Sirens and Lights

Another day, another clinic. I migrate to the “pharmacy” after lunch to help dispense medications. We’re moving at a frantic pace, overwhelmed by the number of patients. I rush around gathering medications and dash back over to the table to provide instructions to the woman in front of me, who is looking at me expectantly from under her red hat, two long black braids trailed out over the shawl on her shoulders. She’s been waiting patiently despite her old age, and I feel a little guilty for that. My gaze connect with her deep brown eyes, nested in beds of creased bronze skin, and I launch into my explanations, adding warnings in the hopes of making this safe. The woman nods along, braids bouncing, listening intently. Finally at the last medication, which I’ve put off because of the complexity of the instructions, I interrupt myself to ask the woman if she’s able to read the written instructions on the box. Those brown eyes examine at the instructions, and then she looks up at me, saying in a slow and honest voice, “Well, senorita, I don’t know how to read. And I also don’t know Spanish.” I’m speechless for a moment, as the recognition of her Quechua background strikes me.

I feel defeated by yet another barrier to providing good medicine.

The day is exhausting for everyone involved. 5 hours, 400 patients, 1 blazing sun, and way too many thank you’s for my comfort level given all of these challenges. We’ve gotten a late start today and finally set up in another dusty playing field today, wondering if this place, recommended by the Ministry of Health, was really an ideal place to be situated: approximately 50 curious children in brightly colored clothing greeted us, running, tumbling and laughing in the lot, all under the age of 6 with parents currently at work; the children are being cared for by a program that provides them with breakfast each morning. I climbed the bleachers along the side of the field and looked out over the desert landscape, with thatched cubes that serve as homes, and then look back at one toddler who has just tripped while chasing a dog. This is definitely an area where people could use help, but the lack of parents is a problem- no parents means no real way to examine patients, let alone provide medications with the necessary dosage and safety instructions.

We started to make plans to change sites after lunch, but the woman from the local health post insisted that she would find more people- I find this a little curious given that there’s a health post nearby that is obviously open. Then, I realize that the real issue is that we have medications and those in the health post often do not, especially in times like these. We negotiate with the children’s caretakers about the ethics of practicing medicine here, and finally begin accepting patients. The morning races by quickly, filled with stories of those we’re serving and decisions on how best to help given our truly less than ideal conditions. I look up after a particularly engaging patient visit to find the health post doctor standing above me. It turns out she’s walked patients over to our clinic, having already diagnosed them, in pursuit of the appropriate medications. The health post has run out of these drugs long ago, so she’s excited by our presence.

Medicine can be as dangerous as it is helpful, especially with regards to medications. I’d been thinking about this issue all week because it’s posed a lot of trade-offs for me regarding the good we’re doing. Many medical students and physicians participate in similar one day clinics in various underserved regions of the world, but this is my first experience with this type of medical care/humanitarian work, stumbled upon unintentionally. I haven’t been able to shake off the sense of discomfort with this type of medicine, particularly after spending a year intensively slaving over learning evidence-based medicine and best practices. It’s hard to do proper exams when you’re in the middle of a dusty lot with limited privacy, laboratory equipment and a language barrier, let alone assess if patients understand the treatments you’re prescribing, both in how they can help and how they can harm. The beauty of primary care is that patients can work together with physicians to sort out their medical problems and develop the best solution, taking into account the fact that often our first diagnoses aren’t the correct ones and that not all medications are suited for all people.

As relief workers, our ultimate goal is rehabilitation of community utilization on state services. If this is the case, then I wonder how our one day clinics really fit in with this objective. These communities were medically underserved long before the earthquake hit, given the pre-existing state of health access and utilization prior to earthquake. Thus, our relief efforts are really the only form of primary care that people are receiving in many of these sites. With so many barriers to our own provision of medicine and the lack of safety net in the form of patient follow up at the local health post, there is a danger in what we’re doing. The distribution of free medications and medical advice, no matter how rudimentary (i.e. done without even a basic laboratory), attracts a large crowd, many of whom haven’t sought health care in a long period of time– but the reality is that most people are healthy, need relatively few medications. Surrounded by these young children and old women that have clamored over to this clinic in the dusty lot, I am envious of those who provide medical relief in places where the primary care system is capable of taking over after a brief period of recontruction.

I suppose I’m not sure if the work we’re doing is actually causing more good than harm. For as uncomfortable as I am, there is significance to our work. In many ways, it’s providing a sense of solidarity for those we’re treating. These clinics do let people know that all of this suffering means something to someone out there, and that they are not alone. It may not be a solution, may not be food or water or blankets or homes, but it’s one step closer to getting those things for the people here. I do believe that simple compassion is the beginning to making a real difference.

The question is if there are other ways to do this that may be better from a quality perspective. To me, there is a huge need for simple public health education in these types of situations, and I’ve certainly felt the lack of its presence here, despite regular mentions of health promotion at the health outreach coordination meetings. In contrast, it’s at the point where it’s hard to find an IDP settlement where one of the handful for medical NGOs hasn’t set up camp for the day at least one day this week, offering clinics similar to our own. Given the severity of the situation, I’m relieved to know that some medical attention is present in this post-earthquake period. Perhaps it would be better if we simply helped the health posts get back up on their feet instead, including supplying medications.

I just wish that the regional leadership here would take this tragedy as a chance to recognize the flaws in access to medical care, and to transform the system to better serve the people. They have certainly suffered enough thus far.

Entering the walled-in IDP camp in the already hot morning sun, I feel almost overwhelmed by the sense of order. Rows of identical white tents shaped like houses stand in a group on the grassy green field, oddly evoking a crisp suburban neighborhood, comforting and almost charming in its predictability and organization. Across Avenida Javier Pardo, as the camp leader jokingly referred to a wide strip of grass, the neighborhood flows from these larger shelters to a similar group of matching smaller navy tents, and then light blue and then sage. The community padre bounds up to our group and thanks us for coming to provide care. He is quick to highlight the perks of this gated-in IDP community: independently housed kitchen tent, full of surfaces neatly stocked with bottles of cooking oil, vegetables, spices, and enough foodstuff to feed this community for at least a month, even if it reaches its full capacity of 1000 persons; two imposing black water tanks, both enclosed and equipped to distribute water efficiently and easily. Around the perimeter of this community of 600 people, approximately 10 portable bathrooms stood ready and, he adds, particularly clean as the man responsible for their maintenance lives himself in this very camp. And, just yesterday, a national news station had shown up to record the story of the first birth post-earthquake– the family was taken to a hospital, but are comfortably housed in these tents that are relatively clean given the conditions and well-protected against the sun, wind and nighttime chill. Every afternoon, the children are brought together to play games, and the stage, with its backdrop of Jesus Christ, is used to put on nightly performances.

