Addition to the Reading List?

September 30, 2006 at 10:43 am (Michael's Posts)

I met an amazing doctor at the Society of General Internal Medicine conference I went to yesterday (more to come on that, to be sure) and here’s a review from of a book by a guy called Anthony Suchman. Sound good? Should we all read it?

From The Annals of Internal Medicine, January 5, 1999

Audience: Health care providers, including physicians, nurses, and social workers; health care administrators; and health care educators.

Purpose: To improve the quality of partnership processes within the health care system.

Content: This book is divided into five sections. The first section contains conceptual material that is generic to partnerships at all levels. Each of the four subsequent sections deals with partnerships at various levels in the health care system: clinician-patient partnerships, partnerships in health care teams, community health care system partnerships, and educational partnerships. The chapters contain a mix of theoretical discussions and practical examples. The authors come from diverse professional disciplines, geographic centers, and personal backgrounds.

Highlights: Four aspects of the book stand out. First, although many practitioners have expertise in promoting partnerships in a specific area, few have knowledge in all four areas discussed. Second, through the discussions partnerships at different levels, one recognizes the importance of the editors’ conceptual framework. Third, the book discusses important topics that are often neglected in similar books. For example, the chapters on spirituality, friends as patients and patients as friends, and guidelines for primary care physician-consultant relationships helped me better understand common but often ignored topics.

Finally, the book includes several innovative programs that a clinician, administrator, or educator could modify for his or her own purpose. The chapters on family systems case consultation and development of an educational consultative service for physicians about whom patients have repeatedly lodged complaints are especially useful.

Limitations: The book has some flaws endemic to an edited volume. Much of the background material on partnerships, their advantages, and the attitude needed to promote them is repetitive. Moreover, because the book is written for a somewhat general audience, some chapters are too basic for readers who are familiar with the field. The chapters on real-world experiences would benefit from more details on the obstacles that innovators faced and overcame. Related reading: Although numerous other books cover specific topics, I know of no other book that surveys partnerships so broadly.

Reviewed by: Robert M. Arnold, MD


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The WHO Definition of Health

September 30, 2006 at 10:25 am (Sarah's Posts)

Note:  This is something that I wrote recently for class.  We were discussing the WHO definition of health, which is: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”  The more that I thought about it, the more completely impractical that definition seemed.  I have a heck of a lot of itchy mosquito bites right now that are a physical nuisance—am I not healthy because of it?  What follows is my own definition and a bit of an explanation.  See the link at the end for some more thoughts from someone who knows a lot more than I do.  Let me know what you think.  There is also a big debate on whether “spiritual” should be added as a part of the definition of health.  But, that is a whole different topic…



Health is a dynamic condition that is identifiable by a physical and mental state that allows a person to pursue his or her goals, given a set of accepted circumstances.


            To make a working definition of health, it is important not to be so broad and lofty that all practical meaning is buried.  Health is a foundation that is necessary for well-being across a variety of fields—personal, economic, social, and spiritual.  Good health plays a role in well-being across these areas and, conversely, well-being in these can contribute or detract from health.  Yet in order to make a workable definition of health, it is important to focus on a description that is applicable to the life of every person.

            Living systems are dynamic, and human health is no exception.  Any attempt to place a set of measured statistics on what constitutes health is bound to be inaccurate.  It seems that perhaps the best measure of health can only come from an individual and his or her expectations.  Given their life circumstances, is their physical and mental state one that allows them to pursue their goals, whatever they may be?  Even the most idealized notion of health cannot guarantee that an individual will obtain his or her goals, but health should not be the limiting factor. 

            This definition does not eliminate the difficulty of objectively measuring health across different populations.  It suggests that measures of health should focus around the expectations and aspirations of the individual, which are nearly impossible to quantitatively assess.  Nevertheless, interviewing people about their concept of health shows that individuals do have set notions of what it would take to consider themselves healthy.  Individuals tend to define health in terms of what they can and cannot accomplish, which is a tribute to the fact that health is different for each individual.  While this makes health a difficult attribute to measure, any definition of health has to take into account the personal nature of health.

            We cannot pretend that this world provides any sort of equality in terms of opportunity.  Across the globe, people have drastically different access to healthcare, economic conditions, and environments.  A more limited definition of health does not deny the fact that these inequalities are present and need attention.  Instead, perhaps adopting a practical definition of health can serve as a reminder that improving the health of people globally is an attainable goal.

