Come to California if you want to live.

That’s my New Year’s suggestion for a new state slogan. California is losing population for the first time since it became a state. The cause of the problem is not people leaving—in fact, our levels of departures, as percentage of population, are among the very lowest in the nation. Rather, the problem is that so few people are moving here.

The biggest reason for that is well known: The cost of living in the Golden State is among America’s highest. But less well known is that our high costs buy you more living. Literally. On average, Californians live to 79, which beats the American average by more than two years, along with the average of all but three other states.

Historically, California was middling in life expectancy. But during the 21st century, federal data has ranked it at or near the very top of the 50 states. Lately, only Hawai‘i residents, who reach an average 80.7 years, have lived longer. Our biggest metro areas are among the healthiest places in the country. The Bay Area ranks second in life expectancy nationally, and Los Angeles third.

Nor do you have to spend your whole life here to gain the extra time. Stanford and MIT researchers have found that moving to California even after age 65 can increase your life span by more than a year, or 5%.

Why do we live longer? There are many reasons. Wealthier, higher-income states with relatively high levels of education—like California—tend to rank highest in life expectancy. Money, after all, buys more access to better health care, and California’s rich people live near some of the world’s best hospitals and highest-quality health systems.

Healthy behavior helps. The percentage of us who smoke is lower than that of any state besides Utah. Our obesity rate is the fourth-lowest in the U.S. We have some of the country’s lowest rates of infant mortality and suicide.

Our more liberal public policy counts too. California’s strong environmental protections for air and water help us live longer. Gun control keeps many of us alive—we have the eighth-lowest rate of gun deaths and gun ownership. A new study from the gun control non-profit Everytown for Gun Safety finds that the Golden State has the strongest gun laws in the country. If every other state copied our regulations, the study found, nearly 300,000 lives could be saved over the next decade.

Then there’s our nation-leading commitment to health care coverage. This month, California became the first state in the union to make all unauthorized immigrants eligible for Medi-Cal, California’s name for the federal health care program Medicaid. With this move, Golden State becomes the first state to expand Medicaid to cover all low-income residents. That portends even longer lives for future Californians, since low-income populations usually have the highest mortality rates.

The news is not all good. California saw its life expectancy drop below 80 years during the pandemic. But the overall U.S. life expectancy dropped even further, to just over 76 years. And there is a significant disparity—approaching 7 years—in expected life span between residents of California’s urban and suburban coastal counties, and those who live in the rural North State and Central Valley.

Frustratingly, California also lags in rankings of mental health services—which is one reason that Prop 1, a $6.38 billion mental health measure, is on the March ballot. And the state has failed to reduce the number of people in the state who are unhoused, a life circumstance that according to a UCSF study makes you 16 times more likely to die suddenly.

California also struggles to prevent deadly drug use, especially among young people. A new “report card” on California from the advocacy coalition Children Now gives the state a “D-” on substance abuse prevention, saying that California’s “unfocused” plan offers little in early intervention “and instead requires kids to ‘fail first’ before getting the help they need.”

Of course, the other states also struggle with drugs, mental health, and homelessness, and many of them offer less in services and support than we do. The statistics demonstrate that California, for all its failures, is a great place to settle if your goal is to stick around awhile on earth.

And if my formulation—“Come to California if you want to live”—seems too sharp, then the state might instead borrow a line from the comedian Mort Sahl, who spent his later years in Marin County, whose residents enjoy the state’s longest life expectancy (more than 83 years).

“You haven’t lived,” Sahl said, “until you’ve died in California.”

He died in 2021, in Mill Valley, at age 94.

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Here’s one technique I’ve used: get them to play cards.

For many years, I’ve drawn on my experience as a medical professional, and as an immigrant, to help elderly Chinese Americans and their families reckon with the challenges of death. And I’ve come to believe that the lessons from our work apply not only to other Americans but also to other societies and cultures around the world.

I first came to the United States at age 23 to fulfill the American need for nurses. I was trained as a nurse in Taiwan, completed my U. S. nursing training at De Anza College in Cupertino, obtained my RN license, and earned my bachelor’s and master’s degrees from San Jose State University. After graduation, I cared for elderly patients with major depression and other mental illnesses at El Camino Hospital in Mountain View. In 2001, I moved to the Sacramento area to work as a public health nurse. Ten years later, I was again recruited by El Camino Hospital and I worked in their out-patient program (OATS) until I retired in 2014.

