Felicia Chow, Shaoguan, Guangdong Province, China

March 2, 2011

Shaoguan, Guangdong Province, China

Medicine can be emotionally draining and neurology, even in the most developed country, is particularly heartbreaking at times.  In my time in Shaoguan, a city in the poor, rural northern region of Guangdong province, neurology seemed still more depressing.  One of the hospitals I visited in Shaoguan, the largest in the city, felt more like a factory than any of the previous hospitals I�d been to in Guangzhou, with over 2000 beds, of which nearly 200 were dedicated to patients with neurologic diseases.  The equivalent of the attending typically sees new admissions while old patients, many of whom stay for weeks at a time, are seen typically no more than once a week.  With that many patients, everyone gets short shrift despite the best intentions. 

On the second day of my visit, I watched as a husband and son pushed a patient of 47 years, dressed in pajamas with the recognizable blank stare of advanced dementia, into the admitting area.  She had the classic �marche a petit pas,� barely lifting her feet off the floor as she shuffled in tiny steps.  I kept looking around for the wheelchair that they had left at the doorway, but of course there was none.  I cannot imagine how long it must have taken them to walk her this way from their home. 

According to the team of physicians I was observing, the patient�s family brought her religiously to clinic every 1 to 2 months, each time asking what could be done.  When I met them, the son was clutching images from a recent brain MRI for which they had raised enough money.  Looking at her�mute, rigid, expressionless face and hands tightly grasping mine�I didn�t need the MRI to tell me that she had end-stage dementia, her frontal lobes slivers of cortex with symmetric subcortical white matter changes.  I tried to get a sense of what testing had been done in the three years during which she had become sick but none of the team seemed to know for sure.  I was surprised that they had tested her for HIV, which rarely enters the differential in China because the infection is supposedly so uncommon (a self-fulfilling prophecy, though; if you don�t look, you won�t know what�s there).  This time around, her family had clearly brought her in because they didn�t know what else to do for her, a point at which in the United States she would have received home services, a wheelchair at the least, or been placed in a facility.  Instead, the team started her on nimodipine given its �protective effects� in vascular dementia.  They said little to the family, for which I could not blame them as there were a hundred plus more patients to see.  When I left their bedside, the son scurried after me, thrusting a paper in my hand with his phone number, asking me to call if I had any more ideas for how to help his mother when I returned to America. 

I doubt there is much more medically we would have been able to do for her in the United States.  There may have been some rare bird diseases missed by the team (and even then probably untreatable), but more than likely this patient had an incurable form of dementia, one that in the United States we�d have little more to offer in the way of treatment.  And, of course, in the United States, we have social services, as inadequate as they may be, that help to alleviate the burden of caring for a loved one with end-stage dementia (and that you would think a communist government would also provide).  But what was so unsettling was that the family didn�t seem to understand this, that none of the doctors had stopped to explain to them that the patient had some terrible neurologic illness, a form of dementia that was clearly not reversible.  Or perhaps they had but the family had simply not grasped the extent of the discussion. 

There is something to be said for giving a family your best-guess diagnosis and prognosis and then helping the family to care for their loved one through a dignified death.  Maybe we only treat ourselves when we feel like we�ve done our best to help a family understand what to expect.  Practicing medicine in the United States, even in the worst circumstances, is a luxury, a pleasure.  

Read More

Felicia Chow, Guangzhou, Guangdong Province, China

February 21, 2011

Today I arrived in Guzhen, a small town in the south of Guangdong province about one hour from Guangzhou, to visit a community health program established almost 20 years ago for the prevention and control of chronic diseases. The Chinese government has heralded the program as a model for stroke prevention in rural China and has attempted to replicate the model in other impoverished regions of the country. Twenty years ago, the concepts of disease prevention and health promotion were foreign to China, as was the idea that investing in prevention up front would save money in the long run. A fortuitous combination of �right time, right place� and the dedication of a team of neurologists from Guangzhou Medical University, however, have transformed the town of Guzhen into a truly impressive example of public health at its best.

