Psychiatrist Annelle Primm recalls a recent home visit in West Baltimore, where she listened to a 40-year-old woman recount her horrific past as calmly as if she were reading a grocery list. She told Primm about her mother who was never properly treated for manic depression and schizophrenia, about a rape in high school that resulted in pregnancy, a drug addiction that left her scaling drain pipes and sleeping on roofs, and the best friend she'd known since middle school who infected her with HIV.
The story is all too familiar to Primm, 50, who primarily treats depression among minorities, particularly African-American women. Many of her patients have dealt with issues of rape, drug addiction, and diseases such as HIV/AIDS. She knows that African Americans have elevated rates of heart disease, obesity, cancers, stroke, diabetes, and kidney disease. Primm also knows that many health disparities can be traced to a healthcare system that doesn't treat blacks and other minorities the same as whites.
That's why she and her father, Dr. Beny Primm, an anesthesiologist who currently serves on President Bush's National Commission on AIDS, and sister Jeanine Primm, who has developed health programs for the National Basketball Players Association, are utilizing innovative methods to address the disparities issue. That's why they founded Health Disparities Services [HDS] in 2003.
At that time, the Primms realized the potential impact they could have if they combined all of their knowledge and expertise. "It was sort of a holiday dinner conversation that never seemed to get off the ground," says Annelle, adding that the discussion went on for at least four years. "I finally said, 'We need to do this.'"
Based in Baltimore, HDS educates health professionals on the ways disparities affect not just minorities, but also the entire nation and its healthcare system.
There is certainly a need for the services HDS provides. In Baltimore City, African Americans represent 90 percent of new AIDS cases; African-American women continue to battle high rates of obesity, cancer, and heart disease; and 40 percent of black men die prematurely. In fact, blacks can, on average, expect to live five fewer years than whites.
According to an analysis in the December 2004 issue of the American Journal of Public Health, "more than 886,000 deaths could have been prevented [from 1991 to 2000] if African Americans had received the same care as whites."
"There are significant disparities in both access to care and outcomes for African Americans," says City Health Commissioner Josh Sharfstein. "The health problems facing African Americans are very serious. We have to address public health problems and address the disparities at the same time."
"Disparities and healthcare—these are not just words," says Jeanine. "These are huge entities that keep thousands of people from getting the care they need. But we talk about it just like it is another issue."
On a Friday night, the Primms are sitting around the dining room table at Annelle's Mount Washington home. Because of their busy travel schedules, it is a rare opportunity for them to be together. Their daily meetings about HDS are conducted via conference calls. In their respective roles with HDS, Beny (president) is the manager, Annelle (vice president) is the detail person, and Jeanine (director of education) provides a creative spark.
As Beny talks about various topics—including the prison system, child support, and AIDS—and how each relates to disparities, his daughters listen intently, but also interrupt him with playful jibes. This apparently represents something of a change in their relationship, as working with Dad is very different than growing up with him. "We are allowed to interrupt Daddy now, and that's nice," Jeanine says with a smile.
Beny Primm remembers wanting to be a doctor from an early age. He grew up in New York, graduated from West Virginia State College, and joined the Army. He served for three years, was injured in a car accident, and eventually used his military benefits to get a medical degree from the University of Geneva in Switzerland in 1959.
Primm returned to New York and worked as a general practitioner while doing his residency in anesthesiology. It was then that he became keenly aware of disparities in healthcare. He would often take his daughters along with him on his home visits with patients. He would also drive them through the streets of Harlem after his shift at Harlem Hospital. Through the window of their father's Lincoln Continental, the girls saw addicts and alcoholics sprawled on the sidewalk, eyes closed, with swollen limbs resting heavily like logs.
"From that early age, we could see what kinds of drugs were decimating the community, and he made sure we knew that," remembers Jeanine. "He convinced the city to open up one of the first drug treatment facilities. He was pretty much a renegade back then. That was a big deal for a black doctor."
Primm soon realized, however, that he was only treating the symptoms to more serious underlying problems. In 1969, he helped found the Addiction Research and Treatment Corporation, in Brooklyn, and has been its executive director for more than 30 years.
Winston Price, former president of the National Medical Association—an organization that represents more than 30,000 African-American physicians—says Primm was one of the first doctors to warn the nation about the far-ranging impact of heroin addiction. "White America thought this was a black problem in the slums of the city," says Price, "and if we simply turned our heads and avoided them they would kill themselves and overdose, but it wouldn't affect us.
