Aldea

Thirty years ago the New England Journal of Medicine (NEJM) published an editorial about Dr. Carroll Behrhorst, a Kansas GP who had moved to Guatemala to work with the rural Mayan communities. The story was compelling and since 1987 I have contributed to the foundation supporting his work, now called Aldea, and followed their progress.  To commemorate the 50th anniversary of its foundation Aldea this month offered tours of  remote villages and a celebration dinner in Antigua, Guatemala, a beautiful old Spanish colonial city near some of the villages. Deb and I have just returned from this celebration.

Guatemala has wealth but it is concentrated in a small percentage of the people. Although the country is a democracy, policy is controlled by the wealthy elite and corrupt politicians; the wealth does not reach the Mayans and other native americans who comprise about 40% of the population. They receive little health care or education. Childhood malnutrition and death rates are very high due to poor food choices, respiratory and gastrointestinal diseases.

Women collect water 5 to 7 times a day

"Doc" Behrhorst quickly recognized that American style medical care was not the answer to the Mayan's needs and developed educational, infrastructure and public health activities to address the problems. Over the decades his successors have refined approaches to provide education, clean water and good quality food to inhabitants of several hundred small villages. Their methods have been cited by the World Health Organization (WHO) as one of the best in the world for developing nations and is used as a model for other countries.

Typical open fire for cooking

The success of this model is emphasized by the fact that all new participating villages have asked Aldea to come work with them; Aldea does not recruit new partners. When a village requests help, Aldea experts evaluate the best way to create a clean water supply for every household and then works with government engineers to design the project. Villagers are then helped to build gray water and sanitary latrine systems at each home. Efficient, ventilated stoves have been specially designed to allow each householder to build their own unit with plans, equipment, and help from experts. Firewood use is decreased 50-80% and the homes are now free of indoor smoke, carbon monoxide and other pollutants.

Efficient smoke free stove

Aldea-trained local teachers have group classes for women, educating them about their rights, nutrition and child care. These women are excited! The new water and cooking facilities cut their work day in half or less; their children, their husbands and they themselves are much healthier (respiratory and enteric diseases almost vanish); they have time to weave cloth for sale; their health, new income and knowledge of women's rights and respectful family relationships create a new world.

Women learning leadership skills

Part of the Aldea team is a Mayan agronomist who shows each family how to cultivate a vegetable garden around their hut.

Woman describing how she cultivates her garden

The best seeds are made available at low cost. For each child  between ages 2 and 5 the family gets a baby goat who will provide milk for that child after maternal breastfeeding ends. Goats are bred and the family passes the kid (goat, not child) on to another village family with a small child. In a few years all the children have a safe, reliable milk supply.

Milking a goat

We met villagers whose lives have been changed and those who are waiting for Aldea; they live in different worlds, all for a cost of $1400 per family.

Deb and Jack with Mayan family

This is lifestyle medicine at its best. Check out the Aldea website to read more details. www.ALDEAGuatemala.org

                          Mistreated

Mistreated is a new book by Robert Pearl, CEO of the Permanente (Kaiser) Medical Group, which is by far the largest physician group in the United States. Dr. Pearl is a plastic surgeon who is also a professor at both Stanford's Medical and Business Schools. In Mistreated he discusses the current status of medical care and practice in America together with his ideas on what needs to be changed.

Pearl feels that our system is poorly designed and is failing in many respects. We pay a huge amount of money for medical care that, by many standards, is the worst in the developed world. One third of American physicians are very unhappy with their job and over half tell their children not to pursue a medical career primarily because of the huge amount of time necessary for record keeping and battles with insurance companies.

Pearl uses the term "legacy players" to describe powerful groups who control how medicine is practiced and who profit from our current system. These are: insurance companies; hospitals; physician specialty groups; drug and equipment manufacturers. To this list I would add a fifth group: medical education including medical schools, residency training and postgraduate education programs. Our medical education determines what physicians learn and value. It is tailored to sustain and perpetuate our current failing system, allowing the other legacy players to continue taking unreasonable amounts of money from health care.

Patients want Pearl's four "C's": cost at the lowest possible level; clinical excellence; coordination of services and information; compassion from their health care providers.
Our current fee for service system pays more for doing more, not for doing things in the best interest of the patient. Such a system is destined to be wasteful and to harm patients by unnecessary procedures and treatments. Specialty physicians are paid much more than primary care givers and preventive services are poorly reimbursed.
200,000 people a year are killed by avoidable medical errors in the United States. Most of these deaths can be prevented by better systems and following proven protocols. Examples offered by Pearl include unintegrated medical record systems in which critical patient information is not shared; failure to follow proven accepted protocols (e.g. hand washing between every patient contact); unwillingness to accept proven life saving approaches (e. g. sepsis work up); hospitals or practices with insufficient experience (volume) in intricate procedures.
He also faults systems and physicians who are not centered around patient convenience and need to know information. Emails and telemedicine visits can save enormous amounts of patient time and expense. Patients have the right to convenience and correct information about procedures and prognosis. Oncology is particularly at fault in this regard. Palliative care without surgery, radiation or drugs is often the best option for a cancer patient, but this frequently is not offered or appropriately discussed.
Medical record systems are poorly coordinated between institutions and are often poorly designed. This can be to hospitals and system purveyors advantage. It's difficult for patients to move to another medical center and more efficient system designers are frozen out of the market. Pearl correctly advocates that all medical record systems must be inter-compatible and open to improvements by outside competition. Most other businesses have this model and their electronic systems change faster and are much more effective.

Pearl's conclusion is that pre-paid, large, multi-disciplinary groups like the Mayo Clinic, Intermountain Health Care, Virginia Mason and Kaiser offer the best medical model- good health care at the best price. His caveat is that individuals in these huge groups have to be very attentive to personal needs and preferences which can get lost in large organizations.

This is a wonderful book which I recommend to anyone interested in health care. It should be required reading for premeds, medical students and residents. 
I have two major disagreements with Mistreated. Best practice is lifestyle medicine which focuses on diet as the first way of preventing and managing chronic disease. Pearl does not even mention this in a book about optimizing health care. He emphasizes screening as an excellent preventive service. There are situations where screening is warranted but it is not the panacea Pearl suggests. Dr. H. Gilbert Welch of Dartmouth Medical School has written several excellent books and many articles explaining the problems with over utilization of screening techniques. A subsequent blog will discuss Welch's research.