Fiji Health Festival
I just returned from two weeks in Fiji. This was a medical mission sponsored by the Rotary clubs of the western Pacific. It was a life altering experience. You may or may not be interested in the comments that are written as a preliminary critique, but I copy them here for consideration and comment.
The Clinics are over now; the festival ran from 13 August until 31 August. The multiple clinics were conducted in Suva, Nausori, Taveuni and Nadi. We saw some 7,000 islanders in about as many days. I think we saw 1% of the Fiji population and as much as 10% of the communities, we visited.
We worked with local caregivers and medical students. All participants were screened for BP, blood glucose and cholesterol by finger stick. The results were reported in mmoles/l-1. A medical questioner asked 23 general medical questions such as chest pain. Do you get short of breath? Do you have pain anywhere? Participants were then lined up, numbered and directed to EYE, GP, GI, Surgeons and ENT and at some sites, DERM. If problems presented in multiple areas, there was an attempt to direct participants to all areas of concern. The consultants consisted of an fp, thoracic surgeon, head and neck surgical oncologist, a gastroenterologist, an ophthalmologist and a dermatologist. Assistance and interpreters were provided by medical students. A formulary of drugs was provided for prescriptions.
The organization and planning grew from the cooperation of eight Rotary clubs on Fiji and the district governor elect. The logistics were massive, consisting of exam tables, chairs, partitions, curtains and tents. The main venue was usually a school house and in one case the hospital. Islanders came great distances in some cases pooling family resources just to afford transportation. In some cases, transportation was provided. This was the largest health initiative ever done in Fiji and the study may provide significant data.
As a first effort, the Health Festival would seem an overwhelming success. The organization, coordination and logistics were outstanding. If there was any fault, it may have been in doing too much. The experience from the viewpoint of the volunteers was life altering, at least for me. Seven thousand Fijians are now part of our hearts if not our family, but that is the way with Fijians. They stand tall, look you in the eye and you become their brother or sister.
What were the problems? For my part, they were largely dealing with the unknown. There were several common but unclear to me skin diseases. Two forms of arthritis seemed baffling in their prevalence, one a straightforward bilateral arthritis of the knees in the Fijian population, and the other, a sort of poly malign with or without bone pain in the Indo-Fijian population. Then there was a common complaint of a burning sensation of the legs and feet. Diabetes II and hypertension were expected, known and overwhelmingly under treated. Many were in early stages of congestive failure. Diet and obesity are significant issues. I thought that many women were anemic. I did not feel a spleen. Many were multiperous with pale lower lid fatigue and resting pulse over a hundred.
Some problems were associated with sheer numbers. There was some pushing, shoving, and very long lines. I was frustrated by the lack of clinical infrastructure, lab, x-ray, ekg, given the level of pathology we were dealing with. The formulary of drugs was insufficiently defined. A few needed items were missing. Many participants were under treatment but came in without their medications or any knowledge about what they were taking. This made it nearly impossible to support the health service treatment they were receiving, to initiate new treatment or to adjust the ongoing dosage of medication. This first years learning experience should make next years effort more efficacious. We should gain some clear sense that we have done more good than we have harm.
What would I like to have?
By way of diagnosis & treatment:
Hba1c
CBC indented items on order
Urinalysis
Uric acid
Serum K+
Cardiac enzymes
Naturetic test CHF
Portable EKG, Ultrasound
Somehow, they should bring their meds.
More detailed formulary
Query the use of Regular Insulin before meals in some of the poorly controlled Dbm.
By way of Public Health:
Immunizations
Mass screening
Stool O&P
Meds for scabies
Screen for Thalassemia and Sickle cell.
Skin scrapings for fungus
TB skin test
Free eyeglasses
If we are trying to promote health education and responsibility, we should not create lines, numbers or triage, but encourage participants to direct themselves freely to the various educational venues. Provide a larger number of displays. Offer bags for the handouts. As for clinical encounters, we need many more examiners, nurses, med students and teams organized in advance. I would be inclined to break the exams up by category that goes with the educational display. One team for Diabetes, One for HT, one for scabies one for fungus, one for Arthritis of knees, one for combined muscle joint and bone pain. Then one might pass the complications of say combined Diabetes Hypertension with early CHF and edema to say a complication team. Each team needs two interpreters unless the examiner speaks the language. The participant might schedule him or herself into any one of these specialties after visiting the display booth and making the determination of a need.
