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Caring for the Most Vulnerable a “Moral, Ethical, Medical Responsibility”

07/31/18

Standing outside the exam room door, Blima Ludmir warns her husband, Jack Ludmir,
MD, that the patient inside is skittish and shy. She quickly relays the young woman’s story: She arrived from Honduras just four weeks ago, somehow making it across the border into the United States with her five-year-old daughter. She speaks no English. She doesn’t know exactly how far along she is in her pregnancy. She only knows she had to escape the violence in her country.

Ludmir nods, motions to the two medical students with him to follow, then throws open the door with a jovial, “Hola!”

Inside, 26-year-old Ingris sits on the examination table nervously toying with the paper pink-orange hospital gown, her daughter, Sandra, by her side. Ludmir immediately starts speaking to her in Spanish, making conversation to put her at ease. He asks her about her previous pregnancy, her family, and then he asks about leaving Honduras.

Speaking softly, she tells Ludmir why she had to leave her country. It was dangerous there for her—so much brutality. Gangs had killed her brother. They had killed many of her friends. For no reason. She feared for her life and the life of her daughter. She risked the dangerous journey to join her husband in Philadelphia.

“And this is why we do this,” says Ludmir, turning to his students. 

Mother and daughter came with only the clothes they were wearing. They had no identification documents, no money, and certainly no medical records from Ingris’ first pregnancy.

“Do you think we can get any medical records?” the doctor asks the students. He answers his own question with a shake of the head and weary smile, “Welcome to my world.” 

That world consists of the most vulnerable of humanity—pregnant, frightened, and often undocumented immigrants in need of someone to trust. These poverty-stricken members of society somehow find their way to the Jefferson Latina Women’s Clinic, where the OB-GYN, his wife, and the dedicated volunteer staff offer medical care and kindness.

“This could be the only time they will be treated with dignity and respect,” Ludmir says. “That is why
it is so important to take time, give them some TLC. They are used to being abused by everyone in society—they will not be abused here.”

The Jefferson Latina Women’s Clinic, which just celebrated its first anniversary, is a comfortable space with a cheerful waiting room and four exam rooms. Here, providers deliver prenatal and postnatal care for women with no money, no support system, and nowhere else to turn.

While the clinic is the brainchild of Ludmir, he says the “backbone” of the center is his wife, Blima, the volunteer patient navigator, translator, and 24-hour on-call advocate for the disenfranchised. 

Both Jack and Blima grew up in Peru and moved to the United States to pursue their education. Throughout their lives they have shared a common belief that they were put here to do some good in the world.

After medical school, Ludmir trained at the Hospital of the University of Pennsylvania in OB-GYN with a specialty in maternal-fetal medicine. He served on Penn’s faculty for several years, and then moved to Boston in 1992. After a six-year stint at Harvard, he returned to Philadelphia as chief of the Department of Obstetrics and Gynecology at Pennsylvania Hospital. 

Around 2003, he started to notice an inordinate number of Hispanic women showing up on his labor and delivery floor who had never had prenatal care. “Most were from Mexico, and I was really concerned and wanted to find out what was going on,” he said. What he found out was the history of Hispanic migration to the United States.

Over the years, the regions of origin of the Hispanic population in Philadelphia has shifted. In the 1940s and 1950s the majority came from Puerto Rico; in later years, immigrants from the Dominican Republic settled in the United States, and in 2000, an influx of Mexicans sought to build a life working in the restaurant industry as dishwashers and line chefs. 

Wanting to learn more, Ludmir sought out Steven Larson, MD, an emergency department physician at the University of Pennsylvania, who had been working with the migrant population in Kennett Square for many years. The two spoke about undocumented immigrants and the need for low-cost or free healthcare; they came up with a plan for a patient and community-centered clinic that served the Hispanic community. 

The nonprofit they created was Puentes de Salud (“Bridges of Health”), with an extra component called Latina Community Health Services that specifically catered to women. Puentes de Salud in South Philadelphia continues to serve as a multidisciplinary, community-based collaborative that promotes health and wellness through low-cost, high-quality healthcare, innovative educational programs, and community building. 

In 2016, Ludmir decided it was time to take a sabbatical—a working sabbatical. He and Blima traveled to Colombia to work toward reducing maternal mortality rates. However, while they were there a new challenge in the region developed—
the Zika virus. Ludmir was contacted by Colombia’s Minister of Health to help write national guidelines on how to deal with Zika during pregnancy. Once the unexpected assignment was completed, the Ludmirs turned their attention back to the United States.

