Herrera wasn’t a saint. But he may have been something better than that.
August 29, 2021 11:30 AM Subscribe
Be that as it may, the US health care industry is the richest and most powerful in the world! WE'RE NUMBER ONE! WE'RE NUMBER ONE! WE'RE NUMBER ONE!
posted by evilDoug at 1:21 PM on August 29, 2021 [3 favorites]
posted by evilDoug at 1:21 PM on August 29, 2021 [3 favorites]
Wow, it's a commentary on our North American health systems perhaps, but reading about how you would be assigned a doctor/nurse team who would call on you to check how you're doing every year is mind-boggling.
posted by storybored at 1:37 PM on August 29, 2021 [8 favorites]
posted by storybored at 1:37 PM on August 29, 2021 [8 favorites]
reading about how you would be assigned a doctor/nurse team who would call on you to check how you're doing every year is mind-boggling
This is true for me too, as someone reading in the UK, with a medical system that's general considered "better" than that of the US in spite of seemingly hanging on by a thread, and even more so following the pandemic.
It also occurred to me while reading that medical systems which rely on acute rather than preventative care require every individual to be pretty literate about their own health - otherwise how do you know when something is wrong to the point that you require medical care? Except western medicine is also a system that seems to encourage at least some degree of arrogance among its practitioners, leading to numerous uncomfortable encounters in which the patient asserts that something is wrong and the physician is extremely skeptical until proven otherwise.
Gawande touches on anaemia as one of the conditions that's now routinely monitored for in Costa Rica. I've had my share of issues with anaemia in recent years, and still remember the medical appointment where I described my symptoms to a highly unimpressed nurse practitioner who seemed unwilling to believe me, even though I knew my body felt off by its own standards, until a blood test proved me right and got me on the path to treatment. The idea that something like that could be screened for routinely - rather than requiring me to a) know myself well enough to tell that something is wrong and b) be willing to enter into an interaction that feels inherently hostile at the outset - is, frankly, revolutionary.
posted by terretu at 3:00 PM on August 29, 2021 [14 favorites]
This is true for me too, as someone reading in the UK, with a medical system that's general considered "better" than that of the US in spite of seemingly hanging on by a thread, and even more so following the pandemic.
It also occurred to me while reading that medical systems which rely on acute rather than preventative care require every individual to be pretty literate about their own health - otherwise how do you know when something is wrong to the point that you require medical care? Except western medicine is also a system that seems to encourage at least some degree of arrogance among its practitioners, leading to numerous uncomfortable encounters in which the patient asserts that something is wrong and the physician is extremely skeptical until proven otherwise.
Gawande touches on anaemia as one of the conditions that's now routinely monitored for in Costa Rica. I've had my share of issues with anaemia in recent years, and still remember the medical appointment where I described my symptoms to a highly unimpressed nurse practitioner who seemed unwilling to believe me, even though I knew my body felt off by its own standards, until a blood test proved me right and got me on the path to treatment. The idea that something like that could be screened for routinely - rather than requiring me to a) know myself well enough to tell that something is wrong and b) be willing to enter into an interaction that feels inherently hostile at the outset - is, frankly, revolutionary.
posted by terretu at 3:00 PM on August 29, 2021 [14 favorites]
Dr. Álvaro Salas, 70, Gawande's main source in the article, is some kind of secular saint. One anecdote: [Salas] became a neighborhood doctor and a public-health officer rolled into one [in El Roble, Puntarenas]. In addition to drawing blood for basic lab tests, he and his team collected stool samples to look for parasites. Because they also tested for blood in the stool, Salas detected one patient’s colon cancer early enough that it could be treated before it spread.
Salas, as a twenty-something physician, using non-invasive methods, working out of a tiny barrio clinic in a pilot program-with-mobile-component, going door-to-door in the neighborhood, identified and successfully treated colon cancer in 1978. [About 8 years later, the doctor's father dies of colon cancer at age 74. Colorectal cancer is the third most common cancer worldwide and the fourth most common cause of cancer death. (2018 research)]
Salas, earlier in the article: In 1977, after his medical internship, he went to work in the Nicoya Peninsula, on a government-funded year of social service. Now a tourist destination, known for its beaches and for having one of the largest populations of centenarians in the world, the peninsula was then a remote and impoverished region, where medical care was sparse and lives were precarious.