As a graduate student at San Jose State, I started a program for Chinese elders at Catholic Charities in San Jose. I was struck by the prevalence of depression among the people who attended the program, and spent quite a bit of time developing strategies to get them to talk about things that were bothering them. That made me wonder how I could do more to help people with loneliness, anxiety, suicidal tendencies, and a whole variety of other end-of-life problems.

I also noticed some differences. Most American families honor the medical wishes of their elderly, but many Chinese families I encountered were more likely to make decisions as a family unit, on behalf of their elderly relatives—even if the outcome was not what those relatives might have wanted. Often, there was little conversation about the older person’s desires—and sometimes the dying person wasn’t even informed of the condition he or she was facing. Children, out of a sense of filial piety, didn’t want their loved ones to become anxious about their prognosis. Thus, the family often decided, almost by default, that the older person should be kept alive, no matter what.

I’ve experienced such dilemmas personally. In 1999, my father, who lived in Taiwan and had terminal cancer and pneumonia, was taken to the hospital. When I talked to the doctors there about a “Do Not Resuscitate” order, they refused to comply, informing me that a DNR was illegal there. As a result, my dad spent a year in intensive care undergoing unnecessary and often painful procedures before he died. Since my dad had never talked to his five children about his medical wishes, at the end—like most Chinese families—we felt we had to do everything to keep him alive even though it was hard to see him suffering. (Since that time, Taiwan’s laws have changed; in 2011, Taiwan’s Hospice Palliative Care Act was amended to include advance directives such as do-not-resuscitate.)

On my way back to California, I decided to do something about improving advance care planning for Chinese Americans so people could make their own medical decisions. Many people had never heard of the Advance Health Care Directive (AHCD), and those who did might have had trouble completing the form because it was only in English.

In 2005, I decided to form the Chinese American Coalition for Compassionate Care, made up of colleagues and health care providers who wanted to be better educated about the experiences and desires of Chinese Americans at the end of life. Some of my friends told me I would give up in less than a year, and that building an organization on such a taboo subject would not be easy. They said that Chinese would not open up to asking for help with end of life issues. But we persevered. CACCC become a nonprofit corporation in 2007. Today, our coalition includes more than 150 organizations and some 1,400 individuals. Agencies who partner with the coalition provide their resources and support to assist our volunteers with our events and trainings.

In 2005, friends told me that building an organization on a taboo subject would not be easy, but now our coalition has 150 organizations. Image courtesy of Beth Baugher.

The Coalition helps to educate people about advance care planning for their later years and also about palliative and hospice care. We train hospice and hospital volunteers, and educate health care professionals serving Chinese Americans. Once trained, they often become hospital ambassadors and hospice volunteers. The most important work we do is helping people start the end-of-life conversations, between patients and family and families and health providers. We do not only focus on the dying; we also encourage those who are still young and healthy to complete their AHCD, so no one will have to guess what they want done when the time comes.

We are a volunteer organization, with only three part-time staff. But we’ve made an impact by pursuing novel strategies for engaging the community. One advantage we have is that we speak both English and Chinese and know the culture of the people we’re serving.

The biggest challenge for us has always been to get people to open up and share their end of life concerns and preferences. A new approach to this problem was CACCC’s Heart to Heart cards, which we created and trademarked in 2014, after being inspired by the Coda Alliance’s “Go Wish” cards, to help people discuss end of life issues in English. People of many cultures enjoy playing cards, and Chinese and Chinese Americans have a long tradition of opening up over card games.

The Heart to Heart cards can be used to play poker, but more importantly, they can be used to discuss end-of-life issues. The cards contain statements about issues that Chinese consider important in the last days of their life. This helps them become aware of more options, options they might not think of without a reminder. They can also use the two jokers to discuss issues not on the cards. Each of the four suits represents a different end-of-life concern. Hearts represent spiritual concerns, diamonds financial issues, clubs social needs, and spades physical necessities. In the game, players pick 12 cards, three from each suit, and then are asked in the course of the game to identify their three greatest priorities for the end of their lives. These card games are typically played at events called the “Heart to Heart Café,” where we serve tea and pastries and encourage participants to discuss end of life issues. (I was inspired by the Death Café, an idea out of England that encourages conversations about death in another context.)

