Ensuring universal health care around the himalayas

Two unique experiments in health care are being orchestrated on either sides of the Himalayas. Both China and India are grappling with the ideals of universal health care(UHC): trying to provide equitable and accessible healthcare to the entirety of its populace, an idea that has been up for talks here in Nepal as well for a few years now. The lessons we learn from the either of our two neighbors’ experiments should prove to be very insightful.

Universal health care has been dubbed as the next big thing in public health. Its ability to shape people’s health over the next several decades has been thought to be nothing short of phenomenal. Our own priorities match hand in hand with that of UHC: the last constitution has enshrined universal health care as a fundamental right. But so have some 19 countries of Latin America, and numerous others all over the world. Without a formidable plan and commensurate action, such policies will be just that: vacuous rhetorics.

That’s where China and India shine. They are putting money where their words are and have a restless audacity to achieve out of this world results previously thought unattainable. Between these two giants, they aim to provide accessible and equitable health care to more than a third of humanity, irrespective of an individual’s ability to pay, thereby preventing people spiralling into a vortex of poverty due to a catastrophic illness as it often the case for poor and middle income people right now.

China has audacious plans. The country has earmarked more than a hundred  and twenty five  billion dollars in additional health care spending to scale up health services to its entire people, and by some estimates health care spending in China will easily top more than half a trillion dollars by the year 2020.  Such spending will come mostly from the government, but private spending out of pooled sources like private insurance will also play a part. Between a hybrid network of public and private providers and pooled resources using public and private funds, China aims to achieve its goals of ensuring the health of everyone of its citizens.

India’s plans are equally bold if not bolder. It plans to provide a basic set of health services to everyone, with costs offset by the government from resources collected from general taxation. For a country that has helped rescue much of the developing world from their AIDS epidemics by means of its cheap generics, it is such an embarrassment that thus far, healthcare seemed so distant for a majority of its people due to unaffordable drug and service charges.

That is finally about to mend. And that is not an unachievable goal. Based on some conservative estimates, the government of India will have to spend at least 3-4% of the GDP on health, in order to achieve such results. That is not a big number to spend in healthcare: The UK government through the NHS spends some 8% of the GDP on healthcare. The US spends a whopping 18% of the GDP on healthcare, sixty percent of which comes from the government in the form of programs such as Medicare and Medicaid.

Current health spending by the Government of India is at around 1.4% of the GDP, only a quarter of the total health care spending. Two thirds of health spending in that country is out of pocket. As a result, for the poor the consequences of a severe illness are sometimes more catastrophic than the illness itself. No wonder then that poor people lose lives to an illness at an alarming rate, through lack of adequate care or by refusing to seek care, because the health system has failed them.

Our own experiences match much of India’s. A large section of our population has been effectively barred from formal health services. Like India, we have toyed with the idea of eliminating user fees at government health facilities to improve access to health care to a subset of underserved people. Research from much else of the world shows, user fees, howsoever nominal deter the most vulnerable and the marginalised from much needed health services. Revenues from such fees have also been shown to be a very poor and an unreliable means of financing health care. Our results since eliminating such fees have been encouraging; health services usage has gone up in these select groups.

It pays for us to be cognizant of a mix of  insurance based and government funded healthcare system like that in China, but that may be difficult for us to implement given that the organised sector through which we could implement employment based insurance system is miniscule. Leaving health care hostage to a predatory for-profit multi-payer private insurance system like the one in the US should not be anyone’s idea of universal health care given how such has healthcare system has systematically excluded a sixth of the population in that country, even while it threatens to usurp the entire economy due to runaway costs.

While stalled politics in the country has left every other priority on the back burner, tomorrow’s Nepal can’t be built no matter what kind of ingenious constitution the politicians come up with, if today’s children continue to risk perennial ill health and preventable death. Our commitment to universal health care is barely a start to end this injustice. Realising this dream will mean matching the talk with the walk, much the way our neighbours are starting to do.

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Pirates of the healthcare industry

The New York Times recently did an expose on hospital overbilling by a group of cardiologists at some hospitals owned by the Hospital Corporation of America (HCA). Immediately after a few days, a rather gloating article about how HCA had become the poster boy of Wall Street with its double digit growth strategy appeared. If the first story had not raised enough doubt about the prudence of the profit motive in healthcare, the second story rammed the point right into place.

Back in the 1950s Kenneth Arrow (a side note: the Nobel winning economist is Larry Summers’ uncle if that’s of any interest) published a paper in the American Economic Review about how healthcare is unlike any other commodity that is freely tradable at the markets. The core of his argument was  that healthcare unlike regular commodities follows a warped logic that does not bow at the altar of demand and supply economics.

Here’s why: first, there is no real linkage between demand and supply with healthcare. In ordinary market economics, demand and supply tend to have an inverse relationship  with each other. Not so with health care; since nobody can really predict the need for a certain health service. And when you do need it, there isn’t really the time to shop around. So the demand and supply can’t really be moderated based on each other.

