A Sock, A Clown’s Story and Other Tales of Health and Care

How on earth are the world’s people going to get healthy?

Can people be healthy when the world itself is unhealthy? When educational systems are not well? When “health care” systems themselves are busted? When there are laws that protect the interests of global pharmaceutical companies ahead of people with limited means to buy drugs?

What do we mean by the word “health?” Can there be different definitions of health in different countries, states and regions around the world? If that is the case, how then can we learn important lessons from each other about how to stay healthy, as we must?

Hardly a symposium of limited ambition, “Transform 2010: Thinking Differently About Health Care,” sponsored by the Mayo Clinic’s Center for Innovation, hosted a group of speakers who took on such big questions.

The morning session on September 13, which kicked off the two-day symposium, offered a case in point. Eight speakers presented dramatically different perspectives – international, domestic, legal, educational and one a silly-but-serious philosophy expounded by a man in baggy clown pants and blue-dyed hair – all encircling the theme of “Health for All.”

A Man's Sock

The first indelible image offered to 500 plus attendees was projected over a vast stage by the speaker, Dr. Alice Tolbert Coombs, the president of the Massachusetts Medical Society. It was a photograph of a man’s enormously swollen left toe, oozing pus and colored in angry red and blue hues.

Seeking relief, Dr. Coombs explained, the man who owned this toe had gone to see a doctor and several other health care workers. Each had listened to the man and then prescribed different remedies, not a single one of which was appropriate to his actual condition – diabetic gangrene.

The simple reason why all these health care professionals missed easy diagnosis: none of them had bothered to remove the man’s sock.

Common sense could answer a lot of health care questions, Coombs suggested. That and education, on the patient’s part especially.

Front Lines

“It’s not just about health care access,” she said. “It’s about giving patients the confidence that they can solve problems themselves.” Teach a patient to ask good questions, she said, and you teach a patient how to help heal themselves. “You ask questions if you don’t know, and then you make decisions based on what you know.” She called that “empowerment.”

Rebecca Onie, the founder and CEO of Project HEALTH, presented another indelible image, that of herself as a young women in her first year at college, taking a job as an intern at a Boston legal services office serving the poor.

She expected to start by answering the phone and fetching coffee.

“Instead, I was thrust onto the front lines on the first day,” Onie said. “As a result, I had dozens and dozens of conversations with low income families in Boston about the real issues they were facing. They would come in with housing issues but whenever you scratched the surface there was always an underlying health issue.”

One client, for example, wasn’t paying his rent. When Onie warned him he would likely be evicted, he reasonably answered that he didn’t have the money to pay rent because he was paying for HIV medicines to stay alive.

“I grew fixated with the connection between health and poverty,” Onie said.

Radical Change

That was the start of Project HEALTH, a Boston-based social service for low income youth and families, in which physicians write out prescriptions for food, housing, fuel assistance and other resources, as well as medications.

Dr. Catherine deVries, a pediatric urologic surgeon based in Utah, told a similar story of an eye-opening conversion to the wider meanings and dimensions of health care. In her case, the epiphany was triggered by overseas trips to the developing world, where she witnessed levels of teamwork and resourcefulness in bare-bones surgical suites that put the super-technological surgeries of the U.S. and Europe to shame.

That experience taught her the need for truly radical change not only in western surgical procedures, but in the medical culture from which those surgical procedures and processes spring.

“In the developed world, ten percent of us get 90 percent of the surgical care,” she said. “We need an acute change of course, a new way of thinking, a disruption of the old paradigm of thinking about surgery. We need to look at the ethics.  Should technology drive surgery? Is surgery good? Does the benefit justify the cost?”

Missing Ingredients

Dr. Sanne Magnan, the Minnesota Commissioner of Health, reminded conference participants that while America spends more money than any nation in the world on health care, it usually scores near the bottom on global surveys of quality and longevity of life.

Those statistics point to two missing ingredients in the present health care system in this country, Dr. Magnan said. The first is to maintain a laser focus on new ways to measure and define the true value of medical treatment, where value equals quality divided by cost.

Second, Dr. Magnan said, Americans need a definition of health that embraces more than the treatment of disease.

“We are focusing more on health care than on health and well-being,” Dr. Magnan said. She knows this first-hand, she said, from caring from her elderly mother who suffers from deafness and dementia. “We are struggling mightily to keep her living independently,” Dr. Magnan said, because if she moves to an assisted living facility her life savings will quickly evaporate.

The husband-and-wife legal team of Tahir Amin and Priti Radhakrishnan offered an international viewpoint on health, this time through the lens of international patent law.

Both patent attorneys, they work full time trying to increase access to affordable medicines in developing countries. They do so by legally challenging pharmaceutical companies that try to secure long-running patents, whose effect is to price many life-saving drugs out of the hands of all but the rich in developing countries around the world.

Dangerous Trends

Amin and Radhakrishnan delivered perhaps the biggest news of the morning.

“There is a new era in patent enforcement around the world,” Radhakrishnan said. “We are starting to see the generics industry shutting down.”

Radhakrishnan cited a 2008 case in which Dutch officials seized medicines that were being shipped from India to Brazil, on the grounds that the drugs were patented and thus were being shipped illegally. However, Radhakrishnan said, the drugs were patented only in the Netherlands and not in India and Brazil, with the Netherlands thus essentially using state power to enforce the wishes of multinational drug companies.

This case, in which Brazil and India are challenging the Netherlands at the World Trade Organization, is one of increasing numbers of similar “battles going on between multinational pharmaceutical companies and the governments of developing countries,” Radhakrishnan said.

Another dangerous trend, Amin said, was the gaming of the patent system in developing countries by pharmaceutical companies that file patents year after year to maintain monopoly pricing control over their drugs.

Clown Pants

That practice contradicts the original intent of patent law which is not only to reward inventors for their innovations – for a finite period of time – but also to disclose and disseminate those inventions to society.

“The days when we actually had flashes of genius, those days are gone,” Amin said. “These days we are giving patents for crustless peanut butter and jelly sandwiches, for new ways to exercise cats, or changing the taste of a syrup.” Likewise, he said, drug companies make superficial modifications to drugs to extend patents – and thus pricing control -- far beyond the 20-year period that is a rough global benchmark for reasonable patent life.

A clown provided the most resonant touchstone word of the morning.

The clown was Dr. Patch Adams, dressed in his trademark baggy clown pants, with a small fork-shaped earring dangling from his left ear. Adams was immortalized by Robin Williams in the 1998 film, Patch Adams, about Adams’ career as a doctor who uses clowning to connect with patients.

His word that rang down the morning discussion was “compassion.”

“Nowhere are hospitals happy in the world,” Adams said. “Medical students are hugely unsatisfied. They would love a joyful, sweet practice of medicine. No medical school in the world teaches compassion as an embedded course, and yet the practice of medicine is the practice of compassion -- to use what humble tools and knowledge we have in order to help another person.”

At his Gesundheit! Institute, a free community hospital in West Virginia, Adams said he has put his principles into actual practice.

“We’ve eliminated 90 percent of the cost of health care,” he said. “At our hospital the cleaning person and the surgeon make the same salary, $300 a month. You may think that only nuts would apply. But thousands of doctors and nurses apply every year. Why? I like to think it’s the gradient of working for money or working for love. People will trade several million dollars a year as a surgeon, for $3,600 to serve humanity.

“People sometimes ask me, ‘Has it been hard?’” Adams said. “I’ve never had any discouragement. Not for one second. Hard would have been to work for the American system.”

This post was written by Doug McGill.