Innovations in “Upstream” Care

My last blog was on how today’s medical system fails by not addressing the real needs of our patients and their communities. Here, I highlight three projects that take such an “upstream” approach to healthcare:

Doctors can give prescriptions for medications, but why not a prescription for healthy foods and safer housing? Health Leads employs young people (usually college graduates interested in careers in health) to be advocates who assist doctors in clinics and ERs in connecting patients with community resources. They help with everything from food assistance to job training to legal counseling. They help to “fill” the other prescriptions that people need to achieve better health.

Recognizing that black males have significant health disparities and that outreach and education must start in the community, Project Brotherhood was conceived from a simple idea: give patients free haircuts, and use barber shops as a place to screen and counsel on illnesses such as high blood pressure and STI prevention. Its model of multidisciplinary, culturally competent care incorporates other aspects of social support, including on fatherhood and job support.

 The New York Times just published a story about an “EMS Corps” in East Oakland that specifically recruits at-risk youth and train them to be emergency medical technicians. They provide mentorship for young men who come from backgrounds of poverty and violence, and train them to become professionals who will serve their communities. As the story cites, these men are taught that they aren’t the problem—they are the solution.

These are only some of the some of the many innovations occurring around the country. We need far more interventions that go beyond “band aid” care. In the words of public health doctor Rishi Manchanda (whose recent TED talk I highly recommend), we must change our entire approach to healthcare, away from simply treating the effects of illnesses to targeting interventions to where people live, work, and play—where health really begins.

Going Beyond “Band Aid” Care

When I was a medical student, I worked with an NGO in Rwanda to provide medical care to women with HIV. Nearly all had witnessed their family members murdered during the genocide, and many became afflicted with HIV as a result of rape. Our initial focus was on getting antiretroviral therapy to these women, but we quickly realized that while it was important for them to have access to medications, they couldn’t be healthy unless they also had enough food to eat. They couldn’t stay safe unless they had shelter. They couldn’t be well unless we addressed their psychological trauma.

As an emergency physician working in inner city ERs in St. Louis, Boston, and D.C., I see this same problem every day. My 8-year old patient, Kami, comes in wheezing and short of breath. She has asthma, and two years ago, she lost her inhaler. She and two brothers are staying with her mother’s cousin; lots of people smoke in the house; and she’s missed several days of school. I can give her a breathing treatment and prescribe an inhaler, but how do I help her achieve good health?

Over the last year, I’ve seen 19-year old Byron in the ER three times. The first time, he was stabbed on the arm. It was a superficial cut; he received some stitches. The second time, he got in a fight and broke his hand. I gave him a splint and sent him home. The third time, he was shot twice in the abdomen. I stabilized him and sent him to the operating room. I wonder when he will be back for another violent injury. Is there a better way to help him than to patch him up, piece by piece?

Then there’s Josephine, a 38-year old single mother of four. She was told four years ago that she has cervical cancer. Between her three part-time jobs and taking care of her children, she had no time to see a doctor. Her boss threatened to fire her if she left in the middle of the day. She tried to call a specialist, but they wouldn't take her insurance. By the time she comes to the ER, her cancer had spread to her intestines and her lung. We set her up for treatment, but what does it say about our society that her disease had to progress this far?

Our healthcare system is good at providing short-term fixes for problems. We pride ourselves in having the most advanced technologies in the world. We can provide this excellent care for the few hours the patient is with us in the ER, hospital, or clinic—but then the patient is on her own and back to the same problems, 24 hours a day, 365 days a year. Numerous studies have shown that it’s where we live, learn, work, and play that have a far greater impact on our well-being than the treatment delivered in a hospital.

I chose to be an emergency physician because I want to provide excellent care to everyone, regardless of ability to pay. We in the ER provide a necessary service, but it’s far from being sufficient. We need comprehensive strategies that promote health and target problems “upstream”. We need to recognize that health does not exist in a vacuum, that it is intimately tied to issues such as literacy, employment, transportation, crime, and poverty. An MRI here, a prescription there—these are Band-Aids, not lasting solutions. Our communities need innovative approaches to pressing issues like homelessness, drug addiction, obesity, and lack of mental health services.