I’m impressed. We’re 12 days post a major natural disaster.

We set up our clinic in a stretch of dirt and grass on the far end of this settlement, and a long line quickly snakes its way to our triage table, along to the doctors’ stations and over to the pharmacy where I’m dispensing medications and instructions today. The sun is warm, but a cool breeze makes today the most temperate day we’ve had; I’m comfortable even after several hours of working, though I wonder how much of that is the relative calm of our patients today, who seem cleaner and somewhat better nourished than the other places we’ve been. The children at my table smile with cheeks unmarred by the effects of exposure to harsh, gritty winds, even as I dispense cold medications and antibiotics for the usual conditions we’ve had at all of the camps thus far. Weaving through the camp doing tent calls with the pediatrician, I can appreciate that the newborns are relatively safe here: the tents are dusty, and mattresses sit perched on stands, though mostly on the floor, providing bedding for many people/infection sources– but there is sunlight and climate protection, and both babies, simply put, look clean. Yet, I still marvel at the lack of instructions given to the two new mothers here, one of whom still had bloody dressings from her C-section 3 days ago, and neither of whom seemed to have been instructed on proper umbilical cord stump care or pain management for themselves.

and now, I’m confused.

I recognize that my examples are a little exaggerated, but I hope they get the point across about the vast difference in qualities of life, even in the universal awful circumstance of no longer being able to live in one’s own home without fear or danger. This is dignity. This encourages support without encouraging a shift to full-out life in an IDP camp rather than re-establishment of homes and lives. This is, it seems, the model IDP camp in a theoretical sense.

What makes a community like this exist somewhere? How do certain people end up in these conditions while other face the hardships of what essentially amounts to lean-to’s of thatched fronds without clean water, enough bathrooms, food or blankets, with people waving signs in the road asking for help, even inflating populations numbers in the hopes of obtaining aid? Does the community pick the people, or do the people pick the community? In either case, how can we establish more places like this, and get them to house people to their fullest capacity?

I can answer some of these questions for myself for today’s community: It is run through a collaboration between an international food company and a large religious organization, providing funding for both resources and planning. The surrounding community seems to have been lucky that they were chosen for this outreach, though from a medical sense they do seem as if they lived in slightly better conditions than the others we’ve seen prior to the earthquake (I have no data on this, but will look for some). As for capacity, this organization claims to want to reach their capacity of 1000 through the addition of 400 IDPs, but seem hesitant to possibly diminish the quality of life here if those they admit have “bad habits,” as one of the leaders tried to euphemistically phrase it. At this point, I wonder how useful or possible it would even be to try to uproot those established in other settlements, no matter how poor, to this one, which may be quite far from their original neighborhoods (most people settled in camps near their own homes– many even use the facilities in their homes and only sleep in the tents, or vice versa)… but it’s difficult to acknowledge the difference in lifestyle that the resources here would provide for the others.

Extending these answers to the greater situation, however, is a bit trickier. How feasible would it be from a cost standpoint to create settlements such as these? Would it be possible to do this without the contributions of large corporations, or should we be trying to enlist more help from these corporations? Regarding capacity, how do we implement this model in other communities that really are suffering and could really use the help, and how do we encourage involvement of all people and reduce fear of “bad habits?”

Most importantly, and a bit late I suppose, how do make sure that the lure of this relative suburbia doesn’t encourage people to stay longer than necessary, only to find themselves worse off when the corporation sustaining the settlement decides it’s time to move on?

There are some good guidelines out on response to disasters, and I’ll read more to see which of these questions I might be able to answer…

“Oh, the tour has arrived.” These are the words we overheard this afternoon as we entered a new camp, several kilometers down the cracked road from Pisco. A group of women still carrying spoons wet with sauces and long bits of noodles greeted us as we crossed the dusty highway to this group of thatched roof and tarp constructed shelters. More women sat in front of big pots steaming over small fires, doling out food to those lined up before them. I eyed a hard blue structure towards the back corner, noting the presence of two portable toilets for this community. As part of surveillance for disease outbreaks (particularly diarrheal diseases), we spent today visiting settlement camps in and around Pisco, asking about access to sanitation, food, clean water supplies and health. Arriving in our once-white van marked with “Dust Devil” in the window and well-identifiable with our gringo appearances, the woman’s casual comment upon our arrival wasn’t so surprising. But, to me, the real issue to which she was alluding is much more significant than countries of origin.

In many ways, these settlements of people trying to survive, rebuild their lives or simply get ready to move on, have turned a bit into places where lives are viewed through a revolving door of aid organizations and agencies all trying to help, to assess the situation, to prevent further harm. The gathering of organizations and volunteers is, I imagine, comforting in some senses, but sometimes I wonder if the disruptions we pose so frequently during the day aren’t making it more difficult to deal with the mental stress of the conditions here, particularly when progress is sometimes still so slow despite all of the conversations with so many visitors from various sectors of relief work. Coordination of relief efforts for those in this area is clearly a tough task; there are organizations and agencies here from all over both Peru and the world, and leadership changes every 5 days or so for most groups; the tasks are numerous, from distribution of clothing, food and water to management of health care distribution, environmental health, sanitation and mental health support; politics, it seems, is impossible to avoid anywhere as long as money and people are involved. While coordination for those affiliated with the health sector is certainly improving, with various groups accepting responsibility for individual zones so as to prevent redundancy or overlooking of a place, this isn’t being coordinated at least on our level with the services provided by other groups. As a result, there are sometimes many groups working on the same issues in the same areas, which seems frustrating for all involved, especially those not receiving help.

