The Social Context and Vulnerabilities that Challenge Health Care in the San Joaquin Valley of California

Call it white privilege or health disparity, it appears to be two sides of the same coin.  We used to consider ethnic or genetic variants as risk factors and prognostic to health conditions. Yet what has become more relevant is the Social Determinants of Health (SDH) as causal to disease prevalence and complexity to health care.

This is was made more evident, in one of the many examples of care I encounter daily as a pediatric hospitalist in the San Joaquin Valley region. A 12-year-old Hispanic boy is admitted with a ruptured appendix and develops a complicated abscess with an extensive hospitalization due to his complication. Why? Did he have the genetic propensity for this adverse outcome? Was it because he was non-compliant with his antibiotic regimen?  No.

Rather it is the social construct and circumstance that hurdles his care. First, he had trouble getting to a hospital or clinic.  Both his parents are migrant workers with erratic long hours. Despite intense pain, he did not want to burden his family and further delays evaluation. In silent desperation, his mother is bounced around from clinic to emergency room and back to their rural based clinic then referred back to the same emergency room more than 20 miles from their home.  By the time he is admitted 2 days later, he is profoundly ill. The surgeon is called in the middle of night for his emergent open surgical appendectomy and drainage. Even after his post-operative care while on broad spectrum intravenous antibiotics, his conditions persists with fevers, chills, and pain. Yet, he continues to deny his symptoms to avoid worrying his mother. His Spanish speaking mother never asserts or doubts why even despite surgery and drainage he was not healing per the usual expectation. Five days post-operative he requires another procedure for complex abscess drainage.  What are the true determinants to his complicated outcome?

In a 2007 study, “We Can Do Better-Improving the Health of the American People, The New England Journal of Medicine, the proportional contributors to premature death are described, and behavioral and social patterns dominate:  

More recently there appears to be a paradigm shift in how health care systems and access is viewed. Health care delivery plays a relatively minor role in its impact to premature death. What governs individual behavior of the patient is a result of SDH, which are a product of:

  1. Barriers to appropriate health care
  2. Economic instability
  3. Unsafe environment
  4. Poor health literacy and education
  5. Limited social and community support
  6. Food scarcity
  7. Social discrimination and language barriers

These are just a few of the factors that part represent and challenge patient care and health inequities. Genetics is relatively a minimal risk factor to disease condition. We cannot just say that Blacks have a greater risk of heart disease, diabetes, hypertension etc. We need to ascertain the social context of our diverse populations in order to address incidence of chronic disease and its effects.  It cannot be just genetics of the immigrant, the refugee, the homeless, or impoverished population that lead to the greater morbidity and mortality.

As a pediatrician practicing in the central valley, I see the consequence of social complexity in pediatric care delivery, daily. In a recent 2017 report by Center for Regional Change and Pan Valley Institute, California San Joaquin Valley, children are “living under stress”. They are not only born under duress but face lifelong barricades to better health, physical and mental. The occurrence of child poverty level in counties of the SJV are profound. The graph exhibits poverty levels of 28 to 38 % in the valley:  

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Even more, California has a large (Gross Domestic Product) in terms of agriculture production in the country. When you break it down by county, crop value in the valley ranks high. Yet, the valley with the largest crop production also paradoxically has the highest child poverty in the state. Even with economic stability, poverty remains rampant in the central valley.  The rates of concentrated poverty, where more than 30% of population are below the Federal Poverty Level (FPL), are greatest in SJV areas and are increasing over time:

Percentage of children under 18 living in areas of concentrated poverty

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Furthermore, poverty rates are highest among children of color. The ethnic gap in poverty is 10 to 35%.

Percentage of San Joaquin Valley children under 6 in poverty, by race/ethnicity

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Despite economic potential, health care access and resources also operate at crisis levels. Rural communities with geographic obstacles face shortages in provider availability and health care systems.  The same fertile communities of SJV producing the food source of the nation, ironically have the larger limitations of access to food. Food scarcity, where food and especially healthy food is either limited or uncertain, remain above 26 to 29% when compared to food shortage for whole of California at 23%. 

Estimated percentage of children under 18 living in households with limited or uncertain access to adequate food, 2014

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The overall pollution burden, which represents the potential exposures to pollutants and adverse environmental conditions caused by pollutants, is the greater than 8 to 10% in the Valley. Not surprisingly, asthma and lung diseases in SJV districts are highest in central California.  

