Nursing is a linchpin to health care success, Johns Hopkins Medicine International has found again and again as we help collaborators around the world sustainably improve health care systems. Raising the level of nursing catalyzes improvement throughout the systems in ways that strongly impact every aspect of the quality and safety of patient care.

Research backs that up. For example, The American Economics Journal: Applied Economics recently published a study that looked at 900,000 patient admissions, and found that patient outcomes on average measurably improved when the nurses in a patient’s unit were more experienced and had more training.

Most of us in health care wouldn’t be surprised by those findings. For a few centuries now, nurses have provided patients with broader, more continuous bedside support than physicians can usually hope to offer. Nurses typically spend more time physically closer to the patient, which means they’re often quicker to spot changes in the patient’s status. They can observe a patient’s mood and level of comfort, interact more, and become more familiar with the patient’s family and lifestyle, all of which can enormously affect a patient’s recovery.

No wonder then that health care safety and quality improved in the United States a few decades ago when nurses started to become regarded as full and equal members of the clinical care team alongside physicians. And the importance of nursing to patient care increased all the more when medicine cut down on the long shifts that physician interns and residents traditionally had to endure. Today patients can rarely expect to be monitored by the same physician throughout the course of an entire day, which means it’s largely up to the nursing staff to maintain a sense of how a patient’s condition is trending over the hours. And nurses not only deliver patient care, but also play a strong role in research, health care innovation and public health, as this article on Johns Hopkins nursing “heroes” illustrates, along with this article on a Johns Hopkins nurse practitioner’s work in the Caribbean.

And now there are new reasons nursing will be even more important in the future. As health care systems look for ways to deliver better care to more patients at lower cost, nurses may need to take over many of the responsibilities that have traditionally belonged to physicians, such as administering routine tests, providing nutritional counseling and answering patients’ questions. Here in the United States, the Affordable Care Act is pushing for those sorts of changes. As this article relates, the U.S. government has already earmarked some $50 million in nursing-education grants to help address a predicted shortage of at least half a million nurses a decade from now.

As challenging as it is to develop nursing to its full potential in the United States, it can be an even more daunting task in many of the countries in which we are working. (There are even nurses who work between countries, as this article explains.) Some countries have lagged behind the United States in elevating the status of nurses, and bridging that gap can be tricky—and this in addition to the fact that the demands on nurses in these countries can be especially high, given that physicians may be in shorter supply. To address these challenges, we’ve established a range of programs that involve not only conventional training, but also nurse exchanges, mentoring, leadership development, team building, culture change and much more.

As a result, the health care systems with which we collaborate globally have made great strides, even while we at Johns Hopkins Medicine’s Baltimore-area hospitals strengthen our commitment to having nursing play an ever larger role. It’s an ongoing effort, and one we know will pay off for patients everywhere.


Moving Beyond the Jellyfish Model of Health Care

by JHI Staff on April 25, 2014

In some regions of the world, elderly family members may be shielded from knowing that they have been diagnosed with a terminal illness. These patients are sometimes brought to clinics with upbeat, generic names, so that they can be cared for without ever having to know that they are terminally ill.

Johns Hopkins Medicine International is committed to respecting cultural differences in the many countries in which we collaborate. But this particular cultural norm—while well intentioned—is challenging for us. Medicine in the United States and most of Europe has become committed, as a matter of ethics, to being open and honest with patients. We at JHI share that belief, and support our collaborators in adopting the same approach. (They all do.)

But even in the United States, it wasn’t always as clear that clinicians should be transparent with patients. A few decades ago, many U.S. physicians would “protect” patients from learning about troubling diagnoses. They gave sugar pills under the guise of prescribing treatments, to fool patients into feeling they were being helped when in fact there was no treatable diagnosis.

More generally, physicians usually called the shots when it came to tests and treatments. This idea that health care is entirely up to the doctors is sometimes referred to as “medical paternalism”—the notion that medicine knows what’s best for you. I call it the “jellyfish” model of medicine: The patient is expected to passively float, pushed in whatever direction the health care system deems appropriate.