Second, and equally important, is the fact that there is a huge information asymmetry between the provider and the consumer of the service. As a result, not only is the consumer not able to shop around for healthcare when he needs it, he has no idea about making an estimate about the quality of the same. Think about haggling around for a cardiac cath when  you have a heart attack. Or for that matter, think about trying to second guess your doctor when she says you need a certain procedure. That puts the doctor at a rather unusual predicament for a service provider; he is not only the provider but also oftentimes the person who determines when there is a need for a certain service. In an idealised situation, the doctor is expected to not only provide services to his consumers, but also be a vanguard the interests of his patients and the society at large.

When doctors are able to fulfill that obligation as the custodians of the well being of their patients and communities, that’s where they derive their reverence. When doctors choose to forgo that obligation, like the Florida cardiologists, it is too easy to make a quick profit. The price that you pay for earning that quick buck however depends upon how much of importance you place upon your moral obligations and failings. Physicians have ordinarily been expected to subscribe to their own ethical tenet. When they fail to do so, they can do undue harm to our communities by virtue of the trust that has been laid on them. The lure of money can be a powerful force to cause a breach of such trust.

And that has already been happening at an alarming pace. HCA is a very relevant case in point. Fuelled by their own greed and the pressure from their administrators to upcode on their services as well as provide services that were not really required, these doctors sold themselves for a quick buck.

Like the NYT story points out, it’s for a reason why the for profit healthcare industry has become the new darling of the private equity industry. At a time when demand for goods and services is sagging almost everywhere, healthcare continues to be a major exception. And when the provider himself can be the arbiter of demand, that is too fertile a ground for private equity firm to not try to stick its feet in.

One may argue, so what is wrong with making money if they provide better services, bring in efficiency and add value to the system. Here’s why that argument is faulty. First, the Florida story is a firm rebuttal to the fact that for profit hospitals provide efficient services. They just provide services that makes them more money irrespective of the need. That loses money for everyone in the longer run. Second the belief that such hospitals create value is faulty as well. Paul Levy has a really interesting blog post on his Not Running a Hospital blog, about how private equity firms dress up results for the short term for the consumption of wall street, fatten up the stock and make their quick exit, while holding such institutions hostage to maverick financial instruments in the longer run. There is a reason why the term “vulture-capitalism” sticks. Dive in, make a quick buck and make an equally quick exit.

A third argument is made about how private entities bring in investment that no non profit institution would have been able to manage on their own. That argument too has no merit when you consider the fact that, as Levy mentions,  no for profit hospital will have access to cheap capital the way a non profit will have given the need to pay taxes, the lack of access to charitable donation  and the constant need to placate the demigods of the markets.

As long as healthcare continues to be a societal good hinged on our belief that it should be a right for all irrespective of the ability to pay, health care services will not be tradable like every other good or service. When it’s defined as a societal good, healthcare is too easy a target to profit from; and making a quick buck out of it is not a terribly difficult thing to do; unfortunately such profiteering tends to be antithetical to larger societal interests. Either the profits or the common good. Unless we recognise that fact,our confusion with whether the market is the best vehicle for delivery of healthcare will continue to throw up buccaneers like these that try to make a quick buck at the expense of everyone else.

I don’t know what’s wrong with you lady

I think my patient hates me! Okay I will admit I am sure she hates me. If it’s any consolation, she hates all her doctors at the hospital. Up until this morning I’d been thinking she hated me a little less than everybody else, by the afternoon I managed to gravitate right to the top of her hate list.

The 78 year old codgette is not entirely without charm though. This morning, for a change, I wasn’t running around like a squirrel, so during my morning rounds I drew up a chair by her side and had a rather longish conversation. She seemed to appreciate that. She even gave me what looked like a begrudging smile.

Resentment however, was still the overbearing emotion during the entire conversation. The lady thinks she has no business being in the hospital. I don’t blame her for that. She thinks I am keeping her here for no reason.

How would you feel if you were brought to the hospital because your daughter thought you were a little short of breath, and the doctors at the ER admitted you because they found a fever on exam which you never experienced, all the while you never really had any inconvenience or felt anything?

Since the admission almost a week ago, it has been just more of the same. Everyday the lady thinks nothing is wrong with her. We however, ever so cautious in tracking the fever, manage to find one spike of fever at least every day that makes us nervous. Okay there are reasons: she is on on an immunosuppressant, and her temperatures records are rather high. However I still don’t have an adequate explanation for the lady.

The enterprising and ever so inquisitive doctors that we are, we never fail to dig. First we start lowbrow, with a simple infection screen. We fail to find anything, and the digging gets deeper. In no while, the digging is walrusian. Yesterday we got a few CT scans, we do the blood works every day. If anything the lady thinks she is starting to get weaker due to the constant blood draw.

