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First published in Hospitals & Health Networks OnLine, August 3, 2010
We're all familiar with letting the punishment fit the crime, but when it comes to solutions for health care problems, we sometimes seem unable to develop answers that fit the situation well. With all the changes coming to health care, some lessons in "appropriate health care technology" are in order.
I was walking with a friend, a nurse practitioner who serves a largely disenfranchised, uninsured, often-homeless patient population at a community health center. A middle-aged man approached us, shuffling along-clearly someone who had suffered at least one stroke and probably more. My friend greeted him and asked if he was taking his meds. He said he was, but it was an unconvincing response. She asked him to come to the clinic soon, he agreed, then shuffled on. My friend explained, "He's had several strokes and basically has no memory. We have him on the right medications, but he doesn't remember to take them. So we pin reminder notes on his clothes during clinic visits."
For a while, I had a primary care physician who was very professional and attentive, but who had one characteristic that drove me crazy: He had a pill for everything. No matter what the complaint — and I am fortunate in having few of them — he wanted to write a prescription. Nutrition, exercise, stress reduction and other alternatives were just not in his lexicon.
I was thinking about both him and the stroke patient the other day as I reviewed some of the provisions of the new health reform statute: complex state-level health insurance exchanges, high-risk pools for those deemed "uninsurable" by the Insurance Powers That Be, penalties by 2014 for people who don't obtain coverage, a push for everyone to have a "medical home," and other initiatives. And I wondered how my friend's stroke-disabled patient could possibly have coped with any of these things (except, perhaps, the "medical home," which was the community health center) and whether the pharmaceutical-obsessed physician (who eventually stopped seeing patients, I was later told) would be able to adapt to solutions that weren't on his radar screen.
Many years ago, a friend of mine was dating a brilliant academician, a refugee from the Third Reich who did a great deal of work overseas, implementing what he termed "appropriate technology." That was when I first heard the term, although some sources trace it back to Gandhi's efforts to promote self-help and empowerment for low-income people in the early 1920s in India by encouraging them to weave their own cloth rather than buy expensive British textiles. The concept really gained traction, however, with the back-to-earth and natural food movements of the 1960s, and especially E.F. Schumacher's 1973 book Small Is Beautiful.
Wikipedia, which in some cases is not the most reliable source of information, defines appropriate technology as "a technology that is designed with special consideration to the environmental, ethical, cultural, social, political, and economical [sic] aspects of the community it is intended for." That's a bit much; I would opt for a simpler definition, which is a technology, or any other approach, that actually works for the purpose and the population for which it is designed, preferably with the least expense, disruption, and discomfort.
A small example from the world of ecology: In his splendid book, A Sand County Almanac, published in 1949, a year after he died fighting a fire on a neighbor's farm, environmental philosopher and activist Aldo Leopold told the tale of a famous grizzly bear in Arizona in the early 20th century. Upon awakening from hibernation, the bear would come down from its mountain cave, kill a cow on one of the nearby ranches, eat it, then go back up the mountain and spend the rest of its awake time feeding on rodents, berries and fruit, which, despite the myths, constitute most of a grizzly's diet. The bear was known as Old Bigfoot. After a few years of this, the federal government hired a trapper, who, after much effort and expense (I have heard that the adventure cost around $50,000, which back then amounted to some real money), emerged from the wild with Old Bigfoot's pelt. Leopold later suggested that perhaps it would have been cheaper, and more appropriate, to just pay the ranchers for the cows and let the poor old bear be. After all, Old Bigfoot ate only one cow per year.
In lamenting the near-extermination of the grizzly in the Lower 48, Leopold wrote, "There seems to be a tacit assumption that if grizzlies survive in Canada and Alaska, that is good enough. It is not good enough for me. Relegating grizzlies to Alaska is about like relegating happiness to heaven; one may never get there."
I love Alaska and have been there many times, but he was right.
The point is that there are always multiple solutions to any problem, but some are more appropriate than others. And there are major lessons in this for health care in a time of impending fundamental change.