It’s different today. Many patients will research their symptoms and want to discuss diagnosis and treatment, and physicians consider them a partner in the decision-making. In hospitals, patients are now seen as full members of their clinical-care team.

That’s the way it should be. There are real downsides to the jellyfish model of health care. First, when patients aren’t encouraged to become involved in their own health care, they’re more likely to fall short when it comes to adopting healthy lifestyles. Second, it can lead to higher costs. As I’ve written here before, patients who don’t know what their treatments cost the system, and who have no incentive for caring, often end up with more expensive procedures than alternatives with the same benefits.

It makes sense for patients to be fully informed, so they can be smart shoppers. We’re already seeing the ground being laid for more of that in the U.S., with the rise of retail health care in the form of urgent-care store-fronts and pharmacy clinics, among other changes.

Cultural preferences for keeping family members in the dark about their health is not the only tricky issue raised by the drive to better inform and involve patients. The U.S. Food & Drug Administration recently stopped the sale of a popular personal genome-test service marketed to consumers, arguing in a statement “that patients relying on such tests may begin to self-manage their treatments through dose changes or even abandon certain therapies.” In other words, efforts to give certain types of difficult-to-interpret personal-health information could lead patients to cut doctors out of the decision-making loop in ways that could be dangerous. (The Journal of the American Medical Association weighed in on the question here.)

In spite of such thorny questions and the tensions that arise over any sea change in health care, clearly the widely accepted trend is to favor patients getting ever more information and being ever more active in their health care. It’s a trend we push for in our international collaborative work—one that our collaborators embrace. Medicine should never abdicate its role of helping us understand and act on health information, and we have to hope that patients recognize the need to listen to their doctors as part of the process—especially when it comes to medication. But rarely is there a real need for medicine to “protect” us from learning too much about our health.


Ron Lavater

From 2009 until a few months ago, I had the honor of serving as the Johns Hopkins-appointed CEO of Corniche Hospital, a bustling maternity facility in Abu Dhabi. Reflecting back on my time there, I recognize our work as a useful case study on how teams of experts from different parts of the globe, from both the public and private sectors, can collaborate around making a very good health care institution one of the best in the region.

This, of course, required navigating a largely unprecedented blend of cultures, medical practices, organizational styles and financing methods in order to raise health care standards to the highest possible levels, especially in a region where relatively few hospitals have yet achieved them.

Corniche Hospital opened at its present site in 1984, and went on to become the busiest tertiary maternity and neonatal service hospital in Abu Dhabi, with close to 9,000 births and 1,000 neonatal intensive care unit (NICU) admissions. The hospital also provides some 120,000 outpatient visits, 25,000 urgent care visits, and 12,000 inpatient admissions for its specialties of obstetrics, gynecology and neonatology.

Corniche Hospital is owned and operated by the Abu Dhabi Health Services Company (SEHA), a quasi-governmental entity. Corniche’s collaboration with Johns Hopkins Medicine began in late 2008 with the signing of a five-year management agreement. At that time, the hospital’s reputation in the community was positive, although SEHA recognized that Corniche needed advancement in several key areas, including evidence-based clinical practice, quality improvement, physical facilities and management practices. An experienced team of Johns Hopkins executives assumed four key administrative positions at the hospital (chief executive officer, chief operating officer, chief medical officer and chief clinical officer). From the beginning, our mandate included establishing a plan not only to transform Corniche Hospital, but to smoothly transition direct management of the hospital back to SEHA in a sustainable way that prioritized developing local talent.

Our collaboration addressed changes in every aspect of the hospital, including people, processes and physical plant. For example, we upgraded the 50-bed NICU with state-of-the-art equipment, and doubled its physical size, adding proper spacing between patients, and providing for 14 more beds. We addressed patient flow by establishing an off-site women’s health center, bringing services closer to our patients. Together, we accomplished these and other projects, including much-needed medical technology additions and upgrades, on plan and on budget.

In patient care, the challenge was to establish best practices that were compatible with local culture, as well as instituting training and mentoring programs. We brought in a stream of world-class clinicians to provide seminars and classes, to work with Corniche Hospital staff to establish and codify new practices, and to conduct rounds alongside staff to facilitate knowledge-sharing. We emphasized embracing a culture of safety. We joined the Patient Safety Net reporting system run by the University Hospital Consortium and adapted locally many of the established Johns Hopkins patient safety programs, such as administrative patient safety rounds.

