Adios México

Today I concluded my trip to Mexico with a visit to a maternal health clinic that focuses on pregnancies with no-to-low complications and, through coaching and education, tries to help lower Mexico's enormous rate of cesarean procedures (almost half of all children here are delivered via c-section). I also visited a government agency that helps repatriate Mexicans who are deported from the United States. They have a dozen offices at the border, and one at the airport in Mexico City where every Tuesday and Thursday at 11:00 am a plane arrives with 135 deportees. It's always 135, the maximum number the plane can transport.  The authorities expect two additional weekly flights will be added.

My 18 days here were well spent. I return to the United States with a much deeper appreciation of a nation that is and will continue to be an important partner for our future in America.  I have new colleagues with whom I can collaborate on ways and means to serve the immigrant population.  And I feel even more deeply embedded in a community of people who are committed to providing the best possible healthcare to all human beings, regardless of their circumstances.  

I cannot begin to say how happy I am to be even a tiny part of this effort on behalf of others.  It gives my life tremendous meaning, great joy, and - I hope - serves as an exemplar for my daughter on what it means to be fully alive.

My Week in Mexico

It was a full week here in Mexico.  Highlights:

* A tour of the Clínica Amistad on the Santa Fe campus of Hospital ABC, a clinic totally devoted to preventative services.

                                               With Dr. Lourdes Rivas of Clínica Amistad

* An overview of how some private hospitals have incorporated the Toyota Production System and the philosophy of Just Culture into their operations.

* An in-depth discussion about Seguro Popular with Mexico's National Commissioner of Social Protection in Health, Dr. Gabriel O'Shea.

                                                           With Dr. Gabriel O'Shea

* A presentation on the complexity of the myriad issues surrounding immigrants and health with Haydeé Pérez and José Knippen of Fundar.

                                               With Haydeé Pérez (left) and José Knippen

* A visit to the Office of Intercultural Development to better understand the roles that traditional and alternative medicines play in the modern Mexican healthcare system.

* The education and training of doctors at the University of Anáhuac.

* A deep dive into data about socioeconomics and international migration at CONAPO.

                                                      With staff members of CONAPO


* Impact measurement and data evaluation at the Office of Evaluation and Performance.

                                                          With Dr. Rubén López Molina

And these are just the highlights, not even mentioning other interesting parts of the week (like Teletón, Mexico's equivalent of the Jerry Lewis Telethon).

                                                 With Tania Karasik of Fundación Teletón

It is very difficult to distill all I saw, heard and learned over the course of the past week into this post, so I will constrain myself to some impressions.

My initial sense that Mexico puts an immense amount of effort into prevention was reinforced.  It was amazing to visit a clinic the size of Casa de Salud that was 100% about promoting and enabling the prevention of disease; to see multiple programs aimed at reducing teenage pregnancy (including movie-quality PSAs aimed squarely at pre-adolescents and teens with explicit messaging - "it's not about preventing sex, it's about preventing pregnancy and disease"); and the government-sponsored bike riding classes to get young children active as soon as possible.

Although Seguro Popular has theoretically led to universal access, to a certain extent this is true only on paper.  As I mentioned previously, coverage does not necessarily equal access, and that is certainly true here. As just one example, Seguro Popular may cover your costs for treatment, but if you live in the state of Chihuahua, which, despite being the largest of Mexico's 31 states, has only two hospitals, then you're going to have a difficult time having your healthcare needs met despite no out-of-pocket costs.

Medical students in Mexico must serve one year in a Level One clinic (basic non-urgent care, similar to community clinics in the U.S.) before being granted their official MD. Not only does this enhance Mexico’s prevention efforts, which locally are often centered at these clinics, it also inculcates a sense of service into the providers.  How I would love to have Casa de Salud and the more than 1,000 other community clinics in the U.S. benefit from this type of mandate.

By the admission of many of the people I've spoken with, Mexico lags in metrics and measurements and their evaluation.  Still, they are not ignorant of the importance of these issues and people like Dr. Rubén López, who I met at Office of Evaluation and Performance, are working diligently to bring the country up to speed (I am grateful that he took the time to review my information about Casa de Salud's operations and make some excellent suggestions about how my clinic can do better in its own impact evaluation).

