Marjorie Wiggins, Vice President of Nursing at Maine Medical
Center, a 650-bed hospital, recalls being in the emergency room on a busy night when patients seemed to be arriving by the dozens. The waiting room was filed. Nurses were unable able to move admitted patients. The emergency department might have to be shut down and patients might have to be diverted to another hospital. Yet records were showing 12 empty beds. What happened? All the housekeepers went to dinner at the same time to give a shower for one member of the staff.
Housekeepers returned to work, prepared rooms, and the threatened shut down and diversion were avoided. But the incident illustrates the extraordinary interdependence of all players in complex modern healthcare systems. One principle of complexity is nonlinearity—small things, like an unusual dinner hour, can have very large effects. Ms. Wiggins discussed the challenge of change and new roles for nurses in today's turbulent healthcare environment. She was one of the presenters at the July 12 -14 Plexus Institute conference at St. Joseph's College in Standish, Maine.
While conventional models have emphasized the role of experts, the partnership model adopted by Maine Medical Center emphasizes the strength of all agents and the mutual relationships of all involved in patient care. The idea, she explained, is that while the nurse as professional caregiver is the expert in some clinical information, "You, the patient, are the expert in you, your family, and your resources."
The concept has created many changes in practice. For instance, nurses traditionally prepared patient information reports for the next shift in a small room behind the nurses’ station. Under the partnership model, the shift change information is delivered at bedside, in the presence of patients and family members, and often with contributions from multiple medical providers. Patient safety checks often are done at the same time. The results, said Ms. Wiggins, include improved patient satisfaction and knowledge. In addition, careful and respectful language to patients and among staff is practiced and becomes habitual.
Studies have shown that patients often do not understand their medical conditions and medication, and patients who are not prepared to manage their own care are often readmitted to the hospital, Ms. Wiggins said. Preventable readmissions within 30 days of discharge waste billions of dollars every year. Using a redesigned discharge process, nurses double time spent preparing patients for discharge from eight to 16 minutes. Families are present when possible, and nurses explain medication, provide devices such as a pill box or alarm when necessary, and help uninsured patients find ways to get their medications. Another change allows families to be present, if the patient so desires, during "codes"--the emergencies when patients lives are in danger. "Dying is part of the life process," Ms. Wiggins observes, "but we often don't bring families in." For those fearing litigation, she added, law suits actually decrease when families are present, because they see that providers did all possible for their loved one.
Ms. Wiggins also described the new role of clinical nurse leaders (CNLs), master's degree level nurses who follow the most vulnerable patients through their entire hospital stays, keeping track of care and treatment during their interactions with countless people as they are moved from one department to another in a hospital. She said CNLs have improved patient care by seeing that patients get what they need, and they have saved money by identifying patterns that show some procedures and practices that don't help patients can be eliminated.
Claire Lindberg, professor at The College of New Jersey School of Nursing presented a brief primer on Complexity Science. She emphasized the interdisciplinary nature of the science, which has influenced scholarship in biology, economics physics, the social sciences, anthropology, management and mathematics, as well as nursing. Complexity is not one theory, she said, but many. Dr. Lindberg briefly described complex adaptive systems and complex responsive processes, as well as such central complexity concepts as self organization, emergence, and distributed control. For fuller treatment of this material, see the chapter she wrote with Curt Lindberg in On the Edge, Nursing in the Age of Complexity, edited by Claire Lindberg, Curt Lindberg and Sue Nash.
Bruce West, chief scientist in the Mathematical and Information Directorate of the Army Research Office, talked about the history of ideas, the roots of complexity science, and the vital importance of understanding variability. One of his recent papers, Why Six Sigma Science is Oxymoronic, argues that eliminating variability is counterproductive in research environments and in human systems generally. The mathematician Carl Friedrich Gauss (1777 – 1855) developed the law of averages that became the bedrock of all statistics we learned in school, Dr. West said, “and it is wrong.” At the end of the 19th Century, the economist and philosopher Vilfredo Pareto asked new questions and looked at data in a new way. He discovered the power law distribution of income, and his work introduced a world view more consistent with the principles of complexity science. Mathematical and averages that create a “normal” distribution curve work fairly well with a subject like human height, which has restricted intervals within a fairly small range. An "average" adult of five feet nine inches tall won't meet another adult twice his height, Dr. West explained. But he could easily meet someone with five times his income. (If Bill Gates were in a room with five minimum wage workers, the average of their incomes would be meaningless.) Income distribution, consumer behavior, weather systems and any system where outliers can dominate requires an understanding of power laws.
Dr. West gave several examples of how averages can distort reality. For instance, the “average” scientist has 3.2 published citations a year. But 35 percent of scientists have no citation, and 90 percent publish less than the average. The scientist who has 3.2 citations is actually in the top four percent for published citations.
Sixty years ago scientists began developing revolutionary ideas about the organization of living networks, he explained, and recent advances in complexity science have dealt mathematics of complex networks. He said complex systems are most robust when they are confronting problems they have evolved to solve. He spoke of, habituation, negative entropy, how two complex systems might influence each other, and the need for more scientific exploration of complexity science. The “take home” message, he advised conference goers, is that the best way to influence complex networks is not direct force or dominant authority. The best influence can be delicate and direct, he said, but the influence must match the network in complexity.
Dr. West has written scores of papers, journal articles and books. His book Where Medicine Went Wrong explores how misuse of averages in human physiology have delayed understanding the role of variability in healthy human systems. Lack of variability, he has asserted, leads to the morgue.
Sunday, July 12, 2009
Friday, June 26, 2009
When in Rome Do as the Romans--Sage Advice or Doorway to Doom?
Can conformity lead to mass extinction?
Some scholars think it can, and has. Hal Whitehead of Dalhousie University, Halifax, Nova Scotia, Canada, and Pete Richerson of the University of California, Davis, believe excessive conformity can prevent the adaptability and innovation needed to survive during periods of rapid environmental change. In fact, they think conformity may have contributed to the demise of the Mayan civilization in southern Mexico on the eighth and ninth centuries, and the Norse settlements in Greenland 1,000 years ago.
Their theory is described in the story by Dan Jones ,"Conformist May Kill Civilization" in Nature News. The scholars modeled how different learning strategies fare in different learning environments, and found that under certain circumstances societies can be doomed by conformist social learning. For example, a "red noise environment" is one in which the environment is stable for long periods then undergoes major changes suddenly in unpredictable ways. They say that pattern has characterized many historical periods. And that's when rampant conformity bodes ill. The ability of humans to learn from each other, to imitate and emulate, has helped societies function and keep chaos at bay, and the story explains that social learning is more efficient than having individuals waste time learning what other around them already know. But the story also points out that "Rapid change puts a premium on the capacity of individuals to learn through exploration and experience, and to adapt their behavior accordingly."
