CLINICAL INNOVATORS
CLINICAL INNOVATORS
implementation research on how to reduce disparities . And it is not a simple solution . Unless one has lived the life of a patient in the inner city , they will not realize that health care is often not the first , second or third priority of a recently hospitalized patient . Rather , the priorities are food , housing , employment , and heat in the winter . Only after these fundamental rights are taken care of — especially for one ’ s children — can a patient can focus on his or her heart failure regimen , salt restriction and diet management . I have watched way too many discharge instructions by trainees and physicians who are oblivious to the challenges faced by patients with few means . Patients are labeled “ non-compliant ” and we assume that they do not take their health care seriously . Often , it is really that they had more important concerns to attend to at home once discharged , or their instructions were provided at a health literacy level way beyond their comprehension .
In addition to socioeconomic differences that may account for patients ’ adherence to treatment , there may be differences at the provider level as well . How do socioeconomic differences impact provider adherence to guideline-recommended preventive treatment ? Where should efforts be focused to reduce this disparity ? We need a smarter approach . It has to be comprehensive , community-based , and patient-centered . We can
take a page out of work done in resource-poor countries . We now know that hospitals in developing countries are relatively ineffective in reducing disease . They may treat disease but they see the same patients over and over again for the same conditions . Interventions that have a much larger impact--for a fraction of the cost — include the provision of potable water and the training of community health workers who live in the villages wherein they provide medical care . This model of community health workers has not been adopted by the U . S , but I think it is the next logical step . We need community workers to walk in solidarity with poor people to ensure they understand the health care directions they receive and the medications they take , conduct home visits to understand what other challenges impede a patient ’ s ability to focus on his or her health , assist in providing transportation for patients to ensure medical follow-up , and connect patients to social services which exist but are often overlooked . In short , we need community workers to be passionate advocates .
We cannot expect poor patients to have the same resources as our suburban upper and upper middle class families , whether these resources are time , money , affordable child care , health literacy , or leisure time . If we are serious about improving guideline adherence among the poorest of our poor in the U . S ., we need to walk with folks throughout the entire health and illness journey and not just within the hospital . Otherwise , we will be setting them ( and ourselves ) for failure . And more often than not , we will blame the patient as ‘ ignorant ’ and ‘ non-compliant ’, or label them as a ‘ frequentflyer ’. My mentor at the Brigham , Paul Farmer , has shown that when we walk in solidarity with the poor , we can accomplish First World cure rates of multi-drug resistant TB , antiretroviral adherence rates for HIV , and comprehensive human development in rural Haiti , the slums of Peru , Rwanda , and other regions of the world written off as hopeless . We can only expect good results in the inner cities and rural regions of the U . S . if we work with patients both in and outside the hospitals .
You have been involved in a number of health organizations in developing countries , particularly in Central America . What are some of the projects that you currently have underway ? As a young man out of college , I spent a summer in Guatemala doing art therapy with kids who were traumatized by recent violence during their civil war . There , I fell in love with the people , culture , and opportunities to improve health . Over the past 26 years , I have returned to Guatemala many times . So far , I think I have had more of an impact in my work there than as a physician . I am a big believer in approaching a community as equals . I was
“ We need a smarter approach . It has to be comprehensive , community-based , and patient-centered . ”
President of an organization whose acronym is ALDEA ( advancing local development through empowerment and action ). We approach communities and ask what their needs are . Invariably , it is almost always the need for safe , potable drinking water . Imagine having to walk 3 to 4 hours each day just to fetch unsafe water to drink and cook with . When we bring water into a community , it frees up time for women to pursue productive economic pursuits ( making crafts and jewelry , farming ) and girls to go to school . Girls , in turn , are more likely to have smaller families with more education . Our organization then works with community leaders to erect latrines , identify and provide supplementation to infants with severe malnutrition , train community health workers to provide key preventive and curative care , implement micro-credit projects to improve disposable income among families , and increase their self-reliance and confidence .
I also serve on the board of Church World Service ( CWS ), a network of 37 Protestant denominations that do rural development work ( like the type described above with ALDEA ) and refugee and disaster relief work . I love this organization because there is no missionary component . I am not even Protestant ! But we believe in a world that can only be healed with solidarity , grassroots development , and peace and justice . So CWS does all of this and more . Every year , we do a fundraiser for CWS , where I and my group walk 50 miles in the Grand Canyon going from one rim to the bottom to the opposite rim and then all the way back ( see : https :// www . crophungerwalk . org / kansascitymo / GrandCanyonHikers ). We trek these 50 miles within one 24-hour period with no stops except to eat , climbing 11,000 feet in total and descending 11,000 feet . And we have built a community of supporters who believe in our vision of a better world where it is just not enough to do our daily jobs . And as a physician , I believe I have a unique opportunity ( and might I say , responsibility ) to promote social justice and equality for those with no voice in our society .
What are some of your research and clinical goals in the coming years ? I am a big believer in mentoring , and not just in research but in life . In research , we have to not be afraid to shake things up sometimes . When we published our paper on rates of appropriate and inappropriate PCI in JAMA in 2011 , I was not very popular with many inteventional and non-interventional cardiologists . I received angry emails and some folks yelled at me in person . Five years later , rates of inappropriate PCI have plummeted , in part because of the growing awareness of how to choose this treatment wisely . I think we have to be creative in our research . I would like the disparities research field to move beyond simple descriptive epidemiology to wholesale engagement and involvement in a community to actually reduce disparities . The goal in any research would , ideally , promote excellence in patient care , and this will require better engagement of patients in more informed decision making about procedural benefits and costs .
Admittedly , I am more excited about what can be done in global health in the future . I recently was involved in donating a substantial amount of money for a mutual fund for water projects in resource-poor countries . Imagine if the next water project did not depend on having to raise another $ 3000 . An organization called water . org ( of which Matt Damon , the actor , is co-founder ), recently launched a mutual fund investment with a guaranteed return of no more than 1 % ( basically , no monetary return on investment ). In return for your money locked up in the mutual fund for 7 years , it would be loaned every 6 months as micro-credit for poor people to access water . These loans get re-paid ( at a 98 % rate ), and the money is re-invested in the next micro-credit water loan . Over 7 years , your initial investment is loaned 14 times , multiplying the impact of your donation 14- fold . At the end of 7 years , the donor gets his or her money back , and it is a win-win for everyone . I have never been happier to part with my money . I am now focused on inspiring our youth . Over the past 2 years , I have taken high school students from the Kansas City area to learn about sustainable , grassroots development . Our goal is to learn from the villagers and to return to the U . S . with a healthy concept of how to engage communities in change . These high school students from an elite private school will serve on their parent ’ s charitable foundations , and my hope is that they will give lavishly to organizations which move beyond charity which creates dependence to development which empowers . ■
34 CardioSource WorldNews November 2016