Percentage of children diagnosed with asthma

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Scientific literature now highlights Adverse Childhood Experience (ACE) in which the number of exposures of toxic stress and trauma: child abuse, neglect, domestic violence, parental drug/ alcohol exposure, incarceration, separation, and or stress, is scored.  The greater number of ACE’s, the greater degree of maladaptive physiological, neuro-architectural, immunological, and epigenetic effects on the fetal and developing children.  The effect of ACE’s on mental health and chronic medical conditions, (asthma, diabetes, Cancer, heart disease, obesity, etc.) correlates exponentially with the number of ACE exposures. Such that, if a child has more than 4 ACE exposures the risk of developing COPD (Chronic Obstructive Pulmonary disease) as an adult increase by 260%; for depression it increases by 460%. In California the prevalence of the number of ACE with 2 or more toxic level stress exposures early in the child’s life is at 16.7%. Per kidsdata.org, a Population Reference Bureau, analysis of data from the National Survey of Children’s Health and the American Community Survey (Mar. 2018) the incidence of parent reported of ACE scores >2 for the SJV counties is even higher: Fresno, Tulare, Madera, and Merced cities range from 17.9 to 19.3% of the population. Such that 1 out of 5 children are exposed to toxic level stress.  The consequences of that same child becoming an adult with a chronic medical and or mental condition cannot be discounted.

Health vulnerabilities in the valley are extreme and burden the limited health care systems servicing the community in SJV. The current California governor’s administration has acknowledged this fact.  Support to implement and maintain medical education and training programs with retention of providers in SJV is necessary. Specific funding allotments for improving mental health, air quality, homelessness among many other SDH’s  in the region is vital. 

Dr Nadine Burke-Harris, California first female Surgeon General, who recently visited the Valley, announced an ACEs Aware campaign. The ACEs Aware initiative is a first-in-the-nation statewide effort to screen for childhood trauma and treat the impacts of toxic stress. The bold goal of this state-wide initiative is to reduce Adverse Childhood Experiences and toxic stress by half in a single generation, and to launch a national movement to ensure everyone is ACEs Aware. ACE’s Aware is not only a complete program with training and readily available tools to implement screening, it is fully reimbursed in preventative pediatric care setting.  

Starting early, as pediatricians we can Identify kids exposed to ACEs through routine screenings and establish prevention programs in healthcare, schools and youth-serving organizations. In their critical and early developmental stages, resources allocation of health services can be provided. It is also imperative to know and stay engaged with our region’s leaders, telling our stories in health care, enlist our community partners, schools, regulatory agencies, and empower our patients and families to advocate for social and health equity.

By Dr Alya Ahmad MD FAAP

Pediatric Hospitalist

www.thecontextofcare.com

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How Strange A Thing Is Life?

By Alya Ahmad, Pediatric Hospitalist

“How strange a thing is life…”

It starts out so simple, just food , sleep, and comfort for the bodily routines. It is the baby regarding the warmth of the mother’s voice, face, and the breast. 

then comes the first turn, the roll over, the baby steps, and so then comes the watchful eye of the mother. She fears the fall, the break, the pain.

as time flows, so does the worry. the child speaks, first asks, then demands, then expects. The mother does it all and then the child runs, spells, and befriends.

The baby becomes the child; the child becomes the teenager.

Very soon, the child has no memory of all those tender kisses, the smell of sweet milk, the hugs, and reassurance. The teenager shuts the door, speaks little, and goes on with what they hold important. The mother upholds, waits, and wonders.

How strange life is? As the man walks out the door, waves goodbye, and moves on. All those days that have melted away, the chalk on the ground, the bicycle lays rusted in the garage, the books on the shelf have aged and grown with the child, soon to be stored away. Memories of movie nights, junk food, cereal boxes, appointments, parent teacher conferences, game days, the audience at graduation, the accolades, and the pictures on icloud streaming away.

How strange life is? As I sit here, waiting, wondering, hoping, watching, thinking, writing, feeling, storing. All the things you spent a life time building and now having to discard, give away, and handover. Forget, forget, forget. 

How strange life is? It stops for no one, it tics away without fail. it lives beyond you. 

