Memoirs of a Black Psychiatrist, A Life of Advocacy for Social Change

Psychiatric Services in Central Harlem, 1982 – 2000

In the 1950s, Harlem Hospital, one of 21 member hospitals in the municipal system, was the chief provider of medical care for the community’s 400,000 residents, almost all of whom were black. Their average income was less than a third of the citywide average, which meant that almost everyone living there was eligible for publicly subsidized services. Psychiatric services had been nonexistent until 1947, after which they were furnished by four part-­time psychiatrists, one social worker, one full-­time and one half-­time psychologist, and one psychiatric nurse.

They could do little more than provide psychiatric and neurologic consultations, and make provisional diagnoses on patients with acute psychiatric disorders, who were then heavily sedated and transferred to Bellevue Hospital, several miles away downtown, from where they were moved to the state-­run Manhattan Psychiatric Center —Ward’s Island for inpatient mental hospital care.

It was not until 1962 that the situation began to change, when Dr. Elizabeth Davis, a black psychiatrist who was in the class behind me at the Columbia University Psychoanalytic Clinic for Training and Research, became one of the part-­time volunteer psychiatrists assisting Dr. Harold Ellis, the black neuropsychiatrist (more neurologist than psychiatrist) and head of the service, in providing the minimal psychiatric care available. Dr. Davis had superb credentials; she was educated at Barnard College and then at the Columbia University College of Physicians and Surgeons, and completed her psychiatric residency at the adjacent New York Psychiatric Institute. She was also from a black family with many members who were blonde and blue-­eyed and could have passed for white, and was the daughter of the Black Episcopal priest of one of Harlem’s largest churches. What’s more, she came at exactly the right time in history.

Several major forces drove the rapid expansion of the American economy after World War II: manufacturers and other corporations profited by satisfying the pent-­up consumer demand created by wartime rationing and shortages; easier credit enabled consumers to purchase homes, appliances, radios (and later televisions), and automobiles; the G.I. Bill of Rights created a new, predominantly white and well-­educated middle class, and there was unprecedented cooperation between corporate America and unionized labor. The result was a fivefold increase in the nation’s gross domestic product between the end of World War II and 1960.

An infusion of federal funds dramatically increased the nation’s hospital capacity as new hospitals were built and existing ones expanded, and receiving those funds required nondiscrimination in staffing and patient admissions. The number of postgraduate medical· training positions in teaching hospitals soon vastly exceeded the number of U.S. medical school graduates, whose quantity had been limited by the American Medical Association in order to maintain its near monopoly of medical manpower. Politics loosened the AMA’s grip: the number of medical schools and their class sizes both increased, and Catholics and Jews were no longer excluded from training positions but, as mentioned in chapter 4, hospitals turned to foreign medical school graduates to fill those slots, with little attention paid to the quality of medical education they had received or their facility with English or their ability to communicate with patients. It was not until the Civil Rights movement of the 1960s that women and underrepresented minority groups in the United States gained widespread access to the education and training that had been denied them. Before then, the overwhelming majority of women or African-­American doctors had graduated from the handful of medical schools set up especially to educate them. But the passage of Medicare and Medicaid, the creation of the Great Society’s neighborhood health clinics, and Community Mental Health Board funding all were aimed at producing a more inclusive America, and with a rising tide lifting (approximately) all boats, affirmative action was popular with the general public as well as the American medical establishment (including the American Medical Association and the American Hospital Association), and was led by the Association of American Medical Colleges, which set standards for the nation’s medical schools.

The quality of medical care provided by poorly trained physicians from other countries in the New York City hospital system had reached a scandalous low by the early 1960s, but Columbia University’s School of Public Health was in the forefront of finding a remedy. The dean of the school, Dr. Ray Trussel, also was director of the New York City Department of Hospitals. He enlisted the aid of Dr. Lawrence Kolb, chair of Columbia’s Department of Psychiatry, who accepted the responsibility of building a department of psychiatry at Harlem Hospital subject to the following conditions: that the new psychiatry department have all hiring, promotion, and firing authority; that it be given funds to hire nurses, social workers, psychologists, activity therapists, and support staff; and that only the support staff be paid from the Harlem Hospital budget rather than the Affiliation budget. With these conditions met, Dr. Kolb selected Dr. Elizabeth Davis, already on the Columbia psychiatry staff, to head the new department. A few years later, after the failure of her first marriage, Dr. Davis married Dr. Trussel. He eventually persuaded the Columbia-­Presbyterian medical and surgical services as well as the Presbyterian Hospital heads of the same departments to enter into a Harlem Hospital Affiliation, which would be managed by an Affiliation Office to be located at Harlem Hospital and responsible for quality of care at all the sites. A gradually intensifying power struggle ensued between the office of the Harlem Hospital executive director and the Affiliation Office’s director and staff.

During her 15 years as director, Dr. Davis built a department of unusual size and strength with an interracial staff, many of whom had worked with her at Presbyterian Hospital; there was no other department of that quality in the United States or the world serving a predominantly black community. As was customary for American psychiatrists at the time, however, they had little involvement with patients suffering from addictions, although heroin addiction plagued the black community and was a leading cause of death; nor were there programs for juvenile delinquents who came in great numbers to courts, corrections, and so-­called state training schools, or for school children with mild or moderate mental retardation, learning disabilities or attention deficit disorders. Almost all patients in the city with these disorders, most of whom were treated by agencies whose budgets were supervised by the State Mental Health Commission, were served by programs not led or significantly staffed by psychiatrists. For several months early in the department’s history, a community group in Harlem had not only demonstrated against this arrangement but also occupied offices of the Harlem Hospital psychiatry department demanding that it develop programs to treat drug addiction and that the community group be given a budget and hiring authority to staff and run these programs. None of these demands was met, and eventually the demonstrators desisted and regular departmental functions resumed, but many similar demonstrations were common in that era.

By 1977, Dr. Davis and Dr. Trussel had retired and moved to Puerto Rico, although they spent several months a year in New York City. The mid-­1970s saw a failure of the financial and banking interests to handle New York City and state bond debt, and the threat that the city would be forced to declare bankruptcy and surrender financial control to the state, which was heavily in debt itself following Nelson Rockefeller’s four terms as governor, during which he spent extravagantly to build a huge state university system, the Twin Towers, and the 19-­story Harlem State Office Building (now the Adam Clayton Powell Jr. State Office Building), among other notable ventures.

