of Health, alongside Providence Mayor Jorge Elorza and Governor Gina Raimondo signed the Paris Declaration in a State House ceremony Monday.

In signing the declaration, the three leaders committed to putting Providence and Rhode Island “on the Fast-Track to ending the AIDS epidemic through a set of commitments. Those commitments include achieving the UNAIDS 90–90–90 targets, which will result in 90 percent of people living with HIV knowing their HIV status, 90 percent of people who know their HIV-positive status on antiretroviral treatment and 90 percent of people on treatment with suppressed viral loads, keeping them healthy and reducing the risk of HIV transmission.

“Rhode Island and the Providence partnership that we’re doing together, represents the first city/state group to join this world wide 90-90-90 campaign.” said Dr. Alexander-Scott in announcing the new effort.

The announcement and signing ceremony came as part of the Rhode Island HIV Prevention Coalition‘s event held ahead of World AIDS Day 2015, which is today. The event was hosted by Kira Manser, the coalition co-chair.

Speaking at the event was Dr. Philip Chan, who works with AIDS patients at Miriam Hospital. Chan said that to curb the spread of HIV we must concentrate on a few areas. First, we must focus on access to care, especially among gay and bisexual and other men who have sex with men. Second, we must “address other STDs like syphilis, which has increased exponentially across the country. Third, we need to perform routine, opt-out HIV testing, to make sure that everyone gets tested at least once in their life. Fourth, we need to get people who are HIV positive on PrEP and lastly we need to need to work together, government and health officials, to end the epidemic.

Richie DeFilippo, the reigning Mr. Gay Rhode Island, explained the importance of PrEP, pre-exposure prophylactic. “PrEP is a preventative measure of HIV negative individuals to take daily to prevent them from contracting the virus.”  It’s a pill taken once a day, but it is very expensive without insurance. DeFilippo aspoke of some of the social and economic barriers that prevent the effective use of PrEP.

Stephen Hourahan, executive director of AIDS Project RI, talked about the stigma still attached to the disease. Hourahan talked about the misunderstanding and stigma attached to the Charlie Sheen announcement. Stigma prevents many from getting tested for HIV, and increases transmission as a result.

The most energetic talk was given by Paul Fitzgerald of AIDS Care Ocean State. “Prevention without advocacy is no justice,” said Fitzgerald, before coming out from behind his podium and leading the audience in activist style chants. “We are not silent! We are not silent!” he shouted to applause. “We have activism to reach! We have people to change! We have policy to make! We have initiatives that must come about, to fruition. And it starts with us. It goes beyond these doors. Every place that we are we should be fighting about AIDS. We should be fighting about those people who cannot access services because they are not there, because they are not paid for, because there’s a political issue.”

Dr. Nicole Alexander-Scott, director of the Rhode Island Department of Health (RIDOH), responded to the Federal Energy Regulatory Commission’s (FERC) request for comments on National Grid’s plans to build a new liquefaction plant at Field’s Point on the south side of Providence.

The project has been the target of sharp criticism by environmental and social justice groups as an example of environmental racism, and much in Dr. Alexander-Scott’s assessment backs up such an assessment.

• FERC listens as no one speaks in favor of National Grids’ LNG facility
• Environmental racism and the Fields Point LNG Plant
• Southside PVD activists speak out against Fields Point LNG Plant

Though the director does not outright oppose the project, she does recommend that “FERC conduct a robust review of the project that fully incorporates public health perspectives and reviews potential public health concerns” and that RIDOH, “be deemed a cooperating agency, with all the rights and opportunities to participate in FERC’s review of this project preserved thereby.”

“Given the set of potential risk scenarios,” says Dr. Alexander-Scott in her final paragraph, “RIDOH requests that FERC consider requiring a Risk Management Plan for both the proposed liquefaction facility as well as the existing LNG storage facility, which does not currently have a Risk Management Plan.” [Emphasis mine]

“As Director,” says Dr. Alexander-Scott, “my strategic priorities for RIDOH are to address the social and environmental determinants of health, to eliminate health disparities in Rhode Island by promoting health equity, and to ensure access to quality services, especially for vulnerable populations.”

