Cover Story
Community Health: Then and Now
By Shari Mycek
A look at two innovative programs a decade later
The following pair of articles revisit two unusually innovative community health programs that Trustee featured in the mid-1990s. Nearly a decade later, we were curious as to whether these programs still existed and, if so, how they had evolved. In a departure from the magazine's usual format, we have begun with excerpts from the original articles, followed by a snapshot of where they are today. We look first at Integris Health's gang intervention program called BEEP (Basic Entrepreneur Empowerment Program) in Oklahoma City.
Then, we revisit Minneapolis-based Fairview Health System's WomanKind program, the first hospital-based support system for battered women in the country.
Both represent compelling social and public health care problems endemic to every U.S. community--no matter the size, location or demographics--that have a significant impact on hospitals' clinical and financial resources. Although the programs might require more resources than some hospitals can commit to in their entirety, features of each could be integrated into many hospitals' existing programs. --The Editors
Gang Violence: Too High A Price to Pay
Integris Health, Oklahoma City
THEN: 1997
"There are those who may say, 'The heck with them--dig a hole and bury them.' But let me tell you how much that costs you," says Lyn Hester, director of community development for Integris Health, a nonprofit, 16-hospital system in Oklahoma City. "Youth gang violence touches all of our lives. You may not have it in your house, but it's affecting you. When you purchase a home-security system, when you're afraid to go to the mall at night, you're paying for it. The moment that we quit saying gang violence is somebody else's problem to fix or pay for; the moment we say, 'This is my problem because I want to live here, raise my children here, retire here,' then change can begin."
Integris spends between $500,000 and $1 million annually on community development programs, a portion of which supports BEEP (Basic Entrepreneur Empowerment Program), a gang intervention program that helps gang members start their own legitimate businesses. In exchange for their agreement not to commit crimes, BEEP empowers gang members to change and become accountable for their behavior.
Although Integris has long been active in building an inner-city youth program, the gang initiative evolved without any formal stamp of approval. It was months before Integris administrators caught wind that gang members--many convicted felons--were meeting in the basement of Baptist Medical Center. Hester's stance? It was easier to "ask for forgiveness than for permission."
Integris president and CEO Stanley Hupfeld reacted, not with fury, but with open-mindedness--by meeting and talking with the kids. "What struck me was that for many of these kids, the American Dream, as we know it, is meaningless," he says. "To say to these kids that they can grow up to be anything they want to be, that all they have to do is work hard, doesn't mean anything, because they have no support from home, no support from peers. Most don't even think they will live to see their 21st birthday.
"If, as health care leaders, we are in charge of people's health, it's incumbent on us to work on violence prevention and all those other areas that make health happen," Hupfeld continues. "BEEP represents the first time anyone has told these teens they can do something better than they think--and here's how."
BEEP began with eight members, and in only two years grew to 26. Represented are the Crips, Bloods, Juaritos and South Side Locos. Members meet weekly and abide by their own self-imposed rules: Those who are late or miss a meeting are fined; those who engage in criminal behavior are fired. All members have quit smoking, perform 20 hours of community service a week and participate in internships. Each receives a $200 per month stipend and between $400 and $600 for their internship program.
The group's first entrepreneurial effort was a firewood business where members cut and split 80 acres of donated wood and learned bookkeeping, computer processing skills and customer service. Other ventures include a franchise with a national cleaning company, an artist-in-residence program and an initiative with St. Louis-based Daughters of Charity (a 72-hospital system) to provide technical assistance and support to implement the BEEP concept nationwide.
Although BEEP is largely about helping gang members, it also focuses on preventing teens from joining gangs. BEEP members are encouraged to talk to schoolchildren as well as members of their own gang about the other side of street violence. Members are not required to leave their gangs, but they must refrain from criminal and antisocial activity.
