Monday, March 30, 2015

Looking Back, Looking Forward...

Next week is National Public Health Week (NPHW).  In previous years of blogging, I've made a point of writing a post each day.  For a variety of reasons, that will not be happening this year...but at least this one NPHW post will.

I like to make lists.  Grocery lists, Christmas lists...and public health lists.  Since "officially" becoming part of public health over ten years ago when I graduated with my MPH, these are a few of the things I've seen:

1.  The passage of the ACA, and the subsequent Supreme Court decision to uphold it.  Definitely the most far-reaching public health happening, and hands down the coolest policy thing I have seen.

2.   SARS, Ebola, H1N1, regular influenza, etc.  Signs that our world is indeed global and that these diseases know no boundaries...and testaments to the intelligence and skill of the public health professionals who handle these epidemics, some of whom are friends and colleagues.

3.  The recent Disneyland measles epidemic, a sharp reminder that immunizations are
a public health triumph....and that more people should get them.

4.    Too many uninsured people (i.e. undocumented immigrants) who have difficulty accessing and paying for care...proof positive that public health still needs to protect and serve vulnerable populations.

5.  Some passionate, effective, powerful public health advocates, who are committed to speaking up and making a differnece.

And no public health list would be complete without includingthings that I hope to see in the future:

1.  The ACA solid and strong, with a King v. Burwell decision that upholds it as is, and without any Congressional repeals or actions to weaken the law.

2.  Fewer vaccine-preventable diseases, and more people who are fully immunized.  My public health friends and colleagues who do epidemics have plenty of material for their knowledge and skills without Measles, etc that could largely be avoided..

3.  More public health professionals who have been trained to advocate, who feel that moral imperative to speak up,  who make advocacy part of their personal and professional lives.

4.  Health care and coverage that are affordable and accessible for all people in our country...wherever they were born, whatever their age, whatever their needs.

5.  More people whose right to health--a right codified in international law--is fulfilled.  People who have access to clean water and safe food, people who earn enough money to stay out of poverty, people who are safe from war and violence, people who can get quality health care when needed.

Happy National Public Health Week!

Sunday, March 22, 2015

The Computer in the Room...

Recently, I was a patient.  Like many patients, I was in an exam room with...a computer. Which was meant for physicians and staff to access Electronic Medical Records (EMRs).  On one hand, I was glad that the EMR provided the history I didn't know well, and that the doctor could access it quickly.  On the other hand, I felt like the computer screen received as much, if not more, attention than I did as the actual patient in the room.

In a previous life when I interpreted, I worked with a bunch of health care providers, who had different ways of handling the computer-in-the-room.  Some managed to keep their attention on the patient while seemingly effortlessly also glancing at and typing on the computer from time to time.  Others were generally glued to the screen.  It varied.

In light of my recent patient EMR experience, I absolutely love the quote that has been floating around the Internet (Medscape article and various Tweets), courtesy of Abraham Verghese, a fantastic doctor-author.  Dr. Verghese spoke at the recent American College of Cardiology conference, and reportedly said "The EMR has nothing to do with your heart, or your patient's heart." 

Wow.  Just wow.  I happen to think this powerful quote should be framed and posted in highly visible locations (i.e. physician/staff lunchroom walls) in almost every clinic, hospital, health center, medical school, nursing school, etc.  As a reminder that the EMR is not the be all-end all of patient care.  As a reminder that the patient and provider are at the center of the health care equation, not the EMR.  
A great New York Times article began with a funny story, about a hospital's print ad, in a journal, to recruit physicians, which stated "no EMR."  This is meant to be a selling point for the hospital.  After I finished laughing, I started thinking more seriously.  Yes, I can probably think of some physicians who would prefer to practice in the world of paper, not EMRs, at a place like this hospital.   And some patients might as well.  Would I go back to pure paper as a patient?  No. The EMR does have being a great memory that reminds my doctors with alerts when it's time for certain exams and tests.  Along with this EMR, though, I want...doctors who look into my eyes rather than just looking at the monitor, doctors who listen closely to what I say rather than just scanning their notes in the EMR from previous visits, doctors who pay more attention to the patient than to the comnputer in the room.  Doctor who follow Abraham Verghese's wise advice.  

Wednesday, March 11, 2015

Eating Some Humble Pie...

Lately I have been immersed in a whole new world.  One with unfamiliar concepts and people and processes and procedures, and its own jargon.

It has been challenging, to say the least.  As a result of my recent foray into this new world, I now understand better what some patients and families I've worked with over the years have experienced as they've interacted with the health care system.

And I have to eat some humble pie.

In the past, I worked with parents who seemingly didn't realize that they shouldn't give their overweight toddler soda to drink.  They thought as long as it was caffeine-free, it was OK. I've met patients who had no clue what a Pap smear was meant to screen for, and who didn't understand the underlying anatomy. And many more such stories.  It happens in poor families and rich families, in English speaking and Spanish speaking--although there are definite disparities in health literacy depending on socioeconomic status.  As I've worked with patients and families, interpreting and educating, I've learned the importance of simple terms, easy-to-read written materials, pictures and visual demonstrations.  Thanks to my public health education and training, I'm pretty knowledgeable about health literacy  Yet sometimes, there has been this quiet-yet-very-shocked voice in the back of my head, asking the question "how can these people not know that?!?  How can they not know the basics of their bodies or the importance of that test?  How can they not know that they have to take their meds every day?"

