Working to Build a Health Care System for the Neediest People

    • October 16, 2015

Originally posted: February 28, 2002
Last updated: October 16, 2015

Position at time if the award: Medical Director, North Dade Health Center; Miami, Fla.

Current Position: Associate professor, Division of Family Medicine, Department of Medicine, Family Medicine and Community Health, Florida International University (FIU); Miami, Fla.

Cheryl Holder devotes the majority of her time and energy to special populations—patients with AIDS, TB, “babies having babies,” and other maladies that plague minority populations. Going beyond the walls of the community health center she heads, she takes her AIDS education and prevention program to beauty salons, barber shops, churches, schools, and under the bridges where the homeless find shelter.—Dade County Public Health Official

This is a person we all need in our lives whether we have HIV or we're healthy. I referred a young man who was HIV positive and a nervous wreck to Dr. Holder. He called me later and all I heard was "Thank God for your Dr. Holder." I never witnessed such a change in a person's attitude. I hung up the phone smiling and thinking another life has been saved. One thing illness does reveal is a person's true heart. Dr. Cheryl Holder definitely has that, a concern, a sincere and true heart.—Patient in the community

Learning early about a lack of health care. When she was nine years old, in 1968, Cheryl Holder's family moved from the island of Jamaica to Brooklyn's East New York neighborhood. There, she soon learned first-hand about the state of health care for America's urban poor. While playing in the street one day, 10-year old Cheryl looked on in horror as a child who had hopped the back of a city bus fell off, and lay bleeding in the street. Cheryl waited helplessly, along with a crowd of onlookers, for over an hour before an ambulance arrived. Later, she heard that the child had died. Two years later, her own father died—at home—because ambulance attendants decided he was not sick, and did not need to be brought to the hospital.

Such experiences lead many people to believe they are powerless; that decision-makers in the wider world don't care about them. But for Cheryl Holder, these early traumas were the beginning of a lifelong passion: she wanted to do her part to build a health care system that would not leave the neediest behind.

Studying hard, she made it into Stuyvesant High School, a specialized high school for mathematics, science, and technology in New York City. There she participated in a special pre-med research educational program designed to interest low-income students in medical careers. The program had a profound effect on Holder—especially her exposure to one of the nation's first community health centers, in Jamaica, Queens. It was here, while doing hypertension screening, that she decided she wanted to be a doctor, and run a community health center of her own.

After graduating from Stuyvesant, Holder went on to Princeton University, then attended the George Washington University School of Medicine as a National Health Service Corps Scholar (under the federal program established in 1970 as part of the Emergency Health Personnel Act).

Upon graduating in 1984, she chose to do her residency at New York's Harlem Hospital. Here, in an understaffed, underfunded, undersupplied city institution, on the front lines of the new tuberculosis and AIDS epidemics, Holder learned to deliver effective medical care with limited resources.

Moving to Miami. When she completed her residency in 1987, Holder began her required four years of service in the National Health Service Corps. Her commitment to serving indigent and special needs populations led her to Jackson Memorial, Miami's only public hospital. In January 1990, she was invited to become medical director of the North Dade Health Center (NDHC), a comprehensive outpatient community health center affiliated with Jackson Memorial.

NDHC was located in Opa-locka, one of the Miami area's most troubled neighborhoods. The poor, multi-ethnic population it served suffered high rates of infant mortality, teen pregnancies, low-birthweight babies, and sexually-transmitted diseases. In facing these and other problems, NDHC stood alone, caring for 16,000 patients annually. Though she was young to be the head of such a large clinic, Holder began pulling its systems together to provide better preventive care. Meanwhile, she went to work creating new programs to meet the community's tremendous needs.

To combat the burgeoning AIDS epidemic, Holder developed Project CARE (Community AIDS Reduction through Education), a creative outreach program that operated under a "train-the-trainer" concept. Health care workers visited beauty salons, coffee shops, bars, laundromats, and street corners—all the places where people congregated. Outreach staff spoke with local business owners, pointing out that the AIDS epidemic affected them directly, and convincing them to accept training as AIDS educators who would then teach their customers about HIV/AIDS and recommend they seek medical care.