The significance of all of this becomes apparent when we take into account the trio of camps to which the settlement above belongs. On the other side of that dusty highway stands another settlement, which often tries to coordinate with this one for donated supplies and resources. Here, as well, 2 portable toilets stand, serving another approximately 200 people (the ideal ratio is 1 bathroom for every 20 people, though this is often imaginably really hard to reach in disasters), and women sat gathered under the shade of a tree cooking a similar meal of noodles and vegetables, protecting themselves from the blazing daytime sun that will eventually give way to shiver-inducing desert night. There is no electricity, and water and food supply is wholly dependent upon the donations from water and supply trucks that periodically speed down the highway going through this town, which can’t possibly be really providing enough water for this number of people. The head of the settlement reports dutifully that they do not have chemicals to purify their water and are relying solely on boiling it prior to use, and that they are careful not to use the water from a small nearby creek for more than sewage when the portable toilets can’t be used. Like in the settlement across the road, she reports to us, as she has to others, the need for blankets to protect the people from the chilly nights spent in thin-walled shelters in the middle of a flat plot of land. No medical concerns are to be reported, aside from colds and coughs from the dust. The physician and epidemiologist in our group comments, “It’s a tribute to the resourcefulness of humanity that these people are surviving, but it shouldn’t be like this when there are resources in Pisco just a few kilometers down the road.” We will report back on this at the afternoon coordination meeting for those working on health-related issues.

We cross back and drive a ways up to the third settlement, set back along a dirt path. Immediately, the car is swarmed by people wiping the dust off of the windows to peer inside our van, anticipating a delivery of donations that we’re unfortunately not providing. The community reports conditions similar to the other two, but also report a few cases of diarrhea. We explain our goals and get permission to obtain samples from some of the children living in a house uphill from the settlement. A young girls answers the door and presents us with her three daughters, 2 month old triplets born at 7 months of age, dehydrated enough to not be producing tears with their cries and with sunken fontanelles. The health post is back in service a few blocks up the road, so we counsel the mom and encourage her to seek oral rehydration therapy immediately for her children…

There has to be a more effective way than this, though I recognize that, in a sense, I’m like those kids smearing away the dust as best I can to peer through the dusty windows of disaster relief here. Primary care mixed with relief efforts and the slow pace of improvement in this settlements even with all of the “aid”, again demonstrating the disastrous conditions that existed long before this earthquake hit. The people trying to live here and those trying to help people live here are both surprisingly strong and resilient, and there is absolutely no way to deny that. Yet, there are flaws in the system. Tomorrow, we’ll be providing medical care in a camp that has served as a model for IDP settlements here, well-funded by an international food company and with beautiful organization, sanitation and food supplies for another month. It’s an IDP camp, no doubt, but the relief provided is done with the greatest amount of dignity and grace that people deserve, regardless of what they possessed before the earthquake hit. I’m not sure if the answer is simply better coordination of aid or a need to restructure the conditions the predispose to such awful conditions following a natural disaster (namely injustice and poverty, I suppose), but I’ll be thinking about this over the next few days.

People can survive a shocking magnitude of devastation and harsh conditions and that is something to respect and remember, but it’s important that we try to help in a way that honors that strength…and that makes us more than tourists observing the suffering and strength of others in our world.

Photos, far better than my own: http://s20133.gridserver.com/peruenemergencia/index.html

We pulled up into a dusty lot today, at the base of the sand-coated foothills near Ica, scattering dogs and attracting children. Fold out tables were quickly unloaded and loaded with boxes and papers: medications, vitamins, facemasks, color-coded triage sheets. Bags stored in the goal box at one end of the field gave away the lot’s typical use, before it was transformed in an impromptu medical clinic in this shantytown, named for a former president’s wife.

Unlike yesterday in the IDP camps, today could almost have been a clinic on any day in this town, where tenuously constructed homes are the norm; we could have been any one of a number of medical organizations that do these sporadic clinic days in similar dusty lots in underserved areas all over the world. The particularly destroyed homes bordering the lot gave a hint to the conditions specific to our motivations, as did the occasional complaints of children and adults who are unable to sleep, are having nightmares or are having crying spells typical of acute stress reactions post-traumas such as natural disasters (20% is the WHO estimate). Despite all of this, the care we provided could have been given on any day- upper respiratory infections, eye exams with glasses distribution, parasite infections, severe dry skin from the cold and dry air, dental extractions…

I guess what I’m trying to say is that it seems impossible to separate the victims of this earthquake from the regular victims of poverty, at least in the time period following the immediate post-disaster deaths from trauma. It’s the poor with their adobe homes that have been left homeless, and to live in camps without nearly enough toilets or water, where infections will almost inevitably spread. It’s the poor who never really had access to medical, opthamological or dental care that most benefit from the post-disaster care, in large part because they never had access to care before. While this is “relief” medical care for others as they begin to piece together their lives, for these people, these humanitarian efforts likely may be the closest thing to routine primary care such as eye care and de-worming that will come this close to this settlement.

Manning the overwhelmed triage desk and attempting to explain our limitations in service (including that we wouldn’t be there ever again, most likely), I really felt the lack of sustainability of our work today. This isn’t relief work, where sustainability isn’t the objective; it’s primary care– which, of course, I knew it would be given the realities of the distribution of health care in most of this world. I’m happy we were there because I do believe that we need to do what we can and people have suffered more because of this earthquake, but this isn’t how primary care is supposed to be done to help people, without continuity or sustainability. It’s frustrating to leave things like this. Relief isn’t supposed to be primary care.

President Garcia here has acknowledged that the inferior communications networks in this region of Peru contributed significantly to the delay in rescue efforts here, and commented specifically that this should be motivation for the entire country to commit more strongly to improving these systems and the other weakness exposed, as it often happens, by natural disasters such as this earthquake. I hope that these weaknesses to be addressed include those in the system of health care, and that these relief efforts can lead to something more consistent. Wouldn’t that be making something good from such a huge disaster?

