Should I Approve My Tax Dollars to do That: Learn from Iran

In 2001, my mom described her health care philosophy to the Boston Globe: "Medical care is ideally broad enough to envelop not only the technical part of treating an illness, but caring for the whole animal - and the family around it.”

(https://secure.pqarchiver.com/boston-sub/access/70460160.html?FMT=FT&FMTS=ABS:FT&type=current&date=Apr+1%2C+2001&author=Naomi+R.+Kooker%2C+)

Though my mom’s expertise pertains primarily to animals, Dr. Aaron Shirley shares a similar sentiment about human patients. In 2010, Shirley founded HealthConnect, a rural Mississippi medical provider that provides a “holistic, intensely personal approach” to patient care. His inspiration for HealthConnect stems from “an unlikely place:” Iran.

In the 1980s, the Islamic Republic of Iran implemented a new primary health care system to combat the unsettling differences in health care quality and availability of rural and urban areas. As a result of this disparity, urban populations that had better access to better health care tended to out-health their rural counterparts.

The system was based on a single, multitiered structure. The first level, “health houses,” were constructed to accommodate the primary health care of approximately 1,500 people all of whom lived within an hour’s walk or less.  The 1000-square-foot houses themselves consist of exam rooms, sleeping quarters, and staff, who men and women trained in basic, preventative care. Services included family planning, prenatal care, nutritional advice, and immunizations.

The next tier was the rural center followed by the district hospital. This way, those who become very sick or require surgery, had access to a better-equipped hospital. It was also relatively inexpensive to implement. (http://www.nytimes.com/2012/07/29/magazine/what-can-mississippis-health-care-system-learn-from-iran.html?pagewanted=1&_r=4&hp).

Here you can see the flow of the hierarchical Iranian system and comparison of that flow between rural and urban centers. By the third tier, the urban and rural areas share the same hospitals. 

Photo credit: http://www.emeraldinsight.com/content_images/fig/0730190502001.png 

I see two crucial and extremely effective features of Iran’s system. The first is that by establishing good primary care, a more serious condition can be caught early before it lands the patient in the (expensive) emergency room or worse, dead. Obviously not all conditions are preventative. But many that face people living in poverty, such as diabetes, malnutrition, water contamination, malaria and other mosquito-transmitted diseases, and to an extent HIV, can be addressed before they reach a point of no return.

The second is that the health care workers are not foreigners imported in their fancy white lab coats and fancy stethoscopes; they are natives. They grew up in the villages they serve. They can relate to their patients on a personal level because they already share common ground, helping to forge an imperative sense of trust between health care provider and recipient. Such familiarity allows them to truly understand the problems their patients face and know certain realities of a solution. Some treatments we consider to be relatively elementary are impossible to prescribe in rural areas. Anything needing to be stored in the fridge, for example, is off the table for isolated areas without electricity.

In explaining how he made the leap from Iran to the United States, Dr. Shirley told the New York Times, “The Iranian model eliminated the geographic disparities, so why couldn’t this same approach be used for racial and geographic disparities in the United States?”

By establishing HealthConnect in rural Mississippi, the state with some of the worst health statistics in the country, Dr. Shirley is putting his money where his mouth is.
(http://www.nytimes.com/2012/07/29/magazine/what-can-mississippis-health-care-system-learn-from-iran.html?pagewanted=1&_r=4&hp).
Photo credit: http://faithandhealthdotorg.files.wordpress.com/2012/07/screen-shot-2012-07-31-at-8-43-53-am.png

The question now is, can HealthConnect actually help Mississippi?

Should I Approve My Tax Dollars to do That: Import Health Care

While most career fields in the United States experienced job loss during the recession, the health care sector added 1.2 million jobs, a lone “bright spot in the economy”. Yet an NY Times Op-Ed Column alerted me to a disheartening reality. To fill the demand for new health care professionals, we are not educating and employing our own. Instead, we are importing them.

The demand for more health care workers arose in part from changes imposed by Obama’s Affordable Health Care Act and the aging of the Baby Boomers.  However, American medical schools have not responded with an increased output of M.D.s. They still reject hundreds of thousands of qualified applicants while we fill the need for doctors by importing foreigners who now comprise twelve percent of the health work force. In 2011-2012, 43,919 students applied to US medical schools. While that number does not differentiate between domestic and international students,  only 19,230 students actually matriculated (https://www.aamc.org/download/153708/data/charts1982to2012.pdf). The author of the Times article, Kate Tulenko, argues that in doing so, we are also taking doctors away from the areas that really need them. Countries where twenty percent of children die before their first birthday should not be losing health care workers to the United States. Leave those doctors to do a job that for many is a matter of life and death and start increasing the production of our own.

As someone pursuing a career in medicine, the ability to get into (and consequently pay for) school is a big concern. Though I plan to enter veterinary school, applicants across pre-health fields face the same dilemmas of completing mile-long lists of requirements, achieving impossibly high test scores and GPAs in order to be competitive and extraordinary volunteer work, extracurricular activities, internships or research so yours stands out among the myriad of applications. Such glitter, if you will, often requires two things: money and connections.

 Politics and financial status should be irrelevant when it comes to health care. Good health care entails a patient and his/her doctor devising preventative, maintenance and recovery plans that best suit the patients needs. Yet a paper application ignores that necessary quality. For example, it is pointless to prescribe insulin to a diabetic patient in rural Mississippi if she does not own a fridge to store it in. The doctor must figure out a more creative, unorthodox approach. She (the patient) frankly will not know or care if her doctor had a 4.0 GPA as an undergraduate or achieved a perfect score on the MCAT. She will just want to feel better.

