UNITED STATES HOUSE OF REPRESENTATIVES HUMAN RESOURCES AND INTERGOVERNMENTAL RELATIONS SUBCOMMITTEE OF THE COMMITTEE ON GOVERNMENT OPERATIONS TESTIMONY OF: Lawrence S. Brown, Jr., MD, MPH Senior Vice President for Research and Medical Affairs Brooklyn, New York and Attending Physician and Clinical Instructor Department of Medicine, Harlem Hospital Center and College of Physicians and Surgeons, Columbia University HIV Related Health Care......page 2 Mr. Chairman, please accept my gratitude for the opportunity to share some experiences and thoughts with you and members of the Human Resources and Intergovernmental Relations Subcommittee. My experiences come from two major perspectives. One perspective is as an internist based at Harlem Hospital Center in New York City. The other is as the physician at the Addiction Research and Treatment Corporation (ARTC) responsible for primary medical care delivery to over 2,000 patients addicted to opiates in attendance at six ambulatory drug treatment clinics in Brooklyn and Manhattan of New York City. Both of these perspectives are intricately related to the problems of health care delivery for the poor, most certainly of New York City, if not for every inner city location in this country. Since the identification of the first case of the acquired immunodeficiency virus syndrome (AIDS), we have witnessed dramatic challenges to the integrity and capacity of the American health care delivery system. The human immunodeficiency virus (HIV) epidemic has further exposed and heightened weaknesses already prevalent in American health care today. These weaknesses included, but are not limited to, the availability of health manpower, appropriate mechanisms to finance health care, and how we transfer the technology that represents the miracles of medicine such that all citizens of this country truly have the opportunity to benefit from these advances. HIV Related Health Care......page 3 The impact of the HIV epidemic can also be examined by evaluating its purely medical consequences and its even more dramatic socioeconomic effects. As of July, 1989, the Centers for Disease Control has reported over 100,000 cases of AIDS. Most estimates suggest that there are probably ten times more Americans infected with the HIV virus. Furthermore, the dimensions of the HIV epidemic also extend to the rise in the number cases of tuberculosis and sexually transmitted diseases. This is especially so in New York City and other inner cities. As a physician, who just completed a tour on one the medical wards at Harlem Hospital, I can give personal testimony to the fact that we are understaffed and lack the appropriate resources to meet the ravages of HIV disease. In the first fifteen days of July, the medical ward, for which I was responsible, averaged at least one new admission associated with HIV infection every second day. This was only one of six medical wards. On many occasions, if not most, we are forced to treat patients presumptively because we can not afford to wait to perform (or if performed, the results of) diagnostic tests. In this atmosphere, we are deeply perplexed at federal policies that transfer physicians, whose medical educations were finance under the National Health Service Corps, from Harlem Hospital with its shortages of physicians to other areas of this country. This is not to say that the Indian Health Service or other areas do not need Harlem Hospital trained physicians. Rather, this is to bring attention to and understand federal policies that will transfer physicians from one area, where physicians are in short supply, to another area where physicians are also desperately needed. anced HIV Related Health Care......page 4 are The medical consequences of the HIV epidemic, mentioned above, is particularly devastating for those portions of the American public already over-represented by excess morbidity and mortality from cancer, cardio- and cerebrovascular diseases, liver diseases, diabetes, homicide, and chemical dependency. As Dr. William Hopkins, who retired after an illustrious career with the Centers for Disease Control, so eloquently stated, for American ethnic/racial minorities, than among the general American public. Evidence points to the prevalence of intravenous drug abuse and other HIV-exposing drug Despite these clear indicators of the devastating toll of the HIV epidemic on ethnic/racial minorities, this portion of the American public continue to be underserved. The advances of AZT and aerosalized pentamidine and the recent pronouncements by the Centers of Disease Control (as to what should be the standard of medical care for HIV infected persons) do not extend to these populations. Wait ing time to be seen in government-run and even some private clinics for these services are measured in terms of months. In my role with the Addiction Research and Treatment Corporation (ARTC), this issue is critically apparent to me. Evidence of HIV seroprevalence among ARTC patients (like other intravenous drug users in New York City) ranges from 50 to 60 percent. Yet, funding of ARTC clinics (like AIDS represents the seventh offer of the Apocalypse. Horseman HIV Related Health Care......page 5 other drug treatment clinics) does not allow for the provision of primary medical care for HIV infected patients. Current staffing for these facilities is only partly responsible for these sad set of circumstances. Indeed, the problems, as mentioned earlier, existed for some time prior to the HIV epidemic. For the moment, let's explore in greater depth some of the obstacles to the delivery of health and human services in the HIV era. The decreasing number of physicians practing in primary medical care specialties most certainly has had a dramatic effect. While this trend began before the 1980s, it is most acutely experienced by municipal hospitals and health care facilities located in the inner cities. These are the same institutions which disproportionately provide HIV-related services for the poor, ethnic/racial minorities, and the drug-addicted. For New York City, this has meant a heavy dependence on foreign medical graduates, as many graduates of American medical schools choose to practice in non-primary care specialties, which tend to be better compensated. Another closely related problem is the under-representation of Black, Hispanic and Native Americans in the health care provider force. This is manifested not only on the hospital wards across this country, but also on the faculties of the institutions that train health care personnel. While foreign medical graduates have been the key to providing support to the shrinking health manpower force serving the poor, an inability to understand a patient's cultural |