Social Enterprise Links

Check out these videos on public health and social enterprising

http://google-africa.blogspot.com/2009/06/google-sms-to-serve-needs-of-poor-in.html

http://www.pbs.org/now/shows/537/index.html

UNAIDS

What do people think of this study published by UNAIDS about the need for routine laboratory testing of patients in Africa on ART

http://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archive/2009/20090911_DART_Story.asp

Social Business

For all business minded people--that seek profits but also a better world, think about social business. This will be the beginning of a series of posts that discusses social enterprise in its many forms. The idea was brought to me by Nobel Peace Prize winner Muhammad Yunus, who started Grameen Bank which provides micro credit loans to the poor in Bangladesh; it is probably the largest social business in the world. Please check out his book:

Creating a World Without Poverty:Social Business and the Future of Capitalism

" I am sure many people would like to create social-purpose companies if such entities were recognized by the economic system. It is a major failure of the current economic system that it cannot accommodate this basic human urge." Yunus 165

EHealth

I am now going to school in Atlanta at Emory University's School of Public Health. The program has a lot of opportunities and adventures in store, the first was at the CDC where they continue to use new forms of media to disseminate important public health information: check out their Ehealth website, google gadgets, facebook page, and youtube channel.

http://www.youtube.com/user/CDCStreamingHealth

http://www.facebook.com/CDC?ref=search&sid=9801631.4133318816..1

Peter Singer: Why We Must Ration Health Care

"It’s one thing to accept that there’s a limit to how much we should spend to save a human life, and another to set that limit."

Paul Farmer: Partners in Health

http://www.pih.org/home.html

Peter Singer: Why We Must Ration Health Care

http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html?_r=2&hpw

"You have advanced kidney cancer. It will kill you, probably in the next year or two. A drug called Sutent slows the spread of the cancer and may give you an extra six months, but at a cost of $54,000. Is a few more months worth that much?

If you can afford it, you probably would pay that much, or more, to live longer, even if your quality of life wasn’t going to be good. But suppose it’s not you with the cancer but a stranger covered by your health-insurance fund. If the insurer provides this man — and everyone else like him — with Sutent, your premiums will increase. Do you still think the drug is a good value? Suppose the treatment cost a million dollars. Would it be worth it then? Ten million? Is there any limit to how much you would want your insurer to pay for a drug that adds six months to someone’s life? If there is any point at which you say, “No, an extra six months isn’t worth that much,” then you think that health care should be rationed."

A Great Dilemma

While I have said we must bridge the gap between public health and community medicine. This poses a personal, ethical dilemma: When faced with limited resources to improve peoples' health, as a public health practitioner one would believe that you use resources to help improve the health of as many people possible (This is the classical utilitarian view). As a medical practitioner when faced with the same dilemma, ones duty is to his/her patient. The question is at what cost? Is there a cost that would prevent you from treating any one patient knowing that those resources could be distributed to help many more (Peter Singer frames this question more eloquently)?

I welcome comments as this is truly a great ethical dilemma for all of us. It applies to health resources and aid for the poor, health care rationing in this country........etc. I also wonder if there is a different way to frame the issue of limited resources. While in theory, I have posed conflicting views, in practice can't we be utlitarians that are also dedicated to the health and well being of individual patients and vice versa? Under what circumsatnces should we act as one rather then the other?

Advocay

I have talked a lot about individual patients and the importance of being patient centered. But I am also beginning to learn while it might be less glamorous, less rewarding in any immediate sense, we must be advocates for our patients.

We must be advocates for better housing, better shelters, better mental health and substance abuse services.

We must have the ear of politicians, community action boards, and hospital administrators

We must bridge the gap between public health and community, frontline medicine; Too often there seems a great void.

12

This is the number of CD4 T-cells that one of our patients has. A healthy person has 500+. At 12 T-cells your immune system has completely collapsed, your body is constantly overwhelmed by bacterial and fungal infections, you our on the verge of death.

A nurse once visited a patient of ours in the hospital with 1 T-cell, his body completely indefensible, but he was nursed back to health, and today I have the pleasure of listening to his Haitian music at least once a week.

This is a reminder of why we do this work.

But today, our patient with 12 T-cells has no interest in taking medications. He will soon die. All we can do is ease his suffering.

This is also why we do this work.

Anthropology

I have been reading a lot about medical anthropology of late-especially this idea that while anthropology in itself is an academic pursuit, an anthropological perspective to medicine and public health is extremely practical and useful. I have learned a lot about this practice from Paul Farmer's works and his experience in Haiti, but it also applies to my work this year in San Francisco.