Image Credit: Ahmed Kutty/Gulf News

We expanded subspecialization clinical services in fetal medicine, assisted reproductive services and maternal medicine. We added respiratory therapy and a clinical pharmacy in the NICU, and strengthened our high-risk obstetrics, lactation, diabetes, dietetics, parent education and physiotherapy areas. As a tribute to these improvements, Corniche Hospital’s medical team safely delivered the UAE’s first live sextuplets, drawing on the skills of more than 25 staff members from a range of specialties.

We also expanded our efforts beyond the four walls of the hospital to have an impact in the community, putting public health initiatives on the management agenda. The hospital recruited Abu Dhabi’s first hospital-based public health director, and developed the first sustainable newborn car safety seat program in the Gulf region. Today, Corniche has distributed more than16,000 infant car seats to parents, who were also educated on the safety benefits of infant car seats. Other public health campaigns focused on pre-pregnancy wellness and screening for cancer, adult diabetes, and newborn audiology and congenital heart disease.

Recruiting top-quality clinical staff is challenging for most hospitals, but when 97 percent are expats from around the world, it’s even more difficult. To address that challenge, we mapped out a plan to develop clinical training programs around our core competencies, creating a pipeline of future caregivers. This strategy also linked to our strategy for developing Emiratis as clinical providers, to build a local talent base.

Corniche Hospital became the first facility outside of the United Kingdom to be recognized by the prestigious Royal College of Obstetrics and Gynecology for providing advanced training skills modules in maternal and fetal medicine. We established a specialized NICU nursing education course that allows nurses to complete a six-month neonatology nursing certificate program recognized by the local licensing agency. We also inaugurated a bachelor’s of applied science in midwifery program in partnership with the Higher Colleges of Technology of Abu Dhabi, an 18-month program that is the first of its kind in the UAE. Working in tandem with another Johns Hopkins-managed hospital in the UAE, Tawam, we created a three-year neonatal fellowship. And, we established a new obstetrics and gynecology residency program recognized by ACGME International.

(from left to right) Bassam Sayed, COO; Judy Lee, M.D., CMO; Lynda Mikalauskas, CCO; and Ron Lavater, CEO accepting the Circle of Excellence Award

All of these changes have helped lead to a string of prestigious regional awards for hospital staff in recent years, including Best Hospital from SEHA, and Excellence in Patient-Centered Care from the Arab Health Awards.

Meanwhile, the project had all along been laying the groundwork for the smooth exit of Johns Hopkins from the daily management, so SEHA and local managers could assume leadership of the hospital. With proper planning, and a great deal of communication that included town hall meetings, that transition went off without a hitch at the end of December. Though it may sound unusual to say it, I’m very proud of having worked myself out of a job—it’s the ultimate measure of our success—and I know my colleagues feel the same way.


Decrying a Scourge of Health Care Development

by JHI Staff on February 27, 2014

There is no shortage of challenges when it comes to bringing affordable access to high-quality, safe health care for populations in countries that don’t yet have it. You need a sound and actionable vision, willing investors, government support, a pool of skilled clinicians, nurses and administrators, and an adequate educational infrastructure, among other resources. If any of these components is missing—as is the case in many countries around the world—it can be difficult or even impossible to get an ambitious health care delivery project off the ground.

Despite our progress in expanding health systems collaborations to new regions, one issue in particular has presented one of the biggest challenges: corruption. There is nothing that more surely undercuts efforts to invest in significant improvements in a society than pervasive parties who create friction and barriers in order to line their own pockets.

As an example of how pervasive corruption can be, let me look at one country generally regarded as pretty low in the corruption scale: The United States. I just looked at this website from U.S. Department of Health & Human Service’s Inspector General’s Office, and found a long list of convictions of and settlements with a range of alleged fraudsters, grafters and kickback-takers. The alleged offenses involved medical clinics, dentistry, medical equipment, hospital administration, pharmacies, diagnostic testing, and speech and occupational therapy, among others—and that’s just the previous eight days-worth of offenses. There have even been accusations of kickbacks within a U.S. organization that has played a strong role in setting patient-safety-related practice standards at hospitals across the nation.

