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.