A Public Health Stranger in the Land of Medical Care
Saturday, August 21, 2010
The greatest asset in Laos is the people. According to our hosts at the Lotus Villas Guest House in Luang Prabang, a town on the Mekong River in north central Laos, the Lao people are what helped them decide to move from their native Australia to make Laos their home.
Laos is also one of the poorest countries in the world with a average annual income of about $1800 a year. Life expectancy is about 60, though “healthy” life expectancy is about 47. Infant mortality is high at about 75 deaths per 1000 live births and the people spend about $85 per year on health care. There is not much health care available.
Luang Prabang is a designated World Heritage City by UNESCO and was the old capital of Laos until the mid 1500s. There are dozens of wats (Buddhist temples) filled with monks. Each morning at about 5:30am, they walk through the streets and are offered alms of different foods mostly sticky rice, which is their daily diet. They proceed single file opening their baskets for food. All is quiet except for calm drumming and the occasional click of a tourist’s camera. As we offered alms, we sat either on chairs or mats. We were expected to serve from below their height. Their simple life made ours seem far overburdened.
One morning, we went to an orphanage supported by Andrew Brown, one of the owners of the guest house. Deak Kum Pa Orphanage houses over 500 children, though only 80 were there at the time (during the summer months children are often sent back to spend time in their villages). We asked Andrew where the children came from and why they were orphaned. He said that life expectancy is very low in the villages partly because there is no infrastructure and no health care. So a parent who falls ill from pneumonia or develops a bacterial infection that could be easily treated with health care, will often die instead.
Andrew is very culturally aware about his engagement with the orphanage. He knows that the directors are suspicious of a white foreigner offering help to young children. They are concerned about exploitation and pedophilia. So Andrew always go there with someone else and recently he hired a Lao woman to go with him and assist in organizing activities. We observed an English class that happened to be discussing using helmets on bikes and scooters, a subject about which I have research and personal experience. When asked, I was happy to tell a short story about how my helmet saved my head once.
Their kitchen is basic. The small concrete cooking space is fired with wood scraps. They were cooking chicken and green bean stir-fry in the largest wok I have ever seen. We were offered at taste and it was good and spicy.
The orphanage is a substantial campus with numerous buildings and many needs: food and supplies, art and recreation activities, and teachers, lots of teachers. The orphanage is officially run by the government, but it is held together by locals who either work or volunteer their time there, like Andrew. I will try to develop their situation into a class project for my International Health Class this fall.
When we read news stories or blogs like this that inform us about the plight of the less privileged, we feel sympathy or something stronger and may be compelled to contribute. When I see the situation on the ground and go to an orphanage or any site where help is needed, there is a compelling difference. It is in front of me, present for my eyes and ears to capture.
At one level, I feel like a wayward tourist, taking in the poor as my object and acting as a “helicopter” helper: handout some toothpaste and soap, drop a few dollars, and go back to my air-conditioned suite at the guest house. When I observe, hear, and participate, however, I am also aware of what I’m doing and I know that steps must be taken no matter how small. Bigger steps will follow.
Monday, May 17, 2010
If you are flying into Singapore’s gorgeous Changi Airport, you might hear a message like this before you land: “We would like to remind you that Singapore does not tolerate illegal drugs. The penalties for using and trafficking in illegal drugs are severe and may include the death penalty.”
Among the highlights of Singapore’s drug policies are these:
*The Misuse of Drugs Act in Singapore allows the police to search anyone they deem to be suspicious of drug use or trafficking without a warrant.
*Police can demand a urinalysis, and the failure to comply carries an automatic presumption of guilt.
*A conviction for trafficking of drugs (which means anyone carrying a certain amount of drugs such as more than 500 grams of cannabis, 30 grams of cocaine, or 15 grams of heroin) carries a mandatory death penalty.
Thanks to these laws, in 2004, Amnesty International calculated that Singapore had more executions per capita than any country in the world. In 2005, a young Australian was executed for carrying 400 grams of heroin despite rallies and protests in Australia against the execution.