In her letter, Dr. Alexander-Scott outlines quite a few hazards and “risk scenarios” relative to the project.

Examining the proposal from a geographic standpoint, Dr. Alexander-Scott notes that the facility is planned within “an industrial area with a concentration of facilities listed in the EPA’s Toxic Release Inventory (TRI), facilities requiring Risk Management Plans (RMP), and Treatment, Storage, and Disposal Facilities (TSDF) that handle hazardous materials.”

Perhaps more critical “is the concentration of healthcare facilities and critical health system infrastructure within close proximity to the proposed project. Rhode Island’s only Level 1 Trauma Center is located in the Rhode Island Hospital complex, which includes Hasbro Children’s Hospital and is adjacent to Women and Infants Hospital. There are many additional primary care, specialty care, pediatric healthcare, and Federally Qualified Health Centers within this area of interest at varying degrees of proximity to the site location of the proposed facility. Providence Community Health Center’s administrative building and Chafee Health Center are within the half mile radius parcel map…”

Having this much emergency and non-emergency medical care infrastructure in one area, and an area so close to the proposed liquefaction facility requires “that careful attention be paid to any potential impacts to this critical healthcare infrastructure, including both for the cumulative impacts of construction and normal operation of the facility, and for any potential increased risk for accidents or emergency situations,” says the Director.

She sums up some of the potential accidents or emergency situations:

Although the possibility of an emergency or disaster may be low, the combination of multiple hazardous facilities, healthcare infrastructure, and vulnerable communities requires extra care and attention. Potential hazards may include leaks, fires, floods, earthquakes, hurricanes, storm surge, equipment malfunction, accident, terrorism, and the added risk of secondary offsite incidents including chemical incidents or explosions from co-located facilities requiring chemical risk management plans. RIDOH is concerned about the health impacts that would results from a worst-case scenario involving secondary impacts, which might involve amplified chemical reactions with substances such as chlorine, ammonium, and heat from flammable materials stored in co-located facilities. The close proximity to the I-95 highway corridor, and Rhode Island’s level 1 trauma center present an additional risk to the critical infrastructure needed for responding to any potential disaster situation. With a medically-vulnerable population and a relatively high percentage of people who are linguistically-isolated in the adjacent community, considerations around communications in disaster preparedness and response should also be taken into consideration as part of the environmental assessment and/or a broader emergency/risk management review.”

Though she doesn’t use the term “environmental racism,” Dr. Alexander-Scott provides numbers making it impossible not to draw such a conclusion.

“Socioeconomically,” says Dr. Alexander-Scott, “the one mile buffer around the proposed facility is 75 percent minority population…, 56 percent low-income…, 17 percent linguistically isolated… and 31 percent have less than high school education.” (86th percentile for state). The combined socioeconomics for the neighborhoods of Upper and Lower South Providence and Washington Park are 82 percent minority population…, 64 percent low-income…, 24 percent linguistically isolated… and 33 percent have less than high school education.” She notes that “these socioeconomic statistics are of important public health interest as significant social determinants of health.”

“RIDOH,” says the director, “has ample data on poor health outcomes, elevated health risks, and racial and ethnic health disparities within the City of Providence and in particular within the neighborhoods of Upper and Lower South Providence and Washington Park, which are in closest proximity to the proposed project. RIDOH’s 2014 Asthma Claims Data Report used health insurance claims data to produce detailed hot spot maps for asthma prevalence, emergency department visits, and hospitalizations, which all show asthma hot spots and elevated asthma risk in this focus area, at some of the highest levels in the state. Providence has the highest asthma-related pediatric hospitalization rates in the state, and asthma is elevated in low-income individuals and Black/African American and Hispanic/Latino communities.”

It seems that the efforts of National Grid, in building this facility, stand in direct opposition to the Department of Health’s mission to improve health outcomes in at risk neighborhoods.

