Social Media and the Health System
Ted Eytan, MD, MS, MPH; Jeffrey Benabio, MD; Vince Golla; Rahul Parikh, MD; Sara Stein, MD
Winter 2011 - Volume 15 Number 1
You know institutions tend to become static; they build walls around
themselves to protect themselves from change, and eventually die.
You should fight that by opening up your thinking and your ideas,
and work for a change.
-Sidney Garfield, MD1
As early as 1960, Sidney Garfield, MD, the co-founder of Kaiser Permanente (KP), foresaw how computers would become powerful tools to help patients.2 It is in his maverick spirit that we examine the potential for social media to be powerful tools to help our patients today.
Social media, or content created and exchanged within virtual communities through the use of online tools, are used by millions of people to converse and to connect.3 Health systems can use social media to engage members and potential members by building trust and making large organizations more accessible and approachable.4 Social media can help patients manage their chronic conditions and make healthy choices; it also can accelerate knowledge acquisition and dissemination for patients and clinicians.
Health and health care organizations are popular topics in social media conversations, and both positive and negative stories shared through online networks can have an enormous reach. KP experienced this in 2006, after unfavorable media coverage of the KP HealthConnect® electronic health record system emerged on social media sites.5 Positive messages can also spread as has been the case of the KP Thrive advertisement “When I Grow Up,” which was hosted on the social network video site YouTube. The video portrayed images of active women seniors alongside a message promoting mammography that attracted more than 125,000 views garnering significant attention from repeat viewers and women in the target demographic of 55 and older.
Although there are risks for health systems to participate in social media, there are also risks in not participating. In a patient-centered model of health care, absence from social networks that are important to patients might lead to a gap between patients and clinicians. In this article, we will focus on the promise of social networking and review potential risks of both participation and abstention.
Social Networking and Social Media
Social networking is not a program or a Web site; it is a community of people who share similar interests and activities who interact through online and mobile technologies. Facebook, Twitter, and blogs are Web platforms used to connect people and transform the publishing of media from broadcast media monologues into social media dialogues.3 The rapid and extensive penetration into society of these sites is related to their ability to facilitate talking as well as listening, consuming as well as participating. Whereas it took nearly 40 years for computers to become mainstream, it took Facebook less than 6 months to add 100 million people.6 Today more than 500 million people use Facebook regularly.7 Among adults in the US, 42% use social networking sites. Among young adults (age 18-29 years), the figure is an impressive 86%.8
Building Trust and Understanding
Because of the “no advertising rule” in the American Medical Association’s code of ethics, which existed from 1847 to 1975, health care organizations were barred from communication that could subject physicians to allegations of “soliciting” patients. In the post-“no advertising rule” era, however, health care organizations have begun to adopt best practices of the public relations and issues management field. One key concept is the “bank of good will.” Good news generated by an organization strengthens its reputation in the marketplace and among policymakers and influencers. Good news also protects against potentially harmful messages. When this bank is depleted because of the absence of positive mentions, organizations face reduced effectiveness as the result of a damaged reputation. Adding to this understanding, large media outlets and organizations no longer generate all news and messaging. In today’s world of democratized influence, consumers generate news. A 2010 report by the Pew Internet and American Life Project9 confirms this reality: 37% of Internet users have actively contributed to the creation, commentary, or dissemination of news. In addition, 75% of online news consumers get news forwarded through e-mail or posts on social networking sites.
In practice, a successful organization tracks positive, neutral, and negative media “mentions.”
Data show that KP has internalized the bank of good will best practice.
Figure 1 demonstrates the visible change in media mentions (defined as a reference to the organization in print publications, television, and the Internet) from KP’s work.
Twitter and other social media exert leverage by using positive network effects. This means that one message reaches the direct followers, who then share the original message in an exponential fashion, increasing the value of the network to the individuals who participate in it. The positive network effect provides fast and free distribution of messages to health consumers. A recent demonstration of this effect occurred with the media release of KP’s electronic health record collaboration with the Department of Veterans Affairs in January 2010.10 Through the use of social networking tools such as Twitter, an audience of hundreds was expanded to an audience of over 75,000 within 48 hours, with 92% of the reach created by individuals not affiliated with KP.11
An example that examines the reach of just one physician demonstrates the potential of building the bank of good will. In Figure 2, the content generated by a single KP physician, in this case coauthor Jeffrey Benabio, MD, a dermatologist, (“Tweet Type” pie chart), is compared to the reach of each piece of content, copied and forwarded, and tracked through the Internet.
Following on this analogy, each impression equals a deposit to a bank of good will. The conservative approach to social media participation has typically been to use social media “handles” and profiles that avoid mention of organizational affiliation, as is the case above. The significant impact of positive mentions and the dominance of user-generated content in media mentions has changed this view, however, turning what was once thought of as a liability into an asset in the positioning of a care system as the model for the future. If the physician instead is identified as part of a Medical Group in their social media handle or profile, the deposit of good will goes to the organizational “account” in addition to the individual “account.” Combined with the network effect of multiple physicians participating, their impact in support of the health system’s efforts to support patient, family, and community health is multiplied exponentially.
Studies of the impact and accuracy of health information disseminated via social networks are only beginning to be published.12 Statistics clearly demonstrate a demand for social media in medicine, which provides an opportunity for clinicians and health care organizations to engage their patients. During the H1N1 outbreak of 2009, the Centers for Disease Control and Prevention (CDC) turned to social networking site Twitter to communicate with clinicians across the US. The CDC employs a Twitter feed for emergency information (more than 1.2 million followers) and also for flu information (46,000 followers).13 There are numerous examples of individual physicians using social media to educate and support patients in preventing and managing chronic illness. Additionally, we are seeing a growing effort within the health sector to embrace social media as evidenced by the creation of the Mayo Clinic Center for Social Media. Physicians involved in these efforts cite the use of social media as the enabler of societal purpose in their professional work, whether it is to “realign families with science”14 or “tap into the reason we all went into medical school, to make a difference in people’s lives.”15
A recent legal review of social media concluded, unsurprisingly, that “in the health care context, complex situations can arise.”16 For example, a physician unaccustomed to mass communication might be misquoted or contribute to negative perceptions of his or her practice or health system, intentionally or not. In addition, a broader perspective of risk must include the actions of physicians, staff, patients and their families. Employees have been terminated for tweets that violate the Health Insurance Portability and Accountability Act (HIPAA); discovered Facebook and MySpace conversations have led to insurance coverage litigation; civil complaints have been filed alleging libel/defamation of clinicians in the use of online rating sites.16 The protection of patient privacy is paramount and requires special attention. Multiplying the number of communicators and the number of environments can increase the risk of harm to those we serve and of harm to the organization’s integrity and ability to carry out its mission. Paul Levy, former CEO of Beth Israel Deaconess Medical Center in Boston, points out in his social media work that “any form of communication (even conversations in the elevator!) can violate important privacy rules.”16p13 For this reason, an approach to social media that is applicable across all forms of communication is fitting.
An organizational social media policy is a first step in acknowledging employee activity and managing risks, “to keep them and your company safe as well as responsive.”17 KP’s social media policy,18 ratified in 2009 has been freely available for organizations to learn from and is considered a model in the health care industry.19 Greater actualization of benefits, including maintaining and growing a bank of good will, requires a transition in thinking from prohibiting all social media activity to active, guided engagement of all who wish to participate.20
Although health care’s understanding of the potential of social media is still in its infancy, more innovation is inevitable. Health care organizations and individual physicians are already using social media regularly to build trust, promote management of health and wellness, and disseminate knowledge. For health care systems and physician groups with a tradition of innovation and responsible growth, organized social media participation can extend the benefits of excellent communication with patients and potential consumers to enhance their relationship with us and promote achievement of their life goals through optimal health.
In an August 2010 conversation with the author (TE), Jack Cochran, MD, Executive Director of The Permanente Federation, the national umbrella organization for KP’s 15,000 physicians, stated: Today’s health system leaders are beginning to appreciate social media as “another societal asset that we need to be conversant in, and imagine how it will all link to a better future, instead of imagining that it will go away.” Leadership in the use of social media is an opportunity and a challenge for a health system to engage with a changing stakeholder group. On the basis of current life expectancy, it is possible that an individual over the age of 50 today could be cared for by a physician who is not yet born, and both these physicians and their patients will have different expectations for interaction than exist today.
“Social media is already integral to how people now live their lives and, increasingly, it plays an important role in how they manage their health,” says Holly Potter, Vice President of Public Relations at Kaiser Foundation Health Plan. “If we want to be relevant partners, helping our members and their families manage their health, it is our obligation to learn how to engage—safely, respectfully, and authentically.”
A sustained educational effort will be required to address gaps in understanding, manage fears, and mitigate tangible risks. We see the enormous potential of these tools to help a care system fulfill its purpose. At the same time, we are mindful of the benefits of learning from and teaching colleagues about this significant change in the way we will interact, with encouragement from medical leaders:
“Social media is very formidable, very real. It’s all around us and gaining momentum. We need to become savvy enough to help direct our colleagues to understand its potential, negative and positive.” Dr Cochran related to the author (TE) in their August 2010 conversation.
It may be normal one day for every physician and nurse to maintain a social media presence as health professionals committed to the health of individuals and populations. We are hopeful that this article will continue conversations already started about this future and the way we will shape it, in the interest of moving ahead together for the benefit of those we serve.
The author(s) have no conflicts of interest to disclose.
1. Debley T. The story of Dr Sidney R Garfield: the visionary who turned sick care into health care. Oakland, CA: The Permanente Press; 2009. p 119.
2. Garfield S. The delivery of medical care. Sci Am 1970 Apr;222(4):15-23.
3. Social media [monograph on the Internet]. San Francisco, CA: Wikipedia; 2010 [cited 2010 Aug 3]. Available from: http://en.wikipedia.org/wiki/Social_media.
4. Understanding the role of the Internet in the lives of consumers [monograph on the Internet]. St Louis, MO: Fleishman-Hillard; New York: Harris Interactive: Digital Influence Index; 2010 Jun [cited 2010 Aug 3]. Available from: http://digitalinfluence.fleishmanhillard.com/.
5. TECH/HEALTH PLANS: A Permanente Group executive speaks [monograph on the Internet]. San Francisco, CA: The Health Care Blog: 2006 Nov 13 [cited 2010 Dec 4]. Available from: www.thehealthcareblog.com/the_health_care_blog/2006/11/techhealth_plan_1.html.
6. Smith J. Facebook crosses 250 million user mark, adds 100 million new users in 6 months [monograph on the Internet]. Palo Alto, CA: Inside Network; 2009 Jul 15 [cited 2010 Aug 3]. Available from: www.insidefacebook.com/2009/07/15/facebook-crosses-250-million-user-mark-adds-100million-new-users-in-6-months/.
7. Press room: Facebook factsheet. Palo Alto, CA: facebook; 2011 [cited 2011 Jan 4]. Available from: www.facebook.com/press/info.php?statistics.
8. Madden M. Older adults and social media [monograph on the Internet]. Washington, DC: Pew Internet and American Life Project; 2010 Aug 27 [cited 2010 Sep 3]. Available from: http://pewinternet.org/Reports/2010/Older-Adults-and-Social-Media.aspx.
9. Purcell K. Rainie L, Mitchell A, Rosenstiel T, Olmstead K. Understanding the participatory news consumer [monograph on the Internet]. Washington, DC: Pew Internet and American Life Project; 2010 May 1 [cited 2010 Sep 3]. Available from: http://pewinternet.com/Reports/2010/Online-News.aspx.
10. Doherty T, Kahn R, Roberts K. Veterans Affairs and Kaiser Permanente share electronic health information to improve care for veterans [press release on the Internet]. Oakland, CA: Kaiser Permanente News Center; 2010 Jan 6 [cited 2010 Aug 26]. Available from: http://xnet.kp.org/newscenter/pressreleases/net/2010/010610vamedexchangepilot.html.