In 2009, 1883 people were arrested on drug charges. This represented a modest decrease of 2% and allowed the Central Narcotics Bureau to claim that it had drug use under control. So obviously, people do use drugs in Singapore. Their prohibition approach is diametrically opposed to that, for example, of the Netherlands, which uses an approach referred to as “harm reduction.”
Those who believe in harm reduction take the approach that drug use will always happen, drug users should be treated not as criminals but as people with social or medical problems, and drug maintenance offers a safer and more beneficial overall model for society than prohibition. For example, the Dutch would treat heroin use as an illness and provide rehabilitation instead of treating them as criminals and providing incarceration.
The Singapore position is that the drug penalty for trafficking is a deterrent and saves many lives. In a much discussed current case, a 22 year old Malaysian, Yong Vui Kong was sentenced to the death penalty in 2008 for having 47.27 grams of heroin (the mandatory penalty for over possession of over 15 grams). His lawyers filed an appeal in March 2010 and a the appeal was denied on May 14.
Recently, in response to questions at an open dialogue sessions, Law Minister K. Shanmugam defended Singapore’s policies in a recent article in The Straits Times. According to the news report, he considers cities that have needle exchange programs (an example of harm reduction) have “given up on it” and he cites the “number of lives that have been spoilt” as a result of drugs. He claims that parents are glad that their children do not have access to drugs in Singapore. In response to criticisms of the Singapore’s policies, he is quoted as having said “You won’t have human rights people standing up and saying: ‘Singapore, you’ve done of great job, having most of your people free of drugs.’ You won’t hear about how many thousands of lives are lost to drugs in other countries” or how many lives have been saved in Singapore thanks to our drug laws. The article mentions that Singapore is a air and sea hub in South Asia near other drug centers and without its strict drug policy it could have been “swamped” with drugs. The Minister added, “Yong Vui Kong is young, but if we say ‘We let you go’, what is the signal were are sending?”
Some think this policy is in keeping with other mandated bans such as spitting and chewing gum, and certain DVDs such as “Borat,” “A Clockwork Orange,” and “South Park.” However, prostitution is legal in Singapore, though brothels, pimps, and public solicitation for sex are illegal. Of course, not all Singaporeans agree with the death penalty for drugs as you can see from the sidebar picture.
The harshness of the drug penalties in Singapore seem to be a sharp contrast to those in the North America, but the U.S. also bans drugs and has mandatory sentencing laws, but not the death penalty. This is called the “War on Drugs” in the U.S. Many claim this “War” has contributed, if not directly caused, the waves of violence that are rampant in Mexico and some U.S. cities today and the ban itself causes more harm than the drugs. However, not even the most fervent drug warriors have suggested the death penalty would work in the U.S. At least not yet.
Thursday, May 6, 2010
If you are an IC student or a college student at most any US college, consider this when you prepare to take your final exam:
You cannot enter the room until 10 minutes before the exam begins.
You will sit in assigned numbered seats.
You are in a room with 200-600 students from many different classes.
You must leave your backpacks outside of the exam room (in an unsecured open area).
You cannot leave the exam room for the first hour of the exam.
You must stay for the entire exam time (2-3 hours) or until the invigilators release you.
If you need to use the toilet during the exam, you will be escorted by an invigilator.
If you are a faculty member who is designated as the chief invigilator, you must read instructions from a prepared laminated sheet that is presented to you by the staff assistant assigned to the exam time. As chief invigilator, you are to supervise the proctoring of the exam by other invigilators. In some final exam sessions, invigilators are not allowed to read, grade papers, or leave the room other than to escort students to the toilet (or use it themselves). Of course, no food allowed.
Such were the rules that the students and I followed during an exam this week at the Nanyang Technological University in Singapore where I teach a class of 18 graduate students in Health Communication. I dutifully followed the instructions since I only skimmed the email that listed them all.
I was fortunate that the Chief Invigilator, whom I had never met before, turned out to be a friendly young faculty member who taught engineering. He misdiagnosed my accent and guessed that my geographical home was Australia. But once he found out I was from New York, he beamed. He told me he was going to spend 4-6 days in New York City and asked me if there was enough to do there for that much time. I suggested 4-6 weeks at least.
