I'll be at the Global Health Council Conference

(From the conference program for the Global Health Council's annual conference, which takes place May 27-31 in Washington, DC More info at the Council's website, www.globalhealth.org.)

Brown-Bag Session: Finding Work in Global Health
Friday, May 30, 2008
12:45-1:45 pm
Capitol Room

Considering a global health career, a part-time internship, or simply a volunteer stint overseas? You won't want to miss this brown-bag workshop. Patricia Ohmans, MPH, co-author of the book Finding Work in Global Health, will offer an insider’s guide to entering the field. Her lively, interactive presentation will cover the 10 top myths about global health; seven ways to work in the field; a dozen questions to ask yourself BEFORE you go, and more. This session is designed especially for entry-level professionals, but NGO recruiters are cordially invited to participate.

In Praise of Plumbing

Tony’s mother Dolores Pink, who was born in 1925, used to say that the greatest invention she experienced in her lifetime was the installation of indoor plumbing in her family’s home in Shakopee, Minnesota.

After nearly nine months of our sabbatical in Bolivia, we know whereof she spoke. We’ve become major fans of toilet paper, a sink with running water, flush toilets, and hand soap, none of which are a given in Bolivian bathrooms, even those in otherwise hygenic settings, like a middle class restaurant, the US-style grocery store, or a landscaped gas station.

It appears that in Bolivia, nobody wants to think about shit, literally. Last week, I visited a squatter’s settlement in which a German foundation has spent millions of euros in the past five years building a lovely nursery school and day care center, a primary school, a high school, athletic fields, a medical clinic and a dental office. The school bathroom was, as usual, awash in spilled water and unflushed toilet paper. If it had been flushed, it would have gone...pretty much nowhere, as the settlement is built on granite-hard soil.

The community had some paved roads, pipes laid for the running water that was coming soon, and they were getting electricity that weekend. When I asked about sewerage pipes, the foundation’s operating manager, a lovely and intelligent young woman, looked amused. “Maybe in 2010,” she mused, half to herself. Where do individuals in this community of 5,000 souls relieve themselves? “Down there,” she said, waving vaguely at an alley we were passing. “Behind their houses. Up in the hills somewhere.”

It’s just as much of a problem downtown, where the few public baños charge users a boliviano for the privilege (and a couple squares of pink papel higenico.) I’ve seen little children pooping on newspaper and throwing it in a sidewalk dumpster, and older women squatting at the curb, skirts hitched up.

I’ve done the equivalent on long bus rides, when the driver stops at a stretch of roadside and everyone gets out and wanders off in what they hope will be an invisible direction. It’s a rare Bolivian bus whose bathroom is unlocked, and if you ask the driver’s assistant to unlock it he may do so, but only after warning you sternly to “solamente orinar!” Hard orders to follow, at times.

I brought a suitcase full of books down with me to Cochabamba, but the only book that I’ve read more than once is a slim manual called Sanitation and Cleanliness for a Healthy Environment, published by the Hesperian Foundation, the folks that produce Where There Is No Doctor. It’s got chapter headings like “Diarrhea and Dehydration,” ; “2-Pit Compost Toilet” and “Pour-flush Pit Toilet”. Increasingly, that book looks like a how-to for healthier life in Bolivia. I keep it in our bathroom.

My doctor, my torturer

Would your doctor knowingly participate in torture? Jokes about colonoscopies aside, of course not, right? Well...maybe not, at least not if said doctor is present at an interrogation.

Last year, researchers at Harvard asked nearly 2,000 medical students how much they know about medical ethics in military situations, specifically, on the ethical obligations of doctors and nurses when prisoners of war are being interrogated.

The students were asked if a physician would be ethically obligated to refuse an order to participate in an interrogation by 1) threatening to inject the prisoner with a psychoactive drug, 2) injecting the prisoner with a harmless solution which the prisoner believes to be lethal, or 3) actually injecting the prisoner with a lethal drug.

Although all three scenarios would be prohibited under the Geneva Conventions, one in three of the students thought that the only circumstance in which they would be ethically required to disobey was when they might cause the death of the prisoner. In any case, more than 100 of the respondents said they would, if ordered, kill the prisoner by injection.

The Geneva Conventions--universally accepted since their promulgation in the wake of Nazi doctors involvement in the Holocaust--ban threatening, coercing, humiliating, degrading, or injuring prisoners of war for any reason, not to mention murdering them. But according to the Bush administration these widely accepted principles don't apply to prisoners we're holding at Iraq-war related prisons such as Abu Ghraib or Guantanamo.

If you want to read the whole medical students study, it was published in the International Journal of Health Services, Volume 37, Number 4, and is available online. For more on the subject of medical complicity in torture, try Minnesota doctor Steve Miles' book, Oath Betrayed: Torture, Medical Complicity and the War on Terror. available on Amazon.

