Addressing the Epidemic of Random Violence

Another unspeakable tragedy has taken place in Newtown, Connecticut.  A familiar story – a mentally troubled person gets access to assault weapons and plenty of ammunition.  Then he senseless takes the lives of innocents he doesn't even know (notice the use of the pronoun “he”).  And again the clamor for gun control echoes across the land.  Gun control alone will not address the complex problems that have led to a rash – dare I say an epidemic - of random violence.  

A comprehensive approach to the problem of random violence is needed.

Firstly, a massive overhaul of our mental health system is required.  We need to find a way to de-stigmatize mental health care and those who access mental health services.  We need to overhaul the laws that make it difficult or impossible to identify and treat troubled individuals who demonstrate a propensity for hurting themselves and others – even without their consent.  We need to find creative ways to make schools safer without turning them into fortresses.  And finally, we need to get assault weapons and assault weapons ammunition off the streets and out of the homes.   Perhaps we need to examine what are the legitimate uses of body armor.  Who needs it in a civil society?   

An overhaul of the mental healthcare system will require a complete rethinking of how mental healthcare is provided.  We need to provide mental healthcare as an integral part of the primary healthcare system.  And it needs to be covered by insurance.  Families who are dealing with troubled loved ones need to have access to counseling and care as well as the legal means to take action when individuals cross the line from troubled to dangerously disturbed. 

Access to schools needs to be dramatically tightened up.  Right now almost anyone can walk into most schools in America with or without a weapon. If this means more personnel dedicated to school security, so be it.  We have a crisis of unemployment anyway.  Using a combination of technology, social media, and human and physical barriers, access to schools must be denied to those who have no need to be there. 

Speaking of gun control. 

We cannot rely on politicians to solve this issue for us.  Citizens need to take this issue up by voting out all those who refuse to budge.  As long as the gun lobby has more power than the citizen lobby, we will not have any progress on controlling access to guns, including automatic assault weapons intended to kill enemies on the battle field.    If nothing happens, we only have ourselves to blame. 

No Health Without Mental Health

 

It’s well known that mental health is a prerequisite for overall health.  But In the United States and in countries around the world many people lack access to affordable mental health services.  Without access to care, people suffer in silence from depression, anxiety, and other psychoses.  Mothers suffer alone from postpartum depression.  Adolescents, suffering from treatable mental health conditions, often resort to self-harm, risky behaviors, and even suicide.  Individuals and families suffer from the ravages of alcoholism and related family violence.  

When tragedies such as the mass shootings at Virginia Tech or in Aurora, Colorado take place, the lack of mental health care for individuals in desperate need is highlighted in the news media, but often only briefly.  But every day, the poor and minorities suffer from inadequate access to mental healthcare.  Even well-off people are can be denied care because of the stigma attached to mental health problems or because insurance does not provide coverage.

In the United States and around the world, health care systems are overstretched by the burden of infectious diseases, non-communicable diseases, accidents and violence.  But this is no excuse to ignore mental health.  It’s time to pay attention to the mental health of the population. Everyone has a right to mental health. The poor and minorities need access.  Even the middle class people need to be freed from the stigma of seeking care for mental health problems.  And insurance companies should find ways to provide coverage for mental health care.

There is no health without mental health.  We must promote access to mental health care for all.    

High Unemployment, Shortage of Medical Doctors

OP-Ed (Haugh)

With High Unemployment, Shortage of Medical Doctors Anticipated

Three recent health-related articles in the New York Times are somehow gnawing me.  All are about whether and how poor people are going to get access to health care.