So what am I left with?  I am in a country with constrained resources (spending just above 6% of GDP on healthcare when the average in Latin America is 8%) and large swaths of territory that are rural and remote, yet has a Constitution that declares healthcare a human right guaranteed to every Mexican and is trying (especially through Seguro Popular) to live up to that ideal.  Its system is complex, fragmented, and siloed, leading to different levels of access and outcomes.  Given this set of facts, it is making an enormous effort to push and prod the population to adopt healthier lifestyles that will unburden the system and free up resources to deal with existing chronic illnesses and an aging population.

In short, though the particular circumstances are unique to Mexico, the country shares the challenges of most other nations of scale:  how to best use finite resources that are always inadequate to the overall need; how to improve outcomes without untenable cost increases; and how to engage the entire citizenry in being responsible for its collective health.  And where there are similar challenges, there is an opportunity to find solutions from cooperation.

This is what I find particularly satisfying about the Eisenhower Fellowships experience. One of the main ideas behind the program is that there is mutual prosperity to be had when nations learn from each other. This premise has been affirmed by my visits to Mexico and Germany, combined with my native understanding of the United States. Each country does certain things very well, while other aspects are lacking.  Each has a different philosophy, but all are trying to achieve the same general result: a healthy population.  To the extent that we are willing to examine what other peoples are doing and have the humility to, when it makes sense, adopt or adapt their strategies that are working, it can only help us. And given the ever-growing global nature of health (can you say Ebola?) it is in all our best interests to do so.

Of Costs and Benefits

I had a really excellent discussion with Alejandro Alfonso, CEO of the Hospital ABC.  I was so impressed that I now think of him as my personal bar setter, the administrator I hope I can evolve to be.

                                                                     Alejandro Alfonso

Some of the highlights of our conversation revolved around the cost/benefit equation of service delivery and the role of technology.  But it started with his assertion that the pillars of a prosperous (with all the things that word encompasses) society are education and healthcare.  The two form a feedback loop.  Education leads to self agency and economic self sufficiency, both of which have a direct impact on health status.  In the same vein, a lack of access to quality care (and Alejandro noted that insurance coverage does not by itself equal access) can negate the advantages of a quality education.

This is also why, Alejandro asserted, healthcare cannot be treated as just another market (a sentiment that I and many others share who critique those who believe that healthcare is a commodity).  If you have a tumor, Alejandro said, you can't go to the surgeon and say, "Take a third of the tumor out now, and I'll come back to you for the rest of it after I've saved up some money."   Thinking of healthcare as just another thing that consumers purchase is misguided.

Of course, providing those services is expensive, which is why Alejandro places a premium on a cost/benefit analysis based on hard data.  Just because you can provide a service doesn't necessarily mean you should. He referenced my earlier conversation about the robot assistant in Zacatecas.  That robot, he noted, costs $140,000 per year in maintenance costs. It might still be a good investment, but you have to show that the investment in this particular item produced results that could not have been obtained otherwise or that were more impactful than another area where you could have spent the money. If not, you might end up with marginal improvements at immense costs.

Alejandro went on to provide a personal example.  Years ago, a certain medical center had lobbied to purchase a very expensive diagnostic machine, the next generation of the equipment the center currently had.  As it happens, Alejandro had to have back surgery, and they told him that now he would see how good this piece of equipment was when it was used on him pre-op. When Alejandro came for his appointment, though, the machine was inoperative.  So they used the first generation machine, which had not yet been discarded. Alejandro made an inquiry from the tech, who said that the next generation machine was faster, but that was about it.

Alejandro thinks of this as a cautionary tale. If you're not careful, he said, you can find yourself in the conundrum of "el cómo sin el qué."  Which is to say, you should first know what you want to achieve before you start talking about how you're going to achieve it.

Powering Public Health

I received a briefing from Jaime Naves, Director of Planning for the Zacatecas health department. Through a great deal of effort and the efficient use of resources, Zacatecas is outperforming many national norms on a variety of measures.  One of the reasons for this is the accessibility of care at community clinics.  I visited one of these clinics, and even though this clinic was a Level 1 clinic (basic services only), it still had two general exam rooms, a gynecological exam room, and a dental suite.  In keeping with the countrywide zeitgeist, the name of the game at this clinic is prevention.  A premium is put on vaccinations, and multiple times a week there are exercise classes and workshops on healthy living including, to my surprise, a robust discussion around reproductive health and family planning. The lead nurse will also go outside the clinic to schools and teach age-appropriate disease prevention techniques.  She also get kids to sign up as promotores (health promoters).  Those that do get more extensive training at the clinic, empowering them to help their peers (and their families) to adopt healthier lifestyles.

