All I can say is, I don’t know how they do it. I have finished my time in A&E and have been on female medical ward for the last week and a half. The female medical ward is housed in a new facility that opened several months ago. There are approximately 8 patients per room. Patients have to bring their own sheets, clothes, toilet paper, water, and any other supplies that they might need. There are many nurses and even more nursing students around, but I have yet to figure out exactly what they do. Care by the nursing staff is haphazard at best.
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.
Prior to my arrival in Guyana, I had the opportunity to spend a considerable amount of time with one of the Guyanese EM residents when they visited Vanderbilt. In one of our discussions, he brought up a fact that surprised me: the majority of Guyanese in the world do not reside in Guyana. Instead, they are scattered throughout North America, namely New York and Toronto. Only 10-20 percent of his family, for instance, remained in the nation, with the rest living in one of New York’s five boroughs. When I asked him if he would eventual join them in the US, he said no. His colleagues, however, had a much different approach.
It has been two months now! Yes, Two months! Over the past two weeks, I have focused on writing and designing the layout for country-level reports on the Status of Implementation of the Framework Convention on Tobacco Control (FCTC) for two countries-Madagascar and Lesotho. While writing the report for Madagascar, I observed that the tax on the most widely sold brand of tobacco is 76%. “Impressive”, I thought, given the difficulties and politics involved in the implementation of such tax policy. Upon inquiry, I learnt that Madagascar has the best practice in Africa. Madagascar also has health warnings on tobacco labeling and packaging covering more than 50% of the package and labels. The issue of health warnings reminded me of the events in the US where the implementation of graphic health warnings on tobacco packaging and labels were ruled as unconstitutional by the courts. I hope tobacco advocacy groups continue to fight for the adoption of such policies. Policies recommended by the FCTC has been shown to reduce tobacco consumption and in turn, premature mortality from tobacco use.
My first week here in Riobamba, Ecuador has been fantastic. In the mornings I attend rounds in the pediatric hospital with residents and attendings. Rounds are a lot like in Nashville except that x-rays are read by holding films up to the light and, of course, everything is in Spanish. Also, an epidemiologist joins us, and sometimes a dentist, though they rarely contribute to the discussion. It is amazing what an international language medicine is. Even with my limited Spanish skills I can follow, and occasionally contribute to, rounds with relative ease.

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.

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.

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.

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.

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