Dispatch from Pat Courneya, MD: Opening Up to Insights From Cuba

Editor’s note: Patrick Courneya, MD, is executive vice president, Hospitals, Quality and Care Delivery Excellence and chief medical officer, Medicare Advantage, Cost and Prescription Drug Plans,  for Kaiser Permanente. He recently traveled to Cuba with several Kaiser Permanente colleagues to learn more about Cuba’s health care system. He shared his observations in this essay.

 

It has been a very busy time these last two months with a lot of travel, and it is good to have a period now when I am not away from Oakland quite so much.

As a part of my recent travel, I had the privilege to visit Cuba with a team of leaders from Kaiser Permanente. We spent a full week learning about how the Cuban people in a very different system have managed to achieve first world population health results with very limited resources. According to the WHO’s World Health Statistics 2016 Report, Cuban overall life expectancy at birth in 2015 was 79.1 and 79.3 in the United States. In that same report, Cuban healthy life expectancy at birth in 2015 was 69.2 years, compared with 69.1 in the United States. In addition, under age 5 mortality for Cuba in 2013 was 6/1,000 live births (U.S. 7/1,000), immunization percentages are in the high 90s, and 100 percent of women get a get at least four prenatal visits (U.S. 97 percent). They have done this while spending only 11.1 percent of GDP on health in 2014, compared with 17.1 percent for the United States.

Cuban Database IT Entryway CubaThis is not to say they do not have challenges. According to World Bank data in 2015, the maternal mortality ratio in Cuba was 39/100,000 live births, a drop from 58 in 1990, while in the United States the maternal mortality ratio was 14. It is important to note that the baseline rate for the United States in 1990 was 12, showing the United States is going in the wrong direction. Obesity is rising, elevated blood glucose rates are similar to the U.S. and one third of men and nearly 29 percent of women over 25 have elevated blood pressure. They have work to do and they understand that well.

The year 1990, used for baseline in the statistics above, has special meaning for Cuba given the events that hit them soon after. The next year, 1991, the Soviet Union collapsed, and with that momentous and historic change, Cuba lost its biggest customer and most generous patron. The Cuban GDP dropped by 34 percent, as 80 percent of Cuban import and export business evaporated. Coupled with tightened U.S. sanctions in 1992 and 1996, the period of the 1990s became one of the most severe and sustained economic downturns in Cuban history. The Cubans refer to it as the “Special Period,” and it has left a deep mark.

So why is this important for the Cuban health care system, and what did we learn from it during our visit? Faced with the impact of the Special Period, Cuba did not have and could not afford the technology and pharmaceuticals that the developed world takes for granted. In response, they did some remarkable things. They dramatically increased their attention to prevention and doubled down on a system focused on primary care at the neighborhood level.

Transportation CubaThey also built their own pharmaceutical industry that now provides 90 percent of the medications Cubans use, including specialty pharmaceuticals. Like they have with the famous 1950s cars that fill the roadways, Cubans have used remarkable ingenuity to keep their health systems going. The story of how they have done it is complex, and I will share just one example.

Clinica CubaIn Cuba, family physicians lead teams including nurses, vector control specialists, psychologists and other health care workers that take responsibility for a panel of approximately 1,000 patients. Each patient is given a health risk score from I to IV and detailed statistics are reported regularly to the referral district. The risk score is used to guide the efforts of the primary care team. The data include the prevalence and level of control for key chronic diseases such as hypertension, diabetes, and lung disease, as well as immunization rates, other preventive services and maternal child health statistics.

The family physician/nurse team staffs a typical neighborhood clinic, seeing patients both at the clinic and in their homes. The team’s knowledge of the family, their living situation, their behavioral health challenges and other social/non-medical factors is deep, and the ability to respond at the community level is strong. The results are pretty amazing, as the statistics show.

Here is what I found most remarkable, though. Within Cuban health care, they depend on accurate statistics and analysis to guide actions, and their level of transparency is admirable. Each month, for instance, the family doctors serving a given referral region gather together to compare their un-blinded population health statistics, reviewing results and strategizing on how to solve problems revealed by the data.

