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.