There are many examples of applying obviously appropriate solutions to health care and social problems. Here are a few of my favorites:
Managing diabetes. In Cambodia, where I have been spending a good bit of time (see my two-part series, "Starting from Scratch," published in this column in June and August of last year), diabetes is a large and growing problem. One private charitable organization, MoPoTsyo, realized that the usual solutions wouldn't work in a country where millions of people are poor and/or illiterate, have no electricity or refrigeration, have little or no access to health care, and often distrust Westerners.
MoPoTsyo creates peer education networks, through which Cambodian diabetics educate others with the disease. Blood glucose meters are an inappropriate solution because of their expense and the widespread unavailability of electricity to recharge their batteries, so the member-patients use urine strips. If the test strips indicate a problem, a peer educator who has access to a glucose meter comes to check things out. Medications that must be kept refrigerated are stored in selected pharmacies that are accessible to patients. There are many other remarkable aspects to this program, but the key is that in every way, it has been designed to be appropriate for the people it seeks to serve (you can learn more at www.mopotsyo.org).
Fighting diarrhea. Also in Cambodia, diarrhea is a serious and, unfortunately, sometimes fatal disease, especially for children. Sin Sumony, M.D., executive director of MEDiCAM, the umbrella organization representing health care nonprofits in the country, discussed the issue with me when I was there in March. He said that there are government plans for (someday) a safe water supply for all Cambodians, with well-monitored sources and municipal water systems-but in the meantime, much of the water supply is unsafe, even in the cities. Toilets and bathrooms (where they exist) are, well, often not very hygienic.
So MEDiCAM teaches hand washing and encourages the establishment of "hand washing stations," which in this case means a clean basket containing a bar of soap and a clean towel, in an area of the house where contact with animals, feces, and other contaminants is not allowed.
Sounds pretty simple, but it works — and do keep in mind that in the United States, we are still trying to pound home the message to health care workers that it is necessary to wash your hands any time you might have come into contact with an infectious or otherwise dangerous transferable substance.
Boy, did I learn that the hard way. I'm pretty good about personal hygiene, but someone else wasn't, and I contracted a norovirus during a stay at what was considered the best hotel in the city I was visiting. I was sick as a dog for 10 days. I have since become the most obsessive hand-washer you have ever met — and I was good about it before.
Dispensing compassion. A woman I know sent me a report written by a friend of a friend (whose name is unknown to me) who volunteered in Haiti after the earthquake. She and her colleagues had raised a lot of money and had secured a large amount of medical supplies.
They left the Dominican Republic in a caravan, only to have most of their supplies turned back at the Haitian border. The reasons were unclear (although a very knowledgeable colleague told me that some pharmaceutical and medical supply firms often use disasters as an opportunity to dump outdated supplies on the unfortunate country where the calamity occurred, which then has to safely destroy the useless products). I don't know if that was the case here — a demand for a bribe was also mentioned — but in any case, these volunteers arrived in Haiti armed with not much more than their good hearts and Ziploc bags containing vitamins; antacids; and pain, iron, hypertension, and diabetes medications. They saw thousands of patients and handed out what they had, ranging from the contents of the Ziplocs to antifungals and "a nasty concoction of Vaseline and sulfur powder" for skin conditions.
"Ostensibly," she wrote, "our patients came for medical care. But very few were really sick. I think they were really looking for a hand to hold, a reassurance that they were OK, and especially for the food we gave to each person.… Over time, we also came to believe that [we] gave them the feeling that there are people outside of Haiti who care about their plight."
Love and compassion can be as effective as medication. Ask any hospice patient or volunteer.
Assisting grandmothers caring for orphans. The Stephen Lewis Foundation (to which, in the interest of disclosure, I am proud to say I am a donor) was founded by the former Canadian ambassador to the United Nations, who served more recently as the UN special envoy for AIDS in Africa. Lewis' extensive work in Africa led him to realize that AIDS had created a familial nightmare: In many places, the entire middle generation between grandchildren and grandparents had died or was dying. He and his colleagues created the Grandmothers to Grandmothers Campaign, whereby grandmothers from around the world can assist African grandmothers — often elderly and frail — who are raising their own grandchildren and, often, orphans they take in. This sure beats orphanages.
