Lobby Day 2009: CA Health Professional Students for Single-Payer Health Care

Early this week, about 500 health professional students from all over California gathered in Sacramento to urge senators and assemblymen to vote yes on Senator Sheila Kuehl's bill for universal health care, SB840 (HR676). After a day of student-led training on how to talk to legislators, we formed groups to create streamlined presentations, marched up to the Capitol for a rally, and set off to our various appointments in the Capitol building. I have lobbied before, several times, but it's always good to remind myself that as a health professional student, I have a political voice and I should make that voice heard.

The only problem is I hate politics.

My dad always says that you can't hate politics because it's ubiquitous: wherever you have two people, you have politics. I can't deny that. Yet, it is so frustrating because reason and logic are either absent or so abstract that their relation to humanity is tenuous.

Our first legislative meeting was with a Republican senator from the Riverside area. We met with his aide, who explained to us kindly and patiently that there was a Political Divide between the Republicans and Democrats on the issue of single-payer health care (in case we hadn't heard). So, if there ever came about a bill that would fix the health care financing crisis (he clearly didn't think SB 840 was a candidate), the Democrats would oppose it purely because it isn't single-payer. And likewise, the Republicans will vote against anything that overhauls our current system. They would rather just plug up the holes.

Now, what about economic efficiency? What about hypertensive patients and diabetics showing up at ER's with blindness and gangrene What about babies dying? What about ranking the lowest of industrialized nations in something so wholesome and universally important as child safety and security?

None of those points, as salient as they are, had a fighting chance in our conversation, because the truth is that they don't matter. Political realities are what matter.

Our next legislative visit was more promising, as it was with an Assemblyman who had not yet voted on the bill. We got to inform his aide that the bill was being reintroduced with Senator Mark Leno (he thought it died with Kuehl), and he listened to our arguments, showed his concern for the issue, and said he would present it to Assemblymember Dutton. He was dubious about Dutton's support for a single-payer solution, but it was the best we could hope for.

The march and rally was overall successful. It was an empowering experience. My only complaint was that a big deal was made of the fact that both Kuehl and Leno are the first openly gay Senators. There was a lot of cheering when that point was made, and it made me angry on a personal level, as well as on a professional level. I came to support SB 840 and health care justice. Insofar as that is a Democratic cause, fine, lump me with the left. But I am NOT in support of every leftist cause, and was offended to be associated with something I don't believe in. Furthermore, I think it hurts our cause as lobbyists to introduce unrelated topics. It makes us seem like nonspecific liberal/hippie protestors who are against The Man, as opposed to future health professionals serious about changing the broken system we're about to inherit.

Was the event a success? Depends on how you measure it. We got 6 more co-authors of SB 840, and educated dozens more legislators about the issues. But Lobby Day is also about empowering students to engage in the political process. A couple of classmates and I are conducting a survey to assess changes in knowledge, attitudes and skills as a result of participating in the two-day experience. Despite my criticism, I am glad I went for the impact it had on me and my future career. I will probably never become a physician-politician, but my involvement in Lobby Day has made me recognize the respect and responsibility of my professional voice.

Post-Int'l Health Project Musings

I just got back from a whirlwind trip to Chiapas to "finish up" a public health project I and three of my classmates at UCI "carried out" over the past six months in three Tzotzil communities. We were first there this past July, but for so many reasons, it was especially difficult to go back this time. We have our own collective blog.

We went to Chiapas to bring ecological stoves to 40 families in the highlands and to measure changes in pulmonary function (via spirometry) and air quality (via PM measurements) after 5 months of stove use. The project was messy in and of itself because that's how international health projects are. We went back to Chiapas to measure (hopefully) a reduction in particulate matter; however, we did not expect that open fires would be blazing all day long (worse than in the summer when we took pre-stove installment measurements) because of the cold season. Oops. We also could not have predicted vast political changes in Las Abejas, the civil society that we are partnering with to carry out the project. The social climate had changed dramatically, and it affected relationships among the health promoters, families and communities we worked with, as well as our relationship to all of them as outsiders.

