Measuring the Health of the Public

The Institute of Medicine released the first of three Robert Wood Johnson Foundation-commissioned reports on public health today:

The United States spends more money on health care than any other country in the world, but there's much more to good health than getting health care from doctors and hospitals. In fact, life expectancy in the United States ranks 49th among all nations, and infant mortality rates are higher in the United States than in many less-affluent nations. A new Robert Wood Johnson Foundation (RWJF)-commissioned Institute of Medicine (IOM) report argues that America’s less-than-stellar standing in these population health measures stems in part from inadequacies in the country’s system for gathering, analyzing and communicating health information that focuses not just on clinical care data but on the underlying factors that contribute to poor health, such as health behaviors and social determinants. The IOM report, For the Public’s Health: The Role of Measurement in Action and Accountability, reinforces the urgency to address health not just in the doctor’s office but where it starts—in our homes, schools, jobs and communities.

Read more here.

Using Cash to Slow Population Growth in India

An article in the NYTimes discusses a new pilot program being implemented in parts of India to slow population growth. Young couples are encouraged to delay pregnancy and are told that they can finish school and even get paid by the government if they wait to have children.

Waiting also would allow India more time to curb a rapidly growing population that threatens to turn its demography from a prized asset into a crippling burden. With almost 1.2 billion people, India is disproportionately young; roughly half the population is younger than 25. This “demographic dividend” is one reason some economists predict that India could surpass China in economic growth rates within five years. India will have a young, vast work force while a rapidly aging China will face the burden of supporting an older population.

The program in Satara is a pilot program — one of several initiatives across the country that have used a softer approach — trying to slow down population growth by challenging deeply ingrained rural customs.

“An educated girl is your best contraception,” said Dr. Amarjit Singh, executive director of the National Population Stabilization Fund, a quasi-governmental advisory agency. He said that roughly half of India’s future excess population growth was expected to come from its six poorest states.

Healthy Americans = Less Costly Americans

While much of the debate surrounding the new healthcare bill speaks to changes in insurance coverage for uninsured and underinsured Americans - a more noteworthy benefit of the overhaul is the (much overdue) focus on prevention. Under the new law, insurance companies will be required to provide preventive services - such as immunizations and check-ups - as part of the patient's insurance coverage. Patients will not be required to pay additional out-of-pocket charges for these services.

“This is transformative,” says Helen Darling, president of the National Business Group on Health, a nonprofit organization for large employers. “We’re moving from an insurance model that was based on treating illness and injury, to a model that’s focused on improving an individual’s health and identifying risk factors.” [link]

Public Health professionals have long known that focusing on preventing illness is much more cost-effective than treating illness. For example - it's much more cost-effective to encourage hand hygiene in healthcare workers than it is to treat a healthcare-associated infection. It's promising that this is also the direction healthcare reform is heading.

Farmer Suicides in Punjab Continue

A recent article in the Financial Times discusses how the suicide rate among small farmers in Punjab is much higher than official statistics.

The north-western state, the main breadbasket of Asia's third-largest economy, had appeared immune to the wave of suicides by indebted farmers that has swept drier parts of India. Yet research shows that more than 2,000 farmers in Punjab kill themselves each year to escape the shame of chronic debts related to agricultural inputs, such as seed and pesticide, and falling incomes.

Official statistics say that 132 farmers in the Punjab killed themselves in the past five years. Most suspected suicides are attributed to natural causes or alcohol or drug abuse. Inderjit Singh Jaijee, a Chandigarh-based human-rights activist and former state legislator, states that up to 40,000 farmers have taken their lives in the past 20 years. Many of their families are left destitute, receiving no state support.

Punjab benefitted greatly in the Green Revolution, a movement in the 1960s to modernize agriculture with more utilization of fertilizer and pesticides. According to the FT article, "Policymakers stress the need to boost the agricultural economy, which supports the bulk of India's 1.2bn people."

International Princess Project

Here's information and a short video about the International Princess Project, an organization aimed at giving women and young girls new opportunities to restore their lives and empower then to live in freedom.

International Princess Project advocates for women enslaved in prostitution, helping them restore their lives and empowering them to live free. Through various initiatives, International Princess Project both helps partner organizations increase capacity and provides direct support for women in need.

Language and Cultural Barriers in Healthcare

A new study, sponsored by the Robert Wood Johnson Foundation, confirms the need to address language and culture in healthcare.

Nearly half of U.S. physicians say language or other cultural barriers are obstacles to providing high-quality patient care, according to a study released by the Center for Studying Health System Change. Forty-eight percent of all physicians in 2008 reported difficulties communicating with patients because of language or cultural barriers, and said they considered the situation at least a minor problem affecting their ability to provide high-quality care. Less than 5%, however, viewed those barriers as a major problem that could result in a disparity of care across ethnic and racial populations, the study reported. Efforts to overcome the obstacles were
considered modest or uneven. [link]

Healthcare providers have legal obligations to provide needed interpreter services, at least for patients with public insurance. However, physicians in solo and group practices were less likely to adopt measures to address disparities than those in institutional practices, such as hospitals, health insurers, and medical schools, according to the study.

