Thursday, October 23, 2014

Speaking Public Health in Politics...

Knowing that election day is coming up, I had this great plan.  I was going to spend several evenings volunteering as a phonebanker for a certain gubernatorial candidate (you can guess who!), as my small contribution to what I hope will be a win at the polls.  From a public health perspective and from other persepctives,  I have rather strong feelings about this election, and figured that it was time to act on them.

Alas, this hasn't happened yet, and the election is just a few weeks away...I had the best of intentions, but with the mix of other evening volunteer activities and meetings, some work travel...guilty as charged.

This whole issue, coupled with recent conversations with friends, has me thinking about public health and politics and activism. Public health advocacy and activism in the US are a little tricky, because much of the local and state public health workforce works got it, the government.  Thus, some people avoid speaking out on anything remotely controversial or politica.  Some of us speak out virtually and/or livr on our personal time, using our public health lens but separating this advocacy and activism from our professional lives.  Some of us pay dues to APHA and make our voices heard through their advocacy and activism.  On an international level, there are many targets for public health advocacy and and human rights issues, international family planning initiatives, etc.  There doesn't, however, seem to be one central repository for international public health advocacy and activism issues and opportunities. There is "Physicians for Human Rights," but--to my knowledge--no public health counterpart.

Thinking back, when I was in college and not working full-time, political advocacy and activism were easier to fit in on a regular basis.  US politics?  Go listen to a Paul Wellstone lecture on campus.  International human rights violations?  Go join poli sci/international relations major friends at an Amnesty International letter-writing extravaganza.  These kinds of activities are harder to manage now.

And public health professionals, whether we do it on our own time or through our jobs, advocacy and activism, speaking out to make a difference, speaking out on behalf of vulnerable populations...these things are part of our responsibility, and we have a moral imperative to do them. At least, per one of our public health profs we do...and this idea, at least in theory, has stayed with me in the years since grad school.  And speaking public health in politics is part of this.

At this point, my rather imperfect answer to fitting politics into the call-to-advocacy-and-activism issued so many years ago by that prof has involved a combination of online and social media advocacy (thank you to my advocate friends whose FB posts and Tweets keep me well-informed), a few checks written to various candidates and organizations, and occasional rants and raves on this blog.  As far as politics and international issues...not much.  Hopefully this will change at some point, because I would really like to speak more public health in politics.

Thursday, October 16, 2014

There's Hope...

Yesterday an email appeared in my inbox, reminding me that today is Blog Action Day.  I skimmed it, prepared to delete it, as it has been a crazy week and blogging hasn't been at the top of my list.

And then I saw the theme: inequality. 

Change of plans...not deleting the message.  Blogging instead. I had literally just finished Nicholas Kristof and Sheryl WuDunn's amazing book A Path Appears, which is about all sorts of inequalities in our nation and around the world--and ways to address them.  Basically, I have inequality on the brain.  And since thousands of other bloggers are speaking up today, I would feel some serious public health guilt if I didn't at least attempt to join the conversation.

First, inequality in our country: from a public health perspective, it often starts before birth. If the mom-to-be is poor, or doesn't have a high school education, or hasn't had prenatal care, or isn't an American citizen, her baby could start life off a step behind...and stay behind.  But this doesn't have to happen.  If mom-to-be gets prenatal and postpartum support from the Nurse-Family Partnership, if she can put baby in affordable childcare and finish high school, if she can get affordable birth control and interconception care, if baby is a patient where Reach Out and Read books are distributed...these things improve the odds for both mom and baby.  Oh yes, there are ways to improve the odds...but we have to be willing to invest in them.  Money, time, energy, advocacy, and political will.  Too often, as individuals and communities and states and nation, we aren't willing.

My "pet peeve" inequality:  unequal access to health care and coverage for non-citizens.  Mexican-born women, who have lived in the US for years and are raising their American-born children access to Medicaid between pregnancies...meaning no coverage for follow-up glucose checks for the woman who had gestational diabetes, no coverage for care and medications for chronic conditions like asthma, no coverage for birth control to space pregnancies.  A Mexican-born man, who works 12 hour shifts to support his family, no coverage for care and medication and health education for his diabetes.  Unfortunately, for the most part these inequalities aren't being addressed...immigration reform seems to be on a back burner, and the ACA doesn't include non-citizens. 