I grew up in the world of medicine.  Terms like "hemoglobin," "hypertension," "antihistamine," and "antibiotic resistance" are part of my first language. The terms and concepts of medicine, and later of public health and health policy, have become such a part of my world that it's hard sometimes to remember that others weren't born and raised in medical worlds. Which is why that quiet, shocked voice sometimes echoes in my head.

Now that I've experienced what it's like to be immersed in a whole new world, where I know much, much less than some others in it, I know how people feel who are unfamiliar with medicine and find themselves immersed--whether for routine care or for crises--in the health care system. Apparently I need to eat some humble pie to quiet that little voice that pops up sometimes.  Ice cream--real, not fake--to sweeten that pie, please.

Sunday, February 22, 2015

The Advocacy Challenge...

This blogger has been too busy to blog for a while.  Now, I'm back.

To say that there has been a lot happening in the world of health policy lately is putting it mildly.  Nationally, there has been another ACA marketplace insurance enrollment period, with all of the accompanying education and outreach.  CHIP, the Children's Health Insurance Program that provides comprehensive, affordable coverage for children and families whose incomes are too high for Medicaid but too low to pay for private insurance, needs to be reauthorized by Congress this fall if it is to continue.  In Wisconsin, the state where I'm a resident and a public health professional, there has also been a lot bubbling up.  (Namely our Governor's proposed budget, which I won't get into).  Aside from that, given that our state has not yet accepted federal funds to expand Medicaid, some legislators have introduced compromise legislation aimed at expanding BadgerCare to childless adults.

Who makes health policy changes become reality?  Government is definitely involved.  The feds, and the states with state-based exchanges, have to implement the policies and procedures around ACA enrollment, and maintain the website.  Congress will ultimately have to vote whether to reauthorize CHIP.  In our state, legislators and the Governor will make the final decisions on Medicaid/BadgerCare expansion.  But behind these decisions, constantly moving and shaking, are advocates.  Interested individual citizens,  non-profit organizations and health professional organizations, health-minded politicians, and more.  People and organizations that care about health policy issues and are willing to speak out.

As I have watched and listened to the advocates in Wisconsin these past few weeks, I'm proud to call some of them public health colleagues and friends.  I am impressed by how articulate and passionate they are, with loud voices (and powerful pens).  They went all out around ACA enrollment, and speak up frequently on any number of public health and health policy issues. I feel fortunate to live and work in a state with such skilled and dedicated advocates helping to shape our health policy.

These advocates set the bar really high for the rest of us, in terms of our public health and health policy advocacy.  Their examples challenge all of us to do some kind--any kind--of health advocacy.  I hope we--myself included--can live up to this challenge.

Tuesday, February 3, 2015

In Poor Health...

1 in 4 American kids are growing up in poverty. 

That number is astonishing.  And appalling.  And really unhealthy for our country. 

Yes, I  spent my evening watching Episode 2 of The Path Appears (based on Nicholas Kristof's and Sheryl WuDunn's incredible book), which focuses on poverty.  Since the weather precluded my spending the evening volunteering at a program that serves families in poverty, I watched poverty  instead.  I saw the family living in the Appalachian trailer park--a mom struggling to overcome a tumultuous childhood, raise her child, and attend school. I saw Haiti--urban slums and poor rural areas.  I saw Colombia--and a program for impoverished pregnant teens.  And I started thinking about my experiences working with children and families in poverty.

I was born and raised in a town with a high poverty rate.  Yes, I knew of the poverty  But I really didn't know much about poverty until later.  As a senior in college, on a medical mission trip to Guatemala, I saw extreme poverty for the first time.  The dump where the poorest of the poor scavenged.  Children begging on streets.  Tiny shack houses.  Patients with horrible tooth decay.  A rural hospital without basic medical supplies in different sizes.

During my MPH years, we learned about the social determinants of health, and poverty was part of the conversation.  But it was after grad school that my real lessons on American poverty commenced.  I returned to my hometown, where I worked as an elementary teacher and a medical Spanish interpreter.  Enter...students without any books at home. Students whose parents were unemployed and laid off.  Students who took their school crayons home to color with because they didn't have other crayons.  Enter...uninsured Latino patients who self-paid, and who skipped specialist appointments because they couldn't afford them.  Patients who didn't get tests done because they couldn't pay.  Patients who couldn't afford glasses for their children. 

Fast forward til now, when poverty and associated problems are increasingly recognized as contributors to toxic stress, and we know that toxic stress early in life can contribute to health problems years later.  The MPH in me cringes at the thought that my former students may be at higher risk for obesity, heart disease, and other poverty-associated conditions when they're adults--just because they grew up in poverty.  The MPH in me wonders if my uninsured Latino patients will suffer long-term consequences of untreated chronic conditions because they couldn't afford needed care.

For those who live in poverty now, how poor will their health be in the future as a result?