 

Guns and The City

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arms-background-bang-1076813By Alya Ahmad MD, FAAP, Pediatric Hospitalist

It was a slow night in the pediatric emergency room, a little after 2 am on April 8, 2000. A 15 years old African American male walked in to the pediatric emergency room with a chief complaint of a sore throat. Working the night shift was always tough for me, as a pediatric resident my body clock struggled between the constant switches from nights to days and vice versa. I was already fatigued that night and wanted a quiet night. I got only the opposite.

I pulled chart for the, 15 year old boy from the bin. Flipping through the paper clip board, I was I have to admit, a little angry at having to see this kids at 2 am for a sore throat at that. The nurse took the teenager to the back. He walked with a swagger, quiet, and expressionless. As he was being triaged, I wondered what he was doing here alone without a parent. He appeared to be the typical disinterested, pubertal, well-built athletic boy, wearing extra loose baggy jeans, and a long basketball shirt visible under his oversized hoodie. He seemed a little tense but without much distress. Lying “restfully” on the patient bed as though he came to the ER to sleep. I eyed him and then went to the back room doctor’s area to get my stethoscope and a rapid strep throat swab.

Within a few minutes, I heard the nurse call for a code. He was the only patient in the back, so I knew it must be this kid who suddenly arrested. Odd.

Alarms rang; monitors beeping; crash cart was wheeled in; and a sudden emergence of staff came rushing in from all corners of the ER. He was in full cardiac arrest. While intubating him and staring down his airway, all I could think was what the heck just happened here? It was only after he was stabilized and CT scanned from head to abdomen, did we discover the reason why he walked into the ER.

We cut through his hoodie. He was covered in blood. He had been shot, and wore the hoodie to avoid suspicion. In his stomach the bullet laid placidly with a small entry wound from his upper deltoid area. While the bullet had penetrated through his chest without significant damage, it was his esophagus, perforated, that was worrisome.

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Next, He had to be transferred to trauma center in the medical center for further stabilization some 15 miles away. As the only resident of the shift I was assumed to take him via ambulance to the medical center. I held my breath, knowing this. My fear of him coding again or bleeding out, was palpable up my chest.

It was only while in the back of the ambulance that I actually saw his whole face, his still youthful features and cherubic face, his large yet graceful hands, and his thickly styled dark hair. In the gurney, he lay unaware of the ambulance swaying, jerking, and sirens blasting. He was helplessly wrapped up in tubing and lines. While staring at him and feeling for his pulse to compare to the monitor I held his hand. It hit me. He must be somebody’s child, a son to someone. I prayed silently in my head for mercy. While also praying, we make it to the regional trauma center, the gunshot capital of the city.

After an eternal 17 minutes later, we were in ER landing area. We wheeled him into the trauma unit. The paramedics quickly regurgitated his details to the accepting hospital’s ER staff, and I handed over his medical details to the next resident. He was swiftly swept up to the operating room and disappeared engulfed by the trauma team and nurses.

I never heard about him again and to this day don’t know if he survived. Years later, I still think about him, and all the other gunshot wound death and survivors who may have passed through our hospital and or our system. As pediatrician we are told to talk to families about gun safety and storage. I do what is recommended, and go through the checklist of gun safety in the home.

Yet, violence persists. Sixteen years later, I continue to take care of kids with intentional or accidental shootings. Teenagers, who have survived gunshots, failed suicide attempts, gang warfare, or accidental miss-firings, continue to stream through the inpatient units. Families now burdened to take care of this special needs patients, permanently disfigured physically and or emotionally from their wounds. A gun injures nineteen children each day in the USA. Among injury related death’s, firearms rank second AFTER car accidents.

Yet, gun injuries and deaths are only getting increasing. Killers are walking with “bombs”. Guns now with AK-fire-power that is more irreparable and destructive.

Physicians are told to first do no harm, and that is the mantra we carry near and dear to our hearts. Guns should do no harm? That is an oxymoron.

By Alya Ahmad MD, FAAP

Pediatric Hospitalist

 

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“There’s No Heartbeat” By Farah Karipineni

Dr Farah Karipineni is an academic endocrine and general surgeon in Central Valley California

“There’s no heartbeat.”

Three words no one ever wants to hear.

Three words no one ever wants to deliver.

And yet, as a community of physicians, we deliver those crushing words on a daily basis. None of us would ever take the task of bearing this piece of news lightly, but for me, it was not until I was on the receiving end of them that I truly grasped how profoundly a physician can shape the experience of a family member or patient in this particular depth of despair.