                             With Jaime Naves (center) and Marisol Marroquín of Hospital ABC

I also visited Zacatecas General Hospital.  Here ones adds efficiency and maximum use of resources to the emphasis on prevention. The most obvious facet of this effort is the telemedicine center linking five regional hospitals.  Through this system, specialists at one hospital can consult with internists at another.  A med-bot that looks like something out of a Hollywood movie is the main tool.  It wheels its way to the appropriate exam room and its "head" is a screen with the face of the doctor at the telemedicine center in Zacatecas.  As circumstances dictate, the face changes to an x-ray, a lab result, or any other document or image from the patient's e-chart. If the specialist is not available at the hospital, there is a mobile app from which they can connect through their mobile device anywhere there is wifi.

I can't help but be impressed at the Mexican commitment to prevention.  Everywhere I turn, there is a program, an activity, or an advertisement for healthy living.  Even at my hotel, there is a sign at the buffet line suggesting that my best choice is the fruits and vegetables.  I didn't heed that sign very well, but I did climb an enormous number of steep steps to get to a local museum. And given that the elevation here in the heart of Zacatecas is 8,200 feet, that has to count for something.

Hospital ABC

My first day of interviews in Mexico City featured a tour of the main campus of Hospital ABC (I will visit the Santa Fe campus next week).  It has quite an interesting history. 

In the morning, I had the opportunity to speak with the CEO of the hospital, Alejandro Alfonso, the COO, Yadira Hernández, the head of Community Outreach, Dr. Blanca Velázquez, and the Corporate Director of Operations, Javier Fernández.  We discussed current issues with hospitals in Mexico, the effect of Seguro Popular, and what might lie in the future.

                                                            With Dr. Yadira Hernández

I then took a tour of the entire medical center, guided by the head of hospitality, Humberto Astorga. It was very impressive.  The building itself is LEED certified, including a solar panel garden on the roof top.  The hospital layout is divided by specialty, with a premium placed on making the complex as patient friendly as possible. By example, this includes family waiting/relaxation areas in each section, and a chemotherapy ward that is adjacent to a broad glass wall with a vista of the surrounding mountains and laid out in what approximates about ten small living rooms, each with a flat-screen TV, a couch, and a lounge chair.

                                                              With Humberto Astorga

The other stand out aspect is the "Yo Soy" (I Am) program, which requires all staff to present themselves to the patient by first name and address the patient by their name.  If that's all it was, of course, the program would not be that impressive. But, as Humberto told me, it's much more.  The important part is the patient-first attitude, where the patient is treated as if they were a family member.  As we toured, it was clear to me that the program had become fully ingrained in the hospital's culture.  In tandem with this was the acronym of CUIDAR, (Spanish, to take care of) which was indicative of the hospital's ethos. Translation: Warmth, teamwork, integrity, discipline, attitude of service, and responsibility. "Cuidar" should be the watch word for all of us in healthcare.

Our last stop on the tour was the Brimex clinic for those who remained uninsured (with the advent of Seguro Popular, Mexico has officially achieved universal coverage, but in reality there are some people - like adolescents - that remain not fully covered).  ABC is a private hospital that typically only sees insured patients, but this clinic within the hospital is quite similar to Casa de Salud (or perhaps a better example is the JFK Clinic at Mercy Hospital in St. Louis).  The main difference is they confine themselves to a five kilometer radius from the hospital, which happens to be an area of particular need. 

I then spoke with Guillermo Reyes, Vice President of Strategic Planning.  He told me how, in addition to the typical clinical measurements of impact, the hospital is measuring "social return on investment." For example, if they are able to resolve a cleft palate for a child, they use a matrix they created that indicates the savings generated by the procedure, which can be monetary (e.g. money to treat complications related to oral health) or social (e.g. avoidance of having the child bullied).  I look forward to examine this more closely, as I want to better capture the overall value that Casa provides to the St. Louis region through its services.