-Sarah Kimball

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Chi-town, part 3: The Public Hospital

September 29, 2006 at 1:09 am (Michael's Posts)

This week, my thoughts are on some time that I spent at Cook County (Stroger) Hospital shadowing a health counselor who specializes in substance abuse.

His work is part of a program called SBIRT (Screening, Brief Intervention, Referral, and Treatment) whose main goal is to educate substance users (from tobacco to alcohol to street drugs) and get them connected to appropriate treatment programs. SBIRT screens every patient that comes into the hospital. They have counselors in the ER, Cardiac wards, on every General Medicine ward, and soon (we hope) in the ambulatory clinic. My program will, ideally, funnel some of the slack in the counselors’ schedules over to the ambulatory clinic where I will be doing the S (Screening) and they will be doing the BIR (Brief Interventions, Referrals), and hopefully, a few people will get hooked up with T (Treatment). How my screening and possibly their interventions will fit into the flow of the ambulatory clinic remains to be seen, but that’s the idea. More posts to follow on my particular program as it evolves.

When I was following this particular counselor around,  there was such a flurry of activity around him all the time, but he just steadily went around on his business, screening each new patient and talking to them a little bit about their substance use patterns and trying to get higher level treatment to the ones who needed it.  It was an elegant dance, but also very relaxed and sweet.  Very compassionate guy, much slower paced than the other care providers, and spent a kind of time with the patients listening that they seemed absolutely starved for.  Those kind of fast-paced, full hospital situations are not ideal for good bedside manner, and this counselor seemed to make up for some of the lack of it in other care providers.  Lovely to watch how relaxed and open they got with him around with his ears just wide open.  A good lesson in listening and being Present.

But back to the hospital. This place is a piece of work. One of the largest public hospitals in the country, it has a wonderful policy to treat everyone who comes through their doors. As you can imagine, they’re in pretty serious debt. But they’re also wonderful. The cases they see are often pretty wild because the people who can’t afford healthcare often get SUPER sick before they check in. For instance, a young man who couldn’t walk from the pain in his leg waited weeks before he decided to check in. By then, his abcess was as big as the palms of both of my hands. I have pretty decent-sized hands. The place is huge and FULL of patients. It’s also full of wonderful people taking care of those patients. The nurses seem tough and compassionate which is a mix that I think is lovely.

I kind of wish that I was spending a little more time at the hospital because it’s so damn cool, but I suppose that in terms of what I see myself doing with my life, the clinic is closer to that vision. It’s a great place to be getting some experience, but also a very interesting look at how unweildy public hospitals can be. I may learn ways to be weildy in them though, as this SBIRT program seems pretty flexible and strong.

In other words, I am creeping closer to the time when I’ll actually be working on this project and I am starting to get a sense of the work environment (fantastic) and the patient base (extremely diverse and mostly very poor) and my colleagues (awesome). Here’s to learning how to do this stuff right!

On a more academic note, I’m reading some Foucault on Western medicine. It’s called The Birth of the Clinic and is fascinating if you can get down with the philosophe. He talks about how Western medicine is based on an intense empirical way of seeing and what that seeing is made up of. It’s pretty deep stuff, and more than a little esoteric, but it’s also very much worth the slog.

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September 26, 2006 at 4:59 pm (Sam's Posts)

The majority of the information gathering in my head the past couple weeks has been directly related to my research project. I am reading a cool book entitled Blood: An Epic History of Medicine and Commerce, but for now I am going to talk about what I am doing in the lab. I know that the theory behind the project is not front end global health, but as Sarah thankfully reminds me, there is lab research behind every product that goes out into the world to improve lives, and that makes me feel useful.

I have repeated the gist of my work multiple times to friends and family since I’ve started, and I’m getting better and better at it. I think my explanation can now be called ‘functional’, although there is still much room for improvement. The big picture is this: DNA tells the cell which proteins to build. The proteins do the cell’s (and thus the body’s) work. If your body’s not working correctly, there probably is something wrong with the DNA in addition to the proteins. So scientists think many diseases announce themselves through changes in DNA sequences. If we can fully identify the DNA content in a given sample, then we can compare DNA in diseased cells and normal cells and figure out which DNA sequences are responsible for the disease.

