Global Health at Home: Caring for Migrant Families on their U.S. Arrival

The American Academy of Family Physicians (AAFP) sponsors an annual Global Health Summit. This year’s conference, in Albuquerque, NM, was the largest so far. The conference started primarily as a venue for family physicians who volunteer their time abroad, providing health care and teaching in generally less developed countries. These were for both long (a year or more) or short trips, often sponsored by religious organizations. They also can include work done through government (eg, Peace Corps) or non-governmental but non-religious organizations (eg, Partners in Health, Doctors without Borders, Doctors for Global Health), but the religious root of much of this work is still apparent in the use of the term “mission trip” for most short-term such activities, especially involving medical students or residents. Overall, most such organizations, including those largely or partially sponsored by churches or religiously-affiliated organizations, no longer make religious proselytizing or efforts to “convert the natives” a significant part of these trips, and focus instead on health care and health system development (although there are certainly exceptions). Many of the leaders in this field are also involved in development of health systems in countries across the globe and in international health organizations and efforts including WONCA (the World Organization of Family Doctors), the World Health Organization (WHO) and its sub-groups such as the Pan-American Health Organization (PAHO), and The Network-Towards Unity for Health.

While such international work remains the mainstay of global health activity, there is also increasing interest in addressing needs in the US. To some degree, this reflects a long-standing discussion regarding the degree to which many doctors and students are more interested in going abroad on such trips than providing care to the needy at home. Of course, this need not be a contradiction, and many of the most active physicians in global health also spend the bulk of their time in the US working with underserved communities. But there are also those, including many students, who are attracted to such trips for other reasons. These include “medical tourism” – using the trip as an excuse for an exotic vacation, particularly if the place they are going is near beaches or mountains. They also include what might be called “medical opportunism”, where students go because they will get to do things to people on these trips that would be forbidden for them to do in the US, especially procedures. On the positive side, they can, provided the physicians or students are open to it and do not just talk to each other and can go beyond the “we are here to help you” mentality, allow learning and increase intercultural understanding, as well as increase knowledge of conditions that are more prevalent in the developing world. In addition, some of these conditions, as a result of the climate crisis and other factors, are moving north into our own country, so we see Chikungunya and dengue and other formerly tropical diseases. The key distinction is in how these trips are approached; they should be of benefit to you, but are not, ultimately, about you, but about collaboration with people, and health care providers, in other countries.

One increasing area of interest that tends to bridge this US/international divide involves the care of migrants coming to the US, an issue that has becoming increasingly front and center over the last few years. While the care is done in the US, the people are coming from other countries; in the case of our southern border primarily Central America and Mexico, but people come from all over the world. Several presentations at the Global Health Summit addressed different aspects of “Border Health”, each of which is important and each of which creates the need for linkages with other aspects of the health system. One is the care of people who permanently live along the US/Mexico border. The border, of course, is artificial, and many families live on both sides including Native Americans, such as the Tohono O’odham of Arizona, whose reservation crosses the border. This is a special case of care for the poor and underserved. Another is the care of people who are migrant workers, who may “live” in the border area for much of the year, but move to other regions of the US to follow the harvest. This creates the need for linkages with migrant health providers across the country. A third is the care of just-arrived migrant families who present at our southern border and may spend just a few days in our border communities before moving on to other parts of the US where they have sponsors. This creates the need for communication with appropriate health facilities in those areas, both for general health care and “warm hand offs” for individuals with particular needs. Such needs include those with ongoing chronic diseases often made worse by the journey, acute but severe issues such as injuries (including traumatic amputation by trains) and acute renal failure from dehydration crossing the desert, pregnancies (especially those that are high risk), and newborn but small or premature infants, etc.

“Global Health at Home: Caring for Migrant Families on their U.S. Arrival” was the title of a presentation by three Tucsonans who volunteer at the Casa Alitas migrant shelter, Anna Landau, MD MPH, Patricia J. Kelly, PhD MPH FNP, and myself. Originally accepted as a seminar, it was “upgraded” to a plenary presentation when the originally scheduled Ostegaard Speaker, Michael Kidd of Australia, was unable to attend due to family issues. While it was an honor to be selected, it was also gratifying to note the level of interest among the participants, from those doing similar work in cities on the border such as San Diego, El Paso, and Yuma, AZ, to those across the US who see these people as patients in their home communities, from big US cities to small towns in SW Georgia.