At first, people often are slow to embrace the cards and open up, but eventually, they all start talking, often in detail. Some talk about the prayers they want said at the end, or their desire to die at home; others about which rituals they prefer at their funeral. The card games, which are limited to eight people at each Café table, are followed by efforts to bring together elderly people and their younger relatives so they can talk through their end-of-life wishes, while also sharing memories and good wishes for each other. Often, when there is time, Café facilitators help participants complete their AHCDs to ensure that the knowledge they’ve gained is not lost in the complexities of life.

While I started this work in California, word got out quickly. Soon we were traveling statewide, and then to Boston and New York, to teach others how to host the Cafés. The cards and Cafés have become an integral part of the trainings we do for hospice and palliative care volunteers and medical professionals. Since the cards are in English and Chinese, we’ve also had interest from people of Vietnamese, Japanese, Indian and Latin American heritage, who are adopting both our coalition model and some of our conversation techniques.

In recent years, I’ve encountered interest in this approach from China itself. This past spring, I went to Wuhan for the third time in three years to hold Heart to Heart Cafés and end-of-life education courses at four hospitals and at symposia where leaders came from several provinces. China ranks low in global surveys of the quality of end-of-life care, and the country realizes it has to do better. In the last few years, we have witnessed considerable progress countrywide.

Not everyone can have a good death. But you can have a better death if you find a way to talk about it, long before you’re facing it. Doing advance care planning and completing an Advance Health Care Directive are the best gifts we all can offer ourselves and our loved ones.

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My experience—I was trained in Mexico and now practice over the border in Chula Vista, in San Diego County—has taught me about just how vital immigrants are to California’s health care. It’s also shown me that immigrant physicians, like me, can play special roles in medical training and provide services and new perspectives in places where doctors are needed most.

I was born in Monterrey, Mexico, but moved to Tijuana when I was young. Medical school in Mexico is a seven-year program that starts right after high school, giving extensive contact with patients right from the beginning. At the medical school at the Universidad Autonoma de Baja California, I encountered all sorts of people and medical problems, reflecting the diversity of people who live and pass through that border city. I also volunteered as a medical student in the shockingly poor indigenous communities in Baja California del Sur. Mexican medicine is less dependent than American medicine on lab tests, so I became quite good at giving physical exams and talking with the people I treated.

In my 20s, I decided to immigrate to San Diego, as my family grew concerned about violence and crime. I could immigrate quickly with the help of my mother, who is a U.S. citizen, originally from Texas.

At first, I didn’t think I’d be able to stay in California, earn a medical license, and win a residency here. Such positions are very competitive. But then I had the good fortune to get into UCLA’s International Medical Graduate (IMG) program.

The IMG program solves two problems. Medical school graduates from Latin America find it difficult to make the transition to practicing here. And California faces a shortage of doctors in primary care, with more than 600 areas that are defined by the federal government as having a shortage of primary care physicians. Many of those areas are Latino, but fewer than 10 percent of doctors in the state are Latino.

So the IMG program prepares bilingual, bicultural immigrant medical school graduates who reside in the U.S. legally to earn a California medical license and obtain a residency in family medicine. In return, the program’s participants promise to practice in one of the state’s underserved communities for two to three years after their residency is over.

UCLA was great. The program didn’t just help prepare me for the licensing exams and score in the 99th percentile for U.S. students; it also gave me an introduction to the culture of American medicine. I helped teach a Medical Spanish course at Geffen School of Medicine, and, as part of a clerkship, I rotated through the UCLA hospital system. That, and my subsequent internship and residency in family medicine, came with surprises. For all the Latino patients I encountered, I didn’t encounter many Latino doctors. And I was shocked by all the resources and how quickly things happened: in Mexico, my patients had waited days and days to get CT scans, for example.

After residency, I decided to return to San Diego to practice family medicine at Family Health Centers of San Diego’s clinic in the extremely diverse City Heights neighborhood. Technically, this was a requirement of the program, but this is also the medicine I want to practice, in exactly the sort of place where I want to practice. I’ve since transferred to the Family Health Centers of San Diego clinic in Chula Vista.