I have a hard time justifying all that we are doing. A snippet of our conversation this morning.

Lady: Why are you keeping me here?

Me: You have a high grade fever. We think its viral, but we are not sure. We are trying to find out why.

Lady: So what did you find?

Me: Well, really nothing thus far.

Lady: So what are you going to do now?

I wanted to say we wanted to do a few more tests, but I simply did not have the liver to verbalise that. I kept mum and gave her a vacant stare.

I did not have to. The lady already knows that.

Yesterday the attending physician had ticked her off on a possible spinal tap if the CTs came up to nothing. The lady was livid. We pitch the idea to her daughter. She has been having headaches now. She complains of weakness. And the fevers. With the suppressed immunity, there are reasons to be worried.

The lady half heartedly approves the procedure, all the while not really hiding her indignation toward all of us. We plan the tap for the afternoon today. I tell her not to worry, the procedure will be over in 10 minutes. Let me try that on you first- she retorts!

Afternoon comes. The lady asks who is going to do the procedure. I tell her I will. The lady is incredulous; she invokes the name of god. Her barometer rises, I can see her fuming. Right there I ascend to the top of her hate list.

The procedure thankfully is smooth. I ask the lady to lie down afterward. She does, and our eyes cross. She rolls her eyes away from me. I don’t really have to guess how she feels about me. What are you going to do now, she asks me, while she looks out of the window. I am going home, I tell her. Good for you she says, the sarcasm very visible.

I call up the hospital later in the day to find out the preliminary results of the tap. Everything normal. I can already imagine my conversation with the lady for tomorrow.

3 decades of AIDS

What a span of 30 years can do.

Fear can ferment; havoc can be wrecked.

For the brave, such fears can be confronted, courage can be mustered; challenges vanquished, the sweet taste of victory savoured.

A generation can be born and come of age. Epochs can be defined. All in a matters of 30 years.

Some 3 decades ago, HIV was a nameless virus without face or form. By mid 90s, it had managed to become the number one killer of young people in much of the world. Within these 15 years, not only had the virus gotten its feared name, it had also managed to reign terror in our collective psyche; HIV had become synonymous with a death sentence.

Up until today, some 25 million people are estimated to have died due to the virus including more than 4 million children. Around 34 million people are walking around with the virus.

In some sub saharan countries, as much as a third of the adult population has the virus. Without much access to treatment, entire cohort of people were wiped out. Schools ran out of teachers, farms out of farm hands, factories out of workers; even hospitals ran out of health workers. Homes ran out of parents, leaving behind helpless kids and equally helpless grandparents to tend after them.

Economies  shrank,  nations were shaken.

To those who were infected, as much physically debilitating the virus was, it was equally emotionally stigmatising. Infected people were treated as social scum, their moral standards were questioned. The readymade assumption was, if you were sleeping around shamelessly what better did you expect? Well the little unborn kid had little where else to sleep but for the mother’s uterus. No one was willing to take note of the invisible socio-economic drivers that were fuelling the epidemic in the most vulnerable patient populations.

In late 1980s AZT came along. By the mid 90s a bunch of other medicines followed, and also the spark of idea that drugs worked much better in combination than as standalone preparation. Science continued to advance, the virus as much form-shifting as it was, was better understood.

In the same time an avalanche of advocacy was launched. Governments were forced to sit down and listen, societies were exposed of the duplicity of their mockery of infected people.

An outpouring of generosity ensued. The US alone spent billions of dollars in form of the President’s Emergency Plan for AIDS Relief (PEPFAR) so treatment access could be increased across the developing world, mostly in Africa. Resources were pooled, in the form of the The Global Fund. And startling progress has been made since then. In what looked like an insuperable suffering, now the advance of the tide looks like has been halted. 8 million people in the low and middle income countries alone are in AIDS treatment.

Today before the International AIDS Conference kicks off in Washington DC, there is much we can sit back and reflect over the journey of the past three decades. AIDS deaths have been showing a steady decline, from their peak of 2.3 million in 2005. 100,000 less AIDS deaths were estimated last year than the year preceding that; there were also less new infections by a similar margin. Infections in newborns have been downtrending steadily as well.

Suddenly “halting the tide” and an “AIDS free generation” do not sound like a hyperbolic activist slogan anymore. They appear to be within the reach, given a steady commitment on a global scale to upturn this menace.

Things indeed look like they have come around a circle in these 30 years.

Primary care’s woes: It’s in the way you see

Primary care is ever the cinderella-esque tragedy. Ever so maligned, ever engulfed in misery and never really the belle of the ball like she rightfully deserves to be. There may be reasons galore to this. Not least of which is the way primary care work is perceived in this country.

Let me illustrate.