Dust is everywhere in this desert city, with 60 kph winds helping it coat every imaginable surface. Carefully constructed tents are pulled taut against the winds tearing through the town, and the dust tortures eyes that have likely already faced the salty sting of tears following the loss of homes. As rubble begins to get cleared up 8 days post-earthquake, the irony is that the dust is getting worse. In our clinic in one of the internally displaced persons (IDPs, victims’) camps, we had no optometrist today, and as a result, no eye drops. At night, the sun goes down and takes with it the comfort of warmth…cold, dusty, windy.

There are boats washed up several blocks inland, in the roads along with piles of rubble and hollowed out shells of homes and churches. Pisco is a coastal city, and a relatively small tsunami made the ocean’s presence known. The hospital, like many buildings here, is built with an outer wall protecting the inner structure. While the older part of the building has been completely destroyed, there are still about 2 wards in operation in the newer part of the building. The various organizations here, domestic and international non-governmental organizations (NGOs) and governmental aid agencies, gather in a hall renamed the Situation Room each evening, to discuss the work in the many IDP settlements across Pisco: medical care, epidemiological surveillance, sanitation and environment, mental health, supplies, nutrition, among others. We’ve just arrived, so it’s difficult to sense how this cooperation is working, but people seem to be trying hard to coordinate and try to achieve actual progress, inclusive of better surveillance systems to monitor emerging disease epidemics. The traumas are subsiding, meaning of course that those who have been injured have either been treated or have passed away…so these are the health concerns now: preventing disease in settlements with way too little sanitation.

The settlements are all over the city. The aid agencies are camped out on the airport base, in tents fields that loosely resemble those in the IDP settlements, but the differences are significant. The settlement camps have the sense of possibly becoming permanent, despite the often makeshift shelters. Small businesses are cropping up among the settlement in which we were working yesterday: “cafes,” among others. Laundry flaps in the wind, swaying on clotheslines between tents, and schools are scheduled to re-open soon, according to the radio. Oddly, the settlements are only somewhat different than some of the shantytowns that are found all over the world, but these are people who had houses and homes elsewhere, even if they were made of adobe. They deserve to at least have those homes again.

We’ve been lucky enough to be associated with a group of physicians and public health experts here, so we’re getting to learn a bit about surveillance methodology, which I’m hoping will be helpful if we’re ever in situations like this again. Sometimes, it’s disturbing how informal everything is- the medical care, the services, the distribution of donations of water and food, and data collection… even though it’s possible to imagine more organization, I can see why it would take a lot to get there. The politics of disaster relief are a whole other issue…

We’re heading to a shantytown closer to Ica today, which hasn’t received much attention in the last week.

i’m sitting in an office right now, waiting for word that the transport to Ica is ready to go. It’s been about 24 hours since we decided to head down to the earthquake site to help with some of the relief efforts, and I have to admit that while I am eager to do something and help, I’m acutely uncomfortable with the potential of being someone who might have been better off sending money– and we’re keeping that in mind as we prepare to work down there.

We’re working on collecting some data, as well as triage with patients in the internally displaced persons’ camp (for earthquake victims) in Pisco. We’re working with a team of doctors, and I hope that we’ll find other ways to help. I, for one, hope to write some on the experience of working here versus post-Katrina (though that was several months later).

About 20% of Ica, where we’ll be staying, was destroyed by the quake. In Pisco, it’s much worse, with ~70% of the buildings destroyed by the earthquake, and where services have still not been restored. Many of the houses in Pisco were made of mud-bricks, and the devestation was far-reaching. The most chilling part to me was that a significant amount of the deaths came from the collapse of a church in which >200 people were worshipping when the earthquake hit. Sancturary, refuge….

We’ve heard lots of stories via the news here, and via our colleagues who have spent the week in Pisco. It seems some aspects of disorder and outages have calmed down recently, but that many do persist. As we’ve been preparing to go, they were insisting for a while that we get the rabies vaccine, among other precautions, given the situation. We haven’t hard of any cases, but it is an indication of the fear that surrounds the emergence of diseases post-natural disasters.

Anyway, we’re heading out, and I apologize that this wasn’t as thoughtful as it could have been. If you can help in anyway- donations of food, water, medications, please consider doing so! Cuidense. We’ll do the same.

….and one last article about the problems in EM and healthcare here in the U.S.- how they represent flaws in the entire system of treating those who are uninsured, unaware and uneducated…. ARGH. If you read The Spirit Catches You and You Fall Down, the book that inspired my Watson, you’ll find a scarily similar story sans cultural conflicts in this article, of immigrants who don’t speak English, don’t have adequate insurance and who are left to navigate healthcare systems that quickly become a mix of maze crossed with fun house.

Immigrant Tale of Navigating Tangled Health Care Maze Is Instructive

NYTimes, July 26th, 2004

Everytime I think that I´ve learned as much as I´m going to learn about EM in Brasil, something else surprises me. The problem with researching the development of a specialty in a country this large is that sometimes even people within a country aren´t aware of the efforts going on just a few hundred miles north of them…and so I´ve started to feel a bit like the country is made up of bits and pieces that should fit together relatively well, if only they knew where the others were, or even that they’re parts of a greater effort. After 3 months of visiting hospitals and talking to various societies involved in EM development (in Rio, Porto Alegre, Curitiba, Campinas, Sao Paulo), I finally met a doctor today who told me point blank they think that they´ll organize a specialty here within a year…. surprising after 3 months of being told that EM will take about 10 years to develop, will take forever to develop, will never develop. Technically, they´ve already gotten approval from the AMB (the Brazilian Medical Association), step one of three involved in setting up a specialty. Yet, depending on who you ask, this step is a false one– a poorly set up move done to keep EM under the guard of Internal Medicine. It´ll be interesting to see who ends up correct. In the meantime, I´ve been doing my part, collecting email addresses and phone numbers of those interested in the development of EM in Brasil and trying to put them all in touch with one another.