I offer the international examples because, in many cases, these are (to use a discreet term I hear often in my overseas travels) "low-resource" situations. In other words, these folks must be creative because they have so little to work with. But that doesn't mean that appropriate health care approaches are not relevant in the United States. To wit:
Tailoring services for the Amish. Faced with a large (3,000 people) local Amish population reluctant to seek conventional medical assistance, the Punxsutawney (Pa.) Area Hospital inaugurated a culturally sensitive program of care that included recruiting a husband-and-wife physician team who settled on a farm in the area, special genetic screenings, and a variety of other approaches, not the least of which was a waiver for Amish patients from the usual requirements for eligibility for Medicaid (Amish religious beliefs generally prohibit their participating in government programs). At least some Amish have already been exempted from the health reform 2014 mandate that all legal U.S. residents acquire health insurance, so the experience of the folks at this hospital may come in handy on a variety of fronts. I am assuming that other religious and/or ethnic groups will seek to be exempted from the mandate.
Care for the "rump group." When, in 1989, Hawaii became the first state to implement universal coverage (see my piece for this column, "Almost Paradise," December 2009), its leaders hoped that everyone would acquire coverage, especially because it would basically be free for lower-income residents.
But it turned out-to the surprise of no one who knows the history of such endeavors-that there is always a "rump group" of people who, for reasons of religion, mental illness, homelessness, general flakiness, disdain of government, other priorities or something else-will simply not get with the program, even if the coverage is free and easy to obtain (a situation that is rarely the case, I might add).
So the state government set up a system whereby community health centers were empowered and paid to become "medical homes" (before the term was au courant) for the lost and helpless, to keep medical records for them, and to coordinate their care as best they could.
This approach, I assure you, is going to be necessary when it turns out that a significant percentage of Americans (including those who are excluded from any government assistance, chiefly undocumented residents) do not obtain traditional insurance coverage when it becomes a requirement in 2014. If history serves us right, the total could be as much as 15 percent of the population, or 45 million people.
Preventing asthma attacks. The Premier Cares Monroe E. Trout Award has honored some spectacular programs over the years, but one of my faves remains the 2007 winner, Paradise Valley (National City, Calif.) Medical Center's South Bay Asthma Advocacy Project (which, I am told, is no longer active due to a change in ownership at the hospital). This went far beyond screening and health education. It sent staff members into homes to check for asthma triggers, from rodents and insects (and their dander) to tobacco use; staff would even go to court to force landlords to clear homes of vermin. In other words, the appropriate thing to do was to keep children (and adults) from exposure to conditions that led to asthma attacks in the first place. Program savings amounted to over $1 million from 2002 to 2007.
In July of this year, Chicago's Sinai Health System won one of the AHA NOVA Awards for a similar, community-appropriate asthma program. Lay health educators are recruited from the low-income, largely minority community that Sinai serves, and are trained to educate children and families about asthma management. They conduct home visits and identify risks within the home, making referrals to attorneys and safe housing advocates when warranted. In addition, they serve as bridges among patients, families, primary care providers, the hospital, and other providers. Each family has an individualized asthma control plan. The results, in terms of better health for asthmatic kids, are impressive.
There are hundreds, probably thousands, of similar stories. The main point is that here and elsewhere, health care folk are finding solutions that work better than what "traditional" thinking would suggest. If medications are unaffordable or cannot be stored safely in the home, find another way. If the nearest specialist is 200 miles away, find another way. If you live in an acutely water-short area, which vegetables and fruits you grow should be determined by that reality. And if a simpler, cheaper, and less problematic solution is most appropriate, then providers should-indeed, must-ignore their own financial benefit and, if necessary, third-party payment policies that are not always in sync with patients' best interests, and go with what works.