Salas ran the initial mobile public-health unit there. Salas and his team treated patients; they conducted household surveys, and pieced together diagnoses of whole communities. He found high rates of severe anemia among women, water contaminated with parasites, and outbreaks of respiratory infections. Owing to the new reforms, Salas could now do something about what he observed. Members of his team distributed iron tablets and vitamins and basic medicines such as antiparasitics and antibiotics. They helped organize sites for clean drinking water. They fought malaria and outbreaks of other infectious diseases. And, in the data they collected and the people they encountered, Salas could see the benefits.
It's like preventative measures and early interventions lead to good outcomes. Less than 20 years later, Nicoya was one of the original five "Blue Zones" (from the influential Nov. 2005 National Geographic cover story, Secrets of a Long Life - .pdf) known for population health and longevity.
posted by Iris Gambol at 3:24 PM on August 29, 2021 [11 favorites]
Salas, as a twenty-something physician, using non-invasive methods, working out of a tiny barrio clinic in a pilot program-with-mobile-component, going door-to-door in the neighborhood, identified and successfully treated colon cancer in 1978. [About 8 years later, the doctor's father dies of colon cancer at age 74. Colorectal cancer is the third most common cancer worldwide and the fourth most common cause of cancer death. (2018 research)]
Salas, earlier in the article: In 1977, after his medical internship, he went to work in the Nicoya Peninsula, on a government-funded year of social service. Now a tourist destination, known for its beaches and for having one of the largest populations of centenarians in the world, the peninsula was then a remote and impoverished region, where medical care was sparse and lives were precarious.
Salas ran the initial mobile public-health unit there. Salas and his team treated patients; they conducted household surveys, and pieced together diagnoses of whole communities. He found high rates of severe anemia among women, water contaminated with parasites, and outbreaks of respiratory infections. Owing to the new reforms, Salas could now do something about what he observed. Members of his team distributed iron tablets and vitamins and basic medicines such as antiparasitics and antibiotics. They helped organize sites for clean drinking water. They fought malaria and outbreaks of other infectious diseases. And, in the data they collected and the people they encountered, Salas could see the benefits.
It's like preventative measures and early interventions lead to good outcomes. Less than 20 years later, Nicoya was one of the original five "Blue Zones" (from the influential Nov. 2005 National Geographic cover story, Secrets of a Long Life - .pdf) known for population health and longevity.
posted by Iris Gambol at 3:24 PM on August 29, 2021 [11 favorites]
Funny how obvious it is in retrospect that a systematic focus on health rather than a focus on treatment leads to the best outcomes.
posted by Ickster at 3:53 PM on August 29, 2021 [8 favorites]
posted by Ickster at 3:53 PM on August 29, 2021 [8 favorites]
Two of my favorite attending physicians when I was in training were a husband-and-wife team from Costa Rica. I asked the husband once what brought them to the States, because CR's health system is just so much better than in the US. Answer: postgraduate training and research opportunities, initially, and then they just ... stayed.
Gawande does touch on this in the article, obliquely: "With Costa Rica’s constrained resources, there was not enough staffing, especially for specialists. When it came to secondary care, months-long waits for advanced imaging and for procedures were common." Regardless, these sorts of community clinics have the greatest impact on both population and individual health in the earliest, intervenable stages. It's the home visit model from the 19th century, and it actually works, because, as noted in the Swedish study, "Relationships with people ... appear to make a major difference in mortality."
And honestly, I think it can and should work for specialist care, too. Until quite recently, the term "social determinants of health" was just ... not a thing, and now it's everywhere in medical education/training. (They even made an epic module for it, with a 34-page training deck, which is a great way to make sure that information gets lost in the bowels of the electronic medical record, never to be seen by human eyes. Trust us to take a simple, foundational concept and muck it up with Meaningful Use.)
But I remember toward the end of my fellowship, giving a practice job talk on exercise as a disease-modifying strategy for neurodegenerative diseases, and being advised to replace the slides showing neighborhood walk scores with more data about mice on treadmills. "You are not an urban planner," said my director. No, sir, and I'm not a mouse scientist either.