From that dubious start, it mostly goes downhill when you look outside of the United States. According to Transparency International, which monitors global attitudes toward corruption, several nations even regard their health care sectors as being among the most corrupt institutions in their countries. Europe does not remain unscathed; far from it. A recent report issued by a European Union commission prominently mentioned health care as a sector in which bribery—specifically, clinicians improperly taking money in exchange for providing patients better care—has become a problem in the E.U., contributing to a total corruption cost of about $160 billion a year. Said one commissioner in introducing the report: “Corruption undermines citizens’ confidence in democratic institutions and the rule of law, it hurts the European economy and deprives states of much-needed tax revenue.” And most E.U. countries aren’t seen as very high up on the corruption scale, either—it gets far worse elsewhere.

Corruption can become part of a nation’s culture, until it serves as a routine way of getting by. Institutions and the population can learn to live with it, in spite of its pathological nature and how it degrades a country’s infrastructure and the fabric of daily life. It can seem like a normal state of affairs, to be expected whatever one does. But it’s insidious, restricting resources, limiting progress, and ultimately scaring off those who would otherwise invest and help improve conditions.

Turning around a culture of corruption can be extremely difficult. At Johns Hopkins Medicine International, we’re used to tough challenges, and we’re willing to work creatively to get through or around obstacles. But we’re fairly helpless in the face of corruption. We spend lots of time in our due diligence process looking for signs of corruption. We also have mandatory training on the U.S. Foreign Corrupt Practices Act and the U.K. Bribery Act for all of our employees. We recently reiterated our firm stand against corruption in all forms in our recently published Principles of Business Integrity, distributed throughout our organization.

We believe in respecting local ways of doing things, but we draw the line at corruption. It’s unethical, it’s illegal, and it’s counterproductive. In the end, our only option is to walk away from it and not get involved in projects that threaten to be tainted by it.

Please don’t take that to mean we’re giving up on countries where corruption is a problem. We don’t like walking away. We want to offer our services to every region that’s interested in improving health and health care delivery. We continue to watch carefully for signs of improvement, and to look for partners who work ethically. Even in places where corruption is widespread, there are plenty of good people and institutions who despair of it and resist it. More and more people around the world are looking for better access to better health care, and if corruption is preventing that access they will find ways to defeat it. We’ll support that effort any way we can.

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The Importance of the “JH” in “JHI”

by JHI Staff on February 25, 2014

Johns Hopkins Medicine International (JHI) is responsible for expanding the Johns Hopkins Medicine mission overseas in two ways—by helping collaborators around the world expand and improve health and health care delivery in their regions, and facilitating Johns Hopkins care for out-of-market patients who require highly specialized, complex clinical services.

In a recent online column, Johns Hopkins Medicine Dean/CEO Paul Rothman discusses the role of JHI, and how our international focus enhances the overall institutional mission. It’s a strong and thoughtful statement about why JHI exists, how we contribute to the organization, and the importance of taking a global view of health care.

It’s fulfilling that JHI’s accomplishments reflect the strong support and vision of the Johns Hopkins Medicine leadership. It’s also important to highlight how much we also rely on the global-minded thinking of clinicians, nurses, administrators, technicians and others in every corner of the institution. That sense of service to all of humanity—taking Mr. Johns Hopkins’ original 19th-century vision of community and extending it to the world, and the cultural sensitivity, patience and respect needed to deliver that service on behalf of patients everywhere—have helped make possible everything we do.

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Our Newest Partnership—and Why It’s Special

by JHI Staff on January 27, 2014

The signing for Johns Hopkins Aramco HealthcareAs I’ve written previously, employers in the United States and in many other countries play a critical role in the health care delivery chain. Employers frequently pay for health insurance, or directly pay for their employees’ care. They also can provide support for efforts to improve employee health. Some big companies partner with hospital systems to provide their employees improved access to care, or to provide tailored types of care. And in some cases, an employer—even one that isn’t in the health care industry—might go as far as to operate its own clinics and hospitals to directly deliver health care to employees.