The first article by Pam Bullock discusses a recent study by Harvard researchers that showed that when more people have access to Medicaid, fewer people die. The study covered three states, Arizona, Maine and New York, that had recently expanded their Medicaid programs.  With the new Medicaid programs, the number of deaths declined by a total of 1,500.  Bullock quotes several public health experts, apparently from all sides of the debate on Obama Care, as giving the study a thumbs up for credibility.   Diane Rowland, of the Kaiser Family Foundation said “In the midst of many claims about what Medicaid does and doesn’t do, it actually shows that it cannot only be beneficial for health, but in preventing some of the premature deaths of the uninsured.”  http://www.nytimes.com/2012/07/26/health/policy/medicaid-expansion-may-lower-death-rate-study-says.html?pagewanted=all

Sometimes we criticize such studies for proving what we already know intrinsically.  I mean – isn’t it just common sense that providing poor people with access to medical care through health insurance should be of benefit to them, making them healthier and prolonging their lives?  Isn’t it obvious that sick people will benefit from care, and that poor people will delay or avoid care if it has to come out of their own pockets, when there is precious little in those pocket.  Maybe it’s common sense, but now, thanks to researchers at the Harvard School of Public Health, we have evidence providing a link between access to insurance and better health outcomes for the poor. The politicians around the country who are thinking about rejecting the federal government’s offer of expanded Medicaid should factor these findings into their equations. Citizens too should demand better and expanded Medicaid programs.

 

And the next article in the NY Times that captured my attention was one by Suzy Hansen entitled What Can Mississippi Learn from Iran?  It turns out Mississippi did learn a lot from Iran. Iran installed a system of community-based health care centers in rural areas that provided access for poor people and a sophisticated referral system for getting people to the correct level of care.  Now agencies in Mississippi, such as HealthConnect, are reaching out to poor people in their homes following the Iranian model.  But why did we have to learn from Iran?  Community-focused health care is no more rocket science than community policing.  My colleagues in the Peace Corps in Korea in the early 1970s were reaching out to villagers to make sure that they were taking their TB meds – and it worked.  Korea’s TB rate plummeted and has remained low in spite of the legacy of war and poverty. http://www.nytimes.com/2012/07/29/health/policy/too-few-doctors-in-many-us-communities.html?src=me&ref=general

Hansen paints a depressing picture of life in the Mississippi Delta where Delta towns have been ravaged by successive economic downturns.  The state’s dismal health statistics are straight out of the 1960s. But the Governor is threatening to close down its lone abortion clinic, leaving women with now access to essential reproductive health services. The heroic individuals providing community-based care to Mississippi’s rural population deserve our admiration.  I guess we have the ayatollahs to thank for this.

 

And finally, an article by Annie Lowrey and Robert Pear  laments that by 2025 the United States will be experiencing a severe shortage of doctors, estimated at over 100,000.   The authors point out that as early as 2008, less than half of primary care doctors were accepting new Medicaid patients – so much for the salubrious effects of Medicaid access.  The aging of the baby boom (yours truly) is partly responsible for this shortage of docs.   But why is it that we can’t fill this gap – we have a huge unemployment problem among well educated people.  Why not gear up for the looming shortage of medical personnel?  And why not look for other creative solutions to fill the gap?  We can train more physician assistants, nurses, nurses’ aides, community health workers, and barefoot doctors.  We can employ the existing workforce more effectively, think about training more personnel overseas (if our institutions can’t gear), and even about continuing to “import” talent from abroad; hopefully while ensuring that the source country doesn’t suffer shortages as a result.   It doesn’t make sense to use the high cost of educating and training personnel as an excuse for inaction.   What is the price of lack of access, delayed care, and other forms of rationing that will surely lead to plenty of premature mortality?   Surely the cost in lost productivity alone will be astronomical.  And we shouldn't forget the potential value of greater and more effective preventative efforts; also a high value investment.   

So, here is an area where there is plenty of opportunity for smart young people to get educated, trained and employed.  All we need is the will, a well-thought-out plan and adequate financing (which will surely produce a robust economic and financial return).  Let's educate and train at least 100,000 healthcare personnel by 2025.  Then let's get everyone enrolled in an insurance plan, such as Medicaid. Instead of a disastrous shortage of healthcare personnel, we can have plenty of young people employed and adequate financing for their services. Then maybe Iran will come and learn something from us. 