Unlike any of the nation’s other great cities, New York voted to share the expenses of the huge new Medicaid program on a 50-­50 basis with the state. It had for decades funded a comprehensive municipal higher education system that enabled residents to attend college virtually for free, as well a vast public transportation system. Moreover, it employed union labor to provide essential maintenance, public health, and hospital services that were unmatched in the nation. The city had tried to cope with the increasing costs of these practices by so-­called deficit financing, but it was at the mercy of the banks that held the debt and were threatening to downgrade its bond rating. Governor Hugh Carey and Mayor Abraham Beame appealed to President Gerald Ford, but he refused to provide financial aid to the city, inspiring the famous New York Daily News headline “Ford to City: Drop Dead.” Thanks to what has been described as masterful political leadership by Governor Carey, the federal government did indeed lend the state $2.3 billion, which it used to fund the Municipal Assistance Corporation (MAC). As a state agency, the MAC could float bonds; it also controlled city expenditures, won concessions from labor unions and their pension funds, and enlisted the collaboration of Mayor Beame in reducing benefits and cutting back on hiring new employees. This had serious consequences for the relatively new Health and Hospitals Corporation, which had been formed in 1969. Its second president, a black physician named Dr. John Holloman, was forced to end or severely curtail services in nine of the 19 hospitals in the municipal system. Mayor Beame had appointed him in 1974 but forced him to resign in 1977 due to his resistance to these reductions. Dr. Holloman and I were friends; he graduated from the University of Michigan Medical School the same year I entered it. Ed Koch, who succeeded Beame as mayor in 1978 and served until 1989, was outspoken in his desire to scrap the entire municipal hospital system, but the private voluntary hospitals kept him from doing so because it shielded them from having to provide health services to patients who had either no health coverage or Medicaid, with its relatively low fee schedules.

Central Harlem’s population had dropped from 400,000 in the 1960s to 230,000 in 1970. This shrinkage was largely due to the flight of the black middle class which had severely weakened the neighborhood’s political clout.

From the time I left Cornell in 1980 until I started at Harlem Hospital in 1982, I worked half-­time on the child psychiatry service at Metropolitan Hospital in East Harlem, a predominantly Puerto Rican neighborhood, and had seen at close hand not only the increasing political power of the Hispanic community but also how a rivalry was being nurtured to drive a wedge between the black and Hispanic minority groups in New York. Comprising an entire new wing of Metropolitan Hospital, this neighborhood’s huge, federally funded Community Mental Health Center was one of the most modern and attractive psychiatric facilities of any kind in town. The Metropolitan Hospital and Community Mental Health Center director, a Jewish psychiatrist named Dr. Al Freeman, had confided to me that when he graduated from medical school in the 1940s, the best internship he could obtain in New York was at Harlem Hospital.

Harlem Hospital’s director then was Dr. Louis Wright, a black physician who couldn’t even get an appointment to its staff in 1927, despite having graduated at the top of his class at Harvard, because whites headed all the clinical services there at the time as well as comprising the entire administrative leadership. Dr. Freeman was proud of having appointed a black woman, Dr. Phyllis Harrison Ross, as the Community Mental Health Center’s director of psychiatry. She and I learned to our mutual surprise that we were both graduates of Albion College.

I noted while working at Metropolitan that they had little trouble recruiting interracial staff to work there, especially on the children’s service, and that their services were very popular and heavily utilized by community members. It seemed clear that the Puerto Rican political leadership had been successful in obtaining maximum benefits from the city and state for its constituents, and that more Hispanics than African-­Americans were being appointed to the city and state offices that oversaw physical and mental health and substance abuse services. Deliberate efforts to divide minority communities were nothing new in New York City, where government funds have historically gone to neighborhoods controlled by ethnic and religious groups. Rivalries along those lines have long been a feature of city life and politics.

It was therefore not surprising that the position of director of psychiatry at Harlem Hospital was vacant from 1977 until 1982. The Columbia University College of Physicians and Surgeons’ search committee could not find a candidate who was willing to accept the job, whose professional credentials were acceptable to Columbia, and who could win the approval of the Health and Hospitals leadership, the Mayor’s Office, and the hospital’s all-­black Community Board. Columbia had proposed a white woman psychiatrist on their faculty as director, who would be assisted by two black psychiatric residents who had recently completed their training and were on the staff of one of their community mental health centers, but the Community Board would have none of it. Overtures had been made to me by members of Harlem’s medical staff, especially Dr. Margaret Haegerty, the director of pediatrics, a white physician who had known me when we were both at Cornell and New York Hospital, but I was not convinced it would be a good move for me. I had long believed that ideally there should not be a separate hospital system for the poor, black or white, but that all income groups would be better served in the same system. True as that was and is, it was and is also true that in New York City, health and hospital services, even for the poor, are distributed on the basis of neighborhoods that are dominated by the religious and ethnic groups who live in them. What this means and meant was that a given neighborhood will have only as much as its clout can get, and Central Harlem lost a lot of influence when its middle class population nosedived. This overwhelming reality was the main reason I decided, after more than a year of vacillation, to accept the position of Harlem Hospital’s Director of Psychiatry.

When I arrived at Harlem, I was pleased to find that the Department of Psychiatry still maintained its own separate affiliation contract with Columbia University, and that essential features of the department remained under the control of its director and administrative staff (as Columbia’s director of psychiatry had insisted). Not only did the director of psychiatry recruit, hire, and promote psychiatrists, of which there were 35 (two-­thirds of them full-­time and board-­certified), but he also appointed and supervised the director of the residency program and its 32 residents. The director also selected the heads of support disciplines such as nursing, social work, and activity therapy; and the department’s administrator also had final authority in hiring all of the more than 300 support and maintenance staff, although their salaries were under control of the executive director of Harlem Hospital Center, who was appointed by the Health and Hospitals Corporation.

I gradually became aware that I had been a victim of “bait and switch.” Within three years of my arrival, the adversarial relationship between the municipally appointed executive director and the affiliation office director ended badly for me. My chief administrator was no longer a member of my affiliation staff but rather a member of the Harlem Hospital executive director’s administrative staff. This left me with direct administrative control only over psychiatrists and the selection and supervision of psychiatry residents. The heads of all of the support disciplines such as nursing and social work and psychology were not selected by me but still required to attend my weekly departmental meetings because, as head of the department, I was responsible for quality of all the clinical services.

