Hilda Ortiz-Morales, ACNP, MSN, PhD, has a history with HIV prevention and treatment—a history that nearly traces back to the origin of the HIV/AIDS epidemic in the United States. With degrees from Lehman College and the College of New Rochelle, Ortiz-Morales has spent 34 years as a nurse practitioner, many of those years at Montefiore Medical Center, one of the busiest hospitals in the Bronx, New York.
Like many registered nurses, Ortiz-Morales had wanted to work in the field since childhood. Her mother was chronically ill, requiring visiting nurses. “The care and caring they provided my mother left a lasting impression on me,” she says. “I knew then that I was going to become a RN when I grew up.”
With immigrants from the Dominican Republic, Jamaica, Ghana, Bangladesh, and many other nations, the Bronx is an extraordinary example of America’s increasing diversity. With a population of 53% Latinos, 30% African Americans, 11% whites, and 3% Asians, the Bronx differs from the average American county in several ways. Almost one-third of its residents were born outside the United States, half of its children are born to foreign-born mothers, and the borough stands as the first borough in New York City to have the majority be people of color.
While the Bronx benefits from its diverse population, historic problems of poverty and poor health continue to plague its residents. The Bronx is one of only five American counties to have more than 30% single-parent households. In New York City, neighborhoods as varied as mostly black Harlem, and mostly white Chelsea, are familiar with the devastation brought by the HIV/AIDS pandemic.
The Bronx is no exception. African Americans represent 12% of the U.S. population and are the second-biggest minority in the Bronx. Yet according to 2010 statistics from the Centers for Disease Control and Prevention (CDC), blacks accounted for about 41% of people living with HIV. Things are especially dire for young black men who have sex with other men (MSM). In 2010, 4,800 new HIV infections occurred in this group. Young black MSM represented 45% of black MSM who newly became infected and 55% among all young MSM newly infected.
Nurses, working at places as varied as hospitals, private clinics, and community centers, are using their scientific knowledge, as well as their helping, healing “soft” knowledge, to educate vulnerable populations about HIV and STDs. Cultural competency is key to reaching people who feel marginalized by mainstream medicine.
“My experiences include infectious diseases, HIV/AIDS, critical care, utilization management/quality assurance, medicine, and surgery,” Ortiz-Morales continues. She currently works at the Montefiore Infectious Diseases (ID) Clinic, where she serves as coordinator and primary clinician of the HIV/Hepatitis C virus (HCV) specialty service. While HCV doesn’t get the constant attention of HIV/AIDS, it’s a serious sexually transmitted infection that many people with HIV have concurrently. The HIV/HCV specialty program evaluates and treats all co-infected and mono-infected patients treated in the ID clinic.
Ortiz-Morales works to educate patients—and the community in general—about HIV and STD misconceptions, such as the “lack of understanding about the acquisition of STDs among adolescents and adults in the Bronx.” Young people bare the brunt of sexually transmitted infections, HIV, and unintended pregnancies. Case in point: Young people aged 15 to 24 years acquired half of all new STDs in 2013, according to the CDC’s Sexually Transmitted Diseases Surveillance statistics. The Bronx, in particular, has several zip codes with some of New York City’s highest rates of STDs and HIV.
Recognizing the importance of HIV/STD testing as prevention and treatment strategy, Montefiore’s Emergency Department launched an initiative to offer HIV testing to all patients coming in for treatment.
“This mandatory offer is the latest example of Montefiore’s commitment to drive AIDS awareness and deliver seamless care to patients with HIV/AIDS,” says Ortiz-Morales. Montefiore also offers the Adolescent AIDS Program (AAP). AAP provides comprehensive care to HIV-positive youth, as well as risk reduction and HIV counseling and testing services for such high-risk groups as young men who have sex with men, intravenous drug users, and young people involved in sex work.
The increasing attention to hepatitis C influences Montefiore’s newest initiative, Project INSPIRE NYC. According to Ortiz-Morales, Project INSPIRE NYC “is an integrated, innovative, and evidence-based comprehensive service model that … demonstrates a model of service delivery and payment that can reduce morbidity and death from chronic hepatitis C … [and] reduce costs associated with its complications.”
Of the estimated 146,500 New Yorkers with chronic hepatitis C, about half do not know that they are infected, according to the New York City Department of Health. Over the next three years, clinicians at Montefiore plan to use an integrated model of care for Medicare and Medicaid patients at risk for hepatitis C. Primary care clinicians work closely with care coordinators and specialists to increase access to effective hepatitis C care for patients. HCV care coordinators provide care coordination, navigation, health promotion, and medication adherence to each patient; they also work with a peer educator. The peer educator is a person formerly with hepatitis C, who shares his or her experiences and helps patients navigate through the process.
