By Nadine Harris, MD
Vanderbilt University: Department of Emergency Medicine
Georgetown, Guyana

It is good to be back in Guyana.  It has been a week since my arrival and there is a feeling of returning home.  Although I left this country when I was very young, the culture, the food, the sayings, even the hot humid climate and cooling ocean breeze are all so familiar and welcomed. 

I have been working in A&E at Georgetown Public Hospital, the country’s tertiary care center, for the last 5 days.  I am amazed at the broad spectrum of pathology that we see in any given day - some of these have included cerebral malaria, snake bites, herbicide poisoning, tetanus, advanced HIV, acute myocardial infarction, infected diabetic foot ulcers, and strokes.  What is most impressive to me is how many complications I have seen from poorly controlled chronic medical conditions, many of the same disease processes that we deal with in the US.  As an internal medicine resident, I think about my own panel of patients back home and how aggressively we are taught to manage diseases such as hypertension, diabetes, and coronary disease.  Unfortunately, this is not possible in Guyana in large part due to lack of a trained physicians to take care of these people and poor medical records (surprisingly, many of the first line drugs that we use to manage chronic illness are available here).  Guyana, like so many developing countries, continues to struggle with “brain drain” as more and more trained professionals migrate in search of a more economically secure way of life.  In the medical profession, those who are left behind do the best they can, but are often overworked and undertrained. 

Working in a developing country with so limited resources certainly requires that I adjust the way I think about and approach a disease process; this is easier said than done.  The emergency medicine residents do the best that they can to be aggressive in the resuscitation of very sick patients - unfortunately, often with so few ICU beds, ventilators, equipment for monitoring, it is difficult to sustain a high level of care for the critically ill and many do not survive.

There is just so much that we take for granted in the U.S.  I met a 17 year old girl who was brought in to A&E by her parents with 6 months of a progressive motor weakness and spasms that left her wheelchair bound and in significant pain.  She had been in and out of the hospital, with essentially negative work up including lumbar puncture, plain films and CT head.  She had seen a private neurologist and needed a MRI.  Due to the cost she has not yet gotten the test and even with her consultant advocating her case to the ministry of health, the outcome is still pending.  Getting such a simple test that is so easily accessible to us in the U.S. seems an almost insurmountable hurdle to overcome in the work up of her disease.

It is humbling experience to be here and is a great reminder of what a privilege it is to be able to practice medicine and to serve those who need the most help.  I am constantly being reminded to how much I don’t know and how much I can learn from my patients. 

The nation's highest court is about to judge the president's signature legislative achievement — and it's not just politicians who are invested in the outcome

The Week
MARCH 13, 2012, AT 6:45 AM
by Bill Frist, MD

Is the new health care law constitutional? You might think it doesn't matter — or at least, that it doesn't matter to you. But the fact is, the Supreme Court's decision on President Obama's Affordable Care Act (ACA) will almost certainly affect you directly.

How, exactly? For one thing, the court's decision could play a key role in determining our next president and possibly your next congressman. If you are poor, the ruling may decide whether or not you have coverage. If you are not poor, it will impact how much you pay for health care. If you own a small business, it might determine if you must purchase health insurance for your employees. And if you work for a large business, it may determine whether you still receive your insurance from your employer. If you're a doctor, it will likely affect your reimbursement. If you're a patient, it will determine your benefits.

On March 26, 27, and 28, the Supreme Court will hear extensive oral arguments on the constitutionality of the ACA. This is the culmination of 26 states filing suits in federal district courts and opinions from seven federal appellate courts. A final written opinion likely will be delivered in June, 18 months before the individual mandate kicks in and just five months before the presidential election.  

If the individual mandate is ultimately deemed constitutional, then for the first time in our history, you will have to purchase a product to live in America.

The ACA is a highly charged law that, according to the latest RealClearPolitics average, is viewed unfavorably by half of Americans. The law essentially does two massive, controversial things: (1) Mandates that individuals purchase health insurance coverage, and (2) expands Medicaid by 16 million enrollees. This expansion means almost one in four Americans will be on Medicaid, the government program originally intended for our poorest citizens. If you don't purchase insurance, you will pay a fine of $695 per adult and $347 per child.

Together, these provisions will reduce the uninsured by 32 million, but will still leave an estimated 23 million individuals uninsured in 2020.

The focus of the Supreme Court opinion will be on the constitutionality of these two issues, though two additional items will also be considered. One is whether the entire law falls if a part of it, such as the mandate, is ruled unconstitutional, and the other is whether the court has jurisdiction to rule at all now, since the law has yet to go fully into effect.