I realize — boy, do I ever! — that just about everyone in health care who has a pulse is "reformed" out. However, the changes are still coming, and I think we should keep in mind a few lessons from the concept of appropriate technology.
Lower-tech solutions often work better. The technology, or the approach, must be appropriate to the target population. For example, it is true that most native-born (and many immigrant) children today are highly proficient with electronic and computer technology; the same is not true for people over 65 and especially those over 75. In addition to race, ethnicity, and gender, age is a powerful determinant of what works best for a given group. And lower-tech approaches often work better for older folks or those who are compromised. In the case of my friend's stroke patient, if pinning reminders on his clothing worked, then that's what worked. The best medications do no good if the patient doesn't take them.
Self-help and peer support are very effective. As we have learned from the various 12-step programs, assistance and support from someone who's been there can make all the difference in the world. From Cambodian diabetics to former Chicago gang members, people who know what it's like to be in a particular kind of trouble are far more persuasive than outsiders who, no matter how well-intentioned, swoop in on the wings of good without realizing that the folks they are trying to help may think that they are from another planet.
Often, programs are designed by wonks for non-wonks, which does not portend success. A friend of mine and I were looking for a particular computer component years ago, and we wandered into a used computer parts store. Oh, boy. We might as well have been trying to buy complex local technology in Nepal. They couldn't get rid of us fast enough, and as we left, an alarm went off. My friend said, "That's the 'non-nerds' alarm!" From insurance to electronic health records to e-prescribing, we must be constantly aware that many health care programs and technologies are utterly mysterious to most of us, although they are transparent to those who design them.
The problem is, health care policies are more likely to be influenced by wonks and nerds than by the great, unwashed masses. In other words, in many cases, inappropriateness is built into the equation. As the changes come, health care may need its own geek squad.
What makes the most money may not be the most successful approach for the patient. I hope it is not too cynical to suggest that payment policies, incentives, investments, and other financial temptations affect many decisions in health care, ranging from which drugs get approved to which medical devices make the "A" list to which specialties get paid what to which therapies a patient is told are the most effective. Despite all the nervousness, we can hope that the new imperative for comparative effectiveness research will solve some of these dilemmas. But it will remain for providers — individual and institutional, even in tough economic times — to put the patient's welfare above their own financial interest and to recommend what is most appropriate.
As the saying goes, don't ignore the good in favor of the perfect. No approach works every time. I have no perfect solution in terms of preventing AIDS in cultures where men are promiscuous and women are powerless and having lots of babies is a cultural norm, other than empowering women to protect themselves as best they can.
I hope that community gardens and farmers' markets can reduce dependence on junk food, but at least where I live, summer is short and winter is long, and we don't have community greenhouses. Convincing people to stay bone-thin and to exercise at least an hour each day can be a hard sell when folks are working 100-hour weeks. Maintaining dental hygiene is a lot easier if you have time and money and dental insurance — although it covers almost nothing.
Appropriate solutions aren't perfect; nothing is. But they have a higher chance of success — and much of the time they work better, don't cost so much, and cause less resentment and fewer hurt feelings.
Once upon a time, in health care research, the question was, "Does it work?" As I have written before, we are moving beyond that to the question of "Which works best?" The next question is, "Which works best for the people we serve, given the resources we have at our disposal?" And whether the answer is an expensive, complex technology or a simple home visit, we all have an ethical obligation to use it. The right thing may not be the perfect thing, but it is still the right thing.
Correction: My thanks to all the readers who, unlike me, can both proofread and count. My Health Management Quarterly piece on what was right with the health care system, which I referenced in my previous column, was published in 1989, not 1999. We did correct the article the next day, but several of you early bird readers noticed the discrepancy. Thanks for that.
Copyright ©2010 by Emily Friedman. All rights reserved.
Emily Friedman is an independent writer, speaker and health policy and ethics analyst based in Chicago. She is also a regular contributor to H&HN Weekly and a member of the Center for Healthcare Governance's Speakers Express service.
First published in Hospitals & Health Networks OnLine, August 3, 2010
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