The answer changes after years of practice.
I remember during my interviews for medical school being asked the ageold question, “So, why do you want to be a doctor?” My response, of course, was to “help people” and “change the world.” Now I ask the same question and hear the same answers from today’s idealistic medical school applicants. For them, as for me many years ago, the ideals are sincere. But for many of us in medicine, they are difficult to maintain over the course of training and practice.
I’ve recently been reflecting on these conversations. Has my answer changed? Have I achieved what I set out to accomplish? Is it even possible to change the world? As I grow older, my answers become less clear.
During the end of my infectious diseases fellowship and the start of my work with HIV, I began to understand how hard it is to implement change. HIV intersects with many major social determinants of health: stigma, socioeconomic status, substance use, homelessness, mental illness, etc. People living with HIV who are on treatment and have an undetectable viral load have a near-normal life expectancy and can’t transmit the virus. However, treating HIV often involves addressing multiple social determinants of health. Some of these, like homelessness and poverty, are likely to take precedence over medical
care. People who don’t know where they are sleeping tonight or where their next meal is coming from may not have the capacity to care about taking their HIV medications or going to see their doctor.
It wasn’t until I reached the level of attending physician and started working with Project Weber/RENEW that I began to understand the scope of the problem. Project Weber/RENEW is the result of the 2016 merger between two previously independent organizations. Project RENEW was started in 2005 by Colleen Daley Ndoye to provide harm reduction and related support services to female sex workers. Three years later Rich Holcomb launched Project Weber to provide similar services to male sex workers. Since its merger, the unified Project Weber/RENEW has served sex workers of all genders, including expanded programming focused on transgender sex workers. My experiences with this organization have forever shaped how I approach my work.
Sex Work in the United States
Few populations in the United States are as poorly engaged in social and health services as sex workers, and specifically male sex workers. Gay, bisexual, and other men who have sex with men (MSM) account for the significant majority of new HIV infections in the US, largely due to biological (anal sex is more likely to transmit HIV than vaginal sex) and network (more HIV cases among MSM) factors.
In the case of male sex workers, the intersection of HIV and social determinants of health is especially evident. Substance use and addiction are highly prevalent in this population, as are other mental illnesses. Social factors such as stigma commonly affect these men. A large proportion identify as heterosexual and perform sex work for drugs. As a result, HIV prevention and treatment services focused on gay, bisexual, and queer men may overlook this group.
To truly support male sex workers and others with similar experiences, we need to understand, and address, these different determinants of health. Project Weber/RENEW provides numerous services to sex workers in the Providence area. I serve on its board of directors and work closely with Colleen as well as Rich, who continues to deliver harm reduction services through the organization. Rich has openly told his story about being a male sex worker, about overcoming challenges that few people have ever faced. His experiences and others were portrayed in the 2017 documentary Invisible.
Project Weber/RENEW provides testing for HIV and hepatitis C virus, education and counseling, clothing, basic
needs, syringe exchange, naloxone training and distribution, and linkage to other services such as housing, mental health care, and substance use treatment. These services are delivered by peer outreach workers—individuals who are in recovery from substance use addiction, have participated in sex work, or have experienced homelessness or incarceration.
Shifting the Paradigm
My experiences with Project Weber/ RENEW have helped shape my beliefs on how medical providers and research scientists need to better engage underserved populations. First, we must make our services more accessible. Those most in need of care are not always going to come to us. We must employ a patient-centered approach: offering services where people live or where the burden of disease is greatest, offering walk-in and evening/weekend hours, improving communication (e.g., through interpreters, materials accessible with minimal literacy), and working to mitigate insurance and cost issues. The health care system is incredibly complicated to navigate, even for those of us who work in it. For those without the means, it can be an impossible barrier.
Second, we as providers and research scientists have to be more involved in the community. It is difficult to research problems in the community without interacting with people to understand their issues and challenges. It is also difficult to understand people if you don’t understand the community they come from. We have to work with local groups to address health issues, listen to their needs, and work with others to help address what they think is important—and then, place the needs of the community above our research agenda. Though research can be an important part of community engagement, it’s not the only part, and it should be guided by the community.
Third, we need to dedicate resources. This includes financial commitments from public health, clinical, and academic institutions to ensure that we can implement change. It means basing care delivery on metrics other than the amount of financial compensation received, and working to implement flexible and innovative health care models. Programs should also be regularly evaluated to ensure that needs are being met and that health outcomes are achieved and equal to the standard of care in other populations.
To achieve this vision, our collaborations should maximize our individual strengths, including the robust policy and data reporting infrastructure of public health institutions, the care delivery of clinical institutions, and the innovation and research funding of academic institutions. Together we can deliver state-of-the-art health care and determine effective policy and implementation science approaches. Furthermore, funding from each sector can better complement and amplify resources than any one sector alone. For example, research grants, public health funding, and clinical revenue can all help offset the infrastructure and cost of care for underserved populations. With this approach, effective and world-class models of care delivery can be implemented for underserved communities.
Am I going to change the world? Probably not. Perhaps I am a little more realistic than I used to be. I continue to learn every day from my patients and from community leaders like Colleen and Rich. My experiences with organizations like Project Weber/RENEW affirm the value of this work and attest to the ongoing need for more physicians and research scientists to be involved in community work. I see this approach as an essential component of addressing the health and well-being of our patients. I may not change the world. But perhaps a community is enough.