The sage Dr. Patch Adams said that if we treat the disease, we lose; if we treat the patient, we win. To help the patient, we must also address the health of the community.

Over the next several blogs, I will be exploring interventions that show promise in addressing the needs of the patient and their community. I welcome your ideas and suggestions.

Guest Post: In a Patient’s Death, My Life Found New Purpose

I am delighted to host this guest blog from Dr. Eric Bing, physician and professor of global health. We share a passion for fighting disparities in health, a passion is deeply rooted in personal experience, and that comes through in this poignant essay.

 

I was a Harvard-educated physician yet I couldn’t save a patient from an easily preventable disease. In her death, my life found new purpose.

Her name was Lorraine. She was abandoned when she was just six weeks old—left alone in a dark building on a cold winter’s morning. Wrapped in only a soiled blanket, she had nothing to soothe her cries. She might have died if not for those cries, for someone heard her and carried the tiny body to the infant’s grandmother. In Philadelphia in the 1930s, neighbors knew everything about each other, and the existence of this child was not a secret. Her grandmother took her in. She had already raised 15 children of her own, so what was one more? 

As a little girl, Lorraine grew up fast. Even with her sharp mind, like many black girls at that time, she had little money and even fewer opportunities. She slept in the crawl space under her grandmother’s stairs. When she was 12, Lorraine began working as a domestic servant, cleaning houses and caring for children not much younger than herself. She later dropped out of school, and while still a teenager began having babies of her own. 

She was so busy taking care of others that when she began having light, occasional vaginal bleeding, she ignored it.  She had already gone through menopause so this was nothing to worry about. But over time the light bleeding became heavy and the occasional occurrence became alarmingly frequent. After an anxious trip to the doctor, tests confirmed that she had cervical cancer, caused by the human papilloma virus she had acquired years earlier.

Lorraine’s life was once again in danger, but this time from an easily preventable disease.

Cervical cancer can be diagnosed in its earliest stages by a simple Pap smear. In developing countries where Pap smears are too expensive, it is being diagnosed using a few drops of vinegar or prevented in girls with a simple vaccination. And it can be treated at an early stage by freezing lesions off, like a wart. But in order for early care and treatment to work, you must not only have access to care, you must use it. And like many women, she did not do that; the needs of others always came first.

By the time her cancer was diagnosed, it had already spread throughout her pelvis. From there it would move to her liver, bones, and lungs before spreading to her brain and taking her life.

I cared for Lorraine until the day she died, however she had cared for me from the day I was born.

Lorraine was my mother. And her death from an easily preventable disease changed my life.

I was a psychiatrist in Los Angeles when my mother died in 1999. Today I am the senior fellow and founding director of global health at the George W. Bush Institute in Dallas and the founding director of the Center for Global Health Impact at Southern Methodist University.

At the Bush Institute, I helped launch, Pink Ribbon Red Ribbon, an innovative public private partnership to combat cervical and breast cancer in Africa and Latin America by increasing access to cancer prevention and treatment. In developing countries, where Pap smears are too expensive, cervical cancer can be diagnosed by putting a few drops of vinegar on the cervix, which is then examined under a lamp. Lesions appear white and can be treated at an early stage by freezing them off.

A recent study from India showed that this simple vinegar test that costs less than $1 can reduce deaths by nearly one-third. There are also inexpensive vaccines that can prevent the viral infection entirely. We can defeat cervical cancer now in simple, cost-effective ways.

The challenge is access.  In Pharmacy on a Bicycle:  Innovative Solutions for Global Health and Poverty, Rice University business professor Marc J. Epstein and I show how even access to care barriers can lowered in developing countries for many diseases, by shifting care to lower-cost providers, focusing on efficiencies, strengthening existing systems and by stimulating partnerships among governments, businesses, nonprofits, entrepreneurs and women of all ages. And, as my mother's death taught me, we must mobilize women to recognize their risk and realize that by protecting their health, they can live to protect the ones they love.