The research is actually going much better here than it did in any other country I´ve been to this year. I spent a decent amount of time in the trauma bays and ERs of the hospitals in Campinas and Porto Alegre, and was able to tour and observe a bit in Rio, Curitiba and Sao Paulo. In Campinas, I spent a day shadowing the SAMU ambulance service on its rounds and then spent a day with the second year med students, who were coincidentally in the middle on learning about pre-hospital services in their city. Consisted of 6 stations set up with various parts of the system– the ambulance service on the highways (www.autoban.com.br), the regular ambulance service, the firefighters (they provide first response services here in Brasil), different doctors and paramedics involved, and a really gory slideshow of the ´´best ever´´ of the Autoban rescue services. I´ve seen a lot of interesting things this year, but that may have won the award for most shocking 15 minutes of my life !

That´s the other interesting part- as doctors work on ambulances here, I wonder if there may be more room for the development of a specialty for ambulance doctors, even if it´s difficult to organize a specialty within the hospital. There is already a residency in EM here in Porto Alegre, even though there is no specialty for these physicians to work in….and I feel like there might be a home here. I´m not sure if it´s what they want, but, maybe it´ll be a start….then again, maybe there´ll be a specialty in a year. Who knows.

Anyway, off to buy a plane ticket home…eek.

At least I can continue to have a little faith in the world (or, well, the U.S. since I think I lose faith in us a lot easier…):

There was a bill proposed to prevent illegal immigrants from using ERs in the U.S. While I understand that it`s a good way to identify illegal immigrants, as well as to stop one of the populations that often lack insurance from abusing ER services….well, the problem is that they lack insurance and can`t be treated anywhere else, and that healthcare around the world is horribly unfairly distributed– they don`t have any other choice really! He does make some very good points, though, about
*treatment often going well beyond stabilizing care,
*the fact that American ERs often feel as if they can`t turn away patients even if they do not really require emergency services,
*and of course the drain of the money for care being given to people who shouldn`t be here in the first place.

The problem is really that by threatening illegal immigrants with deportation if they visit the ER, you`re creating a bit of an ethics situation where people who seriously do need emergency care might not come to the hospital. In my opinion, this isn`t the part that needs to be reformed, though many of related issues do…

In any case, the result of the bill is summarized below:

Modern Health Care’s Daily Dose on 5/18/04:

House rejects bill on hospitals and illegal immigrants

The House voted 331-88 to reject a bill that would have required hospitals
to report illegal immigrants to the Homeland Security Department before
receiving any of the $1 billion set aside to help hospitals care for illegal
immigrants under last year’s Medicare reform law. Rep. Dana Rohrabacher
(R-Calif.) sponsored the defeated bill. It would have required hospitals to
ask patients for their immigration status, report those saying they were
illegal and collect identification information, such as a fingerprint or
photograph, from those patients. Hospitals argued the bill would impose a
difficult burden and could keep some illegal aliens from receiving needed
medical care. — by Jeff Tieman

One of my friends recently sent me an e-mail in response to the post on Lula and Brasil mentioning that I’m getting a really interesting perspective on society, politics and economics this year with my research, as these factors are inextricably linked to the development of health systems….this was, in short, the entire premise of my Watson proposal! Social medicine is a relatively new as a labelled field, but it’s been around for a long time, from public health to the various physicians’ organizations for human rights, etc. I thought I’d put up a little description of how society and medicine are bridged: I borrowed this from a new website on social medicine:

“What is social medicine?

It is possible to argue that all medicine by its very nature is social. The way we define diseases and health, the methods we use for diagnosis and treatment, how we finance health care, all these cannot help but reflect the social environment in which medicine operates.

Social medicine, however, looks at these interactions in a systematic way and seeks to understand how health, disease and social conditions are interrelated. This type of study began in earnest in the early 1800’s. It was the time of the Industrial Revolution and it was impossible to ignore the extent to which the factory system impoverished the workers, thus creating poverty and disease.

The most famous representative of early social medicine is Rudolf Virchow, the distinguished German pathologist who developed the theory of cellular pathology. Virchow was also a social reformer who remarked that “politics is nothing more than medicine on a grand scale.” In the 20th century George Rosen would distill the Virchow’s principles into the following:

Social and economic conditions profoundly impact health, disease and the practice of medicine.
The health of the population is a matter of social concern.
Society should promote health through both individual and social means.
As might be gathered from these ideas, social medicine was not simply an academic pursuit. Its practitioners were political reformers, radicals, activists. Virchow believed that the “physician was the natural advocate for the poor.” And this defense of social justice would stamp future generations of physicians and health care workers.
Social medicine has grown and developed in many different ways in the past two centuries. At times it has seemed as if the “biomedical paradigm” would make social issues in medicine irrelevant. Yet we cannot escape the reality that we are social animals and our diseases occurs in “social animals” and not in test-tubes. ”

Interesting link, from Sujal’s blog again…

Thoughts, anyone?

I apologize in advance for the length of this post, but it´s just about my work in Rio these past few weeks…I´m heading to Porto Alegre tomorrow!

They teased me on the ward today, jokingly introducing me as another little friend of President Lula because of my interests in the social problems in Rio and how they interface with medicine in the emergency department. Behind the smiles, however, was less amusement than resignation to disappointment. When Brazilians discuss the recent election and subsequent administration of their latest president, these are the emotions flavoring their words, touching their faces. As one physician explained to me, “In Lula, we had placed all of our hopes. He was a dream for Brazil, a fantasy. We thought he would help the poor, and there are so many poor. He was our last chance, but he couldn’t do it. It’s not his fault; there’s just no money. He’s trying to pay our debts, and no one is helping.”

Talking about progress in Brazil doesn’t flow easily. It’s not that people have given up believing in it completely; it’s just that they have accepted that in a country where even guaranteeing a basic level of services is a financial struggle, “progress” and “advancement” aren’t necessarily on the radar. The politicians make promises, but as the brasileiros will tell you with a wry smile, once election time is over, all that is left are the billboards stuck in the dusty plots of land, proclaiming the forthcoming new emergency block that there is just no money to construct. The doctors ask me if there is any way for institutions here to get sponsorship from institutions abroad. They do not understand why the countries in better financial positions in the world are not doing more to help out, why the trend is towards investing less in poorer countries, and why people think that the problems here in Brasil that very recently warranted funding are so much less than they once were. “Lula could do more if the rest of the world could just help out,” one doctor said to me.

