Left to right: Mikhalya Brown; Ashaki Smith; Heather Reis, MBA; Amy Balbierz, MPH; and Naissa Piverger, MPH; taken at the The Blavatnik Family Women’s Health Research Institute’s Summer Networking Event in August 2019. 

Since I was five years old, I have been interested in women’s health. This passion comes in part from my background, being raised by a single mother and witnessing the births of all three of my siblings. I was in awe of the trust that my mother, and many other women, had in their gynecologists and obstetricians, as well as the support and attentiveness that OB/GYNs give every woman. I knew from then on that I wanted to become a provider like the ones my mother had.

Both in high school and on campus at Columbia University, finding research and internships in the field of women’s health proved a challenge in itself. Due to experience requirements and age restrictions, I could not take advantage of many opportunities. However, the Blavatnik Family Women’s Health Research Institute (BFWHRI) Summer Undergraduate fellowship afforded me the opportunity to work with skilled researchers in my desired field and get my own feet wet in a vast pool of information.

One focus of BFWHRI, and that of my summer fellowship, is research highlighting health disparities that gravely affect minority women. My initial research therefore focused on endometrial cancer. The most common gynecological cancer and fourth most common cancer in women, endometrial cancer is increasing in incidence among all women.  Among black women, however, the incidence is higher for more aggressive subtypes of the condition compared to both Hispanic and non-Hispanic white women.  Research is needed to identify and better understand risk factors that may increase the development of aggressive histologic subtypes in black women. In the summer of 2019, while under the supervision of cancer epidemiologist and BFWHRI faculty member Tracy Layne, PhD, MPH, I learned about the role of obesity as a risk factor for endometrial cancer in this context.

Obesity rates are increasing globally, but past research indicates that black women have the highest prevalence of class 3 obesity (defined as morbidly obese – body mass index ≥ 40 kg/m²). Socioeconomic factors, such as education level and income level, do not account for the higher obesity prevalence among black women. The physiological impact of obesity promotes an estrogenic environment that can create the perfect conditions for a tumor to grow in these estrogen-sensitive organs.  However, the obesity-estrogen-endometrial cancer association is strongest for non-aggressive endometrial cancer for which black women have a lower risk compared to non-Hispanic white women.  In addition, despite obesity rates similar to black women, Hispanic women do not face the same burden of aggressive endometrial cancer. Taken together, this suggests that other factor(s) beyond obesity may be relevant to risk of aggressive disease subtypes in black women.

During my fellowship, I also worked with Dr. Layne on her research exploring the relationship between vitamin D and endometrial cancer given its potential anticancer activity and the higher risk of suboptimal vitamin D status in black populations.

Along with this research, I learned that I love being in a predominantly female and racially and ethnically diverse work environment. I am thankful for the opportunity that BFWHRI has provided me this summer and for reinforcing my passion for women’s health. I look forward to the impactful research that all members of this team are doing and my continued work with the Institute.

The LEAP team joining the NYC community on the sunny steps of City Hall on May 15, 2019, as part of Hepatitis Awareness Month.

Hepatitis C virus (HCV) is affecting more women now than in previous decades. Many of these women are of child-bearing age. HCV largely affects men in the “baby-boomer” population, or adults born between 1945 and 1965. However, a new wave of HCV infections has started to affect younger men and women due to intravenous drug use.

A recent report from the Centers for Disease Control and Prevention noted that HCV infection has been increasing in women of child-bearing age, particularly in the rural area of Appalachia. The report found that between 2011-2014, increased HCV detection among women of child-bearing age and testing of children under two were observed both nationally and in Kentucky (by 22 percent detection in women and 14 percent testing in children under two nationally; for Kentucky the corresponding increase was 200 percent for detection and 151 percent for testing HCV among these populations). Further, the proportion of babies born to HCV-infected mothers increased by 68 percent nationally and 124 percent in Kentucky.