I must admit I felt as if the results they were getting were too good to be true, so I pressed the question of data accuracy repeatedly during the week I was there. The most compelling response came from a United States journalist who has lived in Cuba for 14 years and is not afraid to say and write what she really thinks. When I asked her how we could be sure that the data was accurate, what she pointed out was profound.

graffitiCuba is on an extremely tight budget and their constitution obligates them to provide care to everyone. In betting on prevention, they have committed to the idea that whatever they do to prevent disease has to work if they are going to be able to afford to provide care. If they make decisions and push interventions based on bad data, they will make expensive mistakes from which they are in no position to recover.

In essence, they have committed the system to the idea that high-quality leads to lower cost and lower burden of morbidity and mortality. With just over 11 million people, with a focus on population health and understanding that they must attend to social/non-medical needs in addition to providing health care, Cuba is getting great results. Affordability and high quality improving the health of the communities they serve. Sound familiar?

Thomas Kaschak, DPM, and Colleagues Return to Vietnam

Editor’s note: Thomas Kaschak, DPM, is a physician at Kaiser Permanente Fresno Medical Center and director of the Viet Nam Medical Project. For the 16th time since 1998, he led a team of clinicians in a medical relief mission in Da Nang, Vietnam, to provide care at the Da Nang Orthopedic and Rehabilitation Center. In 2011 Dr. Kaschak won a David Lawrence Community Service Award, which honors Kaiser Permanente physicians and employees who champion outstanding Community Benefit activities and initiatives demonstrating extraordinary efforts to improve the health of our communities. Dr. Kaschak last blogged from Viet Nam in 2015.

June 22, 2016

Vietnam Medical Project 2016 has proven to be another wonderful venture for both Kaiser Permanente and non-Kaiser Permanente volunteers.  We did have a fabulous team this year!

After a few days of R&R, getting used to the time change, we made it to Da Nang on June 12. We had a wonderful evening dinner with our hosts catching up on old times. It’s always wonderful to see their smiling faces. We have become more family than friends over these 18 years. This is my 16th trip since 1998, and I am so grateful, pleasantly surprised, and flattered that it has become a popular destination for physicians, residents, and students to visit.

Our first day in clinic was Monday, June 13. Quite a busy day! The uncommon is common here, with birth defects, old injuries, new injuries, and effects of years of neglect making up the greatest portion of the pathology that we encounter. Many of the birth defects are quite profound and heartbreaking, particularly when we see them in young children.  On that first day, we evaluated 70 patients and still had to turn 20 away. Throughout the course of our stay, however, we were able to not only see those 20 patients but many more scattered between surgeries and random clinics.

We started surgery on Tuesday, June 14.  Each day, between orthopedic and podiatric procedures, we performed at least 8 to 10 surgeries. It may not seem like a lot, but many of the cases were quite difficult and took 3 to 4 hours! We are challenged by lack of equipment and supplies that we are so used to back home. We try to bring as much of these as we can when we visit, but the weight becomes quite challenging, particularly when checking in for our flights.

Each night, we have the opportunity to visit with our colleagues and their family’s. And, this year, the five wonderful residents from Kaiser Permanente, one from New York,  and four Podiatry students from Pomona, Calif., really made it such a fun and rewarding trip. We all felt that the work was both humbling and rewarding.   Their experiences here, despite the fact that they may never encountered similar pathology at home, still serves well for them to evaluate, determine a plan of action, and implement the action plan for the more difficult situations they will encounter during their practice lifetime. I am so happy that I was able to provide them with the opportunity to gain what I feel is an invaluable professional experience.

Tonight, the eve of our departure from Da Nang, we will have our traditional get together with the entire staff at the “Tulip Lounge”. This has become a wonderful, fun, and touching annual event.  We share the evening with the doctors, nurses, administrators, and others from the Da Nang Orthopedic and Rehabilitation Hospital. We all have such a great time, and it is such a wonderful way to say “Goodbye, and see you next year”!

I truly hope that we can extend the Vietnam medical project to include other hospitals here in Vietnam. We are making inroads at the Da Nang Women’s and Children’s Hospital, and Da Nang General Hospital, but it has been somewhat difficult since my time is typically spend only at the Rehabilitation Hospital. But I am confident that we will be able to offer opportunities to physician, surgeons, residents and students of other specialties so that they can enjoy the gratifying work as well.

I truly hope that our stories  and presentations will inspire others to consider participating. It is my hope as well that some of our “alumni surgeons” can overlap visits with mine, thereby extending the time that we work, and allow a greater number of residents and students as well as attending physicians on their first trip to participate without the anxiety of coming alone.