There is already plenty of discussion on the legal merits of the case, particularly as it regards the taxing power and the Commerce Clause. But what are the very real implications of the upcoming ruling? Here is what to look for:

1. If the court upholds the individual mandate, it will take effect 18 months later — unless Congress acts to repeal or postpone it (which won't happen as long as Obama is in the White House). If the individual mandate is ultimately deemed constitutional, then for the first time in our history, you will have to purchase a product to live in America.

2. If the individual mandate is ruled unconstitutional, the court will then decide whether to let the rest of the law stand, including the expansion of Medicaid and the largely popular individual insurance reforms. If the rest is left intact, the Congressional Budget Office projects that 16 million of the 32 million Americans expected to gain insurance under the law would be ineligible for the new coverage and that non-group, individual premiums might increase 15 to 20 percent. It would then be up to each state to decide whether or not to adopt the individual mandate.

3. If the court decides that the Medicaid expansion is constitutional, it will take effect in 2014 — unless Congress acts to postpone, repeal, or not fund it. But if the expansion is left intact, with almost a quarter of all Americans covered by Medicaid, the program would grow to include a portion of the middle class.

4. If Medicaid expansion is overruled, coverage will remain at current, varying state levels, and an estimated 16 million low-income individuals will not be able to take advantage of the new Medicaid coverage that would have begun in 2014.

5. Politically, if the new law is judged constitutional, Democrats will celebrate the judicial affirmation of the spirit and substance of the historic reform, illustrating President Obama's leadership. Republicans would fan the existing flames of unpopularity among the majority of Americans, citing federal government overreach, rallying around an election call for repeal as they did in 2010. If any part is unconstitutional, the bases of both parties will be emboldened to make health reform the defining issue, after the economy, in the elections in November.

This one is worth following. It will be a game-changer. And not just for the politicians and pundits in Washington. It's a game-changer for you, too.

Dr. William H. Frist is a nationally acclaimed heart transplant surgeon, former U.S. Senate Majority Leader, the chairman of Hope Through Healing Hands and Tennessee SCORE, professor of surgery, and author of six books. Learn more about his work at BillFrist.com.

by Ifeoma Ozodiegwu
East Tennessee State University: College of Public Health
Brazzaville, Republic of the Congo

Over the past two weeks, I have continued to work on the research paper on the status of the Framework Convention on Tobacco Control (FCTC) supply strategies in the African Region as reported by the Parties to the Convention. My plans to have the first event of the employee community service program in March have been stalled. We also had an unfortunate incident in Brazzaville on the 5th of March. A fire started at a military arms depot and set off a series of explosions killing more than 150 people and leaving thousands displaced. This sad event was felt at the office as many workers lost their homes. As a result, things were a bit slow at the office this week.   The event has been postponed to April to allow time for things to settle back down.

However, I have been able to make contact with two Units- Human Resource for Health; and Planning, budgeting, monitoring and evaluation.  The Human Resource for Health Unit is engaged in ensuring an available, competent, responsive and productive health workforce in the African region to ensure improved health outcomes. The latter unit enables the effective and the efficient implementation of the WHO managerial framework through the development of regional policies, systems and tools.

The mission of these two units was explained to me and I was given materials to read in order to have an understanding of their work. I am hoping to do a rotation in those units soon.  

The Week

Americans hear a lot about decline. Declines in manufacturing, fading productivity, plummeting home values, spiraling deficits, and sadly, dwindling faith in the American dream.

Let me tell you where I see the worst decline — but also our nation's best hope.

One in five kids in America lives in poverty. That's 20 percent of America's future left behind. Left to drop out of high school, suffer through shorter lives, commit crimes, have a child in their teens — and then perpetuate this cycle with their own children.

It doesn't have to be like this. Imagine an America with 20 percent fewer high school dropouts, 20 percent fewer teen pregnancies, and a 20 percent reduction in chronic health problems like diabetes and hypertension. Picture an America with a workforce that is 20 percent more productive and packed with 20 percent more qualified job applicants. Dream of an America with 20 percent more middle-class citizens. We would be a country poised to soar.

So how do we get there?

The fastest route out of poverty lies with education. With better education, kids live longer, earn more, wait longer to have a child, and are less likely to commit a crime. More importantly, these benefits pass on to their children, snapping the cruel cycle of poverty.