Many serious problems had developed in the department during its five years without a director, the most serious of which was that the residency program had been placed on provisional status by the national specialty training board, meaning that the program would be terminated if deficiencies in both what they were taught and how they were supervised in their clinical work were not corrected within three years, and we could no longer train future psychiatrists. My clinical training and specialist certifications were to play a major role in the training redesign, as I was able to be a major teacher and supervisor in all the department’s services. This provided my first opportunity to see how much support I could expect to receive from the Columbia University Department of Psychiatry, which had overall authority for assuring the quality of our training and clinical services, and it was considerable. They made me a member of the Columbia psychiatry department’s leadership staff, and I was expected to make a brief report of Harlem’s progress and problems at its monthly meetings. I was appointed to the New York State Office of Mental Health’s Professional Advisory Council, which consisted of directors of psychiatry of state, city, and voluntary private hospitals who met monthly with the New York State Mental Health Commissioner to review statewide problems and possible solutions. I received almost no direct guidance or support from the director of psychiatry at Presbyterian Hospital as to how we should redesign our training program. My director of residency training was scheduled to meet each month with the director of Columbia’s residency training program, but received no specific guidance on how our program could regain full approval. Through a contact I made during my meetings with the State Office of Mental Health, I became friendly with the director of psychiatry residency training at New York University and Bellevue Hospital, who volunteered to help us develop a new training curriculum so we could receive full accreditation again. This was, indeed, accomplished within the allotted three years, and our program received high marks in subsequent reviews by the national residency training board.

One of my primary missions in coming to Harlem was not only to develop a strong program of residency training and clinical service but also to make it an important center for psychiatric research. Thus, one of my requirements for accepting the appointment was that I be given resources to develop clinical service research programs to study the most effective means of providing psychiatric treatment to an inner-­city patient population. I envisioned building on the five-­year experience I had had in Brooklyn as psychiatric consultant to a social work team that provided outreach therapy to a group of 29 multiproblem families with what turned out to be little benefit, producing only minimal improvements in their overall family function. Here was an opportunity to see if adding outreach psychiatric treatment to social service visits would promote better patient outcomes and compliance with the psychiatric treatment planned for them after they were discharged from the hospital. I was able to recruit Dr. E. Joel Millman to join my staff as research coordinator when I learned that he was losing his position at Creedmore Hospital, one of the large state hospitals in the borough of Queens. He had received his PhD from Columbia as well as a master’s degree from the Columbia School of Public Health. Dr. Millman and I worked closely together throughout my 18 years at Harlem in one of the most productive collaborations of my professional life. Another important supporter was Dr. Elmer Struenig, one of the principal epidemiologists for the New York Psychiatric Institute and a professor in the Columbia School of Public Health, whom I had met while I was at Cornell on one of my research projects there. He invited Dr. Millman and me to meet with him, gave us computer access in his department, and welcomed the prospect of our collaborative research.

Many faculty members in the Columbia University School of Public Health also held appointments in the Department of Psychiatry. Since I received my training at Columbia’s Center for Psychoanalytic Training and Research, I had become friends with some members of this Columbia network.

Our clinical services and research programs at Harlem both prospered. Despite continuing budget cuts and reductions in staff, we actually increased the number of our inpatient beds from 37 on my arrival in 1982 to 68 when I left in 2000. This happened largely because the State Office of Mental Health was committed to reducing the number of patients admitted to the Manhattan State Psychiatric Hospital in order to shift responsibility for their care as much as possible to private voluntary hospitals or, as a last resort, municipal hospitals. At Harlem, we usually saw 10 to 20 patients a day in our psychiatric emergency room, half of whom needed to be admitted for inpatient treatment of acute psychotic disorder. Since we ordinarily had enough beds for only three or four of those patients on our inpatient service, the city mandated that we call Metropolitan Hospital, our back-­up city hospital, which had almost twice as many beds as we did, to see if they had room. If we were still left with patients requiring admission, we had to contact other hospitals in the municipal system. Manhattan State Hospital also had an acute hospital service, but they had set a quota in the early 1980s of 20 admissions a month from Harlem Hospital’s ER. When I left Harlem 18 years later, Manhattan rarely admitted more than two or three a month. In fact, it maintained a large day treatment program, treating several hundred patients daily in an attractive, fully staffed facility located 15 blocks from Harlem Hospital in the huge and handsome Harlem State Office Building. When one of their patients decompensated due to lack of compliance and needed to be admitted to a hospital for acute treatment, their protocol specified that the patient be sent to the Harlem ER rather than to Roosevelt Island, where Manhattan State Hospital is located.

In 1990, Richard Surles, the New York State Mental Health Commissioner and his staff selected Harlem Hospital to partner with Presbyterian Hospital’s Psychiatry Emergency Room and become one of the first four psychiatric emergency rooms in the state to be designated as Comprehensive Psychiatric Emergency Rooms. It was to be the first such collaboration in state history between a municipal hospital and a private voluntary one. Each hospital received a grant to renovate its psychiatry emergency room and add six inpatient beds, where patients could remain for up to three days. The grants also paid for additional staff: a general internist, a psychiatrist, and social workers. Increasing numbers of patients were coming to psychiatric emergency rooms suffering not only from acute psychotic illness but also severe substance abuse, usually alcohol in conjunction with several other drugs, especially cocaine. Their ER visits were usually triggered by their substance abuse, and that would be made the focus of their treatment plan. If such patients were unwilling to accept referral for drug treatment, as was often the case, we could only give them counseling and discharge them to the street. Those willing to be referred had to have some form of transitional residential care until they reached to the top of the waiting list for drug treatment. Our designation as a Comprehensive Psychiatric Emergency Room also gave our partnership access to 6 of the 30 beds in the Crisis Residence on the grounds of the Manhattan Psychiatric Hospital, where patients could remain for up to a month while waiting for a residential drug treatment program to accept them. During that time, Manhattan Psychiatric Hospital required that our patients be brought back to Harlem or Presbyterian for day treatment to improve their readiness for drug treatment. Since Presbyterian offered no day treatment for such patients, Harlem was allowed to use all six beds. This new arrangement meant that we were able to provide better care than ever before for patients with both mental illness and substance abuse issues, and our patients’ subsequent clinical course was substantially improved. Today, such patients would not have access to this high quality of continued treatment because residential drug treatment currently is reimbursed for no more than 30 days, rather than the six months to two years that is usually required and was covered in the 1980s and 1990s.