The primary care attending I work with recounted a story from the early 2000s. As is usually the case with visits at the primary care doctor, one day she took care of a sixty something lady with a slew of medical problems: diabetes, heart failure, respiratory disease, high blood pressure and depression. Additionally, the lady had recently lost her husband and had an agonizingly traumatic  bereavement. She spent time counseling her. In addition to all that she had to take care of a retinue of screening and preventive health measures that the primary care physician has to coordinate.

At the end of it all, the lady had a little wart on her great toe that she wanted fulgurated. As a makeshift measure the doctor removed the wart with liquid nitrogen, in a procedure that took less than 5 minutes.

In all the office visit took almost an hour. Orchestrating and coordinating her care took an intense amount of patience, attention to detail and diligence on part of the doctor. Assuming responsibility for the management of such an array of medical conditions is an onerous task by any yardstick.

Some time later, her reimbursements for the visit arrived. She had been reimbursed more for the makeshift procedure that lasted less than 5 minutes over all the rest of the care that she had rendered on the lady!

Such asymmetrical compensation approach produces adverse incentives. Therefore we have family physicians who have to train in minor podiatric and orthopedic procedures like nail clipping and intra-articular injections to make a little extra income to pay their bills! It’s been well established that a well-rounded primary and preventive care is the best health intervention at a systems level. Such routine care can ensure good health while preventing expensive care at the sub-specialists that may accrue later on. However there is no real incentive for the primary care physician to provide such economical care while there is every incentive for the interventionist to jump onto expensive procedures that often are a result of poor primary care and prevention.

It may pay the primary care physician well to start doing more office based procedures, but that beats the point. The point is the recognition of the fact that the meticulous, thoughtful and cerebral work done by primary care physicians is as valuable, if not more, than the procedural work done by interventionists. After all, despite the thankless compensation, the work done by the primary care physician adds way more productive life years to people’s lives per dollar spent than that done by the interventionist for the same dollar spent.

Until we are able to recognise such a fact, primary care’s godsend fairy mother will never arrive, she will never be the belle of the ball. And as long as primary care is not the center of the attraction, healthcare in this country will be eternally doomed to cost overruns that threaten to sink the entire boat on their weight.

Free health care requires infrastructure development

In an attempt to ensure universal healthcare for its people, Nepal started with free health care to a select group of people  in the mid 2000s. The plan met much scepticism, especially from healthcare providers,  when it started out. Five years down the line, it has its fair share of believers.

The moral imperative to ensure healthcare to people disenfranchised by current health system (or rather the lack of one), was imminent. There was also an equally important sociopolitical and economic gain to be had by ensuring a common minimum set of health care gains. However, making a constitutional guarantee of health care as a fundamental right was the easier part. The larger challenge, has been in meeting the promise.

Lets leave the long-term requirement of resources out of the question here, for that is an issue for a separate discussion. By some means of clever management, that should be a doable thing. The issue for discussion, is how to create the physical and the intellectual infrastructure required to deal with such a gargantuan undertaking.

In the absence of such infrastructure, the free health care program has been rather languishing as free drug program for a select group of people. Not that free drugs are not welcome, but policy planners in the hallways of the health ministry  should know that a provision free essential drugs pedaled as free health care is either just a reminder of our lack of ideas and understanding or just plain moral hypocrisy in the face of such understanding. For healthcare involves a retinue of services and facilitation from prevention to end of life care, rather than just plain provision of a few free drugs. 

A basic public health infrastructure has been  available in Nepal for sometime now. However  if this public health system alone is to be used to deliver health care, it will prove to be woefully inadequate. Hospital beds available per person are well below global averages. In the city areas numerous health providers have sprung up; they could be co-opted to provide the required care; however in rural areas still experience a miserable shortfall of health care infrastructure.

Innovative ideas will be required in further expanding health infrastructure in the rural areas. Encouraging and co-opting private providers to provide services in the rural areas may be a good way forward. This has multiple benefits. First, it harnesses capital from the private investors, big and small to fund health care infrastructure expansion. This will be a welcome relief, especially when government sources of funding are already stretched to the limits. Second managing funds allocated to government health facilities has always been a challenge. Leaving the nitty-gritty of setting up and managing such facilities  will enhance efficiency at such institutions.

Of course involving the private sector in government sponsored health care services will be burdened with a monitoring mechanism. However when the services are provided out of a limited gamut, such problems should be manageable. Furthermore the benefit of farming out services in the private sector will outweigh the losses.  

The other thing that needs to be taken care of before health services can be expanded out for the masses is to standardise treatment delivery. The benefit of algorithmic approach to disease management has been validated extensively, both in Nepal and elsewhere. Management of TB, HIV and sexually transmitted infections are ready examples of the prudence of such an approach. Standard operating procedures for a major portion of services covered under free health care services will have to be developed. This will enable farming out service delivery to the private sector, as the quality of treatment delivery can thus be monitored and in the same time payment to such services can be standardised.

Furthermore standardising treatment protocols for the most commonly encountered conditions will enable learning within the system and improving service delivery based on such system.  It will also facilitate institutional learning; system based practices can then be developed to conditions in an effective and meaningful way.