Poverty, especially during formative early years, can be an enormous hurdle for a child's development. At U.S. schools where less than 10 percent of the student body is impoverished, reading scores rank first in the world. Yet these same scores for U.S. schools where 75 percent or more of the student body is impoverished rank 45th.

In a country with a failing K-12 school system, is it really possible to improve education for impoverished children? Yes, and here are three ways: Providing a boost for kids, lending a hand to parents, and pulling together crumbling neighborhoods.

First, we must start young, much younger than you might think. Most poor children are already behind on their first day of school. At age 4, poor children are 18 months behind developmentally, and without access to early education, kids are 25 percent more likely to drop out of high school.

Communities must target vigorous pre-K education and daycare programs for the one in five kids whose parents simply can't afford them. Soft skills such as sharing, negotiation, reason, and concentration are instilled between finger-painting and building with blocks. The critical ingredient of high expectations is introduced. These are not luxury goods. They are essential in making communities more prosperous. When states think about job training, they should begin with pre-K education.

Second, a renewed focus on parents can be the lever to pry kids from a life of poverty. For example, Nashville's Martha O'Bryan Center provides the education and resources needed for parents to raise healthy families. Parents learn positive parenting skills, tools for making their children better learners, and smart exercise and nutrition strategies to keep kids healthy. These lessons, as simple as immunization and reading to kids at night, can also delve into more substantive issues like child maturation and brain development.

Parents learn that their role is not just to put food on the table, but to act as their child's first teacher, role model, and advocate.

In addition, an educated parent is more likely to elevate a child from poverty. A parent who earns a GED provides for his or her family better, giving kids that extra boost that can make all the difference. Learning soft skills and simple trades, such as basic culinary training, can help a parent get that first job, propelling the family to a brighter future.

Third, communities play a role. Last year, Nashville began an innovative strategy providing "cradle-to-career" services to 6,000 children in one of the city's most challenging neighborhoods. The Nashville Promise Neighborhood, modeled after the successful Harlem Children's Zone, is a public-private partnership uniting government agencies, nonprofits, schools, churches, and neighbors to provide continuous, coordinated health and education support.

Instead of uncoordinated institutions attacking different problems in piecemeal fashion, the most pressing needs are attacked with proven solutions. A dependable support network is built for all residents, including early education, expanded access to learning technologies, and family support including day care. Make no mistake, this is an ambitious program and requires total buy-in, but by pulling together, entire communities can pull themselves up.

To get America back on track, we must help those who have fallen behind. Only with our nation's full strength and commitment can we tackle the trends that drag us down.

How do you think America can fix its child poverty problem? Tell us on Twitter using the hashtag #ChildPoverty.

by Ifeoma Ozodiegwu
East Tennessee State University: College of Public Health
Brazzaville, Republic of the Congo

Brazzaville!!!!I can’t believe I am finally here! After weeks and months of applications and planning and finally a twenty-two hour journey from Johnson City in Tennessee, I have arrived and I am ready to do some public health. Driving into town from the airport, the driver with the World Health Organization, the Organization with whom I would be working with during my three month stay, showed some of the remarkable places in town.  He pointed out the President’s residence, the ministry of defense and biggest market in the area known as Marche Makelekele. “Marche” means market in French which is the widely used language in Congo Brazzaville. I completed a three month intensive course in French about four years ago and as a result I am able to understand the language. However, I have difficulty speaking because I have been out of practice for those four years. Right across from Brazzaville was Kinshasa. The two capital cities are separated by a huge river known as Djoue. Congo Brazzaville is a small country located in Central Africa. It houses the African Regional Office of the World Health Organization (WHO).  This is my internship affiliate organization.

My duties as an intern involves, primarily, monitoring and evaluation of country compliance to the Framework Convention on Tobacco Control (FCTC) as well as production of tobacco control country report cards. The WHO FCTC is the first negotiated treaty under the auspices of the WHO and a regulatory strategy to address additive substances. It focuses on cutting off the demand and supply of tobacco products within countries. However, apart from the above mentioned duties, I also get to do rotations in other departments in order to get a well-rounded field experience

 Having arrived on a weekend, I had the opportunity to rest and recharge my batteries in order to be ready for my first week as an intern. On Monday morning, I was at the office bright and early. I got introduced to my supervisor, Dr. Nivo Ramanandraiben and my preceptor, Dr. Ahmed E. Ogwell Ouma. My preceptor is the Regional Advisor on Tobacco Control. I also met other members of the Tobacco Control Team. I was briefed on my duties and by Tuesday, I set to work by trying to understand and extract the information in the FCTC Parties Reports. Countries that have acceded to, ratified and agreed to implement the articles of the FCTC are known as Parties. The agreement to implement these articles is known as entry into force.  These Parties are expected to produce implementation reports two years and five years after entry into force. In the African region, 41 out of the 46 countries in the region have entered into force. Each Party report is 47 pages long and that would be keeping me busy for the next two weeks.