At Johns Hopkins Medicine International (JHI), we’re dedicated to collaborating with health care delivery systems around the world to improve the quality, safety and accessibility of care for as many people as possible. That said, a partnership with a large, employer-operated health care system is not something that any major academic medical center has ever undertaken. But our mission pushes us to go beyond what’s been done before—we’ve been defining (and redefining) the boundaries of global collaborative health care for nearly 20 years.

Today, I’m proud to announce that we have formally entered into just such a groundbreaking partnership with a large employer, and it’s one of the most unique and ambitious opportunities we’ve ever considered.

The employer is global energy leader Saudi Aramco, headquartered in Dhahran, Saudi Arabia. For more than 80 years, Saudi Aramco has been operating a medical services division to provide high-quality health care to a population of its employees, family members, retirees and other beneficiaries that today numbers 350,000 around the Kingdom of Saudi Arabia. The company’s health care system sees more patients than many substantial U.S. hospital systems. That system was a force in building the first hospitals in Saudi Arabia, and has had a significant impact on general population health in the region through its efforts to help eradicate diseases such as smallpox and malaria. We’ve been continually impressed with Saudi Aramco’s dedication to the health of its community.

This new partnership between Johns Hopkins Medicine and Saudi Aramco takes the form of a long-term, joint venture called Johns Hopkins Aramco Healthcare, which will assume the responsibilities of Saudi Aramco’s existing health care system. (Each organization will have an indirect ownership interest in the Saudi-registered company.)

At the heart of Johns Hopkins Medicine’s contribution to this venture will be our expertise in enhancing clinical excellence, specialty care, patient safety, and overall health care delivery and quality in a patient-centered context. In addition, we’ll assist the venture in maintaining high levels of effective administrative leadership. And we’ll contribute to the long-term improvement of the health and wellness of a population. Overall, our shared vision is to establish Johns Hopkins Aramco Healthcare as a sustainable, health care center of excellence that represents a next-generation approach to global collaborative health care, and a model for health care delivery systems everywhere.

As I’ve written before, sustainability is important to our mission, and in our projects we emphasize establishing pipelines for the recruitment and training of health care professionals. Our goal with Johns Hopkins Aramco Healthcare isn’t to continually ship physicians, nurses and administrators from Baltimore to serve in Saudi Arabia for the long term, but to enable the joint venture to draw on substantial new and growing pools of talent in its own and other regions.

In keeping with Johns Hopkins Medicine’s own tripartite mission, we also want to see the venture become an incubator not only for excellence in patient care, but also over the long term for medical education and research. That way, Johns Hopkins Aramco Healthcare will be able to more effectively address those health care challenges that are most relevant to the region, including the management and prevention of chronic illness such as cardiovascular disease and diabetes.

But there is one more reason this joint venture is significant. Health care isn’t like other services and products. It is an essential element of a full human life, one that affects the quality and span of our very existence, and that impacts family and community. That’s true for all of us, regardless of belief, culture and political loyalties. Health considerations can transcend all the day-to-day goals and obstacles that consume our daily lives. Health is the great equalizer. When nations work together on improving health care, they stand to achieve a mutual understanding and respect that is often sorely lacking in many other ways that countries interact today—in a way that has a long-lasting, positive impact on human life.


Why Capacitance Matters in Health Care

by JHI Staff on January 25, 2014

Spain, like most European nations, provides government-paid health care for its citizens, and though it spends a smaller fraction of its GDP on health care than does Germany and some other countries, its system has been considered a pretty good one. But the country has been going through some particularly tough economic times over the past several years, and one result is that the government has been slashing health care expenditures—more than 25 percent nationally over the past two years, and even more in some regions of the country. Now, reports from health care researchers are highlighting the toll these cutbacks have taken in Spain, serving as a reminder that policy and economics really do translate to population health, and sometimes in frightening ways.