“RIDOH is funding 11 Rhode Island non-profit organizations and local governments at various levels to support innovative approaches to improving health outcomes,” says the director. “The Department of Health and these grantees have created Health Equity Zones – defined geographic areas where high rates of obesity, illness, injury, chronic disease or other adverse health outcomes will be improved by coordinated strategies to reduce and manage chronic diseases, promote healthy lifestyles, improve birth outcomes, assure healthy child development, and create environments where healthy choices are easier to make. It is the vision of the Department of Health, that communities are engaged in democracy and committed to equality and diversity. Through these Health Equity Zones we will create and maintain sustainable and healthy places for all Rhode Islanders to live, work, and learn. It is imperative that alterations to the community’s landscape by other sectors does not impede the progress being achieved by such initiatives.”

Ironically, the build up of LNG infrastructure in Rhode Island will contribute to climate disaster, yet the location of the proposed liquefaction facility is at risk from sea level rise caused by climate change. Dr. Alexander-Scott doesn’t explicitly touch on this irony, but says, “Other environmental factors that are worth considering in the scope of the review include coastal flooding, both current and future levels given projected sea level rise, as well as potential storm surge and wind impacts. The effects of climate change on this project and therefore long-term population health is a necessary, additional component of the current environmental review.”

You can read the full letter from Dr. Alexander-Scott here.

Do yourself a favor and watch this video.

This year’s theme for AIDS Walk RI was “Keeping Hope Alive” and despite the reality of nearly 100 new cases of HIV being diagnosed in our state every year, there is hope that one day HIV will be eradicated. Dr. Philip Chan, MD, from the Miriam Hospital’s Immunology Center said that giving a positive HIV diagnosis to a patient is the worst part of his job. He talked about the virtues of a new drug, PrEP, a pre-exposure prophylaxis that prevents the transmission of HIV.

Dr. Nicole Alexander-Scott, MD, MPH spoke of three foci at the RI Department of Health, where she is the director. “We want to continue to enhance partner services, making sure that people know how to stop their partners from getting infected by raising awareness. getting tested and letting them know about PEP ad PREP. We also want to highlight our ‘men who have sex with men communities’ that are disproportionately affected by HIV and syphilis and some of the other STDs… our third priority is also highlighting our youth and our communities of color, where there are higher rates of STDs as well as HIV.”

Members of Hope Harris‘ family gathered on stage to present the “Hope Harris Award.” Harris was a member of the AIDS Project RI board for the last part of her life.  She was also a longtime receptionist for the late Senator John Chafee and also served in Senator Lincoln Chafee‘s office. She was known as a kind and deeply religious person who recognized the value of person, without regard to race, orientation or gender identity.

The award was presented to the amazing Paul Fitzgerald, president and CEO of AIDS Care Ocean State. He was the founding executive director of “Family AIDS Center for Treatment and Support” (FACTS) for children with HIV. FACTS was one of the first 13 pediatric AIDS demonstration projects in 1988. FACTS grew into a full-service AIDS organization, and merged with “Sunrise House” to become AIDS Care Ocean State.

Entertainment was provided by the Providence Gay Men’s Chorus, and other speakers included by Mayor Jorge Elorza, RI State Treasurer Seth Magaziner and US Representative David Cicilline. Cicilline lead the event in a moment of silence for Guy Abelson, well-known local philanthropist, who passed away recently and was deeply involved in the fight against HIV/AIDS.

AIDS Walk RI  2015 was conducted by  AIDS Project Rhode Island, a division of Family Service of Rhode Island, and AIDS Care Ocean State.

The federal government is watching with “keen interest,” says Amy Nunn. She and Gemma Gorham are program directors of this new way to bring good food to poor people.

Senator Jack Reed, who secured the initial $100,000 investment in the program, said it is based on very sophisticated academic research showing that bringing fresh produce into communities increases healthy eating.

Reed too hopes Food on the Move, “will be a model for programs across the country.”

And Rhode Island is the perfect testing ground. “Fifteen percent of Rhode islanders experience food insecurity,” said Nunn. “The highest rate in New England.”