My opportunity to do the more significant clinical research I had sought when I accepted the position at Harlem Hospital came toward the end of my first year there. We were awarded a $400,000 research grant by the Robert Wood Johnson Foundation, supplemented by another $200,000 from the New York City Health and Hospitals Corporation, to collaborate with Dr. Struenig and his staff at the New York Psychiatric Institute in researching the effectiveness of outreach case management in reducing the rehospitalization rate of patients who had been discharged after treatment for acute psychosis, with or without concomitant substance abuse disorder. Our study focused on patients with no psychiatric hospitalizations in the previous two years. Dr. Millman and I met weekly with our case management team to review the patients’ discharge treatment plans and modify them if necessary. Dr. Struenig and his postdoctoral research assistant met with our Harlem team once a month, while Dr. Millman and I met with Dr. Struenig and his research assistant once a week.

Two to three days prior to being discharged from one of our inpatient wards, patients were randomly assigned to one of three groups: the intervention group, the control group, or the chronically ill group, which Dr. Struenig and his team had already followed for several years. Our case management team reviewed the comprehensive treatment plans for the intervention group and control group patients at the time of their discharge, including medical problems, psychiatric problems, substance abuse problems and social problems. A similar plan was prepared for patients in all three groups, but those in the control group and the chronically ill group received routine treatment and care while Dr. Struenig and his team also continued to provide case management for members of the chronically ill group. Intervention group patients were expected to follow the prescribed ambulatory treatment as well, but one of our main findings was that these patients quickly came to rely persistently on the case management team to meet their treatment needs and refused to go to our regular department outpatient clinic.

We followed these patients for three years, from 1985 to 1988, and published our findings in three papers in peer-­reviewed journals. It turned out that more than half of the patients in all three groups had severe substance abuse problems along with their psychotic disorder. The first of these papers showed clearly that despite having no history of previous psychiatric hospitalization, our intervention group experienced relapses and rehospitalization more frequently than expected (during the time of the study, our intervention group had 86 hospitalizations, almost the same as Dr. Struenig’s chronically ill group, which had 81 hospitalizations while our control group had only 37 hospitalizations). Our explanation was that both our case management team and the patients’ families watched our intervention group patients more diligently, so signs of relapse were detected sooner and were followed up with the only intervention we had available: a hospital bed, rather than a safe, secure and less heavily staffed holding environment. In other words, the reimbursement system was dictating the kind of service we delivered, which was not as good as it would have been in the best of all worlds.

The second paper asked, “Does outreach case management lead to improved physical health and longevity of the Intervention Group by comparison with the Controls?” We were surprised that the answer was negative, but that may have been because patients entered the study continuously over the three-­year period, which was too short a time to reveal different mortality rates. However, our physician assistant’s scrupulous care in taking care of our patients’ physical health needs, often going with them to see their physicians and helping them follow recommended treatment, did not make any significant difference in their health outcomes and those of the Control Group that we measured over those three years.

The third paper sought to answer the question, “Does outreach case management lead to a better quality of life as measured by current instruments clinically available?” Again, surprisingly, the answer was negative. It was easy to observe that, as was the usual practice in American psychiatry at the time, the medication prescribed for our patients was excessive compared to the norm in the early years of our use of these psychotropic drugs and, still today, most of the rest of the world use smaller dosages of these drugs than we use. This high drug dosage left many of our patients appearing to be lethargic rather than sociable, outgoing, and apparently enjoying life. This lowered their overall quality of life score but not enough to be statistically significantly different from the Control Group. In other words, we came close to finding that no treatment at all was better than what was available at that time in psychiatry. Nowadays, articles in professional journals and the general media have raised serious concerns that the entire U.S. population has become overmedicated in the last 40 years. The pharmaceutical industry in recent decades gained permission to market its drugs directly to the public, which would have been inconceivable years ago. Moreover, the extreme reductions in length of inpatient hospital stay, demanded by the insurance industry and the so-­called managed care revolution, has forced patients to receive large doses of several medications to qualify for reimbursement for the few allowable days for inpatient care. To be sure, appropriate doses of medication will improve the quality and effectiveness of treatment within four to six weeks, but such lengthy stays are no longer reimbursed. It has become increasingly clear that newer forms of cognitive behavioral psychotherapy, along with relaxation and meditation techniques, are underutilized in the current management of severely mentally ill patients in this country, compared with most other nations, including those in the developing world.

 
We made several significant improvements in the clinical practice of psychiatry during my last decade at Harlem. Within a relatively short time in 1991, we reduced the proportion of patients coming into our psychiatric emergency room who were restrained, the first in a series of reductions in the use of force and violence in our management of acutely ill psychotic patients. New York City police protocol required that when officers encountered a person behaving in a disorderly and potentially dangerous manner in public, the person should be subdued and handcuffed for everyone’s protection (i.e., it is safer for the patient and also prevents the arresting officer from using excessive and brutal force). Once the patient crossed the threshold of our ER, those handcuffs were by protocol removed and it was to be our staff’s clinical assessment which determined whether physical restraint was necessary or the situation could be handled better otherwise. In one of our accreditation reviews by the Joint Commission on Accreditation of Hospitals, we were asked what percentage of our patients continued to be restrained by medical order, after police handcuffs were removed, and we found it was about 85%. The reviewer suggested that we consider making it a goal to reduce the percentage to, say, 50% within six months. To our amazement, we found that simply by trying to use less forceful methods we were able to reduce our restraint percentage from 85% to 15% in the first month, simply by clinically quieting and talking down these frightened and angry patients.

Maintaining that low level of physical restraint in our emergency room became a source of pride for us and was, of course, a vast improvement for our patients.

Restraints had been used on our inpatient wards only sparingly since the earliest days of our department; we began providing acute inpatient care in 1962, and our patients were never placed in an isolation room, where they would have been constantly monitored and sometimes also restrained. Only in recent years have accrediting organizations and the American Psychiatric Association leadership banned isolation as a general practice.

At that time, we were averaging about 12 restraint orders a month on our 62 inpatient beds, but we noted that almost half of these were occurring on weekends, at which times nurse staffing levels were lower due to budget restraints. We brought consistent pressure on hospital administration and nursing administration to increase our weekend nursing staff levels but with little improvement.