The Picture on the Pack

I just got back from a week's trip to northern Chile; mostly a vacation, but also a chance to see what Chileans are doing about the country's smoking problem. Suffice to say, it's more than we do in the US.

The picture above shows what every smoker in Chile has to look at when he or she pulls out some smokes: a gruesome close-up of a set of snaggled, stained teeth set in some funky gums, all of them ruined by tobacco. Apparently, a two-year old Chilean law mandates that half the space on a pack must carry anti-smoking messages specified by the government. Packs used to feature a grim, explicit photo of a Chilean smoker who lost his larynx to cancer; he has since died.

The consistent warning message on the pack, a masterpiece of blunt health education, reads: “ The smoke of each cigarette you smoke contains, along with other toxic products: tar, which causes cancer; nicotine, which makes you addicted; carbon monoxide, a toxic gas like that from tailpipes; and arsenic, a chemical used as rat poison.”

And yet, Chile has the highest tobacco consumption in all of South America. 40% of the general population smokes, as do 45% of women of childbearing age; thanks to vigorous efforts by the tobacco industry’s advertisers, this is the highest smoking rate among women in the world.

It’s not something the government health folks are ignoring, obviously; the health education campaign is accompanied by laws firmly restricting cigarette advertizing in media, creating no-smoking zones in restaurants and bars; and banning ads and sales within a certain distance of schools. It's good public health--social marketing and social engineering. But given the number of young kids—maybe 12, 13 years old— we saw in Arica wielding that ugly-looking pack and puffing away, the messages may have to cover the whole box before they truly get people’s attention.

Poor kids' lives are only half worth saving

Say you are an emergency room nurse. Two 6 year olds come to your ER. One's been hit by a car, one thrown from a horse, both have serious head injuries. The prognosis is the same for both—except for one factor that suggests that the first kid is TWICE as likely to end up in the morgue. What is it?

One of my jobs is to comb through recent news about medical research on health status disparities and post relevant stuff on a website for the Multilingual Health Resource Exchange (www.health-exchange.net)

This is work that can become somewhat tedious, believe it or not. There are only so many times that one can feel a sense of outrage about differences in the level of kidney cancer screening between whites and asians, or about the lingering mistrust blacks feel for the health care system given our history of medical experimentation on minority patients (stop the presses!)

But the other day I read an article I found truly shocking, one that laid bare the problem with our unfair health care system. Here's what it said:

Children who lack health insurance are twice as likely to die from their injuries after being hospitalized as children who are insured. In other words, the parents have paid up their insurance premiums (along with those horseback-riding lessons, perhaps) are twice as likely to walk out of the hospital with a live kid.

This is according to a report by Families USA, in which researchers examined the records of 25,000 uninsured children with general injuries and 6,500 with traumatic brain injuries and compared them with the records of insured children. Read it yourself, for the full details.

You'll find a lot to be shocked by, but I doubt if there's much that's more shocking than the realization that the bottom line really is, for poor kids, the bottom line.

Best Health Care in the World?

My husband, daughter and I are spending this school year in Cochabamba, Bolivia. Many things about our lives here are vastly different, but one of the biggest differences is in the amount we spend on health insurance and health care.

As self-employed people, we are also necessarily self-insured. We pay nearly $10,000 a year for coverage in case of catastrophe, but essentially (since we are all relatively healthy) we are on a fee-for-service plan--we never reach our $5,000 deductible. So every year we live and work in the US, we pay more than $10,000, just in case.

Are we getting our money’s worth? Not according to the usual measures of public health, says an editorial in today's New York Times. "The United States ranks 45th in life expectancy, behind Bosnia and Jordan; near last, compared with other developed countries, in infant mortality; and in last place, according to the Commonwealth Fund, a health-care research group, among major industrialized countries in health-care quality, access and efficiency."

Fortunately, we haven't had to experience much of the health care system in Bolivia. I'm not suggesting I'd necessarily like to be treated here for a complex problem. But when Anna had a severe case of strep throat, a clinic doctor cured it with a shot of penicillin. Total cost:less than $10. My three visits to a dentist for teeth cleaning totalled $40. And we're not paying $10,000 this year, just in case.

March 24th is World TB Day

Tuberculosis kills 2 million people a year and sickens millions more. It's a terrible plague in South America, Asia and Africa. Closer to home (although US incidence of the disease declined precipitously after the 50s) there's actually been a 9% increase in each of the past two years, in the number of cases in Minnesota. And if you worry about super-bugs, try reading about "MDR TB"—tuberculosis that is resistant to many or all of the known treatments. Good reason to support the CDC and state health department in their efforts to de-stigmatize TB, especially among vulnerable immigrants and refugees. Check out the Minnesota Department of Health's World TB day webpage for more info.