When the program began, two neurologists from Guangzhou Medical University, Drs. Xu and Liu, who have been tireless champions of the community health effort, traveled regularly to Guzhen to educate local health and government officials on the health benefits of disease prevention, while at the same time emphasizing social and financial incentives, eventually convincing the provincial and national government to invest in the program. They brought their own supplies from Guangzhou, including refrigerators and other lab equipment, and traveled by bicycle down dirt paths to visit one community health clinic (or �hygiene station� as they are called here) after another, training local health workers on how to take a neurologic history and do a neurologic examination, how to take a reliable blood pressure, how to run a lipid panel, how to choose a blood pressure medication and, most importantly, how to educate patients on these same issues.

Drs. Xu and Liu were local fixtures in the community, showing up to town meetings, school functions and other events where they helped to shift the mentality of local residents to understand the benefit of coming to the hygiene stations BEFORE illness struck. At first, the entire team was available to train and supervise during makeshift clinics in hygiene stations. Later, only one team member was available per hygiene station. Eventually, local health workers were flying solo with one of the team members from Guangzhou only checking in every few weeks to months to field questions and ensure quality control.

Initially, the team from Guangzhou paid 1 RMB out of pocket to local health care workers for each patient they were willing to see, essentially buying the cooperation of the local health workers in the hygiene stations. Now, though, as the program has become established it is backed almost entirely by the provincial and national government. Health care is nearly free for the entire community, including thousands of local farmers, with an annual copayment of only 3 RMB, the equivalent of less than $0.50. This year marks the first year that the hospital has turned a profit which is largely attributed to reaping the benefits of 20 years of prevention efforts. Their current goal is to ensure every adult over the age of 35, estimated to be about 45,000 residents, is enrolled and seen annually in clinic.

Because the provincial and national government are extremely invested in this effort, resources have been set aside for health education, including written materials that are plastered on most walls of the local hospital and hygiene stations, along with community classes for �hypertension and diabetes clubs� which focus on nutrition, exercise and medication management. Each night, thousands pour onto the beautifully lit main square to perform exercises and traditional Chinese dancing en masse. Even sales of chicken livers and other cuts of meat that are known to be high in cholesterol and fat have fallen since the program�s inception.

The model has been effective in large part due to the dedication of the neurology team from Guangzhou Medical University who for years volunteered their time and resources to make the program work. Drs. Xu and Liu knew that in order for their efforts to be beneficial, not only did they have to train the local health workers in Guzhen to be able to stand on their own, but the relationship with Guzhen had to be a mutual collaboration, as it has been and continues to be to this day. The question, though, is how to translate this model into a more comprehensive program for all of China, including the most rural and difficult to reach regions of the country. Some of what made Guzhen such a success holds true for the rest of China, namely minimal emigration from rural areas and the power of the totalitarian Chinese government to set public policy that is actually followed by the Chinese people. (As one of the neurologists I worked with told me, �For better or worse, when the Chinese government sets out to do something, there is no question that it can be accomplished.�) What makes Guzhen unique, however, is the boom economy that has stemmed from a relatively new and thriving light manufacturing industry. Without this extra financial cushion, even Drs. Xu and Liu who were staunch supporters of Guzhen long before anyone could imagine the public health success that the community enjoys today, are skeptical about the ability to replicate Guzhen elsewhere in the country.

Read More

Felicia Chow, Guangzhou, Guangdong Province, China

February 17, 2011



We saw 70 patients in one afternoon today in general neurology clinic. 70 patients, one attending and two students fresh from the basic science lab where Chinese medical students seem to spend most of their time. It was controlled chaos.