We also felt that our inpatient length of stay was too long. Our average length of stay of 30 days was less than that of most other municipal hospitals but far more than the range of 12 to 15 days in the private voluntary system. We were therefore at a competitive disadvantage with managed care corporations, which preferred hospitals with shorter lengths of stay. Discussions were under way to bring the municipal hospitals in line with managed care principles in order to survive. One reason for the shorter stays in private voluntary hospitals was obvious: all patients at the leading private hospitals were not only admitted voluntarily but also had to show proof of ability to pay before being admitted; police ambulances brought disturbed and impoverished patients with no coverage to municipal hospital emergency rooms. We knew, however, that we should do our best to set and meet more competitive goals. The facts were that about 70% of all psychiatric hospital admissions nationwide were voluntary rather than involuntary, and the percentage for New York State was 59%. To our embarrassment, our rate of voluntary admissions was close to zero. We increased our voluntary enrollments to 60% within six months. At the same time, we reduced our average length of stay from 30 to 15 days.

How did we do it? When an acutely ill patient was brought to our emergency room, hopefully with a family member or friend, our emergency room staff called them to a conference room when the patient had been quieted as much as possible, and we explained to them that we should make a decision together as to how long it would take for the patient to be discharged. The patient was usually already known to our staff from previous admissions, and our staff and the patient’s friends and relatives usually knew why the patient had relapsed; we would send our emergency staff’s estimate of how long the hospitalization should take to our inpatient service. It was no wonder both voluntary admissions and cooperation with treatment plans soared. Unfortunately, our readmission rate within 30 days of discharge was about 11%. This was twice as high as other municipal hospitals, but their average length of stay was about twice as high as ours. This caused a great deal of controversy, but I was willing to be unpopular for the sake of what I thought to be better clinical practice. My approach was seen as just another example of my incorrigibility, which led to a mutual parting of the ways by the end of 1999.

This chapter will end with the story of the twin plagues that afflicted the Harlem community in the nearly two decades I was there: the AIDS epidemic and heroin addiction. I’ll begin by explaining some basic facts about the Human Immunodeficiency virus (HIV), one of the most serious of all sexually transmitted diseases. Its severity became manifest in this country in the early 1980s, when it was first understood that the HIV virus attacked the body’s CD4 lymphocytes, the source of the immune system that protects us from infections as well as killing the new cancer cells which regularly form in all of our bodies. This virus can be transmitted to an uninfected person only by an exchange of bodily fluids — such as semen, vaginal fluids, rectal mucosa exudate, breast milk, or contaminated blood on needles or other injection paraphernalia used by intravenous drug abusers — with an infected individual. A few days after contact, a newly infected person may experience non-­specific flu-­like symptoms.

Although these symptoms go away spontaneously, the virus begins to multiply rapidly throughout the body. It may take 2 to 15 years before the signs of Acquired Immune Deficiency Syndrome (AIDS) appear. All during that long time, an infected person can unknowingly transmit the disease to sexual partners or persons with whom needles are shared. Even newborn infants can become infected as they pass through an infected mother’s birth canal.

Within three months of the initial infection, the body’s immune system will have produced enough antibodies to destroy the virus, but this virus mutates rapidly as the body creates new antibodies against it, and this struggle goes on for years. A blood test of the infected person for HIV infection during all of those months will show positive. Men who have sex with men were the first group in which the diagnosis appeared, but since no known treatment existed, this vulnerable but often socially powerful group resisted the stigma and discriminatory treatment that would result if their infected status were to become known, as it could make it impossible for them to purchase health or life insurance, obtain employment, rent an apartment, or avoid personal isolation.

Ordinarily, sexually transmitted diseases, like syphilis and gonorrhea, by law had to be reported to the state health department, and proof of treatment had to be produced prior to obtaining a marriage license. Moreover, all newborn infants were tested and, if found to have been infected during childbirth, had to be treated for sexually transmitted disease to prevent serious subsequent illness. HIV infection was different, because there was no treatment for it and only palliative treatment for AIDS. Those wishing to know if they were HIV-­infected could be tested (but, in New York, only in a State Health Department laboratory) and there were two stages in the procedure: an initial test to see if the virus were probably present, taking one to two weeks, and an additional confirmatory test, which would take up to another two weeks. Activist homosexual groups demanded that no one could be tested without seeking it and undergoing two phases of counseling: the first to outline to the patient the pros and cons of finding out whether they were infected and, if so, a second phase explaining how to avoid infecting others and best manage their subsequent medical care needs. This would clearly have a chilling effect on the participation of persons who were well aware of their potential future victimization. Moreover, state health departments were only required to report cases that had been diagnosed as AIDS to the federal Office of Infectious Diseases, not those whose lab tests revealed they were HIV­infected and possible carriers of a then-­fatal disease (a serious conflict between privacy and public health). Not until 1988 did the first treatment drug appear, when AZT (also known as zidovudine), was found to reduce the infection rate of babies born to HIV-­infected mothers if they received the medication just prior to labor and delivery. Since effective antiviral medications began to be available in the mid-­1990s, federal health authorities have required that anyone past the age of puberty seeking treatment in a medical facility be tested for HIV infection (results can now be known definitively within an hour), unless they refuse even after counseling. Treatments are now so effective that HIV infection, though still not curable, can be controlled.

During the past 25 years, when a patient complies with treatment, their life expectancy has risen to be almost as long as that of a person never infected. And it is of great significance from a public health perspective that persons receiving treatment are almost completely unable to infect anyone else. But during the many years that I served at Harlem Hospital, the only effective means of preventing the spread of this disease was through preventive counseling preceded by testing, and the efforts I exerted to implement that were among the most frustrating and also exhilarating of my psychiatric career. In other words I ran against the current and attempted to have patients tested as soon as they were willing to do so, and to counsel them against knowingly infecting others or their newborn infants even before effective treatments became available. This made me unpopular in many quarters.

By the mid-­1980s, AIDs had become the leading cause of death in the United States for men 25 to 45 years old, and more than half of AIDS victims were black or Hispanic, as were 90 percent of mothers with children who had AIDS, excluding those who had been infected by contaminated blood transfusions. Almost 10 percent of babies born to infected mothers in New York City were testing HIV positive at birth, and more than half of these infected newborns were in Harlem.

Harlem Hospital admitted about 35 AIDS patients a week, with an unknown additional number of infected patients because routine HIV screening was not a part of standard admissions procedure. There were special problems associated with discharging infants who were infected or showing signs and symptoms of disease, such as mothers abandoning their babies and refusing to bring them home; their numbers were piling up on the pediatric inpatient wards. Clearly, a public health emergency existed, more so in Harlem than in any other community in the State. Intravenous drug abuse was a major reason in Harlem, more so than men having unprotected sex with infected men, which was the leading cause in other communities.