For our part, we might be able to recruit appropriate specialists. We might do more to reinforce the stature of the existing delivery system by involving them to a greater extent and in a more primary way. In other words, leverage the imported resource. Make a bit less of the great white doctor.
Statistics are an issue. We need valid data. The questions we asked on the form, which might have served as a routing for further evaluation tended to suggest the symptoms we were looking for and thus everybody responded to nearly all the questions. The Fijian population seems compliant or suggestible in this regard. The responses had little to do with the problems experienced by participants. What is more the participants in a long line got the idea that checking off chest pain would move them to the front of the line. Some of the other positive responses may have resulted from a similar strategy. While the intent and the design of the questions may have been ideal, it points up some of the problems with triage based on subjective criteria. The finger stick results for blood sugar may yield poor over all statistics for adequacy of control. Some people were fasting some were not.
As for further activity, continue. Much is lost without follow-up. Take advantage of what we have learned. Emphasize education and public health. Use the opportunity for mass screening and mass inoculation. Perhaps establish an educational outpost for tropical medicine. There seems no reason Fiji cannot become a paradise of healthy living given the magnitude of the Rotary initiative and the obvious enthusiasm of the population.
One question remains in my mind, that is the uniformity of complaints of polymyalgias, bone pain and arthralgias. Such uniformity of complaint cries for a common etiology. There may in fact be two patterns of musculo-skelital complaint suggesting either two underlying causes or a different manifestation in two population groups. I wonder if the answer lies in the purview of tropical medicine rather than in rheumatology. There seems a remarkable absence of PIP disease.
On philosophical grounds, medical care has, historically, grown from a tradition of bottom up management. The patient first, he or she both chose and paid for the physician at the primary level. The hospital, the insurance and the government were secondary concerns. When an issue became a matter of patient care the provider was and still is for the most part prompted to proceed to do the right thing. English law still more or less supports such action based upon outcome, but the trend is the other way towards more and more top down management.
Public Health on the other hand, with an outstanding history, has been much the reverse with authoritarian control exercised from the top down. Communicable disease was isolated without recourse or right for the local provider to interfere. This is as it should be. One can easily see that a range of risks to the public welfare might run counter to the personal freedom and even choice of the individual patient. This tradition too is under pressure to be reversed on grounds of personal liberty.
Without commenting on the rightness or wrongness of either trend, there seems no question as to which produce the best results. That is top down for public health and bottom up for patient care. This elaboration applies to what I saw in Fiji, an enviable system of free medical care. The challenge is to achieve some of the quality in patient care that only a bottom up system can generate while maintaining central control, top down management of public health. The Medical School, the performance of the private hospital and the physicians involved seem to suggest that they can. The providers working in rural public hospitals must have the authority to insist on the sanitation, the sterilization capacity, the instrumentation and the prioritizing and directing of funds to achieve these goals, and yes the medicines.
Public health on the other hand might engage in mass screening and mass prophylaxis, isolation inoculation and immunization also emphasizing water sanitation, dietary and environmental hazards. For example, Sodi Pallares, a Mexican cardiologist at the Instituto National de Cardiologia de Mexico persuaded the country to use only raw sea salt. I do not know the details or the statistics but Mexico has far less HT than the US. The prevalence of hypertension in Fiji might be seriously altered by the distribution of sodium poor sea salt in place of refined sodium chloride for the table. Such a strategy might be possible without significant cost. A similar strategy to eliminate the village use of sugar cane might affect diabetes and dental problems, but might be hard to enforce. The educational program will be expensive up front but pay dividends in the long run. A projected image of all Fijians as healthy in their life style, their body, and their environment could give them a reputation to live up to as well as the education necessary to mitigate the Diabetes II. An economic bonus in medical costs and enhanced tourism may be achievable.
These are thoughts only, not testimony but these considerations of management, top down for public health or bottom up for patient care, might have a bearing on the design of the health festival. We seem to embrace both aspects of health, the public health mission and patient care. It might be wise to recognize which is which from the standpoint of organization and traffic. One tends to direct the participant paternalistically while the other encourages responsibility choice and free movement.
There is a debt of gratitude for being allowed to participate in this first Fiji Health Festival. We owe a special thanks to Warwick, Marilyn, Geoffrey, Shantilal and all the wonderful Fiji Rotary family.
