Author Archive: Tim Broas

Is a New Norm Emerging for Doctors in the United States?

The deputy medical director for Haiti at Partners in Health, Dr. Michelle Morse splits her time between research and treating patients in Boston and training physicians in Haiti. While some may consider her dedication to training foreign doctors exceptional, she argues that this level of engagement with the profession outside of the United States should become the norm. Dr. Morse completed a residency in global health equity two years ago and has since served as an attending physician at Brigham and Women’s Hospital in Boston. In this position, she mentors young residents and encourages them to consider work abroad as an important element of their careers.

As a director at Partners in Health, Dr. Morse strives to improve the overall quality of medical care in Haiti by developing new, rigorous residency programs for doctors in the country. In Haiti, she works at University Hospital in Mirebalais, a teaching hospital that the organization built in cooperation with the Haitian Ministry of Health following the devastating earthquake of 2010.

Dr. Morse’s push for greater international engagement represents the next evolutionary step in a shift in the medical profession that began with Dr. Paul Farmer, who co-founded Partners in Health. While in medical school, Dr. Farmer traveled frequently between Boston and Haiti to undertake work that few of his classmates understood or wanted to pursue. Today, the fact that a hospital like Brigham and Women’s offers a global health equity residency demonstrates changing attitudes, and Dr. Morse’s and Dr. Farmer’s careers provide guiding examples for U.S. physicians interested in health care in the developing world.

Health care inequalities remain a serious problem both domestically and abroad. Lack of access to quality care can result in unnecessary death. Furthermore, health care problems quickly compound in poor countries when a lack of public infrastructure and basic sanitation prevent even simple interventions. If more American doctors dedicated a small amount of time to work abroad, they could save millions of lives around the world.

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The Pan-Massachusetts Challenge and the Dana-Farber Cancer Institute

Founded in 1980, the Pan-Massachusetts Challenge (PMC) now generates more than $35 million each year in support of the Dana-Farber Cancer Institute, a leading cancer treatment center in Boston. The majority of funds raised by PMC go to Dana-Farber as unrestricted gifts that fund some of the institute’s most important treatment and research efforts.

One of the major research projects at Dana-Farber, Profile, looks at gene mutations possibly linked to cancer. At present, Profile looks for about 500 different possible mutations in 41 genes. The Profile project strives to develop therapies that target genetic causes of cancer. In addition to Profile, PMC funding supports the Longwood Research Center, which will help 30 independent investigators undertake their own research while initiating collaborative efforts when the facility opens in late 2014. Dana-Farber has used the center to attract the most promising researchers to Boston as part of its staff.

To fuel new discoveries, Dana-Farber utilizes a significant amount of PMC funding to attract future oncology leaders and provide them with a high level of training. The institute is an affiliate of Harvard and teams young doctors with senior faculty able to guide their research. To that end, PMC funding also provides early stage support for researchers with especially innovative ideas. In addition, Dana-Farber must often grant bridge funding between grants so that researchers can continue their work.

Outside of research, Dana-Farber remains committed to improving community health. Recently, the institute used PMC funding to complete a health needs assessment for underserved parts of the greater Boston area. Another initiative will supplement the Mammography Van, which already screens more than 4,000 women annually, to raise awareness of breast cancer in surrounding neighborhoods.

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A Global Approach to Cancer Treatment and Healthcare Equality

Cancer affects individuals around the world, but only the wealthy countries offer real treatment options for the disease. In low-income countries, 90 percent of children with leukemia will die due to the disease. In the industrialized world, 90 percent will live. Paul Farmer, the co-founder of Partners In Health, addressed this issue at a recent symposium held at the Dana-Farber Cancer Institute in Boston. While the symposium dealt specifically with global oncology, Farmer situated the cancer issue within a larger struggle for healthcare equality in his closing talk. Farmer looked at the dropping costs of treatment modalities and vaccines due to government investments and called for societal intervention.

At the symposium, Rifat Atun, a Harvard professor, echoed Farmer’s call to action by demonstrating the efficacy of worldwide healthcare initiatives in the case of HIV. Formerly a deadly disease, HIV has become a manageable condition for individuals around the world due to a concerted effort that has caused significant drops in infection rates. A similar push for cancer could see similar results.

Other professionals have raised concerns about a global oncology initiative because cancer simply looks different in other countries. Due to the prevalence of HIV in parts of Africa, doctors have encountered alarming rates of non-Hodgkin’s lymphoma, Kaposi’s sarcoma, and other cancers that are relatively rare in richer nations. While no one knows why HIV contributed to a rise in these types of cancers, a clear link exists. This link makes treating cancer in Africa much different than treating it in other locations.