I have attached the slides in 'Links to Documents', found on the right side of the blog screen. It is important to recognize that medical care, which given the fact that guests are usually present for only 1-3 days, follows a public health model of dealing with acute needs and screening for infectious disease, is only a small part of the Casa Alitas operation. Hundreds of volunteers – and all are volunteers -- work on food preparation and service, contacting sponsors and arranging transportation, collecting and sorting and distributing clothing, doing laundry, driving guests to the bus station, and the multiple other needs that migrants have. I would also like to quote some parts of an email sent out by the Reverend Delle McCormick, a long-time leader in working with migrants in Tucson, after the recent move of Casa Alitas, which she has given general permission to share widely:

Every day is a triumph of small steps toward smoothly operating, warmly encouraging, just and loving spaces for our guests and volunteers. We have fallen for this new place and time. With each move we get more nimble, creative, and courageous in what we do together. Love shines here….Despite new draconian immigration policies at the border, we still have received 2484 men, women, and children at our new Casa Alitas Welcome Center shelter, making a total of 17,418 since October of 2018 when we stepped up our efforts to provide shelter for families seeking asylum.

Our volunteers still provide extra touches to encourage the human dignity and rights of every person who passes through our door. We hear and hold the most harrowing of stories: from 80+ year-old Sra. T. who stayed with us for a month because we couldn’t locate her sponsor, to the young man who had his toes burned off because he couldn’t pay for his release from kidnappers, to the woman who was shot in the head by her husband, to the daughter whose 68 year-old mother, who is blind, was detained, to the teenager kidnapped and prostituted and beaten by the local gang,  to the many, many others, each of whom has harrowing stories that drove them to leave everything behind to seek asylum.

If anyone is interested in learning more about the work in Tucson at Casa Alitas, in coming to volunteer, or in donating, more information is available at the website https://ccs-soaz.org. Donations can be made directly to CCS at  Support Migrant Aid - Tucson and through its GoFundMe page https://www.gofundme.com/casa-alitas-for-migrant-families.

Hospitals increase cost of health care...and pick and choose what they market to whom

The greed of pharmaceutical and insurance companies is the stuff of legend. There can be no justification for the huge costs that the American people have to bear as a result. Their administrative costs and profits alone are unconscionable and drive up the cost of health care so much that it takes a completely self-serving and willfully ignorant Democratic presidential candidate to disingenuously ask “how will we pay for” Medicare for All – and we  have a lot of them. The financial cost is, however, is not the most evil part of what they do. That would be the deaths and disability and bankruptcy that affects so many Americans because the insurance companies deny them care and the pharmaceutical companies make their drugs unaffordable. (This is a mild term for drugs that can cost $30,000-$100,000 a year and more!)

I have written about these issues many times. More recently I have also written about the role that providers (mainly hospitals and “health systems”, but also some physicians, nursing homes, etc.) play in the two-pronged scandal of the US health care system – too expensive and too unavailable to too many. There are some hospitals (I include “health systems” but will use “hospital” to avoid confusion with the “health care system”) that are actually for-profit, but most are officially “non-profit”. This means that they don’t have shareholders – and don’t pay taxes – but they otherwise behave just the same, trying to make as much money as possible. They say that they plow this back into the services that the hospitals provide, but it also includes salaries for C-suite executives that look just as outrageous as those in the “for-profit” sector.

More important, the “improvement” in services does not always – or even usually – create new services that were absent from the community previously, or make them available to more people than previously, say the poor and uninsured. They are usually efforts to attract insured, paying, profitable patients away from other hospitals by building a new, fancier cancer center, or heart center, or orthopedic center. Hardly ever pediatrics (except neonatal intensive care) or mental health – they only want to expand those services that are big profit centers. In this way, it is parallel to the behavior of drug companies; they prefer to minimally modify existing big sellers to get a piece of that market (“me-too” drugs) rather than to develop drugs to meet needs not currently being met.