And global inequality:  we need look no further than the current Ebola crisis. There are so many drastic inequalities in access to care and medications, in public health infrastructures, in living conditions and economic status.

OK, so this MPH is a little overwhelmed right now after writing about all these types and levels of inequality.  Yikes...the decks are really stacked against some people, through no fault of their own.  And yet, my public health training also reminds me that there is also hope.  There's hope in the pages of a Reach Out and Read board book.  There's hope in the affordable primary care services provided by community health centers.  There's hope in the work done by groups like Doctors Without Borders and  Partners in Health.  There's hope inherent in all of the organizations profiled in Kristof's and WuDunn's book.  There's hope for a world with more equal access to health care, in which the basic human right of health is fulfilled for more people.

Sunday, October 12, 2014

Words of the Masters...

Yes, I own both books pictured above, and am in awe of their authors. And yes, when I actually finish reading them, there will probably be more blog posts on the subject.
At first glance and upon starting to read them, the two books couldn't be more different.  Being Mortal is by Atul Gawande, a surgeon-writer-researcher.  A Path Appears is by  Nicholas Kristof and Sheryl WuDunn, a husband-wife couple with a history in international journalism. Gawande's book focuses on aging, quality of life, medical treatment, death, dying--end-of-life topics.  Kristof and WuDunn's book focuses on organizations and programs that give hope by improving health, alleviating poverty, providing education, etc. 

There is, however, one very big similarity:

Both are about public health. 

Gawande's focus is on the aging population, and through case examples of patients receiving--or not receiving--care as they age and experience health problems, he highlights end-of-life care as a critical public health and health policy issue.  What kinds of safe, homelike places are available for elderly people to live in who cannot live independently, and how do we preserve their independence and ability to make choices in these settings?  What advance directives should be in place to ensure that patients' decisions are respected?  These are some of the issues that arise in the pages of Gawande's book that fall squarely in the public health and health policy arena.

Kristof and WuDunn write about programs such as the Nurse-Family Partnership and Save the Children, which--although they work child-by-child, family-by-family--are addressing classic public health issues...poverty, teen pregnancy, maternal and infant health, etc.  They write about Reach Out and Read, a pediatric literacy promotion program that has been implemented on a large scale across the US.  They write about microcredit programs that help families to escape extreme poverty and earn enough money so their children can attend school.  Their book is an inspiring reminder of the power of helping through volunteerism...and when that is not possible, of the power of writing a check and making a donation.  It is also a call to action for advocacy for change.

Any MPH student knows that sometimes the required textbook reading for classes can be a bit...dry.  Not these books.  Gawande and Kristof/WuDunn are experts at telling stories, at making patient care examples interesting and at making the social determinants of health vivid and captivating.  These books are public health....exciting and powerful, written by some of the masters.

Read them!

Thursday, October 9, 2014

$$ Dollar Signs, Part 2 $$

Back to $$$, which--unfortunately--seems to be an ever-present part of our health care system that looms larger every day. Two issues.

Issue #1:  Medical debt:  38% of Americans owe some type of medical debt.  Medical bankruptcy is the number one type of bankruptcy for  Americans.  Whoa.  I was shocked when I read this article and saw the pie graph illustrating diffeent kinds of debt--with medical debt being #1.  Above credit card or student loan debt.

Now, I've seen medical debt in action.  As an interpreter I occasionally had to help interpret for patients with billing issues, to arrange payment plans--which I liked doing, and once in a while to tell someone that if they didn't pay something the bill would go to collections--which I didn't like doing.  I understood the health care institution's need to make money, but on the other hand, I knew that for the patients, paying medical bills might mean no food on the table.  And I encountered patients who didn't seek out needed specialty care because they couldn't afford it, and patients who skipped ultraounds and lab tests because they couldn't afford them.  