Anyone who is interested I invite to contact me at Kaiser Permanente Fresno Medical Center. I would love to discuss our work and the possibilities for those who may be interested in participating in the future.

Best wishes to all,

Thomas J Kaschak,  DPM
Kaiser Permanente Fresno Medical Center
Director, Viet Nam Medical Project

Sarah Beekley, MD, Blogs from Guatemala: Seeing First-hand the Value of Health Education

Editor’s note: Sarah Beekley, MD, is a pediatrician at Kaiser Permanente Redwood City (Calif.) Medical Center. She is serving a relief mission in Guatemala for Faith in Practice. She last blogged here from Guatemala in February 2015. She also helped lead Kaiser Permanente’s relief response to the massive earthquake and tsunami in Indonesia in 2004, and was part of a physician team that deployed to Texas to aid victims of Hurricanes Katrina and Rita in 2015.
Greetings from Guatemala
I am in the middle of my week of volunteering with the international health care organization Faith in Practice. Based on the believe that to “whom much is given, much is expected” and that actions speak louder than words,  FIP’s mission is to provide life changing health care to underserved communities in Guatemala.

My team and I (including Cori Glover, MD, and Hilary Bartels, MD, Kaiser Permanente Santa Rosa Medical Center) have treated nearly 1,500 patients in three days of  mobile medical clinics.  Integrating pediatrics, medical, dental, OB-GYN, family practice, optometry, lab, pharmacy, translation, counseling, and referral services, we are blending preventive care with diagnostic, treatment, and referral services.  In addition, we are able to utilize Faith in Practice’s  extensive referral network of Guatemalan and American specialists and surgeons.  This is critical, as I have seen more untreated and under-treated illness while working in Guatemala than in my 30-year career in the United States.

beekley_guatemala_1The most disturbing of these was a previously healthy man who had broken his forearm at work.  A rod had been placed to repair the break, but he was without adequate follow-up care and 2 years ago the rod broke through both the bone and skin.  He presented to the clinic asking for help for his “broken arm”.  Further examination by Dr Glover revealed an infected and essentially useless forearm and hand. Without the social safety nets like workers’ compensation, disability insurance, and health insurance that are so easy to take for granted, he was unemployed and out of options.

beekley_guatemala_2Dr. Glover was able to start him on antibiotics and get him an urgent referral to the orthopedic surgeons in Antigua.   FIP’s extensive network will now work with him to coordinate the 2-3 hour journey to Antigua, his  pre-surgery preparation, and follow up.  Payment is on a sliding scale, and as he is also without a family, I expect  that the majority of his care with be free.

On a positive note, this village proves the value of health education. At our last village clinic, the majority of parents and children had decayed or missing teeth. As fillings are not a realistic option, these teeth need to be removed to prevent deeper and more dangerous infections.  One young patient had the maximum of five teeth pulled, and he needed to return for the remaining 15.

beekley_guatemala_4 In Morazan, however, dental disease was rare.  The parents uniformly and proudly confirmed that they and their children were brushing 2-3 times a day.  I can imagine one teacher, one health provider, or  one community leader a generation ago making dental health his or her mission, with these beautiful smiles being the result.

We ended the day with a record of 107-degree heat….so hot that my stethoscope, plastic chair, and bottled water  were all warm to the touch.   And again, no rain.

***

May 19, 2016

I have never been so grateful to be caught in a rainstorm.  After 107-degree heat and a deadly drought in this area of Guatemala, the downpour last night was a blessing.

I am working with a Faith in Practice multidisciplinary team, providing medical services to underserved communities in El Progresso, Guatemala.  Today was the last of 4 intense days of medical, dental, pediatric, and OB-GYN care at our mobile clinic.  As a pediatrician, I am reminded how important education is, as parents regularly expressed (misplaced ) guilt for their child’s deformity or disability, believing that the “chiles they ate” caused his blindness, or that an argument or “the wind” caused their child to be born with a cleft  palate or club foot.  Though too often we could not fix their child’s disease or disorder, we could help them access resources and prioritize.  We could reassure and compliment them where ever possible, and counter the personal and societal misinformation that was undermining their health.   While doing this work, I was reminded that parents (and gbeekley_guatemala_3randparents) around the world share common hopes and fears for their children.  I was also reminded how a disabled child could consume the resources of a family while binding that family together in the loving care of that child.