Also troubling is the notion of us "executing" a "project". I hate it when people write in quotation marks as if the punctuation alone imbues your words with the hidden meaning you hope to convey. I hesitate to say we have finished our project because completing a finite project with a beginning, middle and end was never my intention. In fact, having done similar things in the past, that was exactly what I wanted to avoid. As a future public health professional (God willing), I'm looking to establish relationships and make lifelong investments in international health. I want to lay down roots. When I signed up for Chiapas, I saw that potential. Looking back on our interactions with the communities, however, I don't think we built relationships so much as we completed a study.

Why do I say that? Months ago, I would have said that we were doing a good job building the relationship with Las Abejas health promoters. We were building bridges, hanging particulate matter machines in homes, making stoves together, making people breathe into tubes over and over again...together. We went to a health promoter meeting to announce our arrival and plan, went to church to introduce ourselves to communities, dined with families, celebrated a local festival. We bathed with rainwater, used the latrine, ate twice a day, walked up and down mountains.

But we also called all the shots. We brought these mysterious machines and collected all the filters to take back to our fancy laboratory with our fancy weighing machine to run sophisticated statistical tests to come up with Significant Data to publish in a fancy journal that the health promoters and their families will never see or understand or care about, it's that irrelevant to their daily existence. If that is true, did we truly collaborate the way we set out to do? It was a big part of our project's self-image that we had community buy-in to ensure the sustainability of our project. True, it's a huge challenge to achieve true collaboration, but if we don't have that, then what do we have? Yes, we installed 40 stoves. But do they like them? Did they make a positive impact on their health? Their quality of life? Did we gain their trust in a way that makes future cooperation likely? My head is full of these questions.

Whether they use the stoves we installed or not is a fair, honest question that deserves our evaluation, and I think that we did justice to that problem by carrying out a follow-up study of past stove recipients (last year's UCI-Chiapas cohort also installed stoves in similar communities). Whether or not the stoves improve health outcomes is another fair question we have and are continuing to evaluate through our study. But whether or not we and the health promoters of Las Abejas (and the communities they represent) have invested in a truly collaborative relationship working toward the betterment of health and quality of life in the highlands of Chiapas is another question that I don't think we gave enough thought to. And in the long run, I think it's a far more important facet of our "project" than the simple delivery of 40 ecological stoves that may (or may not) improve respiratory health.

I was talking to John Rose, the founder of UCI's relationship with Las Abejas, on the way back to San Cristobal from the community one day when we thought of a way to really work on the collaborative relationship aspect of our project versus the service aspect. The service aspect is undoubtedly important, but it gets in the way of the collaboration and two-way learning, as it did in our case. When you're running around trying to get a spirometer donated to you, designing a study, writing grants and stretching money, worrying about how to pay for 40 stoves and endless other logistical details, it's hard to concentrate on the philosophy of health promotion, the rich history of indigenous rights and resistance in Chiapas, and the intricacies of binational communication as it applies to international public health projects. We need to strike a balance between service and learning.

What we came up with is an idea that may or may not end up happening: a series of workshops next summer in which students work with health promoters to design comprehensive projects addressing their top five or so community health concerns. They can learn how to define a health problem, write a grant, gather data, and present findings. We med students can learn how health promotion works and focus more on building relationships and communicating ideas. At the end of it, UCI med students will come out having had a fulfilling experience a) learning about how health promotion works in Chiapas, and b) having shared knowledge and know-how regarding how to go about convincing the people with the money to give you funding to carry out a health project. The health promoters will be invested, too, because they will pick the health problems that will be addressed in the workshops. At the end of it, they will have several of their biggest health concerns fleshed out in a language that funding organizations understand, and whether it is in collaboration with UCI or independently, they (or together, we?) will be primed and ready to present a convincing case to attract funds.

It's an exciting prospect. I only hope I can be a part of it next year, too. Because as much as I love stoves and my experience in Chiapas this year, the idea of investing further in our relationship excites me even more.

Happy holidays!

Prop 4: Abortion Waiting Period and Parental Notification Initiative

For those of you who haven't read up on the propositions yet, Proposition 4 is on the ballot this year in California.

The initiative prohibits abortion for unemancipated minors until 48 hours after physician notifies minor’s parent, legal guardian or, if parental abuse has been reported, an alternative adult family member.