My patients were primarily uninsured-because they were non-citizens.  Many were low-income, and it wasn't surprising that even with charity care program discounts, they sometimes could not afford care.  Upsetting, but not surprising.  Clearly, though, judging from the article and its stats, other Americans--including those with more income and some with health insurance--are also struggling with medical debt. Struggling a lot.

Issue #2:  The exorbitant price increases of generic drugs (click here to read the article).  Just recently--as in, since 2013, some generic prices have gone up.  Way, way, way up.  Example:  per data from group purchasing organizations, Doxycycline, a comnon antibiotic, went from $20 for a bottle of 500 tablets in 2013 to $1849 in 2014. Yes, I typed those numbers correctly!   Doxy is not a brand new superdrug that has just entered the market.  It's an old med that has been around for a while.  You wouldn't know it from that price increase!  These price increases affect hospitals, health care organizations, pharmacies, insurers, and ultimately patients.  And generics are meant to be cheaper than brand name drugs!!!!!  That's the whole point of them.  

There are far too many dollar signs affecting our health care. It's time for change on all sides, because this just isn't sustainable.  Time for more government involvement in drug pricing (thank you to the two politicians investigating the increases in generic prices!), time for more reasonable and transparent charges from health care systems, hospitals, and physicians, and time for everyone involved to put patients first before profits.

Sunday, October 5, 2014

Breaking the Cycles...

Breaking the cycles.

Of poverty, abuse, alcoholism, mental illness, teen pregnancy, school failure, etc.

How do we do it? 

This is a billion dollar question.

Those of us who work with families, whether in public health or medicine or education, have all encountered families where the same problems seem to repeat themselves, generation after generation.  We've all wondered what will happen to the kids whose parents go through nasty divorces, to the kids who witness domestic violence, to the kids raised by adults with substance abuse issues...will the kids struggle with similar problems when they're adults?  Or will they a good way?  Will the child from a completely dysfunctional family go on to shine academically and make it to college?  Will the child who was born to a young teen mom finish school and have his/her own children--as an adult? 

An article in the New England Journal of Medicine, specifically the graphic in this article, got me thinking about cycles and breaking them.  Looking at the graphic, which is a sort of three-generation pedigree of medical, mental health, and social problems, took me back to my days as a teacher.  I remember a young student who was frustrated and disengaged with school. As I probed the situation, I learned that older siblings had dropped out because, as non-citizens, they didn't see school as worthwhile and didn't think there was any hope for them.  Talk about teacher frustration and sadness. How were we supposed to break this vicious cycle?  How could we convince that young student that there was a reason for studying math and reading, that the social challenges of school were good practice for life as an adult, that school could be a pathway to a better life?  How could we change the mentality that this student had learned at home?

I'm not sure what happened to that student, but I hope that caring teachers and friends have had an impact, and that that student has hopes and dreams now, and views school as a way to make them come true.  For my other students, the ones who endured other problems at home, I hope that at least some of those cycles are being broken, that the kids are getting the help and support they need...whether it's from teachers, Girl/Boy Scout leaders, physicians and counselors, or others.

My favorite "breaking the cycles" experience, and the most powerful one I've ever seen, was when I worked in a family literacy program that served Latinos.  Parents who had received less than a high school education in their native country of Mexico were learning English, and many obtained GEDs.  The English language/GED education helped these parents to be able to communicate with others, to understand what was happening at their kids' doctors' appointments and school conferences, to follow directions at work.  The English language/GED education enabled these parents to get better jobs, increasing family income--and demonstrating to their kids that education and learning make a real difference.  Cycles of low parental educational attainment and of family poverty were broken, one family at a time. 

Yes, there are ways to break the cycles.  Not easy ones, but there are ways. Helping to break vicious cycles is the job, and the privilege, of all of us who work with families. 

Monday, September 29, 2014

$$ Dollar Signs $$

For the past week or so, although I haven't blogged, I have been paying attention to health policy issues.  Namely, to health care costs.  Thanks to the amazing NYT/Elisabeth Rosenthal moderated Facebook group "Paying Til It Hurts", good health care cost articles are at my fingertips (literally as  I scan FB) on a daily basis. 