The Clinics are over now; the festival ran from 13 August until 31 August. The multiple clinics were conducted in Suva, Nausori, Taveuni and Nadi. We saw some 7,000 islanders in about as many days. I think we saw 1% of the Fiji population and as much as 10% of the communities, we visited.
We worked with local caregivers and medical students. All participants were screened for BP, blood glucose and cholesterol by finger stick. The results were reported in mmoles/l-1. A medical questioner asked 23 general medical questions such as chest pain. Do you get short of breath? Do you have pain anywhere? Participants were then lined up, numbered and directed to EYE, GP, GI, Surgeons and ENT and at some sites, DERM. If problems presented in multiple areas, there was an attempt to direct participants to all areas of concern. The consultants consisted of an fp, thoracic surgeon, head and neck surgical oncologist, a gastroenterologist, an ophthalmologist and a dermatologist. Assistance and interpreters were provided by medical students. A formulary of drugs was provided for prescriptions.
The organization and planning grew from the cooperation of eight Rotary clubs on Fiji and the district governor elect. The logistics were massive, consisting of exam tables, chairs, partitions, curtains and tents. The main venue was usually a school house and in one case the hospital. Islanders came great distances in some cases pooling family resources just to afford transportation. In some cases, transportation was provided. This was the largest health initiative ever done in Fiji and the study may provide significant data.
As a first effort, the Health Festival would seem an overwhelming success. The organization, coordination and logistics were outstanding. If there was any fault, it may have been in doing too much. The experience from the viewpoint of the volunteers was life altering, at least for me. Seven thousand Fijians are now part of our hearts if not our family, but that is the way with Fijians. They stand tall, look you in the eye and you become their brother or sister.
What were the problems? For my part, they were largely dealing with the unknown. There were several common but unclear to me skin diseases. Two forms of arthritis seemed baffling in their prevalence, one a straightforward bilateral arthritis of the knees in the Fijian population, and the other, a sort of poly malign with or without bone pain in the Indo-Fijian population. Then there was a common complaint of a burning sensation of the legs and feet. Diabetes II and hypertension were expected, known and overwhelmingly under treated. Many were in early stages of congestive failure. Diet and obesity are significant issues. I thought that many women were anemic. I did not feel a spleen. Many were multiperous with pale lower lid fatigue and resting pulse over a hundred.
Some problems were associated with sheer numbers. There was some pushing, shoving, and very long lines. I was frustrated by the lack of clinical infrastructure, lab, x-ray, ekg, given the level of pathology we were dealing with. The formulary of drugs was insufficiently defined. A few needed items were missing. Many participants were under treatment but came in without their medications or any knowledge about what they were taking. This made it nearly impossible to support the health service treatment they were receiving, to initiate new treatment or to adjust the ongoing dosage of medication. This first years learning experience should make next years effort more efficacious. We should gain some clear sense that we have done more good than we have harm.
What would I like to have?
By way of diagnosis & treatment:
Hba1c
CBC indented items on order
Urinalysis
Uric acid
Serum K+
Cardiac enzymes
Naturetic test CHF
Portable EKG, Ultrasound
Somehow, they should bring their meds.
More detailed formulary
Query the use of Regular Insulin before meals in some of the poorly controlled Dbm.
By way of Public Health:
Immunizations
Mass screening
Stool O&P
Meds for scabies
Screen for Thalassemia and Sickle cell.
Skin scrapings for fungus
TB skin test
Free eyeglasses
If we are trying to promote health education and responsibility, we should not create lines, numbers or triage, but encourage participants to direct themselves freely to the various educational venues. Provide a larger number of displays. Offer bags for the handouts. As for clinical encounters, we need many more examiners, nurses, med students and teams organized in advance. I would be inclined to break the exams up by category that goes with the educational display. One team for Diabetes, One for HT, one for scabies one for fungus, one for Arthritis of knees, one for combined muscle joint and bone pain. Then one might pass the complications of say combined Diabetes Hypertension with early CHF and edema to say a complication team. Each team needs two interpreters unless the examiner speaks the language. The participant might schedule him or herself into any one of these specialties after visiting the display booth and making the determination of a need.