Find an Urge to Help on World AIDS Day

[From The Langar Hall]

December 1st is World AIDS Day. Each year on this day we take the time to consider the impact HIV and AIDS has had on people around the globe. This year’s focus is on Universal Access and Human Rights. For as long as I can remember, the conversation has focused on the growing number of infections and deaths associated with AIDS. This year, however, the United Nations reports a notable decrease in HIV infections in some of the hardest hit areas of the world. It is clear, then, that the enormous amount of effort by HIV treatment and prevention programs have helped to provide education to raise awareness.

A recent NYTimes article discusses how humans may be born with an urge to help, and it makes me consider how very important this attribute is. Our communities rely so heavily on the help of each other – something we often take for granted. If humans are born with an urge to help, then Sikhi provides us with a strong foundation to make this happen. It is up to each and every one of us to seek out those opportunities. While World AIDS Day is a way to raise awareness about HIV/AIDS, it is also a reminder of the potential we each have to make a change. In Guru Nanak Dev Jis words,

In the midst of this world, do seva.

India's sick 'suffer needlessly'

Hundreds of thousands of sick people in India are suffering unnecessary and excruciating pain because of a lack of funds, according to a new report. The Human Rights Watch group says that budgetary constraints result in poor medical training, restrictive drug regulations and poor patient care. The group says that many major cancer hospitals do not provide patients with the painkilling drug, morphine. This is even though it has a reputation as an effective form of pain relief.

More than 70% of cancer sufferers in India have an incurable form of the disease, Human Rights watch (HRW) says. It is estimated that more 500,000 advanced cancer patients are left to suffer. HRW health researcher Diederik Lohman says that the main problem is a lack of government leadership. "It just hasn't integrated palliative care - or the alleviation of illness-related pain - into treatment programmes," he said. "And it's not just cancer. People living with HIV are also neglected. Doctors simply aren't trained and in many states, restrictive drug regulations add to the problem. "The irony is that India provides excellent private healthcare. Ironic too is the fact that it's one of the world's biggest legal producers of opium - the raw material for morphine. But almost all of that is exported."

Severe pain is a common symptom among cancer patients, particularly during the last stages of the disease. HRW estimates that there are more than one million advanced cancer patients in India who experience severe pain in any given year. In addition many other patients, including those with HIV, TB or other infections or illness, may face acute or chronic pain. [link]

Learning About Primary Care Shortages

The United States currently faces a shortage of primary care professionals that threatens to develop into a major crisis if not addressed. Primary care comprises four main features:

• A first contact for any new health issue or need
• Long-term, person-focused care
• Comprehensive care for most health needs
• Coordination of care when it must be received elsewhere (i.e. with a specialist)

General practitioners, general internal medicine practitioners, family physicians, and sometimes general pediatricians are considered primary care physicians. Other health care providers, such as physician assistants (PAs), nurse practitioners (NPs), nurses, and health coaches or care coordinators, may also provide primary care. Care delivered with an orientation toward primary care has been found to be associated with more effective, equitable, and efficient health services; residents of countries more oriented to primary care report better health at lower costs.

60 million Americans, or nearly one in five, lack adequate access to primary care due to a shortage of primary care physicians in their communities. Very few new physicians today are choosing to enter primary care: whereas fifty years ago, half of U.S. doctors practiced primary care, just over 30% do today, and just 8% of the nation’s medical school graduates enter family medicine compared to 14% as recently as 2000. People who are uninsured, low-income, members of racial and ethnic minority groups, or living in rural or inner-city areas are disproportionately likely to lack a usual source of care (USC)—a key indicator of access to a primary care provider.

Many experts believe that this skewed distribution contributes to overspecialization of care and fragmentation and inefficiency in the health system; for example, more than half of specialist visits are for routine follow-up, a misuse of expensive care. Furthermore, a higher ratio of primary care physicians to population is associated with lower mortality rates while a higher ratio of specialists to population has been correlated with higher mortality rates, perhaps because patients with a usual source of primary care tend to use more preventive health care and have health problems treated at a less advanced stage.

Learn More.

Knitting for babies in Rwanda

A message from Partners in Health:

In the chilly mountains of rural Rwanda, where last year PIH's partner organization began working with the Burera District Hospital, resources are very limited and the temperature often drops into the 50s. Newborn babies, particularly those born prematurely, often struggle to keep warm. In a country where one in 10 babies dies before her first birthday, hypothermia is a serious threat.   A simple solution that can help save some of these little ones is to provide them all with beanies to keep them warm. 