Part of the problem is that Spain’s cuts do not seem to be well thought out from a health care impact point of view. Following in the footsteps of Greece, which preceded and has so far outdone Spain in running into severe economic difficulty, Spain has singled out its large immigrant population for many of the cutbacks, including access to vaccines and other basic services. Aside from the obvious and disturbing humanitarian considerations of this sort of policy, it is also an irrational policy from a simple health economics point of view. As The Economist put it in a recent blog post

Not vaccinating the children of not only mean, but also inefficient. It is much cheaper to vaccinate than to deal with the outbreak of a contagious disease....The price tag of controlling a TB outbreak in New York City in the 1990s, a whopping $1.2 billion, proved the value of prevention, which would have cost an estimated one-tenth of that and saved much misery in the process.

Some of the likely dire and inequitable consequences of these cutbacks are laid out in the research reports, which are from the London School of Hygiene and Tropical Medicine. One of the reports, described in a blog post from the school, notes of Spain that

873,000 non-residents have lost entitlement to comprehensive care as a result of the decree, and the authors warn that these changes could have “serious consequences for population health, especially with regard to tuberculosis and HIV infections, and could threaten access to mental health, addiction, and chronic care services for vulnerable populations, such as the homeless.”

(In my last post here I myself noted that universal health care is not such a wonderful thing—nor is it “universal,” for that matter—if it excludes chunks of the resident population.)

An awful irony of this sort of policy is that it cuts health care to the very people who most need it, and at a time when there are more of them who need it, because of the economic hardships. As another blog post from the London School of Hygiene notes, Spain’s cuts are

particularly affecting the elderly, disabled and those with poor mental health....[and follow an] increase in depression, alcohol related disorders and suicides in Spain since the financial crisis hit and unemployment increased.

The same post also notes that the cuts were made without the benefit of good evidence that they would maximize savings while minimizing harm, and that they could lead to a “rise in drug resistance and spread of disease.”

In a way, it almost feels unfair to pick on Spain. The fact is, many countries could easily end up in similar positions if their economies go far enough south on them. That’s because even though the health care systems of many nations seem to be adequate and well-managed, as Spain’s did, they actually lack “capacitance”—that is, resilience to shocks to the system. A sudden surge in demand, rise in costs, or drop in resources can send the system into a tailspin from it which it can’t easily recover.

Capacitance is often poor when a system is operating on resources that are stretched thin, and lacks the flexibility and depth to reorganize itself around a change in the health landscape. A system with sufficient capacitance retains in a crisis the means—through some combination of good management, good policy and sufficient human and economic resources—to deal with blows to the system. It’s hard to measure capacitance, and sometimes you find out it’s lacking when a crisis strikes.

It’s probably true that the U.S. health care system, for all its shortcomings, has a fairly high capacitance. But that’s not to say that the U.S. and other heavily industrialized countries with relatively strong economies and high-capacitance health care systems aren’t vulnerable to catastrophic public health crises. For one thing, the personal behavior of Americans—driven, ironically, by our affluence—has led to a crisis of obesity, which is stealing an average decade of life from a third of the population. Our medical system hasn’t begun to come to grips with that. What’s more, many Americans are choosing to avoid vaccinating their children over ungrounded fears that vaccines cause, rather than prevent, serious health problems.

Economic difficulty isn’t the only road to a plunge in population health. But it’s probably a better excuse for one than not taking care of ourselves when we have the means for doing so.



There’s been a growing amount of attention paid recently in the U.S. media to the question of whether our country should offer universal health coverage, and move to a “single-payer” health care system. The two concepts are sometimes used almost interchangeably, as in this article about former Secretary of State Colin Powell’s advocating that the U.S. adopt those approaches to paying for health care:

“I have benefited from that kind of universal health care in my 55 years of public life,” Powell said....“And I don’t see why we can’t do what Europe is doing, what Canada is doing, what Korea is doing, what all these other places are doing.” Europe, Canada and Korea all have a “single-payer” system, in which the government pays for the costs of health care.

I’m sure Mr. Powell is aware of the differences between the concepts of universal health coverage (sometimes called universal health care) and single-payer systems, but it’s easy to misinterpret him as meaning that with either one, everyone in the country gets full health care and the government foots the bill. But as this article from Forbes points out, that’s really not the case. As the article puts it, universal health coverage “is less about how healthcare is funded and focuses more on who has access to healthcare.” What’s more, a single-payer system doesn’t necessarily guarantee everyone full access to good health care.