As Holder later put it: "When I did hypertension screening in Jamaica, Queens, there was nobody to remind people about checking blood pressures after I was gone; no continued focus on hypertension education, except while the health center was there. So my goal was to find a way to make sure the community could take care of itself."

As part of Project CARE, Holder also organized forums focusing on nutrition, folk medicine, and job search skills—complete with entertainment by a Haitian Youth Choir. AIDS education was creatively woven into all these presentations. In a relatively short time, because of Project CARE's activities, NDHC's comprehensive AIDS program went from serving 60 HIV-AIDS patients to serving more than 400.. Holder was also responsible for raising more than $350,000 in funding for the program. She fought to have NDHC included in community-based clinical trials of AIDS drugs, thus making them more accessible to her patients. She chaired NDHC's AIDS Case Management Team; coordinated ongoing AIDS in-service training for physicians, nurses, and other staff; and helped produce a play with and for teens about safe sex and AIDS awareness. On her own time, she also worked to create AIDS housing.

During the same period (the 1990s), Holder also began dealing with teen health issues. Believing once again that people's health needs were best served where they were located, she thought that adolescent health care would be best delivered where most of them could be found—in schools. She focused on opening the John H. Peavy Adolescent Health Center, based at Northwestern High School in Miami's Liberty City area.

The proposed Peavy Center had been awarded a grant by the Robert Wood Johnson Foundation (under its School-Based Adolescent Health Care Program), but community resistance from an anti-choice coalition led the governor of Florida to reject the grant. It looked as though the center would never open—but Holder was determined not to let the dream die. She organized community meetings, offered health education classes, held health fairs, attended PTA meetings, and participated in community events—all in an effort to promote Peavy as the best place for students to receive comprehensive health care.

Through the Public Health Trust of Dade County, the entity that takes care of the county's indigent, NDHC was able to get the center opened, in spite of a bomb threat and several other obstacles. It offered medical care, psychosocial and dietary counseling, eye care, peer counseling, mentoring, and health-related classroom presentations. Slowly, Holder and her team helped quiet the anti-choice coalition, and convinced the community and the school board of the model's effectiveness. By 1994, another comprehensive school-based center had opened.

Seeing that diabetes was ravaging the community she served, Holder opened an in-house diabetes clinic at NDHC, the Diabetes Treatment and Education Program. She and the administrative team of NDHC also developed and implemented a special satellite women's health center, the Opa-locka Women's Center (OPWC), located near a housing project in an area with high infant-mortality rates.

The clinic for women had the feel of a private office, delivered comprehensive pre-natal care, and was staffed with physicians affiliated with the University of Miami School of Medicine, Jackson Memorial Hospital nurse-midwives, and NDHC support staff.

Receiving a Community Health Leader award. These efforts led to Holder's nomination and selection as a Robert Wood Johnson Foundation Community Health Leader in 1995. The award of $100,000 to further her vision presented Holder with an opportunity to bring another dream of hers to life. The program’s staff advised her not to mount yet another program, but rather to use her award money to help her handle her already large commitments, perhaps by hiring a personal assistant. Nevertheless, Holder used the bulk of the award money to open a new center for teen mothers: the Teen Parenting Program, which focused on preventing second pregnancies and improving parenting skills. The concept worked like this: pregnant teens had a combination of clinic and home visits with a case manager. Later, after giving birth and learning to care for their infants, these same teens were hired to assist the case manager with new clients, using their newfound skills as community health workers. Monthly meetings were held, providing a peer-support group where participants discussed relationships and parenting, and worked on skills such as public speaking. Social events also helped the participants bond with each other.

This decision did not turn out as well as she had hoped. As Holder later said wistfully, "I'm an example of what not to do with the money from the award." In order to set up the new program, she handed over leadership of Project CARE to other participating agencies. Without Dr. Holder's supervision, CARE workers stopped "training the trainers" and went back to direct AIDS education. Worse, to Dr. Holder's dismay, when the award money ran out, NDHC was not prepared to keep the Teen Parenting Program going. The program closed down after only four years of operation.