The Bronx represents both the best and worst developments in 21st-century America. The future of this borough’s young people, as well as people of all ages and backgrounds, is dependent on nurses comfortable with sexual intelligence, reaching people without judgment.
Behlor Santi is a freelance writer based in New York.
When welfare reform, also known as Temporary Assistance for Needy Families (TANF), became law in 1996, direct funding from the federal government turned into block grants each state spent at its discretion. All states had to follow federal regulations, such as lifetime benefit limits for each welfare recipient. Some states, however, placed heavy emphasis on a concept called “self-sufficiency,” getting welfare recipients into salaried and self-employed positions as quickly as possible. With this emphasis on self-sufficiency, certain types of higher learning became preferred over others.
According to Joron Planter-Moore, a representative with the Virginia Department of Social Services in Richmond, Virginia, education for TANF recipients includes studying in vocational programs for up to 12 months. Vocational programs, such as trade schools, community colleges, and four-year institutions, should prepare the student for employment. Simply put, people on TANF who want to study liberal arts at the University of Virginia would be out of luck.
“Working towards a degree in philosophy would not be considered vocational education,” explains Planter-Moore, “because it is not directly related to employment.”
Nia Gilmore, RN, of Louisville, Kentucky, currently works as a registered nurse at a local hospital. She also earned a Bachelor of Science in Nursing (BSN) from the University of Louisville. She heard her mother say a common refrain: Blacks, especially black women, had to work twice as hard to succeed in America. Her mother’s emphasis on high standards extended to getting high grades.
“In Kentucky,” says Gilmore, “an A is a 93. My mother would always say ‘do better.’” Medical tragedies in her family led Gilmore towards nursing. Her mother suffered from chronic illness through much of her childhood, and her nephew has sickle-cell anemia. During her numerous times at the hospital, Gilmore noticed the bedside manners of the nurses.
“The care they gave made a big difference,” she says. “I wanted to do the same when I became older.”
Ruth Aina, a current member of Family Scholar House, looks forward to December 2014, when she’ll receive her BSN. A busy single mom and a devout Christian, Aina says that she has always been drawn to caring for others.
“I’m thinking of specializing in pediatrics, neonatal,” she says. A typical day for Aina includes waking up at 6:30 a.m., preparing breakfast for herself and her child, dropping her child off at school, attending classes at the university, studying a lot, running back home to pick up the kid, cooking dinner, and then a little bit of solitude before sleep.
Lots of prayer is included. “I ask the Lord for strength,” says Aina.
Gilmore received public assistance to support herself and her daughter. She’s aware of the vicious stereotypes. “Some people think people on welfare are lazy,” she states. “That we have no plans for the future. That most of us are black.”
She took a while to sign up for TANF, having had internalized the stereotypes. Eventually, she realized that she and her child needed the help.
According to Stephanie Rowe, relationship coordinator and director of program support integration at Family Scholar House, breaking the cycle of poverty and dependency is about environment and support.
“Through our comprehensive programming,” she says, “which includes, but is not limited to: academic advising; supportive housing; family support services/case management; children’s programming; childcare; counseling; mentoring; tutoring; life skills building; financial education; family nutrition and wellness programming; peer support; assistance with basic needs; and community referrals, our participants are empowered to break the cycles of poverty, homelessness, and dependency—not only for themselves but also for their children—by earning a college degree, achieving career-track employment, and attaining self-sufficiency.”
Nursing students especially need the supportive environment Family Scholar House offers, according to Rowe. “Further, we assist with childcare, which is important for nursing students who have classes in addition to hours in the hospital for clinical experience. We connect participants with tutors, as necessary, and internship/networking opportunities through our strong network of health care supporters and board members in the field.”
Gilmore joined Family Scholar House as a high school senior. “My guidance counselor informed me about this program,” she says. “It was called ‘Project Women’ back then. Same program, but only 16 women.”
Since its beginning in 1995, Project Women has grown into the current Family Scholar House. The originally all-female student body now includes single fathers.
Gilmore praised the support system at Family Scholar House. “It’s people working for people,” she says.
Welfare remains a heated topic, with activists for and against government entitlements stating their opinions, loudly, on the nightly news. For Nia Gilmore and Ruth Aina, whether the government has a safety net or not isn’t about abstract theory in a book or slogans for taxpayers. It’s about feeding their children and eventually standing on hard ground, so they can contribute to the vital field of nursing.
As Nia Gilmore points out, single moms—in and out of the public-assistance system—should focus on why their nursing education matters. She knows why her degree matters.
“I didn’t want to become a statistic.”
Behlor Santi is a freelance writer based in New York City.
According to 2012 statistics from the Centers for Disease Control and Prevention, 1 in 88 American children have autism spectrum disorder (ASD). The National Institute of Mental Health defines ASD as “a group of developmental brain disorders,” with a “wide range of symptoms, skills, and levels of impairment, or disability.” Children living with ASD can show minor or severe impairment.