We are looking for knitters to help us put a warm beanie cap on every baby born in Burer--as is done in American hospitals. The Burera District Hospital welcomes about 100 new babies into the world each month, so our current goal is to provide 100 caps per month. 

All beanie styles and colors are welcome. Hats can be made to fit either premature babies (head about the size of an orange) or full-term babies (head about the size of a grapefruit). We will arrange shipping from Boston to northern Rwanda. 

Hats and donations may be sent to:
Jesse Greenspan
Partners In Health, Attn: Baby hats
888 Commonwealth Ave, 3rd floor
Boston, MA 02215

More information about this initiative and pattern samples can be found at: http://hotheadknitters.blogspot.com/

Pollution and Disease in Punjab

In the Faridkot centre… Harmanbir Kaur, 15, was rocking gently backwards and forwards. When her test results came back, they showed she had 10 times the safe limit of uranium in her body. Her brother, Naunihal Singh, six, has double the safe level.

An article in The Observer discusses the link between the dramatic rise in birth defects in Punjab and pollution from coal-fired power stations. Many of the children are being treated in Faridkot and at the Baba Farid centers for special children in Bathinda, where there are two coal-fired thermal plants. Staff at these clinics had noticed an increase in the incidence of severely handicapped children who were born with hydroencephaly, microencephaly, cerebral palsy, Down’s syndrome and other complications. They suspected environmental poisoning.

The healthcare workers rightfully voiced their concerns about this and wondered, if some children were being treated, how many more were being affected? As with governments’ other dirty little secrets, staff at the clinics were visited and threatened if they spoke out. In addition, a visiting South African toxicologist arranged for tests to be carried out and found that the children had massive levels of uranium in their bodies, in one case more than 60 times the maximum safe limit. The scientist was later warned by the authorities that she may not be allowed back into the country.

Read more on The Langar Hall.

New Book: Strength in What Remains

Many of you first learned about Partners in Health by reading Kidder's bestseller about Paul Farmer and the founding of Partners In Health, Mountains Beyond Mountains. Today, Random House is publishing not one but two works by Tracy Kidder--his powerful new book, Strength in What Remains; and a new, deluxe paperback edition of Mountains Beyond Mountains that features an epilogue updating the story of PIH through early 2009.

Strength in What Remains tells the riveting true story of Deo, a young man from the mountains of Burundi in East Africa. After a hairsbreadth escape from death and a horrifying journey on foot through Burundi and Rwanda-two countries wracked by genocide and civil war--Deo landed in New York City, penniless, speaking almost no English, and living homeless in Central Park. From there, the generosity of people he met and (mostly) his own indomitable determination took him to Columbia University and later to Harvard--where he found work, friendship and a sense of common mission with Paul Farmer and his colleagues at Partners In Health--and, finally, back to Burundi to start a community health project modeled very much along the lines of those he had seen and helped at PIH.

For people who care about global health and social justice, both of these books are must reads. The same goes for people who simply enjoy outstanding writing that opens their eyes, their hearts, and their minds. That's Tracy Kidder's specialty. As Susan Salter Reynolds of the Los Angeles Times wrote in one of many rave reviews and feature articles that have appeared about Strength in What Remains, "With his most recent book, he helps the reader walk in the subject's shoes."

Dengue Outbreak in Punjab

A potential dengue outbreak looms in Ludhiana. Dengue, an infectious disease caused by a virus, can be transmitted via mosquito bites. Cases of gastroenteritis were found first among the community, followed by cases of cholera. The fear of a dengue outbreak is now of concern in the region.

"As for gastroenteritis, illegal water connections in vehras of various areas of the city inhabited mainly by migrant population are the root cause of the outbreaks. It has been taking a toll on the lives of migrant population who live in poor hygienic conditions prevailing in their surroundings," says Dr SS Dhir, district health officer... "We have filed cases against six persons in connection with illegal water connections in the vehras of Punjabi Bagh where habitants fell sick with gastro. Besides, we have constituted a 40-member team which would be responsible for creating awareness in four MC zones and will conduct house to house visits in the disease-prone areas," Dr Charanjeet said.

Humanitarian IQ

Last week I got this in my inbox. Try it - even as activisits - you'll be surprised how much there still is to learn! http://www.humanitarianiq.com/

Humble The Poet

A million here
A million there
Two million dyin from malaria
Who really cares

Happy Mother's Day

The New York Times has a great piece on celebrating mothers around the world. They ask, What Do You Give the Developing World for Mother’s Day? In five different pieces they explore the developments which have helped and have the potential to improve the health and wellbeing of women and children across the globe:

A Birth Pill
An inexpensive medicine could save lives.