The deputy director of the National Cancer Institute Center for Global Health calls for a different strategy to deal with cancer. Rather than importing newest technologies and medications, he asks for richer countries to fund partnerships with poorer countries to target efforts towards the exact needs of a specific region.

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Partners in Health – Caring for AIDS Patients in the Dominican Republic

While Partners in Health (PIH) has expanded its mission to bring medical assistance to vulnerable populations around the world since its inception in 1987, it remains dedicated to the people it first began assisting: the underserved migrant communities of Haiti. One of its current programs is a public health initiative in the Dominican Republic province of Elias Piña, which borders Haiti and is home to numerous migrant workers, 45 percent of whom are from Haiti. Through PIH’s Dominican partner, Socios En Salud (SES), and aid from the U.S. Agency for International Development, PIH works to improve HIV care in these communities, where the disease is still prevalent.

The people served by SES, which is directed by Dr. Alexandre Widner, face numerous challenges in obtaining health care. Haitian migrants in the Dominican Republic are largely undocumented and unable to overcome language barriers and discrimination, a combination of factors that lead many into sex work, which in turn leaves them vulnerable to contracting HIV. Since 2009, Dr. Widner and his colleagues have sought to work with the Dominican Ministry of Health in order to stem the tide of HIV infection by providing testing, medical care, and training for health care workers.
Those suffering from HIV or tuberculosis can obtain food through SES, and support from community health care workers known as “acompañantes,” who have been trained to offer psychological help, assist them in seeking aid from support organizations, and help them overcome the discrimination and stigma they face because of their marginalized status. Meanwhile, SES has also launched programs to train hospital staff in preventing the spread of HIV between mother and child, and has obtained a mobile testing unit that measures immune system functioning in those with HIV, which allows health care workers to identify patients who should begin antiretroviral drug treatment.
In addition to its work in the Dominican Republic, PIH operates 12 clinics and hospitals throughout Haiti through its sister organization, Zanmi Lasante, and is also active in Mexico, Russia, Rwanda, Lesotho, and other countries.

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Honest Services Fraud – Past and Future

What attorneys and jurists refer to as “honest services fraud” has a complicated legal history that can be considered the foundation of white-collar crime as we know it.

Its origins can be traced to the mail fraud statute of 1872, a piece of legislation created at the behest of the Postmaster General, who sought to eliminate fraudulent activities carried out via the mail system. The statute applies to any plan to defraud via “false or fraudulent pretenses, representations, or promises” and was initially rather clear-cut. However, as the damages from such schemes became more abstract and less tangible, new legal definitions were needed to address the changing nature of fraud. The first case that established an expanded definition of the statute was the Supreme Court’s opinion in Shushan v. United States, in which the court upheld a decision against a public official who had accepted bribes from businessmen in exchange for encouraging city government actions and policies that benefited their businesses. In this case, the court found that the public had been deprived of their right to honest government. However, in McNally v. United States, a case involving kickbacks and patronage that benefited a private citizen, the Supreme Court found that the scheme did not violate the mail fraud statute. In response, Congress added language to an unrelated piece of legislation, stating that fraudulent activity covered by the law would include any “scheme of artifice to deprive another of the intangible right of honest services.”

The new legislation, which was likely crafted in response to the court’s decision in McNally, has received frequent criticism for the vagueness of “honest services,” a term previously untested in the American justice system. In the years since its passage, courts have generally held that this applies to activities like bribing a public official in exchange for some non-monetary action, or keeping a particular conflict of interest hidden in order to gain advantage. The Supreme Court only addressed the vagaries of the law in its 2010 decision in Skilling v. United States, a case concerning the activities of the former Enron executive. The result was a deliberate limitation of the honest services provision, which eliminated charges involving “undisclosed self-dealing by a public official or private employees,” leaving only kickbacks or bribery as the necessary components of honest services fraud.

A more recent case in the D.C. Circuit Court of Appeals, United States v. Ring, has modified this somewhat, however. Lobbyist Kevin Ring was originally convicted in 2010 of honest services fraud for providing various gifts to public officials. In the original trial, the district court judge maintained that the honest services statute could still be violated even if the government did not present evidence of an explicit “quid pro quo” arrangement. The D.C. Circuit Court agreed, finding that lobbyists can be guilty of honest services fraud when they offer something of value with the intention to influence an official act, even if no transaction actually takes place. Given that the Supreme Court denied Ring’s petition for certiorari in October, the D.C. Circuit’s ruling adds new complexities to the law, especially as they pertain to lobbyists.

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