So for the next 3 hours, myself and 9 other invigilators (all male) watched, walked, sat, and patiently waited (except one professor did sit down in an empty exam seat and slept for about an hour) for something to happen. It did. Students needed to use the toilet, mostly women at first. Dutifully, the male invigilators followed the women out of the freezing ice-cold exam room out into the hot humid density of Singapore air to the ladies toilet. No, we did not go inside with them. As far as I could tell, no cheating occurred. Thankfully.
The Singaporeans love air conditioning, or “aircon” as they say. They like it very very cold. It’s so cold that often when I leave my office, classroom, or taxis, my spectacles fog up and leave me temporarily blinded. This is a consistent concern for those of us who care about the environment and is also a reason that many of us carry sweaters or shawls around whenever we expect to spend time indoors. It was freezing in this exam room.
Back to the invigilation. At first, it was boring, really boring. So boring that I had to make things up to do. I decided to count the number of students in the room and to visually assess whether I thought they were overweight or not (this is the public health connection to this post for those of you who were waiting). Of 178 students in the room, I counted a total of 10 (at most) who I thought were overweight. I thought that was a remarkable (though not publishable) finding. While overweight issues are considered a pandemic by the WHO, it was not so evident in this classroom.
Finally, we approached the end of the 3 hour exam. The Chief Invigilator gave a 15 minute warning and at exactly the prescribed time, students were told to put their writing utensils away, tie their exam books together with string (provided) and turn them into the invigilator. I brought my collection to the Chief Invigilator who verified and signed off that there were indeed were 18 exams. I was then asked to take an additional thicker piece like shoestring and tie all 18 exams together. It was over and we took a class picture.
All these rules are intended to provide a fair playing field for the students. I must admit that I could become accustomed to the reliability and consistency of this approach. The rules are clear, followed in every exam, in every class. However, not all exams are created equal and not all courses might require an exam, but every class (except the lucky art courses) are required to have an exam of at least 30%.
I wonder if I can bring these procedures back to Ithaca.
Monday, April 12, 2010
During a recent stay in Bangalore, India, we visited a farm unlike any we had seen before. Brought there by our host, Georgekutty (known as “Kutty”), it’s about 50km and 90 minutes outside of the dusty, busy, noisy streets of Bangalore near Kolar.
The farm has no edible crops, no sowed fields, and no silos. At least not yet. What it does have is Kutty’s vision and passion, which is more than enough as it turns out. It has been his dream to develop an organic farm that would be used for educational and nutritional purposes. After many years, by which time most of us would have grabbed onto new dreams, Kutty found some land, raised the funds, and started this non-profit community venture.
To the uninitiated like me, it looks more like a rocky desert than a farm. I wondered how anything would grow in this soil. There were a few trees, bushes, bamboo, and lots of rocks and boulders. But as we walked around, Kutty showed us what I was not seeing. He showed us all the saplings and seedlings that he planted and explained how they will be used. The trees and bushes there were planned to assist with irrigation and preventing erosion. The rock formations were placed there by design to create a funnel-like system to collect rainwater. He pointed out the cozy and functional building with red clay or thatched roofs that had been designed by architects to encourage interaction, a sense a space, and cool cover on hot sunny days. After a few hours of showing us the embodiment of his vision, the place came alive.
Last summer, Kutty said, a group of 20 students from the US had spent a summer there helping on the farm. They lived in the small dormitory buildings sleeping in cots, preparing their own food, and learning about sustainable ideas, politics, and organic farming from professors (who stayed at hotels in Bangalore) who were selected for the openness to the knowledge that these opportunities can convey.
Kutty seemed especially proud of small trees he called “Neem trees.” These, he said, have medicinal and antibacterial qualities and are very common in India. However, a few years earlier, WR Grace, a large chemical company, had applied for and received a patent from the European Patent Office for a pesticide derived from the Neem trees in India. Pharmaceutical companies were also interested in patenting the Neem tree’s other natural substances.