HCV was called the “mystery virus” when patients were first diagnosed in the 1970s. Before the virus was identified in the early 1990s, the medical community called it “non-A, non-B hepatitis.” Researchers pursued this unknown virus that was largely asymptomatic, though complications from HCV include decompensated cirrhosis, which presents with a buildup of toxins resulting in yellowing of skin, tar-ish stool, and psychological confusion. Risk factors for acquiring the virus were found to be largely blood-borne, including sharing contaminated drug items and tattoo or piercing needles. Other factors now include medical transmission through a pre-1992 blood transfusion or organ transplant, sexual transmission, and prenatal transmission.

HCV is easier to cure now than ever before. New treatments introduced after 2011 are highly effective, boasting more than a 90 percent cure rate and few side effects. These drugs, called Direct Acting Antivirals (DAAs), are taken once a day for 8-12 weeks for most patients diagnosed with HCV. However, patients with HCV may face many barriers in getting these medications. As health care advocates, we must challenge the health system to put patients first, and extend additional efforts to cure an infected population facing complex comorbidities and psychosocial barriers to care.

HCV presents unique challenges to pregnancy and reproductive health. In 2015, the New York State Department of Health noted that in New York State, “57% of female cases of HCV were of child-bearing age.” A recent weekly update from the Centers for Disease Control and Prevention reported that approximately 68 percent of pregnant women with HCV infection also have opioid use disorder. The American Association for the Study of Liver Diseases and the Infectious Diseases Society of America now recommend HCV screening for all pregnant women. Increased screening during prenatal care can lead to an expanded sphere of testing that includes partners and children. Currently, children are still rarely screened for HCV.

Tatyana Kushner, MD, a hepatologist with a joint appointment in OB/GYN at The Mount Sinai Hospital, says that women are particularly affected by the spike in intravenous drug use. Women, she notes, may engage in particularly high-risk behaviors specific to intravenous drug use. She states that “women who inject drugs appear to have a higher risk of incident HCV, possibly due to higher risk-injecting behaviors compared to men. Women are more likely to be injected by others, more frequently to be injected by sex partners, and more likely to engage in high-risk sexual behaviors for drugs than their male counterparts.”

Dr. Kushner also highlights the challenge of linking HCV infected patients to care, citing research indicating that out of the approximately 3.5 million people estimated to be living with chronic HCV infection, 50 percent are aware of their diagnosis, just 16 percent have been prescribed treatment, and only 9 percent have achieved sustained virologic response. The steep drop in participation at each point of contact for HCV patients reflects the challenges of medical intervention in this at-risk population, and suggests that pregnancy can be used as an opportunity to diagnose new HCV infection among women who may otherwise not present to health care.

HCV treatment during pregnancy remains a controversial topic, since more data is needed to accurately represent current HCV treatment safety in pregnancy. The Food and Drug Administration has warned that the earlier HCV treatments interferon and ribavirin are teratogens, which may cause abnormalities in fetal development. Direct Acting Antivirals, however, are not classified as teratogens. Some hepatologists, including Dr. Kushner, advocate treating pregnant women with DAAs during pregnancy to reduce the risk of passing the virus on to children, which is uncommon but is thought to occur at or around the time of delivery. Many HCV DAAs are not associated with toxicity in animals, but human data is limited. According to Dr. Kushner, DAAs used in the third trimester after embryonic organogenesis is already complete can significantly decrease a high viral load in a matter of weeks and is likely to reduce mother to child transmission.

Linking patients with HCV to care, including the younger female cohort, can improve future health outcomes by positively reinforcing each point of contact between the patient and the health care system with care coordination initiatives.

What resources do we have to help connect vulnerable patient populations, including pregnant women, to care? The Liver Education and Action Program (LEAP) works to improve engagement in persons living with HCV infection as part of the Institute for Liver Medicine at Mount Sinai Health System. Led by Medical Director Ponni Perumalswami, MD and Behavioral Director Jeffrey Weiss, PhD, the LEAP program advocates for a system-wide approach to HCV screening and linkage to care that includes patients seen in the inpatient, outpatient, and emergency department units.

Our patient navigators help link persons who screen positive for HCV to follow-up care, while our care coordinators and peer navigators guide linked patients through the HCV treatment process. Patient navigators provide education and counseling, assist with scheduling appointments, and offer to accompany patients to appointments with peer navigators.