Given the prevalence of mosquito-borne illness here, we had anticipated more concern about Zika and malaria.  Instead, the more serious diseases are dengue (with its bleeding and encephalitis) and chikungunya (with relapsing arthritis).  Unfortunately, we saw plenty of the latter.  In pediatrics, we also treated seizures, pneumonia, dehydration,  and trauma (both physical and psychological) among other things. We were able to newly diagnose children with muscular dystrophy (7 years), club feet (2 years), and severe scoliosis (17 years), all of whom received referrals to the specialists with whom Faith in Practice collaborates.  Dr. Bartels even accessed the expertise of one of our own Kaiser Permanente infectious disease specialists to review pictures of a rare, leprosy-like deformity.  In addition to improving the health of these communities, we will return home better for the experience.

Working in an austere medical environment, in another culture and language, is challenging. Yet, this has been an intensely rewarding week, reminding me of the 21 year old who, 37 years ago, decided that she wanted to be a doctor so that she could be of service.  A simple wish, fulfilled this week.

-Sarah Beekley, MD
Kaiser Permanente Redwood City (Calif.) Medical Center

Diane Sklar, MD, and Jean Kayser, MD, Blog from Nicaragua: Care and ‘Consulta’ for Impoverished Women

Editor’s Note: Urogynecologist Diane Sklar, MD,  from San Francisco Medical Center, and OB-GYN Jean Kayser, MD, from Kaiser Permanente Walnut Creek Medical Center, are among several Kaiser Permanente physicians serving a relief mission in Nicaragua to provide women’s health services in impoverished areas there. They provided us with this post.

May 23, 2016

Writing you guys from Nicaragua, where we are 3/4 of way through a 9-day surgical mission trip taking care of the poorest of poor women who need surgery for various gyn issues – mostly related to bladder issues. We’ve been here helping these women who have so little, and who ask for so little.

We saw 130 patients on Sunday lined up on every corridor of the indoor/outdoor clinic. After interviewing every single patient (I learned how much more Spanish I have to study!) we scheduled 25 for surgery – that was a huge challenge in itself. Many came from various living conditions and towns far away. Even if they didn’t need surgery, it was important to give them a “consulta” and hear their concerns.

 

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Then, imagine that we operate out of a tiny clinic converted to an operating room/ hospital where there is no automated sterilization- all instruments are dipped in liquid chemical cleansers and remarkably no one gets infections here! Sometimes the air conditioner works in the OR but no one can hardly complain about sweating too much. Remarkably the patients all recover from surgery with the equivalent of ibuprofen and acetaminophen – rarely requiring narcotics – which is unheard of among our patients at home.

 

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We take a van to the town where we operate daily – about a 30-minute ride – and the days are long. We start after breakfast and usually leave around 6-7:30 pm to go back to our hotel but somehow the time flies and if they didn’t make us stop to eat lunch, sometimes we would forget. The same sweet woman Anna from years past feeds us daily- the local hot menu of rice, various meats and vegetables.

 

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It has been incredible bonding with my American colleagues and the local doctors and staff here who are dedicated to helping those who need it most and many of them live in totally humble conditions. The average salary of a doctor here is $800/month and 40 percent are unemployed. Needless to say they are not very fond of the Ortega Dynasty — their president has some ownership in every major business, hospital and utility in the country!

Nearly every morning we meet various members of the surgical crew at 0545 and hike up the hill  behind our hotel to “La Cruz” – approximately 1,000 steps! It takes about 1 hour and 20 minutes – my calves have never been in such good shape!!

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The Kaiser Permanente physicians joining us on this mission are anaesthesiologist Robert Karoukian, MD, Brandon Chen, chief resident, both in the Kaiser Permanente San Francisco Medical Center, and urogynecologist Karen Simpson, MD, in the Kaiser Permanente San Ramon Medical Offices.
 
We miss you all!

Sarah Beekley, MD, Returns to Guatemala with Faith in Practice

Editor’s note: Sarah Beekley, MD, is a pediatrician at Kaiser Permanente Redwood City (Calif.) Medical Center. She is serving a relief mission in Guatemala for Faith in Practice. She last blogged here from Guatemala in February 2015. She also helped lead Kaiser Permanente’s relief response to the massive earthquake and tsunami in Indonesia in 2004, and was part of a physician team that deployed to Texas to aid victims of Hurricanes Katrina and Rita in 2015.

