Thursday, March 31, 2011

Felicia Chow, Shaoguan, Guangdong Province, China

March 2, 2011

Shaoguan, Guangdong Province, China

Medicine can be emotionally draining and neurology, even in the most developed country, is particularly heartbreaking at times.  In my time in Shaoguan, a city in the poor, rural northern region of Guangdong province, neurology seemed still more depressing.  One of the hospitals I visited in Shaoguan, the largest in the city, felt more like a factory than any of the previous hospitals I’d been to in Guangzhou, with over 2000 beds, of which nearly 200 were dedicated to patients with neurologic diseases.  The equivalent of the attending typically sees new admissions while old patients, many of whom stay for weeks at a time, are seen typically no more than once a week.  With that many patients, everyone gets short shrift despite the best intentions. 

On the second day of my visit, I watched as a husband and son pushed a patient of 47 years, dressed in pajamas with the recognizable blank stare of advanced dementia, into the admitting area.  She had the classic “marche a petit pas,” barely lifting her feet off the floor as she shuffled in tiny steps.  I kept looking around for the wheelchair that they had left at the doorway, but of course there was none.  I cannot imagine how long it must have taken them to walk her this way from their home. 

According to the team of physicians I was observing, the patient’s family brought her religiously to clinic every 1 to 2 months, each time asking what could be done.  When I met them, the son was clutching images from a recent brain MRI for which they had raised enough money.  Looking at her—mute, rigid, expressionless face and hands tightly grasping mine—I didn’t need the MRI to tell me that she had end-stage dementia, her frontal lobes slivers of cortex with symmetric subcortical white matter changes.  I tried to get a sense of what testing had been done in the three years during which she had become sick but none of the team seemed to know for sure.  I was surprised that they had tested her for HIV, which rarely enters the differential in China because the infection is supposedly so uncommon (a self-fulfilling prophecy, though; if you don’t look, you won’t know what’s there).  This time around, her family had clearly brought her in because they didn’t know what else to do for her, a point at which in the United States she would have received home services, a wheelchair at the least, or been placed in a facility.  Instead, the team started her on nimodipine given its “protective effects” in vascular dementia.  They said little to the family, for which I could not blame them as there were a hundred plus more patients to see.  When I left their bedside, the son scurried after me, thrusting a paper in my hand with his phone number, asking me to call if I had any more ideas for how to help his mother when I returned to America. 

I doubt there is much more medically we would have been able to do for her in the United States.  There may have been some rare bird diseases missed by the team (and even then probably untreatable), but more than likely this patient had an incurable form of dementia, one that in the United States we’d have little more to offer in the way of treatment.  And, of course, in the United States, we have social services, as inadequate as they may be, that help to alleviate the burden of caring for a loved one with end-stage dementia (and that you would think a communist government would also provide).  But what was so unsettling was that the family didn’t seem to understand this, that none of the doctors had stopped to explain to them that the patient had some terrible neurologic illness, a form of dementia that was clearly not reversible.  Or perhaps they had but the family had simply not grasped the extent of the discussion. 

There is something to be said for giving a family your best-guess diagnosis and prognosis and then helping the family to care for their loved one through a dignified death.  Maybe we only treat ourselves when we feel like we’ve done our best to help a family understand what to expect.  Practicing medicine in the United States, even in the worst circumstances, is a luxury, a pleasure.  

Tuesday, March 29, 2011

Felicia Chow, Guangzhou, Guangdong Province, China

February 21, 2011

Today I arrived in Guzhen, a small town in the south of Guangdong province about one hour from Guangzhou, to visit a community health program established almost 20 years ago for the prevention and control of chronic diseases. The Chinese government has heralded the program as a model for stroke prevention in rural China and has attempted to replicate the model in other impoverished regions of the country. Twenty years ago, the concepts of disease prevention and health promotion were foreign to China, as was the idea that investing in prevention up front would save money in the long run. A fortuitous combination of ‘right time, right place’ and the dedication of a team of neurologists from Guangzhou Medical University, however, have transformed the town of Guzhen into a truly impressive example of public health at its best.

When the program began, two neurologists from Guangzhou Medical University, Drs. Xu and Liu, who have been tireless champions of the community health effort, traveled regularly to Guzhen to educate local health and government officials on the health benefits of disease prevention, while at the same time emphasizing social and financial incentives, eventually convincing the provincial and national government to invest in the program. They brought their own supplies from Guangzhou, including refrigerators and other lab equipment, and traveled by bicycle down dirt paths to visit one community health clinic (or “hygiene station” as they are called here) after another, training local health workers on how to take a neurologic history and do a neurologic examination, how to take a reliable blood pressure, how to run a lipid panel, how to choose a blood pressure medication and, most importantly, how to educate patients on these same issues.