My patients here remind me of the diverse working people I helped treat in Tijuana. And I’ve tried to use my background and experience on behalf of the community. I started a Spanish-language version of the diabetes group classes here. I often counsel patients who get assigned to specialists but struggle to communicate their needs.

But the value of having foreign-trained doctors is not only about speaking the language, but also about understanding the culture. Sometimes, that makes patients originally from Mexico more willing to share things with me. I’ve had a patient open up to me about rectal bleeding she was experiencing when she wouldn’t talk with other doctors.

In certain circumstances, my background gives me the chance to advocate, or convince my patients to be more assertive. I intervened on behalf of a patient who kept getting injections for an aching back and wouldn’t speak up despite the injections not working. I often remind patients that they have a right to have a translator when they are referred out of our system to see a specialist. And I’ve been able to make some progress convincing mothers from Mexico, where baby formula is highly popular, of the virtues of breast milk.

In family medicine, I have the advantage of seeing multiple generations of a family, from the grandma to the baby. That allows me to understand the family environment and diet and suggest changes that can reduce the risks of diabetes. With elderly patients, who sometimes struggle to read, I’m able to communicate clear dosage instructions through younger relatives. When dealing with a colicky baby, I talk with a grandmother about not feeding them in ways that may contribute to the problem.

And in border communities, I’ve seen treatment become broader and more culturally sensitive because we have both physicians and patients who have migrated from so many different parts of the world. We screen people for a variety of diseases from around the globe, and are very attentive to the risks associated with hepatitis B and other infectious diseases.

When it comes to health care, at least, the border isn’t much of a barrier anymore.

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Immigrants are already essential to health care in California. But they will become even more important in the future.

Today’s health system is a giant mess—timely care is hard to find, drugs and treatments are ruinously expensive, and lethal mistakes are all too common. But things would be even worse without the immigrants who serve as doctors, nurses, and aides, often in places and in roles for which our clinics and hospitals can find no one else. In America, one in six medical professionals, and nearly one-third of physicians, are foreign-born; the numbers are slightly higher in California.

While many of these immigrant providers represent a stopgap for now, they also hold the promise of a brighter future. Immigrants bring not just their labor but also ideas that can help us imagine how to change our health system.

This will mean more than just encouraging immigrant providers, some of whom were schooled in practices missing from our impersonal health care—the value of individualized care, the importance of staying well as opposed to using drugs to fight disease, and the power of leveraging families and communities to improve public health. It also will mean prioritizing research, which means backing the immigrants who are responsible for one-fifth of all biomedical research and clinical trials.

And finally, it requires supporting entrepreneurial immigrants who turn research into treatments, devices, or drugs. In California, more than 40 percent of new companies are started by immigrants.

So I was intrigued but not surprised when I learned that a new tool to keep thousands of heart attack survivors from returning to the hospital was created by three immigrants—from India, Nigeria, and China—at a startup based in downtown Los Angeles.

Their start-up, Moving Analytics, marries health care innovation with the state’s famous technological know-how. Founded by Harsh Vathsangam, Ade Adesanya, and Shuo Qiao, the company’s efforts to improve cardiac care today show how much room there is for new ideas and new technology to transform Californians’ health over the next half-century.

I connected with the three co-founders in a very 21st-century California way. After trying to reach them online for a couple of days, I discovered that their office was in the very same L.A. co-working space, Cross Campus, where Zócalo Public Square, the producer of this column, is headquartered.

The story of how Harsh, Ade, and Shuo found each other is another small-world tale. Harsh, now 34 and the CEO, was born in India but grew up in different Middle Eastern countries before returning home to study at the elite Indian Institute of Technology Madras. At the institute, he met Shuo, a Beijing native who was also studying there.

After graduating, Harsh won a scholarship for grad school at USC, where he joined a robotics lab but ended up on a project that was more about health technology than robotics. Under the guidance of Gaurav Sukhatme, a computer scientist who would become a mentor and a member of the Moving Analytics board, Harsh invented new tech tools for health, including a communication device for kids with cerebral palsy.

USC was a magnet for Shuo, now 29, and Ade, also 29, who had come to the U.S. from Lagos, Nigeria to study electrical engineering at the University of Houston. Ade enrolled in USC’s engineering management program and got a job at the university’s Stevens Center for Innovation, where he worked with researchers to commercialize their intellectual property and form startup companies. One of the researchers Ade met was Harsh, who by then had secured two patents.