Since 2018, LEAP has partnered with the Mount Sinai Beth Israel Emergency Department in a comprehensive effort to screen patients in New York presenting at the Emergency Department for HCV. The program then uses its unique care coordination resources to effectively link infected patients to HCV care.

As a patient navigator with LEAP, it is my job to empower patients to feel like they are at the helm of their health journey. My role is part customer service and part advocacy. After speaking with the patient on the phone, I want them to know that they are in control of when and why they go to the doctor. I want to provide them with as smooth an entry into care as possible by helping them interact with insurance, medical record acquisition, and referrals.

A patient navigator is an important advocate for patients who need support when embarking on an HCV treatment regimen. Patients can call a patient navigator if they are billed incorrectly by the clinic, if they aren’t treated well by the front desk, or if they are having a hard time scheduling an appointment or transportation. The role is flexible, and provides patients with as much or as little support as they need. Efforts to provide patients with testing options, transportation, referrals to Mount Sinai’s social work office for financial support, reminder calls, appointment scheduling, and emotional support have contributed to positive changes in the health and lives of patients.

Drs. Perumalswami and Weiss also created HepCure, an innovative electronic web-based application that enhances patient engagement by providing resources directly to patients and offering a secure communication tool between patients and their providers. HepCure also sponsors weekly webinars that update the medical community on a range of HCV-related topics, including the evolving epidemiology of the virus and new trends in diagnostics, testing, and treatment.

The increased incidence of HCV among reproductive-age women presents significant public health challenges. These challenges are matched, however, by an enormous opportunity to support patients when they need it most. Care coordination programs utilizing patient navigators can provide substantial opportunities to increase the quality of life for some of NYC’s most at-risk patients by linking them to the health care system—for good.

Colleen Stapleton is a patient navigator with the Liver Education and Action Program (LEAP) at The Mount Sinai Hospital, where she works to improve care for patients living with hepatitis C.

Omara Afzal, DO, MPH, training community health workers in South Africa.

I have spent much of my career involved in global health care. I am an obstetrician/gynecologist, and the massive scale of maternal morbidity and mortality globally has humbled me. I have traveled to villages in South Sudan, refugee camps in Jordan, rural areas of South Africa, and a post-war post-Ebola Liberia among others, to train, educate, and increase health care capacity of areas in need. And yet, when I return home to New York, I see a country with advanced medicine and resources–and also the highest rate of maternal deaths among developed countries. I have come to the startling understanding that women at home in New York and the United States are also suffering in and around pregnancy at alarming rates, and something needs to change.

Sixty percent of maternal deaths in the United States may be preventable with better access to prenatal and postpartum care and self-management of chronic diseases. The United States has an overall system of care that focuses intently on a healthy baby and perhaps not as much on the mother, particularly in the postpartum period. Mothers are taught to take their prenatal vitamins, avoid unpasteurized products, and count belly kicks, but are often unarmed in knowing when and how to seek care for their own illnesses. Women also often do not receive the health maintenance and disease management that they need in the postpartum period. For example, very few women with gestational diabetes return for the recommended postpartum glucose testing to make sure blood sugar has returned to normal, and many others do not seek care for blood pressure checks, depression screenings, and other support that can help women get their health on track after childbirth.

At the Obstetrics and Gynecology (OB/GYN) Ambulatory Practice at The Mount Sinai Hospital, we have worked hard to provide comprehensive and evidence-based medicine while also offering a network of support services. However, the current care model depends on clinic-based counseling, requiring the patient to come to us. This really does not hit where the most impact may be made–in the patient’s home. Chronic diseases and evolving medical conditions require a holistic approach to manage and address issues, and office visits alone in a medical setting are just not enough.

A common health approach used globally, but especially in areas of low resources, is using community health workers (CHW). These are non-medical people who live and work in the same communities as the patients. They connect with the patients in a way that medical professionals may not be able to. This model, though used widely outside our borders, is now catching on within the United States and right here in New York City. Community health workers, or “health coaches,” bring much needed support into the home, through education and care coordination. Health care providers will often work closely with CHWs to connect patients who may need additional management and liaison with the medical system. These workers are trained to help women gain the skills to successfully self-manage their health and navigate medical and social services through one-on-one coaching and ongoing check-ins.