"It wasn't until the early 1980s, when heroin started to find itself in rural, suburban areas, and outskirts of the city, that the outcry of 'We need to stop the drugs from coming into the city and the country' began to raise its head. But the Beny Primms of the day already knew that this was a problem that was going to affect everyone."
Primm was a pioneer in providing care to underserved populations. He linked addiction with infectious diseases, most notably AIDS, and approached treatment from a social perspective. At his treatment centers, addicts received help with housing, job training and, for those who were developmentally disabled, residential care. Primm was even chosen by President Richard Nixon to go to Vietnam to survey the extent of heroin abuse by U.S. soldiers.
Today, Primm oversees seven treatment centers—three in Brooklyn and four in Harlem. The centers serve an estimated 3,500 patients annually, more than any other minority-owned, nonprofit, community-based treatment center in the country. In addition to the substance abuse centers, he operates four shelters for battered women in Brooklyn and Harlem.
Primm, who currently resides in New Rochelle, New York, also serves on the President's Advisory Commission on HIV and AIDS, a commission of experts from different fields who advise the president on how to approach the epidemic.
He says convincing African Americans to get tests and seek treatment is a major obstacle, one that plays a large role with the disparities that exist in healthcare. "We don't want to go to the doctor until it's too late." he says. "We think, 'The Lord is going to help me. The Lord is going to take care of all my problems.'"
Annelle cites her father as her main inspiration for getting into the medical field and fondly remembers accompanying him on house calls. "I think I knew at that point that I wanted to be a physician," she says. "Early on, I was interested in psychiatry, listening to people's problems."
After graduating from Howard University's medical school, Annelle earned a master's degree in public health at Johns Hopkins' Bloomberg School of Public Health. She was also awarded a fellowship in social and community psychiatry at JHU's School of Medicine. One of the requirements of the program was to design a treatment approach that would address unmet mental health needs in the neighborhoods around Hopkins, where most residents are African-American.
So, in 1985, Annelle established Community Support Treatment And Rehabilitation [COSTAR], a program that provides specialized treatment for minority patients with severe and persistent mental illness. Many of these patients were not receiving conventional outpatient treatment because, due to the severity of their illnesses, they wouldn't show up for appointments or take their medication. Annelle's COSTAR program put together teams of psychiatrists, social workers, and nurses to provide home outreach to such patients, some of whom had schizophrenia. In addition to medical treatment, the team also monitored and addressed needs such as access to medication and adequate housing.
COSTAR was one of the first programs to implement such techniques in an urban setting. "The way I think about mental health is an underpinning of a number of health issues," says Annelle. "If mental health isn't treated, some people will self-medicate with drugs. Once they start doing that, that opens them up to risk to STDs, like HIV/AIDS."
Though the program still exists, Annelle stepped down as COSTAR's director in 1995; she continues to serve on the Hopkins faculty as an associate professor of psychiatry and an assistant professor of health policy and management at the Bloomberg School of Public Health.
She's become more keenly aware that the mental health needs of African Americans are not being addressed effectively. Depression often goes undetected and those who are diagnosed often don't get proper treatment.
As a result, she developed two videotapes, "Black and Blue: Depression in the African-American Community" and "Gray and Blue: Depression in Older Adults," to address stigmas associated with seeking mental help.
"I used the medium of video to level the playing field in terms of literacy," says Annelle, who is also director of minority and national affairs for the American Psychiatric Association. "In terms of educating people about mental health, we used people who had actually suffered from depression, so that it would come directly from them.
"When you are trying to educate people about mental health issues, the more authentic you make it, the better. Having someone give a testimonial about their illness hits home. And it removes the stigma when they see everyday people talking about their illness."
Jeanine is similarly committed to breaking down barriers. But her target audience and message can be quite different. Jeanine often conducts seminars on health education for a very privileged group: NBA basketball players.
Minorities are certainly well-represented in the NBA, but does such a privileged, wealthy group really need these type of programs? As it turns out, disparities exist for minorities with resources and access to quality care.
"I have worked with health disparities for many years, and in years prior, the problem was that there was a lack of statistics," says Kima Taylor, assistant city health commissioner. "Because of that, people would say it didn't exist or existed anecdotally. Now that we have the stats, they show disparities across the board, and people say the disparity exists because of a lack of access to healthcare. But studies show that even minorities with high incomes and access to healthcare are victims."
As a result, education about disparities is needed at all economic levels. Like her sister, Jeanine communicates her message in ways that are tailored to reach a particular audience.
She speaks, for instance, on unwanted pregnancy as part of the NBA's Rookie Transition Program. "So you and your boys are dressed, you're going to the club, you look good, you smell good," Jeanine tells players assembled in an auditorium.