"Gangs are not bad," says Hester. "We're all in gangs. They're called ... sororities, fraternities, garden clubs. Gangs are not bad, it's what gangs do that are bad and that's what we need to stop. These [BEEP] kids are like any other kids except they've been disenfranchised for a million different reasons, most of which are not their fault. They were abandoned; they were abused; they were following a course set for them by their parents and grandparents because beating their children, stealing cars, selling drugs, picking up guns to solve conflicts, was all they knew. Most of these kids are interested in finding a better way of life but feel trapped. Yet, if given a positive path, most will take it."
Few dispute the impact of the program. The Oklahoma juvenile justice department, sufficiently impressed with BEEP results, asked Integris to widen its scope beyond Oklahoma City. And those in the program say they feel empowered and hopeful about their futures for the first time.
"On the penitentiary of the streets, there are a lot of unwritten rules. It's either kill or be killed," says BEEP member Stephen Bruno, previously known on the streets as "Lunatic." At age 13, Bruno joined the Crips. His record includes arrests for disorderly conduct, possession of controlled dangerous substances with intent to distribute and shooting with intent to kill.
"The community, the environment I grew up in colored me because it was the only thing I knew. My life was from day to day, not really knowing what to do next, just doing any and everything that came to my mind at the time," he says.
Since joining BEEP, Bruno, now 20, has become the youngest person to be appointed by Oklahoma governor Frank Keating to serve on the State Advisory Board of Juvenile Justice. He is also a peer educator, educating youth on sexually transmitted diseases and AIDS.
"Most kids see the glory of the gangs. But there's a lot of hatred and anger that builds up and results in a lot of the fighting," says BEEP member Sandino Thompson. "Kids need to be exposed to other avenues where people can be successful other than by selling drugs. BEEP has helped me find a way to be productive with my spare time. Writing lyrics is one thing I have been good at since my brother taught me how to rap. I always thought that as a secondary skill I would like to make music. Recently, the prospect of making music and writing lyrics, for profit, instead of as a hobby, seems more realistic. I hope BEEP will continue to grow and spread, giving those who would have never had the [opportunity] to become entrepreneurs."
Thompson helped coordinate BEEP's firewood business. He has opened and maintained a checking account and is currently trying to start his own production company.
"I've been gang-banging since I was 12," says 19-year-old Daniel Charqueno. "I went from stealing car stereos to selling drugs to doing drive-by. If it wasn't for this program I would probably let my art--and myself--go to waste. I'd be back in jail. Or dead. Although I still have problems to work out on my own, I am confident [now] that I have this program and new friends to guide me through it. A second chance was all I needed."
After Charqueno participated in a drive-by shooting and was sent to prison, he was "fired" by fellow BEEP members. While incarcerated, he reached out to the membership, asking for a second chance. To show his gratitude for those who tried to help him, Charqueno melted the outside coating of M&Ms and used a bird feather to paint "thank you" illustrations. Upon his release from prison, BEEP members voted, in an unprecedented move, to reinstate him. Charqueno has since finished high school, is involved in BEEP's artist-in-residence program, and is hoping to attend college on an art scholarship.
"People have to care, and kids have to know they care," says fellow member Lakisha Thorton. At age 7, Lakisha was abandoned by her crack- and alcohol-addicted mother in the vacant building where they lived. She survived alone and undetected until age 8. Following her mother's incarceration a year later, she moved to Oklahoma City to live with her great-grandmother, who died recently. Now, at age 17, Thorton is on her own, with no family support. Through BEEP, she has secured a fall internship with Oklahoma State University on a scholarship.
"Feeling sorry isn't enough," says Thorton. "People have to be inspired to get up and do something to remedy the situation. People will encounter us. Maybe not Lakisha Thorton or Stephen Bruno or Daniel Charqueno, but they will encounter people who have come from where we've come. And the question is, 'How do you want us to be?'"
She continues: "If you give us 100 percent of yourself, if you help us change where we're going and who we are, then when you meet us we'll be the teacher to your children or the doctor who may very well save your life. But if you've failed us, if you've refused to help us--as children in your own community--then you will meet us as a drug pusher. Or holding a gun to your head."
(Excerpted from "Gang Violence: Ain't No Denying It, Trustee, March 1997.)