  

http://www.nytimes.com/2012/07/29/magazine/what-can-mississippis-health-care-system-learn-from-iran.html?pagewanted=all

A Life's Journey in Public Health

A Life's Journey in Public Health 

I first became interested in public health when I was a Peace Corps Volunteer (PCV) in a rural town in South Korea in the early 1970s.  Korea was a relatively poor and undeveloped country then.   I was assigned as a middle school English teacher.  Another PCV in my area was assigned to a rural health clinic.  We talked a lot about the treatment of TB and leprosy patients. I was particularly interested in the TB program. As a PCV, I visited remote villages where the elders suffered from TB. Skinny old men in tee shirts sat on the porches of their mud-walled huts wasting away from TB. Each cough spewed infectious bacilli into the air. Our Peace Corps health program was designed to ensure that patients were regularly taking their TB medicines, instead of discontinuing when they started “to feel fine”. The combination of rural sociology, primary health care and cross-cultural dynamics fascinated me.

In 1977-78, I attended the School for International Training in Brattleboro, Vermont. One of the requirements for the Masters in International Administration was a six-month internship.  I was sent by Catholic Relief Services (CRS) to Semarang, Indonesia where I opened and operated a field office to supervise USAID programs in East and Central Java.  We implemented a Maternal Child Health Project that included infant care, growth monitoring, mothers’ education and supplementary feeding.   I managed all aspects of the program, including the administrative aspects, as well as the compliance monitoring. My key concern was to ensure successful outcomes from the program – healthy, normal weight babies and knowledgeable mothers.    This program, which intervened in children’s health at an early age, provided a robust economic return over the lifetime of the individual.  I thought it also provided an excellent return on the US investment.

    

After a year in Indonesia, I was transferred to Manila, the Philippines where I supervised a nation-wide nutrition program.  I travelled the whole archipelago, visiting MCH centers, leper colonies, and school feeding programs.  I realized that extreme poverty was at the root of many problems and that health interventions were not enough to improve the lives of the rural poor.  Investments in water supply and sanitation, and in basic education, supported by strong institutions and pro-poor policies are equally important.

         

While working in the Asian Development Bank, I was able to use my experience as the manager of a social sector division that designed and implemented health, and education projects throughout Asia.  We refocused our agency’s health sector strategy from investing in urban, tertiary care to one focusing on primary care.  (We faced an interesting challenge trying to convince our “authorities” that investments in primary health have strong economic returns). My colleagues and I devised health sector strategies for each country with an interest in borrowing for health projects. I worked on a range of projects to strengthen national health care systems, including HIIV/AIDS interventions that focused on ethnic minority populations living in the border regions of the Mekong Sub-region, and primary health projects that promoted “contracting out” of services to non-government agencies.   During the 1997 financial crisis in Thailand, we developed a policy-based project designed to protect the central government’s budget for HIV/AIDS and promote gradual decentralization of government hospital administration.   

I took home several lessons from my work at ADB.   To improve health outcomes, the entire health delivery system must be strengthened.  This includes building physical assets to provide access, but also designing effective management systems, training and motivating personnel, and addressing demand-constraints.  One simple example - a women’s clinic in Vietnam had no waiting room to provide clients shelter and privacy while waiting for their consultations. Women had to wait in the hot sun in front of the clinics, exposed to the entire community.  Improving privacy by installing a comfortable waiting room was an easy way to convince women to optimize use of the clinic. I also came to the conclusion that the health sectors in developing countries were highly fragmented, with a plethora of international donors and non-government organizations supporting too many small, vertical projects rather than systemic strengthening of  health sector institutions, which are often among the weakest of national institutions.  The leadership ranks in many developing countries are also very thin, making training an important component of capacity building. 

I moved to North Carolina in 2007 and began working with the Executive Service Corps of the Greater Triangle. I have been assigned to several projects to strengthen the operations of health-sector non-profits.  Recently, I have been working with community health centers that provide low-cost services to underserved populations. I was surprised to find that these agencies face similar problems to those in the developing world.  I also learned that health disparities in North Carolina are not too different from those in the developing world – poor and marginalized peoples face a disproportionate burden of poor health. Mental health services are underfunded and community health centers are burdened by bureaucracy.  Families in North Carolina have been steadily losing their health insurance as jobs in traditional sectors have been disappearing. Effective interventions have to be designed to overcome these disparities.  Like the clinic in Vietnam, providing the uninsured with accessible, quality services will likely increase their use of the facilities.

