Treating the Whole Patient

Treating the Whole Patient

Highland Hospital’s Dr. Harrison Alter focuses on social emergency medicine, which addresses social and economic factors that cause disease.

Ever since Dr. Harrison Alter fell in love with emergency medicine while interning at Oakland’s Highland Hospital, he has become increasingly convinced that social ills among the poor and vulnerable translate directly into big medical problems for individuals and society.

“Our doors open at street level. We have a very thin membrane separating us from our communities,” Alter said.

Now, after years of advocacy and research, Alter is playing an important role in getting doctors across the country to develop and promote programs to help patients address social and economic factors, including getting access to nutritious food, stable housing, employment, transportation, drug abuse treatment, and protection from exploitation and violence.

Notably, in late October, after two years of preparatory work, Alter presided over the first “Social Emergency Medicine” track at the 37,000-member American College of Emergency Physicians’ annual gathering in Washington, D.C. Establishing such a section put the subject of social emergency medicine on par with other specialties like critical care, ultrasound, and field treatment and trauma transport.

“This is a watershed moment for social emergency medicine. It’s kind of like a coming out party,” said Alter, who today is Highland’s research director and also the founding director of the Andrew Levitt Center for Social Emergency Medicine, based in Oakland.

Alter, 55, who graduated in 1993 from a joint UC Berkeley-UCSF medical/public health master’s program, is quick to say he didn’t “invent” anything — that he is following other doctors who doggedly highlighted “social determinants” in health care.

Yet Dr. Jerome Hoffman, an emeritus professor of emergency medicine at UCLA who has long focused on social issues, said that, in recent years, Alter has been a catalyst to unite doctors like himself. “No great events happen because of one person, but you do need the right people at the right time to be spearheads,” Hoffman said. “Harrison has been without any question that person. He has worked hard, reached out, been articulate. I’m very proud of him.”

The key role of social determinants on health outcomes has long been understood by public health professionals, but has until recently rarely been considered by medical providers or taught to medical and nursing students, Hoffman said.

Though central to patients’ lives, such factors were often treated by doctors as peripheral to the patient’s complaint of sickness or injury, at best warranting a referral to a social worker, Alter said.

The irony to both Alter and Hoffman is that medical systems devote vast quantities of money to costly machines, which, though impressive, often have less impact than more mundane tactics such as ensuring access to healthy food and adequate housing.

Alter cited the case of a middle-aged mother of four children who was brought into the Highland emergency room by ambulance on an involuntary psychiatric hold for suicidal thoughts. It turned out the woman, who was strapped to a gurney with leather restraints, had threatened to kill herself in the middle of a public housing office after learning that, despite her efforts to correct a bureaucratic mistake, her housing subsidy was about to be terminated. A psychiatrist subsequently determined the woman was not suicidal, and the hospital helped find her an attorney, who in turn cleared up the housing problem.

Based on such experiences, Alter founded the Andrew Levitt Center for Social Emergency Medicine in Oakland in 2008. It’s named in memory of Alter’s predecessor, a long-time research director at Highland Hospital and was established with a gift from the Levitt family. The Levitt Center sponsors research in areas ranging from health coaching to gun violence and has helped establish various programs to address specific needs.

Alter was a key driver in the early stages of launching the Health Advocates program at Highland Hospital. Started in 2013, Health Advocates now relies on 120 volunteers—particularly from local colleges and universities—and partnerships with several legal clinics to help patients confront life challenges considered barriers to health. Last year, it helped 2,730 patients deal with issues ranging from domestic violence to immigration status and crushing debt.

To illustrate how Health Advocates can help a patient avoid future hospital visits, program coordinator Kimi Tahara cited repeated cases of people coming to the emergency room needing surgery to remove cockroaches stuck in their ear canals. Health Advocates worked to find those patients advocates to pressure landlords to clear their rental properties of such infestations, she said.

Tahara cautions that Health Advocates is no panacea for poverty. She pointed to the case of a homeless woman who first came to the emergency room in 2015 after being mugged and beaten. Two years later, social workers were still trying to get the woman into subsidized housing. However, they were able to get her government victim-of-violence assistance, a primary care doctor, and a therapist, with whom she meets regularly, Tahara said.

Early data from the program shows patients getting plugged into helping agencies and becoming less likely to revisit the emergency room, according to a research paper published last spring that Alter co-wrote.

“We know it works,” said Alter, who is grateful he has been able to step back from the program’s day-to-day operations (he was exhausted at the time of his interview for this story after working five nine-hour emergency room shifts in the prior seven days).

Health Advocates is now run by Alameda County, which has given it grant funding and employs Tahara and a handful of social and community workers.

The program has been expanded to include Fairmont Hospital, Eastmont Wellness Center, and Hayward Wellness Center. For services, Health Advocates partners with Bay Area Legal Aid, Centro Legal de La Raza, East Bay Community Law Center, and Housing and Economic Rights Advocates, as well as numerous community-based organizations.

Regionally, Health Advocates also paved the way for the Bay Area Regional Help Desk Consortium, a collaboration of Bay Area hospitals, including Zuckerberg San Francisco General, Alameda Health System, and UCSF Benioff Children’s Hospital Oakland.

Alter continues to address “social drivers to care” in other ways. In his capacity as head of the Levitt Center, for example, he is currently chair of a countywide effort to develop streamlined protocols for identifying and responding to victims of human trafficking.

The project is an outgrowth of the H.E.A.T., or Human Exploitation and Trafficking, Institute run by Alameda County District Attorney Nancy O’Malley, and its partners include Kaiser Permanente-Oakland, Children’s Hospital Oakland, and Sutter Health’s Alta Bates Summit Medical Center.

Alter said some 87 percent of commercially sexually exploited children will seek medical care, with 60 percent of that total coming to emergency rooms. The goal is not necessarily to get victims to disclose their situation, which can put them in immediate danger, Alter said.

“We want to be a safe place, a place where they don’t feel under threat, where they don’t feel judged. The constant repetition of screening questions, some feel, works at cross purposes to that,” he said.

Two years ago, Alter began pushing to establish a special section within the American College of Emergency Physicians through which to coordinate research and advocacy efforts nationally. The response was much greater than anticipated, with the requisite 100 physicians rapidly joining the group.

Dr. Jahan Fahimi, an emergency doctor Alter trained at Highland who currently works at UCSF, said perhaps Alter’s major contribution was to see that different efforts to address social drivers to care around the country shared common elements and then to give the overall field a name.

“Harrison is interesting person because he’s been championing social emergency medicine for well over 10 years. He’s the one who coined the phrase,” Fahimi said.

In the future, Alter hopes the Levitt Center can provide consulting services to hospitals and schools around the country to spread best practices.

“I hear every week from a new academic department of emergency medicine, ‘We want to form a division, we are forming a residency track, what should we do?’ ” Alter said. “There are people all over the country doing inspiring and expansive work in social emergency medicine who thought that they were alone.” 

Faces of the East Bay