NOW: 2005
When I made a call to Integris Health in Oklahoma City after nearly seven years, I was delighted to hear the voice of Lyn Hester, now vice president of Community Services for the system. Like old friends catching up, she immediately relayed the whereabouts of various BEEP members, including that of Corrina Ramirez, a BEEP graduate not mentioned in the original story, whom Hester hired in 2001 to direct the program.
Lakisha Thorton, abandoned at age 7 by her crack-addicted mother, graduated from Oklahoma State University and is now an elementary school teacher in Texas, where she lives with her husband and 3-year-old daughter.
Stephen Bruno, once known on the streets as "Lunatic," remains in Oklahoma City, where he's "clean" (no drugs) and still working for the Juvenile Justice Department.
Sardino Thompson also graduated from Oklahoma State with a degree in engineering and is now working as a contractor for a large construction firm in Tulsa.
And Daniel Charqueno, who, from his jail cell, had made paintings from melted M&Ms, resides in Alaska where he works for a mobile phone company and still pursues his art on the side.
"Daniel had a difficult time," Hester tells me. "When you're raised on the street and in a gang, your community is used to you being a certain way. It was hard for Daniel to change his old ways, and he 'fell off the wagon' a few times. Finally, he decided that the only way to truly change his life was to leave [Oklahoma City]."
Not every story has been a success. One BEEP member returned to jail and died while incarcerated. And between 1999 and 2001, the BEEP program was suspended due to a lack of funding. "It was difficult," Hester admits. "I hated seeing the program cut, as we all did. But at the time, there were cuts across the board, and BEEP was just one of many. Then Stanley [Hupfeld] and the entire board, really, thought better and said, 'Let's bring it back.' And I used the relaunch to make a few changes, redirect a few things."
Most significantly, Hester expanded the criteria for membership beyond gang involvement to include juvenile offenders who've committed a crime. Although this change came about largely because parents and courts wanted to refer kids to the program, gang activity in Oklahoma City has also significantly declined.
"Gangs are still present in Oklahoma City, of course," says Hester. "But they're not as high-profile. They were really at their peak [in the 1990s] when we started the program. We don't have the drive-by shootings as much. And while I'd love to say that's a direct result of BEEP, I really think society has a lot to do with it."
Accordingly, BEEP's mission has also broadened: "Rather than focusing on helping members stay alive, get through the night, we're able to focus more on life strategies," says Hester. "We stress that members have to work for a living and take responsibility. Having three children and not knowing who the father is, or fathering three children and not sticking around to raise them isn't a viable way of life. We stress good health and nutrition--we teach that it's not okay to give 3-month-old babies Coca-Cola in their bottles. We provide vaccinations, eye and dental care, complete physical examinations. And if anything comes up, we cover it."
The same goes for education.
While the program is still called BEEP, the second "E" in the acronym has evolved from standing for "entrepreneur" to standing for "education."
"We found that, even though it helped tremendously for our members to have a business, what they needed, first and foremost, was education," says Hester. "We saw this back when members were doing their first project, selling firewood. They had no clue how to invoice for their services, how to market. So, with the relaunch, we said, 'Look, these kids really need education. And we'll foot the bill.' Our rules are simple: You must finish high school (or earn a GED), and you [must] pursue further education. You don't have to go to college, but you must pursue some kind of formal training." In lieu of monthly stipends, members now receive educational support.
"The stipends weren't really working," says Hester. "Instead, we pay for school tuition, books, school supplies and fees--allowing [BEEP members] a small amount [of money] to assist with car repairs and down payments. Occasionally, we have had to assist monetarily with an emergency here and there, but these [cases] are decided on [an individual] basis."
Hester's community development budget is now around $2 million (which has doubled in the last ten years), with about $100,000 (not counting salaries) now devoted solely to the BEEP program.
"There's no question, the investment is worth it," she says. In Oklahoma, the average annual cost to incarcerate a youth is $87,000; while the average cost [for BEEP] to retrain, nurture and mentor each member averages $2,000 per year.
"Quite a savings," says Hester, noting that recidivism for most juvenile offenders is around 87 percent, while in BEEP, it's less than 5 percent.