In those years Methadone Maintenance Treatment (MMT) was known to be the most effective treatment for heroin addiction. Although it did not cure the disorder, it was determined to be the most effective corrective measure by federal health authorities and the standard-­setting National Academy of Medicine.

When injected into the bloodstream, heroin produces a euphoric high which lasts three to four hours, but tolerance develops quickly and ever higher dosages are subsequently required to match the effect of that first high. By contrast, the person who takes methadone orally in front of the nurse at the medication window will be free of craving for 24 to 36 hours. This makes it possible for the addict to come to the clinic, daily at first, and once an effective maintenance dose is established, the addict will feel comfortable and have free time to pursue a meaningful and productive life, rather than constantly needing money for his habit and committing crimes or stealing from family members or friends to obtain it.

Not surprisingly, MMT was found effective in reducing the rate of HIV infection as well as hepatitis C, since both are spread by sharing needles with an infected addict. The best of these MMT programs, like the ones we offered at Harlem, had primary care physicians, social workers, and psychiatric consultants with regularly scheduled hours to assess the severity and interaction of the addict’s physical, psychiatric, social, and legal problems and make a treatment plan suitable for his or her particular combination. The patient and the treatment team then came to an agreement as to which staff member would work with the patient on what problems within a prescribed time period. When the American Board of Psychiatry established the new subspecialty of addiction psychiatry in 1994, the head of our emergency service and I were the first of the 94 psychiatrists to be certified in it. Two more of our attending psychiatrists joined us the following year.

We also studied the attitudes and behaviors of our MMT patients and the counselors treating them at our four offsite clinics in Harlem, the results of which were published in the Journal of the American Medical Association in 1989. The state of New York provided HIV testing only to persons seeking it voluntarily, with the stipulation that neither their name nor other identifying information would be known by the laboratory doing the test. The other way the HIV test could be administered was termed “confidential,” rather than anonymous, meaning that the patient had requested the test from a private physician who agreed not to reveal the patient’s identity without his or her written consent, or had elected to have it in a medical clinic or hospital as a part of a medical workup or in preparation for surgery, with the understanding that the results would be placed in the patient’s confidential medical chart so that all personnel who might come into contact with the patient’s bodily fluids would be aware of the need to use infection control measures.

Of the approximately 70 percent of our 1,400 MMT patients who voluntarily responded to our questionnaire, 21 percent said they had received anonymous testing but none had received confidential testing. Moreover, in not a single instance had the patient sought this testing on the advice or suggestion of our treatment staff, nor had the treatment staff been informed of the test result, nor had the staff recommended the test. There had been no previous article that reported what percentage of MMT patients was asking to be tested for HIV infection of any kind, nor of any MMT program staff recommending testing or knowing of test results. In short, it was a potentially lethal case of the blind leading the blind, one of our previously unreported findings. Both staff and patients knew almost all the risk factors, and that the two main ones were sharing needles with an infected addict and having unprotected sex with an infected partner. About 80 percent of our 58 staff members answered the questionnaire. Only 15 percent believed that patients were on their own in reducing risk-­taking behaviors, whereas 49 percent of the patients believed the opposite. It was truly surprising that neither situation had been previously reported, considering that, especially early in their treatment, patients were required to see counselors as often as five times a week, depending on their compliance with clinic requirements.

There were no easy generalizations to be made about the patients in the study. In terms of education, they were almost equally divided among those who had dropped out of high school, those who had graduated high school, and those who had had at least a year of college. We knew from our own files that approximately 20 percent of all our MMT patients had had some college education, but in our study sample it was 32.4 percent; in other words, a significantly higher percentage of the educated patients answered our questionnaire. Overall, about 90 percent of patients reported that they had shared no needles with anyone in the current year, compared to 81 percent in the preceding year. As for sexual activity, about 29 percent said they were celibate in the current year, and 62 percent were monogamous, which were smaller percentages than the previous year in both cases. A total of 68 patients had been celibate the year before, compared to 145 in the current year, and there was an overall general decline in numbers of sexual partners.

We learned more by seeing what happened when needle sharing and a high level of sexual activity coincided. Generally, the rate of needle sharing went hand in hand with the number of sex partners, reaching such levels that roughly half a dozen patients shared needles with 13 to 35 others and also had 16 to 50 sex partners in a given month. Such patients knew the risk they were running of becoming infected, but the fear it instilled in them was not enough to improve their behavior, which is usually the hallmark of clinically dangerous self-­destructiveness requiring involuntary hospitalization or isolation to protect themselves and others.

Clinical studies and our own observations at the time showed that one-­fifth to one-­quarter of addicts also suffered from clinically severe psychiatric problems, especially depression, with histories of suicide threats or attempts requiring brief hospitalization and subsequent treatment, to which they seldom adhered. These problems were usually secondary to their use of one or, more often, several substances, along with heavy drinking and chaotic personal relationships.

In May 1987, New York City Health Commissioner Stephen Joseph asked me and a small group of other black physicians to his office to discuss the twin crisis of AIDS and heroin addiction in the black community, ending with an invitation to submit our suggestions for an appropriate response to him. We knew that he was planning to initiate a needle exchange program in the city, under which heroin addicts could go to health department offices and pick up clean needles in return for their used ones. They would not be tested for HIV infection or counseled about it, but they would remain in the needles program until they could enter drug treatment, preferably MMT. The presumption was that patients had to wait weeks or months before entering MMT because there was such a long waiting list.

The program was, in my opinion, a publicity stunt to divert attention from considering a truly effective program, which would test for HIV infection and counsel both the addict and his or her close contacts, who also needed to be tested. My private conclusion was that a deliberate effort was being made to conceal the actual number of people infected with the HIV virus, although the Centers for Disease Control had said from the earliest years of the epidemic that any geographic service area or medical facility with as much as a 1 percent incidence of AIDS (the end stage of the disease) in its population should include HIV screening, testing, counseling, and appropriate treatment referral as part of its routine medical workup. There was every indication that the entire Harlem Hospital patient population exceeded that threshold, but the leadership of the Health and Hospitals Corporation refused to act on it, and I surmised the reason was that there was not enough money to pay for the serotesting and counseling which could absolutely prevent this fatal disease, even in the absence of effective medication. While I did everything within my power to make this message known, I encountered increasing resistance, which evolved into attempts to shut me up. So I appealed to the black political leadership in Congress, gaining the support of Representatives Charles Rangel and Floyd Flake, as well as Manhattan Borough President David Dinkins, Special Narcotics Prosecutor Sterling Johnson, the influential black newspaper The Amsterdam News, and the black clergy leadership, which had presented signed petitions to Mayor Koch and State Health Commissioner David Axelrod. The needle exchange program was launched nonetheless and it failed miserably, with only a handful of addicts signing up. The idea that a gimmick like this would be the salvation of the black community was both insulting and a disgrace, but well-­intentioned people hailed it as compassion.