And so I've been reading, and thinking, about the dollar signs in health care.

I've read appalling articles about outrageously expensive "assistant" surgeons.  I've read articles about ER visits (expensive to begin with) with costs that go through the roof because the privately-employed ER docs are not in-network, though the hospital is. I've seen full-age newspaper ads from local insurers--yes, it's almost enrollment time around here--and wondered just how much those cost, and if reductions in advertising costs might mean premiums for patients could be a bit lower.   I've seen one of my own medical bills for routine services, which reminds me of the generally high costs of health care (let me be clear: I never begrudge the doctors who treat me fair pay for their work). 

With visions of health care dollar signs in my head, I've had some mixed emotions.  Like many, I'm frustrated and alarmed that our system has come to this. There are days I would like to take my health policy red pen out and just start slashing some prices.  As irritated as I get over this, I still believe there are solutions.  For example, I find it very hard to believe insurers and private groups of ER docs can't figure out some arrangements so that if patients go to an in-network ER where the docs are in the private group, the insurer covers the care-and patients aren't left with ridiculous bills.  Seriously, there are some smart minds among insurers and ER billers.  Where there's a will, there's a way.  Don't even get me started on prescription drug costs, chargemasters, facility fees. insurer administration costs (Medical Loss Ratios), etc.  Or this post could get very long!

On the flip side...

I appreciate all the more the doctors, health systems, and insurers who play fair.  The doctors who code appropriately for the services provided, and who offer their patients inexpensive alternatives when possible. The health systems that keep the charges fair and reasonable--and transparent.  The insurers who provide comprehensive coverage, offering broad provider networks, with policies and documents that normal people can actually read and understand. 

To all those doctors, health systems, and insurers who are honest and fair and ethical, who truly and consistently put patients first before dollar signs...thank you. 

Monday, September 22, 2014

At the Heart of It All...

Tonight I watched one of my favorite movies, Something the Lord Made, for what is probably the fifth or sixth time.  Yes, I really love this movie.  If you haven't seen it--watch it.  Briefly, it is the story of Vivien Thomas, the black carpenter turned dog lab cleaner turned lab/surgical assistant to Dr. Alfred Blalock.  Thomas was at Blalock's side the whole time in devising the blue-baby operation, which is now known as the Blalock-Taussig operation.  This operation has saved the lives of countless babies born with Tetralogy of Fallot over the years.

In the past when I've watched the movie, the racial and gender issues have come to the forefront (blacks and women, as in Thomas and Taussig, weren't exactly accepted by the good old boys at Johns Hopkins).  Tonight, something different came to the forefront.  I was watching the movie for the first time on DVD (versus VHS-yes, our family has some TV/electronic antiques), and there was some written text at the end...about how this operation in 1944 was the beginning of the field of cardiac surgery.

Wow.   That's huge. CABGs (bypasses), valve procedures, congenital defect repairs...these are the bread and butter of cardiac surgeons these days.  Still certainly major procedures, but fairly common. And it started in 1944.  Taussig had observed and cared for many cyanotic young patients as their pediatric cardiologist and provided the diagnostic acumen needed, Blalock was brave enough to operate on the previously untouched heart..and Thomas' skilled hands and intelligent mind guided the development and execution of the procedure.

As I watched the movie, with its depictions of "old-time medicine"--ancient oximeters, IV fluids in glass bottles, hand-operated blood pressure made me think of how much medicine has changed since the days of Blalock, Taussig, and Thomas.  The heart is no longer uncharted medical and surgical territory.  New technology makes it possible to perform longer and more complex cardiac surgical procedures on patients.  Transplants can be performed to give patients new hearts and second changes at healthy lives.

So many changes in heart surgery since Blalock, Taussig, and Thomas paved the way back in 1944.  It is nothing short of incredible. And yet the main ingredients from their work....intelligence, diagnostic ability, ingenuity, perseverance, skilled and steady hands, and brave and caring hearts...are still applicable and relevant today--in heart surgery, and in medicine as a whole. No pun intended, those ingredients are still at the heart of it all.