I wholeheartedly support the exchange of techniques, theories, and developments across nation lines. But I have a real problem with the fact that the US has imported and is importing tens of thousands of health care workers while there are thousands more already here ready to take the Hippocratic oath. The Federal Government needs to apply more pressure on medical schools and state regulators to increase the number of teaching hospitals, increase class size and reduce the cost of a health profession education. Everyone has the right to adequate health care. But first, they need access to the people. Thus even before we facilitate the access, we need the people.

So in asking myself whether I approve my tax dollars to import health care, my answer is no. I want more of my tax dollars devoted to encouraging the education and output of American health care workers.

Think about it: what do you want from your doctor? 

I Approve My Tax Dollars to do That: Prevent Another Attack

It is no secret that the illegal drug trafficking persists between Latin America, the Caribbean, South America and the United States. From breast implants to teddy bears, smugglers have concocted creative guises to evade authorities and shuttle drugs across nation borders. Now a new even more covert courier has emerged: a fully submersible submarine.

Described as “the Super Bowl of counternarcotics” by Commander Mark J. Fedor of the Coast Guard in a recent NY Times article, these aquatic crafts have been increasingly detected in the Caribbean within the last year.  Semi-submersible submarines are not rookies in the narcotics game; it is their fully submersible cousins that are now startling and worrying authorities. Only required to surface at night to recharge their batteries off the onboard diesel engine, they can travel underwater and therefore virtually invisible from South America all the way to the United States.

In addition to the challenge posed by their imperceptibility, authorities also face the problem of the submarines’ increased carrying capacity compared to their predecessors. The more commonly employed high-powered fishing and leisure boats can transport approximately one ton of cocaine. The fully submergible vessels, meanwhile, can haul upwards of ten tons, which are then ferried to shore by small boats once in shallow enough water.

Of the potential drug shipments identified by the Joint Interagency Task Force South, the group at the helm of American counternarcotic efforts, only one-fourth is ever intercepted. Manpower, aircrafts, and ships simply cannot respond to every shipment. Increasing the number of shipments seized involves working with local South and Central American authorities to prosecute the drug trafficking networks.

But there’s another unique aspect of these fully submersible submarines weighing on the minds of American authorities: the potential use of these vessels by terrorists to transport attackers or weapons. Though such use of submersibles by militants has yet to be detected, no one though a bomb could be smuggled through airport security in someone’s shoes or in a Gatorade bottle (for fact citations, see NY Times article above). Obviously air travel is a much more popular method of travel by the typical citizen, as 48% of adults in the US having flown for business or leisure in 2009 (http://www.ustravel.org/news/press-kit/travel-facts-and-statistics). But it seems both naïve and careless not to protect our ports and coasts from an attack. The United States has been caught unprepared twice within the last 75 years. I personally do not want to see another terrorist attack in my lifetime.

The $15 billion Obama allocated toward combating the drug war in 2010?  (http://www.msnbc.msn.com/id/37134751/ns/us_news-security/t/us-drug-war-has-met-none-its-goals/#.UFSiNu0ZdSo). Yes, I approve of my tax dollars going toward that if it means combating these sneaky submarines.

I Never Approved My Tax Dollars to do That: Elephant Poaching

Elephant poaching is nothing new to the park rangers of Africa. But what is new is the increased organization, voracity and militarization of elephant poaching in the pursuit of precious ivory. Also new? The decisive role my tax dollars play.

According to a New York Times article from September 4, 2012, tens of thousands of elephants lose their lives each year to poachers who then hack away their tusks and leave the corpse to rot. Officials seized a record-breaking 38.8 tons of ivory in 2011, an amount accumulated at the expense of over 4000 elephants. Though poaching was a “job” previously thought to be reserved for the criminal type, the increasing demand of ivory from China has encouraged more participants to join the lucrative hunt. Ivory has peaked at $1000 per pound in some areas. At that price, and especially when compared to the minuscule salaries soldiers receive, one can understand the irresistible attraction of the ivory trade.

Efficient elephant hunting, however, requires proper weaponry. Proper weaponry costs money. Conveniently, the United States appears happy to help.

During 2011 fiscal year, the United States gave 456.1 million dollars to Uganda, 400.2 million to Sudan and 215.9 million to the Democratic Republic of Congo (http://www.fas.org/sgp/crs/row/RL33591.pdf). Soldiers from all three nations have been caught and reprimanded for elephant poaching (see the above NY Times article).  To Tanzania, another area of active elephant poaching, the United States gave 501.7 million (http://www.fas.org/sgp/crs/row/RL33591.pdf). In addition to funds, the United States also provides some armies, including the Ugandan military, the Congolese Army, and the South Sudan military, with training and assistance (see the above NY Times article).

I don’t dispute the need for foreign aid in many African countries. Poverty and disease are rampant and as a leading world power, we have a responsibility to aid weaker institutions and areas. Yet corruption is also a notorious problem. At the same time, ensuring that financial assistance reaches the rightful recipient is an impossible task, one that no amount of manpower, sanctions, or security could resolve.

My concern lies directly with the funding and training of the military groups that in turn use the US assistance to kill elephants and buy more weaponry from the sales of the ivory. In my opinion, stricter regulation and oversight should accompany further donation of funds. Conviction or acknowledgement of participation in the ivory trade should result in deductions or withholding of aid.

It’s simple: If abused, I want my tax dollars going somewhere else.  Preferably, I want them going away from the elephants.