A Dose of Care
Counseling should be an important part of food aid programs.

An Education
Make going to school affordable.

A Safer Labor
Provide clinics with the basics to preform Caesarean deliveries.

A Custom Drug
Research to better medicate mothers-to-be.

Happy Mothers Day!

Operation Walk

I was especially proud when I heard about Operation Walk - an organization established by Harpal Singh Khanuja and his wife Maria Khanuja. The non-profit organization is dedicated to providing free knee and hip replacements to underserved people around the world. The concept behind the organization was to perform complicated surgeries on people in developing countries, “where arthritis progresses to its end stages and reconstructing joints becomes technically challenging.” Often times, it is people who are most at need who cannot afford the surgery. A news article discusses Operation Walk’s recent trip to Lima, Peru where they performed 48 surgeries to replace knee and hip joints. Here on TLH we like to highlight examples of seva - this is another important example of what it means to do selfless service.

The organization’s goal is to replicate the Peru mission to Panjab where the need is also great (some of which can be attributed to the chemical farming of the Green Revolution).

The goal is to learn the ropes and move on to Punjab, Harpal Singh said. “It’s done more than cross my mind.” To coordinate a trip to India would require an extra week’s stay and extra money for cargo, lodging and food. He was initially ready to go to Punjab this year, but when it came time to select a location last November, the Mumbai bombings scared many of the volunteers. Some of them had not been outside of the state of Maryland before the trip to Peru. Perhaps they needed one more trip under their belt, and wait another year to go to Punjab, Harpal Singh said.

“Our community is very eager to have this done in their own area,” he said. “In some respect, a group of sardars or Sikhs doing seva outside Punjab is more of an education.”

Read more at The Langar Hall.

Nobel Prize for Public Health?

An excellent piece from Nicholas Kristof in the NYT discussing how the recent Swine Flu scare reinforces a flawed medical system.

Think of the 47 million Americans who lack insurance. They are less likely to receive flu vaccines (which might or might not help), less likely to receive prompt care when they get sick, and less able financially to stay home from work — and thus they are more likely both to die and to spread the virus inadvertently.

The larger problem is that we over-invest in clinical care like CAT scans and underinvest in public health. There should be a Nobel Prize for Public Health, so that we might get more great minds wrestling with nonmedical pieces of the health puzzle, like industrial hog farms that can serve as breeding grounds for viruses and bacteria, from swine flu to MRSA.

“If a severe pandemic materializes,” Dr. Redlener said, “all of society could pay a heavy price for decades of failing to create a rational system of health care that works for all of us.”

Read the entire piece here.

Universal Healthcare and Health Disparities

It should go without saying, but now we have a study to confirm it - universal health coverage could reduce health disparities. The Commonwealth Fund conducted a study which suggests that medicare coverage for all provides a dramatic reduction in the level of poorer health among African American, Latino and low-income Americans.

Their research team, led by J. Michael McWilliams, M.D., Ph.D., sifted through medical data for 6,000 people ages 40 to 85 with diabetes or cardiovascular disease. They tracked their conditions from 1999 to 2006.

The researchers found that despite overall improvements in controlling the diseases, black, Hispanic and poor patients under 65 -- those not yet old enough for Medicare -- fared no better, or got worse.

However, at age 65, when people become eligible for Medicare coverage, the differences in health by race, ethnicity, and socioeconomic status declined significantly.

Read more here.

Punjab Farmer Suicides

Hearing about farmer suicides in Punjab is no longer (and quite unfortunately not) a unique thing anymore. It's a topic which i find very disheartening, and it's recurrence in the news reinforces the need to pay closer attention to the root cause of these deaths and who is being impacted by them.

Mandip Kaur, a 29-year-old housewife from a farming family in southern Punjab, guards her husband round the clock. "I fear he may commit suicide," she says... Almost every village in Punjab has witnessed a suicide in their once-prosperous farming families and it is a major issue in the general election.

As a friend recently noted, it is women who often bear the burden of their husband's death. The impact that farmer suicides is having on wives, children, and entire communities cannot be understated.

National Crime Records Bureau statistics say close to 200,000 farmers have committed suicide in India since 1997. Punjab, responsible for producing nearly two-thirds of the grain in India, has faced many economic crises since the the mid-1990s. No comprehensive official figures on farmer suicides in the area are available. But a report commissioned by the government of Punjab this week estimated that there had been "close to 3,000 suicides" among farmers and farm labourers in just two of Punjab's 20 districts in recent years, agriculture ministry sources told the BBC.

There are several issues which have caused the increase in farmer suicides over the last number of years. The Punjab government's website proclaims that "India has gone from a food-deficit to a food-surplus country" largely because of the Green Revolution of Punjab. Is the Punjab we envisioned? Read more about this article here.