I am very fortunate to be given an opportunity to intern with the Tobacco Control Unit of the WHO for the next twelve weeks and want to thank Hope Through Healing Hands and the Niswonger Foundation for their scholarship support.   I will keep everyone “posted” so be on the lookout for my next blog report.  In the meantime, here is where you can find me :  http://maps.google.com/maps?hl=en&cp=12&gs_id=0&xhr=t&q=brazzaville+congo&qscrl=1&nord=1&rlz=1T4SUNA_enUS310&gs_upl=&bav=on.2,or.r_gc.r_pw.,cf.osb&biw=1672&bih=762&ion=1&wrapid=tljp132818884994700&um=1&ie=UTF-8&hq=&hnear=0x1a6a32ac441bb83b:0xab3deababe7de443,Brazzaville,+Congo&gl=us&ei=sY0qT7mxO4fAtgfAq6zmDw&sa=X&oi=geocode_result&ct=title&resnum=3&sqi=2&ved=0CE4Q8gEwAg

by Joseph Schlesinger
Vanderbilt International Anesthesia
Kijabe, Kenya

joe schlesinger blog 2

Death and dying are never easy to deal with as a physician.  However, that process is different in Africa.  Morbidity and mortality are more commonplace and seem to be accepted.  Religion is pervasive in all aspects of healthcare: the Wednesday morning chapel service, the preoperative prayers, and the prayers after meetings. 

I was taking care of a very sick patient that was not expected to do well.  Previous deaths in the ICU were simply accompanied by filling out the Kenyan Death Certificate and the family finding out the news when they arrived in the morning.  However, this patient’s family drove about two hours from Nairobi to discuss the hospital course and prognosis.  All six of them spoke perfect English and were aware of lab values and surgical findings.  They were more informed than typical American families I have had discussions with.  Despite the expected grief and frustration, they were grateful for the dedication of the hospital and physicians.  We prayed together at the end of the meeting.  The patient died later the next day.

Despite several deaths in the ICU during the previous week, the evaluations of the anesthesia students were completed.  The improvement was remarkable.  They were pushed harder than they have been pushed before, and they rose to the challenge.  This was evident in the final didactic portion on our final clinical day where we asked the students to present a given topic to their classmates.  Not only did they exceed our expectations, they started quizzing their fellow classmates.  The lecture was completed by presenting us with high quality coffee table photography books of the Mara.  The students signed the inside cover, we took group photos, and we were asked why we can’t stay longer and when we will return.

As we took care of final business with the hospital such as paying for our lodging and Kenyan medical license, the operating room manager asked to meet with us because she wanted feedback on how we can improve things.  Kijabe is a place that can follow through on initiatives for change.  The cohesive atmosphere is amazing and will provide the impetus for being one of the leaders in Africa for healthcare and mission work.  It has been a sincere pleasure to be part of the global health initiative here, and for me, it won’t end here.

by Tracy Curtis
Duke University, Physician Assistant Student
Galle, Sri Lanka

duke office

In my third week at Karapitiya Hospital I was introduced to Dr. Kumara, senior lecturer in Surgery. Participating in various surgical cases was what I was most looking forward to on my rotation in Sri Lanka. Walking into the OT I noticed it was quite a different set up from the operating rooms back in the states.  Patients were lined up on a bench right outside of the open theater doors with their medical chart in hand. Some patients were even curious enough to stand and watch the ongoing procedures from the doorway. On the other side of the patient bench was a make-shift PACU where the post-operative patients were still coming out of their anesthesia. Inside the operating theater, there were multiple procedures going on at the same time. In one corner of the room, a woman was having a lumpectomy under local anesthesia. In the center of the room, a man was under general anesthesia having an open cholecystectomy. Finally, off to the side of the room a woman was getting a carpal tunnel release.