So, instead, the Brazilians are working with what they’ve got. The hospitals try to make changes as smooth as possible, preparing the hospital for changes that may or may not be approved so that passage will go quickly if funded. They attempt to keep negotiations within the hospital, where approval and implementation are faster. In one hospital, they have decided on having one chief for the in-patient, out-patient and emergency departments so as to stop the fights between them. With medical education, they are attempting to bring students back to emergency medicine as they are being seduced by the sophisticated technologies and procedures of other specialties—a trend that reflects those in countries around the world, but that in Brasil, simply does not match the needs of the patient population. The emergency departments are not poorly funded. “They are the gateway to the hospital and so the care is strong, with well trained doctors,” several of the physicians told me, “Of course, everywhere, we need more staff, more technology, but it’s beyond the basic level of care in the hospital that we really have problems.”

Often times, the solutions are creative. The State Ministry of Public Health in Rio de Janeiro has just begun a pilot program to ease the burdens on the emergency departments here, which are often forced to hold patients for extended periods of time because there just aren’t beds open in the rest of the hospital. The doctor in charge of the program tells me, “In a country where over 90% of the population is poor, the problem is the public health care system. It is overcrowded, and people often go to the emergency department for primary health concerns because they think the care will be much faster. The biggest problem in the emergency departments is that there are too many patients.” They have created a telephone center that people can call if they think they have an emergency. They discuss their symptoms with trained operators who use set algorithms to decide if the patient truly has an emergency, and consult with doctors who are standing by if necessary. If there is reason to think it is a true emergency, an ambulance that is essentially a mini intensive care unit on wheels is taken out to the patient’s house. The idea is to treat the patient at home, so as to never have to bring them into the hospital. Of course, if hospital care is needed, the patients go directly to the intensive care units. Their physicians can call the center and find the closest hospital with beds available instead of just going to any hospital and hoping for an opening.

In Porto Alegre in the southern state of Rio Grande do Sul, the solution for the overcrowding issue in state hospitals has simply been for the government to purchase beds in the private hospitals. It’s cheaper than completely building new hospitals to accommodate the growing number of patients who need to utilize the public health systems because private insurance is a luxury very few in Brazil can afford (and because the public health system is arguably better than the private one, anyway).

The Red Cross (Cruz Vermelha Brasileira) head office in Rio just reopened two years ago, when the new administration decided to recommence funding the organization, which had been closed with the previous administration for the last ten years. The office is a beautiful grey building that stands in its own square, Praca da Cruz Vermelha, ambulances and buses hurtling by the castle-like structure. Inside, the staff, in large part volunteers, works hard in rooms humming with ceiling fans, computers and telephone conversations attempting to unite and support the branches of the organization spread out across Brazil that have all stayed open independently even while the head office was shut down.

On Monday, I spoke with a nurse who volunteers during the week for the Disasters and Emergency Department at Cruz Vermelha when he is not at his paying job or with his four year old son and pregnant wife. He wishes he could work here as a staff member, but again, the government has enough burdens without funding this organization any more. He patiently answers my questions about how to affect change in health systems here. “You can’t expect fast progress. We make changes and hope that they will affect other parts of the system well, and will attract the notice of those above us. We don’t have enough funding, and until we do, we won’t even be able to buy the supplies we need. The government is always changing and until it stays the same, it won’t be easy.”

A physician at one of the municipal hospitals (there are three types of hospitals here: municipal, state and federal) echoed those sentiments, explaining to me, “in 1998, there were new traffic laws that were passed that improved the rate of accidents. Within 2 years, there were 20% less accidents than before the laws were passed. However, like everything else in Brazil, good or bad, the project was let go and now has returned to the pre-1998 levels. Health can’t work like this; it requires continuity. Work needs to be done one step at a time- it’s better to go slowly than to take one step forward only to go two steps backwards!” Emergency medicine took off here in the early 1980s, but in many ways it faces the same issues it always has. The change from a dictatorship to a democracy allowed people to move across state lines, and as people entered Rio, the need for more staff, equipment and space emerged. She acknowledged that the social problems in Rio are a large aspect of the cases seen in the emergency department, and also within the city. Rio is a violent city, and while there are many programs designed to address this amongst other social problems, associations between the hospitals and public health are new here.

Here in Rio, doctors do get involved with these issues through a variety of NGOs and sometimes in the hospitals. Medicos da Familia, Medicos Sems Fronteiras, and Medicos Solidarios are all working in various sectors of this issue. In particular, Medicos Sem Fronteiras (Doctors Without Borders) focuses on social exclusion and disaster relief in the area. They work in the favelas and those living in the street, attempting to establish health care centers for people who otherwise have difficulty accessing them. They are attempting to change the accepting attitude towards the violence and misery in the city by creating sustainable medico-social initiatives and showing community members how to fight for their own rights. Through these efforts, they also are creating a channel of communication between these socially excluded communities and the government that ought to serve them.

On a national level, the public health issues across the country are vastly different, as the Head of International Affairs at Cruz Vermelha explained to me. First off, there are only 50 regional Cruz Vermelha branches in a country that simply needs more help (there are 200 offices in the much smaller country of Chile, just to give an idea of what the density of offices should be like). Then, there are the issues. In the Southern states, which are much richer, the problems are the high concentration of people in the major cities: Rio de Janeiro, Sao Paulo, Porto Alegre. Drugs and violence here place many of the citizens in dangerous situations, as exemplified by the current drug wars in the favela of Rocinha, which many people are calling the worst moments in its history. Access to clean water, which has been identified as a world-wide public health focus, is also an issue here. Near Niteroi, an area of Rio, there is one community where less than 30 percent of the people have access to adequate clean water. And then, there is the weather. While not a problem here in Rio, in the southern cities, such as Porto Alegre, the cold means tough times for the homeless in the streets. Moving up north, tuberculosis and yellow fever are concerns of the middle regions of Brasil. In the northeast, in the state of Bahia and around, the problems are more of a social nature: poverty, abuse. Machismo is a strong part of the culture and men often take out their misery on their wives. Finally, in the Amazonas, the communities of indigenous peoples are spread out and development is sporadic at best, limiting access to healthcare services. The cultures of these people also have conflicts with Western medicine and the attempts at establishing healthcare systems in the region in the past simply haven’t worked. Then, there are the problems of the country as a whole: the widely publicized spread of HIV/AIDS, the presence of other STDs, and the disastrous effects of the floods that often occur.