Of course such standard operating procedures do not have to be restricted to the delivery of free health care; however the effective and affordable delivery of free health care  depends more than anything else on how well we can develop the intellectual capabilities on which to deliver such care.

Unless we can tackle come up innovative solutions to manage the requirement of physical and intellectual infrastructure, just mandating free health care into people’s right will not ensure such delivery; free health care will then be worth no more than the weight of the paper it was mandated on.

Between heaven and earth

Miss K came to the hospital as a wreck of a person: 48 going on 88, lives at a nursing home, has no immediate family, weighs twice what is considered healthy, can’t breath on her own- is tied to a breathing machine through a tube in her neck, and can hardly speak; has big wounds in the back and all sorts of scary resistant bugs, has been brought to the hospital because she has a fever and her blood pressure is almost non-existent.

The sight was eerily familiar for a hospital in that part of Chicago, with its predictable demographics and illnesses. The pathos was increased only by the intensity of the events.

Wonder what it would feel like to hear this story as a lay person: no matter how hard I try, as a doctor, my opinions on such matters are bound to be  fore-shadowed by the layers of experiences and education. Pulling yourself out of a set of learned behavior and patterned thinking is very very hard indeed.

No matter what your vantage point into these events is though, it’s hard to miss a discomforting undercurrent of thought: how would anybody feel living Miss K’s life anyway? Every morning as I made my daily rounds on my patients, Miss K seemed to be choking up on thoughts that she could not let out; constipated with emotions that she wanted to vent off. Her being on a breathing machine for so long had left her unable to verbalise speech. She would make a great attempt to motion her lips and tongue to try and help me understand what she wanted to say, but despite her best efforts I would still not “get it”. She would not drop the attempt that easily though, still to no avail. I would try and make a very sincere guess at trying to understand her, but my apparent stupidity would perhaps baffle her.

Then we would turn the tables, I would start asking her a few close ended questions, expecting a nod for a yes. Still all I got was a very difficultly maneuvered sideward motion of the neck to denote a no. Writing to communicate was out of question; her hands had long fallen out of use due to gross swelling, as had the rest of all her body parts. The repertoire of my ability to predict her thoughts, and that hardly amounted to much anyway, severely limited such means of communication. Sometimes Miss K used to get so frustrated at the inadequacy of what she was able to communicate with me, she would just drop the attempt, stare into the ceiling and fall into a slumber of deep despair.

This was in her best day. On the others, she would never be aware enough to try and communicate; she would either dip in and out of lucidity, or she would just flop in the bed unconscious.

And then there would be the scary days. Days when we would be so close to losing her, we would start a vigorous attempt of resuscitation, when we would make last-ditch attempts at reviving the heart. One of those times, we ended up breaking her ribs; more than once- we shocked the chest with  electric current powerful enough to rattle the whole body. Somehow she managed to comeback from such gates of death, though she had to go through a ride-through-hell doing so.

Her God would not let her live. And modern medicine would not allow her to die in peace. Miss K in the middle, was tearing apart in this stalemate.

For me this was an uncomfortable and an unfamiliar emotional territory. Having been brought up, educated and  thus far trained in a different cultural and socioeconomic milieu altogether, I have never had to go through such a gut wrenching upheaval of emotions, even as a care-provider along the sidelines of many a deathbed. In my culture, death was never really contested this intently between man and the forces, leaving behind horrifying remains of a bloody, grisly war. When it was sufficiently clear that death was imminent, it was accepted with a modicum of decorum as an eventuality that offered no escape.

Such shoulder-dropping at the altar of death sometimes appeared unfair- at times even cruel. Back then, many a times we were left wondering of the life that could possibly have been saved: the mother who meant the entire world to her children, the son who was the only reason the elderly parents lived their life for, the kid who would not see his sixth birthday, for the want  of a little more advanced medicine, a little more sophistication, a little more resources. Technology and more advanced medicine, at such times appeared to be the  all curing panacea for our health woes; that was until I came to the US and saw technology’s underbelly. Modern medicine could save lives, but sometimes preventing a natural death without  a concern for what remained of a life was repackaged and dished out as a life saved; or at least it was mistaken for a life saved.

In the back rooms, in the hallways in the unit, care providers often wondered if they would ever subject themselves to such agony as an appendage of the machine; with Miss K it was hard to gauge where man ended and the machine started. They of course had the luxury of not having to be in that unenviable position, the very edge of the precipice of death from where modern medicine could not exactly bring you back to life, but could still manage to prevent you from hurtling down to death right away- forcing you to die the agonising death of a slow poison instead of a swift and honourable transition in peace.