Some patients traveled all day from neighboring provinces including Hunan and Guanxi to come to clinic while others lived just blocks away. They lined up before dawn, even as early as the night before, in order to get a number that would allow them to be seen by the doctor before the clinic doors closed. Their patience, lack of any sense of entitlement and adherence are remarkable and lay the groundwork for the patient-physician relationship (although later I find out that the physician I am working with and the time she takes to build relationships with her patients are unique in China, atypical of the mindset of many other Chinese physicians, and thus the adherence of her patients is unusual for most Chinese patients). They are grateful for what she does for them, even in the average 5-minute encounter, and they work hard to follow her orders within the limitations of social, financial and cultural barriers.

The clinic is a microcosm for the rest of China, at least what I�ve seen in my short time here on this trip: overbooked, overcrowded, overwrought and overwhelmed. No matter where you go, there is no respite from the throngs of people in this city. I�ve been to some of the biggest cities in the world on most of the continents, but I still cannot get used to the scale of the population here, as millions push and shove their way past me in an attempt to get a seat on the subway or to clear a path up the stairwell. I am unaccustomed to this mindset of having to compete so hard all day, every day. I wonder what would happen if all billion plus people decided to wait in line instead of pushing their way to the front.

That the same holds true in the clinic, in the place where the masses come for medical care, should not surprise me. In a way, the fact that patients return week after week is a testament to the value placed on health prevention in certain aspects of the Chinese medical system and to the trust that patients place in the physicians who are willing to take the time to build a relationship, despite their unwavering attachment to Chinese herbs and cocktails of roots and other unidentifiable ingredients, some of which likely do have benefit. In another sense, the overbooked clinic underscores the weaknesses in the system. Most patients have to return weekly or bimonthly in large part because the Chinese government won�t allow physicians to prescribe more than a week or two of medications at any given time. Physicians� salaries are docked if the amount of medication prescribed is out of proportion to the number of revenue-generating examinations ordered. No different from in the United States, the really special physicians that I�ve been working with have tricks up their sleeve to try to get around these restrictions. They often write multiple prescriptions for the same medication and instruct patients to have them filled outside of the hospital pharmacy. It�s more difficult, though, to game the system in the inpatient setting where, when the cost of a patient�s stay exceeds the limit covered by insurance and the patient cannot or is unwilling to leave the hospital, the hospital will take what is needed to pay for services out of the attending�s salary.

In a country with such intellectual prowess and value placed on scientific and medical progress, it remains stunted by the policies of the government. For example, it is illegal for patients to go outside of the country for certain medications that cannot be obtained in China, even if they are readily available in easily accessible neighboring cities such as Hong Kong. It is also illegal to send blood samples out of the country for laboratory testing, even for research purposes. On the other hand, the power of a totalitarian government, if applied in ways that benefit the people, is pretty astounding, an example of which I will visit later this week in a small town outside of Guangzhou where the government has spent over 20 years cultivating one of the strongest and most successful chronic disease prevention programs in the country.

There is an upside to requiring patients to return to the clinic with a frequency that we would never, could never accommodate in the United States. The model is akin to �weekly observed therapy� but instead of sending out health care workers to locate patients in far-flung corners of the world�s most populous nation, we�re lucky enough that the patients come to us, week after week. Some patients have literally been seen every week for nearly 10 years since their stroke, now transformed into a walking advertisement for secondary stroke prevention with perfect blood pressure, lipid and diabetes control.

For most of the patients who are follow ups, like speed-rounds, we take 1.5 minutes to review symptoms (�Any new stroke symptoms, any seizures, how�s the headache?�), 1 minute to do an abbreviated version of medication reconciliation as we root through the bag of medications they�ve brought in, discarding those that they should not be taking, 30 seconds to take their blood pressure, 30 seconds for a breezy neurologic exam and then 1.5 minutes of scanning any new labs or other studies and then counseling before calling for the next patient. By seeing patients on a weekly basis, blood pressure control, for example, becomes a precise science, very different from when we see stroke follow up patients in neurology clinic once every few months, at best.