Others also see the long-term merit of BEEP. Several area colleges and universities--Oklahoma State, in particular--now work closely with BEEP.
Back when Lakisha Thorton was a member, she was instrumental in securing an agreement with the college, and today, the university provides a $1,000 tuition credit per semester to BEEP members--along with the options of tutoring, mentoring and work-study jobs. The program's structure has also changed, as more than 100 members have passed through the BEEP program.
"Restructuring was necessary," says Hester. "We'd work with a group of kids, get their ducks in a row; they'd be doing better, and a new batch would come in. Everyone would share the same meetings, but they were at drastically different levels with different attention needed. It was hard to have this vast mix [of learning needs], so we broke it into groups."
Today, "freshmen" BEEP members focus on securing their high school diploma or GED while learning basic life skills, which may take from six months to several years. "Seniors" comprise those who've been with the program for some time and are enrolled in college, technical or some other training beyond high school, while "alumni" are those who have jobs and serve as mentors to the "newbies." Each group meets monthly on its own as well as collectively--and all members perform community service.
"When I look at the individual lives touched and forever changed as a result of this program, it's beyond anything I could have envisioned at the beginning," says Hester.
But that's not to say she doesn't have some regrets about the program.
"We would have loved to have seen the program replicated ten-fold by other hospitals and communities nationwide. But it's a tough nut," she says. "We get lots of calls [from] people wanting to replicate the program but [who] didn't in the end--not because of money but [because of] the time [involved]. It takes a lot of time and emotion [to work with kids from gangs]. Although our program is open to those who live outside the metropolitan area, these youth find it difficult to attend the meetings and participate in the program, which is held in Oklahoma City. We haven't had the manpower to place someone else in another geographic location. The director needs to be in close proximity to the participants. It's like raising a child. It's easier if they are closer to you."
Shari Mycek is a writer from Belle Mead, N.J.</</body>
Domestic Violence: The Silent Killer
Fairview Hospital and Health System, Minneapolis
THEN: 1996
"A woman may not acknowledge that she is living in an abusive situation," says Susan Hadley, director of WomanKind, a support system for battered women at Fairview Southdale Hospital, Edina, Minn. (The hospital is part of the seven-hospital Fairview Hospital and Health System, based in Minneapolis). "But she will always remember that she was asked. Knowing that the health setting is a safe place to return when she is ready may be the most valuable assistance that health professionals can provide."
Certainly that was true for "Olivia," a 35-year-old mother of two from Minneapolis. When she decided to seek help after four years of continuous physical and verbal attacks by her husband, she found a supportive system in place. Olivia credits WomanKind with saving her life and the lives of her two little girls. But her story begins in fear and confusion:
We had a storybook romance. And then, the day after our wedding, everything changed. He would punch me in the arm for buying the wrong brand of Cheetos; slug me in the stomach for putting the bread on the wrong side of the freezer; wave a pistol in my face and threaten to pull the trigger. How do you tell someone? Do you just come out with it in the middle of a normal conversation?
It was Susan Hadley, a small-in-stature, but big-on-ideas woman, who worked to bring domestic violence out of the underground in the Twin Cities in the mid-1980s. Edina, an affluent suburb southwest of Minneapolis, is probably not the first place most people would look for domestic violence. But, as in every community, domestic violence is prevalent here. And Hadley knew it.
As a full-time mother, graduate student and battered women's crisis volunteer, Hadley recalls sitting in rush-hour traffic one day and wondering what happened to victims of abuse when they came into the health care setting. Were they identified? Did anyone talk to them? Was there ongoing contact?
Soon after, she approached Fairview Southdale Hospital with a proposal: She would train emergency department personnel on how to identify women who were victims of domestic abuse, and in turn, the hospital would support the women and refer them to the appropriate health care, law enforcement, and legal and social services. The hospital agreed to provide office space, supplies and equipment, but no formal funding. It was good enough for Hadley.
"There was a notion that domestic violence was not a problem here," she says. "Or that if it was a little bit of a problem, we certainly did not need to stand on the front steps of the hospital and talk about it."