As if all this was not troubling enough for all of us who had seen Miss K suffer, we did not know if all this that we had been doing to her was what she really wanted for herself. What if she did not want this torment tied down with the machine? Time and often, such feelings of guilt tore us apart. We would ask her if she wanted the tube down her throat, attached to the machine huffing and humming, and the vigorous compressions when her heart stopped. Most often she would just return a vacant stare. Every once in a while though, the stares would be punctuated by tears that welled up in her eyes; still not be able to let a sob out. She would just give a very gingerly negotiated side-ward motion of the neck. Guilty emotions choked our hearts.

With all the ingenuity of modern medicine, when we thought we were finally beginning to checkmate death itself, we are now beginning to realise may be we were double-crossed.  Our intelligent science, the sophisticated tools, the wizardry of our care providers was clever by half after all: we are still losing the war and oftentimes we are being thoroughly disgraced en-route.

One day we gathered up her close relatives by the bedside: a sister and the sister’s two daughters. The sister seemed visibly distressed with all that her sister, younger to her by almost 10 years, had to go through. What’s all the pain for: she seemed to question. Every day she would religiously turn up at the hospital, look at her little sister and mutter “poor thing” part out of benevolence and part out of desperation. It was not hard to gauge the sister’s torn state of being. One half of her seemed to suggest may be it was time to let go; to let nature take its own course. The other was even more lost in the possibility that a miracle could possibly materialise out of the deep recesses of modern science to bring her back.

The sister however could not decide how to proceed with with Miss K’s further care; the onus of making that decision fell onto her two twenty something daughters, who were in fact the powers of attorney. They were even more bewildered they had to make the decision, so they put the question back to her aunt. “What do you want auntie? Do you want them to compress your heart when it stops beating?” Miss K held her gaze for a long time. She seemed to be lost in her own reverie, not caring the least about the commotion that was going on around. After a while, she nudged her head down. “See that” the two nieces said. “She said wants the compressions.” A look of relief crossed their eyes.

This has come to be modern medicine’s quicksand; enthralled by the armamentarium of tools and skills we have come to gather, modern medicine has been making promises of an infinite loop of health and life; and suddenly death has come to be a distant concept for us. No is not an answer; letting nature take it’s course when medicine has run out of options somehow appears grossly incompetent. Put such hollow promises in place, couple that with a system where patients and their surrogates are always expected to make their own decisions, with doctors too happy to play second fiddle, and we have a potent recipe for disaster.

After that event Miss K closed her eyes. She would not really wake up even if we called out her name. She moved in and out of consciousness. A few days later, the family made a decision to move her to another hospital. They said may be she would get better there. I for all my training and education, could not figure what we could possibly have done different, done better. Or, what the other hospital for that matter could do different.  Well, they did advertise on the radio that not only did they practice cutting edge medicine, but they created it. It was not hard for the harried sister and nieces to buy into that promise of a miracle. At least, they had the radio ads to fall upon; may be that was where the miracle they were looking for was.

Miss K was in the hospital for a total of 21 days. During that period, at least 4 dozen notes were written on her- replete with daily exam reports, assessments, plans and just plain question marks of uncertainty; an equal number of doctor’s rounds were made, round the clock down to the minute nursing care was provided,  close to 30 odd x-rays were done with more than half a dozen CTs and MRIs, medications worth just a few cents to those over a thousand dollars were administered. We scratched our heads, sweated hard, pondered and questioned, tried something one day, and tried the opposite the other. Nothing really worked. Nothing changed. Miss K went from being miserable to miserable.

And this is how things have been for Miss K for the last 2 years. In and out of one hospital to a nursing home to another hospital, intercepted just by the wail of one ambulance siren to the other.

How could things have gone so wrong for Miss K, and for our health care system? Why did Miss K have to suffer the way she did? How come our health care system has come to tolerate and even encourage such gross misappropriation of resources? Why did she go on getting aggressive, expensive care  when it was not really care; when doctors more or less knew they would not be able to make things any better for her, this way or the other in terms of the quality of life? Was it because the family “wanted all that could be done”? Was it because the doctors did not have the spine to talk to the family and firmly say, any further care would not be beneficial? Was it because someone was benefiting out of the whole sordid affair?

At the end of it all, the hospital ran a bill in excess of  $ 200,000. Later I learnt, the hospital had been reimbursed a quarter of the amount of the total bill.

One night at about 2 in the morning an ambulance came to whisk Miss K away to the other hospital. A fresh new patient; a fresh new doctor; yet another admission note.  A glimmer of miraculous hope for the family. What all this meant for Miss K, I don’t know. I had a feeling she sunk further down into her shell; bowing and nodding for every one else’s convenience, waiting in the balance for the transition to arrive.


The world needs the Global Fund

After the blistering pace of its heady start in the early 2000s, the Global Fund to Fight AIDS,  TB and Malaria (GFATM)  of late has been losing some steam. First, there was the issue with corruption in  Africa, where millions of dollars worth of GFATM funded malaria  drugs were embezzled in over half a dozen  African countries. And then there has been a crippling short fall in finances. Funding requirements to  just meet existing obligations for the year 2011- 2013 run a total of 13 billion dollars. The Fund has a little over  11 billion dollars in  its coffers.