It is good to see the hospitals being called out by major health system critics. Elisabeth Rosenthal, president of Kaiser Health News, wrote an important article on September 1, 2019 in the New York Times (where was once the health reporter) titled “That Beloved Hospital? It’s Driving Up Health Care Costs”, in which she makes many of the same points. She writes that

Data shows that hospitals are by far the biggest cost in our $3.5 trillion health care system, where spending is growing faster than gross domestic product, inflation and wage growth. Spending on hospitals represents 44 percent of personal expenses for the privately insured, according to Rand.

A report this year from researchers at Yale and other universities found that hospital prices increased a whopping 42 percent from 2007 to 2014 for inpatient care and 25 percent for outpatient care, compared with 18 percent and 6 percent for physicians.

The reason, of course is the political clout that the big hospitals can buy (with, of course, our money!).The Democratic presidential candidates are beholden (with the exception of Sens. Sanders) to both hospital contributions and the role of big hospitals as major employers and economic drivers. “In 2018, PACs associated with the Greater New York Hospital Association, and individuals linked to it, gave $4.5 million to the Democrats’ Senate Majority PAC and $1 million to their House Majority PAC. Its chief lobbyist personally gave nearly a quarter of a million dollars to dozens of campaigns last year.” Could this have anything to do with why “The cost of a hospital stay in the United States averaged $5,220 a day in 2015 — and could be as high as over $17,000, compared with $765 in Australia”? Ya think? Ask you politicians what they are going to do about it…

The media, including Kaiser Health News, has been running stories on hospitals that are aggressively pursuing lawsuits against patients who have been unable to pay their bills. On September 3, 2019, the Times ran a long piece on the poster child for this practice, Carlsbad Medical Center in New Mexico, in “As Patients Struggle With Bills, Hospital Sues Thousands”, but Carlsbad is by far not the only one. The practice is most common in towns with just one hospital, and of course, patients do not know how much they owe – or for what. It doesn’t matter if you are insured: “Ms. Price, 40, a nurse and local 4-H leader, has been sued five times by Carlsbad Medical Center, for bills totaling more than $17,000….Ms. Price said she had never received an itemized bill outlining exactly what she owed money for. The collection agency wanted the balance in full, and she was not able to work out a payment plan until after she was sued.”

This article names other hospitals that sue patients as a core business practice, and mentions over 20,000 suits in Virginia. Turns out that this was in no small part driven by the state-owned University of Virginia hospital in Charlottesville, documented by the Washington Post and MSN in “‘UVA has ruined us’: Health system sues thousands of patients, seizing paychecks and putting liens on homes”. In a quick response, the Governor of Virginia and the University vow to stop suing patients, but this has apparently not affected those already sued: ‘“Fixing the problem “is complicated,” in part because “we are legally obligated as a state agency to collect debts,” he [UVA president Ryan] said. “But we have discretion within those legal constraints to make our system more generous and more humane.”’ It also has not hurt the CEO of the hospital “…Pamela Sutton-Wallace, who will leave in November to join New York-Presbyterian Hospital as a senior vice president”. Maybe she can teach them to sue their patients…

Many of us have sort of emotional attachments to our local hospitals, where we were born, or delivered our babies, or had our life-saving surgery or other treatment; for which we raised money through bake sales and car washes, or maybe volunteered in the gift shop. But these are not the warm fuzzy hospitals you remember. Rosenthal acknowledges that many rural hospitals are in financial trouble – and they are – but supporting the fantastic (“non-”) profit of these major hospitals is not going to change that. As in every other sector of society, we have two classes of service. One is to those in major metropolitan areas with money or good insurance, with conditions that are highly-profitably reimbursed, like cancer. Preferably all of the above. There is no limit to what will be invested in them. Then there are those without money, or good insurance, who live in rural areas, or have problems that are not well reimbursed, like mental health or substance use. They will not get investment. Simple as that.

Major hospitals are big businesses and act like it. You are a customer – but, compared to other industries in which you are a customer, a particularly uninformed one. Need a car? A refrigerator? Financial services? Dental care in Mexico (had to get that one in)? You can find out what it will cost and compare prices. Hospital care? In the US? You gotta be kidding.