However, there were other aspects of her selection as a Community Health Leader that ultimately enlarged and empowered Holder's vision as effectively as the money was intended to do. Soon after receiving the award, with technical assistance from CHLP staff, Holder learned how to use the Internet to expand her reach, increase her productivity, and find and spread information quickly. All of NDHC's staff are now getting up and running on the Internet, and Holder has written a grant to train and compensate "student computer teachers" who will help other students acquire computer and Internet skills.

Annual program retreats allowed her to get to know dozens of other award winners, who have shared their stories, celebrated their successes with her, and most important, showed her ways to more effectively manage the award money.

An immediate benefit of the award was the attention Holder received from the media, and from local and state leaders. Out of this experience, she began to understand how advocacy can serve as a powerful tool to affect health care policy and access for the needy.

"I saw that much of the real answer for the population I serve is much wider than what my center can do," she says. She had always been a visionary; now Holder found her voice.

She developed the Florida Coalition for School-Based Health Care, to spread the model she'd developed throughout the State of Florida, and to get it supported and sustained by state funding through the state's health department. Advocacy in this area now constitutes a major part of her work.

Perhaps the most powerful effect of receiving the award was the one-week leadership course Holder took at Harvard's Levenson Institute, using the small amount of award money designated for personal use. "It was just a fantastic experience," she later reported. "It was the best $5,000 anybody ever spent on me. It crystallized the leadership style that I took forth from that point on, focusing on understanding people and their specific needs—what makes somebody do what they do."

Following the closure of the Teen Parenting Program, Holder spent time revamping NDHC's diabetes program, re-integrating it with the center's general medical practice. She involved the school-based health centers in their schools' truancy programs, feeling that many truants have psychological problems and family problems that counselors can work with if they know about them early on.

To Cheryl Holder, success lies in "...understanding the needs of my community and how to make solutions happen." The central theme of her efforts is to meet patients on their own ground. "The patients are never hard to reach," she says. "Folks say that all the time, but many times, we set up systems that meet our needs rather than the patients' needs. If we wouldn't do that, there'd never be a hard-to-reach patient."

Perhaps Holder's most important leadership quality is summed up best in the words of one of her patients:

“When I met her, I was distraught. In July I discovered I was HIV-positive, and in October my fiancée died of AIDS. I was considering suicide. Holder listened to me, and made me realize how precious my life was. She made me think about my children and what their lives would be without me. By giving up, I wouldn't be there for my daughter's first date, my son's first touchdown, their proms, or their graduations.

“I looked up, and Dr. Holder said to me, 'If you believe in life, and take good care of yourself, you can be one of those proud parents.' I'll never forget that by the time I left her office 45 minutes later, I had found a reason to live.”

Postscript. With the economic downturn of 2008 and succeeding years, funds for the North Dade Health Center were cut so sharply that Holder felt she could no longer reach her goal of making a difference in underserved communities. "The economic changes moved us away from prevention and into primary care," she said.

At Florida International University (FIU), where she is an associate professor in the Division of Family Medicine, she feels she is able to continue her mission in the underserved communities of Dade County, particularly with respect to the social determinants of health.

Much of her work has been with the Pipeline program, in which medical students and undergraduates from FIU go into Dade County households to mentor and tutor young people in the areas of math and science, hopefully to prepare some of them for medical careers. The project is part of the Green Family Foundation Neighborhood Help Program.

In 2008, Holder was named one of Success South Florida's 50 most powerful black professionals. More recently, in July 2015, she received a Diaspora Community Service Award from the Consulate General of Jamaica.

RWJF perspective. The Foundation recognized the first 10 RWJF Community Health Leaders in 1993—unsung and inspiring individuals who work in their communities, often among the most disenfranchised populations, to address some of the nation’s most intractable health care problems. The last round of leaders was chosen in the fall of 2012. The program closed at the end of 2014. For more information, see the Special Report.