As I was taking in the similarities and differences of the OT, one of the general surgeons asked me to scrub for a thyroidectomy. The case got underway and I was impressed by the speed and precision of the surgeon. Thyroidectomies are a very common procedure here in Sri Lanka and these surgeons perform so many each day, I’m sure they could do this procedure in their sleep. Following the procedure, I noted that the turnover time between cases is quite rapid. Turning over an OR at home takes a bit of time, but here, there is no time to waste. They have so many patients in need of surgery and not enough resources to do so.

One thing I found truly amazing about the Sri Lankans is their strength to overcome adversity. But more impressive is the way they do so without complaint. The patients waiting in the hallway of the theater could be there all day long, sometimes not having their surgery until 1 in the morning, but there was no complaining. I commented to one of the orthopaedic about how refreshing it was to have people be thankful for the help they are receiving instead of complaining about the wait time, or cosmetics of the scar, or the post-op pain, or even the food at the hospital! The surgeon told me that Sri Lankans are very accepting of their own problems and illnesses. Then he smiled, leaned in and said, “Sri Lankans don’t sue their physicians and that’s something you all have to worry about over there.” Sri Lankans understand that this is the life they were given and they will deal with it as best as they can. They do not blame physicians (or others) for their problems, but instead are grateful for the care they receive.

After a few orthopaedic surgeries, I stepped into the general surgery suite to watch an open cholecystectomy. Since we do these procedures laparoscopically in the states, it was a new operation to me. There is only one scope for the entire hospital so most all procedures that we would do laparoscopically at home are performed as an open procedure here. Similarly, the hospital does not have mesh implants for hernia repairs. Instead, I learned an old suturing technique to weave a meshwork of suture over the opening. Quite impressive and cost effective. As a global practitioner, I’ll need to be prepared to assist in surgeries with fewer resources and embrace both old and new techniques to achieve good end results. I am very grateful to have watched so many procedures and techniques that I won’t get to see (or rarely see) in my training in the US.

I also spend time with Dr. Kumara during his thyroid, vascular, and endoscopic clinics. In the thyroid and vascular clinics, I was surprised to see patients bring their own injections to Dr. Kumara. In the endoscopy clinic, I was stunned to see that patients were not sedated for upper endoscopies or colonoscopies. But once again, there are no resources available to take care of these patients post-procedure if they were to have an anesthetic so using a local anesthetic is the only feasible option.  

With that, we headed to meet up with two German medical students, also doing an elective clinical rotation. They were already in the casualty theater where we spent the rest of our day assisting in I&D’s, suturing small lacerations and bandaging head wounds. Overall, surgery in Sri Lanka very much surprised me. For the limited resources available, the shortage of qualified surgeons and the ever increasing number of patients in need of surgery, the surgeons here are very efficient with their time, skilled in technique and quite resourceful. We may have different ways of carrying out a procedure, but we all get the job done.

When I wasn’t in the OT, I was out in the community, learning more about the public health system, specifically the care of orphans and elderly. My colleagues and I have already been to a government run orphanage, and this week we wanted to see how the private orphanages compared. We visited an SOS Village, an Austrian run organization which hosts 12 children per home in 12 total homes on the property. Each “family” home consists of children aged 0-16 years brought in by the courts in cases of abuse or abandonment. The children are cared for by a “mother” in each home who cooks, cleans, and teaches the children valuable life lessons. These “mother’s” undergo years of training and a very intensive screening and selection process. The children still attend public schools like their peers, and return to the village to live a life as close to their peers as possible. It was wonderful to see an organization like this one, working so hard to give these children a rich and meaningful childhood.

We also made our way to a catholic-run elderly home where I had the pleasure of meeting an amazing woman who was blinded by the tsunami. She told us her story and how the sisters had found her on the streets, nearly dead, and brought her to the facility because she had no money, no family and no way to survive. The sisters were able to find a surgeon, who just this past year, performed an incredible surgery to restore her vision! She was able to see for the first time since 2004.

There were so many great stories from the folks at the elderly home, but what I liked most about the facility was that every resident helped out in any way they could. Some set the dining room tables for meals, others cleared dishes, or peeled vegetables, and some knitted bedding or doilies for the sisters to sell at the markets to bring in money for the home. Not everyone could pay, but no one was turned away.

With another fantastic week in the books, it’s hard to believe my time in Sri Lanka is coming to a close. I have learned so much in my short stay; it will be hard to leave. I am very grateful to have had this learning opportunity here in Sri Lanka and I hope that I may return here as a provider one day. 