11. TweetReach for va, Kaiser Permanente [data on the Internet]. San Francisco, CA: Appozite; 2011 [cited 2011 Jan 8]. Available from: http://tweetreach.com/reach?q=va%2C+kaiser+permanente.
12. Scanfield D, Scanfield V, Larson EL. Dissemination of health information through social networks: Twitter and antibiotics. Am J Infect Control 2010 Apr;38(3):182-8.
13. CDCemergency: Twitter profile [Web page on the Internet]. San Francisco, CA: Twitter; 2011 [cited 2011 Jan 4]. Available from: http://twitter.com/CDCEMERGENCY.
14. Eytan T. “The more we change the world”—Blog-ter-view with Wendy Sue Swanson, MD, about physicians and social media [blog on the Internet]. Washington, DC: Ted Eytan, MD; 2010 Aug 8 [cited 2011 Jan 10]. Available from: www.tedeytan.com/2010/08/10/6078.
15. Brown M. The doctor will see you now?? Comment by Sara Stein, MD [blog on the Internet]. Knoxville, TN: Pershing, Yoakley and Associates; 2010 Aug 13 [cited 2011 Jan 10]. Available from: http://healthcareblog.pyapc.com/2010/08/articles/healthcare-reform/technology-social-media/the-doctor-will-see-you-now/.
16. Coffield RL, Joiner JE. Risky business: Treating tweeting the symptoms of social media. AHLA Connections 2010 Mar;14(3):10-4.
17. Bernoff J, Schadler T. Empowered. The Harvard Business Review 2010 Jul-Aug:94-101.
18. Kaiser Permanente social media policy [monograph on the Internet]. Oakland, CA: Kaiser Permanente 2009 Apr 30 [cited 2010 Aug 3]. Available from: http://xnet.kp.org/newscenter/media/downloads/socialmediapolicy_091609.pdf.
19. Li C. Open leadership: how social technology can transform the way you lead. San Francisco: Jossey-Bass; 2010. p 336.
20. Owyang J. Breakdown: The five ways companies let employees participate in the social web [monograph on the Internet]. San Francisco, CA: Web Strategy; 2009 Jul 15 [cited 2010 Aug 3]. Available from: www.web-strategist.com/blog/2009/07/15/three-ways-companies-let-employees-participate-in-the-social-web.
More from this Journal section
Monday, 30 August 2010
Lee Jacobs, MD Fall 2010 - Volume 14 Number 3 When Haiti suffered one of the worst natural disasters ever to occur in the Western hemisphere, people from all over the world responded with donations of time and money. The first response was excellent—although at times overwhelming the fragile infrastructure—it was substantial and well intended. In the past The Permanente Journal (TPJ) has chronicled the experiences of health professionals responding to disasters, including the Katrina flooding1 and the Bande Aceh tsunami.2 Here, TPJ shares the stories of those who responded to the earthquake in Haiti and of those who support them; more stories will appear in the Winter 2011 issue. As important as these stories are, they are only the first chapter in the story yet to be told of Haiti’s recovery: The story of a country almost completely destroyed and the story of a people caring for each other and coping with their present difficult situation. The story yet to be written will be of the massive rebuilding and relocation that must be supported by people and finances from around the world. During my recent trip to Haiti with a health care team, I had several community leaders describe how immediately after the earthquake, groups from several countries and agencies provided food, living supplies and health needs. After the initial response, care from outside Haiti has markedly decreased and now there are only a precious few volunteer short-term teams, most faith-based, assisting the Haitians. Haitian leaders wonder: Have Americans forgotten their plight already? There is excellent ongoing support by several large agencies, but the challenge is just too great to meet the basic living needs of the Haitians. The destruction in Haiti is more widespread and devastating than imaginable. Having been part of a medical relief team in Bande Aceh, I have seen destruction and the plight of displaced people. Although the challenges in Haiti are quite different, it is my opinion that the long-term relief needs in Haiti will actually be greater than Bande Aceh. Living conditions for most Haitians were bad before the earthquake, now the conditions are unspeakable. Thousands of Haitians are living in tents creating clusters that look like refugee camps. Fortunately, large-scale disease outbreaks have been avoided because international agencies have provided clean water and scores of port-a-potties. Tent life is awful. Several Haitians I know who are living in tents tell me of the difficulties of their present living conditions, especially during the heavy rains of May when water would flow through the floors of their tents. One friend of mine lives in a tent with 15 family members. People are hungry. Initially, rice and beans were delivered, now only rice is being made available. Without jobs, many walk aimlessly around these camps. Finally, there are no regular communications from the Haitian government. Nobody knows what to expect. I’m certain talented people at the United Nations, World Health Organization and US Agency for International Development are making plans to help the Haitian people. InterAction, a coalition of aid organizations, planned to divide their available funds for immediate relief and for long-term rebuilding.3 It can only be assumed that holding funds in reserve must reflect the belief that no further major inflow of relief funds is expected. If that is in fact the case, then the overall funds available will be tremendously inadequate. The funds donated for Haiti relief in the first 4 months was $1.3 billion, which is significantly less than the donations in the first 4 months to either 9/11 ($2.3 billion) or Katrina ($3.4 billion).4 Several major needs over the next decade will include: orphan care, medical and dental care, optical support, microenterprise development, and, of course, light and heavy construction. People and money will be badly needed for years to come. So What Can Be Done? First, the extent of this ongoing disaster and the immediate needs of the Haitian people must return to the awareness of the world, especially those of us in North America. Champions are needed to advocate for the Haitian people, beginning with President Obama and then others who can influence Americans, such as celebrities. Second, major funding far in excess to what has already been donated is needed. Giving must be considered an ongoing need and not an isolated fundraising event. I remember the time when the tragedy of the African AIDS epidemic eventually made such an impact on the world that we started to see regular fundraisers, documentaries, and other ongoing reminders of the needs of the African continent. The living conditions of the Haitian people need to be raised to a similar level of awareness. Finally, we must make certain that some of our erroneous assumptions do not blunt relief responses. The history of corruption in the Haitian government doesn’t change the need. Past living conditions do not make current conditions any more tolerable: the majority of Haitians are living in great uncertainty and in much poorer living conditions. The Haitians are a wonderful people, a highly literate people, a caring people. Now they are a people in need. How would you answer the question asked by the Haitian leaders? Have we already forgotten them? References 1. Assisting hurricane evacuees in Houston and Louisiana. Perm J 2006 Fall;10(3):59-61. 2. Beekley S, editor. Permanente and the tsunami relief efforts—one year later—the volunteers’ stories: a journal. Perm J 2005;9(4):72-82. 3. Moore MT. Haiti relief less than Katrina, 9/11 [monograph on the Internet]. McLean, VA: USA Today; 2010 May 13 [cited 2010 Jul 28]. Available from: www.usatoday.com/news/sharing/2010-05-13-haiti-donations_N.htm. 4. Parker S. Comparing contributions [graph on the Internet]. McLean, VA: USA Today; 2010 May 13 [cited 2010 Jul 28]. Available from: www.usatoday.com/news/sharing/2010-05-13-haiti-donations_N.htm.
Disaster Medical Relief— Haiti Earthquake January 12, 2010
Monday, 30 August 2010
Disaster Relief Organization Hernando Garzon, MD Fall 2010 - Volume 14 Number 3 Our collective organizational response and my personal experience in Haiti were different from any prior disaster response in which I have been involved. I have had the fortune to be involved with Kaiser Permanente (KP) volunteers and disaster relief efforts during large-scale disasters since we sent the first teams to Southeast Asia after the 2004 tsunami. In addition to the more than 40 people we sent in relief efforts to Sri Lanka and Indonesia for the tsunami, multiple KP physicians volunteers traveled to Kashmir after the earthquake in Pakistan in late 2005 to work as part of Relief International’s program. KP physicians collaborated with the Department of Health and Human Services to provide medical care in the Gulf Coast after Hurricane Katrina in 2005. Another KP physician and I volunteered with Doctors Without Borders after postelection violence broke out in early 2008. In the years since we first sent volunteer disaster medical relief workers to provide aid after the tsunami, many changes have occurred within KP’s Global Health and volunteer programs that have resulted in better support for this distinctly important and rewarding work. Under the sponsorship of The Permanente Medical Group leadership, we have: Created a framework to support physician volunteerism by coordinating the efforts of the Assistant Physician-in-Chief of Health Promotion, Community Benefit, Public Affairs and dedicated physicians at each facility via the KPCares program. Developed relationships with multiple medical relief organizations including Doctors Without Borders, Relief International, International Medical Corps, Medshare, and others. Created a KP National Volunteerism Web site (www.KPCares.org) for all employees of the Northern California, Mid-Atlantic and Georgia Regions. This enables all KP staff to both post and search volunteer opportunities. In addition, it allows staff to register in a comprehensive disaster response database that was used, with the invaluable support of Program Office’s Community Benefit, to identify skilled clinicians immediately after the Haitian earthquake. This database continues to serve as a resource should a disaster occur in our own local communities. Developed and delivered several Continuing Medical Education courses on the topics of disaster medical relief and humanitarian medical work in austere environments. In total, these efforts created a KP response to the Haiti earthquake unlike any response we have mounted in the past. A small number of KP staff traveled to Haiti with organizations they had identified on their own immediately following the earthquake, or reconnected with relief organizations with which they had worked in the past. The greatest impact however, was via KP’s contribution as the main contributor of medical personnel and logistical support to Relief International’s disaster response (see www.RI.org). We used the KPCares.org Web site to gather information on interested volunteers, and in the first month alone sent over 30 physicians and nurses to Haiti with Relief International. In the first few weeks we staffed a team of emergency physicians, nurses, and medics who largely delivered trauma care. Our subsequent waves of volunteers ran the spectrum of Family Medicine, Pediatrics, Ob/Gyn, Internal Medicine, and Mental Health. They represented the Regions of Northern California, Southern California, and the Mid-Atlantic. All donated at least two weeks of their time with the support of their departments and colleagues. We are now also involved with the Relief International long-term capacity building project in Haiti, and contribute about two medical volunteers at a time for their efforts to run five community clinics, staffed primarily by Haitian medical personnel. Our volunteers provide teaching and educational support for the Haitian national staff. On a personal level, as intense and chaotic as the first few weeks of the relief effort were, I was deeply inspired by the successful development of our new capability to respond. KP now has the ability to mobilize our volunteers and their expertise to assist in future humanitarian disasters. I could not be more proud to work for an organization that supports volunteer and community service efforts in such a comprehensive and systematic way. There is no greater reward than to be of service in a time of need in a way that honors the principles of our professional commitment to medicine.