(Not surprisingly, there is no privacy in clinic. Despite valiant efforts by the medical students to maintain crowd control, patients and their families hover over us as we see patients. We ask about bowel function and sexual dysfunction with more than 20 people looking on. I keep looking for a curtain to draw but there isn�t one.)

As with everything in China, the question remains as to how to disseminate the practice of health promotion and disease prevention beyond the clinic doors of a few very special and wise physicians, primarily located in the large cities. Strolling down the glittering streets of Guangzhou where China�s rapid development and growing wealth are apparent, the widening gap between rich and poor is hard to miss. Caring for all of this country�s patients, a billion strong, will be one of China�s most formidable public health challenges in the years to come.

Read More

Poveuy

Hasan Merali, MD

On the way to Poveuy, Tonle Sap Lake, Cambodia

I went to visit Say-la last weekend but she had already been discharged. She had her echo done and it turns out she has aortic stenosis. The physician who saw her recommended a follow-up echo in one year. All of her care while in the hospital was provided at no cost by the Angkor Hospital for Children transportation back to her village was provided by The Lake Clinic.

Our regular boat is now in Phnom Penh where the water levels are higher so this week we had the pleasure of taking the 'small boat'. The small boat is a wooden boat that is about 7 meters long. It has no seats, just wooden planks where we placed some plastic chairs for the journey. There is an outboard motor which is so loud that we cannot have a conversation during the trip. The motor can push the boat along at 10 km/h but we were further slowed by the fact that we had to tow another boat that carried all of our medical supplies. At one end of the boat there is a 4 sided tin structure about 0.5 meter high and only enough room inside for a Cambodian child. One side is a door, and in the center, on the floor, there is a hole directly into the lake. This is the toilette.

The 9 hour (3 on land, 6 on water) journey is uncomfortable but much more beautiful as we navigate the smaller water ways covered with aquatic plants. There are a countless number of different birds along the way gracefully catching fish and flying away. In Pouveuy there is an old temple which has survived hundreds of years and will be the site for our clinic. We are greeted by the monks living there and they offer us some floor space to sleep. It is almost evening time so we quickly set up our mosquito nets and climb inside. Unfortunately, the mosquito nets cannot cover all of the cracks in the tiles so I am soon covered with tiny black ants. Monks, of course, respect all living beings so I just lie there and let the ants go about their business. Black ants don't bite, I think to myself, only red ones do.....

I am awoken the next morning at 5 am to the sound of screeching. As I look up, there are hundreds of bats all flying into the tower of the temple. My legs feel painful. I look down and see dozens of open sores. It turns out that black ants do bite.

Clinic in Poveuy was fantastic. One day, we saw a TLC record number of patients - 180 between the three of us. It's wonderful to see how much trust, and what a good reputation TLC has built among the communities. Several families also traveled from surrounding smaller villages to see us. It was so busy, in fact, we even a small group of women protest that they weren't being seen in order. This was the first time this had happened. I knew that with two generalists around, it would slow down clinic even more if I needed to look things up and ask Dr. James or Dr. Sambun questions anyway, so I asked Savanh to only send me pediatric patients that day. Savanh tried to explain to the women that the reason why some children were ahead of them was that this doctor only sees children. They looked at me confused/there was something wrong with me. I smiled at them as I held up a baby.  They seemed accepting and a few mintues later they were seen by Dr. James.

Entrance to Poveuy Village, Tonle Sap Lake, Cambodia

Although it is 36 C everyday and we are surrounded by water, I have resisted the temptation to jump in the lake due to the two species of crocodiles and several different kinds of water snakes that live in Tonle Sap Lake. This week, however, without even the simple fan we had on the larger boat, I decided it was time. The water was only about a meter deep and I quickly began sinking into the cool mud. It was quite refreshing. Savanh taught me how to dive for snails and how to choose the best ones which we later ate with lime and chili sauce. I had a quick bath and hoped out. It doesn't matter what color the crocodiles are, they will bite me.