“How long someone lives should not depend on the zip code they come from” said Nicole Alexander-Scott, executive director of Rhode Island Department of Health. She said 85 percent of those making under $50,000 a year do not eat the recommended servings of fruits and vegetables per day. This program is one way “we are going to [impact] social and environmental determinants of health.”

Towards the end of the presentation Dr. Nunn pointed out that many people only get a small amount of money in their SNAP benefits, and that Food on the Move might not reach them until the second or third week of the month. She hopes that many people will be able to hold onto some of their SNAP money until they can reach a Food on the Move location and double the impact of the benefits.

Neighborhood Health Stations, developed by the RIDOH under the leadership of Dr. Michael Fine, is that plan.

Neighborhood Health Stations are “basically community hospitals without walls,” says Dr. Fine in conversation with Richard Asinof of ConvergenceRI. Dr. Fine planned to build one station for every 12,000 Rhode Islanders, between 75 and 100 such stations in all. The first one was to be built in Central Falls.

Neighborhood Health Stations would locate pediatricians, internists, family physicians, dentists, nurse practitioners, licensed and registered nurses, advanced practice nurses, physician assistants, mental health and social workers, physical therapists and occupational therapists, pharmacists, emergency medical technicians and paramedics, registered dietitians, home health workers, promotoras, health coaches, navigators and other healthcare workers under one roof, in a facility that would also offer programs such as “nutrition courses, Zumba classes, or group counseling sessions.”

According to Dr. Fine, if we implemented this plan, we could shrink the hospital system in our state. “When you build out the full delivery system of one neighborhood health station for every community of 12,000 people,” says Dr. Fine, “it is very likely that we can reduce the total number of hospital beds by 40 to 45 percent. That means dropping [the number of hospital beds in Rhode Island] by about 900 beds.”

Governor Gina Raimondo’s budget proposes cutting $88 million from Medicaid’s $2.7 billion in spending, a 3 to 6 percent reduction. Since “Reinventing Medicaid” is being presented as an answer to an imminent disaster, improving the quality of health care or paying adequate wages to health care workers is taking a back seat to saving money.

That’s a shame, because a fully realized health care system of the kind imagined by Dr. Fine would attract business and investment to Rhode Island, while draconian cuts in services to our most vulnerable will have the opposite effect. If we could build Neighborhood Health Stations and make them work, “then health care spending becomes a business magnet. People come and locate businesses here, just because of our health care,” says Dr. Fine.

It’s a great idea, but not one that’s likely to happen. Since Dr. Fine’s departure, Neighborhood Health Stations seem in jeopardy. The new head of the RIDOH, Dr. Nicole Alexander-Scott, has yet to comment on the plan. But a more immediate reason for the plan’s quiet demise can be intuited.

“…if I have had one failure [while serving as director of the R.I. Department of Health],” said Dr. Fine, “if I want to be self-critical, [it’s] that I haven’t made it clear enough to people that we don’t have a problem with insurance, the problem is insurance. That thinking, that insurance, as a financial mechanism, can impact health, is a fundamental, categorical mistake.”

Dr. Fine saw his Neighborhood Health Stations as saving money by cutting out for profit insurance companies, and actually reducing the size of hospitals. The Reinventing Medicaid working group is comprised of a diverse group of people, but for-profit insurers and health-care providers have a prominent seat at the table. Timothy Babineau, MD, president and CEO of Lifespan, Peter Andruszkiewicz, president and CEO of Blue Cross Blue Shield of RI and Helena Foulkes, executive vice president of CVS Health and president of CVS/pharmacy will ensure that their corporate, for-profit interests are protected.

To Dr. Fine, Neighborhood Health Stations are the future of health care. “…if we don’t do it, all we’re doing is perpetuating a costly infrastructure that doesn’t work.” An infrastructure that will remain immeasurably profitable to those sitting at the top of certain health care empires.

The “artwork was created by Roger Williams University students, in consultation with students at Rhode Island College School of Nursing, to illustrate how Neighborhood Health Stations could enhance well-being in Rhode Island communities.”