"During long periods with only modest amounts of change, conformist social learning is a more successful strategy than costly individual learning," says Richerson, but he adds, "The mix of individual and social learning that evolves during the quiet periods of red noise environments tends to have too little individual learning to cope with the rarer big changes." Luke Rendell, a biologist at the University of St. Andrews in the UK,. thinks it is plausible that excessive conformity can collapse civilizations. "People might find it difficult to believe that humans, in all their complexity, would do something so stupid as to copy themselves to extinction," he says, "but in my view that may rely on an overly rosy view of human omnipotence. What matters to most people is how they are doing as individuals right now, and longer term considerations are very easily pushed down the priority listing."
Whitehead and Richerson argue societies should promote individual learning and innovation over social conformity. They also suggest "prestige bias", meaning that people copy successful role models rather than just indulge in unselective imitation, can be helpful. They say, however, testing their models requires more knowledge about how people really use learning strategies before further testing can be accomplished.
Over the years, scholars have developed many theories about the crash of the Mayan civilization and the demise of Norse settlements in Greenland. Whitehead and Richerson believe entrenched conformity and social inertia may have played a role in the inability of both populations to cope with harsh environmental and ecological changes and societal adversities.
As Ralph Waldo Emerson said, "A man must consider what a rich realm he abdicates when he becomes a conformist." And in the words of a Chinese proverb, one dog barks at something, and a hundred bark at the bark.
But how can we nurture innovation and individuality while still supporting the useful conformity that promotes and order, a body of standard knowledge, and some consensus on manners and values?
Some scholars think it can, and has. Hal Whitehead of Dalhousie University, Halifax, Nova Scotia, Canada, and Pete Richerson of the University of California, Davis, believe excessive conformity can prevent the adaptability and innovation needed to survive during periods of rapid environmental change. In fact, they think conformity may have contributed to the demise of the Mayan civilization in southern Mexico on the eighth and ninth centuries, and the Norse settlements in Greenland 1,000 years ago.
Their theory is described in the story by Dan Jones ,"Conformist May Kill Civilization" in Nature News. The scholars modeled how different learning strategies fare in different learning environments, and found that under certain circumstances societies can be doomed by conformist social learning. For example, a "red noise environment" is one in which the environment is stable for long periods then undergoes major changes suddenly in unpredictable ways. They say that pattern has characterized many historical periods. And that's when rampant conformity bodes ill. The ability of humans to learn from each other, to imitate and emulate, has helped societies function and keep chaos at bay, and the story explains that social learning is more efficient than having individuals waste time learning what other around them already know. But the story also points out that "Rapid change puts a premium on the capacity of individuals to learn through exploration and experience, and to adapt their behavior accordingly."
"During long periods with only modest amounts of change, conformist social learning is a more successful strategy than costly individual learning," says Richerson, but he adds, "The mix of individual and social learning that evolves during the quiet periods of red noise environments tends to have too little individual learning to cope with the rarer big changes." Luke Rendell, a biologist at the University of St. Andrews in the UK,. thinks it is plausible that excessive conformity can collapse civilizations. "People might find it difficult to believe that humans, in all their complexity, would do something so stupid as to copy themselves to extinction," he says, "but in my view that may rely on an overly rosy view of human omnipotence. What matters to most people is how they are doing as individuals right now, and longer term considerations are very easily pushed down the priority listing."
Whitehead and Richerson argue societies should promote individual learning and innovation over social conformity. They also suggest "prestige bias", meaning that people copy successful role models rather than just indulge in unselective imitation, can be helpful. They say, however, testing their models requires more knowledge about how people really use learning strategies before further testing can be accomplished.
Over the years, scholars have developed many theories about the crash of the Mayan civilization and the demise of Norse settlements in Greenland. Whitehead and Richerson believe entrenched conformity and social inertia may have played a role in the inability of both populations to cope with harsh environmental and ecological changes and societal adversities.
As Ralph Waldo Emerson said, "A man must consider what a rich realm he abdicates when he becomes a conformist." And in the words of a Chinese proverb, one dog barks at something, and a hundred bark at the bark.
But how can we nurture innovation and individuality while still supporting the useful conformity that promotes and order, a body of standard knowledge, and some consensus on manners and values?
Thursday, June 11, 2009
The Neurochemistry of Time Influences the Workings of Mind
The American physicist John Archibald Wheeler observed that time is what prevents everything from happening at once. Researchers are now beginning to suspect that impaired time perception is important in a wide range of psychological ills.
A June 10 New Scientist story by Andy Coghlan reports that children with attention deficit hyperactivity disorder (ADHD) have a hard time with time. He cites a study by Katya Rubia at the Institute of Psychiatry at King’s College London who suspected time perception might influence the short attention spans and impulsive behavior of children with ADHD. Researchers used MRI scans on 12 boys who had ADHD, and discovered below normal activity in the frontal lobe, basal ganglia, and cerebellum, brain areas thought to be critical for time perception. Those boys were also less adept at estimating time than 12 boys without ADHD. Interestingly, their time estimates improved after getting Ritalin, which boosts dopamine levels in the brain and is a drug commonly used to treat ADHD. The research is published in the Philosophical Transactions of the Royal Society.
For a child with ADHD, a few minutes of sitting still can seem like endless torment. Unusual and risky behavior stimulates dopamine, scientists say, and Rubia thinks that when kids with ADHD engage in hyper and disruptive behavior, they may actually be self medicating.
Some scientists have divided our time-keeping abilities into three domains, according to a livecience.com story by Robert Roy Britt, “The Human Brain Seen as a Master of Time.” The circadian clock keeps us in sync with a 24 hour night and day cycle. Another clock operating on a millisecond level controls movement and speech and other vital functions we don’t consciously think about. Neuroscientists think a lesser known middle mode “interval timing” clock helps us manage functions that require seconds, minutes and longer periods of concentration.
Duke University neuroscientists Warren Meck and Catalin Buhusi, who is now with the Medical University of South Carolina, found that interval timing ability seems to be faulty in non-medicated Parkinson’s patients. They note that people who have Huntington’s disease, depression or mania also have been found to have impaired time perception. In addition, researchers have found faulty time perception in persons with schizophrenia. Researchers think drugs to influence the neurochemistry of time have potential to treat many disorders.
But out own thoughts, too, influence our understanding of time. Just think of the old sayings: time flies when you’re having fun and a watched pot never boils. And stress is a factor: One study showed smokers and non smokers were equally accurate in estimating time in an experimental setting. But when the smokers went cold turkey for 24 hours, their estimates deteriorated.
Time is the school in which we learn,
Time is the fire in which we burn.
Delmore Schwartz, "Calmly We Walk Through This April’s Day"
Friday, June 5, 2009
Scientists Probe the Mysteries of Scaling:The Math Applies for Mice, Elephants and Cities
What does the borough of Manhattan have in common with a mouse? As Steven Srogatz explains it, they are “variations on a single structural theme.”
In a guest column in The New York Times, “Math and the City,”. Strogatz describes similar patterns mathematicians have seen in social and biological systems. Strogatz is a professor of applied mathematics at Cornell University, His books include Sync, The Emerging Science of Spontaneous Order, and The Calculus of Friendship: What a Teacher and Student Learned about Life While Corresponding about Math, to be published in August. Melanie Mitchell, in her book Complexity: A Guided Tour, offers a lucid discussion of power laws, fractals and scaling, and why a tiny mammal and big city can operate on the basis of similar underlying principles.