Being here for a month, my Khamer has improved significantly. �Min ____ day?� is the basic question for "Do you have _____?" and I can fill in fever/cough/vomiting (gadou cloon, ke ah, go-od) etc. I know how to ask about age, time course of illness, sick contacts, and a few other relevant details. This has been quite useful as Dr. James and I often have to share one translator (our �translators� are a nurse and a midwife who are busy doing their own work when we see patients). On the weekends when I am back in Sieam Reap, however, I have not found my language skills very helpful. "Do you have diarrhea"? will not help you locate a toilette, order food, or find a guest house.
  

I am sad to be leaving this weekend and truly wish I could stay longer. After working in several different countries, this has by far been the best experience for me. I learned a lot in 4 weeks and have been inspired to work on my physical exam skills that are so important when no diagnostic tests are available. I have also been thoroughly confused by some of the skin findings I have seen and would like to do a dermatology elective and read much more about dermatology when I return to Boston. If anybody is interested in working at The Lake Clinic, please let me know if you have any questions. They are especially in need of a dentist.

http://www.lakeclinic.org/

Read More

Say-la

Hasan Merali, MD

Tonle Sap Lake, Cambodia

This week our destination was Poveuy. Poveuy is the furthest village that TLC serves. It is located on a sub-lake of Tonle Sap, called Tonle Chma. Currently, a narrow, shallow channel of water separates Tonle Sap and Tonle Chma but in a few weeks this channel will dry up and create two separate lakes until the rainy season begins. To reach Poveuy, we must travel through Preambang, the village we worked in last week.
 
After passing through Preambang, we reach the channel leading to Poveuy. We go as slow as possible but after just a few minutes we are stuck in the mud. There is no one around to help so we all spend about 45 minutes using oares to get the boat free. Finally after much effort we are back afloat. The decision is made that we cannot cross this channel and will have to come back next week with a small boat to reach Poveuy. We turn around and head back to Preambang. Closer the village we get stuck again. Luckily this time we are in view of some of the villagers and few men come in one of their boats to tow us out. The sun is just setting and we decide it is not worth going on any further just to get stuck again, in the dark. We drop the anchor and rest there for the night.

Since we are already in Preambang we decide to see patients there. We set up our clinic in the 2nd level of the school. Since we were just in Preambang last week, we were not expecting a big turnout but we were pleasantly surprised when 123 patients came that day! This was the most patients we had seen in one day, and it was only Dr. James and I as Dr. Sambun had gone to another province for a meeting this week.

The most interesting patient I saw was Say-la, a very cute 12 month old girl with a systolic heart murmur. She had been seen two times previously, at 7 months and at 10 months. The murmur was noted both times, but she never had any further evaluation other than a physical exam. We have Cambodian adjusted weight for age growth charts and she was at the 20th percentile. I felt that she needed an echo-cardiogram to evaluate the structure and function of her heart and tried to explain this to her young parents with the assistance of my translator. Their main concern was that they had no money for travel, accommodation and food while in Siem Reap. I assured them that TLC and the Angkor Hospital for Children would provide everything at no cost. They assured me that they would go next month but Savannh, our nurse, told me that that's what they had said before. I tried my best to convince them that I thought it was important that she come with us the next day but her parents were unconvinced. I then had our midwife, Sri Mom try, and finally Savannh tried. After about at 30 minute conversation between them the parents decided that they would go and speak to their family and then return in the afternoon. Perfect, I thought to myself, but they did not come back.

I was frustrated that the parents did not return, but I could completely understand why. If a few complete strangers asked me to trust them to take my baby on an 8 hour journey to a city I had never been to (or any city for that matter) where I didn't know anyone, I would probably be scared as well. My plan was to return to Siem Reap and talk to others with more experience as to how I might convince this family to come with me.