Two examples come to mind: One is the understanding of punk rock culture and its influence on a number of our homeless and chronically drug-addicted patients. The second is the influence of the gay rights movement, and gay subcultures in San Francisco, on patients that engage in sexual activities that put them at high risk for HIV infection.

While I am sure books have been written on these subjects, I think it is important to understand how these social and cultural movements influence the health, life, and identities of our patients.

You cannot do motivational interviewing with a Punk Rocker if you don't know what Punk Rock is all about (I still have a lot to learn). It is difficult to do effective harm reduction counseling with a gay man that doesn't use condoms if you don't at least bring up ideas of sexual liberation and the history of HIV in the San Francisco gay community.

You have to talk about peoples identities, and how those identities relate to their health and well being. I believe the study of anthropology helps you do this.

Measuring Success

It is often difficult to measure the success of much of what we do at Tom Waddell. We have little quantitative data about health outcomes and quality of care. We simply don't have the resources to do many of the studies we want to do.

We do however have a great deal of qualitative data: Discussions with IV drug users that have administered narcan, show that the drug overdose prevention trainings we provide have saved numerous lives. The transgender-specific care we offer, including assistance with injecting hormones, has prevented deaths and serious injury that would have resulted from use of hormones on the black market.

In other words, while many of the harm reduction approaches we employ may be difficult to analyze quantitatively, we certainly see qualitative evidence to support these approaches.

On the other hand, there are certain initiatives that might require more evidence to show their efficacy: HIV testing in the urgent care clinic has been useful in detecting a few unknown positives, but without adequate time for counseling, I wonder if the more frequent HIV negative result is validating risky behavior amongst our patients

Hydrocele

A victory was had at Transgender clinic the other day. One of our male to female transgender patients was diagnosed with a hydrocele--a benign but painful fluid accumulation in the scrotum that is often removed surgically. One of our providers seized this opportunity to recommend that the surgeon actually perform a bilateral orchiectomy at the patients request. A bilateral orchiectomy is the surgical removal of both testicles, which for transgender male to female patients is an elective surgery not covered by their insurance.

Fortunately, the surgeon realized the strong desire of the patient to have this surgery done, and sure enough performed a bilateral orchiectomy to "ensure that the hydrocele did not reoccur"

This certainly was a victory in a system that makes it difficult for transgendered individuals to even get hormone therapy covered by their insurers.

The Road

I often visit our patients at the hospital or at their homes (if they have one) to see how they are doing. I will see them on the street or at the Martin De Porres soup kitchen. I never quite know what to expect.....

I have had a patient offer me weed and asked me on a date for chicken and waffles 

I have had a patient run out of his room with no pants on (or underwear) to change his cat's liter box

But I have also...

Visited a patient in the hospital who was bone thin and being worked-up for leukemia. 

I have seen patients curled up on the streets in the freezing rain. Another, in the hospital detoxing from alcohol and on so much ativan she didn't know where she was. 

Like I said,  you never know what to expect, and you never know what emotion is going to hit you next.......

Political Thought

I know this is not a political blog (unless you believe that the right to health care should be a political, rather then human rights, issue), but an idea has come to me since watching the debate over whether GITMO detainees should be moved to high security prisons in the United States. There has been calls by both Democrats and Republicans in Congress to prevent this from happening--generating fear that some how these terrorist suspects will pose a threat on U.S. soil. The fact of the matter is that not a single person has escaped from a high security prison in the United States, and this argument by Congress is entirely irrational.

Since, it seems that both democratic and republican congressmen,and even presidents, often lack the intellectual competency to make rational decisions and statements in public office, I have come up with the following idea:

All persons interested in running for public office must pass a series of litmus tests before they are eligible. We do this with lawyers, doctors, nurses, dentists..... we should do it with our politicians. An independent body of experts from a number of fields should develop tests on the following topics:

Constitutional Law

Health care

U.S. History 

World History

Macroeconomics

Microeconomics

Environmental issues

(and probably more)

We have a representative democracy instead of direct democracy for a reason: The average individual does not have the depth of knowledge required to make fair and rational decisions for the good of our country (Case in point: California). Therefore, we most elect representatives that understand the concerns facing their constituencies, but also have the intellectual ability to develop rational  and evidence-based solutions to complicated problems; many of our elected officials lack this ability and we must rectify that. 