The first issue sabotages credibility. Transparency has been a keystone of the Global Fund’s operation, without which none of the donors will put their money on the table. For an organisation whose sole purpose is to pool together financial resources for the sake of global health, that lack of credibility will be akin to a death blow in the keel.

A discredited Global Fund could likely undo the organisation, but way more importantly, it will undo the revolution that has been unleashed globally in AIDS, TB and malaria control through the use of  such funds.  And the revolution has been nothing short of spectacular. Before the Global Fund arrived AIDS treatment was beyond the fancy of much of the patients in the developing world. Today support from the Fund alone provides AIDS treatment   to over 3 million people and TB treatment to more than 8 million people. Hundreds of millions of insecticide treated bed-nets have been disbursed.

These  three killer infectious diseases together claim around four  million deaths all over the world each year.

Earlier on, due to the lack of a centrally coordinated funding mechanism, donors had their individual funds to disburse,  oftentimes overstepping each other’s priority areas, and in the meantime creating a colossal waste through the creation of a panoply of redundant monitoring mechanisms. Herein was the Global Fund’s genius; it not only did away with such multi-vessel trickle down fund disbursement, it also allowed individual countries to come up with their own priority areas to use the funds on.

The global fund is said to have saved almost as many as 7 million lives since its inception in 2002. As many as 150 countries the world over depend on global fund resources in order to battle these three leading killer infectious diseases.

A few months ago Gabriel Jaramillo, a banker, replaced a public health expert at the helm of the Global Fund after the African scandal rocked the fund. To his credit, Mr Jaramillo is trying to shore up the  fund’s financial discipline while maintaining its global-health do-good ethos.

The discipline may well take care of the credibility part, however there is no denying the squeeze of the difficult economic times. While the continuing generosity of a lot of the donors has been vital  to the Fund, some have been forced to withhold their pledges, or have not been able to scale up their commitments. The two billion dollar funding deficit will force thousands of patients in some far off corner in the world off their treatment regimens. As much as the global fund has been able to renew hope in millions of lives all over the world, such situation will prove to be equally catastrophic not only in the lives of the patients involved, but also to our moral authority to say that we have a collective will to fight off such scourges facing humanity. When the tide of global burden of infectious diseases has been showing signs of inflecting, letting go of our willpower to fight them will only make these diseases much bigger a global public health threat than what we started with.

The seven odd billion dollar price that we need to run the global fund on a year or year basis is indeed a lot of money. However if you consider the fact that 12 million people are benefiting with life saving AIDS and TB drugs from the use of that money globally, and that we could possibly achieve zero malaria deaths by 2015, it swings the balance a lot in the funds favor. When we have been annually spending billions of dollars  in meaningless sabre rattling at borders-crosses  all over the world, and billions more in amassing ammunition that can annihilate the world a dozen times over, saving lives at a few hundred dollars per person per year is a great deal of a return on investment by any standards. For that reason alone, the Fund can’t afford to lose its momentum halfway down the highway.

The case for health information exchanges

Picture a medical  district that bundles more than half a dozen hospitals in the matter of a few square miles, toss in a patient population that walks in and out of every single hospital and what results is a yet another utterly forgettable night at work for an already harried intern.

Patient visits are everywhere, health information is everywhere, and in an environment of competing interests were coordination between care providers is systematically stymied, putting together the jigsaw of the patient’s medical history and care for a midnight admission becomes a nightmare come alive. This in fact should have been the patient’s nightmare as well, but no body is telling him  how hospital information systems refusing to talk with each other is putting his care on the back burner.

With the advent of the electronic medical records (EMR),  sharing health information between disparate care providers should have been easy. Turns out it is not.

There are challenges. Some technological but mostly to do with policy and practice.

First there is the issue with adoption of EMR itself. Not every provider still can manage to see the value proposition in EMR. But even when that has been sorted out, the idea of  sharing health information in exchanges is still a hard ball to sell to providers. They think they have nothing to gain by sharing and supporting such exchanges.

Care providers fear losing revenue that is currently generated by what would then prove be redundant care, were such information freely available. Furthermore in the current scheme of things, care providers are often asked to support such information exchanges, when in fact they are the ones who are losing money out of expensive information infrastructure they have to pony up, and the revenue they have to give up. And then there is the issue of inertia: “things were so much better the old-fashioned way” kind of attitude to overcome.

If it does not make an outright  business sense for care providers, who does a health information exchange benefit?  

Free flowing, standardized, interoperable health information will co-ordinate patient care by an order of magnitude. Such a scenario won’t be a chip at the stone incremental innovation; it will be a path breaking way forward.  Aggregating such data bases at a central or federated repository will help scale and  analyse such data at a population level thereby helping form epidemiological trends and predict disease out breaks. De-identified data sets can be used in research studies that will benefit society in the longer run.