But the numbers couldn't be ignored. In 1986, WomanKind's first year, 141 women--a majority of whom (59 percent) were referred through the hospital emergency department--used the program. By the following year, 271 women came through the program. By the first half of 1995, more than 75 new clients were receiving help each month through WomanKind, and more than 7,000 victims of domestic violence had been helped since the program's inception. Referrals came from hospital units (44 percent), the emergency department (19 percent), the general public (15.4 percent), community-based physicians and health care providers (11.5 percent), and hospital employees (5 percent).
"We started in the ER and found, sadly, that there was as much, if not more, cases of domestic violence showing up in other areas of the hospitals, particularly the obstetrical units," says Richard Norling, president and CEO of the Fairview Hospital and Health System. "In looking at the downstream cost of domestic violence on the health care system, it became clear to us that we had both a moral and financial obligation to make the connection between a patient's health problems and the abuse and violence in her life. Any organization that is really trying to be more accountable for improving the health of its community does."
In 1992--with the understanding that WomanKind would maintain its mission and structure and receive departmental status within the hospital--the program officially joined the Fairview system, making it the first hospital-based support system for battered women in the country. Today, WomanKind operates from three hospitals sites: Fairview Southdale Hospital, Edina; Fairview Ridges Hospital, Burnsville; and Fairview Riverside Medical Center, Minneapolis. It has an annual budget of more than $200,000, with major funding from the Fairview Health System, the Fairview Hospitals Auxiliary and the Fairview Foundation.
The program offers training and education on domestic violence to health care providers, as well as support, information and referrals to battered women. One of the training component's main priorities is routine screening for abuse. Since March 1995, every woman entering a Fairview Health System hospital has been asked about abuse--if they are in an abusive relationship where someone is hurting them physically, emotionally or verbally. The initiative has also been supported by many private physicians throughout the Minneapolis/St. Paul area. Because medical professionals often experience frustration at a woman's seeming inability to "get out" of an abusive situation, WomanKind also concentrates on helping health care providers understand the victim's perspective.
New Jersey resident Courtney Esposito, who, in the years following her own abuse, moved from volunteering at a local shelter to training health care professionals nationwide on the issue, says there is an overwhelming tendency to look at an abused woman and say: "'Why don't you...? How come you don't...? I wouldn't.... I couldn't.... I don't....' If you've never been afraid of losing your life at the hands of another person, it's difficult to understand why an abused woman does what she does," Esposito says. "And so, health professionals have to try to get to that place. Otherwise they will make recommendations that could cause great harm."
As Olivia describes it:
It's easy to say you'd never stick around if someone was hitting you, but it's so hard when you're in the situation. He would hide my car keys, take my credit cards out of my billfold, threaten to take the children. I knew he would hurt me--he'd already done it--but I couldn't take the chance that he would hurt the kids. Afterward there would be flowers and apologies, and he'd say everything I wanted to hear. That it would never happen again. That he loved me ....
During one of her many training sessions, Esposito recalls the following conversation she had with Ronald Chez, M.D., of Tampa, Fla., who today is a staunch advocate of domestic violence identification and intervention by physicians.
Chez: I'm an ob-gyn.
Esposito: Yes.
Chez: I've been practicing medicine for 30 years.
Esposito: Uh-huh.
Chez: I've delivered more than 7,000 babies.
Esposito: Yes.
Chez: I've never seen a battered woman.\
Esposito: (Silence.)
Chez: Something's wrong, isn't it?(Excerpted from "Cries and Whispers," Trustee, May 1996.)
NOW: 2005
My follow-up on the WomanKind program--at least after my initial contact with Southdale Hospital in Edina--left me a bit disheartened.
"No one here by that name," I am told when I ask for Susan Hadley, which is perfectly understandable. My last contact with her was nearly a decade ago.
"Could I have the WomanKind program, please?"
Very long pause.
"Ummmm. There's no department by that name. Would you like Social Services? I'll put you through to 'M,' who should be able to help you."