So the challenge lies in knowing the exact DNA content of a sample. We figure out what’s in a sample by mixing it with a probe that is complementary to only one specific DNA sequence. Only DNA that has a code complementary to the probe will bind to that probe. If we label the sample DNA beforehand, either with magnetic beads, or radioactive particles, or with molecules that can fluoresce, then we can measure magnetic field, radioactivity, or light emission, respectively, in order to know how much of a certain DNA sequence is in the sample.

I don’t do any of that.

What I do is figure out how we can raise the detection limit of the DNA analysis. The more fluorescent molecules you can bind to a piece of DNA, the brighter the light will be and the easier it will be to detect. This is where nanotubes come in; we think we can load a whole boatload of light-emitting molecules onto a nanotube and use it as a label. Then even if only a couple copies of a certain DNA sequence are present, we might still be able to detect it. And that gets us closer to knowing exactly what’s in the DNA and thus what’s causing the disease.

So it’s pretty far removed from widescale disease prevention. But it’s something. I’m thinking about the eventual arrival of a cheap and straightforward mechanism for rapid, full analysis of ones DNA. You know, one that can be done every year for every patient, just take a sample, toss it into a DNA purifier, throw it onto a chip with thousands of probes, and then slide it into a luminometer to measure the light and figure out what’s there and how much of it there is. I think some people are calling it a “lab-on-a-chip”. That would be pretty amazing.

I wonder what infectious disease research is like. Ideally I’d feel closer to the need, and to the actual advent of a technology. i guess I’ll take what I got right now though. It’s a good start.

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Hi from DC!

September 23, 2006 at 5:33 pm (Shannon's Posts)

Hi! I’m Shannon. I just graduated from Brown and have settled in Washington, DC, where I’m applying to medical school and playing waitress for docs as an ObGyn medical assistant. As far as international health goes, I studied abroad in Mexico and am super interested in public health efforts in Latin America and women’s health worldwide in general. Midwives, HPV vaccines, sexual health education and empowerment, that sortof thing. Sexual health is really my thing, actually, but I’m still figuring out how that field exists in the world. I’m looking forward to posting and learning from you all!

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AIDS in India: My Favorite Topic

September 22, 2006 at 9:15 pm (Michael's Posts)

The case of AIDS in India is one I have studied and worked on in Delhi and is one that I have a few insights on. The thing that needs to happen is to change the local attitudes towards AIDS. The attitude of the public health people who propagate the opinion that AIDS ought not to be treated (the opinion that Sarah Kimball was picking up on in her look at the situation) is firmly based in the deep fear of facing the underbelly of Indian society in the form of the most formidable infectious disease. Indians are very reluctant to admit that their society harbors such ills as prostitution and intravenous drug use and for a long time, there was a campaign of denial by public health officials stating that AIDS did not even exist in the country. With this kind of attitude, it is very difficult to envision any enthusiasm for a program that would work with such a stigmatized disease. Indeed, many Indian doctors refuse to even touch AIDS patients. The question that Sarah raised in her post today (HIV/AIDS: The Case Not To Treat) about resources possibly not being allocated to such a cause is based in an understanding of the situation as one of great resource scarcity. Which, in India’s public health world, is definitely the case. Truly, it is the case in most public healthcare situations. Public health appears to be a great exercise in resource triage.

But we must also critically examine the social attitudes that underpin the assessment of how many resources can be allocated to a certain cause. If one looks at the AIDS crisis in India (and it is a crisis) through the lens that it very well could reach extremely threatening proportions in the next decade (and may already have reached those proportions but it is hard to tell because of poor epidemiological coverage in the impoverished North), resources can be MADE available.

However, if the situation is assessed through the lens that AIDS ought not to exist in India at all and that if we simply hope hard enough, it will take care of itself, those resources inevitably look better somewhere else. This, unfortunately, is the prevalent attitude in many of the upper echelons of the Indian healthcare system and is definitely the one that prevails in hospital management. A brief story: I went to talk to an Indian hospital manager about their AIDS program and the conversation was quickly steered away by my host to a much more benign topic. I was informed on the way out that AIDS is not discussed. There was a quarantine program some time ago and there was something about individual doctors having differing policies, but that was all I was to know. From my reading, doctors often turn away AIDS patients or charge them exorbitant sums for taking up their stigmatized cases. In order for those cases to be addressed with the resources they deserve, the attitudes of Indian healthcare workers and policymakers must change.