As a Fellow in the Clinical Scholars Program of the Robert Wood Johnson Foundation, I found an opportunity to engage in research around community health worker programming for maternal health. Collaborating with organizations that work with the model of CHWs, our team aims to train coaches in the prenatal and postpartum period, to increase health literacy, and improve outcomes for especially high-risk patients with diabetes or hypertension during their pregnancy. The health coaches will also continue to support patients postpartum with goal-directed health promotion and disease self-management counseling. Health care providers will be in close contact with CHWs to ensure that patients are on track in-between visits and after their deliveries. We are hoping a program such as this will improve rates of preventable maternal morbidity and mortality by empowering women for self-care and management of high-risk diseases. Through ongoing research and program development, we have the ability to change the statistics and improve a woman’s outcome during pregnancy and beyond.

Omara Afzal, DO, MPH, is a member of The Blavatnik Family Women’s Health Research Institute, the Medical Director of The Mount Sinai Hospital OB/GYN Ambulatory Practice, and an Assistant Professor in the Department of Obstetrics, Gynecology, and Reproductive Science at the Icahn School of Medicine at Mount Sinai.

Author Heather Reis, center, with members of her team at The Blavatnik Family Women’s Health Research Institute, from left. Front: Ashaki Smith and Anna Kheyfets; Back: Teresa Janevic, Tracy Layne, Elizabeth Howell, and Amy Balbierz

I had a background in genetics and started my career as a laboratory scientist before pivoting to the field of reproductive medicine. That’s when I found a love of helping people in a new way: from beyond a lab bench.

I recognized I had a deep interest in women’s health and helping provide health care opportunities for those who previously did not have access to them. At that point, I started working with egg donors and families who needed third party reproduction services in order to start a family.

Then I went back to school to get an MBA in order to learn more about how to combine business with my background in science and women’s health research. I knew that improving on my management, analytical, and marketing skills would allow me to achieve my goals of helping others in a way that was practical and made sense for me. And it worked.

Transitioning to my role as a project manager in the Obstetrics, Gynecology and Reproductive Science Department at the Mount Sinai Health System seemed like an ideal way to expand upon my previous experiences.  Becoming more hands on in a position at the intersection of administrative executives and physicians, and seeing how my impact can make a difference, is an exciting challenge.

Since joining Mount Sinai in October 2018, I’ve been fortunate to experience both personal and professional development. I’ve always had a goal of helping others and having a positive impact on the community, and I find that in my role I can achieve this.

As a project manager I work on special projects and operations alignment opportunities. This involves making sure each division within the Department communicates and shares best practices and ways to improve with a broader goal of achieving better outcomes and continuing to be one of the best health care systems in New York City. I also assist with administrative work surrounding appointments and promotions in the Department, which includes onboarding new physicians, maintaining credentialing, and updating and creating contracts.

One of the greatest pleasures working at Mount Sinai has been my opportunity to join the staff of the Blavatnik Family Women’s Health Research Institute. Working with the team at the Institute has been a rewarding experience. Being able to work with others who share a passion for women’s health, while working on expanding the research opportunities at Mount Sinai and beyond, keeps me engaged and focused on current trends in the women’s health field. The Institute seeks to address women’s health concerns across the lifespan by engaging in research, education, and networking activities that foster a positive community in search of a common goal.

The team at the Institute is inspiring, energetic, intelligent, and hard working. Whether it’s planning the Inaugural Women’s Health Research Symposium, attending the informational seminar series discussions, or competing with each other in the Reach Your Peak Wellness Initiative (a system-wide wellness program encouraging teamwork and healthy habits with the goal of increasing physical activity) I continue to be excited about the work being done at the Institute and look forward to the many opportunities ahead. The monthly Blavatnik Family Women’s Health Research Institute Seminar Series offers lectures on a variety of topics in women’s health and I encourage anyone looking to learn more about a wide range of topics at the forefront of women’s health research to join us. 

Heather Reis, MBA, uses her experience, education, and personal interests to foster her career as an administrative women’s health professional. As a project manager in the OB/GYN department and member of The Blavatnik Family Women’s Health Research Institute at the Icahn School of Medicine at Mount Sinai, she continues to develop her passion for women’s health current topics and innovation.