I have delivered this news more times than I can count. I would like to say that I recall each time vividly, that I remember each patient’s name, story, and the faces of each family member as I broke the news that ended their world.

But alas, I do not. I recall the poignant ones: the 26-week pregnant mother who lost the fetus in a motor vehicle crash; the 12-year-old schoolgirl shot in the chest; the 40-year-old roofer who arrested in the operating room as we stretched his ribs to massage his heart.

I do not remember the exact words I used to convey this most unwelcome information. What I do recall is the mixed sense of fear, dread, pity and my own grief immediately prior to entering the room. For yes, I would walk away scarred, and my scar was important for me to acknowledge, but it did not deserve to take up space in that haunted room. I had to be fully present for their grief.

And then I became the patient. It was a much-wanted pregnancy requiring multiple cycles of assisted reproduction, our life’s savings, money we didn’t have, a lot of failures, hundreds of injections, and so, so much guarded hope. The words seemed to come too easily to the physician who delivered them, far too easily. They were accompanied by no eye contact, no outward emotion, and no additional words. While I am sure that I was more than a transaction or a diagnosis to this practitioner, there was a devastating failure to acknowledge my humanity in the experience. My mind immediately wandered to my patients—how often had I unwittingly made them feel the same way?

Until I required health care on a regular basis, I was often surprised by how grateful my patients are by what I consider common decencies. Giving them my cell phone number for emergencies. Making them feel heard in the office. Collecting details about their personal lives and families. To me, this all falls under the umbrella of caring for, and about, a patient. Not just a patient’s medical problem, but a person. A human being, just like me.

But after being on the patient side for far longer than I wish, I realize why patients have such low expectations. Humanity in medicine is in crisis. Health care workers feel overworked and under-appreciated, and institutional values center around financial success rather than employee and patient wellbeing. When dollars are our bottom line, and not people, we put every patient interaction at risk of being reduced to a transaction.

Recognizing this challenge in our current healthcare system can be discouraging, but it can also be uplifting. We can make an intentional, collective effort to treat our patients like human beings. We can grasp that almost sacred moment where we inhabit another’s suffering and bear witness to their struggle, in an effort to heal not just their ailing body, but also their ailing spirits. For in those inevitable dark moments when there is no heartbeat, that may be all we have to offer. And it may be enough.

 

 

This Story took my breath away….

edward gelano embraces

TEXT EXCERPT –

LETTING STORIES BREATH” -by Arthur Frank

Fifteen years ago I became caught up in a story that I have told on numerous public occasions, sometime reading it, sometimes telling it from memory.

This story is by the South American writer Eduardo Galeano, and it is titled “Christmas Eve.”

Fernando Silva ran the children’s hospital in Managua. On Christmas Eve, he worked late into the night. Firecrackers were exploding and fireworks lit up the sky when Fernando decided it was time to leave. They were expecting him at home to celebrate the holiday.

He took one last look around, checking to see that everything was in order, when he heard cottony footsteps behind him. He turned to find one of the sick children walking after him. In the half light he recognized the lonely, doomed child. Fernando recognized the face already lined with death and those eyes asking for forgiveness, or perhaps permission.

Fernando walked over to him and the boy gave him his hand. “Tell someone . . “ the child whispered. ”Tell someone I’m here.”

—Arthur Frank

Letting Stories Breathe: A Socio-Narratology

Chicago: The University of Chicago Press, 2010:4

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A Surgeon Mom’s Call For Action Against Gun Violence, By Dr. Farah Karipineni MD

www.educaterefugees.org

@FKaripineni

Like many of us, I have been struggling to reconcile my love for everything good about this country with the senseless gun violence that terrorizes us today. In the wake of each shooting, I vow to do more—to speak up as a surgeon, as a former victim of gun violence, and simply as a fellow human—but the words escape me. How do we make meaning out of such shameful tragedy

My first and most intimate experience with gun violence occurred at the age of 5. “I’ve been shot.” Those three words, and the events immediately preceding them, changed my family’s world forever. It was 1988, and we had just moved into a new house in the hills. Building a house in the previously barren hills was an endeavor that upset many in the predominantly Caucasian community. And so, on a warm summer night, a gunman broke into our property, broke the glass in the kitchen window, and shot my father multiple times. Ever calm in chaos, he climbed the stairs dripping blood, informed my mother of what had occurred, and hid my sister and me under a dresser desk before calling the police.