Across the World

I was recently thinking about the time I spent in South Africa--the experiences I had working in impoverished communities there vs. San Francisco. Not surprisingly there are many differences, social, economical, political, and historical, but there are also a few important similarities.

I spent much of my time in South Africa working in the Nyanga and Masphumalele townships outside of Cape Town. One striking similarity, was the degree of economic and social inequality that exists in Cape Town as well as San Francisco. While the former is on a much larger scale, the spectrum of wealth and poverty in Cape Town is very similar to that of San Francisco, and for that matter, most major cities in the United States. Living in the Nyanga Township, people face many of the same problems seen in the San Francisco Tenderloin--lack of adequate housing and health care--persistent violence, pervasive drug use, and the abuse of women.

I have seen people smoking tic (methanphetamine) on the streets of Masphumalele, and I see patients struggling with their meth addictions everyday in our clinic. I have heard the horrible stories of women being raped and contracting HIV in Nyanga and our patients being raped and abused in the Tenderloin.

These two countries have some of the greatest disparities in wealth in the world--yet the United States is always seen as "different" or "paramount" to African nations. I think some self reflection is desperately needed.

Why David Simon is Right

Last night, I watched David Simon being interviewed on Real Time with Bill Mahr. David Simon, who I know as the creator of the HBO series the Wire (a fascinating social critique of intercity Baltimore), was discussing how the war on drugs in the United States has failed miserably. He explained that the United States has more people serving prison time for non-violent offenses (most of them drug related) then any other country in the world.

Many of the people I see at my clinic are non-violent drug offenders who are constantly in and out of prison, which exacerbates their addictions, and often leaves them looking for their next fix the minute they are released. In prison, there is no treatment, there is no rehabilitation, only a breeding ground for physical and emotional abuse, and frankly a waste of tax payers' dollars (only 7% of people in prison today are actually violent offenders).

In other words, the war on drugs has really become part of a cycle of social and economic marginalization. Throwing a person with paranoid schizophrenia and crack addiction in prison for shop lifting, just perpetuates that cycle.......

The Haitan

We have a patient that has a very sad story. He was born into a wealthy family in Haiti during time of major political strife. When he was 18 years old, his father, who was still very wealthy at the time, had him board a plane to New York City. From that point on, he was on his own --the Haitian government prevented the rest of his family from leaving Haiti and froze their bank accounts.

He worked as a taxi driver in New York City for many years before coming to San Francisco. Today, he is a patient of ours struggling with HIV disease, crack addiction, poverty, and extreme loneliness.

He always comes into the clinic in a jacket and tie, a reminder of past prosperity. His loneliness is his most pervasive quality. He often comes in just to speak with me or the nurse (occasionally he will have a medical complaint). He speaks about Haiti all the time, and usually has some kind of stereo playing Haitian music. As far as I know, he has little or no contact with his family to date.

You can learn a lot from his story, about the cause of poverty and illness, and about the broad, even global, impact of political and social injustice.

Dr. Z #2

I believe good medical science combined with an ability to relate to patients and their needs is important. One of our patients is heavily addicted to crack and is diabetic. While he is trying to recover from his addiction, he is replacing that addiction with overeating, making it more difficult to control his blood sugar levels and diabetes. Being supportive of his effort to move away from crack, and the damage it is doing to his body, seems more important at this stage in his care. Addressing one of his primary reasons for engaging in care is important, as it will hopefully keep him engaged, and allow us to treat his other medical problems.

Another patient of ours is paranoid schizophrenic; she often has horrible hallucinations that make her fearful of people and different environments. The ability of our medical team to create a calming and safe environment for her is essential to engaging her in care. Once we were able to do that, the use of anti-psychotic drugs has dramatically decreased her level of paranoia and fearful hallucinations. Furthermore, she is able to take her other HIV medications and get linked with a regular mental health provider.

TG night

Tuesday nights is Transgender night at Tom Waddell. This clinic has been around for over 15 years and has quite the history. It is one of the first clinics to provide TG-specific primary care and specifically focus on low-income and homeless populations. Many of our patients have fully transitioned from either male to female or female to male and simply receive basic primary care services; others are in the process of transitioning and are on different regiments of hormone therapy; some people are pre-sex operation others are post-sex operation; some patients identify as gay others as straight, others as gender fluid (sexual orientation is very different then someones gender identity).