It's also called "Sarah's Law" after a 13-year-old girl who passed away from a botched abortion after having a relationship with a 39-year-old sexual predator, Gary Cross. When she became pregnant, he took her to an abortion clinic and then resumed sexual relations with her, all without her parents' knowledge. Sarah's mom found out about the abortion after coming across related paperwork in her daughter's room.

Anti-Prop 4 arguments include the very realistic fear that more minors will opt for illegal and dangerous abortions. Communication between minors and their parents/guardians is never uncomplicated; teens probably fear that their parents would react irrationally and/or hurt them. Whether that fear is real or perceived, it affects a minor's behavior at such a crucial, traumatic moment. Another argument cited is that no law can mandate family communication; rather, it's something that has to come naturally. And what if it doesn't? Then take the lesser evil, because a safe abortion is better than an illegal one.

I am against abortion. I think it's killing an innocent being that was meant for life, if not for our intervention (ie, abortive procedure). Does this mean that I don't care about the poor minor in this traumatic situation?

Of course I care. But I think instead of figuring out ways to deal with the symptom of the problem, such as rules regarding abortion among minors, we need to concentrate really hard on figuring out ways to reduce unwanted pregnancies. Of course, they will still happen. But when they do, we need a plan. A plan that supports life--both the life of the baby and the life of its young parents (who are kids themselves). Two wrongs don't make a right; there's no real way to undo a pregnancy. Does having an abortion make a minor whose had a sexual relationship mentally sound and "over it"? I don't think so, having been through a pretty rocky decade myself at that age. It's short term relief, but the emotional wounds leave big scars you have to deal with sooner or later.

I don't have a real answer. I just know that what needs to be done is to focus on prevention, and on building a society where support systems are in place for minors who would be at risk for this kind of behavior. And when sex and unwanted pregnancy happen, there should be support for that, too. There are plenty of young people who DO choose to carry their babies to term. What makes them different? Probably less hopelessness, more of a support system, more emotional maturity. Doesn't every minor deserve that, pregnant or not?

In a way, maybe Prop 4 will help some families. I agree that it will backfire in many ways, particularly in families where communication isn't possible. I know in my own family, when I was a minor, communication definitely didn't feel AT ALL possible, so I can only imagine what it's like in families with more diverse challenges. But in those families where parents or guardians are ready to reach out and help their minor, maybe it will force-foster some needed healing. Because when a teen is pregnant and wants an abortion, clearly something isn't going right.

Ramblings, on becoming a doctor

“When we come to you
Our rags are torn off us
And you listen all over our naked body.
As to the cause of our illness
One glance at our rags would
Tell you more. Tis the same cause that wears out
Our bodies and our clothes”

From Bertoit Brecht's A Worker's Speech to a Doctor

I'm visiting home this weekend and am fascinated watching my sister interact with her newborn child. He is such a helpless little thing. As my sister said, anyone can do anything to him, and all he can do is cry. It's an obvious point, but I guess that degree of fragility is something we don't often encounter in daily life.

It got me thinking about the above excerpt from Brecht's poem. One of the reasons I love medicine as a profession is that people come to you with their problems, and you get to fix them. Anyone reading this will probably immediately think, "Oh yeah? Is that how it works? Because that isn't how it's been working!" Nevertheless, it is that idea(l) that attracts me to the field.

It's a scary thought, not to be taken lightly. As a physician, you are asking someone to come to you in their most vulnerable state, helpless as a baby (let's leave litigiousness aside for the moment). You have powerful drugs at your disposal, compounds that can wreak havoc on the body, or fix it instantly, or some compromise thereof.

Small things make a huge difference. Maybe your marriage is in trouble, or your teenager is a nightmare. Maybe you're depressed. Maybe your finances are suffering. Maybe you don't want to talk about it. Maybe you do. Maybe you shouldn't, but maybe you should.

How will I know if I don't ask?

Sometimes I frankly cannot believe that they let me into medical school. That assuming all goes according to plan, I will be a doctor and I will have this huge responsibility of someone's life in my hands. That I will have a pad on which I write treatments that could do a lot of damage to another human being. Or if I become a surgeon, that I will be fiddling around inside a fellow person.