The answer? Improved an expanded Medicare for All, a single-payer system in which, as in Canada, hospitals get global budgets, and separate capital budgets so that they cannot use the money (profit) they earn on your care to build spas to attract high-paying patients from competitors. Where everyone gets the care they need, and no one gets excessive care. Possible? Too expensive? Ask the Canadians. Or Australians, where the average hospital bill is less than $800. Or British, or French, or Swedish, or Danish, or Dutch, or German, or Taiwanese….

Some medical care may not help. Alternatives may not either.

‘Why Doctors Still Offer Treatments That May Not Help’, by Austin Frakt in the New York Times, August 27, 2019, is a well-done article that, despite its title, is fairly optimistic. He reports that while about 50% of current medical treatments no not have good evidence supporting them, only 3% have evidence showing them to be harmful, and another 6% unlikely to be helpful. This means about 41% (or only 41%, if you prefer) have good evidence that they are helpful.

Frakt cites some of the research on health interventions that do not work, or may even harm, quoting leading researchers Vinay Prasad and Adam Cifu (although he does not mention John Ionannidis, arguably the father of the field). He discusses the important “Choosing Wisely” campaign, initiated by the American Board of Internal Medicine Foundation, that asks each medical specialty society to identify at least 5 things often done in their specialty which usually should not be done. There is not, however, always consensus. For example, among its 20 recommendations (a high number that continues to grow, perhaps because of its discipline’s broad scope), the American Academy of Family Physicians (AAFP) recommends against imaging (including MRI and CT) for uncomplicated back pain, as does the American College of Physicians (Internal Medicine) (see ‘Medicine should not be primarily a business: choosing appropriate care for all, not excess testing for some, August 19, 2018).  Yet, neither the American Academy of Orthopaedic Surgeons, or the various groups of radiologists who perform these procedures, make this recommendation. Of course, both stand to benefit financially from doing these procedures.

It is concerning to think that, at least in some cases, financial benefit may influence the selection of some medical societies’ “Choosing Wisely” recommendations. Sadly, it is not a surprise, and financial benefit is, I believe, the reason for the use of many unproven treatments. Another important reason is an understandable reluctance for providers to abandon therapies that they have used for many years and believe to be successful. After all, if 50% of treatments do not have good evidence that they help or harm, many probably often do help, even if most of the evidence is anecdotal. Much more malicious, however, is the intensive marketing of new drugs and therapies to physicians by drug and device makers with a strong financial profit motive.

Frakt provides a litany of therapies-since-found-not-to-work-or-even-do-harm, including hormone replacement for post-menopausal women. The only drug he specifically names is Vioxx®, the “miracle” anti-inflammatory pulled from the market when it was found to cause heart disease (at least publicly found; the manufacturer actually knew it before it was released!). He also mentions “tight blood sugar control in critically ill patients” (and actually, probably most patients). This certainly relates to drug. The plethora of new, expensive, and marginally advantageous diabetes drugs is a testimony to their profitability. Ironically, it is often the same physicians who are unwilling to give up on treatments that are unproven or even proven to be of no benefit or of harm who are the first to begin using new (and, redundantly) more expensive drugs heavily promoted by the manufacturers.

Of course, it is not just diabetes drugs that are expensive. Compared to some of the newer drugs for rare diseases they seem like a bargain. In “The $6 million drug claim”, Times writers Katie Thomas and Reed Abelson discuss a woman who has $1 million in drugs to treat her condition in her refrigerator! While in her case they were paid for by her husband’s union, the cost can still be backbreaking: “At one point in 2018, for every hour that one of the union’s 16,000 members worked, 35 cents of his or her pay went to Alexion to cover the Pattersons’ prescriptions.” And what about those who have poor insurance, or no insurance? Or a union that goes bankrupt paying for them? Alexion, of course, does well, though.