Everyone knows that Brasil is a large country with a large population and many problems. Creating collaboration between physicians and public health officials to address these issues is clearly not something new here. However, it seems as if in this era of failed promises, continuing frustration and let down by the one man they had entrusted to deliver Brasil from its social issues, the brasileiros are finding it hard to keep looking forward. The little steps are continuing, but it’s as if many people just don’t know quite where to go from here.

The world situation and WHO (Lancet)

Oi! It’s funny how my only real commitment these days is the hour of Portuguese class that I take, and yet I feel as if my days are so packed! Over the last 3 weeks, life in Rio has been better than I could have imagined! I wake up bright and early and join the many Cariocas (that’s what they call people from Rio) running along the black and white tiled boardwalks of the Ipanema and Copacabana beaches. My apartment is almost right between the two beaches, five minutes walking to either one, with a little view of the Ipanema beach. I can’t believe how lucky I was to find this apartment, and that I found it because I accidentally spoke in English when Payal and I were celebrating our birthday in a club in Leblon, another neighborhood in Rio. Ipanema is a really safe, beautiful area of Rio.

Usually, I spend my afternoons either calling potential contacts, visiting/interviewing/observing. Lunch at one of the lanchotes or suco (juice) bars on the street—vitamina de maracuja (sort of a passion fruit milk shake, but less thick and less sugary) is my new favorite drink. If I’m lucky, I get to study Portuguese on the gorgeous Ipanema beaches, sipping tender coconut water (I’m addicted) and people-watching with the best of them—and trying to resist the draw of really cheap jewelry hawkers lining the boardwalk! If it’s a research day, I normally spend the afternoon taking the bus or metro out to Centro and meet with a range of people involved in hospitals or NGOs—Pelavidda (an AIDS/HIV organization), Cruz Vermelha (Red Cross Brasileira), the Ministry of Health, road condition groups, Medicos Sem Fronteiras (Doctors Without Borders), etc. My Portuguese is finally at the point where I can conduct basic interviews. Though I kind of regret not just trying to find more contacts who spoke English rather than waiting until my Portuguese was good enough to get by, I’m pretty excited by everyone I’ve been able to talk to here. I’ve been learning about an amazing range of health projects going on in Brasil that I might have the opportunity to learn more about/get involved in, from providing healthcare in the favelas to bridging cultural divides with the indigenous populations in the Amazon region to build basic health systems there. There’s a lot of emphasis here right now on improving the roads so as to reduce all of the injuries and accidents related to that.

Nightime here has been a good mix of just chilling with friends and heading dancing, to concerts (my flatmate is a drummer in a few bands in Rio) or spending time just reading and writing here at home. It’s funny, but much of Brasilian nighttime culture is just hanging out at outdoor chopperias, standing around and talking with everyone else. When the chopperias close, we all just head down to the beach and sit at the plastic tables at the kiosks there until we’re tired enough to go home or until the sun rises, whichever comes first! The beach is lit up at night, so you can still see the waves crashing violently on the shore, producing a sea green foam that shoots high into the air. In the background, the lights from the favelas climbing up the hillsides are the only indications of the many hills that stand within the confines of Rio, but that blend into the nighttime darkness once the sun sets.

Sujal had a link to this incredible blog of a guy who’s working for an international NGO in Baghdad on his blog, and I really think it’s one of the most interesting things I’ve read in a while… I know it sounds weird, but I wish I could be there. Back at WHO, one of my boss’ suggestions for my future was to go to Afghanistan to work with this guy who was basically responsible for the distribution of funds and organization of the redevelopment of the health care infrastructure there. We got to meet him…amazing task ahead of him, really. Sadly, the Watson Foundation would have nixed that as there was currently a U.S. State Department warning against travel there (it’s one of the few hard and fast Watson rules- no travel to areas the State Dept. advises against visiting). I’ve been to some incredible presentations on the development and management of health care facilties and systems (from ambulances and hospitals to straight up field clinics) in war and austere environments this year, and I’d love to someday do some work with that kind of systems development because it’s a blank slate in so many ways. Regardless, happy reading! Glad I found something to read since it’s pouring outside and it’s Easter holidays, and this being a super Catholic country, it took out the only thing open today- the beach!

oh, now that i think about, another cool link I’ve never put up… Relief Web. A few friends and colleagues were involved in this back in Geneva. Good stuff….an incredible network of information on relief and humanitarian efforts around the world. If you’re motivated, you can find organization to which you can make donations, as well as places you might get involved in contributing the efforts going on (or just learn more about them).

…and one more thing. The results of a quick Google search (there’s an article on the impact of Google on our lives in Newsweek…anyone read it? In any case, I’m in love…) Emergency medicine in Iraq. This, basically, was the kind of work I was involved in at WHO…developing guidelines and best practice standards for essential health services, though specifically potential emergency surgical procedures. Iraq wasn’t one of the main target countries, but I could see it really being used there…

On terrorism and ERs: http://www.terrorismanswers.com/security/hospital.html (USA)

Definitions for emergency rooms: http://en.wikipedia.org/wiki/Emergency_room (not just USA….explains the different terms used in different countries to refer to the department dealing with these services: Accident and Emergency, just Emergency, Casualty, etc.)

and for further proof that it’s not only nerds like me (;)) who are interested in EM development, look at what was just shown on Australia and New Zealand’s TV History Channel”:

Modern Marvels - Emergency Room
Monday 19 Jan, 8.30pm
Emergency room medicine has only been a recognized specialty since 1989, and it took close to two millennia to get to this point. This programme examines the advances that led to the modern-day emergency room from the Byzantine’s establishment of the first hospitals around 1050 AD to today’s telemedicine. The prognosis for its future looks good.