But wasn't that the dream? Isn't this what I've been striving for, that very responsibility? Didn't I write in my medical school applications that there was nothing I wanted more than to be in this position?

And it's true, it is still true. There's nothing I want more. I don't know how this sounds, but I want to be a resource, a beacon for people. I want to be a giver like a tree that bears fruit. You pluck the fruit and it grows more, no problem, no questions asked. It bears so much fruit, in fact, that sometimes the tree bends over with the weight of its bounty. I want to be like that, if God wills it.

I pray I never forget what Brecht is referring to. The exquisite vulnerability of that moment with a patient. Eventually, it will be up to me: I can treat their symptoms (or what I perceive to be their symptoms), or I can treat them whole.

I'm sure I have no idea what I'm talking about right now, but I'm also sure that what I'm saying is true.

Food for thought from Infidel

I’ve read quite a few novels this summer, but Ayaan Hirsi Ali’s Infidel has probably been the most provocative. While I oppose with her fundamental conclusions about Islam, I do agree with some of her injunctions against traditional Muslim culture.

That fundamental point of disagreement is this: I think she fatally misinterprets Islamic tradition as being part of the Quran—the word of God is NOT the same as what your imam or Quran school teacher tells you, necessarily, nor is the word of the Prophet in Hadith. She’s had some seriously crooked people/institutions rear her in their seriously crooked (mis)interpretation of Islam.

Anyway, while I think she takes her frustration out on the Quran when she should be directing that energy against opportunist, backwards interpreters of the scripture, I found her account of refugee camp life and her criticism of faith-based schools particularly interesting, especially as I was interacting with kids who had been through this unfathomable experience. I wanted to share some excerpts:

“The UN began to distribute food; basically they handed rations to people who claimed to be clan leaders, and these people either kept it for their own families or sold it.”

“It began happening al the time: Kenyan soldiers came at night to rape Somali women who were alone without protectors. And then all these women would be shunned and left to die.

This is what my grandmother had meant when she warned me: if you are a Somali woman alone, you are like a piece of sheep fat in the sun. Ants and insects crawl all over you, and you cannot move or hide; you will be eaten and melted until nothing is left but a thin smear of grease. And she also warned us that if this happened, it would be our fault.

It was horrible. Everyone in the camp called themselves Muslims and yet nobody helped these women in the name of Allah. Everyone was praying…but no one showed compassion.”

And on Muslim schools (this is the author’s opinion; I personally know nothing about Muslim schools but imagine it’s similar to Islamic tradition/culture):

“Muslim schools reject the values of universal human rights. All humans are not equal in a Muslim school. Moreover, there can be no freedom of expression or conscience. These schools fail to develop creativity—art, drama, music—and they suppress the critical faculties that can lead children to question their beliefs. They neglect subjects that conflict with Islamic teachings, such as evolution and sexuality. They teach by rote, not question, and they instill subservience in girls. They also fail to socialize children to the wider community.”

I believe strongly in gender equity, like Hirsi Ali, but I also think men and women were created to fill different roles in life (I’m thinking particularly about family life). Different, but equal. I also believe in creationism—to me, evolution is an undeniable truth, but within a species—but I agree with the author in that whether you believe it’s true or not, children need to be educated about the ideas that exist in the world they’re living in. That’s the only way they can make real choices and be intellectually and spiritually strong enough to believe in something worth standing up for.

A new outlook on my future in global health

Yesterday I had lunch with my dad, and we got to talking about global health. He's not against aid to Africa; on the contrary, he was the one who accompanied my mom to Kenya last year, when the project was in its incipient stages. But he always seems to ask, "Why not India?" Considering that we are definitely Indian, and speak Indian languages, and eat Indian food, and know Indian culture, and have family there, it's a more than legitimate question. Why Africa?

Until I really got to know all these students and delve into their personal histories and, more importantly, the history of their place of origin (Southern Sudan, specifically Bor Town), this was my question too. I love India. I may not speak the languages my parents do, but something happens to me when I go there, oddly: I feel at home.