Fifty years ago, Strogatz writes, George Zipf, a Harvard linguist who had studied word distribution in various pieces of writing, looked at size distribution of cities and found that in any country, the biggest city is always about twice as big as the second largest, and about three times as big as the third, and that the size and rank pattern is one that continues. Strogatz adds that, amazingly, the law has held in different countries, different cultures, and in different time periods. Xavier Gabaix wrote an in depth discussion of Zipf’s law for cities in the August 1999 issue of The Quarterly Journal of Economics.
Scientists don’t agree on why Zipf’s law seems to work, but new research has been done this decade on the mathematics of cities. Mathematicians have been looking at how size affects infrastructure. Studies have been done, for example,. on the number of gas stations, miles of roadways, and length of electrical cable. It turns out that bigger is greener, and that all of these resources decrease, on a per person basis, as city size increases. Strogatz says these resources all grow in proportion to a power of the population that is pretty close to three fourths.
Now comes another amazing fact that Strogatz thinks is not likely to be coincidental. The metabolic needs of animals grow in proportion to body weight raised to the 0.74 power. Mitchell explains in her book how three scientists, James Brown, an ecologist at the University of New Mexico, Brian Enquist, a biology graduate student, and Geoffrey West, a theoretical physicist, collaborated to probe the mystery of ¾ power scaling. They suspected that in living creatures, the answer might lie in the branching networks of blood vessels that carry nutrients to cells and the branching structures of the bronchi in the lungs that carry oxygen to blood vessels. Mitchell explains, with elegance and detail, that fractal structure is one way to generate a power law distribution. She says the three scientists developed a mathematical model of blood vessels and bronchi as “space-filling” fractals, and discovered that, as body mass rises, metabolism decreases, and that the metabolic rate scales with body mass to the 3/4 power. In other words, a mouse will consume more energy, per pound, than a person or an elephant, and there is a mathematical formula that calculates how much more. Further, fractal networks of living creatures and resources in cities may generate similar power law distributions. Mitchell’s stories of decades of biological research andmathematical reasoning are fascinating, and she discussed the intricate math in her chapter notes.
In a cover note for Complexity: A Guided Tour, Strogatz, wrote, “Finally! For years people have been asking me where they can learn the basics of complexity theory. Now I’ve got the answer. Read Melanie Mitchell’s book.”
In a guest column in The New York Times, “Math and the City,”. Strogatz describes similar patterns mathematicians have seen in social and biological systems. Strogatz is a professor of applied mathematics at Cornell University, His books include Sync, The Emerging Science of Spontaneous Order, and The Calculus of Friendship: What a Teacher and Student Learned about Life While Corresponding about Math, to be published in August. Melanie Mitchell, in her book Complexity: A Guided Tour, offers a lucid discussion of power laws, fractals and scaling, and why a tiny mammal and big city can operate on the basis of similar underlying principles.
Fifty years ago, Strogatz writes, George Zipf, a Harvard linguist who had studied word distribution in various pieces of writing, looked at size distribution of cities and found that in any country, the biggest city is always about twice as big as the second largest, and about three times as big as the third, and that the size and rank pattern is one that continues. Strogatz adds that, amazingly, the law has held in different countries, different cultures, and in different time periods. Xavier Gabaix wrote an in depth discussion of Zipf’s law for cities in the August 1999 issue of The Quarterly Journal of Economics.
Scientists don’t agree on why Zipf’s law seems to work, but new research has been done this decade on the mathematics of cities. Mathematicians have been looking at how size affects infrastructure. Studies have been done, for example,. on the number of gas stations, miles of roadways, and length of electrical cable. It turns out that bigger is greener, and that all of these resources decrease, on a per person basis, as city size increases. Strogatz says these resources all grow in proportion to a power of the population that is pretty close to three fourths.
Now comes another amazing fact that Strogatz thinks is not likely to be coincidental. The metabolic needs of animals grow in proportion to body weight raised to the 0.74 power. Mitchell explains in her book how three scientists, James Brown, an ecologist at the University of New Mexico, Brian Enquist, a biology graduate student, and Geoffrey West, a theoretical physicist, collaborated to probe the mystery of ¾ power scaling. They suspected that in living creatures, the answer might lie in the branching networks of blood vessels that carry nutrients to cells and the branching structures of the bronchi in the lungs that carry oxygen to blood vessels. Mitchell explains, with elegance and detail, that fractal structure is one way to generate a power law distribution. She says the three scientists developed a mathematical model of blood vessels and bronchi as “space-filling” fractals, and discovered that, as body mass rises, metabolism decreases, and that the metabolic rate scales with body mass to the 3/4 power. In other words, a mouse will consume more energy, per pound, than a person or an elephant, and there is a mathematical formula that calculates how much more. Further, fractal networks of living creatures and resources in cities may generate similar power law distributions. Mitchell’s stories of decades of biological research andmathematical reasoning are fascinating, and she discussed the intricate math in her chapter notes.
In a cover note for Complexity: A Guided Tour, Strogatz, wrote, “Finally! For years people have been asking me where they can learn the basics of complexity theory. Now I’ve got the answer. Read Melanie Mitchell’s book.”
Friday, May 29, 2009
"Crowdsourcing" and Crisis Mapping: Technological Ingenuity Makes it Happen
After the disputed election of President Mwai Kibaki in December 2007, violence and looting swept the normally stable country of Kenya, killing hundreds of people and displacing thousands. News from conventional sources was temporarily unavailable. In the midst of the chaos, a small group of tech savvy young Africans created a real-time reporting system that has since been used for relief efforts in other crises and natural disasters.
Erik Hersman, a self-described geek and power networker who grew up in Kenya and Sudan, tells the story in a TED interview. In three days time, Hersman, Ory Okolloh, a Kenyan native with a Harvard law degree, and Juliana Rotich developed free software that allowed anyone with a cell phone to report what was happening on the ground to a website where the collective information was available to aid workers and relief agencies. Ushahidi, which means testimony in Swahili, has simplified technology so that any one can use it, and it takes advantage of what Hersman calls the “default device of Africa”, the mobile phone. Some 59 percent of the world’s cell phones were in the developing world, according to a 2006 Washington Post story, making cell phones the first communications technology in history to have more users in the developing world than in industrially developed countries.
Ushahidi uses crowdsourcing to gather information during unfolding crises. Listen to Jeff Howe, one of those who coined the term, for a discussion of crowdsourcing. Ushahidi can collect information from hundreds of people. A web administrator receives the information, and can call back some contributors seeking verification, send out a blast alert to a large number of people, post the information on a web page with location information from Google maps, or do all three. It has been used to help coordinate relief efforts after earthquakes in Peru and China, to monitor Indian elections, and to track swine flu. Ushahidi has received a $200,000 grant from the John D. and Catherine T. Mac Arthur Foundation.
