By Amber Hsiao
Originally published in the2x2project.org
The day after Thanksgiving, the 2014 Greater New York Dental Meeting (GNYDM) convened at the Jacob K. Javits Convention Center, bringing together thousands of health care professionals from across the country to six days of exhibitions, seminars, and workshops. Up until this August, Remote Area Medical Volunteer Corps (RAM) had also planned to be in attendance, potentially bringing in hundreds of volunteers to provide a range of free health services to patients in need.
Dr. Ian Lerner, the general chairman of the GNYDM who was in charge of this year’s meeting and its exhibition—the largest dental convention in the country—had already been involved in running a dental program as part of the yearly meeting for the past 5 years. The Give Kids a Smile Program, underwritten with a grant from the United Federation of Teachers and the DentaQuest Foundation, provided dental screenings for third and fourth graders in NYC public schools. Colgate also donated oral hygiene supplies and knapsacks, as well as staff and vans for holding the dental screenings. Dental hygiene student volunteers and faculty from New York University, New York City College of Technology, and Hostos Community College also educated children on nutrition, and how to properly brush and floss.
“We saw about 2,100 school children last year all over New York City. A lot of the hygiene students and dentists were looking at these kids, many of whom had never seen a toothbrush before, or even toothpaste,” said Dr. Lerner. “Their gums were bleeding; it was a mess.”
Dr. Lerner wanted to find a way to do more. Since thousands of licensed health care professionals were already convening at the Javits Center for the meeting, it was the perfect opportunity to do something big.
“I thought, what if we followed up and gave these kids care?” Dr. Lerner said. “Their teachers said, ‘I can’t even get these kids to get eyeglasses, how will I get these parents to bring their kids to the dentist?’ I wanted to see if we could do more.”
Dr. Lerner initially approached Mission of Mercy, an organization that provides free health care, dental services, and prescriptions to those in need. However, since 2003, the organization had an existing partnership with the New York State Dental Association, providing free oral health services and education through 2-day clinics. They were not so interested in partnering for the Javits event, according to Dr. Lerner.
Enter RAM. A Tennessee-based volunteer medical relief corps, the organization provides free health care services to people in remote areas of the world, with a focus in recent years on addressing unmet health care needs in the United States. Since its founding in 1985, the organization has led 742 special “expeditions” via massive mobile clinics to needy areas. Founder Stan Brock and his teams bring in all the equipment—millions of dollars worth of it, including dental chairs, eye exam equipment, and more—at their expense, set up the operations, and run the logistics of serving several hundred patients per expedition. Patients often line up during the wee hours of the night, sometimes waiting even days, to receive one of the limited number of tickets that gets them access to free medical, dental, vision, and preventive care they otherwise don’t receive.
Speaking about RAM’s previous successful operations, Brock said, “When you stand at the gate at 5:30 in the morning on a cold winter’s day, or a hot summer’s night, and you open the gate and watch these people come in by the thousands—some of whom have been waiting more than 48 hours [to receive services], it’s really tragic, and I might add, a depressing look at America and what’s happening to the terrible number of poverty-stricken people who can’t afford or don’t have access to health care.”
Given RAM’s mission and history of successes holding expeditions, Dr. Lerner contacted Brock to see if he could bring RAM to the Javits Center for four of the six days of the dental meeting.
“We only go where we are invited; this is a key point,” Brock explained. “Our job was to show up and perform the event. This meant that any permits, etc. that had to be done would be done by Dr. Lerner’s group, including negotiations with the City and State of New York, the Unions, the people who work at the Javits Center—it was a big job to get all that done.”
A dental volunteer who was the head of the dental department at RAM flew out to NYC to scope out the Javits Center’s facilities to see the space and meet with Dr. Lerner. After coming back with a positive report, RAM and Dr. Lerner’s team began making arrangements for the multiday event.
Within the Javits Center, Dr. Lerner had identified an 80,000-sq-ft north section of the building that was street and handicap accessible, had multiple bathrooms, and access for tractor trailers—the whole deal. With the Governor’s help and support, the space—which would have normally cost upwards of $60,000 to rent—was provided to RAM free of cost, according to Dr. Lerner.
Dr. Lerner was also responsible for leading the huge effort to recruit volunteers for the event. Because of New York practice laws, volunteers had to be New York-licensed health professionals in order to provide health services. RAM would need roughly 1,500 volunteers, 60 percent of whom would be licensed. They planned to distribute 700 pairs of eyeglasses per day and provide services including dental extractions, fillings, root canals, general women’s health, cardiology, and podiatry. RAM expected to reach roughly 7,000 patients in the four days, according to Chris Hall, RAM’s chief operations officer.
"In New York City, there are plenty of free clinics where people can get care. We were just providing more free care, but the city didn’t want $3 million worth of free care.”
Unfortunately, state health regulations put brakes on the planning process. Somewhere along the way, Dr. Lerner and his team landed on the New York State Department of Health’s (NYS DOH) radar. According to the NYS DOH, a call for volunteers was posted in the newspaper sometime in the spring. The NYS DOH reached out to RAM, offering guidance on how to ensure health regulations were not being violated.