In reality, there was no waiting list for addicts seeking methadone treatment; Harlem admitted all acceptable patients within two days of their application. Drug dealers in Harlem usually included clean needles with the powdered heroin they sold in a glassine envelope, and other addicts sold clean needles they had stolen from drug stores or obtained from diabetes patients who used them to inject insulin. When David Dinkins became mayor in January 1990, one of his first acts was to terminate the needle exchange program, but these programs continued to operate underground in New York City despite the local ban. The same was true elsewhere as well; the ban against federal funding for them was lifted in 2009. And preposterous claims for the success of these programs are still made, although research had shown that addicts had been changing behavior on their own since the 1990s without any staff intervention of any kind.

My research staff and I wrote a proposal for a voluntary screening and testing program, not only for patients entering our MMT program but for anyone admitted to any clinic or emergency room or inpatient ward on any service at Harlem Hospital. The Johns Hopkins University Hospital, located in black, inner-­city Baltimore, had already found that as many as 10 percent of the patients in its general emergency room, almost all of them black, were HIV­ infected.

Our proposal was that, at a cost of $1.25 million a year, we could test, screen, and counsel all incoming new patients at our medical center. Department of Psychiatry staff would interview and assess the patients and formulate treatment plans for effective preventive counseling. This proposal was submitted to all the appropriate city agencies, and strong letters of support came from the dean of the Columbia University College of Physicians and Surgeons, their director of the Department of Psychiatry, and the dean of the School of Public Health at Columbia. Harlem Hospital’s Ethics Committee voted for it, and it was forwarded to the Research Committee of the Health and Hospitals Corporation, whose approval was necessary before it could be submitted to the National Institutes of Health. When that committee (to me deliberately) delayed approval until the last day proposals could be sent, ours was disqualified for being a day late.

We received a sort of consolation prize in 1990, a two-­year service grant from the city Department of Health that made it possible to reduce the caseload of the counselors at one of our four MMT clinics from 50 patients to 35. This allowed them to counsel not only patients but also family members who were willing to participate. We also were able to hire a primary care physician. The percentage of new patient enrollees who were HIV positive had already begun to decline, and fell from 44 per cent in 1990 to 23 percent in 1997; addicts were changing their own behavior, as our previous research had shown. A major factor was that addicts were giving up intravenous injection of heroin in favor of smoking crack cocaine, which had become by far the drug of first choice, especially among younger users. Perhaps the most dramatic finding was that when our Department of Obstetrics and Gynecology offered AZT treatment to women in its clinic for prenatal care in 1994, only 10 of 50 accepted. Of those 10, only one gave birth to an infected baby, while nine of the 40 who refused AZT treatment delivered a child testing positive for HIV. Contrast this with what we found for women enrolled at all four of our MMT clinics during the 1990s. Federal regulations required that all women attending a methadone clinic be tested for pregnancy every six months. From 1988 to 1993, we averaged six to eight pregnancies annually among the 150 women of childbearing age in the one clinic of ours that we could follow more intensively. (We were only able to focus intensively on one clinic because the grant did not allow the reductions in caseload which would have allowed fewer patients per counselors and would have also allowed counseling of family members and patients in group sessions.)

After we counseled all the women who might become pregnant on the need for HIV testing, every one of them agreed to be tested, and not a single baby was born with an HIV infection.

Fortunately, federal regulations since 2006 have required that all pregnant women be tested without any special consent beyond what’s routine for all patients before receiving medical care, unless they opt out for reasons documented in the medical record. The same is true for all persons above age 13. While health departments expect special vigilance to ensure compliance in health service areas with a high incidence of HIV infection (which are now reported by 35 states), the only health areas exempted are those where repeat testing shows that fewer than 1 in 1,000 patients are HIV positive.

Required case finding presents problems, however, because the states vary in their requirements regarding health insurance coverage for HIV treatment. There is no effective nationwide coverage even under the Affordable Care Act, which still leaves more than 10 percent of citizens uninsured, although that 10 percent is the lowest level ever achieved. Obviously, this burden rests most heavily on unemployed or low-­income individuals, particularly those in disadvantaged minority groups.

At the end of 2006, 46 percent of the 1.1 million people living with HIV infection in the United States were African ­Americans, who represent only 12 percent of the overall population. Rates of new infection for African-­Americans have steadily increased since federal monitoring began, even as they have fallen for all other ethnic groups. There is no prospect that these disparities will be erased without special affirmative action efforts aimed at the still segregated black community. Even reducing poverty, increasing the minimum wage, and fixing our broken education system will not be enough to reshape opportunities in the most highly segregated and isolated black communities. My years at Harlem Hospital provide compelling evidence that despite this bleak portrait, special efforts can make a significant difference, but black leadership alone does not have the power to bring about change without the commitment and support of others.

 
What I value of what I learned is that one must have clearly stated objectives and plans in order to achieve a worthwhile goal, and periodically document how your whole treatment team can identify what works and what doesn’t, and be willing to adjust the pathway to meet your goal. Such an evidence-­based group effort will not necessarily be accepted by outsiders with different agendas, so you should attempt to mediate your differences to replace conflict, as much as possible, with at least a shared vision of an outcome that would be in the best interest of all.

Let me give some concrete examples. When Mayor Rudolph Giuliani assumed office in January 1994, one of former Mayor David Dinkins’s staff members arranged a reception for me in February, Black History Month, at which I would be honored for my contributions to improving health care in Harlem. Mayor Giuliani knew that I had been a strong supporter of Mayor Dinkins and that he had provided our hospital with sufficient financial support to keep our programs not only alive but thriving. In his speech, Mayor Giuliani talked about what he would be doing to improve life for Harlem’s citizens but not once did he mention my name. Just a few weeks later, Mayor Giuliani announced his intention to terminate all MMT programs in the municipal hospital system, of which mine was largest, despite expert medical opinion that MMT was and still is the most effective treatment for heroin addiction. This alarming news came to me at the worst possible time.