A team led by Patrick Meier, a doctoral fellow at the Harvard Humanitarian Initiative, posted an analysis of crisis mapping during the post election violence in Kenya. The team found that mainstream media reported actual death counts before citizen journalists, but did not report incidents and early warnings that led to the deaths. Citizens reported early violence before main stream media. Ushahidi reports documented important violent events mainstream and citizen journalists missed, and also covered a wider geographical area.
Hersman’s vision is not only to have real time reporting used for humanitarian aid around the world. His team is working on a “crowdsource filter” that he thinks will be able refine and weigh information and allow system administrators to determine the probability of its accuracy. It’s interesting, he observed, that this innovative technology is coming from Africa, from young smart developers in places one wouldn’t expect.
Erik Hersman, a self-described geek and power networker who grew up in Kenya and Sudan, tells the story in a TED interview. In three days time, Hersman, Ory Okolloh, a Kenyan native with a Harvard law degree, and Juliana Rotich developed free software that allowed anyone with a cell phone to report what was happening on the ground to a website where the collective information was available to aid workers and relief agencies. Ushahidi, which means testimony in Swahili, has simplified technology so that any one can use it, and it takes advantage of what Hersman calls the “default device of Africa”, the mobile phone. Some 59 percent of the world’s cell phones were in the developing world, according to a 2006 Washington Post story, making cell phones the first communications technology in history to have more users in the developing world than in industrially developed countries.
Ushahidi uses crowdsourcing to gather information during unfolding crises. Listen to Jeff Howe, one of those who coined the term, for a discussion of crowdsourcing. Ushahidi can collect information from hundreds of people. A web administrator receives the information, and can call back some contributors seeking verification, send out a blast alert to a large number of people, post the information on a web page with location information from Google maps, or do all three. It has been used to help coordinate relief efforts after earthquakes in Peru and China, to monitor Indian elections, and to track swine flu. Ushahidi has received a $200,000 grant from the John D. and Catherine T. Mac Arthur Foundation.
A team led by Patrick Meier, a doctoral fellow at the Harvard Humanitarian Initiative, posted an analysis of crisis mapping during the post election violence in Kenya. The team found that mainstream media reported actual death counts before citizen journalists, but did not report incidents and early warnings that led to the deaths. Citizens reported early violence before main stream media. Ushahidi reports documented important violent events mainstream and citizen journalists missed, and also covered a wider geographical area.
Hersman’s vision is not only to have real time reporting used for humanitarian aid around the world. His team is working on a “crowdsource filter” that he thinks will be able refine and weigh information and allow system administrators to determine the probability of its accuracy. It’s interesting, he observed, that this innovative technology is coming from Africa, from young smart developers in places one wouldn’t expect.
Friday, May 15, 2009
Sixth Annual Unite For Sight Conference: Insights and Innovations in Public Health
Goals for a dignified and decent life on our planet have been enunciated three times in the last 60 years, and timetables and accountability are the only hope of achieving them, in the view of Jeffrey Sachs, an economist, professor and director of the Earth Institute at Columbia University.
In 1948, the Universal Declaration of Human Rights had profound significance around the world as people tried to recover from the ravages of World War II, Sachs said. In 1978, the Declaration of Alma-Ata proclaimed health as a fundamental human right. In 2000 the UN Millennium Development Goals constituted an international agreement to reduce extreme poverty, disease and hunger by the year 2015.
The goals have not been met, Sachs said, but the wisdom of the documents is still alive, and like all great documents they need to be renewed and refreshed by each new generation.
“The goals declared at the start of the new millennium were full of hope and renewal,” Sachs said, asserting that security, safety, health, and educational opportunity, as well as freedom from conflict and preventable disease, are basic human rights. Rather than defining poverty in terms of dollars, he added, the document recognizes that extreme deprivation is multi-dimensional and needs to be addressed in a multi-dimensional way.
It is inexcusable that nine million children die before their fifth birthdays, when nearly all of those deaths are caused by extreme poverty, Sachs declared, adding it is a disgrace that children die of malaria for lack of a $5 bed net, that women and infants die because of unsafe childbirth, and that pandemic, parasitic, infectious and controllable diseases cause suffering, blindness and death.
“We need to keep these goals alive, and hold leaders accountable. That is our most important tool,” Sachs said. “We need international leadership. The new world is multi-national, and any solution needs to be cooperative….We are networked. The joy of our time is that we can cooperate in ways we couldn’t even think about in the last century.”
Corporations, businesses, nongovernmental organization, universities, scientists, civil society and individuals can collaborate and create partnerships to find solutions, he said, adding that he sees himself “as a plumber, making connections across these areas, finding ways to make the pipes fit.”
Sachs was a keynote speaker at the Unite For Sight sixth annual Global Health Conference at Yale University April 18-19, 2009. Unite For Sight is a nonprofit organization founded to empower communities worldwide to improve eye health and eliminate preventable blindness. The conference drew more than 2,200 participants from 50 states and 55 countries and a multitude of disciplines, to exchange ideas in all areas of public health and international development. Presenters included physicians, nurses, professors, organizational development practitioners and workers and specialists from dozens of public health-related fields. The following summaries represent just a few of the presentations and discussions at this extraordinary event.
Idealism is Not Enough
Nicholas Kristof tells a cautionary tale about cassava farming in Nigeria.
He recalls that he and his wife worked on a farm where women were raising cassava they ate and sold. Their cassava bed had a low yield, so they welcomed the opportunity for a new variety of the plant that yielded five times more crop. But they didn’t have the time or equipment to harvest it all. Further, the cassava plants absorb mercury and arsenic in areas where it remains in the ground from earlier gold mining operations, and the plant itself has naturally occurring chemicals that trigger production of cyanide. So the increased processing was polluting the ground water. The crop, however, was making money, and men decided they should be in charge of a cash crop. So they took over the operation, and the women were left with nothing.
“Idealism is not enough,” Kristof said. “You need grass roots understanding. There is a danger of making things sound too easy. Ideas are easy. Acting on them is a difficult. And you need to learn form your mistakes.”
Kristof, the Pulitzer Prize winning New York Times columnist who has written stories about human suffering and courage in remote trouble spots all over the world, urges would-be activists, “When you think you know what’s happening, back off. Travel in grass roots areas, find a cause larger than yourself, and get out of your comfort zone. You have to be bewildered.”
Kristof addressed the Unite For Sight conference last month at Yale. People are sometimes dubious about whether aid interventions work, he said, but they are necessary and they can help. See his May 13 column “What A Little Vitamin A Can Do” to combat unnecessary blindness among people in Africa.
Grass roots efforts tend to work best, he said. Great effort has been expended since 1970 to reduce female genital cutting in Afghanistan, he said, but conferences and new laws have had little impact. What helped a great deal was getting girls to school. Politics also may not be helpful. In combating AIDS, he noted, conservatives want abstinence and liberals want condoms, but the most effective approach may be something else. Girls in school who have learned the AIDS rate among middle-aged men are less likely to become involved with “sugar daddies”, despite the economic pressures to find financial help from older men. Kristof was one of several presenters who observed that when girls are educated and women have more social influence, poverty declines. More money is spent on children and small businesses and less on alcohol, prostitution and other vices.