A single-payer system is one in which payer (almost always the government) pays all health care costs. It’s generally considered one form of universal health coverage, and it’s by far the most common form of universal health coverage in the world. But saying that the government pays all costs isn’t the same as saying everyone gets all the care they need. Critical questions remain: For example, does the government only pay for health care for citizens? That can be a big issue in many countries that have large permanent-resident non-citizen populations who may be living under work or student visas, or who may not be granted citizenship for reasons relating to their origins even though they were born in the country. It might be a sticky issue in the U.S. if the government were to take over all health care costs, for example, given our large population of non-citizen residents.

In addition, just because the government pays all costs doesn’t mean that it actually covers all the health care that people may feel they need or deserve. It may only provide what might be considered to be a low level of care, or the needed services may not be available to some or all of the population. As the World Health Organization notes, true universal health coverage entails

a strong, efficient, well-run health system....access to essential medicines and technologies, [and] a sufficient capacity of well-trained, motivated health workers.

Any or all of these may be lacking in countries that have single-payer systems. (You even hear complaints to that effect in countries like Canada and the U.K. that are considered models of single-payer systems—though on the whole these systems are pretty good, and of course any system has its boosters and detractors.)

By the same token, countries without single-payer systems can do a good job of making sure the great majority of the population has access to good care. Singapore comes to mind. There, as I’ve noted in a previous post, the government requires people to save up so they can afford to pay for decent health care out of pocket.

What’s more, the U.S., for all its health care shortcomings, actually doesn’t do a bad job in making good care available to virtually everyone who lives in the country. People who don’t have insurance can end up in heavy debt if they need costly treatments, but they won’t be denied treatment. And the fact is, between employer-paid insurance, state or federally subsidized insurance, and government-paid health care, including Medicare, Medicaid, and military and veteran benefits, the vast majority of people in the U.S. are either covered or can afford to be. It’s a flawed system, but not nearly the catastrophe it’s often made out to be, especially given the high general quality of care here. Under Obamacare, the breadth of coverage and affordability will further improve for most people who currently find it hard to get coverage.

Would a single-payer system work well here? The argument relayed to us by the media is often between people who take the opposite extreme points of view: that government ruins everything and should leave as much as possible to the super-efficient private sector, or that the private sector is unethical and should be shouldered aside by the fair and effective government. As you might guess, I’m not especially comfortable with either extreme view. But I’m fairly agnostic about where we ought to be between those extremes.

The question of how much of our health care should be paid for by the government is important, but I don’t think there’s a right answer. From my point of view it’s really the wrong question to focus on. The real question should be: What are the best ways to deliver the highest quality care to the most people? The answer to that question has less to do with who foots the bill and more to do with what it takes for a population to have access to a lot of good, local hospitals; to a pool of dedicated, highly trained clinicians; to the latest standard of care in evidence-based diagnosis and treatment, and to the education and support they need to take good care of themselves.

We have all that in the U.S., but many countries throughout the world are still working on it. Let’s remember that the next time an article makes it sound like we’re a backwards nation in terms of health care because we don’t have a single-payer system or universal health care. Sure, we have problems here, but in many ways they’re the easier problems to solve.


Taking Stock of Global Cancer Care

by JHI Staff on January 2, 2014

Cancer is the disease many of us most worry about. And understandably so. For one thing, the odds of getting cancer at some point are rather high—each year more 1.6 million new cases turn up in the U.S. alone. The World Health Organization points to cancer as a leading cause of death worldwide, projecting 13.1 million cancer-related deaths globally in 2030. Plus, cancer is an extraordinarily complex disease category, comprising a huge number of different diseases that have uncontrolled cell replication in common, but can vary tremendously in their cause, nature and aggressiveness—and how they present from person to person.