 

May 15, 2016

Greetings from San Antonio la Paz, Guatemala.  I am working with the  non-governmental organization Faith in Practice.  FIP has been one of the largest charity providers of primary, dental, gynecological and surgical care in the underserved communities of Guatemala for the last 20 years.  It was built on the premise that of “whom much is given, much is expected”.  Our team is eager to be of service.    Last year this team provided 2,348 clinical visits, and we plan to surpass that number this year.

We assembled yesterday in Antigua,  a UNESCO World Heritage Site and international treasure, famous  for its history, culture,  and architecture. The team is made up of both new and veteran volunteers, including my colleagues Cori Glover, MD, and Hilary Bartels, MD, of Kaiser Permanente.  We visited FIP’s pre/post op care facility and Los Obras Sociales, their site for surgery and specialty care.

Today we set up our clinic site at a rural elementary school.  FIP works closely with local community leaders throughout the year to coordinate logistics, local volunteers and patient information.  Our team is able to then step right into this highly functioning collaboration and deal mainly with direct patient care (after a little hard labor setting up the clinics at the beginning and the end ).

Tomorrow starts at 5 a.m., and I expect to have some interesting stories and pictures to share.

-Sarah Beekley, MD
Kaiser Permanente Redwood City (Calif.) Medical Center

 

May 16, 2016

Greetings from Guatemala. This is my second year volunteering with Faith in Practice providing mobile medical clinics in the rural areas. Beside being a wonderful opportunity to be of service and to challenge myself both personally and professionally, this is a labor of love. I first decided to become a physician during a health care project in Guatemala during college, and the people and place have been dear to my heart ever since.

FIP’s mission is to provide life changing medical care, in an integrated and sustainable way, to underserved communities in Guatemala. Working with local staff and facilities, they have been providing medical, dental, and surgical care in Guatemala for over 20 years. Last year our team completed 2,348 patient contacts, and we expect to exceed that this week.
Each day our mobile team is met by a large team of “Red Hats”, community leaders and local Guatemalan volunteers who work tirelessly to shepherd both the providers and the patients through a maze of services. Our team is made up of pediatrics, dental, internal medicine, OB-GYN, optometry, lab, counseling, and pharmacy providers from across the county. All services and medications are provided free of charge and obligation, but we are rewarded in the forms of hugs, laughs, and tears. Many past patients are now local volunteers, and good will is paid forward with every encounter. While some patients have easily treated issues, there are many patients needing complex speciality or surgical care. They will have their referrals facilitated by FIP’s Guatemalan staff and will follow up in either Antigua or Guatemala City.

As a pediatrician, I saw a large number of children with cerebral palsy and developmental delay. While this was most likely due to complications at delivery, some also had microcephaly, reinforcing our concerns about a possible Zika epidemic. We also saw multiple cases of meningomyelocele and spina bifida, disorders significantly less common in the US due to the routine use of prenatal folate. If an ounce of prevention is worth a pound of cure, this is the perfect example, and we plan to give away more than 500 pediatric one-year supplies this week. Many children with disabilities are being carried in their parents arms, even the teens. In addition to OT/PT and ortho referrals, we will be able to fit each of these children with a specialized wheelchair. This lightens the parents burden significantly, and the whole family benefits.

One young girl with severe cerebral palsy arrived at the clinic today febrile, lethargic and having seizures. She was quickly given an intravenous line with fluids, antibiotics, and fever meds. Working with supplies out of a portable trunk, and with a team who had only met the day before, she was quickly started on intravenous fluids and medications. A transport to the local hospital was arranged. The conditions were austere, but the care was good, and it was a lesson in doing more with less.

It is easy to become overwhelmed by the medical and psycho-social needs of the families on a medical mission of this kind. There are very few options for most people here, both financially and geographically, for access to medical care. In addition, this mainly agricultural area has been in a 5+ year drought. Unlike California, were drought translates into rationing, in Guatemala it has resulted in a significant increase in poverty, displacement of families, malnutrition, infant mortality, disease and death. Despite this, I also saw immense tenacity, equanimity, family support, and both faith and optimism within these communities.

Tomorrow we return to our elementary school based clinic in San Antonio de la Paz. I have heard that the word is “now out” that our team is doing good work and that Cori Glover, MD (KP Santa Rosa/ San Francisco) and I should expect to see more than the 75 patients that we saw today. And with enough luck, we will have rain.

-Sarah Beekley, MD
Kaiser Permanente Redwood City (Calif.) Medical Center