Years ago, Kristof said, a New Yorker donated $100 to educate bright girls in a Chinese village he had written about. The bank erred, and gave the village $10,000. On a return visit 15 years later, Kristof found girls’ education and scholarships continuing, and many more educated young women holding good jobs, starting businesses, and educating their siblings.
Infectious and Chronic Diseases: Today’s Health Threats
Susan Blumenthal, MD, a former US Assistant Surgeon General who is a professor at Georgetown and Tufts University Schools of Medicine, spoke of trends and changes, not all reflecting progress. In 1969, she said, the US Surgeon General declared the battle against infectious disease had been won. Today, she said, the greatest health threats world wide are infectious disease and chronic disease.
Since 1972, she said, more than 32 new infectious diseases have emerged, and 1,500 people die every hour world wide from infectious disease. When people and animals live in close contact, pathogens flourish, and modernization and international travel facilitates dissemination. Climate change and extreme temperatures also foster emergence of new diseases that are water borne, air borne, and carried by rodents and insects. She added massive forest cutting promotes lymes disease in humans.
“We need public health policy that focuses on chronic disease,” she said. “We need to combat childhood obesity: 24 percent of our kids are over weight, and diabetes is becoming epidemic.” Inactivity, which contributes to obesity, impacts every organ system in the body. She added that one fifth of American children are shorter than children of a decade earlier. Published reports have documented that Americans are no longer the tallest people the world.
Disease and “Socioemergence”
In 1948, the Universal Declaration of Human Rights had profound significance around the world as people tried to recover from the ravages of World War II, Sachs said. In 1978, the Declaration of Alma-Ata proclaimed health as a fundamental human right. In 2000 the UN Millennium Development Goals constituted an international agreement to reduce extreme poverty, disease and hunger by the year 2015.
The goals have not been met, Sachs said, but the wisdom of the documents is still alive, and like all great documents they need to be renewed and refreshed by each new generation.
“The goals declared at the start of the new millennium were full of hope and renewal,” Sachs said, asserting that security, safety, health, and educational opportunity, as well as freedom from conflict and preventable disease, are basic human rights. Rather than defining poverty in terms of dollars, he added, the document recognizes that extreme deprivation is multi-dimensional and needs to be addressed in a multi-dimensional way.
It is inexcusable that nine million children die before their fifth birthdays, when nearly all of those deaths are caused by extreme poverty, Sachs declared, adding it is a disgrace that children die of malaria for lack of a $5 bed net, that women and infants die because of unsafe childbirth, and that pandemic, parasitic, infectious and controllable diseases cause suffering, blindness and death.
“We need to keep these goals alive, and hold leaders accountable. That is our most important tool,” Sachs said. “We need international leadership. The new world is multi-national, and any solution needs to be cooperative….We are networked. The joy of our time is that we can cooperate in ways we couldn’t even think about in the last century.”
Corporations, businesses, nongovernmental organization, universities, scientists, civil society and individuals can collaborate and create partnerships to find solutions, he said, adding that he sees himself “as a plumber, making connections across these areas, finding ways to make the pipes fit.”
Sachs was a keynote speaker at the Unite For Sight sixth annual Global Health Conference at Yale University April 18-19, 2009. Unite For Sight is a nonprofit organization founded to empower communities worldwide to improve eye health and eliminate preventable blindness. The conference drew more than 2,200 participants from 50 states and 55 countries and a multitude of disciplines, to exchange ideas in all areas of public health and international development. Presenters included physicians, nurses, professors, organizational development practitioners and workers and specialists from dozens of public health-related fields. The following summaries represent just a few of the presentations and discussions at this extraordinary event.
Idealism is Not Enough
Nicholas Kristof tells a cautionary tale about cassava farming in Nigeria.
He recalls that he and his wife worked on a farm where women were raising cassava they ate and sold. Their cassava bed had a low yield, so they welcomed the opportunity for a new variety of the plant that yielded five times more crop. But they didn’t have the time or equipment to harvest it all. Further, the cassava plants absorb mercury and arsenic in areas where it remains in the ground from earlier gold mining operations, and the plant itself has naturally occurring chemicals that trigger production of cyanide. So the increased processing was polluting the ground water. The crop, however, was making money, and men decided they should be in charge of a cash crop. So they took over the operation, and the women were left with nothing.
“Idealism is not enough,” Kristof said. “You need grass roots understanding. There is a danger of making things sound too easy. Ideas are easy. Acting on them is a difficult. And you need to learn form your mistakes.”
Kristof, the Pulitzer Prize winning New York Times columnist who has written stories about human suffering and courage in remote trouble spots all over the world, urges would-be activists, “When you think you know what’s happening, back off. Travel in grass roots areas, find a cause larger than yourself, and get out of your comfort zone. You have to be bewildered.”
Kristof addressed the Unite For Sight conference last month at Yale. People are sometimes dubious about whether aid interventions work, he said, but they are necessary and they can help. See his May 13 column “What A Little Vitamin A Can Do” to combat unnecessary blindness among people in Africa.
Grass roots efforts tend to work best, he said. Great effort has been expended since 1970 to reduce female genital cutting in Afghanistan, he said, but conferences and new laws have had little impact. What helped a great deal was getting girls to school. Politics also may not be helpful. In combating AIDS, he noted, conservatives want abstinence and liberals want condoms, but the most effective approach may be something else. Girls in school who have learned the AIDS rate among middle-aged men are less likely to become involved with “sugar daddies”, despite the economic pressures to find financial help from older men. Kristof was one of several presenters who observed that when girls are educated and women have more social influence, poverty declines. More money is spent on children and small businesses and less on alcohol, prostitution and other vices.
Years ago, Kristof said, a New Yorker donated $100 to educate bright girls in a Chinese village he had written about. The bank erred, and gave the village $10,000. On a return visit 15 years later, Kristof found girls’ education and scholarships continuing, and many more educated young women holding good jobs, starting businesses, and educating their siblings.
Infectious and Chronic Diseases: Today’s Health Threats
Susan Blumenthal, MD, a former US Assistant Surgeon General who is a professor at Georgetown and Tufts University Schools of Medicine, spoke of trends and changes, not all reflecting progress. In 1969, she said, the US Surgeon General declared the battle against infectious disease had been won. Today, she said, the greatest health threats world wide are infectious disease and chronic disease.
Since 1972, she said, more than 32 new infectious diseases have emerged, and 1,500 people die every hour world wide from infectious disease. When people and animals live in close contact, pathogens flourish, and modernization and international travel facilitates dissemination. Climate change and extreme temperatures also foster emergence of new diseases that are water borne, air borne, and carried by rodents and insects. She added massive forest cutting promotes lymes disease in humans.