That complexity challenges health care systems to make the best possible cancer care available to the populations they serve. Providing standard-of-care cancer treatments can in some cases require significant resources, in terms of expertise, equipment and costly medications. That’s why the establishment of a leading-edge cancer clinic is often a major milestone for a hospital that’s seeking to build a regional reputation in specialty care. In fact, one of the reasons health care costs are so high in the U.S. is that we have so many hospitals capable of providing advanced cancer care.

But though the U.S. is indisputably an international leader in terms of the availability of high-quality cancer care, we have by no means gotten everything right. That message was hit home by a report that came out in September from the U.S. Institute of Medicine, which is the branch of the U.S. National Academies focused on medicine. Consider this statement from the report’s summary:

In the United States....the barriers to achieving excellent care for all cancer patients remain daunting....The cancer care delivery system is in crisis due to a growing demand for cancer care, increasing complexity of treatment, a shrinking workforce, and rising costs. Changes across the board are urgently needed to improve the quality of cancer care.

If the challenges facing the U.S. in cancer care are that significant, and we’re a leader, then the state of cancer in most of the rest in the world is, on average, all the more problematic.

But that’s not to say there aren’t many countries with hospitals offering excellent cancer care. We at Johns Hopkins Medicine International know well how comprehensive and leading-edge the cancer care is at many of our collaborating institutions internationally, including, to mention just a few, Johns Hopkins Singapore International Medical Centre, Beirut’s Clemenceau Medical Center, Istanbul’s Anadolu Medical Center, and Clinica Las Condes in Santiago, Chile.

Some, in fact, have made strides that we in the U.S. can learn from. Clinica Las Condes, for example, provides families in the clinic’s waiting rooms with interactive online information about the patient family member’s care. Tawam Hospital in Abu Dhabi has a world-class molecular imaging center, and has been running one of the world’s largest mobile breast-cancer screening programs.

Unfortunately, cancer care in much of the developing world badly lags the U.S. As one indication, the U.S. spends almost one thousand times as much as India does per cancer patient. Higher costs don’t always directly translate to better care or better outcomes, but that sort of extreme disparity leaves no doubt that cancer patients in India are undertreated, on average. These global inequities in access to good cancer care is a challenge not just to developing countries, but to the health care community throughout the world. (Johns Hopkins oncologist Gilberto Lopes, who, until recently practiced at our Singapore facility and teaches at our affiliated post-graduate medical school in Malaysia, is one of the world’s leading researchers on the economics of cancer care in developing countries, and a passionate advocate for addressing the care gap.)

Unfortunately, the gulf between the have and have-not nations may only grow in the coming years. That’s because cancer care is a fast-moving field, with a stream of potential research breakthroughs emerging from labs and heading into clinical trials daily. Among the currently hot research areas that could some day render most cancers manageable rather than terminal: drugs targeted at mutated genes specific to each patient’s tumors; therapies that boost patients’ immune systems into fighting cancers; gene therapies that directly alter the DNA in patients’ cells; therapies that halt cancer growth by targeting stem cells, and new types of radiation therapies that more thoroughly eliminate tumors throughout the body. But most of this research progress happens in the U.S. and few other highly industrialized countries, and even after the approach is proven effective it might take years or even decades to make its way around the world—if it can be afforded at all.

One bright spot: As medicine struggles to develop effective treatments against the more dangerous cancers, advancements in patient-centered care are improving the quality of life of patients and their families during the cancer journey. It’s a type of progress that’s affordable in most countries, though it still requires a large, ongoing commitment from health care providers and the institutions, government agencies and insurance companies that support them and pay the bills.

To quote again from the Institute of Medicine report on the state of U.S. cancer care:

All stakeholders – including cancer care teams, patients and their families, researchers, quality metrics developers, and payers, as well as [the U.S. Department of Health and Human Services], other federal agencies, and industries – must reevaluate their current roles and responsibilities in cancer care and work together to develop a higher quality cancer care delivery system. Working toward the recommendations outlined in this report, the cancer care community can improve the quality of life and outcomes for people facing a cancer diagnosis.

To which I would only add: Let’s make this a revolution in cancer care that doesn’t end at U.S. shores.

Feel free to listen to my podcast for further insight.

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Happy New Year!

by JHI Staff on December 31, 2013

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