When Disaster Strikes, Humanity Becomes our Patient
Monday, 19 September 2011
Robert T Hughes, MD, Patricia Trantham, MD Summer 2011 - Volume 15 Number 3 Introduction I volunteered at a hospital in Haiti for one week in the month following the disastrous earthquake of January 12, 2010. This article discusses natural disasters in general with a focus on earthquakes, and the geography and timing of patient presentation. I will also discuss the role of family physicians in disaster response, and share my own experience as a resident family doctor. Background Natural disasters affect millions of people worldwide each year. A disaster, as defined by the International Federation of Red Cross and Red Crescent Societies, is an event negatively impacting 100 or more people, 10 or more deaths, or an appeal for external aid.1 Improved technology has allowed the population to expand into disaster-prone areas. In Southern California, the shift from an agricultural society has concentrated populations in large centers. The impact of disasters is expected to increase in the future. Disasters overwhelm the resources of the community in which they occur. When large-scale disasters affect nonindustrialized countries like Haiti, these developing countries do not have reserves to respond to the pursuing devastation. Recent events such as Hurricane Katrina remind us that even developed countries, like the US, are not immune to such tragedy.1 It has been said that the difference between a disaster and a catastrophe depends on the response of the community. As physicians we are likely to be part of the response to a local disaster. The general public expects that physicians will be the first to respond in disaster situations. The American Medical Association’s (AMA’s) Declaration of Professional Responsibility2 commits that physicians will “apply our knowledge and skills when needed, though doing so may put us at risk.” This duty to treat has been a longstanding ethic seen in the AMA code, which reflects the ethics of our profession, and overrides our autonomy as physicians to choose whom and how we serve in nonemergent times. Our special abilities create a unique obligation to assist during a greater level of need. Assisting, in turn, can have a rewarding and liberating effect on the clinician. Disaster Geography and Timeline Proximity to the “total impact zone” of a disaster, such as an earthquake epicenter, will affect the severity of injuries seen. Physicians must be prepared to serve in the “total impact zone,” the “marginal impact zone,” which may have some destruction, and the “filtration zone” in which patients from the directly affected area seek refuge. Disaster victims present in a cycle with three distinct but overlapping stages. The first stage presents in the first few hours after an event. This group of patients usually has mild physical injuries and are commonly called the “walking wounded.”3 Though life-threatening injuries occasionally present in this group, most are well people searching for information about the disaster. It is important to triage this group in preparation for the next group. The second stage may contain more critically ill patients. These patients typically take hours to days to be extricated and require transportation to medical facilities. During this stage, following the Haitian earthquake, the overwhelming need was for intravenous rehydration, narcotic analgesia, wound care, and fracture management. The third phase includes patients who eventually present for care of untreated acute or chronic medical conditions. This group tends to present days to weeks after the initial event. Generally, this group requests treatment of chronic diseases and prescription medication refills. Disasters are known to increase primary health care use for 12 months or more following a disaster.1 Although medical and surgical issues are addressed immediately, as physicians we know that not all wounds are visible. Symptoms of acute stress are normal in both the general population and in responders in the first days following a disaster. Although patients should be assured that many recover without intervention, new onset psychiatric disorders as well as exacerbations of preexisting psychiatric conditions and substance abuse are especially common. It is important for the physician to remember that post-traumatic stress disorder (PTSD) cannot be diagnosed immediately following a disaster, because an acute stress reaction may be normal for up to one month following the event. One useful screening tool is provided by the Department of Veterans Affairs (www.oqp.med.va.gov). A comprehensive resource for treating patients with PTSD following emergencies is the IASC Guidelines on Mental Health and Psychological Support in Emergency Settings In one recently published retrospective study of the survivors of the Greek earthquakes in August 1953, 49% of the interviewees recalled symptoms of PTSD in the first 6 months post-quake. This statistic is consistent with rates reported elsewhere. Three decades after the Greek earthquakes, about one third of the survivors still suffered from PTSD.1,3,4 Survivors of the Haitian earthquake are expected to follow this course as well. Groups at higher risk for development of PTSD after an earthquake include women, those with prior psychiatric disorders, those who were indoors during the event, and those who settled in temporary residences (tents) afterward. In view of the fact that close to half of the population may be affected, therapy for PTSD should be a priority. Traditionally, debriefing after a disaster has been the standard of care for prevention of PTSD. One effective model that uses debriefing techniques is Critical Incident Stress Debriefing (CISD). Soon after a disaster, specially trained practitioners of this model lead groups of patients that discuss the event and their emotional and physical reaction to it. The model then uses relaxation methods and coping skills to deal with the emotions and symptoms. Organizations such as the Trauma Resource Institute (TRI) work to ensure that effective, culturally sensitive care is easily accessible to those who desire it without forcing participation. TRI is currently involved in the Haitian relief effort. The group trains physicians, nurses, community leaders and aid workers in the Trauma Resiliency Model. This model is biologically based and grounded in Mind-Body Theory. In short, the model uses eight skills to release energy from blocked sympathetic reflexes. This reduces the risk of emotional flooding and retraumatization that can occur with traditional talk therapies such as CISD or Cognitive Behavioral Therapy (CBT).5 Physicians with strong skills may be called to work with highly distressed survivors. The role of the physician is to encourage the patient to minimize the helpless victim mindset, and reestablish predisaster routine. This is often best done in a community rather than office setting. Counseling should focus on relaxation techniques, learning effective coping skills, and healthy grieving. It is during the early stages of disaster response that rapport is built with patients that may go on to develop PTSD and require further treatment. Family Physicians in Disaster Relief Many of the acute and chronic physical and mental health issues that commonly occur following a disaster are within the scope of practice for family physicians. During residency, family physicians receive training in adult and pediatric medicine, minor surgery, nonoperative orthopedics, mental health, and obstetrics. However, one recent study found that while 80% of primary care clinicians would be willing to assist, only 20% consider themselves well prepared to respond to a disaster.6,7 Though disasters are “low-probability, high-impact events” we must commit to preparing for such events so that we are not caught off-guard. Whereas an infinite number of disaster scenarios are possible, it is important for physicians to have knowledge about the threats specific to their region. In Southern California, the most likely natural disaster is an earthquake, but floods and fires are also common. Family medicine physicians, are well suited to respond in the event of an earthquake given their training in medical, minor surgical and psychological care for all ages. Disasters cause a wide variety of physical and mental health pathology. Family physicians receive formal training in both of these broad areas. Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) courses are standard curricula for residency programs. The AMA has developed a similar training program called the National Disaster Life Support course that residency programs might consider to better prepare their residents. Specific training in treating PTSD might also be appropriate additional preparation in residency. Physicians at all levels of training may participate in the Medical Reserve Corps (MRC). The MRC is a nationwide network that organizes multidisciplinary teams of health care professionals who are committed to improving health in their communities and responding to disasters. MRC volunteers are trained to respond to local and national disasters as needed. There are several other such organizations that physicians may join such as Doctors Without Borders. It is important for physicians to become involved with these groups before a disaster scenario because the credentialing process is a time factor. Relief groups are more likely to select health care professionals with previous relief experience. Volunteers should be positioned to integrate with the coordinated response effort. Untrained volunteers may occasionally be needed, but can overwhelm a response system, turning a disaster into a catastrophe. Physicians are also responsible to prepare themselves personally for disasters. This includes making preparations for the physician’s family safety, which will be subject to the same physical and mental health risks as other victims in the community. Physicians should make preparations for their families so that they may continue to balance the care of both family and patients. Examples include maintaining portable survival kits, designated meeting places, and back-up communication methods. These should be reviewed on a regular basis. Physicians should equip their offices with the necessary supplies in the event of a disaster. Those interested in assisting abroad should ensure that their travel documents and immunizations are current and take appropriate prophylactic medications. The Centers for Disease Control and Prevention Web site (www.cdc.gov/travel) is a helpful resource for health requirements.8 Although medical outcomes in disasters are poorly documented, in one follow-up study of the victims of the 2001 Gujarat earthquake, 10% of orthopedic injuries were missed, 19% became infected postoperatively, 12% were noted to have restricted range of motion, 23% suffered nonunion, and 30.5% of patient’s required reoperation. Only 14% of compound fractures were treated conservatively in plaster. The amputation rate was considerable at 12%.9 Whereas these statistics may be due to the nature of the injuries after an earthquake, it is thought that aggressive surgical management and poor follow-up led to these exceedingly high rates. Surgical management is essential in many cases following the trauma of an earthquake. However, this study does argue for conservative management when possible. Family physicians with fracture management training could play an integral role as part of an orthopedic team. In the wake of Hurricane Katrina, family physicians have been an integral part of the response. Primary care physicians are best equipped to deal with the long-term recovery stage of disasters. When designated emergency personnel become overwhelmed, family physicians will be called to assist. Family physicians must be prepared to care for patients in all three zones of a disaster. Given that family physicians are present in most communities, they will be the first responders in areas ranging from rural to metropolitan. Family Medicine trainees receive longitudinal training in the diagnosis and management of psychiatric disorders in children and adults, which also equips them to treat patients suffering from PTSD, acute stress, and other mental health conditions following a natural disaster. My Experience in Haiti I have witnessed poverty while working in hospitals in rural Uganda and Belize. Port-au-Prince was equally impoverished before the earthquake. Neither my time abroad, nor the news reports had prepared me for the enormity of the devastation in Haiti. I have worked with the Medical Reserve Corps in San Bernardino County for the last 2 years. The training proved helpful in my trip to Port-au-Prince 45 days following the 7.0 earthquake that struck on January 12, 2010. As I was arriving during the recovery phase, I was unsure what type of pathology to expect. As a second-year family medicine resident, I was worried that my limited experience could make me a hindrance rather than a help. Many of the relief organizations that I approached had rejected my application. Most of these groups were requesting surgeons with prior disaster experience. After much searching, I connected with a group from my alma mater, Loma Linda University, which was sending residents to a sponsored hospital in Port-au-Prince. Upon initial descent of our somber flight into Haiti, I saw no destruction. The roofs on all of the buildings looked intact. However as we approached the runway, I could see that many buildings had lost their roof-support structure causing them to fall straight down. As my driver took me from the airport to the hospital, such scenes were commonplace. Though I speak no French, my driver spoke enough English to convey the death tolls for which several of the cinder-block structures were responsible. We drove past the fallen palace and the remains of what was one of the country’s few medical schools. The language barrier continued to be problematic, with very few volunteers speaking Creole or French, and fewer trained interpreters. The one piece of graffiti written in English was ubiquitous: “WE NEED HELP.” Through the crumbled streets, past tent cities, we continued to make our way to Hôpital Adventiste d’Haiti. When I arrived at the hospital, the Medical Director greeted me and asked where I felt comfortable working in the hospital. Thanks to my diverse family medicine training, I was able to reply, “Wherever you need me.” The facility has a 70-bed capacity. However, more than 1000 people were staying on the hospital grounds. Most of these patients required close follow-up. The hospital had a primitive laboratory, x-ray and three operating rooms. In the Haitian earthquake, children accounted for approximately 30% of the casualties.10 As a family medicine resident, I was the volunteer physician with the most inpatient pediatric experience. Therefore, the Medical Director placed me in charge of the 7-bed pediatric ward and clinic. I would eventually act as a pharmacist reconstituting medication, a radiologist reading all of my own films, and assist in multiple surgeries. As I rounded on the ward that first night, the predominance of the cases was pneumonia, asthma exacerbation, and viral gastroenteritis. This was the “bread and butter” of inpatient pediatrics at the community hospital where I am training. However, some problems were very foreign to me. Throughout my stay we