Individual patient care will improve simply by the fact that information is freely available and care can be coordinated over geographical barriers. Patients can’t be stopped from moving from one hospital to the other, we can at least have their health records  move with them.

One of the major challenges today to ensure efficient and effective, yet affordable health care is to move patient care out from the hospital to the community and to design health interventions at a population level than at just the individual level. Such practices will need population level data; health information exchanges will achieve just that. And a tremendous amount of value will be created right there.

There in lies the value proposition to such information exchanges. This is a societal good that needs benevolent policy environment to grow to fruition.

To be fair, the Health Information Technology for Economic and Clinical Health (HITECH) Act  made policy provisions to encourage such information exchanges. More than half a billion dollars worth of funds were ear marked for state-wide adaptation of such information exchanges. In fact some form or the other of health information exchanges have been tried out as far back as the ’80’s. However thorny issues remain. Most of them as mentioned ahead, are policy and practice issues.

The states and the federal government have a magic wand they can flaunt here: the Centers for Medicare and Medicaid (CMS) by virtue of being the largest payer in this country can tie up payment with participation in such health exchanges. To be fair, hospitals and care providers should not be burdened by the costs of supporting such exchanges. Since  such exchanges are a societal good, such costs which can easily run into the 10’s of million of dollars to set up and millions of dollars each year to run, should come out of the public domain where such benefits are actually accrued.

Then there is the challenge of standardising such health information, so that information provided by one care provider is trusted by the other.

And there is the tricky issue of patient privacy: how to use such information to the greatest benefit without compromising on patient privacy. Who gets to see and use what, who sets permissions and who maintains the final custody of  the information, these are valid but challenging policy questions.

And finally though great technological advances have been made, challenges still remain on how to create interoperable databases and  use such information in a meaningful way in the doctors offices. Experiences from Indiana, that runs one of the oldest health information exchanges in the country show that oftentimes the final mile to the doctor’s office is the hardest mile to cover for such information exchanges.

Such challenges aside there is a real case for health information exchanges. This is an idea whose time has rightfully arrived. With a right set of policy environment, this might as well prove to be the be the leapfrogging health innovation we have all being dying to see.

The runaway patient

My patient ran away from the hospital.

This ordinarily is almost common place for a hospital bordering the south side of Chicago. In the last two years at the hospital, I had first grown surprised, and then helpless and finally weary to such mysterious absconding. This time however, it struck a chord.

Long before Mr B ran away, I had an inkling the new diagnosis of HIV would be difficult for him to accept. I had thus decided to recruit the help of counselors to join me discuss the diagnosis with him. If that was a thoughtful decision, it wasn’t any useful nonetheless. My patient showed little emotion during the discussion of his new diagnosis; however a little while later he was nowhere to be found.

Patients usually bolt out of the hospital because the pull of the street is too strong for them to resist. They come to the hospital when their bodies can’t take it anymore, but as soon as their as they gain any bit of composure, they are out of  the door. I have however, thus far, not had a patient who had bolted out because he was apparently traumatised by his new diagnosis.

A few years ago when I was a doctor halfway across the world, patients met a similar diagnosis with uncharacteristic resignation. Young housewives, growing up in grinding poverty, social oppression and lack of education had never really had any say whatsoever about how their lives had shaped up thus far. So if their husbands came home one day and then gave them the virus, that was just another of the upteen unfair hands life had dealt at them; there wasn’t anything for them to say or react about that. While their predicament was  profoundly unfortunate, their reaction was absolutely muted.

To these women HIV meant perennial ill-health, and burdensome stigma and discrimination in what was already a much marginalised existence. Here in America such barriers were not easily visible: treatment options were available and stigma if any was banished to the underground. Examples abound of people who had been able to overcome the crippling effects of the infection and lead a healthy and productive life. Rights groups and patient advocates were available. More importantly, my patient here had made informed choices about his own life; he had the chance to be the master of his own destiny. So while I had expected him to be shaken by the diagnosis, his running out of the hospital took me by a little surprise.

A few hours later, we traced our patient, and he returned to the hospital. He was visibly sorry for having run out, but it was not hard to gauge that he had been overwrought. By his own description, he blanked out and did not know what to do, so he ran away in a nervous frenzy.

I could not help rationalise how upsetting this new found diagnosis must have been for Mr B, but then my mind did a throwback to those housewives half way across the world; for them even an upset emotion was a luxury they could not afford; the grind of an overly unfair life had blunted their emotional responses to such an extent, their bodies did not even know how to react to a horribly unpleasant event. These women had been robbed of their ability to emote.

Such reminder brought me peace of mind- Mr B might as well have tripped into a hole right now, but is was no where the bottomless hole life could summarily consign you to. So what if he ran away from the hospital, that still is much comforting than an unaffected silence and an emotional void for a response.