“You don’t have to go overseas to encounter misery and poverty—you can find it here in our own neighborhoods,” Ludmir says. Although the city boasts areas of great wealth, Philadelphia is overall the poorest of the large urban cities in the United States. More than 25 percent of its residents live below the poverty line; it has some of the highest rates of obesity, smoking, HIV, low-birthweight babies, and maternal mortality of any of the country’s 10 major cities; more than 20 percent of the population does not have access to inexpensive, nutritious food; and there is a serious lack of available healthcare in many of its poverty-stricken neighborhoods. 

Because of these staggering statistics, Ludmir sought a new opportunity to help on a “glocal” basis—global and local. That opportunity came in
a phone call from Stephen K. Klasko, MD, MBA, president and CEO of Thomas Jefferson University and Jefferson Health. 

“He gave me the task of creating an initiative that will narrow the health disparities gap and improve conditions in Philadelphia. And that is where the Philadelphia Collaborative for Health Equity originates,” Ludmir says. 

The P-CHE is a new citywide initiative Jefferson is helping to launch that addresses the social determinants that contribute to the health disparities in so many communities within Philadelphia. The grassroots approach seeks to build trust in the communities and create an alliance of government, business, philanthropic and nonprofit organizations, and citizens to address challenging issues that contribute to the complex social problems of Philadelphia and its residents.

The Jefferson Latina Women’s Clinic is part of that collaborative effort. Once a week approximately 16 to 20 women seek low-cost or no-cost prenatal and postnatal care at the clinic—women such as Ingris, who Ludmir says is an example of the latest wave of immigrants from Honduras fleeing the violence that claims one out of every 1,000 people
in that country. 

The lucky are able to escape to the United States, and yet, they are still afraid. The political climate in the country has all undocumented immigrants on edge, concerned they will be scooped up by Immigration and Customs Enforcement (ICE) and deported to home countries to face what amounts to a death sentence. 

But to Ludmir’s team, caring for pregnant women and their babies is not a matter of political right or wrong, it is a “moral, ethical, and clinical issue; prenatal care should be a universal right,” he says.

Lack of prenatal care puts both the mother and child at significant risk for health complications, including premature birth. Many complications of pregnancy are easily preventable and easily treatable, but can be serious or fatal if left untreated. 

“It just makes medical sense to provide this care, it makes moral sense … and it makes financial sense,” he says, noting an extensive study in California that found it costs three times more to care for a sick baby than to provide basic prenatal care that would result in a healthy baby. 

“Como esta, amiga?” Ludmir greets Berenice, a very pregnant woman, as he enters the exam room. 

Berenice is from Mexico and speaks very little English. She is all smiles, and says she is grateful that she only pays $5 or $10 for the clinic visits that help to keep her pregnancy healthy—and that she doesn’t have to pay at all if she doesn’t have any money that day. 

He then recruits her as his “ambassador” to the community by asking in Spanish, “Will you tell others what good care you get here?” 

“Oh yes, yes,” she replies emphatically in English.

Due to the political issues surrounding undocumented immigrants, the clinic relies on word of mouth to let patients know it exists. But Ludmir avoids talking about the “politics of immigration,” focusing instead on devoting time and energy to providing healthcare to a population under stress. Aside from poverty, the language barrier, high rates of suicide attempts, and other challenges, his patients often face societal prejudice, even from some within the medical community—something he is trying to change by bringing more healthcare professionals into the clinic to experience its mission firsthand. 

The team at the center includes Ludmir’s “right hands”—Dacey Stratton, CRNP, medical director at Puentes de Salud; Annette Silva, LPN, community
nurse liaison at Puentes de Salud; and Sanlly Helena,
a medical assistant with Jefferson’s OB-GYN department—as well as ultrasound sonographers and receptionists. In addition, SKMC residents and medical students rotate through, as do visiting residents from other programs. In an exchange program with Latin American countries, a recent medical school graduate from Colombia doing a year clerkship with the OB-GYN department also lends a hand. 

“We went into this challenging field to care for people, and I hope we can inspire at least one person to do the same,” Ludmir says. “I hope we can help them to understand what a great privilege it is to care for another human being.”