If anyone catches that, tape it for me :P. I missed it here and I’ll probably be too busy hiking another volcano (today’s activity in NZ!!) to catch it on TV….

Here’s an article on federal law and emergency service provision in the U.S. A lot of people have been asking me how we cover ER visits for people who can’t afford the services…this article provides lots of details…

The Emergency Department is almost inherently a loud place. Squeaking stretchers, the hum of doctors’ conversations, machines beeping notice of the moments of a patient’s life. Silence in the ED usually only means one thing: a particularly sad case or tragedy. I don’t think that the department is actually quieter, but it’s just that the air is heavier somehow and everything is just a little more still. The first time I really felt that was a few summers ago when I was working at the Children’s Hospital of Philadelphia the day that a little girl came in who died after her grandfather accidentally left her locked in his car all day in the summer heat. It was easily one of the saddest experiences I had in three summers in the ED there. Today, I think, has added itself to that unfortunate list. I don’t know why there were so many kids in the ED today..and why so many kids with such serious issues: a teenager with HIV that’s progressed to fullblown AIDS (she now has pneumonia, sarcomas, etc.), an adolescent with advanced leukemia, a kid with a tumor… and the one that caused that horrible stillness in the ED, a 3 year old who was crushed by a lorry (aka goods carrier) and whose parents (1) refused the blood donation to help their daughter for religious reasons; (2) and then discharged her to transfer her to the free government hospital because they couldn’t afford CMC’s services.

I think that in the past week and a half, I’ve seen more than I did in nine months at CHOP. Much of that stems from the economic level of the patients CMC sees, but moreso from the way that uninsured patients are handled in this hospital, as opposed to in the U.S. In the U.S., the ED is a place that some uninsured people tend to flock to because the ED technically cannot deny care, even if the patient cannot pay for it. Thus, EDs are often abused in the U.S., with patients coming in for even minor problems. This pretty strongly affects the type of patients we see. In India, because uninsured people are required to pay for all of their treatments out of pocket, people are often hesitant to come to the ER…and when they do, the cases are often really serious. They’ll travel long distances to come to CMC, widely (and deservedly, in my experience) regarded as one of the best hospitals in India, and certainly in South India. In India, government hospitals offer free services, but the quality is considered low as they are overcrowded. Thus, people often prefer to come to the private hospitals. Often, they can’t afford the treatments, but have heard that CMC will sometimes provide services at a reduced rate or for free thanks to the support of their generous donors…so they will show up hoping to be lucky enough to receive some aid. Of course, while CMC does assist its patients to an incredible extent, they can’t always help everyone as much as they need…but the greater problem is that people often come and try to get services for cheap or free, even if they can afford more. All of this combines to a lot of heart-breaking cases where patients need to leave because they can’t afford services…and a lot of tension between doctors and patients as they “bargain” for health care costs and services. It’s really the doctors trying to assess what the patient actually can afford and appropriately reducing the actual price to a reasonable amount for the patient…and then getting them to actually pay it, but it can seem rather heartless to the casual observer, who will see the doctor call out for a nurse to discharge a patient who is clearly in need of further care. The nurse will then wheel the patient out to Quiet Counsel, and sure enough, ten minutes later the family will have come up with the money to pay the fee determined by the doctors. In reality, it’s all part of how things work here….like anywhere, even trying to be generous can backfire. Seeing this is the only thing keeping me from pushing the contents of my bank account at the patients…because I know that it leads to patients coming to the hospital thinking they’ll be able to receive top-notch care at an affordable price, when in the end it just leads to them having to pay a little for what they accept and then having to be transferred to the government hospital (the transfer isn’t always the best thing for the patient). It’s really bizarre knowing that I could make such a huge difference with what amounts to a small sum of money in my terms, even if I don’t know enough yet to do anything with my knowledge….but that if I decide to “help,” the outcome might be worse.

Not to sound horribly naive, but why can’t things just be simpler? *sigh*

If there’s one thing that I adore about India, it’s that everything is done with a touch of Indian flair. I mean, even the English spoken here is particularly Indian with all kinds of different ways of saying things, as compared to how Americans say things. It’s much more different than even U.S. versus, say, Australian english. And to think, all of these years I spent “correcting” my mom’s English…. My main point is that no matter how much globalization might hit India, the people here will never adopt anything the way that it’s handed to them…they’ll adapt and modify it until it’s something exclusive to them. This is definitely the case with medicine and particularly with EM. Sometimes it feels a bit like being in bizarro world when you think of how differently things are done when there is so much infrastructurally similar in the systems…..

In case you can’t tell, today was my first day at CMC Vellore in the hospital. I’ll be rotating in the ED for 2 weeks, then a week in a community health program and then a week in the Neonatology department. I’ll go more into cultural commentary in another entry…for today, i’ll just leave you with an image of my day:

The nurses in Triage (pronounced TRY-age) sit just inside the gate to the Casualty Department, dressed in immaculate white saris covered with a dark blue smock, little plastic nurses’ hats bobby-pinned to their heads. As a ceiling fan whirs overhead, people crowd into the waiting area: Women in brightly colored saris with chains of jasmine adorning long, black braids. Men in button down shirts over loose, plaid sarongs. The first Road Traffic Accident of the day pulls in, the patient carried in off of a rickshaw. As they rush him onto a trolley (stretcher), I catch a glimpse of his face, marked with a tikka. Vellore is a hospital that sees mostly rural people, but it is actually the largest private Accident and Emergency (aka Casualty) Department in India…the contrast is so evident in the fact that while English is the language of the hospital, every single patient we saw today spoke only Tamil. Ok….more on the hospital later. gotta go for now….

someday we will be these women flying all over the world starting and sustaining this huge ngo network that helps all these children actually get access to quality medical care

till then, the struggle continues

–e-mail from a friend at WHO concerning finding funding/jobs to work abroad.

for all of my complaining about anything…..this is what it’s all about….

World Health Organization, Geneva