saw multiple cases of presumed malaria, which is endemic to Haiti. Thankfully, it is a region of relative chloroquine sensitivity. I quickly gained the simple but novel skill of treating malaria. In talking with volunteers who had preceded me, other acute issues seen following the Haitian earthquake included respiratory distress from presumed fat emboli after fractures, gangrene, sepsis, compartment syndrome, and tetanus.10 The lack of ventilators complicated the use of general anesthesia.10 Most patients were treated in field hospitals consisting of tents and damaged buildings, because of the devastation of the country’s medical infrastructure.7,10 In many cases, there were too few tents and tarps to cover all patients.3 Anecdotally, many of the local obstetricians and midwifes reported an influx of laboring patients immediately following the earthquake. In the absence of an obstetrician, I had the training to deliver several Haitian babies. Many of the problems we saw could have been prevented with better education. It is customary in Haiti to warm children who are having fever and Tylenol is a rare commodity in a typical Haitian household. Multiple children presented with febrile seizures. We did our best to teach the parents about cooling measures. When I first arrived, none of the problems seemed to be directly related to the earthquake. Then a baby boy, age two months, presented to our tarp-covered makeshift clinic. The boy’s grandmother told us that he had begun having blood-tinged stools. His mother had died in the earthquake. As his grandmother could not afford formula, she had fed the boy only sugar water since. On exam, he had generalized edema and looked like the Kwashiorkor babies I had seen in children’s fund commercials. He was admitted and slowly fed with formula as we had no parenteral nutrition. Gradually, the bleeding resolved and his edema improved. I felt a sense of accomplishment when we were able to discharge him four days later. His grandmother was instructed to return every three days for follow-up and to restock on formula. The local nurses informed me that if given a large supply of formula, many parents will sell it. Just like at home, we needed to discharge our stable patients to make room for the steady influx of new patients, some of whom had to travel six hours via public bus to be seen. The boy’s grandmother, like many others, was hesitant to leave, as the hospital ward was the only permanent shelter she had experienced since the earthquake. Although many were hesitant to leave, others were resistant to entering the building. One sign of acute stress that I witnessed was that patients requiring admission for acute medical problems were resistant to staying under the hospital roof even after engineers had deemed it undamaged by the quakes. Many patients even left the hospital against medical advice during the aftershocks. Occasionally I worked in the Emergency Department. Here again, I saw many with similar complaints to the patients in my clinic. I relied almost entirely on history and physical examination for diagnosis. However, there were very few physical findings to substantiate the complaints of the patients. Pain out of proportion to physical findings can be one of the signs of acute stress reaction. One afternoon, we had a woman walk past the line of patients to be seen and collapse just inside the room. She began to convulse erratically, not in a typical tonic-clonic pattern. She was also screaming incoherently. I examined her and as I pulled up her eyelids, watched as her eyes looked briefly at me then rolled backward. After a small crowd had gathered around her, the movement and screaming stopped. I was suspicious for pseudoseizure. Though I had to pass off her care to another physician to return to the pediatric ward, I later obtained further history that she had lost her whole family in the earthquake and had several similar episodes since then. I wish that I or someone even more skilled in psychiatry had been able to further evaluate and treat her for possible PTSD as the possible underlying etiology for her likely stress response. One night I assisted in a cesarean delivery of an abrupted gravida 8, para 0 lady at 27 weeks. I scrubbed out immediately and assisted in the resuscitation of the newborn. He was so premature that he was not breathing spontaneously. However, his heart was beating well, and oxygen saturations were adequate with bag ventilations. We had trouble finding a mask small enough, let alone an endotracheal tube that would properly fit. We worked without speaking as the expressions on our faces said it all: we did not have the staff to keep ventilating this patient indefinitely. We knew we would have to stop and the mother would lose her 8th baby. We were able to keep him alive long enough that his mother held him after waking from anesthesia. He died in her arms. The obstetrical ward was down the hall where I slept on a cot. The wailing of the woman penetrated my earplugs and I could not sleep thinking that the baby would likely have survived had it been born in a facility like the one I work in at home. I arose and found one of the physician assistant volunteers. We shared with each other the emotional fatigue that we were experiencing while surrounded by such dire need. I am usually reserved with my feelings, but found myself sobbing to this person I had met only days before. All over the hospital, I saw instant bonds formed between volunteers and patients. Being able to express stress is very important to clinicians in disaster situations. Also, provision must be made for relaxation time including eating, showering, and sleeping. One of the most restoring moments occurred after my last long day of work. I sat on the hospital’s front steps listening to a choir of Haitian children sing a local children’s song. When they were finished, a game of “keep-away” broke out. The object of desire was a latex glove that I had inflated and given to one of the children earlier that day. It landed at my feet, and I snatched it up. Suddenly I was attacked by a swarm of 30 children clambering for the prize. Three of the smaller ones managed to scale the height of my frame and regain the glove. Even after the mob had retreated with the object, 4 or 5 children stayed and hugged my legs. Conclusion Natural disasters are common threats both at home and abroad. Medical aid will continue to be required at all stages of disaster recovery. Family physicians with their broad medical training are well equipped to provide a unique combination of whole person care to the diverse array of patients in the aftermath of an earthquake. I hope to continue to prepare for and serve in times of such great human need. Disclosure Statement The author(s) have no conflicts of interest to disclose. References 1. Freedy JR, Simpson WM Jr. Disaster-related physical and mental health: a role for the family physician. Am Fam Physician 2007 Mar 15;75(6):841-6. 2. Declaration of professional responsibility: medicine’s social contract with humanity (monograph on the Internet). Chicago, IL: American Medical Association; 2001 Dec 4 [cited 2011 Jun 14]. Available from: www.ama-assn.org/resources/doc/ethics/decofprofessional.pdf. 3. Murdoch S, Cymet TC. Treating the victims after disaster: physical and psychological effects. Compr Ther 2006 Spring;32(1):39-42. 4. Lazaratou H, Paparrigopoulos T, Galanos G, Psarros C, Dikeos D, Soldatos C. The psychological impact of a catastrophic earthquake: a retrospective study 50 years after the event. J Nerv Ment Dis 2008 Apr;196(4):340-4. 5. Leitch L, Miller-Karas E. A case for using biologically-based mental health intervention in post-earthquake China: evaluation of training in the trauma resiliency model. Int J Emerg Ment Health 2009 Fall;11(4):221-33 6. Somers GT, Drinkwater EJ, Torcello N. The GP as first responder in a major medical emergency. Aust Fam Physician. 1997 Dec;26(12):1406-9 7. Auerbach PS, Norris RL, Menon AS, et al. Civil-military collaboration in the initial medical response to the earthquake in Haiti. N Engl J Med 2010 Mar 11;362(10):e32. 8. Merchant RM, Leigh JE, Lurie N. Health care volunteers and disaster response—first, be prepared. N Engl J Med 2010 Mar 11;362(10):872-3. 9. Roy N, Shah H, Patel V, Bagalkote H. Surgical and psychosocial outcomes in the rural injured—a follow-up study of the 2001 earthquake victims. Injury 2005 Aug;36(8):927-34. 10. Ginzburg E, O’Neill WW, Goldschmidt-Clermont PJ, de Marchena E, Pust D, Green BA. Rapid medical relief–Project Medishare and the Haitian earthquake. N Engl J Med 2010 Mar 11;362(10):e31.
First Responders: The DMAT Team
Monday, 30 August 2010
Judy O’Young, MD Fall 2010 - Volume 14 Number 3 Twilight on Tuesday, January 12, 2010 in Port-au-Prince, Haiti: about 40 seconds of chaos. 7.0 magnitude. Buildings begin to crack and the sound makes people think of the gunfire that is all too frequent in the downtown area. For safety, people run inside. Buildings, shoddily constructed, crumple, trapping those inside. One of the best hotels, the Montana, on a verdant hillside overlooking the steaming plain of lowland Port-au-Prince, pancakes entombing more than 300 people. The air is thick with heat and the dust of concrete. Afternoon on Tuesday, January 12, 2010 in Oakland, CA: news on the car radio tells me I will make my fourth trip to Haiti sooner than planned. During 2009, I had worked in and around Port-au-Prince as a volunteer anesthesiologist on three separate Smile Train-funded surgical mission trips. I had stayed at the Montana. I had walked through the Cité de Soleil. My friends and colleagues lived in Delmas, now largely destroyed. We had operated on nearly 200 children and adults with congenital cleft lips and palates, tumors, and burns, after seeing and screening several hundreds more. Because of the poverty, neglect and lack of long-needed medical services, many more adults needed our teams’ attention. Despite the dire living circumstances and lack of resources, locals were unfailingly polite, helpful, and grateful for our efforts. I loved this Pearl of the Antilles with its vibrant culture and people, rara music, voodoo, and native art. Despite Haiti’s turbulent history, the indigenous spirituality and resourcefulness were unparalleled by any country that I have traveled to. I check my ready bag that evening and prepare to depart. My Disaster Medical Assistance Team (DMAT) is on call in January and all members are on standby for deployment. DMATs and International Medical Surgical Response Teams (IMSuRT) are groups available for national disasters and emergencies such as 9/11 and Hurricane Katrina. Recently the National Disaster Medical Service (NDMS) had been preparing DMAT and IMSuRT groups for work on a global scale. Months of team meetings involving disaster response and planning, equipment training and orientation, and numerous deployments have prepared team members to provide triage, evaluation, and first-response treatment of populations in times of disaster. Wednesday, January 13, 14:53 pm: simultaneous cell phone text, e-mail, and voice mail set us in motion. By the grace of our Kaiser Permanente departmental scheduler and the generosity of my departmental chief and colleagues, I commit as a rostered team member, and leave the following day for Atlanta. After an overnight briefing, including DMAT teams from Massachusetts, Florida, and New Jersey, we board a government charter aircraft and fly directly into Touissant L’Overture airport in Port-au-Prince, landing Friday, January 15. Long distance disaster relief is seldom smooth. Teams arrive before the equipment caches. Security cannot be guaranteed in the logical hospital sites where patients are. Infrastructure and transportation are nonexistent. Running water, electricity, cell phone, and Internet service are absent. An alphabet soup of international and federal agencies (PAHO, UN, USAID, and CDC) as well as the pre-existing nongovernmental organizations are in disarray. Air traffic control and the airport terminal are destroyed. The one runway, unlit, is not built for receiving overloaded flights. All these issues become secondary once the teams find their sites and equipment and supply lines are established. The Petionville Country Club becomes a triage and day treatment center for the tent city that forms on the nearby golf course. The Quisquiya School in Port-au-Prince adjacent to the Ministry of Public Heath’s Gheskio HIV clinic becomes a mobile field hospital with surgical and obstetric capability for the tented camp built on the neighboring soccer field. Federally deployed US teams of medical volunteers from different states are working cooperatively in a single encampment. The teams quickly adapt to the heat and insects, the lack of running water, the MREs (“meals refused by enemy”), and to each other. Day and night shifts alternate sleeping on cots in tents and battling mosquitoes and heat rash. The US Army’s 82nd Airborne establishes a helicopter landing zone across from the soccer field and ensures a steady flow of the most critical patients evacuated from the University Hospital and the surrounding neighborhood. The cases shift from week-old orthopedic crush injuries and long bone fractures to gunshot wounds and day-old babies with sepsis and respiratory failure. We deliver 11 babies and operate on 30 patients. We can run 2 simultaneous operations, but are limited by the lack of oxygen and supplies for spinal or nerve block anesthesia. There seem to be babies and children everywhere. A respiratory therapist hand-ventilates a tiny premature infant overnight before she can be helicoptered out to the USNS Comfort. A pharmacist cradles a child while dispensing medication. A warehouse supply logistician comforts a boy who has lost his leg. The work is constant, grueling because of the heat and uncertainties, and often hopeless. Bright spots appear in the camaraderie of shared adversity and in the unexpected resilience of a particular patient. Guillame, not expected to live, gets hope in the form of an oxygen tank delivered by his brother’s motorcycle. Micheline, upon being told she is paraplegic and will never walk again, finally consents to a much needed amputation of her gangrenous lower leg. Robert, a lost child, is re-united with an uncle. Patient #361 gets the next available spot for air evacuation out to Florida. At night and on Sunday morning, the hymns of prayer and gratitude from the people in the adjacent tent city rise above the generator’s drone and float back to us through the warm heavy air. Arms are raised in supplication, and thanks are given for the “it could be worse” scenarios. Small groups of team members pray together. The scent of garlic and peppers being cooked mingles with the acrid smoke of burning trash and decay. After two weeks, word arrives that a plane is to take the first teams back to the US. Landing and equipment resupply schedules remain highly variable and uncertain. However, replacement teams are en route to relieve us. The transition is rapid but thorough, with shifts overlapping and orientations completed. We had been cocooned inside the surgical field hospital where we had arrived in darkness, isolated within and guarded by the 82nd Airborne, so it was a shock to transit through the main streets of the still-ruined city. Daily activity, as I had seen in my previous travels to Haiti, is returning. Strangers were helping each other and it is good.