As my mother lay dying in her home in North Carolina, her house was once again full— with people who had been helped and touched by her over the decades. My mother had scoffed at the notion of filling a funeral home with flowers for the dead. "Give me my roses while I can smell them," she had said.  So people obeyed, coming to bid farewell while she could still hear them.

Despite the steady stream of people at her bedside, she fretted in her final days about what she saw as her lack of accomplishment and lasting impact: She was intelligent but uneducated. She was courageous yet lived in fear. She had done nothing with her life, she felt. She had not fulfilled her life's mission.

When she was finished reliving what she thought was a string of disappointments, I began to re-tell her life story—not as she understood it—but as I saw and experienced it as her youngest son.

I told her that I believed that her life's mission was to unleash passion and purpose in the lives of those she touched. Not only had she raised five children who went on to careers in business, education and medicine; she had applied her quick mind, hearty laugh and steel backbone to helping anyone she came across who was in need.

She taught us that love is what creates a family. She helped us see that a good heart must be coupled with hard work in order to succeed. Those that she had helped were now helping others, and they would in turn help others, and they, still others. Through others, her spirit would live on, continuing to change the world.

As we spoke, I could see a shift occurring within her as she sat there quietly. Softly, a warm smile filled her face, as though she was looking in the mirror and for the first time loved the woman she saw. 

My mother died in my arms, leaving the world far more peacefully than she entered it. In her death, my life found new purpose.

Eric G. Bing is the co-author of "Pharmacy on a Bicycle: Innovative Solutions for Global Health and Poverty" and senior fellow of global health at the George W. Bush Institute. He is also a professor global health at Southern Methodist University and founding director of the Center for Global Health Impact.

A version of this article originally appeared in the LA Times, June 23, 2013, as A cancer that need not kill, by Eric G. Bing.  It is reprinted here with permission of the publisher.

You Can Catch a Cold From Being Cold and More--8 Common Health Myths, Debunked

This weekend, I am presenting a session at the Asian American Women Leadership Conference to high school and college students about taking care of our bodies. One the topics is common health myths. Despite our best efforts at debunking them, here are 8 pervasive myths:

#1. You can catch a cold from being too cold. Growing up, how many of us have heard this from well-meaning parents and grandparents? It’s easy to see how this myth came to be. People do get more colds in the winter. Going outside in the cold without proper protection isn’t particularly pleasant, and if you do it enough, might lead to a weaker immune system. However, we also know that colds are viral infections that are transmitted through viruses. You catch a cold from someone else who has a cold, not from being too cold yourself. So, to avoid catching colds, be diligent about washing your hands (though bundling up in cold weather isn’t a bad idea either).

#2. You will get blind if you read in low light. If this is the case, then our ancestors will surely all have suffered from blindness! It’s not true that reading in low light leads to blindness. That said, why strain your eyes unnecessarily? If you have the choice, read in an environment with lighting that is pleasant to you.

#3. In order to tan, you must burn first. This is definitely NOT true. Sunburns are potentially dangerous, and can lead to sunstroke and dehydration, not to mention skin cancer. Tanning itself carries similar risks. How much you tan depends on your skin type (there are some people who burn and never tan, for example), but you should definitely not plan to get sunburned in order to tan.

#4. Muscle turns to fat if you don’t use it. Anatomically, this just isn’t the case. Muscle and fat are two different types of tissues, and one doesn’t turn into the other. However, there may be some truth overall in that if you don’t exercise, you lose your muscle mass. If you consume the same number of calories as when you were exercising, you will probably gain weight. So make sure to exercise regularly!

#5. Alcohol kills brain cells. In junior high, I watched my teacher drop a rat brain into alcohol, and the alcohol seemed to eat away at the brain. So alcohol kills brain cells, right? Well, not exactly. The alcohol that you drink enters your bloodstream, and doesn’t actually attack your brain directly. Of course, there are other ways for alcohol to injure your brain: for example, binge drinking can lead to decrease in breathing and injury to your brain that way, and drinking while driving has many other dangerous effects. As with everything else, drink responsibly, and in moderation.