A focus of this clinic, and really my job, is to be "culturally" sensitive, or simply, respectful of a person's gender identity. Many patients have names, other then their legal name, that they prefer to go by. It is important to use proper pronouns when talking about patients, whether it be with them or with their provider. Respect for this identity is a core value of the clinic.

Dr. Z

I have started to see some of the essential qualities needed to become a good primary care doctor.  I have learned that the practice of medicine is as much art as it is science, and certain doctors have really mastered this art form. 

The ability to develop a rapport with patients that often have a great distrust of other people, takes time, patience, compromise, and often a tremendous amount of flexibility.  We see patients that one day are raving about their doctor and the next day want nothing to do with them. 

I also see a tremendous amount of flexibility in the care for our patients.  While a patient might have uncontrolled diabetes, liver disease, methamphetamine or heroin addiction, that might not be their main concern when they come into the clinic. Their chronic pain, neuropathy or depression might be more important to them on that day. The physician has to prioritize care, knowing when to treat the patients primary concerns, but also knowing when to bring up other serious health problems that the patient might not want to deal with.  

The art of patient care is truely seen here: knowing how to discuss a patient's health problems without alienating them; finding practical ways to treat these problems, i.e. with drugs they will adhere too, and harm reduction approaches that will keep them engaged in care.

Linda

I see a number of people with Paranoid schizophrenia at our clinic. This disease can manifest itself in many different ways, and the people living with such mental illness find different ways to cope and adapt to their perceived realities.

Linda started developing signs of paranoid schizophrenia when she was in college. When I met her she was 60+ years of age, living in the tenderloin--she could have been my grandmother. Instead she lived alone in a hotel room, addicted to crack, her hair infested with lice.

She often hallucinates about different smells in the room--she is paranoid about getting sent to the psychiatric emergency room. But for the most part, Linda is able to live on her own--she now takes her medications, eats, sleeps, and baths herself.

While she can relate to you, her view of the world, the environment around her, is evidence of her illness. She knows who I am, but often confuses me for someone else--an ex-boy friend, a member of the KKK (which I thought was particularly out there).

She copes with her illness by often self-medicating--smoking crack and cigarettes. Drinking coffee to stay awake because the vivid dreams she has keeps her from sleeping.

Linda has a family, a community of people that takes care of her--helps her survive in the real world. Since being on medications her hallucinations have become less intense and disturbing. She now lives in a brand new independent apartment where nursing staff and case managers are there to assist her. Many of the mentally ill are not so lucky.

The Exchange

Monday nights and Tuesday mornings I work at the needle exchange run by the HIV prevention project in San Francisco, with medical staff provided by Tom Waddell Health Center. Since needle exchange was legalized in San Francisco, rates of HIV infection amongst intravenous drug users has dropped dramatically. 

While the needle exchange has proven to be an effective public health intervention, just as importantly, it has decriminalized the disease which is addiction. People may not agree with the use of illegal drugs, but every time I come to the exchange I witness the stranglehold of addiction.

One girl played for the under 18 U.S. women's national soccer team, after injuring her knee, which ended her career, her father shot her with speed and heroin for the first time (to help her with the pain)--she has been addicted ever since.  

Many of the stories you hear at needle exchange are this tragic, yet these are in many ways forgotten people--lacking medical, mental health and effective drug/addiction treatment services.  Many are to afraid to access these service because their behavior is criminalized; many can't find services that are right for them; many can't afford services. 

Best Soup in Town

Every Thursday, I assist doctors on a medical outreach van at a local soup kitchen in the Mission. It is here, where you find a sense of community on the streets--people from all walks of life interacting with one another.

People have many stories here.....

Discussions range from conspiracy theories to life on the street and how people got there. Some people are haunted by hallucinations and delusions, others are perfectly logical and articulate--no signs of mental illness. People come from all walks of life--salesman, carpenters, constructions workers--from all over the world--Dallas, Ireland, Mexico, San Francisco.

There is no stereotype that characterizes this place.

Tenderloin Health

I have spent the past 6 months working for Tom Waddell Health Center--a homeless health care provider in San Francisco's Tenderloin. What strikes me the most are the people I have worked with--their level of compassion and dedication--and their ability to meet people where they are at in their lives.

When I took this job, one of the most challenging things for me to understand was the idea that health, suffering, rehabilitation..etc. are all relative and fluid states of being. 

What we are doing at Tenderloin Health, one of Tom Waddell's community clinics that sees many of our sickest homeless patients, is alleviating suffering one day at a time; suffering that for many, if not all of our patients, has persisted for years, and will never be eliminated in any absolute sense.