As my call is transferred, I can't help thinking of my original interview with Hadley, and how proud she was that WomanKind had earned departmental status within the hospital. I leave a long and detailed message on "M's" machine, but never hear back. Several days and many phone calls later, I'm finally connected to Linda Dahlquist.
"So you're the head of WomanKind," I say happily.
"No. I'm the director of Care Coordination. I oversee Social Work, Spiritual Health, Nurse Care Coordinators. And yes, WomanKind," Dahlquist replies. Effective Jan. 1, the WomanKind manager position at Fairview Southdale was dissolved and the program folded into social services.
"WomanKind is alive and well and still offering great and much-needed services to our community," Gary Strong, president of Fairview Southdale, reassures me later in the day. "Just a few days ago, I received a call from a mother whose daughter, due to a tragic incident, received our [WomanKind] services in the ER. And she couldn't have been happier with the way the situation was handled. That's what WomanKind is about. Yes, we had a manager and about 15 or so volunteers. But our social workers are already trained to do these [domestic violence] conversations. So it made sense to redirect the internal reporting.
"WomanKind was a pilot," Strong continues. "We looked at it and said, 'Do we need this? We think we do. Let's see if it's as important as we think it is.' The reality is that the program is so important that it has become integral--actually part of the infrastructure of the [health care] system."
According to Dahlquist, one major difference in Edina is the advent of a "very large and very wonderful" domestic violence shelter in the community: the Sheila Welstone Center. An affluent woman who had worked with victims of domestic violence, Sheila Welstone, along with her husband, Minnesota Sen. Paul Welstone, and their daughters, were tragically killed in a small plane crash in October 2002. Following her death, monies were left to the community's existing shelter, Cornerstone, which was renamed in Mrs. Welstone's honor and expanded to include more intensive services, apartments and [Section-8] temporary housing accommodations for up to two years.
"We don't want to duplicate services," says Dahlquist. "We can help [domestic violence survivors] for a few months, but eventually we have to fade away. So the Welstone Center is really wonderful to have in our community. We refer a lot to it."
But the hospital doesn't rely completely on the shelter. Every person who walks through the hospital's doors--whether via the emergency department, ob-gyn, or another service--is still asked the same question: "Are you in a physically, emotionally or verbally abusive relationship?" Community-based physicians, too, make the same inquiry.
"Domestic violence is a health care issue," says Joanne Seaberg, director of WomanKind at the Fairview Riverside campus, Minneapolis, which still operates as a hospital department. Seaberg has been with the program for many years and worked with Hadley in the 1990s. "Hospitals need to share the burden. Shelters are absolutely necessary but they can't function completely alone. For many individuals, shelters are scary. It's difficult to walk up to a shelter door, ring the bell, wait as the latches are unlocked. Being asked the question in a health care setting normalizes the experience. It lets people know that it's OK to talk about this here and that you're not the only one dealing with this issue."
Jennifer Larson, director of WomanKind at Fairview Ridges, Burnsville (which also operates as a hospital department), echoes the sentiment. She says she see a steady number of patients passing through WomanKind--many of whom would likely not have been identified otherwise. In 2001, she noted 589 total incidences (which could include seeing the same person more than once); 719 in 2002; 510 in 2003; and 586 in 2004. Among all three hospitals, an average of of about 2,000 incidents have been identified.
Additionally, in the three years she's been at Fairview Ridges, she's noticed an increase in the number of men seeking treatment for abuse. And the same is true at Riverside. So much so that Seaberg wonders if a name change may be in order.
"When we established the program, domestic violence was seen primarily as a woman's issue. We now know that's not true, and with the influx of men seeking treatment, I think the name WomanKind may be somewhat of a barrier."
Regardless of the name, everyone involved with WomanKind believes the program is important."Dollar to dollar, I don't think you can say that if this program wasn't in place, it would cost [Fairview] $100,000 or $1 million," says Seaberg. "But we can say that the cost of women and men not being intercepted is high. Hospitals have to share the burden of domestic violence. It's part of their responsibility, part of a person's ability to be healthy."
Shari Mycek is a writer from Belle Mead, N.J.
This article 1st appeared in the December 2099 issue of Trustee Magazine.
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