“We need public health policy that focuses on chronic disease,” she said. “We need to combat childhood obesity: 24 percent of our kids are over weight, and diabetes is becoming epidemic.” Inactivity, which contributes to obesity, impacts every organ system in the body. She added that one fifth of American children are shorter than children of a decade earlier. Published reports have documented that Americans are no longer the tallest people the world.
Disease and “Socioemergence”
A collection of interacting economic, political and environmental processes over several decades may have facilitated the movement of the viruses, Simian Immunodeficiency Virus SIV and Human Immunodeficiency Virus HIV, from nonhumans to humans. Rebecca Hardin, PhD, an assistant professor at University of Michigan’s School of Natural Resources and Environment has studied “socioemergence”, the political and cultural dimensions of emergent viral diseases in Africa’s equatorial rain forest. From 1890 to 1930, she said, the area was under brutal colonial control, with forced labor drawn from small villages for logging and road building. Because the environment does not lend itself to raising cattle, workers were fed wild game. In later decades increased hunting and a growing trade in wild game meat was a threat to African wildlife in the Congo Basin, where the populations of chimpanzees and other primates plunged. Continued road construction from remote areas and human migration increased environmental pressures. Researchers found high HIV prevalence among women in commercial logging areas, and theorized that their vulnerability was related to the social and economic networks created by the industry. The Bushmeat Crisis Task Force website says wild game commercialization is a human as well as natural tragedy: loss of animals means endangered livelihoods and food insecurity for indigenous and rural populations most dependent on wildlife in their diet, and bushmeat consumption is increasingly linked to deadly diseases like HIV/AIDS, Ebola, and Foot and Mouth disease.
Mosquitoes and Malaria
Malaria is a preventable and curable disease that kills a million people a year, most of them children in Africa. Marcelo Jacobs-Lorena, PhD, a malaria researcher and professor in the department of Molecular Microbiology and Immunology at the Johns Hopkins School of Public Health, is seeking ways to increase the arsenal of weapons against mosquitoes. Mosquitoes bite an infected person, then pass the malaria germ to the next person they bite. Bed nets offer some protection for people sleeping. Insecticides bring resistance, Dr. Jacobs-Lorena said, and as soon as all the mosquitoes in an environmental niche are killed, more will come to fill the niche. A malaria vaccine does not yet exist. “We will never conquer malaria with a single approach,” he said. “We will have to do multiple things.”
Dr. Jacobs-Lorena’s research involves genetically modifying mosquitoes so that they will be resistant to the pathogen and unable to transmit it. That has been achieved, he said, and the next step, still being researched, is to spread the resistant gene to the rest of the mosquito population.
"Let the people Lead"
Pamela Lynam, MD, is country director for JHPIEGO in Kenya. (That’s pronounced Ja-pie-go-, and its one word, not an acronym.) In her Unite For Sight presentation she stressed letting people lead the way toward health in urban slums. By 2030, she said, three of every five people on earth will be living in cities, and 95 percent of urban growth is in the developing world. One third of all urbanites world wide live in slums, and 72 percent of African urbanites are slum dwellers.
The characteristics of slums, she said, include poor quality health care, lack of access to a hospital, lack of access to public services, good drinking water, and sanitation. “You’ve heard of the flying toilets of Nairobi? People use plastic bags and then throw them,” she said. “Sixty percent of the people live on five percent of the land. And officially, they are not there, so they have no rights where they live. No one has to supply them with water, electricity, or anything else.” Such conditions promote distrust between communities and health services that do exist, she said, with real issues of insecurity and neglect. Breakdown of traditional social structures in urban slums mean large numbers of HIV deaths, children given to neighbors, violence, and very sick patients.
The traditional approach to aid, she said, has been to have experts tell people what they need. The better approach, used by JHPIEGO and many others, is to let people define their needs, and have aid directed towards fulfilling the needs. For example, she said, in one large slum near Nairobi, an aid organization offered to bring people clean water, and was surprised to find what they really wanted. “People said that’s fine, we do want clean water,” Dr. Lynam said, “ but first we’d like covered bus stops, because we get soaked waiting for buses to go to work.”
The community-owned JHPIEGO intervention included anti-rape training, peer education, a village health committee, and a community theater. A community garden is generating small income and better nutrition. A self-defense group made a map of their own community showing places where people can get medical help and counseling, and its members have helped victims of rape and other crimes file police reports so that suspects are charged. They have also traveled to other communities to help others address their local needs.
“Great things happen when people start to respect and appreciate each other,” Dr. Lynam said. “The key is having people come up with their own solutions, and building trust, which takes time and patience, as well as enthusiasm and energy. You have to have a local staff. Consumers do know their own health challenges, and the results are sustainable because they come from all stakeholders.”
Dr. Lynam added that monitoring and evaluating aid programs is a very big challenge that carries with it the need for flexibility from policy makers and donors.
Women as Change Agents
Educated, empowered women are society’s change agents and the key to community health, said Jill Lester, president and CEO of The Hunger Project, a non profit that fights poverty not by direct aid, but by mobilizing women and forming partnerships with government. The organization operates in eight countries, using an “epicenter strategy”, in which clusters of villages that have up to 20,000 people work together to improve health, education, sanitation, or start small businesses. “If a woman can earn enough income so that her family goes from one to two meals a day, it changes her relationship with her husband,” Ms. Lester says. “The whole family changes if the mother has enough money for her family to eat.” She described a group of women in Senegal used a small loan to begin manufacturing a vitamin supplement for children using millet and nuts. In the process they learned skills in nutrition, hygiene, marketing and finance. A women who was illiterate a year ago now takes pride in being able to read her Bible, have soap and water in her house, and handle money without being cheated.
Destruction and Building Back Better
The Chinese got it right, Neil Boothby says: Crisis does represent both danger and opportunity. The aftermath of the devastating Indian Ocean tsunami that struck just before Christmas 2004, killing more than a quarter of a million people, also brought some beneficial legal and social changes.
Boothby is a professor and director of the Program on Forced Migration and Health at Columbia’s Mailman School of Public Health, addressed a session entitled The Epidemiology of Human Rights. He has studied efforts to protect children and families in war and disaster, and described several positive changes that developed from viewing emergency responses through a human rights-based lens. For one thing, he said, the tsunami was a tipping point for cessation at the time of civil war in Sri Lanka and Indonesia In Aceh, an emergency response framework resulted in establishment of family tracing and legal changes to protect children. New laws banned children from leaving the country alone so that child kidnapping and trafficking was greatly reduced. Police patrolled bus stations and created special desks in police stations for women and children. Before the new laws, only eight percent of children accused of crimes had lawyers, so a child who stole a piece of fruit would receive the same treatment as one who committed a felony. After the change, 71 percent of accused youngsters were represented, and the rudiments of a juvenile justice system was begun. In addition, 82 percent of children who were separated from their families in the disaster were placed with families or reconnected with relatives as a result of a family search program. Under the old system, orphanages would recruit and pay families for bright children with good academic records. A large Muslim nonprofit organization that formerly supported orphanages is reexamining its policies.