#6. People are fat because they don’t exercise. While exercise is necessary to maintain good health, the primary contributor to being overweight is poor diet. An overweight person will have difficulty losing weight by exercise alone; a good diet with decreased calories is also necessary. Genes also play a role. That doesn't mean you shouldn't exercise if you want to lose weight--but make sure you also change your diet.

#7. Birth control/HPV vaccine/etc leads to more sex. A myth like is testament to people using anything as “research” to support their views. It’s hard to imagine that anyone will choose to have more sex because they have better information and a few shots in their arm. A better way to think about this is that people are going to be sexually active anyway. Why not empower them with information to make good choices (i.e. birth control and sex education)? The HPV vaccine can guard against cervical cancer; why not protect our young?

#8. Women need annual pap smears starting from age 18. This used to be the case, but the guidelines have been revised such that it’s recommended for women to get pap smears every three years, starting from three years after they begin sexual intercourse. This doesn’t mean that you should only see your doctor every three years; an annual woman’s visit is beneficial for a number of reasons, including checking up on your health in general and addressing other aspects of your sexual health.

Many of these myths are partially based on the truth; that’s why it’s so hard to sort them out. Yet, they have been proven time and time again, with a variety of scientific studies, to not be true.

Do you agree? Disagree? Have other myths that you want to share? Please write your comments below! I would love to hear from you.

Well-Women Visits Are Critical to Your Health

As an emergency physician, I tend to work on the other side of preventive care services. I see what happens when women don’t know about safer sex and birth control, and end up with complications from sexually transmitted infections. I see what happens when women do not get routine screening for cervical cancer and struggle with life-threatening cancer. I see what happens with out-of-control hypertension and diabetes, and the heart attacks and strokes that are detected far too late.

These experiences have shown me that prevention is the best medicine. That’s one big reason why the Affordable Care Act provision requiring new insurance plans to cover women’s preventive care without any extra charges or co-pays is a real victory for women. These requirements, which go into effect Aug. 1, will be phased into existing insurance plans over time.

Because of this change, women will be able to obtain complete contraceptive care, screening for sexually transmitted infections, and screening and counseling for intimate partner violence. This builds upon earlier requirements that insurance companies cover – at no additional cost to women -- mammograms and screenings for cervical cancer. It’s clear to me that these mandates will significantly improve women’s health and lives and ultimately lead to a reduction in health care costs.

The Well-Woman Visit
One of the easiest ways to obtain preventive services is through a well-woman visit. These visits, which will soon be covered with no co-pay, give you the opportunity to ask key questions about birth control, sexually transmitted infections, and other reproductive issues, along with questions about diet and exercise and any health concerns you have. You can also discuss changes in your family’s medical history that are important for your health care provider to consider. For example, when my mother was diagnosed with breast cancer, my doctor recommended that I get earlier screenings.

Along these same lines, your health care provider may have questions or issues to discuss with you. Smoking, drinking and recreational drug use can create and contribute to health problems, and often need to be discussed and addressed multiple times before change happens. Well-women visits also give your health care provider a chance to screen for potential high blood pressure, diabetes, depression, domestic violence, and more.

The well-woman visit is important for another reason: it gives you and your health care provider a chance to get to know each other. Most people go to their provider or to a clinic only when there’s a problem, but the best time to get to know your provider isn’t when you’re in distress from a painful or troublesome condition. Studies have shown that health care providers make more accurate diagnoses when they know their patients and can put the symptoms in the context of your life. A well-woman visit is a precious opportunity to build this trusted relationship.

As an emergency physician, I am excited about the new provisions taking effect Aug. 1, which include annual well-women visits for those who want them. I would much rather women regularly visit their health care providers than come to the E.R. later suffering from preventable problems. So please take this opportunity and make an appointment with your provider. The importance of investing in your health is too crucial to ignore.

I wrote this article as a guest blogger for Our Bodies Our Selves. This post also appeared as part of the National Women's Health Network blog. I welcome your comments and your emails!