Anyway, if it's language we're talking about, why not Mexico? I speak pretty good Spanish and have grown up around Latino culture. Why not the urban poor of San Francisco, for that matter? The needy communities of Santa Ana?

Those are all legitimate questions, no doubt. How did we become all about Southern Sudan?

Sudan is not a cause (if I can momentarily reduce it to that) that we sought out, it's something that just happened. We weren't looking to work in this particular part of the world, necessarily. Most of my global health experience is in Central and South America. And last year I did a project in India.

But there's something about Africa's need that is staggering right now. I know well that the indigenous in Chiapas have suffered unspeakable violence in the highlands--I'm thinking of the 1994 Acteal Massacre that earned the Pillar of Shame. I know that Hindus, Muslims and castes and subcastes (the Gujjars and Meenas, when I was last there) have been at it for centuries.

But right now, I feel that Africa is in a crisis mode we as members of the human race cannot ignore. Particularly, Sudan right now is in crisis. A whole nation is utterly torn apart, and at its heels are Ethiopia and Somalia and Rwanda. The instability is staggering. This extent of civil upheaval, of human cost, is among the greatest of international atrocities. Yes, the Acteal Massacre was horrific. It almost took our breath away to hear Manuelito's account of it (a survivor who lost both parents and several family members, including babies). But what about the 1991 Bor Massacre no one talks about? Yes, the social and political drivers are not comparable. But I'm talking about human suffering and consequent human need. So for me, and for my mom, that is why Africa.

(Banner from the film "Not Lost" on the Lost Boys of Sudan)

Faith-based schooling in East Africa

State House Girl's High School in Nairobi


Osama bin Laden once said, “You are either with the Crusade, or Islam.” This summer, that definitely seems true—in Mexico, it was the Crusade, and in East Africa, it’s Islam (and the Crusades, too).

In my two-week crash course on Kenyan secondary schools, I learned that almost all (if not all) schools incorporate religious education as a required part of the curriculum. There simply are no secular secondary schools (or so few that choosing to go to one is not an option for most students). In the fee structure for each term or year (3 terms in a year, 4 years total), the Bible is included as a necessary expense. Masses are held, and religious classes are mandatory. You even get a grade that factors into your point total. A part of the national exam administered at the end of high school, called the KCSE (Kenyan certificate of secondary education), is devoted to religion—if you are Muslim, you take the Muslim version, if Christian, likewise. You have two or three choices—I think Hindu is now a choice, according to Kwai, What if you decline? It is rare, but possible. Most people don’t decline—they already have their tidy social designation.

Anyone who knows me can predict where I’m going with this: why not let people think for themselves? Why make religion part of the curriculum at all? What are you going to teach, anyway? Piety 101? Charity, modesty, honoring your parents? Those are life lessons. You have to choose them all by yourself.

But there’s more to it than that. Everyone is so neatly categorized. In Southern Sudan there’s the Dinka, the Nuer and the Murlee, and more that I don’t know about. In Kenya there are clear lines between Somalis, Ethiopians, and other expatriates. Within each nationality, clans and subclans exist. You should know your family’s ancestry; it’ll help you in case you need to stay at a distant relative’s home, or if your people are at war. A relative won’t turn you down or leave you hanging; it would look bad. Clan/tribe/family ties are so strong in places like East Africa (eg Sudan, Somalia, Rwanda)—no coincidence that these are nations utterly torn apart by civil war.

Of course, they’ve had help from outsiders, no doubt about that. Khartoum in Northern Sudan is the #1 slave trade spot. Egyptians have historically come there to steal human beings—particular Southern Sudanese—for bondage. The discovery of oil has drawn often destructive, purely self-interested international attention (like China’s). But the fact remains that the Hutus and the Tutsis tore each other apart on their own, as did the Hawiye and Darod in Ethiopia, and the Nuer and Dinka in the Bor Massacre in Southern Sudan (in 1991). They didn’t need any help.

Nor did they receive any. Yeah, it’s true that civil strive had to do with internal tribal/clan conflict, but it’s much more complex and much larger than I’m pretending for the purpose of this post. And regardless, for wealthy nations to stand by when the chips are down, and step in when they eye something shiny, is in some ways more abominable than the civil unrest itself.