In Sri Lanka, a proliferation of orphanages came to be viewed as a secondary cause of family separation. Government and non-government agencies have started finding ways to reduce institutionalization of children, and to create safe recreational space where large numbers of children can be reached with basic social supports. Social spending has been increased in Sri Lanka and Indonesia since the tsunami.
Violence Against Women
Marie Skinnider, MD, Health Advisor to Medecins Sans Frontieres/ Doctors Without Borders, Canada, described the “consequences of gender-based violence in Papua New Guinea,” which has one of the world’s highest rates of domestic and sexual violence. One of her patients, in the first trimester of pregnancy, was gang raped while walking across a field in mid-afternoon. She had returned to her parents’ home because of domestic violence, and it appeared her husband had arranged the attack as revenge for her leaving him. Dr. Skinnider cited national survey data showing 67 percent of wives say they have been beaten by their husbands, and 60 percent of men say they have participated in gang rape at least once. The violence, she said, is generated and reinforced by the low standing of women in society: women are regarded as property of their husbands, and there are traditions of bride price and polygamy as well as a history of compensation and retribution attained at the expense of women. These social forces contribute to men being pressured by their peers to control women in their homes. Many women do not feel empowered to seek medical help, Dr. Skinnider said, and lack of transportation also prevents many women from going to health clinics.
Liberation Medicine in Education and Action Toward Health For All
Lanny Smith, MD is Professor of Medicine in the residency program of primary care and social medicine at Montefiore Medical Center, Albert Einstein College of Medicine in The Bronx, New York. He sees patients from the Highbridge and Morrisania sections in the Bronx, communities that are predominantly Hispanic and African American and that have extremely high poverty rates. He is also assistant director of the Human Rights Clinic for Victims of Torture and founder and president of Doctors for Global Health. He explains that liberation medicine has its roots in theology, psychology, ethics, education and liberation movements. The clinic design is inter- and multi-disciplinary, community-oriented and bottom-up, risk-taking, compassionate, and uses a praxis—practice in action—model. Online resources include Social Medicine and the People’s Health Movement. In a discussion after his presentation, he stressed the importance of careful listening and action learning. He cited Daniel Levin, who was acting assistant US Attorney General when he voluntarily endured waterboarding to decide for himself whether it constituted torture. He decided it did and later lost his government job.
Educated, empowered women are society’s change agents and the key to community health, said Jill Lester, president and CEO of The Hunger Project, a non profit that fights poverty not by direct aid, but by mobilizing women and forming partnerships with government. The organization operates in eight countries, using an “epicenter strategy”, in which clusters of villages that have up to 20,000 people work together to improve health, education, sanitation, or start small businesses. “If a woman can earn enough income so that her family goes from one to two meals a day, it changes her relationship with her husband,” Ms. Lester says. “The whole family changes if the mother has enough money for her family to eat.” She described a group of women in Senegal used a small loan to begin manufacturing a vitamin supplement for children using millet and nuts. In the process they learned skills in nutrition, hygiene, marketing and finance. A women who was illiterate a year ago now takes pride in being able to read her Bible, have soap and water in her house, and handle money without being cheated.
Destruction and Building Back Better
The Chinese got it right, Neil Boothby says: Crisis does represent both danger and opportunity. The aftermath of the devastating Indian Ocean tsunami that struck just before Christmas 2004, killing more than a quarter of a million people, also brought some beneficial legal and social changes.
Boothby is a professor and director of the Program on Forced Migration and Health at Columbia’s Mailman School of Public Health, addressed a session entitled The Epidemiology of Human Rights. He has studied efforts to protect children and families in war and disaster, and described several positive changes that developed from viewing emergency responses through a human rights-based lens. For one thing, he said, the tsunami was a tipping point for cessation at the time of civil war in Sri Lanka and Indonesia In Aceh, an emergency response framework resulted in establishment of family tracing and legal changes to protect children. New laws banned children from leaving the country alone so that child kidnapping and trafficking was greatly reduced. Police patrolled bus stations and created special desks in police stations for women and children. Before the new laws, only eight percent of children accused of crimes had lawyers, so a child who stole a piece of fruit would receive the same treatment as one who committed a felony. After the change, 71 percent of accused youngsters were represented, and the rudiments of a juvenile justice system was begun. In addition, 82 percent of children who were separated from their families in the disaster were placed with families or reconnected with relatives as a result of a family search program. Under the old system, orphanages would recruit and pay families for bright children with good academic records. A large Muslim nonprofit organization that formerly supported orphanages is reexamining its policies.
In Sri Lanka, a proliferation of orphanages came to be viewed as a secondary cause of family separation. Government and non-government agencies have started finding ways to reduce institutionalization of children, and to create safe recreational space where large numbers of children can be reached with basic social supports. Social spending has been increased in Sri Lanka and Indonesia since the tsunami.
Violence Against Women
Marie Skinnider, MD, Health Advisor to Medecins Sans Frontieres/ Doctors Without Borders, Canada, described the “consequences of gender-based violence in Papua New Guinea,” which has one of the world’s highest rates of domestic and sexual violence. One of her patients, in the first trimester of pregnancy, was gang raped while walking across a field in mid-afternoon. She had returned to her parents’ home because of domestic violence, and it appeared her husband had arranged the attack as revenge for her leaving him. Dr. Skinnider cited national survey data showing 67 percent of wives say they have been beaten by their husbands, and 60 percent of men say they have participated in gang rape at least once. The violence, she said, is generated and reinforced by the low standing of women in society: women are regarded as property of their husbands, and there are traditions of bride price and polygamy as well as a history of compensation and retribution attained at the expense of women. These social forces contribute to men being pressured by their peers to control women in their homes. Many women do not feel empowered to seek medical help, Dr. Skinnider said, and lack of transportation also prevents many women from going to health clinics.
Liberation Medicine in Education and Action Toward Health For All
Lanny Smith, MD is Professor of Medicine in the residency program of primary care and social medicine at Montefiore Medical Center, Albert Einstein College of Medicine in The Bronx, New York. He sees patients from the Highbridge and Morrisania sections in the Bronx, communities that are predominantly Hispanic and African American and that have extremely high poverty rates. He is also assistant director of the Human Rights Clinic for Victims of Torture and founder and president of Doctors for Global Health. He explains that liberation medicine has its roots in theology, psychology, ethics, education and liberation movements. The clinic design is inter- and multi-disciplinary, community-oriented and bottom-up, risk-taking, compassionate, and uses a praxis—practice in action—model. Online resources include Social Medicine and the People’s Health Movement. In a discussion after his presentation, he stressed the importance of careful listening and action learning. He cited Daniel Levin, who was acting assistant US Attorney General when he voluntarily endured waterboarding to decide for himself whether it constituted torture. He decided it did and later lost his government job.
Health Disparities and Startling Similarities: Life and Death in Baltimore and Bangladesh
The United States ranks second out of 177 countries in per capita income—behind Luxembourg—but 34th in the survival of infants to age one. The United States spends $5.2 billion a day on healthcare, more than any other nation in the world, yet ranks 24th among the world’s 30 most affluent nations for life expectancy.