A new law allows “gravely ill” patients the “right to try” drugs that the FDA has not approved. It sounds good; as a friend told me “I figure if I’m going out and they want to try something that might kill me I haven’t got much to lose. At best I’m cured. At worse, I go out but knowledge is gained.” Except for maybe dying sooner or more painfully, or possibly going bankrupt. It is not uncommon for doctors to suggest something new, unproven, or even a treatment that has already failed, one more time. Not everyone in this country has good insurance, and if your insurance company appropriately refuses to pay because there is no evidence of efficacy (yes, they are sometimes right!), you are on the hook for the bill. You may be dying, but your family may need the money you were saving for retirement. Thus, there may be a great deal to lose.

A certain percentage of people will take all this to mean that mainstream medicine is not to be trusted. This is definitely an overreaction, although a healthy skepticism is warranted, especially when the treatment is incredibly expensive and it is obvious that somebody (or some corporation) is making a killing on it. Some people will decide to pursue only what used to be called “alternative” medicine. These practices, often with hundreds or thousands of years of experience, are often called “complementary” and are now frequently offered along with mainstream medical therapies in “integrative” practices. But the same cautions must apply; because something is different, or traditional, does not make it necessarily either effective or safe.

For example, while people sometimes believe it is safer to choose only “natural” medicine, because a therapy grows in nature does not mean it is necessarily safe. Earlier in my career, medicine virtually abandoned the use of digitalis, made from the natural plant foxglove, to treat heart disease, after it had been used for decades. The key point is that if a substance works biologically and has “good” (i.e., desired) effects it can also have “bad” (i.e., undesired, or “side”, effects). This is true if it is straight from the plant, modified and standardized, or completely created in the laboratory.

Another real danger is what Frakt calls “wishful thinking”. Being optimistic and hoping that things will turn out well is good, and often useful when confronting serious illness. But when this transitions into the realm of “magical thinking”, being convinced that something good will happen to you because you want it to (or vice versa, that something bad will not happen because you don’t want it to), or believing a treatment will work because it is “natural”, or because your doctor recommended it in the absence of evidence, it is a real risk. “Magical thinking” is normal in three year olds, but dangerous in adults.

So what to do? Be open to new treatments, but do not reject the old, whether “traditional” or medical. Ask for evidence for treatment, such as when just changing a drug from an inexpensive standard (say, metformin for diabetes) to a new, costly one. Learn to understand probability, and ask for numbers. Do not reject anything out of hand, but do not believe that something will work just because you want it to.

Stay skeptical but not intransigent. Look for the evidence. And look also, when something is expensive, for the profit motive. Cui bono? It may not always be you.

"Medicare for All" means ALL -- Accept no substitutes!

Let’s start with the good news. “Medicare for All” is definitely trending. It is the central domestic issue for the Democratic primary. This is because of the absolute crisis in the health system. It is also, let us remember, because of Bernie Sanders, who has supported a single-payer universal health system for decades and made it a central part of his 2016 presidential campaign. He didn’t win the nomination, but he won the battle of ideas, which is why it is so important in this campaign.

People love the idea of being covered for their healthcare needs, and having that coverage untethered from where they work (assuming that where they work provides health insurance), whether they can work if they have been laid off, can’t find a job, or are disabled, or whether they are quite old enough to qualify for Medicare, whether they are quite poor enough to qualify for Medicaid (and let’s be straight, you have to be REALLY poor, even in the most generous states, and in some states it is just ridiculous). This is because the current healthcare system in the US really stinks. A huge percentage of those who are insured have terrible coverage, those who have reasonable coverage pay (often along with their employer) an extremely high amount for that coverage in premiums, deductibles and co-pays, and an unconscionable number of Americans are completely uninsured. The health outcomes in the US are terrible, trailing all other developed countries (discussed here many times). The only thing we lead in is the cost of the system, and of course the amount of profit made by the predatory components of it such as insurance companies, drug companies and some providers – which is of course totally related to why it costs so much.

An excellent example of the insanity of our current profit-driven system is provided by the Kaiser Health Network and covered by CBS Morning News and the medical news site “Medscape”, detailing how a dialysis patient received a half-million dollar bill because the dialysis center he went to, which was closest to his home (70 miles) was “out of network” for him. This particular patient will probably have his bill written off because of the extensive national coverage, but it happens all the time; it is the norm, not the exception. No wonder people are fed up!