Exploring Health Care and Medical Tourism in a Modernizing Society: Journey in Chennai, India
Wednesday, 30 June 2010
Janani Krishnaswami, MD Spring 2010 - Volume 14 Number 1 The Start of a Journey I am riding in the front seat of a Ford Icon, taking in the left-sided passenger view as we bump along narrow dirt roads. The driver is cheerfully unperturbed as he navigates various obstacles in our path: children, motorists, stray dogs, cycle rickshaws, carts of bright red tomatoes. By the end of my trip, my mind—and stomach—will be desensitized to the labyrinth of vehicles, pedestrians, and animal life constituting traffic in Chennai. But today is my second day; thus, I still shut my eyes in instinctive terror as our car swerves to avoid the mammoth trucks lurching toward us. Chennai, India: A city in which I have never lived, but whose ancient culture shapes my roots. My memories of this south Indian city centered on its role as default destination of onerous family vacations. Back then, the sweltering summer weeks of bumpy rickshaw rides, obligatory extended-family visits and inevitable digestive woes felt more like forced medicine than my parents’ claim of “relaxation.” Yet these trips nurtured my subconscious appreciation for Indian culture, as I studied Sanskrit literature and trained as a student of Indian classical vocal music. Over the years, summer trips lessened in frequency, but my connection to Chennai grew tenacious as I pursued its art forms. That connection had planted the seed for this trip. As an almost-physician, I was returning to Chennai with two specific goals: to provide medical service, while immersing myself in the culture inspiring my cherished hobbies. Since my last visit (nearly a decade earlier), both of us had changed rather substantially. I’d moved across continents, worked for a behemoth investment bank and a tiny nonprofit agency, studied economics in England and parasitology in Texas—and now, months away from medical school graduation, was embarking on a future career in preventive medicine and public health. In India, transformation permeated society. A patriotic, pro-tradition movement had sparked a nationwide flurry of renaming Indian cities in indigenous language (Bombay to Mumbai, Calcutta to Kolkata, Madras to Chennai) even while popular media captured evidence of India’s resolute modernization: humble tea stalls replaced by Internet cafes, expansive rice fields now home to gleaming “tech parks,” mobile dosa-poori-masala stands juxtaposed near freshly painted Pizza Huts, bright yellow auto-rickshaws lost in the roar of sporty Honda Citis. And so it was thus, on this occasion of visiting a home I secretly feared would seem rudely foreign, that I found myself cowering in the passenger side of a Ford Icon. A Snapshot of Daily Life in Chennai Chennai operates in a chaotic, stubbornly functional context. First, people are everywhere. Chennai’s 7 million people share a space of 180 square km, representing a population density of 24,231 people per square kilometer. (Los Angeles, one of the most population-dense cities in the US, has a density of 3170 people/km2).1-4 Life in Chennai splashes boisterous color on the seemingly mundane. On the road, trucks groaning with loads of cargo are festooned with painted curlicues and canary-yellow paint jobs; shifting into reverse gear, they emit tinny renditions of various bhajans, Hindi film songs, or the national anthem. On nearly every corner, stores sell milk and pistachio (“pistha”) biscuits along with artists’ paintbrushes, crochet kits, an array of sketchbooks, and Fevicol-brand craft glue. Street vendors wheeling carts of fresh vegetables, sugarcane juice and customers’ folded laundry advertise their wares by shouting at the top of their lungs, creating a collective vocal cacophony that only a professional mother-in-law cooking in apartments above can interpret. Everyone loves music, and fittingly, every street in Chennai pulses to a perpetual soundtrack: Bollywood, classical, bhajans, instrumental mandolin/veena/violin, drum beats of tabla and mridangam. And every December, the whole city celebrates the Chennai Music Season, a five-week festival featuring hundreds of heavily attended classical music and dance concerts, lectures, demonstrations, and performances.5 Religious diversity is often matter-of-fact on Chennai’s streets, even as India’s borders are caught in religious quagmire. Travel down one road and you will see a prestigious convent school facing a billboard that proclaims Jesus Loves You, catercorner to a procession celebrating Ganesha Chaturthi at a Hindu temple. On another corner, traditional Muslim prayer call echoes from a mosque tucked in between “Krishna Tailoring Stores” and “Muhammed and Sons Jewelers.” Turbans, burqas, saris, suits, dhotis, dresses, shalwar kameez, pants and shirts (“pant-shirt” in Chennai-speak), and sometimes no shirts are all accepted Chennai attire. It can sometimes seem as though the city is in a state of perennial celebration of some festival or holiday, with the sight of a sequin-bedecked, palanquin-hoisting, hymn-chanting and dancing group in the street almost as commonplace as rush-hour traffic. A Bit Lost The address I’ve been given is “19, 12 Cross Street, Indira Nagar, Chennai.” The car meanders through increasingly pot-holed, nameless dirt roads; I wonder restlessly how we know where we’re going. “Oh, 12 Cross Street,” my driver, Shekhar, had said confidently. “We’ll get there, we’ll get there. No problem.” Shekhar, of course, never said we couldn’t do anything. Drive across town in 20 minutes during Chennai’s rush hour, which makes Rockefeller Plaza at Christmastime look like Germany’s Autobahn? “Of course, we’ll get there, we’ll get there. No problem.” Everything is possible for Shekhar. Except, apparently, finding this clinic. The car slows to a pathognomonic I’m-lost pace, and I peer worriedly out the window. Still no street signs. Flat-roofed cement houses—pastel pink, lime yellow, mint green—line the road, each enveloped by lush green creepers and vibrant hibiscus and jasmine. In lieu of door numbers, each house features a name painted in neat white letters atop an iron-railing fence. Lakshmi Nivas. Swaathi. Sai Krupa. Despite this decidedly non-numerical pattern, we creep by in hope of finding number 19. The car pulls to a stop in front of a turbaned man idly chewing a betel leaf. Shekhar rolls down the window and beckons. “Are, 12 Cross Street engu irruku theriyama?” [Hey, do you know where 12 Cross Street is?] he calls. The man spits out the leaf, squints for a moment and points. “Angu left thirumbi, conju neru pettu, inooru ora right…” [Turn left there, then go straight for a while, then another right … ]. I try to ignore the angry red betel stains on his teeth and instead concentrate on trying to understand the circuitous route. I’m lost after the first “left” and “right,” but Shekhar nods in apparent excellent understanding. And we’re off once again, narrowly dodging the cow that suddenly is in front of us, placidly turning its tail. Surveying Chennai’s Health The context of health in Chennai is framed by a mammoth, decade-long rollercoaster ride of growth and development. As India expanded its information technology (IT) sector and liberalized foreign investment laws, wealth flooded into Chennai’s economy. Chennai now serves as one of India’s major IT and IT-related services exporter, with its newly constructed “IT Corridor” employing over 300,000 people. Upward mobility thus touches and transforms the lives of many once-poor Chennai residents.6-9 India’s poverty rate declined over 50% from 1983 to 2007, and the 2006 South Asian Economic Report10 noted a “remarkable” reduction in the rate of absolute poverty in the region surveyed “primarily due to accelerated growth in India.” Among Indian states, Tamil Nadu ranks in the top five in terms of level of urbanization and literacy rate and has a lower-than-average poverty ratio. And in the 2009 Global Rankings Quality of Life Survey—covering 254 cities and conducted by the international human resources firm ECA International—Chennai was the top-ranked Indian city in which to live.11-14 Health care and health delivery are important beneficiaries of India’s economic boom. The preceding decade’s newfound wealth spurred grassroots efforts and nongovernmental organizations to fill basic public health needs: waste disposal, hygiene and sanitation, and access to clean water. Tangible examples include Friends of the Beach, an initiative in 1999 that installed garbage bins and public toilet facilities on Chennai’s heavily polluted beaches and provides stable wages to slum-dwellers in exchange for beach cleaning and construction services.15 The World Bank-supported Tamil Nadu Health Systems Project is a hospital-centered public health effort; this five-year, $110 million project will roll out electronic information systems in the state’s district hospitals, streamline disposal of hospital waste and construct 24-hour OB/GYN centers.16,17 And in the realm of drinking water access, the successful completion of the Sai Ganga Water Project represented a milestone. This multimillion-dollar initiative provides safe drinking water to millions of Tamil Nadu citizens, including the very poorest communities and slum dwellers, via groundwater pipeline connections from the neighboring water-rich state of Andhra Pradesh.18 Such measures dent the devastating death toll wreaked by India’s endemic infectious agents. Tamil Nadu achieved a near-100% target vaccination rate from 2007-2008, and the death toll from six major vaccine-preventable diseases is zero.13,19 Even once-rampant, “classic” developing world conditions are declining: in Chennai, malaria’s incidence fell 43% between 2001-2008, and leprosy’s prevalence is currently less than 1/10,000 in Tamil Nadu.20,21 Expanding health care infrastructure also spurs dramatic increases in medical treatment and diagnosis. In 2008, Tamil Nadu’s patients obtained 19.4 million lab tests, 19,000 Pap smears, and 600,000 surgeries.22 Despite such advances, however, poverty and poor health still trouble many residents of Chennai. Almost ten times as many infants die at birth in Chennai compared to Beijing; the average Chennai female can expect to live only about 67 years. The city’s residents are served by about 1800 physicians, leading to a ratio of 42 physicians per 100,000. (In the US, the average is 286 physicians/100,000).23-25 Even as enterprising students graduate from Chennai’s institutes of higher education, others drop out of poorly funded, deplorably run government schools where student and teacher attendance is optional, desks and chairs are a luxury, and basic infrastructure is in flux. For example, a recent study found 38% of these schools lacked proper toilet facilities for its students. The city’s overall literacy rate hovers at 73-78% (soaring from 46.7% in 1991), but literacy rates lag behind nearly 10-15% among poor classes, where sanitation, air pollution, and improper waste disposal hinders quality of life.26-30 The dichotomy between rich and poor is stark in gentrified locales like Besant Nagar. Here, idyllic gardens and glass-doored shopping malls featuring “export-only” clothing and goods cater to the area’s upper-middle class. One corner turn away on the paved road to the beach, however, is Oduma Nagar, a fishing colony and slum. In the slums of Chennai, populations exceeding the size of small European countries coexist on a few square kilometers. For slum inhabitants, mundane needs and activities—bathing, garbage disposal, drinking water, and defecation—are daily battles. Garbage and human waste invariably ends up in the same water used for bathing and drinking, promulgating a vicious cycle of parasitic and communicable disease.31-33 Entering the Clinic A khaki-uniformed security guard paces pensively by the wrought-iron gate encircling the cream-colored house. He pauses as we pull to a stop. “Idhu doctor veettu ah, doctor Krishna Raman?” [Is this Dr Krishna Raman’s house?] Shekhar questions the guard. I peer anxiously as the guard smiles and nods vigorously, briefly pondering the irony that the word for “doctor” in vernacular Tamil—a hybrid of Tamil and English—is “doctor.” Shekhar turns to me and nods with vigor and triumph; with good reason, as against all seeming odds, he’s successfully brought me to my destination. Although, I fret, this so-called “clinic” looks much more like a house. Then I see the small, thatched-roof annex tucked alongside the house, bearing a hand-painted sign and a red cross inside a circle: “Dr Krishna Raman—Medical Doctor.” I gingerly step down from the car, my relatively pampered muscles bruised from the jarring hour of swerving over Chennai’s obstacle paths. Then the reality of the moment floods over me. Here it is: the clinic of Krishna Raman, MBBS, FCCP, graduate of the BKS Iyengar Institute.34 Traveling down the inevitable extended-relative grapevine earlier, news of my medical “rotation” with Dr Raman had sparked much excitement. “Just one look at the frozen shoulder, and he knew exactly what to do: a few medicines, creams, and some yoga postures and I was completely back to normal,” my aunt had gushed. My grandmother had solemnly agreed. “Dr Krishna Raman, he’s a big name,” she said with hushed reverence. “He’s been on TV, helped many people … you’re lucky to be able to work with him.” Although I have grown accustomed to my relatives’ proclivity for exaggeration (eg, “air-conditioned” referring to “extra ceiling fan”), I figured at least some truth inspired this exuberant praise. A perusal of the clinic’s Web site and Dr Raman’s publications introduced me to his mission of providing quality health care to all patients regardless of socioeconomic status. And his treatment came with an added twist: allopathic medicine supplemented with an emphasis on lifestyle changes, including the incorporation of a personal practice of yoga. Brushing beads of sweat off my forehead, I leave my slippers outside the door—the custom in Chennai—and step barefoot onto the mosaic-tiled floor of the clinic. The room is empty, except for the clamoring rattle of a fan, which seems to be producing more noise than breeze. A bare light bulb