The next morning I sat quietly on the bow of the boat as we slowly departed Preambang. Something wonderful happened. Say-la's parents were waiting outside their house ready to go! I was so excited. They brought one plastic bag with them and hopped on our boat. Say-la was happy and playful as usual and she made the 8 hour journey back fun for all of us. Why didn't I bring any toys? It didn't matter too much because when you're one years old, a lot of things can be fun. For Say-la it was water bottles. Between water bottle games and naps, she made the time go by much faster and soon enough we had her and her parents registered at the Angkor Hospital for Children. Hopefully she can get all of the testing finished before we leave again on Tuesday and then we can bring her back home.

Read More

Where are the Doctors?

by Leana S. Wen, M.D.

Of the 29 graduates of the emergency medicine training program that I�m interviewing here in Cape Town, South Africa, 5 are living and working abroad, in the U.K. and Australia. That may not seem like a lot, but these are already from the select pool of individuals who chose to stay in South Africa for their post-graduate medical training. Many more South Africans leave after medical school to seek higher-paying positions in developed countries.

Why do they do choose to leave? It�s for the same reason that qualified professionals from throughout the developing world leave their home country: to seek better opportunity and better pay. On the individual level, this pursuit it completely understandable. I�m the child of immigrants who came from China to seek a better life; I am only where I am today, a resident physician in the U.S., because of choices my parents made.

On the systems level, the exodus has created health systems that are deficient in doctors, nurses, and other health professionals. When I was in the Congo a few years ago, the going joke was that there were more Congolese doctors in Washington D.C. than there were serving the entire 68-million population of the Democratic Republic of the Congo. The motivations of individual doctors to leave the Congo was very much understandable�the country was in the midst of civil war! But their departure left the country without a functional healthcare system.

The problem of the global brain drain is described in some excellent papers, and Professor Fitzhugh Mullan among others are working on solutions that take into account individual preferences while also building systems solutions. There are two main issues that need to be addressed. Capacity within the developing country needs to be built. We�re talking the basics like security, but also salary needs to be sufficient, and the type of practice needs to be adequately attractive to retain doctors. In South Africa, for example, there need to be enough consultant posts for these EM graduates�otherwise they will go elsewhere to practice the skills that they were trained to do.

There also needs to be policies in place for developed countries to prevent dependence from doctors trained in the developing world. Currently, the U.S. relies on foreign medical graduates to supply its workforce, with 1/3 of all residency spots filled by graduates of non-U.S. medical schools. Foreign graduates have much to offer our country, and yes, the U.S. is also experiencing a workforce shortage. And yes, we do want to provide opportunity for foreign graduates to train and, if they choose, to establish a better life in our country. But we should take care to not have a policy that effectively poaches the few qualified doctors of a developing country whose services are needed far more there. The U.S. (and our partners in the U.K., Australia, Canada, etc) need to develop more training programs to ensure that we adequately provide for our own workforce.

In South Africa, there are two other workforce issues that should resonate with those of us from developed countries as well. The first is that the private sector continues to offer far more lucrative options than the public sector. What can be done to retain the best and brightest to serve the more than 80% of people who rely on public provision of care? The second is the training of other healthcare providers. The vast majority of care in the country takes place in rural settings that are staffed by nurses and mid-level providers. What kind of training can be done to improve the quality of care in these rural areas, and not just in the cities? Other than compulsory service, what can entice qualified doctors to work in these settings?

My final reflection is that almost every single doctor I�ve talked�including the ones who immigrated�genuinely want to be in South Africa. South Africa is home; they want to improve care for their home, their people. Those who left express a lot of regret, and say that they wish the posts were available for them to come back and fill them so that they can continue to improve health care in their country.

My time in South Africa has been invaluable, and I thank the Partners COE for making my trip and this research possible. I look forward to returning. Please send your thoughts and comments on my posts. Thanks for reading. Wen.leana@gmail.com.

Read More