Drs. Xu and Liu were local fixtures in the community, showing up to town meetings, school functions and other events where they helped to shift the mentality of local residents to understand the benefit of coming to the hygiene stations BEFORE illness struck. At first, the entire team was available to train and supervise during makeshift clinics in hygiene stations. Later, only one team member was available per hygiene station. Eventually, local health workers were flying solo with one of the team members from Guangzhou only checking in every few weeks to months to field questions and ensure quality control.

Initially, the team from Guangzhou paid 1 RMB out of pocket to local health care workers for each patient they were willing to see, essentially buying the cooperation of the local health workers in the hygiene stations. Now, though, as the program has become established it is backed almost entirely by the provincial and national government. Health care is nearly free for the entire community, including thousands of local farmers, with an annual copayment of only 3 RMB, the equivalent of less than $0.50. This year marks the first year that the hospital has turned a profit which is largely attributed to reaping the benefits of 20 years of prevention efforts. Their current goal is to ensure every adult over the age of 35, estimated to be about 45,000 residents, is enrolled and seen annually in clinic.

Because the provincial and national government are extremely invested in this effort, resources have been set aside for health education, including written materials that are plastered on most walls of the local hospital and hygiene stations, along with community classes for “hypertension and diabetes clubs” which focus on nutrition, exercise and medication management. Each night, thousands pour onto the beautifully lit main square to perform exercises and traditional Chinese dancing en masse. Even sales of chicken livers and other cuts of meat that are known to be high in cholesterol and fat have fallen since the program’s inception.

The model has been effective in large part due to the dedication of the neurology team from Guangzhou Medical University who for years volunteered their time and resources to make the program work. Drs. Xu and Liu knew that in order for their efforts to be beneficial, not only did they have to train the local health workers in Guzhen to be able to stand on their own, but the relationship with Guzhen had to be a mutual collaboration, as it has been and continues to be to this day. The question, though, is how to translate this model into a more comprehensive program for all of China, including the most rural and difficult to reach regions of the country. Some of what made Guzhen such a success holds true for the rest of China, namely minimal emigration from rural areas and the power of the totalitarian Chinese government to set public policy that is actually followed by the Chinese people. (As one of the neurologists I worked with told me, “For better or worse, when the Chinese government sets out to do something, there is no question that it can be accomplished.”) What makes Guzhen unique, however, is the boom economy that has stemmed from a relatively new and thriving light manufacturing industry. Without this extra financial cushion, even Drs. Xu and Liu who were staunch supporters of Guzhen long before anyone could imagine the public health success that the community enjoys today, are skeptical about the ability to replicate Guzhen elsewhere in the country.

Felicia Chow, Guangzhou, Guangdong Province, China

February 17, 2011

We saw 70 patients in one afternoon today in general neurology clinic. 70 patients, one attending and two students fresh from the basic science lab where Chinese medical students seem to spend most of their time. It was controlled chaos.

Some patients traveled all day from neighboring provinces including Hunan and Guanxi to come to clinic while others lived just blocks away. They lined up before dawn, even as early as the night before, in order to get a number that would allow them to be seen by the doctor before the clinic doors closed. Their patience, lack of any sense of entitlement and adherence are remarkable and lay the groundwork for the patient-physician relationship (although later I find out that the physician I am working with and the time she takes to build relationships with her patients are unique in China, atypical of the mindset of many other Chinese physicians, and thus the adherence of her patients is unusual for most Chinese patients). They are grateful for what she does for them, even in the average 5-minute encounter, and they work hard to follow her orders within the limitations of social, financial and cultural barriers.

The clinic is a microcosm for the rest of China, at least what I’ve seen in my short time here on this trip: overbooked, overcrowded, overwrought and overwhelmed. No matter where you go, there is no respite from the throngs of people in this city. I’ve been to some of the biggest cities in the world on most of the continents, but I still cannot get used to the scale of the population here, as millions push and shove their way past me in an attempt to get a seat on the subway or to clear a path up the stairwell. I am unaccustomed to this mindset of having to compete so hard all day, every day. I wonder what would happen if all billion plus people decided to wait in line instead of pushing their way to the front.