During September to December 2010, I had a professional opportunity to assist a free clinic in Moore County, NC to prepare a plan to become a federally qualified health center.  I was excited to use my experience and new knowledge from the UNC Gillings School of Public Health to analyze the health issues in the county, the strengths and weaknesses of the clinic, county demographics, and economic trends in preparing the project.   I am hoping the clinic will be selected for federal funding as this will allow an expansion from about 900 to about 4,000 patients.

These days I have been working with the Gillings School of Global Public Health to design a new global health issues program, undertaking a systematic review of quality improvement interventions focusing on maternal mortality and thinking about a monitoring and evaluation program for a mental health program in Madhya Pradesh, India.   

  

.... Ed

Here is the strategy of the Global Fund

Hello, Hello... It's Time to Vaccinate Your Baby

Can technology be harnessed to improve the health of the world’s poor?  The Ministry of Health in India thinks it can improve the country’s dismal child vaccination record by calling mothers on their mobile phones to remind them when vaccinations are due.  As reported by the Wall Street Journal, India’s vaccination rate is low, with only about 72% of babies receiving a full course of the critical DPT vaccine, compared with 95% in neighboring Bangladesh and 83% in Indonesia (WHO estimates). 

The Health Minister himself demonstrated the cell phone system in a meeting with WHO officials, but alas only about 60% of the phone numbers were correct.  So is this the most effective approach to reaching these moms?  Health workers in rural areas are underpaid, overworked and under motivated.  Do they have any incentive to get the data (phone numbers) right?  And will moms maintain their phone lines (usually prepaid phones)?  Will they even answer a call and will the person on the other end be able to speak their language?  Many of these issues will have to be resolved if cell phones are really going to make a difference in child vaccination rates. 

The Wall Street Journal article points out that high level political commitment is necessary to bump up vaccination rates.  India’s five year national vaccine policy is being finalized. How much will it rely on high tech solutions remains to be seen.  Maybe we still need “boots on the ground.”

http://blogs.wsj.com/indiarealtime/2011/08/04/india-turns-to-mobile-phones-in-bid-to-improve-vaccination-rate/?mod=wsj_share_facebook

New Year's Mayhem in Manila Brings Many Casualties

On any New Year's Eve Manila is a battle zone. Explosions, smoke, and gunshots fill the air as the megacity's residents celebrate the new year. The tradition stems from a Chinese belief that loud noises will ward off evil spirits. By mid-night, the smoke is so thick that flights in and out of the city have to be postponed or diverted.

Unfortunately, every year, hundred of revilers are injured by fire crackers, gun shots and burns. This year the New York Times reported that almost 500 people were seriously wounded. Many of the injured are the poor residents of Manila's slums. On any night they may be injured or killed by knives, guns and other lethal weapons. But New Year's Eve is particularly dangerous. This is not to say that the rich are unaffected. Their neighborhoods also descend into mayhem as the New Year comes in.

This year Manila's authorities, ranging from local officials to the President, mounted an unprecedented public health campaign to encourage people to celebrate in a safer way. Grisly posters were displayed ly showing mangled fingers and doctors appeared on TV with their bone saws to warn would be revilers. One politician did a funky dance on TV to demonstrate a safer option to usher in the new year.

Statistics showed that the campaign resorted in reduced causalities, but interviews with health workers in emergency rooms did not seem to bare this out. Expats who have lived through many New Year's Eve sieges are highly skeptical of the public health community's ability to stem the tide. And according to the Wall Street Journal, even the Health Secretary, Enrique On, admitted the campaign had failed.

Mounting an effective public health campaign to reverse deeply ingrained social behaviors is a huge challenge for the public health community. And is it worth it? After all New Year's comes but once and year, and maybe the perceived benefits of this mayhem outweigh the costs. What public health experts do know is that changing such behaviors is a long-term process that will require sustained and innovative approaches on a range of levels.

Here is a link to the NY Times article: http://www.nytimes.com/2012/01/02/world/asia/despite-crackdown-philippines-new-year-is-marred-by-fireworks-injuries.html?ref=world

And here is the link to the Wall Street Journal Article: http://blogs.wsj.com/searealtime/2012/01/02/philippines-tallies-cost-of-firecracker-binge/

Thanks to Paul McCabe for pointing me to these two articles.