I ended the day at the hospital with the Chief Medical Officer, Dr. Elías Horta.  We had a broad ranging discussion, including the hospital's efforts to cut costs through waste reduction, the training and sanctioning of physicians, the role of the hospital for Mexico in its capacity as a teaching hospital, and the potential future roles for non-physician providers.

My final interview of the day was at the office of Dr. Gudelia Rangel, Migrant Care Coordinator for the Secretariat of Health.  Dr. Rangel was called away on business, but her deputies, Daniela Nuñez and Hilda Sosa, were able to cogently discuss the sensitive issue of the Central American child refugee crisis, the efforts of Mexico to programmatically address public health, and potential collaborations between Mexico and Casa de Salud by way of the Mexican Consulate in Kansas City. 

                                                With Hilda Sosa (left) and Daniela Nuñez

In all, it was a very good first day, and I am indebted to my two program organizers, Marisol Marroquín and Paulina Trápaga, for the excellent job they've done in organizing my itinerary and guiding me through the day.

More than Words

I went early this morning to the Basílica de Nuestra Señora de Guadalupe where, as a practicing Catholic, I attended Mass, and then got to lay eyes on the Tilma, the cloak upon which an image of Mary was miraculously embedded after she appeared to the indigenous peasant Juan Diego in 1531.

When I returned to my hotel, I saw a miracle of a more temporal nature: an almost two mile swath of the main drag in the heart of Mexico City had been closed to traffic, replaced by myriad people biking, running, skate boarding, in-lining, and walking.

I walked by a man who was obviously an organizer.  His gray tunic was emblazoned with yellow letters identifying him as a "health promoter," and below that there was a tag line: Mexico City - Deciding Together.

What they had decided was that talking about health and disease prevention was just words.  They were going to put words into action.  So every Sunday from 8:00 am until 2:00 pm, the traffic thoroughfare is converted into an all-are-welcome circuit for people to exercise.  The nexus is the main stage where professional dancers take hundreds of people through multiple routines.  But if that's not you speed, there are myriad other choices along the elliptical path, including Zumba, kinetic movement, and hula hoops. There are also tents set up for small group "classes" about various topics.

Around the perimeter of all this, thousands of people are on their bikes.  If your bike needs some basic maintenance to keep you moving, the city has several complimentary bike repair tents in place.  Didn't bring a bike?  No problem. Sign up for a free card, and use it to unlock one of the hundreds of bikes in the city center.

It's all part of the city effort, and the country at large, to "show our commitment to good health and to reduce social inequalities" that can result from health disparities (accion2015mx.wordpress.com, in Spanish).

Frankly, I was blown away.  This was good social policy, good public health, and good government. This was, as the banner on one of the pavilions said, an active community.

An example has been set for us to follow in the U.S. We cannot simply rely on doctors and clinics to provide good health, any more than we can expect to meet our nutritional needs by popping some supplements.  We must have entrega, commitment, to making good health more than just words.  We must come to the realization that the health of one affects the health of many, and then move beyond that awareness into an investment of time, effort, and money that results in a community that thinks about good health as an imperative instead of an afterthought.

We need to move in this direction now.  As the dance leader at the main stage said to the crowd, the future depends on what you do today.

De Camino a México

I depart today from St. Louis to Mexico, a country with a rich history, an amalgam of the indigenous and the colonial, of faith and fractiousness, of tradition and modernity. There is much to be learned here, and I go on this journey with a searcher's heart.

In both Mexico and the U.S., there are people in poverty, people in need.  It breaks my heart, because I know that it is a lack of will, not ability, that allows this to be true.

When it comes to health, both countries have made some strides in recent years.  In the U.S., there was the enactment of the Affordable Care Act.  Mexico has gone farther.  Despite its economic struggles and the ongoing strife and violence that emanate from the drug cartels, the nation declared that healthcare is a human right and set itself upon a path to make that right a reality, even among the poorest.

Our two nations share a common border, an intertwined history, and an inextricably linked future.  We are emblematic of a core principle of Eisenhower Fellowships, that the future of a peaceful and prosperous world lies with international cooperation, that we make the most progress when we work together for the common good.  So I go to Mexico to listen, learn, share ideas, and seek opportunities to make a better life for our respective peoples.