In the background, the music to the Isley Brothers' signature and seductive ballad, "Between the Sheets," is playing on a CD player. "So you look around the room and you say to your boy," Jeanine continues, as the CD mix shifts to "Big Poppa," a song that has the same instrumental riff as "Between the Sheets." The voice of rapper Biggie Smalls booms, "I see some ladies tonight that should be having my. . . ."
"Baa-a-bay, baby!" the players yell in unison with Smalls.
She's gotten their attention and established some credibility. Over the course of a single seminar, Jeanine will use snippets of between 10 and 40 songs to introduce topics and underscore points. She also uses the music to reinforce her message over the long term; she hopes that when players hear these songs later, it will trigger memories of what she covered in the seminar.
"I think she does a great job with us in how she presents information," says Purvis Short, director of player services for the NBA Players Association who played professionally for 12 years with the Golden State Warriors, Houston Rockets, and New Jersey Nets. "She makes it interactive, she accompanies it with music. The response from the players has been positive; they like the different approach."
For the past eight years, she has conducted seminars for the NBA (most recently, through a contract with HDS) on topics such as fathering, domestic violence, healthy relationships, HIV/AIDS, and other sexually transmitted infections. She uses the CD mixes of hip-hop and other popular music to make the seminars more culturally relevant to the players.
"You want to draw them in with your media," says Jeanine. "We are talking about edu-tainment. A teaspoon of sugar helps the medicine go down, as Mary Poppins says. The music helps get them in the mood."
Jeanine has a master's degree in social work from Simmons College and has long been involved in the health field. In the 80's, she worked for the city of New York as a disease intervention specialist in Brooklyn, interviewing patients who had contracted sexually transmitted infections. As part of the job, she attempted to convince patients to help her anonymously contact their partners—to inform them that may be infected, too.
She went on to work as AIDS coordinator at a drug rehab-ilitation center in Harlem, and later, at an HIV counseling and testing program in Cambridge, Massachusetts. It was by counsel-ing patients that she honed her skills at making presentations that appealed to the African-American community.
"Sometimes we would use our own [African-American] sayings," says Jeanine about ways that she subtly made her work more culturally relevant. "Maybe it is something your mother may have said to you when you were cutting up at the table that resonates and would draw them in."
Jeanine hopes to one day take her "non-Western" style of teaching that involves storytelling and music into high schools and colleges. "I would really like to do relationship education with boys who are locked up or high school dropouts," she says. "They may not be in situations now where they are in relationships, but they will be in the future."
What Annelle wants to see from HDS in the future is a focus on preventative treatments, "We have to look at what leads to drugs in a community, what leads to that kind of stress," says Annelle. "We have to look deeper to see how we can prevent problems like these."
And access to services is an ongoing issue. Annelle recently attended a conference in New Orleans, where she and other mental health professionals discussed ways of treating patients in isolated communities where there are shortages of psychiatrists and mental health experts. New Orleans, post-Katrina, poses particularly difficult challenges, and the group considered using videoconferencing to help patients access mental health workers.
Annelle would also like to see HDS up its national profile as it continues to educate about health disparities. Former Surgeon General David Satcher, now director of the National Center for Primary Care at Morehouse School of Medicine in Atlanta, is familiar with its work. "[The Primms] have been an outstanding family in dealing with some of the major health issues of our time and major issues dealing with the black community," he notes, citing HIV/AIDS, mental illness, and substance abuse as particular examples.
Last year, Bay Area Addiction Research and Treatment in San Francisco consulted with HDS on addiction in minority communities and its relation to mental health. In 2004, HDS developed training and curricula linking mental health and chronic diseases for pharmaceutical companies interested in ethnic and cultural issues. HDS contracts with the NBA to teach sexual health issues to the players. It also just finished a major contract with the D.C. Health Department to conduct town hall meetings in black churches and community centers throughout the District on health related issues such as diabetes, asthma, cancer, and obesity.
While the company's future is bright, it is a bittersweet kind of success for the Primms. "I think, unfortunately, HDS will get a lot of requests, because it will be a long time before health disparities go away," says Annelle. "Poverty, racial discrimination, substandard education—all of those things are the ingredients for health disparities. Until those social conditions change, we will continue."
"There could be many companies like ours and the work still would not get done," adds Jeanine.
"Health disparity seems to be like a 'Jack and the beanstalk'—it is growing to enormous and gigantic proportions," agrees Beny. "It is being hastened by more and more poverty and disenfranchisement. It is a job for private companies like ours to educate the public so we can get the public to influence the political arena. We can't look to the government to save us, unless we are holding them accountable."