flickers overhead, casting feeble light over a wooden table placed in the center of the room. Five chairs are neatly lined in a row, empty except for a stack of magazines and newspapers: Time. India Today. The Hindu. “Welcome!” I am greeted by a trim, elderly gentleman wearing a light green polo shirt and cleanly pressed khaki pants. Dr Raman ushers me inside to give me the one-room clinic tour. It’s short: there’s the waiting room, which I’ve already seen, and the combined exam-room/physician’s office featuring familiar fixtures of outpatient medicine—a Dell computer station, exam table and the less familiar x-ray viewing box. Dr Raman shows me the day’s schedule, explaining that he routinely sees between 40-50 patients a day. Most come in with a chief complaint of musculoskeletal pain. “There are sometimes significant social issues,” he says in lightly accented English. “Some women come with carpal tunnel syndrome from rolling chapattis all day for 20 in-laws, for example. It’s impractical to tell them to stop cooking, when it’s what everyone—including the patient—expects.” I nod, wondering how anyone could tolerate standing even slightly near heat-generating kitchen equipment in the searing 100-degree-plus weather, especially in 9 yards of a silk fabric sari. “But I get patients from all backgrounds,” he continues, leaning back in his chair as I take a seat in front of the desk. “Muslim, Hindu, Sikh, Christian, Tamil, Hindi, Telugu, Marwari. There are those who can’t afford to pay—the care is free for them. Others are successful businessmen and women; they pay the regular fees.” (Regular fees, I find out, are anywhere from 250—800 rupees [INR], $6-$12.) Dr Raman also eagerly expounds on the aspect of yoga and lifestyle education interweaved into his clinic services. “These days, the nine-to-five tech jobs … so many people are sitting, no such walking or activity as they had in the past. Only a decade ago, people walked more. Activity was built into their lives: walk three miles to school, to go to the temple and to do 40 pradakshinams.a Now it’s staring at the computer screen.” “So naturally,” he continues, “muscle pain complaints are the biggest part of my practice. Herniated disks, osteoarthritis, carpal tunnel syndrome, chondromalacia. A lot of it, of course, is sedentary lifestyle and being overweight. For these people, I do give allopathic treatment for the pain and swelling. But that cannot change lives. A daily yoga practice, however, can—it improves flexibility, lean muscle mass, peace of mind all in one,” he concludes triumphantly. I had half-expected an introductory discourse on Chennai’s clinical epidemiology covering topics such as Pott’s spine, leishmaniasis, and leprosy; my mind now shifts gears in the face of a medicine demographic echoing my patient encounters in the US. Dr Raman turns to his computer and, with a few mouse clicks, brings me even closer to home as he pulls up the ubiquitous blue screen of a Microsoft PowerPoint presentation. “Here, you can take a look at some MRIs and x-rays of some of my patients,” he explains as we click through slides containing radiologic proof of patients’ suffering and photos of patients (without faces blackened out as in my lectures back home) trying out yoga. There are sari-clad women holding onto a wall and twisting their spine; somewhat pot-bellied men stretching up valiantly to the ceiling; “before” and “after” MRIs that show the progression of a herniated disc back into its rightful place after a year of yoga. I’m impressed. Dr Raman looks up abruptly at the clock. “Well, it’s 8:30. Let’s see our patients.” The Rise of Chennai’s Medical Tourism Industry As India tackles basic deficiencies in public health indicators, another phenomenon transpires in parallel: the explosion of an elite private health care sector worth nearly $15 billion. Catering to the upper-class segments of Indian society with “five-star” hospitals, this emerging industry is responsible for India’s “extreme makeover” of health care.35 Each year, over 150,000 patients fly in from around the world to receive comparatively lower-price treatment or escape long waiting lists. Their stories are featured in op-ed pieces and magazines: Bill W from California, denied health insurance because of a high PSA and suspected cancer, paying cash to receive a transurethral resection of the prostate (TURP) in New Delhi’s Fortis Hospital for a quarter of the cost back home; Mohammed S from Kuwait, undergoing an eight-hour removal of a glioblastoma in Chennai’s MIOT hospital only a few days after receiving his diagnosis at home.35,36 Nearly 50% of patients treated in Chennai travel from outside Tamil Nadu. Chennai’s hospitals go to great lengths to attract this lucrative group of patients, offering city tours, swanky hotel rooms for guests, airport pick-up and drop-off, and hours of one-on-one time with staff physicians. All with calculated reason, for the industry is forecasted to grow at a rate of 13% per year for the next six years, eventually constituting 3% to 5% of the health care delivery market and contributing $1-$3 billion additional revenue for tertiary care hospitals.10,35,37,38 The medical tourism industry in India traces its roots to Chennai—specifically, the Apollo Hospitals group, a private entity, which opened its first international branch in 2007. Navigating the traffic-choked streets of Chennai, it is hard to miss the handsome, coffee-colored marble building with its gold-emblazoned “Apollo” moniker, towering above the hand-painted shops and stalls. Apollo’s success inspired the creation of private hospitals and “super-specialty” centers in Chennai offering everything from liposuction to laparoscopic, minimally invasive joint replacement. There is the Shankara Netralaya Eye Institute; MV Hospital for Diabetes and Diabetes Research Center; Madras Ear Nose & Throat Research Foundation, Heart Institute and Institute of Cardiovascular Diseases, all of which are privately owned and nationally recognized.39-42 These hospitals steered India’s most lucrative health trends, including telemedicine and medical outsourcing, and have received critical acclaim as the home of various medical “firsts” in Asia and India. Examples include the first successful transmyocardial revascularization laser surgery in 1994, the concept of magnetopexy in 1988 and the first successful heart-lung transplant in 1995, to name a few.43,44 The effect of modernized medicine is seen even in such seemingly low-tech places such as the Chennai Central railway station, where there is a telemedicine facility complete with EKG machines and virtual consultation stations for those passengers who suddenly feel a bout of chest pain along the main concourse.45 Glamour and wealth in Indian health care transpire primarily in the private sector, which generates over 70% of all health care revenue (or 6% of GDP in 2005). Highlighting the regional dominance of health care by the private sector, the South Asian Economic Report notes that “the proportion of private health expenditure to total health expenditure in the [South Asian] region surpasses that of most countries in the world.”43,46 Contrast this with the US, where the government’s share of per capita health care spending tops 50%. The private sector’s starring role in India’s health care stems from the dynamics of supply and demand: Private providers’ domain encompasses services from x-rays and MRIs to treatment of childhood diarrhea and malaria to prescription drugs. In contrast, government spending on health care actually decreased over the past decade.10,43 Paucity of funding sustains inefficiency in government hospitals, where shortages of drugs, supplies, and personnel persist. One article describes Chennai’s Government General Hospital, which sees 10,000 patients per day, as having a workforce “not even adequate to cater to a fourth of these numbers.”43 Such basic deficiencies prompted an acrid editorial comment in the city’s major newspaper, The Hindu: “It is an ironic outcome of neo-liberal economic reforms that in spite of fundamental policy failures in public health, India is increasingly seen as an attractive international health care destination.”38 First Encounter The couple walking into the room comprises an elderly man and woman who instinctively seem to lean on each other for support. The woman is slightly heavyset, with salt-and-pepper hair loosely threaded into a braid and secured with jasmine flowers that have begun to brown in the midday heat. She absently pats these flowers as she looks up respectfully at Dr Raman. Her husband, a stocky, dark gentleman wearing a white dhoti and a rather ill-fitting button-down shirt, is carrying a bulky briefcase that he sets down before cupping his hands together. “Vanakkam, doctor,” he says with genuine reverence and enthusiasm. It is only two words—hello, doctor—but the undertone of hope in his voice is almost palpable. Because there isn’t an extra chair, I am trying to stand as inconspicuously as possible under the x-ray viewing box. I wonder what patients will think of my rather random presence as they discuss their aches and pains. Would they request that I leave? Demand an introduction? Should I introduce myself—exposing my broken, American-accented Tamil—or wait for Dr Raman to take the lead? As I find out, introductions are apparently unnecessary. Patients seem to think that as long as Dr Raman accepts my presence, they don’t need to know who I am, or what my qualifications are for listening to their concerns. Indeed, throughout my rotation here only one patient actually looks at me directly and asks, “And so, who exactly are you?” It’s somewhat of a relief in a sense; part of me fears that by opening my mouth and talking too much, my status as foreigner will instantly be revealed. Throughout the rotation, I grow used to my place as a nameless physician-in-training, nodding in sympathy during the discussions of pain and suffering, hanging up x-rays on the lightboard, helping frail patients climb down from the table. Now, Mr Vasu launches into a description of his wife’s agonizing back pain. A few sentences in, however, Dr Raman stops him. “She’s the one with the pain?” he asks in Tamil. Both nod hesitantly, and Dr Raman motions to the lady. “Then you talk,” he says pointedly. Mrs Vasu looks taken aback for a second, reaching up to her jasmine flowers for support. But she begins, after a moment, to describe the dull ache in her lower back that has disturbed her for the past two years, now intensifying to the point where she can no longer sleep. Dr Raman nods in understanding and is already scribbling down something on a prescription pad. “Let’s see the x-ray?” he half-asks, half-commands as he signs the pad with a flourish. Mrs Vasu looks at her husband expectantly; he readily pulls a large manila envelope from his briefcase. Across the front is stamped in faded gray print: “Swaminathan Scans, Ltd.” The envelope contains a glossy x-ray of what is apparently Mrs Vasu’s spine. As I will discover throughout the month, even the poorest of patients come to clinic with “high-funda”b radiologic images capturing their anatomy. Obtaining a computed tomography scan or x-ray is as easy as going into a neighborhood stall and paying a few dollars, depending on where the scan is obtained. Meanwhile, if a patient is not able to afford these prices, Dr Raman has agreements with specific x-ray and MRI centers that will perform the tests free of cost. Dr Raman and I look at Mrs Vasu’s x-ray. He asks me what I see; I gesture, with weatherman-style vagueness honed during third-year rotations, over an area with joint-space narrowing. He nods thoughtfully, studies the scan for a few more moments and then switches off the viewing light. “Right,” he tells the couple, who seem to be hanging on his every word. “Absolutely nothing to worry about. No TB, no infection. Take these medicines, and I will give you some exercises; it will become all right.” He slides over a prescription (for what looks like an NSAID, PPI, and a topical muscle relaxant) as Mr and Mrs Vasu nod vigorously in tandem, relief evident in both their faces. Dr Raman stands up. “Also, you will need to lose five kilos,” he says bluntly. “You’re overweight, and your pain will improve if you lose this weight.” Mrs Vasu and her husband look genuinely surprised, almost as though the concept of having “too much” weight is foreign. Dr Raman briskly continues as he hands her a card. “My dietician—Jyotsna—she is very good. You can make an appointment with her, and she will give you a diet. Then come and see me day-after-tomorrow. I will show you some yoga exercises to help the pain.” She mouths agreement, looking at her husband with a slightly bemused expression. Side Effects of Modernization: New Challenges to India’s Disease Burden As the lifestyle of material success touches more of India’s citizens, so also does the sobering impact of a new set of health conditions. They are a cohort of “lifestyle” diseases: metabolic syndrome, Type II diabetes, coronary artery disease, obesity, and tobacco and alcohol addiction. In 2004, almost half the disease burden in South Asia consisted of noncommunicable diseases, a 10% increase over the past decade. Over the next decade, these “lifestyle” diseases will comprise an estimated 57% of India’s total burden of disease—with heart disease rising as India’s number one killer—whereas infectious diseases’ share will sink below 24%.10,47,48 Heart disease already kills 15% of India’s population each year, whereas over a third have metabolic syndrome. The Public Health Foundation of India notes: “India tops the world list in terms of the disability burden due to heart and blood vessel disease (more than all industrial countries put together).”49 Tobacco use persists as a major killer, responsible for India’s world dominance in oral cancer prevalence. And noninsulin-dependent diabetes mellitus (Type II Diabetes) is also a health scourge for Indians: With over 12% of its adult population developing the disease each year, India is the “diabetes capital” of the world, housing more diabetic patients than any other nation.10,48-50 The changing disease demographic is rooted partly in lifestyle transitions—urbanization, sedentary