One of my concerns had been that a large number of prisoners at Rikers Island, the city’s largest jail, were known to be addicted to heroin, among other substances and probably were also infected with HIV, but they received no HIV testing or counseling either during their stay or when they were released back into their home community, which for a huge percentage of them was Central Harlem. It seemed to me that Harlem Hospital, with its large addiction treatment program and my growing interest in preventive counseling for persons at risk for HIV infection, should expect and accept a leadership role. I realized that as an essential first step, these discharged prisoners should have immediate access to a safe, attractive, and treatment-­oriented place to live, where they could be given a treatment plan that met their general medical health care needs, appropriate mental health and substance abuse therapy, and help with plans to develop their readiness for employment, and that they should remain in the residence until they were ready for independent living.

Just such a residence was, in fact, already in operation in Brooklyn, where a gentleman named George McDonald, his wife, and other associates provided a home for homeless men, many of them addicted to various substances and with histories of incarceration, under the aegis of the Doe Foundation, their nonprofit corporation. These addicted men were invited to live in their residence located in the Brooklyn Armory at no cost for room and board, with the understanding that it was totally drug-­ and violence-­free and that they must commit to participating in structured group sessions, run by the men themselves in various stages of recovery, and in job training for cleaning and maintenance work. The foundation had contracts to provide janitorial services (and, later, building renovations) at city-­owned facilities, employing residents who could then earn money to help support themselves after their discharge. With surprisingly little traditional professional staff, this work program, named “Ready, Willing, and Able,” was highly successful in turning lives around. It enabled many of these men to form or reunite with their families.

The program soon expanded to have residences in Manhattan and Queens, and Mr. McDonald agreed with me that one was also needed in Central Harlem. I served on his board of directors for several years, but the Health and Hospitals Corporation never provided funds for us to rent and renovate a suitable building. As a result of this process, I renewed my friendship with Dr. Mitchell Rosenthal, who for many years had directed the Phoenix House drug-­free residential treatment programs for adults and teenagers, many of whom were former addicts or prisoners. Phoenix House did not use MMT, but its treatment programs eventually led to sustained remission for as many as a quarter of its clients (which, we both realized, was roughly the same long-­term success rate we found in MMT patients). It seemed that a number of us were finding that a safe, therapeutic, and caring place to live and develop new relationships was what worked.

In late 1998, I had lunch at the White House with Gen. Barry McCaffrey, appointed by President Bill Clinton as director of the Office of National Drug Control Policy (or “drug czar”). He knew of my interest in developing a program for prisoners returning to Central Harlem from Rikers Island, and had invited me because he felt my experience with MMT and our plans for transitional and therapeutic housing, work experience, and peer group support and leadership showed great potential for success. The General gave me great encouragement and expressed a willingness to come to New York and discuss the matter with me and appropriate authorities. But when Mayor Giuliani learned of my meeting with General McCaffrey, he instructed the municipal hospital leadership and the executive directors of both Harlem Hospital and the Affiliation Office of Columbia University to advise me to discontinue this project. I was further advised that I needed prior approval from their offices to meet or have written contact with anybody outside the hospital. It was clear to me that staying at Harlem was unthinkable under such circumstances.

For that reason it was a surprise when I was notified that, far from being terminated, our MMT program would receive a $1.1 million grant for enhancements from the Health and Hospitals Corporation, but hopes for a therapeutic residence and collaborative planning program for the prisoners at Rikers Island had to become a “dream deferred.” This unexpected grant must have been arranged by silent supporters unknown to me, who did not agree with the way I had been treated. If I had learned one thing with certainty by this time, it was that most important matters are managed behind the scenes by hidden players, who are opposed to transparency in the allocation of public resources for the good of the entire public. The last thing the powers that be will tolerate is that planning be open and visible and with the participation of the leadership and citizenry of the area involved.

 
With the passage of years I can see more clearly how some of my views were changed dramatically for the better because of those 18 eventful years at Harlem Hospital. When I came in 1982, the psychiatry residency training program was only provisionally approved by the national accrediting agency, and it was my belief that the major flaw was that the overwhelming majority of the residents were graduates of foreign medical schools, many of which had standards which were far beneath those of schools in the United States. Furthermore, almost all of them had come from families of the privileged elite in those countries who looked down on persons of lower status, an attitude I feared would be brought with them when they came here. An even greater handicap was my view that their frequent lack of facility in speaking and understanding English, and their lack of cultural competence in understanding Americans, and especially black people, would fatally impair their ability to form effective communicating and collaborating relationships with black patients.

My reservations and prejudice toward foreign medical school graduates were totally wrong, reflecting an unfair bias of which I was unaware. Under the supervision of our attending psychiatrists, including me, these young aspiring psychiatrists did indeed form close and effective working relationships with their black patients in spite of substantial cultural and language differences. These psychiatric trainees came from countries like India, Pakistan, Korea, the Philippines, Haiti, Nigeria, and Ghana. Moreover, 30 or more years later, many of them have become faculty members at medical training centers across the United States, and almost a dozen remain at Harlem Hospital’s Psychiatry Department; one who came from Pakistan has for the past few years been Director of the department.

In all my years at Harlem, we failed to recruit for our residency training even one first-­rate American black graduate from a black American medical school. We also never recruited an American black from a US integrated medical school. By contrast, I had been able to recruit as members of my psychiatry attending staff half a dozen highly qualified American black graduates from leading integrated medical schools, including three from my former Cornell program and three others who I had supervised when they were pursuing subspecialist community psychiatry training from Columbia University.

Also, two Jewish leaders in the Department — the Director for Quality Assurance and Coordination for Research, Dr. E. Joel Millman, and Stuart Aaronson, an Administrative Director — have helped to hold the department to its high level of performance since they came to work with me more than 35 years ago. This has been a remarkable demonstration that people coming from disparate origins can work as effective team members because of their common humanity. Our department was never short of well-­trained white psychiatrists applying to become members of our staff. The Columbia University Medical Center Affirmative Action Office required regular reports guaranteeing that we were not discriminating against them because they were not black. Harlem Hospital gave me the opportunity to experience the full meaning of affirmative action from the inside out.

Figure 5-­1. Me receiving an award for services delivered by the Department of Psychiatry in the Harlem Hospital by members of the Community Mental Health Board and its Commissioner, Sara Kellerman, as well as Dr. Louis Marcos, Director of Psychiatry of the NYC Health and Hospital Corporation.

Figure 5-­2. Me with two of my Harlem Hospital chiefs of service who had trained in our residency training program years earlier. Dr. Charles from Haiti (second to left) and Dr. Naidu from India (far left) and four of our residents then in training.