 

by Holly Stump
Duke University, Physician Assistant Student
Galle, Sri Lanka

duke group photo

I wasn’t sure what to expect when I arrived at Mahamodara Maternity Hospital. The tuk tuk dropped us off outside of what appeared to be fortress walls. We were met by our Duke coordinator and led through the gate, past a building that was in disrepair and dilapidated. We traversed through a labyrinth of crumbling plaster and boarded up windows. There was a smell of mildew lingering in the air. I thought to myself, “Women come here to give birth”? Once we rounded a corner, I noticed an area to my right which looked as if it should have been full of expectant women, but was eerily vacant. It was then I realized what I was seeing was the shell of the Mahamodara which stood during the 2004 tsunami. I stared into the ward, and could imagine this area full of pregnant women and newborns on that day, and could almost feel their terror. I was told the hospital was hit by 3 waves. The first wave destroyed the “fortress” walls that I had seen earlier, but these barriers had lessened the impact to the building. It flooded the first level and knocked out the electricity. The doctors and staff evacuated the mothers and infants, some to higher ground, and others to Karapitiya Hospital. The second wave was estimated between 20-30 feet high. There are many stories of heroic men and women from that day, including one physician who calmly completed a Cesarean section by flashlight after the first wave hit. He then safely evacuated the mother and child. Due to lack of funds to demolish the building, it now stands as a temporary memorial.

We moved on, and at the end of the hallway we entered a courtyard. In front of us was a beautiful new building which now housed high risk expectant mothers. The ward contained 64 mothers who had a variety of problems, such as gestational diabetes, hypertension, and preterm premature rupture of membranes. There were strict visiting hours here, so there were no hovering families or concerned husbands. The hospital has very few fetal heart rate monitors, so the midwives and nurses monitor the fetus through the use of a pinard.  I spent a lot of time in this ward, and in the antenatal clinic, examining patients. I practiced with the pinard, straining to hear the fetal heartbeat as clearly as these experienced midwives, who could easily estimate fetal heart rates. I did many abdominal examinations, measuring the fundus, palpating the fetal position, and attempting to guess the baby’s weight in kilograms. I was certainly attaining one goal I had for this rotation, to get back to basics!

I witnessed the miracle of birth for the first time this week. I made my way through the maze of exterior hallways at Mahamodara to the labor and delivery room. Once I entered, I saw 10 wrought iron beds sitting side by side, each containing a woman in varying stages of labor. Two had just given birth and were coddling their newborns, encouraging them to breast feed for the first time. Several were in the final stages of labor. I chose a mother and joined the midwife and medical student who were at her side. I again noted the palpable absence of the typical “cheering squad” you see in America. These women were left to hold their own legs, and labor alone. There are no epidurals or pain medication, just pure will and true grit. After another hour of exhausting effort, she gave birth to a healthy baby girl. A new mother’s joy transcends all language barriers!

This was my final week in Sri Lanka. I cannot express enough gratitude to the doctors and staff at Karapitiya Hospital, and the University of Ruhuna Faculty of Medicine, for all of their time and willingness to share their vast knowledge.  The long journey home gave me time to reflect on my experiences here, and all that I have learned. Of course I am extremely grateful to have had the opportunities to assist in surgeries and delivering babies, to learn about rare illnesses not seen in the United States, and to practice primitive examination skills; but some of the most invaluable lessons I have learned were from the Sri Lankan people themselves. They are a hopeful people. Having recently suffered through a natural disaster, as well as a three-decade long civil war, they see brighter days ahead and are working hard to be sure the whole world can see them too. They are patient people, accepting of the fact they may have to return to the hospital daily in hopes of being admitted, or that their surgery may be delayed by many weeks. They are people who are full of grace, willing to undergo painful procedures without pain medication or anesthesia, with no complaints. Finally, they are a grateful people. They understand they are fortunate to have free healthcare and very skilled physicians. The phrase “medical malpractice” is foreign to them, and litigation against their physicians is unheard of. They are grateful for visitors from faraway lands and are eager to share their history and culture with all those who are willing to make the trip!

Huffington Post

POSTED ON FEBRUARY 3, 2012, AT 9:47 AM

This post is part of a series on childhood poverty in the United States in partnership with Save the Children and Julianne Moore. Moore leads the organization’s Valentine’s Day campaign, through which cards are sold to support the fight against poverty in the U.S. To learn more or to purchase the cards, click here.

More than one in five American children lives in poverty. In my home state Tennessee it is an astounding one in four.