For our part, we might be able to recruit appropriate specialists. We might do more to reinforce the stature of the existing delivery system by involving them to a greater extent and in a more primary way. In other words, leverage the imported resource. Make a bit less of the great white doctor.
Statistics are an issue. We need valid data. The questions we asked on the form, which might have served as a routing for further evaluation tended to suggest the symptoms we were looking for and thus everybody responded to nearly all the questions. The Fijian population seems compliant or suggestible in this regard. The responses had little to do with the problems experienced by participants. What is more the participants in a long line got the idea that checking off chest pain would move them to the front of the line. Some of the other positive responses may have resulted from a similar strategy. While the intent and the design of the questions may have been ideal, it points up some of the problems with triage based on subjective criteria. The finger stick results for blood sugar may yield poor over all statistics for adequacy of control. Some people were fasting some were not.
As for further activity, continue. Much is lost without follow-up. Take advantage of what we have learned. Emphasize education and public health. Use the opportunity for mass screening and mass inoculation. Perhaps establish an educational outpost for tropical medicine. There seems no reason Fiji cannot become a paradise of healthy living given the magnitude of the Rotary initiative and the obvious enthusiasm of the population.
One question remains in my mind, that is the uniformity of complaints of polymyalgias, bone pain and arthralgias. Such uniformity of complaint cries for a common etiology. There may in fact be two patterns of musculo-skelital complaint suggesting either two underlying causes or a different manifestation in two population groups. I wonder if the answer lies in the purview of tropical medicine rather than in rheumatology. There seems a remarkable absence of PIP disease.
On philosophical grounds, medical care has, historically, grown from a tradition of bottom up management. The patient first, he or she both chose and paid for the physician at the primary level. The hospital, the insurance and the government were secondary concerns. When an issue became a matter of patient care the provider was and still is for the most part prompted to proceed to do the right thing. English law still more or less supports such action based upon outcome, but the trend is the other way towards more and more top down management.
Public Health on the other hand, with an outstanding history, has been much the reverse with authoritarian control exercised from the top down. Communicable disease was isolated without recourse or right for the local provider to interfere. This is as it should be. One can easily see that a range of risks to the public welfare might run counter to the personal freedom and even choice of the individual patient. This tradition too is under pressure to be reversed on grounds of personal liberty.
Without commenting on the rightness or wrongness of either trend, there seems no question as to which produce the best results. That is top down for public health and bottom up for patient care. This elaboration applies to what I saw in Fiji, an enviable system of free medical care. The challenge is to achieve some of the quality in patient care that only a bottom up system can generate while maintaining central control, top down management of public health. The Medical School, the performance of the private hospital and the physicians involved seem to suggest that they can. The providers working in rural public hospitals must have the authority to insist on the sanitation, the sterilization capacity, the instrumentation and the prioritizing and directing of funds to achieve these goals, and yes the medicines.
Public health on the other hand might engage in mass screening and mass prophylaxis, isolation inoculation and immunization also emphasizing water sanitation, dietary and environmental hazards. For example, Sodi Pallares, a Mexican cardiologist at the Instituto National de Cardiologia de Mexico persuaded the country to use only raw sea salt. I do not know the details or the statistics but Mexico has far less HT than the US. The prevalence of hypertension in Fiji might be seriously altered by the distribution of sodium poor sea salt in place of refined sodium chloride for the table. Such a strategy might be possible without significant cost. A similar strategy to eliminate the village use of sugar cane might affect diabetes and dental problems, but might be hard to enforce. The educational program will be expensive up front but pay dividends in the long run. A projected image of all Fijians as healthy in their life style, their body, and their environment could give them a reputation to live up to as well as the education necessary to mitigate the Diabetes II. An economic bonus in medical costs and enhanced tourism may be achievable.
These are thoughts only, not testimony but these considerations of management, top down for public health or bottom up for patient care, might have a bearing on the design of the health festival. We seem to embrace both aspects of health, the public health mission and patient care. It might be wise to recognize which is which from the standpoint of organization and traffic. One tends to direct the participant paternalistically while the other encourages responsibility choice and free movement.
There is a debt of gratitude for being allowed to participate in this first Fiji Health Festival. We owe a special thanks to Warwick, Marilyn, Geoffrey, Shantilal and all the wonderful Fiji Rotary family.
posted by Clancy Hughes | 9/14/2004 12:33:00 AM
0 Comments:
Post a Comment
<< Home