behavior, changing food choices—which escalate classic risk factors causing diabetes and heart disease. Where Indian residents once feared undernutrition, they are now caught in a growing epidemic of overnourishment: obesity, and its anvil of chronic disease. A large cohort study found nearly half of Chennai’s urban population was obese by a standard of BMI > 25; adopting a waist-circumference-based definition (waist size greater than 90 cm) placed even more Chennaites—55% of Chennai females—in this category.51 Another study identified 16% of urban Indian schoolchildren as overweight, with close to a third demonstrating insulin resistance (a precursor to diabetes).52 Misra et al comment that “the rapid nutritional and lifestyle transition in urbanized areas … are prime reasons for increasing prevalence of obesity and the metabolic syndrome.”50 More evidence supports a coupling of urbanization and lifestyle disease. In urban Chennai, high socioeconomic status was found to be an independent, statistically significant predictor of being overweight or obese.51,52 Lifestyle may also be partly responsible for hypertension in nearly a third of Chennai’s urban residents; a Madras Medical Institute cross-sectional study of 2007 Chennai-based volunteers found that higher monthly income correlated positively with blood pressure. In this study, belonging to a middle-class classification or higher increased the chance of having high blood pressure by 150%.50,52-54 Hastened by obesity and metabolic syndrome, diabetes is a particularly problematic component of the “lifestyle epidemic” in urban India. A large cohort study from Chennai’s MV Diabetes Center (Chennai Urban and Rural Epidemiologic Study, CURES) found that diabetes prevalence in urban Chennai increased by 72.3% from 1989 to 2004.55 Although this increase arises partly from improved methods of detection and earlier diagnosis, lifestyle factors are also contributors. The Diabetes Prevention Program underscored the role of obesity, lack of physical activity, and poor diet in exacerbating cardiovascular disease and diabetes. Various epidemiologic studies even quantify this effect, suggesting obesity is responsible for up to 90% of the risk of acquiring type 2 diabetes.56 As the incidence of obesity and impaired glucose tolerance rises in a younger Indian population, the number of Indian diabetic patients inevitably increases. Urbanization has clearly transformed India’s health, but new evidence suggests genes may also contribute to Indians’ growing burden of chronic disease. Of note, India has a higher prevalence of diabetes and cardiovascular disease than other Asian industrializing nations. Factors hastening cardiovascular disease—high cholesterol, cell markers of inflammation, obesity and overweight, endothelial dysfunction (disruption in the lining of blood vessels leading to formation of artery-clogging plaques), thrombosis (clots which can block blood flow, leading to heart attacks), glucose intolerance (a precursor to diabetes)—affect a greater proportion of South Asians than Caucasians, with onset in Indians occurring 10 to 15 years earlier. Nearly half of all cases of heart disease are detected in Indians younger than age 50—and over half of all cardiovascular deaths occur in people <70 years in India, compared with 22% in developed countries.50,55,57,58 Several studies extricate the genetic component to lifestyle diseases in India. One study by the International Diabetes Epidemiology Group showed that Indians’ risk of acquiring diabetes increased at lower levels of body mass index (BMI) compared with Europeans—and is more sensitive to smaller increases in BMI.59 The National Urban Indian Survey found central obesity had a higher prevalence (50%) among Indians; even lean-BMI individuals tended to have central obesity and high percentages of body fat. This is particularly significant as central adiposity—the so-called “apple shape”—carries the strongest relationship to impaired glucose tolerance in Indians.50,55,57,58,60,61 In fact, the “unique” Indian overweight and obesity patterns prompted the Association of Physicians of India to issue revised 2009 guidelines for obesity and metabolic syndrome, aimed at identifying more at-risk Indians and staving off disease through early prevention strategies.62 In sum, such research supports a theory that Indians may have inherent genetic susceptibility to diabetes and cardiovascular disease, now unmasked by lifestyle changes accompanying India’s urbanization and industrialization. Co-pay As the Vasus stand to leave, Mr Vasu asks, “Evlovu, Doctor?” [How much, Doctor?] Dr Raman waves them off. “You can pay me later; it will be 500 rupees.” Mr Vasu cups his hand once more in respect, and the couple exits the room. I am struck by this trust-based system of accounting—when exactly is “later”?—as I begin straightening the room for our next patient. Paying for India’s Modernizing Health Care Most citizens pay out of pocket for health care (40% of the $27 per capita health spending in 2002). Talking to various patients during my rotation, I gleaned that a typical middle-class Chennai household (mean income INR 10,000) generally finds outpatient medical care at a government hospital to be affordable: A clinic visit costs anywhere from $.50 to $5; a knee x-ray can be obtained for $4; a week’s supply of antibiotics will run less than $3.63 Unfortunately, current trends in health and social demographics are already driving up prices, threatening to render an era of affordable health care obsolete. First, as private tertiary care hospitals flourish in the wake of the medical tourism goldmine, state-of-the-art procedures and facilities demand increasingly prohibitive prices. Second, as the prevalence of “lifestyle” diseases increase, so also does the cost of receiving treatment. In contrast to times when disease treatment entailed an empiric course of relatively cheap chloramphenicol, today’s urban diseases demand expensive antidotes—cardiac catheterizations and stents, a multidrug regimen of blood pressure- and cholesterol-lowering medications, coronary bypass procedures, and total knee replacements. Thus, staying healthy is getting expensive in urban India. A five-year cohort study of 556 diabetic patients found that total household expenditures on health care—constituting 34% of median annual income—increased 113% during a five-year period, with the highest increase in percentage outlay occurring in the lowest socioeconomic group.64 Another study found that 50% of patients hospitalized in 2004 faced hospital expenditures exceeding 10% of annual household spending.64 Reaching deeper into their pockets to receive medical care, India’s citizens often must sell their assets or borrow to meet costs—as was the case for 40% of Tamil Nadu’s inpatients in 2007.10 Debriefing When Dr Raman and I sit down later to debrief, I ask him if he thinks his patients will take the medications he prescribes, make the appointments he recommends or follow-up on his instructions. “Oh, they do,” he tells me matter-of-factly. “It is a different doctor-patient relationship. Patients here take these appointments very seriously. It is almost never the case that a patient will not schedule a follow-up appointment or fail to obtain the scans needed or ignore the prescriptions. They want to get better, of course, and they believe that will come from listening to the doctor.” I think back to my small repertoire of patients encounters as a medical student in Michigan: the hour spent answering the questions of a pneumonia-ridden businessman who is concerned about taking a new antibiotic, explaining to an irate sickle-cell patient the rationale for capping her morphine dosage, reiterating to a frustrated patient that her work-up to date has not yet revealed a specific etiology to “fix.” As I will find throughout the month, it is a different world here. Dr Raman does very little explaining; the patients, in turn, question and challenge very little. They accept the added medications, the reassurance that “it will become all right,” the exhortation to “get an MRI scan and follow-up in a week,” almost as if it is a duty. The inherent trust they place in Dr Raman’s opinion is, perhaps, reflective of the prevailing cultural attitudes toward physicians. As a patient stated: “For the majority of us, a doctor is virtually God—one who is beyond questions or doubts and has solutions to all our ills.” Reflections: The Future of Indian Health Care The opulent luxury of private-sector hospitals, juxtaposed with creeping improvement in basic health indicators, hints at the dichotomy of health care in India. Even as efforts abound to quash pathogens and parasites—the vestiges of underdevelopment and poverty—India’s private health care industry flourishes, bringing with it the promise of profits. This twin agenda operates at polar opposites of socioeconomic class, two seemingly disparate foci running in parallel. Is it sustainable—and equitable? The Asian Development Bank’s South Asian Economic Report warns, “Although medical outsourcing will give impetus to economic growth in the region, it could also distort the availability of medical care away from South Asia’s poor as the health systems cater to clients from the developed world.”10 Growing evidence supports the troubling emergence of a two-tier system, whereby quality health care caters to and becomes the de facto privilege of the upper class, and the average citizen depends on underfunded, understaffed public facilities. This, in turn, portends a spiral of suboptimal health for the nation’s poor and middle class, carrying somber ramifications for goals of public welfare and social equality. The dramatic changes in India’s health environment and shift of the disease profile presage an economic and social transformation in health care delivery. On the one hand, the nation’s newfound riches promote certain types of health, effacing the disease-ridden India stereotypes of middle-school geography books and quaint Rudyard Kipling tales—where epidemics of cholera and polio consumed millions and curable infectious diseases terrorized the lives of city inhabitants. But even as strides are made in the realm of hygiene and hospital infrastructure, new health challenges emerge in the shifting face of disease, cost containment, and health care access. Such challenges carry relevance to health care in the developing world, as they represent the prototypical public health needs of a nation straddling the realities of persistent poverty and the heady success of breakneck growth. Reflections: The Beginning of a Journey I am waiting for takeoff. It is pitch black outside—approximately 1:30 am, Indian Standard Time—and my head is heavy with fatigue. The dry Lufthansa cabin air keeps forcing me to sneeze, thwarting half-hearted attempts at sleep. My mind also appears to be part of the plot to keep me awake, buzzing with a flurry of thoughts and impressions of a summer in India. I revisit the trepidation that pervaded my first bumpy car ride to Dr Raman’s clinic. I had imagined—and feared—the rapidly urbanizing, technology-championing, café-laden “new” Chennai would serve as a rude shock, alien from the “Madras” of childhood visits. I had wondered if any trace of my heritage—the culture that sparked my passion for art, music, and dance—might remain in this revamped, modernizing pantheon of software outsourcing. And, with quavering hope and resolve, I had entered this city with the goal of serving in a medical capacity, of understanding the city’s unique health needs. Chennai had changed. There were glitzy new stores, air-conditioned restaurants, new highways, the flood of bright matchbox Fords and Hondas. There existed a growing sense of empowerment: young professional women confidently rode to work on scooters and mopeds in the midst of rush-hour traffic; billboards heralded the grand opening of new technology parks; newly installed garbage cans on street corners exhorted in Tamil: “Don’t Litter: Keep Chennai Beautiful.” And, of course, there were momentous changes in health care. Multistorey hospitals towered over dilapidated clinics; clean public restroom facilities emerged as reliable fixtures in malls and restaurants. Complex surgeries no longer necessitated expensive trips abroad; instead, medical tourism now brought thousands of foreigners and a steady stream of profits to Chennai’s hospitals each year. And yet, in Chennai much remains the same. The ancient temples I had visited on trips past are still as ancient as ever. The homemade palgova and cardamom milk from my favorite (non-air-conditioned) dairy store still tastes as divine as I remembered it, and unfortunately is still as fattening. Cows still lazily ruminate as they always have on pot-holed side roads, unperturbed as surrounding cars unleash a blaring cacophony of honks. The unique aroma of incense, spices, humidity, car exhaust, roasted peanuts, and coffee powder still hangs in the air—it’s simply mixed with more exhaust fumes. Chennai’s health also sadly carries echoes of the past. Beggars still cry for food on street corners; slums still spill human filth and suffering. Public health initiatives have mitigated—but not eliminated—once epidemic communicable diseases. India still carries the world’s greatest burden of patients with tuberculosis, and must face the challenge of emerging multidrug-resistant strains. Polio and measles may no longer consume lives in Chennai, but HIV/AIDS and malaria persist as important health concerns; infectious diarrhea still kills an unacceptable number of children each year. The battle to provide fundamental public health needs is still not won, and it must not be ignored in favor of the haute trend of elite health care. India’s paradox of constancy and change—epitomized by its health care—serves as Chennai’s major theme. As a student in Dr Raman’s clinic, I interacted with a truly diverse socioeconomic, cultural, and religious cross-section of Chennai society, many of whom were crippled by pain exacerbated by a sedentary lifestyle, excess weight, and poor dietary habits. Often, patients had no idea that they were overweight—or that lifestyle could potentially undermine their health. Several patients were unfamiliar with the concept of a “heart-healthy” diet, or unaware that they could modify their risk for diabetes and heart attacks with simple dietary and activity modifications. Here lies a crucial area for future medical service in Chennai: public health education, enabling its citizens to understand—and practice—the elements of a fundamentally long and healthy life. The plane revs up its engines in preparation for the final rapid acceleration before takeoff. As we rise smoothly above the twinkling lights of Chennai, I peer out the window, straining for a final view of the city and its roads (which are, even at this hour, packed with cars), exhaling a wave of nostalgia as the city lights fade, covered by growing patches of clouds and mist. I press my face against the cool window, imagining I can still see a twinkling light or two. As the last visible light disappears from view, I realize it is only a matter of time before I return. For the past month has introduced me to a challenge—a medical need that speaks to my interests in public health, service, and culture—that I am determined to revisit and tackle as a physician. Even with all its chaos and inefficiency, Chennai somehow, miraculously, inexplicably, stubbornly, still works. It’s reassuring, for I know it will still be working when I fly back at some point in the future into the humid air surrounding Anna International Airport. I wave goodbye one last time before pulling the window cover shut. “Paarkalam,” I whisper, to no-one in particular. It’s a promise: See you soon. a Pradakshinam: walking around the temple in a sign of respect—40 pradakshinams, depending on the size of the temple, can equal several miles! b High-funda: a slang term used to capture the idea of “high-tech,” “new-age,” or “chic”—as in: “That’s one high-funda Lexus IS Coupe you’re driving!” Disclosure Statement The author(s) have no conflicts of interest to disclose. References 1. 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HAITI: The Kaiser Permanente Experience—Part 1