That the same holds true in the clinic, in the place where the masses come for medical care, should not surprise me. In a way, the fact that patients return week after week is a testament to the value placed on health prevention in certain aspects of the Chinese medical system and to the trust that patients place in the physicians who are willing to take the time to build a relationship, despite their unwavering attachment to Chinese herbs and cocktails of roots and other unidentifiable ingredients, some of which likely do have benefit. In another sense, the overbooked clinic underscores the weaknesses in the system. Most patients have to return weekly or bimonthly in large part because the Chinese government won’t allow physicians to prescribe more than a week or two of medications at any given time. Physicians’ salaries are docked if the amount of medication prescribed is out of proportion to the number of revenue-generating examinations ordered. No different from in the United States, the really special physicians that I’ve been working with have tricks up their sleeve to try to get around these restrictions. They often write multiple prescriptions for the same medication and instruct patients to have them filled outside of the hospital pharmacy. It’s more difficult, though, to game the system in the inpatient setting where, when the cost of a patient’s stay exceeds the limit covered by insurance and the patient cannot or is unwilling to leave the hospital, the hospital will take what is needed to pay for services out of the attending’s salary.

In a country with such intellectual prowess and value placed on scientific and medical progress, it remains stunted by the policies of the government. For example, it is illegal for patients to go outside of the country for certain medications that cannot be obtained in China, even if they are readily available in easily accessible neighboring cities such as Hong Kong. It is also illegal to send blood samples out of the country for laboratory testing, even for research purposes. On the other hand, the power of a totalitarian government, if applied in ways that benefit the people, is pretty astounding, an example of which I will visit later this week in a small town outside of Guangzhou where the government has spent over 20 years cultivating one of the strongest and most successful chronic disease prevention programs in the country.

There is an upside to requiring patients to return to the clinic with a frequency that we would never, could never accommodate in the United States. The model is akin to “weekly observed therapy” but instead of sending out health care workers to locate patients in far-flung corners of the world’s most populous nation, we’re lucky enough that the patients come to us, week after week. Some patients have literally been seen every week for nearly 10 years since their stroke, now transformed into a walking advertisement for secondary stroke prevention with perfect blood pressure, lipid and diabetes control.

For most of the patients who are follow ups, like speed-rounds, we take 1.5 minutes to review symptoms (“Any new stroke symptoms, any seizures, how’s the headache?”), 1 minute to do an abbreviated version of medication reconciliation as we root through the bag of medications they’ve brought in, discarding those that they should not be taking, 30 seconds to take their blood pressure, 30 seconds for a breezy neurologic exam and then 1.5 minutes of scanning any new labs or other studies and then counseling before calling for the next patient. By seeing patients on a weekly basis, blood pressure control, for example, becomes a precise science, very different from when we see stroke follow up patients in neurology clinic once every few months, at best.

(Not surprisingly, there is no privacy in clinic. Despite valiant efforts by the medical students to maintain crowd control, patients and their families hover over us as we see patients. We ask about bowel function and sexual dysfunction with more than 20 people looking on. I keep looking for a curtain to draw but there isn’t one.)

As with everything in China, the question remains as to how to disseminate the practice of health promotion and disease prevention beyond the clinic doors of a few very special and wise physicians, primarily located in the large cities. Strolling down the glittering streets of Guangzhou where China’s rapid development and growing wealth are apparent, the widening gap between rich and poor is hard to miss. Caring for all of this country’s patients, a billion strong, will be one of China’s most formidable public health challenges in the years to come.

Friday, March 4, 2011


Hasan Merali, MD
On the way to Poveuy, Tonle Sap Lake, Cambodia

I went to visit Say-la last weekend but she had already been discharged. She had her echo done and it turns out she has aortic stenosis. The physician who saw her recommended a follow-up echo in one year. All of her care while in the hospital was provided at no cost by the Angkor Hospital for Children transportation back to her village was provided by The Lake Clinic.

Our regular boat is now in Phnom Penh where the water levels are higher so this week we had the pleasure of taking the 'small boat'. The small boat is a wooden boat that is about 7 meters long. It has no seats, just wooden planks where we placed some plastic chairs for the journey. There is an outboard motor which is so loud that we cannot have a conversation during the trip. The motor can push the boat along at 10 km/h but we were further slowed by the fact that we had to tow another boat that carried all of our medical supplies. At one end of the boat there is a 4 sided tin structure about 0.5 meter high and only enough room inside for a Cambodian child. One side is a door, and in the center, on the floor, there is a hole directly into the lake. This is the toilette.