“We were still waiting for permission to hold the event before we took some more expensive steps to see where we would house all the volunteers and provide food to several if not thousands of patients,” Brock said. “All of it was pending further permission from the state.”
Under the NY Code Public Health Law Article 28, “no hospital can be operated without a valid operating certificate,” according to a statement regarding RAM’s event released by the NYS DOH. Furthermore, “RAM’s unapproved plan to operate a dental and health clinic is not allowed under New York State licensure laws and raises concerns with DOH about infection control and follow-up care.”
In other words, without an operating certificate required by Article 28 to support RAM’s operations at the Javits Center, there would be liability issues, particularly with infection control.
“Although we didn’t have direct contact with the State of New York authorities—all of that was done by Dr. Lerner—I did hear it mentioned that the State of New York authorities were concerned about infections," Brock explained. "Bear in mind that we have done over 740 of these expeditions and have never had any infection control problems. We have served hundreds of thousands of patients without problems.”
In recent months, RAM held a massive event in the city premises in Seattle with several thousands of patients and that was in an arena without any problems at all, according to Brock.
Nevertheless, NYS DOH did not have the authority to waive state law. While Article 28 generally applies to hospitals and nursing homes, RAM’s intention to provide services under the supervision of physicians and dentists in a “clinic” constituted the operation of a hospital.
“I got a call from the Department of Health,” Dr. Lerner said. “They gave me really good advice. There were some people there who really knew a tremendous amount, and we kind of negotiated what procedures would be acceptable at the Javits. They wanted me to find an Article 28 sponsor.”
Dr. Lerner subsequently made numerous phone calls and contacts with hospitals and federally-qualified health centers in the city, all of whom were Article 28 compliant.
“But none of them were willing to take the risk,” Dr. Lerner said. “It was their license they were putting on the line.”
“Who is making these choices, and why is RAM being held to a standard that doesn’t seem to be the same standard? It all just seems very, very political.”
Dr. Lerner explained that the Mayor’s and Governor Cuomo’s office were supportive of the effort, as was the New York City Department of Health and Mental Hygiene.
“The NYS Department of Health made several attempts to assist Remote Area Medical on set up of this event, but unfortunately RAM refused to host the clinic in accordance with New York State Law,” reads a statement from the NYS DOH spokesperson Monica Mahaffey. “DOH is willing to continue to work with RAM to provide services in the future, once RAM has met its legal requirements.”
The New York City Department of Health and Mental Hygiene declined to comment.
“It really came down to being a liability issue. [NYS DOH] would have expedited the approval process if we had found someone with an Article 28 who could co-sponsor us,” Dr. Lerner said. “But when push came to shove, I ended up having to cancel the event.”
As these events were unfolding, producers and directors Jeff Reichert and Farihah Zaman were on the road for the theatrical release of a documentary on RAM—and the first day that RAM would have been in operations at the Javits Center would have also been the day of the film’s debut in New York City. Given the unfortunate news and timing of the event’s cancellation, Reichert and Zaman co-wrote an op-ed in the Huffington Post, suggesting that Governor Cuomo’s office lacked the political will to take action.
“Given the timing of [the cancelled event] coming up on Thanksgiving week, it felt like an outrage,” Reichert said. “Here were some legal requirements that the state had asked RAM to make … everyone [in internal correspondences] was saying ‘this is really weird that we have to do this, but let’s try and do this.’ So they did try to meet the stipulations.”
Reichert explained that other similar types of events have been held in the past in New York State, which seemed to suggest that some of these decisions were being made arbitrarily.
“Sure, [NYS DOH] did try to help in some regards, but we feel that there were things that probably could’ve been done that weren’t done. Some of the objections they’ve raised are important—of course NYS should be concerned about infections. Meanwhile though, there are other clinics that operate in a similar way,” Reichert said. “Who is making these choices, and why is RAM being held to a standard that doesn’t seem to be the same standard? It all just seems very, very political.”
Nevertheless, Brock and Dr. Lerner are both hopeful that they may be able to hold an event in the future, now that they are aware of the legal circumstances.
“A lot of people are down on the Department of Health, but I think a lot of them are wrong. [The NYS DOH] is just doing their job,” Dr. Lerner explained. “I would like to say for the record that the NYS DOH was very professional and genuinely nice to speak with. I hope to work with them again. What it boiled down to was that everyone had a lot of good intentions—including the Department of Health.”
Dr. Lerner continues, “In New York City, there are plenty of free clinics where people can get care. We were just providing more free care, but the city didn’t want $3 million worth of free care.”
Taking the lessons learned from the planning experience, Dr. Lerner has already started thinking ahead to where and when he might be able to bring RAM’s services to the city. Brock is also hopeful that the event is simply “postponed” for the time being, and that they might be able to renegotiate the details to eventually host an event for the benefit of the underserved.
“There are millions of underserved people,” Brock said. “Not being able to hold the event isn’t any type of indictment of the State or City of New York—you could blindfold yourself and put a pin on the U.S. and you’d find scores of hundreds of thousands of people who are desperate for care. It’s just something the country needs to fix.”
Edited by Dana March