Monday, 30 August 2010
Sarah Beekley, MD Fall 2010 - Volume 14 Number 3 HAITI: The Kaiser Permanente Experience—Part 2: Personal Stories Our cause is health, our passion is service, and we are here to make lives better. This is the social mission of Kaiser Permanente (KP), and the personal mission of the staff whose stories are shared in this collection of essays. Each volunteered their time, sacrificed their personal safety and comfort, and challenged themselves to extend well beyond their normal limits both personally and professionally. And each of them would say that they gained more than they gave. Why is volunteering such an elevating human experience? Why is being of service to someone who cannot repay you so profoundly rewarding? Perhaps it is legacy, knowing that one has truly made an invaluable contribution to the lives of others. Perhaps it is mastery, the challenge of testing one’s expertise, resilience, and resourcefulness in an unfamiliar and austere environment. Perhaps it is gratitude, the recognition that we live and work in a community of extraordinary wealth and privilege, and that with this privilege comes the opportunity, even the responsibility, to give back. Perhaps it is just the human desire to connect in an authentic and noncontractual way. These stories give us a glimpse into the many factors that motivate us. Every physician and nurse who worked in Haiti did so because colleagues and family at home made it possible. These stories are written both to inform and to express gratitude to the many silent partners that made this work possible. Many are extracted from letters, blogs, or e-mails written while in Haiti or soon after returning to the US. They are written to honor the people of Haiti, suffering or healed, living or dead. They are written to acknowledge the courage, the sacrifice, and the skill of those who continue to dedicate themselves to making lives better. Because the desire to share the stories was as great as the outpouring of compassion , this collection is being published in two parts. This first part is an introduction and commentary on the experience, the need, and the organization of answering the need. The second part, in the Winter 2011 issue, will be the personal stories, triumphs and failures of some of those who traveled to Haiti whose lives were changed.
From Tragedy, Opportunity—A New Beginning for Haiti and the Dominican Republic
Monday, 30 August 2010
John Freedman, MD Fall 2010 - Volume 14 Number 3 I went to Haiti in late January as a member of an Operation Rainbow (www.operationrainbow.org) surgical team which comprised both Kaiser Permanente (KP) and non-KP team members. As background, my own medical charity, Medical Exchange International (www.medicalexchangeintl.org), had partnered with Operation Rainbow in the past to provide anesthesia equipment for several surgical missions in the developing world. In Haiti, we had an opportunity not only to provide pulse oximeters and anesthesia supplies, but also to help out on the clinical front line. As an anesthesiologist with a background in medicine and critical care, I split my time about half and half between the operating rooms and the intensive care unit (ICU), both of which were intense and busy. Whereas I could write at length about what we did and how we coped with severely constrained resources, I want to focus this article on an important “epiphenomenon”: the catalytic action of the earthquake tragedy to create a new inflection point in the long history of Haiti-Dominican Republic relations. Although we experienced the startling devastation in Port-au-Prince when we went into the city to deliver a pulse oximeter, our clinical work took place entirely at the Buen Samaritano (or Bon Samaritain in French) makeshift hospital in the town of Jimani, one mile east of the Haitian-Dominican border in the Dominican Republic. Before the earthquake, the facility was a yet-to-open complex comprising a chapel, an orphanage, and a dental clinic. After the earthquake, the chapel and the orphanage were rapidly converted to hospital wards, and the dental clinic became our acute care venue including a 4-room operating suite. We estimated we had about 250 patients on site, almost all of whom were injured Haitian refugees. We did between 20 and 50 surgical cases a day in 4 converted dental consultation rooms. The vast majority of our surgical cases were orthopedic and plastics procedures, as expected. In our makeshift ICU, I cared for 5 to 10 patients on any given day, and we also opened up a perinatal ward when we suddenly found ourselves doing C-sections (if you build it, they will come …). The facility was staffed by volunteers from all over the world. We worked closely with our own superb Operation Rainbow orthopedic surgeons, including our mission lead Dave Atkin, MD, from San Francisco and pediatric specialist Chris Comstock, MD, from Corpus Christi, Texas, and with surgeons from around the US and around the globe. In the ICU, I worked closely with an excellent emergency/critical care team from Barcelona (and by closely I mean cross-covering to maintain 24/7 on-site care—the real thing). Nurses and pharmacists from all over the world worked together, and I remember being particularly touched when I saw a group of Israelis help an Arab team unload several tons of food that was brought in by the United Arab Emirates. All this is to say that there was a tremendous and truly inspiring internationalism—a deep humanism was in full bloom here. This leads me to my main point: I witnessed first-hand an extraordinary stepping-up-to-the-plate by the Dominican government and the Dominican people. From the moment we arrived, we saw that the Dominicans had dedicated their major international airport in Santo Domingo to international relief efforts. Because Haiti’s airports were marginally functional at best, this was crucial to the immediate relief efforts. The short aid corridor between the Dominican Republic border and Port-au-Prince was active 24/7 with an endless stream of trucks laden with food, water, tents, coal, firewood, blankets, medical supplies, and more from dozens of countries and with a very notable contribution from the Dominican Republic itself. For example, the Dominican Republic sent 15 mobile cafeterias serving 100,000 meals a day into Haiti. Santo Domingo Water Corporation sent dozens of tank trucks, each containing 2000 gallons of water. Estimates of total Dominican Republic aid for Haiti to date have exceeded $17 million, no small sum for a small island republic that is itself a developing nation. We witnessed the Dominican army conspicuously keeping the Dominican side of the relief corridor safe and functional until the United Nations (UN) Peacekeeping Force (which fortuitously had been in Haiti prior to the earthquake) took over on the Haitian side to assure the relief lifeline kept flowing. Thankfully, the Dominican authorities allowed thousands of Haitian refugees to cross the border eastward into the Dominican Republic to seek care in our emergency relief hospital and in other Dominican hospitals. At Buen Samaritano, I noted that many of the drugs we used, and a hefty component of the supplies we used such as oxygen masks, epidural kits, and IV catheters, came from the Dominican Republic. The Dominican personnel presence was huge, literally hundreds of Dominicans representing the Dominican Public Health Department (known by its Spanish acronym of SESPAS), the Dominican Food Aid Program, the Dominican Republic’s major emergency relief organization (known as URN for Unidad de Rescate Nacional), as well as Dominican representatives from countless humanitarian programs such as the Pan-American Health Organization (PAHO), US Agency for International Development, the UN World Food Program, and Ninos de las Naciones. The Dominican-based ARS Humano provided the trailers we used for our tuberculosis isolation ward and our spinal cord injury care unit. Dominican interpreters navigated the tricky Creole-French-Spanish language challenges for us. The Dominican government allowed US military transport choppers as well as those of several private US entities into their airspace to help us evacuate some of our most critically ill patients to the USNS Comfort hospital ship. The Dominican army was on-site day and night in Jimani, keeping us safe and keeping the peace amidst the influx of refugees. The Dominican charity Esperanza provided transportation and meals for our team. Last but certainly not least (from an anesthesiologist’s standpoint), the Dominican Red Cross filled our rapidly depleting oxygen tanks every few days—life-giving assistance, literally and figuratively. This Dominican largesse would be worthy of praise and worth relating in and of itself. But what makes it all the more heartening and extraordinary, in fact truly “game-changing” if one can apply that adjective to international relations, is that it opens a new era in the long history of tense and violent relations between these two neighboring nations. Columbus landed on the island of Hispaniola on his first voyage to the New World in 1492 and promptly claimed it for Spain. But it did not take long for the French to wrest half of the island from the Spanish, thus establishing two separate but equal colonies with political, cultural, and economic disparities that persist to this day. The Dominicans still resent a period of Haitian occupation from 1822 through 1844, though some Haitian scholars insist that the Haitians were “invited” in to ensure abolition of slavery in post-Spanish Dominica. Little known to most outsiders, the Dominicans ultimately had to win their independence not from Spain but from their Haitian overseers. The Dominicans repaid the favor in kind with a brutal retaliatory massacre of over 20,000 Haitians by the despotic Trujillo regime in 1937. To make matters worse, the persistent sharp contrast in prosperity, and some say an inherent racism in the Dominican Republic—have continued to fuel the fires of hatred, fear, and mistrust. The Dominican Republic ranks a respectable 90 out of 182 countries on the UN’s Human Development Index, a composite measure of wealth, health, and educational indices. Haiti comes in at a miserable 149, just a hair above Sudan. The Dominican economy has long profited from cheap Haitian labor: more than 90% of the country’s sugar workers are of Haitian origin. The average Dominican can expect to live into his or her 70s, whereas 61 is the average life expectancy for Haitians and this is now surely reduced as a result of the earthquake. All of this makes it understandable that Haiti rejected an offer of over 3000 Dominican troops which was tendered the week after the quake with the intent of assisting the UN battalion in securing the aid corridor in eastern Haiti. To many Haitians that offer was similar to the idea of having Russian “peacekeepers” come into the Ukraine. But that long and mostly ugly relationship which has prevailed for centuries may now be coming to an end. The opening was there after January 12, 2010, and the Dominicans took it. Some say it is in their interest to prevent a “failed Haiti” (if that is not already the case) and that the Dominicans are just pragmatists working to stem the tide of refugees. No doubt there is, as always, an element of public relations at work here and in fact the Dominicans have received some good press for their efforts. But having seen it in action, on the front lines, the Dominican effort by my observation is more than pragmatic and more than PR. It is huge and robust, carefully thought out, and thoroughly genuine. Time will tell if this represents a true turning point and ushers in a new era for these two countries that uneasily share an island in our own backyard. Haiti’s tragedy is the costliest natural disaster in recorded history according to the Inter-American Development Bank. But as with any great tragedy, there is great opportunity inherent in the rebuilding phase, and the Dominicans seem to have grasped that. The Dominican effort and the healing of Haiti-Dominican Republic relations may turn out to be a very major ingredient in the formula for Haiti’s long-term (and I use the word advisedly) reconstruction.