My point in this post is that these public health resource-allocation situations are not simply a matter of resources but also attitudes. In the case of AIDS in India, it is my studied opinion that the attitudes must change before much action can be taken. Resources will not be allocated in the ratio that they are needed until this happens. The most important thing for AIDS in India now is the work of changing attitudes towards AIDS.

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HIV/AIDS: The case not to treat

September 21, 2006 at 11:20 am (Sarah's Posts)

Let’s make some assumptions about the global community. Let’s say that you’re a developing country with limited resources. You’re working hard to push for the development of your country. So there are many sectors that are fighting for a piece of your national budget.

Let’s also say that you have an HIV epidemic. You don’t have tremendous disease surveillance systems, but you know that HIV prevalence rates in antenatal clinics are about 1%. Consequently, you know that your epidemic has crossed over from those people who engage in high risk behaviors to the general population. The question to you, the policy maker, is what do you do with your limited budget to deal with this epidemic?

There are folks around here who make the argument that, from a public policy perspective, it is better not to treat India’s 4.5 million infected individuals. They argue that adequate treatment is simply not possible in the current Indian context. There are the immediate issues like availability of ARVs and treatment, infrastructure to deliver care, trained personnel to offer counseling and treatment, poor diagnostic services, stigma, and the very real possibility of introducing drug resistant strains of the virus due to poor compliance. Perhaps the most disheartening argument is that the Indian health care system simply is not equipped to deal with long term chronic infections. For most purposes, HIV/AIDS in a chronic disease in the developed world. We have the treatment and care to keep people living with HIV/AIDS healthy for quite a long time after infection at a very high standard of living—a wonderful achievement. But the Indian health care system is built to handle infectious diseases and acute short term care. The financial burden of keeping these 4.5 million people alive, such that they are accessing health care for a very expensive disease for years longer, would drain the small pockets of the health care budget. Perhaps that money needs to be poured, instead, into developing the health care system to deal with long term chronic care. With limited resources, it could be that the money needs to be invested in developing the ability to deliver care at the cost of the individuals who need treatment.

This is deeply neglecting the humanitarian side of HIV care. Just thinking about it makes my stomach turn. Still, it has been striking me lately that the subject of public health policy sometimes necessitates thinking about such cruel balances. I would love to pretend that we live in a world where resources are not a limiting factor. But when I look at the scenes around me every day, I am forced to admit that this is idealistic and that the situation on the ground is stark. There is a horrible synergy between poverty and disease—how do we begin to break that cycle?


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September 19, 2006 at 6:39 pm (Maintenance)

Michael and I are working on optimizing the blog, but for now, comments go largely unnoticed unless you are looking for them. Be sure to click on posts even if they are not new, because someone might have replied with something interesting. Case in point: I just replied to Michael’s post about Paul Farmer and his alleged arrogance. Check for me, y’all.


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Teach me, o masterful ones

September 19, 2006 at 5:57 pm (A Mission Statement (or two), Sam's Posts)

I don’t know why I decided to co-found a blog about global health when I didn’t know the first thing about it. I know some science; does that help? Thank you, Ben Feigenberg, for suggesting I come along to that fateful gathering that co-founder Soule hosted in May of 2006.

I am a Brown University graduate with a degree in biomedical engineering. I like the tissue engineering research I did last year. I like the nanotechnology research I am doing this year. But I’m not convinced that this is how I really want to improve the world. I think there might be more pressing health issues than the ones I am exploring in the laboratory. Maybe I should join the Peace Corps; maybe I should go to medical school; these are things I think about a lot. To help me figure out if these things are the answers, or if there are other better answers, I am going to talk. Read, and talk.

What I’m realizing as I do this reading, and this talking, is that there are so many areas of health out there that beg for contribution – each time I read about another one, I think, maybe this is my cause. And maybe I’m a little overexcited; maybe I haven’t found my cause yet; but if I haven’t, and if you haven’t, then maybe we can all help each other find our causes.

Right. So maybe we should talk. About health. In the world. I think it would be good for me. And probably you.


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Dust in China (From Monica Young)

September 18, 2006 at 2:01 pm (Links, Monica's Posts)

Monica sent me this link

with this note:

one for the blog, on global environmental health…wait till you get to the part about chinese farmers using antique anti-aircraft missles loaded with chemicials into passing clouds to make it rain…WILD

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