Ever since Bruno Bettelheim came out with pioneering Freudian theories concerning ASD, researchers have tried to uncover this ailment’s mysterious origins. In the 21st century, Bettelheim’s theories blaming maternal alienation are considered dated. Researchers now look to genetic, environmental, and behavioral factors.
In the May 2013 issue of JAMA Psychiatry, two researchers from the Harvard School of Public Health (HSPH) in Cambridge, Massachusetts—Andrea Roberts, PhD, and Marc Weisskopf, PhD—presented a new, intriguing theory. The HSPH researchers found that women who experienced physical, sexual, or emotional abuse as children had a higher chance of bearing children with ASD than women not abused as girls. The most severely abused women had three-and-a-half times the risk, and even women who endured more moderate abuse as children had a higher risk of bearing children with ASD—a 60% higher risk. The authors of the study had gathered data from more than 50,000 women in the Nurses’ Health Study II. The findings suggest that childhood trauma not only affects the victim but her offspring as well.
“Our study identifies a completely new risk factor for autism,” said Roberts in the school’s press release. She then called for further research to understand the connection between a woman’s experience with abuse and her child’s autism. Such research will be used to treat preventable risk factors.
Traditionally, the “face” of ASD has been white, middle-class children. Organizations like New York City-based Autism Speaks work with clinicians around the country to make care available to children and families of all backgrounds. Even with the numerous stories of minorities breaking through the “concrete ceiling” to middle-class success, a third of black American children remain in poverty—and poverty is one factor that leads to child abuse, according to a 2011 Washington University study on race and child-abuse statistics. As the HSPH study implies, child abuse is partly responsible for America’s high ASD rate.
Alycia Halladay, PhD, is senior director for clinical and environmental sciences at Autism Speaks. On the job for nearly nine years, she entered the field back when few services existed for any autistic child.
“The average age of diagnosis was eight,” says Halladay. “We thought it could only be diagnosed by age seven. Now, we know it is much lower.”
Halladay’s focus is on helping minority children become diagnosed as early as possible. Despite the changes in treatment in the last 10 years, minority children living with ASD still get diagnosed less often and later in life. “Seeing families receive help they deserve . . . is incredibly gratifying, but challenging,” says Halladay. “For every one person we help today, there are hundreds of thousands that need the same help.”
In Autism Speaks’ Early Access to Care Program, families receive scientific information and tools, health care providers are trained to refer families with a concern, and culturally competent material is created to reach underserved groups.
“We can’t expect people in the community to find us,” says Halladay, urging health care providers, including nurses, to reach out. “Please contact us, and we’ll work together to help your families get the help they deserve.”
Kathryn Smith, BSN, MN, DPH, works as a registered nurse and nurse care manager at the Boone Fetter Clinic at Children’s Hospital Los Angeles in California. What drew her to pediatric nursing? “I like working with children and their families,” says Smith. “Plus, the kids are so cute.”
For Smith, working with cute kids brings a bit of levity to a condition as perplexing as ASD. “Parents come to the Boone Fetter Clinic with concerns about their child’s behavior or development, and they are afraid,” she says. Smith and her colleagues take parents through a process where parents describe their concerns, and the clinicians at Boone Fetter provide a comprehensive, interdisciplinary assessment.
Smith hasn’t seen a direct link between child abuse and ASD, as theorized by the HSPH study. However, she talks about young patients coming from families with additional stressors, like poverty or drug abuse. She believes that nurses can help women of all backgrounds. They can help women optimize pregnancy health, take time from busy schedules to take care of their own health, prepare and eat healthy food, and exercise.
“[This] may be particularly important,” says Smith, “for those women experiencing other life stressors.”
Dorothea C. Lerman, PhD, currently directs the University of Houston-Clear Lake’s Center for Autism and Developmental Disabilities (CADD) in Texas. After volunteering and working at facilities with mentally disabled people, Lerman decided to make the field of psychology her life’s work.
Lerman teaches graduate and undergraduate students in practicum activities, conducts research, administers the behavior analysis graduate program, and directs CADD. Most of CADD’s services are offered at no cost, a godsend for Houston’s low-income families. The waiting list for the early-intervention program runs about two years.
While Lerman is not a clinician, the graduate students at CADD provide clinical services, all while learning on the job. With a grant from Autism Speaks, CADD has started a program for Spanish-speaking families. In the program, the families learn how to communicate with their autistic child, and they also receive English-enhancement classes.
“Making services more accessible to non-English-speaking families, minorities, and those with low-income is very important,” says Lerman.
Since the days of Bettelheim, academics have advanced research into autism, advocates continue to educate, and nurses show families ways to live with their child’s disability. As the HSPH study suggests, maybe the first step in reducing the autism pandemic is respecting our daughters before they become mothers.
Behlor Santi is a freelance writer based in New York City.
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