The US infant mortality rate is on a par with that is Croatia, Estonia, Poland and Cuba. If the rate were equal to that of first-ranked Sweden, 21,000 more American babies would have lived to see their first birthdays in 2005.
The US has five percent of the world’s population and 24 percent of the world’s prisoners.
Those numbers come from The Measure of America, 2008-2009, an extraordinary report produced by the American Human Development Project. Sarah-Burd Sharps, co-director of the project, explained the organization’s report maps the level of human development—described by life expectancy, access to knowledge, and a decent standard lf living—in terms of history, geography and congressional district. Ms. Burd-Sharps addressed last month’s Global Health Conference at Yale University sponsored by Unite For Sight.
It’s not only international disparities that are shocking: the report document stunning disparities within ethnic, economic and regional sectors of the US.
For example, Ms. Burd-Sharps said, Asian American women have a life expectancy of 88.6 years, whereas African-American women have a life expectancy of 76.3 years. Asian American men live an average of 83.6 years but the life-expectancy for African American men is 69.4, a difference of 14 years. The average life expectancy in Washington, DC, is 73.8years, whereas a person in Hawaii, where the life expectancy is 81.7 years, can expect to live eight years longer. The infant mortality rate in the nation’s capitol is 11.4 for every 1,000 live births. In Vermont the same rate is 4.7.
Ms. Burd-Sharps said US healthcare spending made up six percent of the gross domestic product in 2006, and 95 percent of that spending went to treatment rather than prevention. We ration care by who can pay rather than who is in need, she said, and the infant mortality rate suggests we do a poor job protecting future generations.
Rebecca Onie, JD, is co-founder and CEO of Project Health, an organization she helped create to break the link between poverty and poor health. The Project maintains family help desks in clinics in Boston, Providence, New York, Baltimore and Chicago, where trained volunteers work with healthcare professionals to identify conditions that impact patients’ health. They have food pantries and offer help, and follow-up, with applications for employment, food stamps or better housing. We tend to think of serious problems existing abroad, she observed, yet some challenges in US healthcare are strikingly similar to those in the developing world. Policymakers need to understand the need for infrastructure changes, she said. “Doctors know they are prescribing inhalers and antibiotics to children when there is no food in the house,” she said, adding that a February 9 article in the McKinsey Quarterly discusses the need for clinical leadership in healthcare.
In comparative terms, she said, “We have one doctor per 20,000 villagers in Sub-Saharan Africa, and domestically we have one social worker for every 16,000 visits to Harlem’s children’s hospital, and on the south side of Chicago 60,000 patients a year get the services of one social worker.”
She offered some dramatic parallels between Bangladesh and Baltimore:
In Bangladesh, life expectancy is 63.1 years. In Baltimore, it’s 62.5. In Bangladesh, there are 20 low-birth-weight babies—those who weigh under five pounds, eight ounces—for every 1,000 life births. In Baltimore, there are 15. In Bangladesh, the adult illiteracy rate is 52 percent, and in Baltimore it is 40 percent.
The Measure of America Report has a section examining the social, economic and environmental reasons for the infant mortality rates and life expectancy in Baltimore. A Baltimore Sun story by Annie Linskey reports a 20 year difference in life expectancy difference between an impoverished Baltimore neighborhood, where it is 63, and a wealthy section of town where it is 83. The Southwest Baltimore Health Profile 2008 published by the city department of health and the Johns Hopkins Bloomberg School of Public has similar analysis. The figures in different reports vary slightly because they are compiled differently, but similar stories emerge.
The US infant mortality rate is on a par with that is Croatia, Estonia, Poland and Cuba. If the rate were equal to that of first-ranked Sweden, 21,000 more American babies would have lived to see their first birthdays in 2005.
The US has five percent of the world’s population and 24 percent of the world’s prisoners.
Those numbers come from The Measure of America, 2008-2009, an extraordinary report produced by the American Human Development Project. Sarah-Burd Sharps, co-director of the project, explained the organization’s report maps the level of human development—described by life expectancy, access to knowledge, and a decent standard lf living—in terms of history, geography and congressional district. Ms. Burd-Sharps addressed last month’s Global Health Conference at Yale University sponsored by Unite For Sight.
It’s not only international disparities that are shocking: the report document stunning disparities within ethnic, economic and regional sectors of the US.
For example, Ms. Burd-Sharps said, Asian American women have a life expectancy of 88.6 years, whereas African-American women have a life expectancy of 76.3 years. Asian American men live an average of 83.6 years but the life-expectancy for African American men is 69.4, a difference of 14 years. The average life expectancy in Washington, DC, is 73.8years, whereas a person in Hawaii, where the life expectancy is 81.7 years, can expect to live eight years longer. The infant mortality rate in the nation’s capitol is 11.4 for every 1,000 live births. In Vermont the same rate is 4.7.
Ms. Burd-Sharps said US healthcare spending made up six percent of the gross domestic product in 2006, and 95 percent of that spending went to treatment rather than prevention. We ration care by who can pay rather than who is in need, she said, and the infant mortality rate suggests we do a poor job protecting future generations.
Rebecca Onie, JD, is co-founder and CEO of Project Health, an organization she helped create to break the link between poverty and poor health. The Project maintains family help desks in clinics in Boston, Providence, New York, Baltimore and Chicago, where trained volunteers work with healthcare professionals to identify conditions that impact patients’ health. They have food pantries and offer help, and follow-up, with applications for employment, food stamps or better housing. We tend to think of serious problems existing abroad, she observed, yet some challenges in US healthcare are strikingly similar to those in the developing world. Policymakers need to understand the need for infrastructure changes, she said. “Doctors know they are prescribing inhalers and antibiotics to children when there is no food in the house,” she said, adding that a February 9 article in the McKinsey Quarterly discusses the need for clinical leadership in healthcare.
In comparative terms, she said, “We have one doctor per 20,000 villagers in Sub-Saharan Africa, and domestically we have one social worker for every 16,000 visits to Harlem’s children’s hospital, and on the south side of Chicago 60,000 patients a year get the services of one social worker.”
She offered some dramatic parallels between Bangladesh and Baltimore:
In Bangladesh, life expectancy is 63.1 years. In Baltimore, it’s 62.5. In Bangladesh, there are 20 low-birth-weight babies—those who weigh under five pounds, eight ounces—for every 1,000 life births. In Baltimore, there are 15. In Bangladesh, the adult illiteracy rate is 52 percent, and in Baltimore it is 40 percent.
The Measure of America Report has a section examining the social, economic and environmental reasons for the infant mortality rates and life expectancy in Baltimore. A Baltimore Sun story by Annie Linskey reports a 20 year difference in life expectancy difference between an impoverished Baltimore neighborhood, where it is 63, and a wealthy section of town where it is 83. The Southwest Baltimore Health Profile 2008 published by the city department of health and the Johns Hopkins Bloomberg School of Public has similar analysis. The figures in different reports vary slightly because they are compiled differently, but similar stories emerge.
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