(I left the walkscore slide in; I got the job.)
posted by basalganglia at 5:05 PM on August 29, 2021 [13 favorites]
Gawande does touch on this in the article, obliquely: "With Costa Rica’s constrained resources, there was not enough staffing, especially for specialists. When it came to secondary care, months-long waits for advanced imaging and for procedures were common." Regardless, these sorts of community clinics have the greatest impact on both population and individual health in the earliest, intervenable stages. It's the home visit model from the 19th century, and it actually works, because, as noted in the Swedish study, "Relationships with people ... appear to make a major difference in mortality."
And honestly, I think it can and should work for specialist care, too. Until quite recently, the term "social determinants of health" was just ... not a thing, and now it's everywhere in medical education/training. (They even made an epic module for it, with a 34-page training deck, which is a great way to make sure that information gets lost in the bowels of the electronic medical record, never to be seen by human eyes. Trust us to take a simple, foundational concept and muck it up with Meaningful Use.)
But I remember toward the end of my fellowship, giving a practice job talk on exercise as a disease-modifying strategy for neurodegenerative diseases, and being advised to replace the slides showing neighborhood walk scores with more data about mice on treadmills. "You are not an urban planner," said my director. No, sir, and I'm not a mouse scientist either.
(I left the walkscore slide in; I got the job.)
posted by basalganglia at 5:05 PM on August 29, 2021 [13 favorites]
If people want other people to live or people want people to die, they'll find a way.
posted by bleep at 7:16 PM on August 29, 2021 [1 favorite]
posted by bleep at 7:16 PM on August 29, 2021 [1 favorite]
Ctrl+F "army" = 0 results
The most important part of this story is missing:
Costa Rica abolished its army in 1948
President Carlos Alvarado has called Costa Rica’s demilitarization “one of the most politically relevant decisions of our nearly 200 years of republican existence, and an essential part of our national identity.”
By not funding a military, Costa Rica invested more heavily in education, healthcare and infrastructure.
posted by Tom-B at 5:03 AM on August 30, 2021 [17 favorites]
The most important part of this story is missing:
Costa Rica abolished its army in 1948
President Carlos Alvarado has called Costa Rica’s demilitarization “one of the most politically relevant decisions of our nearly 200 years of republican existence, and an essential part of our national identity.”
By not funding a military, Costa Rica invested more heavily in education, healthcare and infrastructure.
posted by Tom-B at 5:03 AM on August 30, 2021 [17 favorites]
Jurassic Park, written 31 years ago, opens telling us how superior the Costa Rican health system is.
posted by phunniemee at 5:35 AM on August 30, 2021 [5 favorites]
posted by phunniemee at 5:35 AM on August 30, 2021 [5 favorites]
Costa Ricans are very proud of their health care system, at least going by the various people I met there. It came up a lot in the context of snake bites which was both terrifying and reassuring.
posted by lesbiassparrow at 8:44 AM on August 30, 2021 [2 favorites]
posted by lesbiassparrow at 8:44 AM on August 30, 2021 [2 favorites]
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"In the nineteen-seventies, Costa Rica identified maternal and child mortality as its biggest source of lost years of life. The public-health units directed pregnant women to prenatal care and delivery in hospitals, where officials made sure that personnel were prepared to prevent and manage the most frequent dangers, such as maternal hemorrhage, newborn respiratory failure, and sepsis. Nutrition programs helped reduce food shortages and underweight births; sanitation and vaccination campaigns reduced infectious diseases, from cholera to diphtheria; and a network of primary-care clinics delivered better treatment for children who did fall sick. Clinics also provided better access to contraception; by 1990, the average family size had dropped to just over three children.
"The strategy demonstrated rapid and dramatic results. In 1970, seven per cent of children died before their first birthday. By 1980, only two per cent did. In the course of the decade, maternal deaths fell by eighty per cent. The nation’s over-all life expectancy became the longest in Latin America, and kept growing. By 1985, Costa Rica’s life expectancy matched that of the United States. Demographers and economists took notice. The country was the best performer among a handful of countries that seemed to defy the rule that health requires wealth."
posted by Iris Gambol at 12:49 PM on August 29, 2021 [11 favorites]