Shards from his eyeglasses would wedge themselves into his cornea and change his vision forever. Other, less visible wounds would bleed into our lives over time. To this day, in my thirties, in the darkness of my own home, I still at times fully expect to turn a corner face-to-face with an armed intruder.

Still, we chose not to live in fear or anger. After a 3-month stint in L.A. where my dad grew a thick beard and purchased a bullet-proof car, he insisted we move back into that house. The message was clear: we would stand tall and persevere.  Not only did we persevere, we thrived; that home is where my sister and I were married, where innumerable farm animals have reproduced, and where hundreds of trees bear the weight of many fruits each season.

Fast-forward several years to my surgical residency, where gunshot victims showed up in our busy north Philadelphia ER every day of the week.  Perhaps as a result of my own history, each penetrating trauma victim is imprinted on my mind: the 12-year-old schoolgirl in plaid uniform and braids who arrived D.O.A.; the young prostitute in shock, eyelids closing shut for the last time to reveal thick false lashes; the teenage boy thrown hastily out of a friend’s backseat to the E.R. doorway, whose heart could not be massaged or resuscitated back to existence. What was I doing to help reduce these preventable deaths? The problem was too vast, too deep, too messy, many times involving children with no sense of purpose or belonging other than the gang they pledged their lives to.

Both of those experiences lie in stark contrast to the mass shootings that plague us today. I have never cared for a patient shot with a military-style weapon. I have never cared for a victim of a mass shooting, although with AR-15s, the likelihood of surviving a bullet is low. But I know we as a society can do better. I know that apathy towards mass shootings, or opposing efforts to stop them, is not constitutional. I know that the majority of Americans do not own guns, and that of those who do, only 7% of them are members of the NRA.  I know that young people are fearlessly mobilizing in this era of social media, senseless killing and alternative facts, and they are roaring to be heard.  I believe they are our future, and they may very well accomplish what we have failed to.

These facts give me hope.

Out of our darkest moments come our brightest light, and there is much we can do. We can support bills that prohibit assault weapons, as no civilian needs an AR-15—this is common sense, not a constitutional loophole. We can sign up to be Sandy Hook Promise Leaders, and initiate their prevention programs that address alienation of at-risk youth, empower school children to speak up, and educate people on the warning signs of citizens who are at risk of hurting themselves or others. We can support H.R. 4909, the STOP School Violence Act. We can support legislation to keep guns out of the hands of individuals with criminal or mental health backgrounds, and institute more stringent policies for gun owners to obtain and maintain possession of their weapons. Because consumers have more power than we may realize, we can also support businesses that stand for responsible gun policies, and vociferously shun those that don’t. And we can advocate for changing the very fabric of a political system that values financial gain above basic humanity.

Gun violence is about public health, not politics. When kindergarteners and high schoolers alike cannot attend school in America without being gunned down by military-style weapons, and any public place becomes a target for mass killing, we need to recognize that this is not a partisan or constitutional rights issue.  Gun violence kills 96 people each day in this country; 7 of them are children. Over twice as many are injured.

As physicians, we are uniquely positioned to stand up for social welfare, and the time is now. We have a voice, and we must use it. Our very lives, and those of our children, depend on it.

 

Dr Alya…. A long time coming

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Dr Alya … Welcome to this Site

Dr Alya Blogs… in The Context of Care

The Stories of our patients, families, and even providers in the field.

Medicine can only best provided, as we learn, listen, understand the “context” of illness as it relates to the stories of our patient’s lives and experiences.

The Stories told here are real. They are a collection of narratives of medicine.

We physicians only see and understand part of the story, there is so much more we need to know, feel, and gather, and even that is not enough. Narrative medicine teaches us that the stories of patients, their lives intertwined with illness, recovery, and the unsurmountable is a reflection of who we are as a society.

With the filter of electronic record, meaningful use, checklists, order sets, and algorithm- based data science takes us a measure away from actually bearing witness to what really heals patients. Knowing who our patients are, their lives, their struggles, limitations, and strengths is also vital to care.

 I write in order to convey some small part of that narrative. I or my interpretation of my experience in medicine may not be all, but I hope it begins the conversation of how we as healers can look beyond the filters.

I invite you, also, to share and reflect, your experiences or struggles in illness and health through any form of literary, art, music, or narrative.

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