Concern grew from all over India that the Neem tree would be “owned” by major corporations. Vandana Shiva and others have labeled this an example of “biopiracy”. To the surprise of many, the European Patent Office listened to the protests and revoked the patent that had already been awarded to WR Grace. This was an enormous (though perhaps temporary) victory for farmers and those opposed to biopiracy. But as a result of these events, Kutty, among others, refers to the Neem tree as the Freedom Tree. It is, he said, an emblem of freedom from corporate dominance of our natural resources that belong to everyone.
As Kutty remarks below in his comment, the Free Tree Commune was inspired by Corinne Kumar, the founding director of the Center for Informal Education and Development. If you would like a copy of the brochure, please email me at firstname.lastname@example.org.
Sunday, March 14, 2010
I received excellent treatment from my physiotherapist for my upper back pain and was able to complete the hot 168km Bike Rally 2010. Physiotherapists in Singapore are like physical therapists in the U.S., however they are not yet licensed professionals though acupuncturists are. They are working with the government to change their status.
My physiotherapist, Sylvia Ho, co-founder of Core Concepts Physiotherapy Centre, was trained in Australia where she earned both her bachelor’s and master’s degrees. She prefers to use manipulative therapy and massage to ultrasound or electrical stimulation machines. She believes my discomfort came from a major change in my ergonomics related to my daily use of 2 computers at new desks and subsequent poor posture. My upper back and neck pain improved more with each visit, exercises she recommended I do at home, and changing my computer posture.
Core Concepts charges about $56 for each therapy session that lasts about 30 minutes and consists of intensive manipulation and massage. Physiotherapists employ hands-on techniques that try to remove blockages, loosen and stretch muscles and joints, and improve posture.
After my first visit, I submitted the bill to my Singapore insurer, which I have through my employer. Soon thereafter, I received an email asking me for the original copy of my written referral. This was news to me. For my U.S. insurer, no written referral is required, so it had not occurred to me that I would need one in Singapore. That was a mistaken assumption and I should have known better.
I told the insurance company the truth: that my physician told me to see a physiotherapist. They responded that they still needed the original written referral. So I contacted the physician via email. He did not respond. One week later, I called his office. They said they would email me the referral. They did not. I called a week later and tried again. This third attempt proved successful. They emailed me a scanned copy of the handwritten referral from the doctor and I received the original in the mail a few days later. However, I did notice one potential problem: there was no date on the referral.
Nonetheless, I filled out the on-line medical claim submission forms and submitted the “certified original” referral and bills. I was told they pay about $35 maximum for each physiotherapy visit.
I should hear within a few weeks.
Meanwhile, I tried to learn more about the “Sixth Best System in the World.” Keep in mind: No system is perfect.
I was interested to learn that at least some of Singapore’s hospitals publish their bed charges and the Ministry of Health publishes the mean costs for certain diagnoses at some hospitals.
Standard Ward Class C - $21- 9 bedded room, natural ventilation
Standard Ward Class B2 - $56 - 6 bedded room, individual ceiling fans, semi-automatic bed
Standard Ward Class B2+ -$84 - 5 bedded room, air-conditioned, attached bath and toilet
Standard Ward Class B1 - $130 - 4 bedded room, all of above, TV, phone, choice of meals
Standard Ward Class A1 - $215 - Single room, all of above, toiletries, fully automated bed, optional sleeper unit
Upgraded Ward Class A1+ = $243- All of above, plus mini-safe, fridge
The charges listed above are what the patient will pay out-of-pocket for their beds exclusive of any care. “Out-of-pocket,” however means that the patient can use a Flexible Spending Account or a Medical Savings Account (Medisave), into which their employer and/or they are required to put a minimum amount. As of December 2008, the average Singaporean had about $10,000 in their Medisave account. They can also use the accounts of the close relatives and dependents in some circumstances.
While this seems complicated to me, most Singaporeans seem to understand how it works. They also have to pay “out-of-pocket” for some expensive therapies including chemotherapy and HIV drugs. How much? I’ll find out and report on it in Part III.