And it’s only getting worse. Less than four years ago, the national number was one in six children. Childhood poverty has increased 18% since 2000, as 2.5 million more children live in poverty today. But those are just cold, hard numbers. It’s what happens to kids who happen to be born into poverty that matters.

Childhood poverty does not just mean a family of four makes below $23,050 a year (it’s estimated that a family needs over twice that income to actually meet basic needs). No, childhood poverty limits access to the simplest, most basic things such as healthy foods, books, the Internet, and a secure place to play, exercise, or even sleep.

It means poor children,nearly half of whom are overweight, grow up with worse health.

It means at the age of four, poor children are already 18 months behind developmentally.

It means without early education programs, poorer children struggle and are 25% more likely to drop out of high school.

It means they are more likely to become teen parents, commit a violent crime, and be unemployed as adults.

It is a sad fact that at birth, one in five Americans today is well behind in the pursuit of happiness. The evidence increasingly points to the fact that once a child falls behind in the crucial early years, they may never catch up.

As a doctor, I focus on the devastating, long-lasting impact poverty has on a child’s health. Simply put, on average, the lower on the “socio-economic ladder” a child falls, the shorter life he will live. Americans in the lowest income category are more than three times more likely to die before the age of 65 than those in the highest income bracket.

For a child, a healthy body, a strong heart, normal development, and progressive learning all require adequate and balanced nutrition. But poor families too often don’t have access to nearby, affordable healthy foods. This stands as a major reason that debilitating chronic conditions like obesity and diabetes disproportionately afflict these impoverished youths.

“Food deserts” are those all too frequent regions of a city or rural areas, wherever poverty may exist, where affordable, healthy, fresh and nutritious foods are nowhere to be found. A 2011 Food Trust Report found that nearly one million Tennesseans, including 200,000 children, live in communities underserved by healthy food-providing supermarkets.

Across America 23.5 million live in areas that lack stores selling affordable, nutritious food. Without access to healthy foods, the cheap, fried, over-processed foods that accelerate the path to obesity become the mainstay diet. And the cause of early death.

This can be fixed. And an effective way to do so is for enterprising grocery retailers to partner with others in the private sector.

For example, just this year the Partnership for a Healthier America secured commitments from seven leading grocery companies to build new stores in areas where they’re needed most. All told, these commitments will bring fresh, affordable foods to ten million people!

Calhoun Enterprises alone will be building ten new stores in Alabama and Tennessee, creating 500 new jobs while figuratively bringing water to these deserts. And forward-thinking companies are increasingly learning that such “social partnering” not only helps the health and welfare of millions of Americans, but it also improves their own bottom lines.

And our government can also be a lot smarter. For many impoverished children, the majority of their meals, breakfast, lunch and even an afternoon snack, come from their schools. In 2010, almost half of all Tennessee students received government-subsidized school lunches. However, for longer life and better learning, we as tax-paying parents and citizens must insist on trading out pizza and tater tots for more whole grains, fresh fruit and vegetables.

Tennessee has recently started on this process. In June of last year, Tennessee, along with Kentucky and Illinois, joined a USDA pilot program for the “Community Eligibility Option,” allowing kids in low-income areas to skip the applications and red tape and receive the benefits of a free, healthy breakfast and lunch at their schools.

Nationally, last month the Obama administration overhauled the school lunch program for the first time in 15 years. Overall the menu will include items with less sodium, more whole grains and a greater selection of fruits and vegetables. Don’t worry, pizza will still be on the menu, but made with better ingredients.

Partnerships that focus on health and nutrition between the public and private sector, and between faith-based and secular nonprofits, will help lift children from the dire consequences of poverty.

America is the wealthiest nation in the world. The most technologically advanced. The most generous and accepting. We are the fastest car on the fastest track. We cannot afford to leave more than a fifth of our children behind.

Tracy Curtis
Duke University
Physician Assistant Student
Galle, Sri Lanka

After a long journey to the other side of the globe, I was finally in Sri Lanka. It was 1:00 am when I landed then I arrived at my lodging at 4:00am. I had 4 hours to sleep and be ready to work! When I woke up to monkeys howling and playing in the trees 20 feet away, I knew I would like this place.

I was excited and nervous to start my global health rotation at Karapitiya Teaching Hospital. Despite the fact that the University of Ruhuna Faculty of Medicine is conducted in English, there is still quite the language barrier with the Sri Lankan version of English and the amount of slang that we unknowingly use. Even the everyday medical language and abbreviations varies between the U.S. and Sri Lanka. I wasn't sure how this would pan out when I arrived on the medicine ward.