The less good news is that, although most of the Democratic presidential candidates (notably excluding front-runner Joe Biden) have endorsed the words “Medicare for All”, their proposals are all over the place. Most of them do NOT guarantee universal coverage, not to mention the necessary expansion of benefits (“Improved and Expanded Medicare for All”) needed to ensure that the American people get ALL the health care that they need (including mental health, vision, hearing, long-term care, substance abuse treatment, etc.) The New York Times, which has made a crusade of limiting coverage of Bernie Sanders and trying to minimize or denigrate him when they do cover him, and is also an opponent of truly, universal, comprehensive single-payer health care, does have a very useful graphic in an article originally from the “Upshot” in February but in the print edition of August 13. It portrays the characteristics of many of the health plans proposed currently, and makes clear that only two, those sponsored by Sanders in the Senate and the bill in the House with Pramila Jayapal (D-WA) as the primary sponsor and over a hundred co-sponsors, actually would provide what we need.  

A clear exposition of many issues, including facts misrepresented about universal single payer, is summarized in an elegant piece in the Washington Post by Rep. Jayapal. It is an excellent point-by-point response to various criticisms and concerns that have been raised, and is well worth the time to read, even if you don’t have time to read the whole bill (Medicare for All Act of 2019).

Two of the most important criticisms to which she responds are particularly telling, since they are deeply tied. One is that people want to be able to keep their private insurance (presumably those who have, or possibly mistakenly think they have – good insurance). The “evidence” provided for this claim is that the percent of people who say that they support “Medicare for All” goes down if the question “even if you have to give up your current insurance” is added. Of course, the question is misleading; when people are told that they would be fully covered for everything, with no co-pays or deductibles or co-insurance, and that they will have completely free choice of providers, this objection goes away. Let’s be honest; no one cares about having a choice of which insurance company will deny them what they need; this is a nonsense concern. And, yet, this is driving the proposals of some presidential candidates and members of Congress to do a less-than-universal solution, some version of Medicare-for-More, or “buy-ins” or expansion of Obamacare.

The other objection, “how will we pay for it”, is also frequently heard, even from those who know how but just don’t want to accept it. The answer is very closely tied to the answer to the question above, because the cost only becomes impractically expensive if insurance companies – and their overhead and profit – are built back into the equation. A comprehensive Medicare-for-All program, when fully implemented, will be funded by the money that Americans and their employers pay for health insurance currently, including all the money spent by the federal government and states on Medicare and Medicaid, supplemented by additional taxes on corporations that do not already provide comprehensive insurance and on the wealthiest Americans. Yes, most people’s taxes would increase, but for the vast majority, the increase would be far less than they pay now in insurance premiums, co-pays, and deductibles, and would “buy” them comprehensive care for all medical problems with no limited ‘panels’ of providers. Those who would pay more can well afford it. But the key here is not having insurance company profit and overhead built into the system; this is one big reason that the US health care system is so expensive, and leaving it in makes it much less affordable. To suggest such solutions is like saying “the cost of business is so high, especially including payoffs we make to gangsters for protection -- but of course it is really important that any new system we develop include those gangster payoffs!”

Why would many pundits and “liberal” media outlets like the NY Times, CNN, etc. want to create such confusion and undermine efforts to create a truly universal, comprehensive single-payer system? I can’t know. I do know that they are all in the upper tiers of income, have good insurance, and are surrounded at work and in their neighborhoods by those in similar situations. Maybe this makes them blind to the needs of most people; maybe they believe that the top 10% of income of which they are a part is in fact typical. Or maybe they realize their privilege and want to keep it, and don’t want everyone else diluting their access.

But including everyone is key, not only for the financial reasons, but for quality reasons. When the upper income and well-educated are in the same system as the poorer and less empowered, they can be depended upon to ensure that the system is of quality, and this benefit then applies to everyone. It is why we cannot let them opt out.

Out health care system is a mess, delivering poor outcomes for lots of money, and is a maze of different programs and eligibility. We don’t need more of that; we need to simplify it and have one outstanding system that covers everyone.