Global public health development goals: Paul Farmer on who lives and who dies.

Global public health development goals: Paul Farmer on who lives and who dies..

Economics should never have sought to divorce itself from the other social sciences and can advance only in conjunction with them. -Thomas Picketty

A day late for World Health Day. I hope my prof won’t mind if I share an article from this week’s readings. It’s going to be a task to disentangle the social injustice from the ethics of access from the rageifying post-colonialist cut-and-run, then weave in a thread of third world problems here in the US, but hey I’ll do my best to analyze coherently.

I can’t tell if the article is unwieldy or if it’s just my feelings on the subject. Either way a worthwhile read.



I’ve lived nearly all my adult life in rural Virginia. I’ve tried to leave it and do something shinier with my life, to no avail. It calls me back. As I hone in on where I want my practice to go I’m more and more certain that health care access and preventative care issues among rural people, especial rural black people, is my dissertation in waiting.

And as much as I complain about the year round life-size outdoor nativity set down the road and the absurd number of sheds people have and the omnipresent target rounds being fired, I can’t imaging a life without my incomprehensible neighbors (who btw think I’m a space alien. Running at night down my unlit road with a headlamp confirms that suspicion). I’ve got a great post brewing about how my tiny county has managed, by being so indisputably red and according to a poll of bumper stickers having only two political issues (out of my cold dead hands and NOBAMA), to create progressive local educational and health care initiatives. When no one has to prove their redness, a space opens up for common sense arguments.

I am a physical wreck by the end of my semester and trying to get a tree up and make the Christmas magic happen for my lovely kid, so this make take a day or two. In the meantime enjoy this picture of my doc’s patient room. DISCLAIMER: This is the best PCP I’ve ever had. Hands down.

photo (2)

It’s World AIDS Day. Epi changes in HIV/AIDS.

CDC – Geographic Distribution – Statistics Overview – Statistics Center – HIV/AIDS.

Some highlights:

-> Largest percentage of newly diagnosed infections: The South

-> Largest percentage of people living with AIDS: Dixie

-> Largest percentage of deaths from AIDS: Former Confederate States of America

Racial disparity also observed (new diagnosis highest in African-American population, particularly African-American women).

What does it mean? The epidemiological profile of AIDS has changed quite a bit since the 1990s. HIV/AIDS needs to be on the radar for health care providers (and people having sex) everywhere: in the south, in rural areas, as well as major urban areas, the northeast, and the west coast. Screening should be taking place at every primary care visit and, since it is often used as a primary care, the Emergency Department. Normalizing HIV screening as one of those tests we do for everyone at every point of contact just makes sense. Broken leg? How about a side of HIV screen gratis b/c of Obamacare?

I’ve been HIV tested 3 or 4 times and I promise you it is fun and easy. Do it! Ask your doctor or nurse if they offer the test to everyone. If no, why not?

Think globally, outrage locally.

One of the volunteers at our tiny county’s only food bank/emergency assistance provider/shelter is always wearing a t-shirt that says IF YOU AREN’T OUTRAGED YOU AREN’T PAYING ATTENTION. He’s one of the gentlest guys I know–a middle aged black man living in rural poverty who relies on the food bank and is its most faithful volunteer. I used to give his son a lot of (unsanctioned by my employer) rides back when I was working in our nearby town. Also soft-spoken and kind. And tall and broad and one of those kids whose stupid luck ends him up in the wrong place sometimes. I worry.

But that t-shirt, oh man it makes me like that guy.

So here’s something I wasn’t paying attention to before one of my nursing colleges (Michael Swanberg, a member of ACT UP, certified nurse midwife, and enchanting human being) brought it to light. This data is pulled from the Thomas Jefferson Health District’s community health assessment, 2012. Page 54. The image quality is terrible but the dark blue is TJHD black infant mortality, teal is TJHD white infant mortality.

infant mortality image

An examination of infant mortality stratified by race demonstrates the same phenomenon in Virginia and TJHD as in the nation — African-American babies die more frequently than white babies. In 2007-2011, the rolling average IMR in TJHD was 4.5 infant deaths per 1,000 live births among white infants, lower than the Virginia (5.4) and U.S. rates; it was 17.3 among African-American infants, which was higher than the Virginia (13.8) and the U.S. rates (Figure 109).

Check my math but that means that African-American neonates in our health district are nearly four times more likely to die than their white counterparts. Brand new no-jackass-on-earth-can-say-their-deaths-were-deserved babies. Are you feeling the outrage? The black neighborhoods in Charlottesville are literally in the shadow of the towers of an academic health center. Tell me how this can be.

RAM: Remote Area Medicine

RAM is well know within the VA healthcare community. Clinics are held in tents, trailers, and the Wise County Fairgrounds’ livestock stalls. Lines are legendary. People sleep in cars and on the open ground for days to get a chance to have teeth pulled, rudimentary diagnostics, and the scant amount of education and management of chronic conditions that time allows. Efforts by medical and dental staff are herculean and all volunteer. Patients are nearly all uninsured (which does not at all mean they are not working if you must ask).

This is an access issue, people! RAM was developed to provide care to remote villages in South America. Over 60% of RAM clinics are now in the US. It is the primary source of healthcare for thousands of people in Southwest. WaPo did some great reporting on it this year,  and now we’ve got an independent film coming out.

The WaPo article is titled Misery that Shouldn’t Exist. Cough Medicaid expansion cough cough. More to come on the politics, the policy, the people.

The struggle is real.