Three of us are here in Sri Lanka from the Duke Physician Assistant Program. Since Duke University and the University of Ruhuna Faculty of Medicine have an established relationship in medicine and research, many of the professors and researchers were very welcoming to us. We met with Professor Ariyananda, the Senior Professor of Medicine, and he was quite excited to bring us to Grand Rounds and introduce us to his faculty and fellow consultants before we got started the next day.

The next day, we began clinical activities on the women's internal medicine ward, where we spent the week. We met with the Senior Registrar (similar to our Chief Resident) and she hurried us to the first patient to begin morning rounds. It was definitely intimidating on the first day while rounding with their equivalent of residents and attending.

After a few days, I was able to understand how the ward works to admit patients, complete investigations and diagnostic assessments and carry out a treatment plan. There are many similarities, but a greater number of differences between the U.S. and the Sri Lankan inpatient wards. The overall appearance of the ward and staff, the admitting process itself, and the types of illness and their treatment protocols are notably unique.

When I first walked onto ward 11, I noticed there were more patients than beds, with some patients lining up with their belongings on the floor or with a make-shift mattress on the ground in the hallway. Some privacy is maintained with green curtain that can be drawn to a close, though this greatly reduces the air circulation and increases the already hot temperatures found on the ward.

Another distinct difference between the U.S. and Sri Lankan hospitals is the admitting process. Patients can only be admitted to a ward on Casualty Day. While casualty typically means trauma or catastrophic event, here in Karapitiya Hospital, it simply means acute care. Each ward has its own Casualty Day, rotating every 5 days, so on any given day there is at least one medicine ward holding a Casualty Day. It's quite obvious which ward is having their day because the hallway outside the ward is lined with sick people waiting their turn to speak to a House Officer (intern). Because Sri Lanka has a public health system, and Karapitiya is a public teaching hospital, patients are first seen at their local community health clinic or rural hospital and if their illness is deemed to be beyond the capabilities of the small hospital or clinic, they are referred to the teaching hospital. The patient brings their diagnosis card to the House Officer- a laminated square paper with their personal identification information, their chief complaint, lab work if done, and treatment to date. The House Officer is the first to speak to the patient; they do a complete history and determine if they need to be examined or treated outpatient. If they are in need of an exam, they proceed to the line for the single admitting bed where the Junior House Office and/or Senior Registrar (residents) examine the patient. They will determine whether the patient gets assigned a bed or follows up with outpatient treatment. Unless the patients’ illnesses warrants a longer stay, most patients are typically released to outpatient care after 4 days- just in time for the next Casualty Day.

When admitted to the hospital, patients must bring their own medical record, clothing, toiletries, pillow and blankets. The hospital only provides one pillow case and one blanket which are typically used to cover the bed. Visitors are only allowed between 1-5pm, though one person is allowed to stay at all times.


Needless to say, patients who get admitted here are very ill. We have seen many patients with Dengue and Typhoid fever, severe heart murmurs, and strokes. Many of these illnesses are quite advanced at the time of initial evaluation. There was one patient who had such a loud heart murmur that it took me a minute to realize that it was her mitral valve making all that noise and not her breath sounds! I've never heard such a loud, distinct murmur in my training. When I felt for her apical pulse, it was as though her heart was punching my hand through her ribs. Thankfully, the patients here are accustomed to medical learners examining and questioning them every day, so it was nothing new for me to listen and palpate myself. In fact, these patients have a crew of consultants, house officers, registrars, medical students and nurses rounding on them daily.

Another interesting difference that struck me was the absence of beeping monitors and other technology on the wards. Vitals are obtained manually at regular intervals and charted on a paper above the patient's bed. There were no oxygen tanks hooked up for the COPD patients, no controls to adjust the hospital bed for comfort and certainly no television sets. The physicians and students are heavily reliant upon their physical exam skills. It was impressive how well these physicians could hear breath and heart sounds with all the background noise and conversations amongst providers. I hope I will be able to acquire this same level of competency in my physical exam!

I can already tell that I will learn a great deal here in Sri Lanka, both culturally and medically. I'm grateful to have already seen so many tropical diseases that are rare or non-existent in my hometown. This will certainly prove beneficial for future international aid work. Also, learning about the public health system and adapting to the difference in technology will allow me to be a better global practitioner. In the next few weeks, my colleagues and I will also participate in pediatrics, OB/Gyn, community medicine and surgery. There will be many interesting patients and experiences to come!

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