In 2013, intrigued by the potential of technology to improve the way people manage their health, the three men interviewed clinicians, hospital administrators, and others before deciding to take on the leading cause of death in the world—heart disease—because of the opportunity it presented.

One of the great failures of the American health care system is that only 15 percent of heart attack victims complete rehab after hospitalization. With rehab—which includes exercise and lifestyle changes—the likelihood that a heart attack survivor will live another five years doubles. Rehab also cuts the risk of a second heart attack in half. And yet, because rehab is time consuming, and may include extra costs for patients and lower remuneration for doctors, most patients don’t do it—which eventually lands them back in the ER. Or worse.

The Moving Analytics team thought technology might be able to achieve what our crisis-focused care system hadn’t—help patients follow a personalized rehab program from home, managing their medication and exercise and creating better health habits (like giving up smoking), while reporting their activities to their doctors and other caregivers. They sought out the best existing cardiac rehab program they could find, which is based at Stanford, and licensed its research, evidence, and care management system, called MULTIFIT, to create an app that remotely monitors and coaches people. The app is linked to hospitals and doctors so they can see patients’ programs; it is integrated with billing for insurance purposes.

Image courtesy of Moving Analytics.

The company says its approach lowers rehab costs, requires fewer doctor visits, and, most important, gets 80 percent of patients through their rehab programs. The company has signed up clients including the VA and delivers cardiac rehab through major medical centers including NYU Langone Medical Center.

Moving Analytics, with its USC and Stanford influences, is clearly a California company—but its founders say it is profoundly influenced by their experiences as immigrants.

Their own struggles to translate concepts between languages and cultures has helped them design a health tool that they believe to be more intuitive and easier to understand for all kinds of people. And their strong commitment to home-based care reflects their own familiarity with national health systems that aren’t so tied to doctor’s offices and hospitals.

Ade attributes the company’s frugal style—they’ve managed all this with less than $3 million in venture funding—to their own belt-tightening habits. And the founders say their highly diverse staff of 15 reflects their strong belief in the advantages of diverse backgrounds and experiences.

“I don’t think we could have started this company in any other country,” says Harsh.

But they also have had to make adjustments—particularly in trying to understand an American health system that is stranger and more complicated than any other on earth. Harsh says he found the extreme health disparities between rich Americans and poor, non-white Americans especially shocking.

The peculiarities of American politics also have posed a challenge. Ade says their original business model capitalized on Obamacare incentives that encouraged hospitals to use remote care tools like theirs. But President Trump’s election and his rapid reversals of parts of Obamacare pulled the rug out from under them for a time. For a year they had no revenues, and had to cut their own salaries to survive.

“We lost a lot of business and had to go back from scratch really and try to build a business model,” says Ade.

Ultimately, they pivoted to a new model that focused not just on improving outcomes for patients and doctors but also on convincing insurers of the financial advantages of the technology.

Part of what makes the founders of Moving Analytics so tenacious is their firm belief that this new approach to cardiac care is only the beginning of a broader, systemic change in health care that will offer much opportunity for innovators like themselves. They envision a more effective, efficient, and inexpensive health system that looks more like Netflix, allowing patients to choose from a wide variety of care, and receive treatment from medical professionals, without always having to get to a doctor’s office.

“It’s not just about changing health care—it’s broader: how can technology better serve people,” says Shuo. “In health care, we think that means things will be patient-controlled and patient-centered.”

Harsh says it’s important that such a system is carefully designed so it makes health care better and more accessible for people with fewer resources. That’s a worthwhile mission for a lifetime.

“I have 50 or 60 years left and I’m in a place where I really have the opportunity to do whatever I want,” says Harsh. “So you gotta make your life worth something … being an immigrant, you have to prove more—the bar is higher.”

The post How California’s Immigrants Are Bringing Innovation—and Heart—to Health Care appeared first on Zócalo Public Square.

Answering that question is the focus of my research and practice at Children’s Hospital Los Angeles, where I’m chief of gastroenterology, hepatology, and nutrition. Here in Southern California, we face a silent tsunami of obesity, diabetes, liver disease, and more, afflicting the health of our community.

The prevalence of sugar-driven diseases has had an especially devastating impact on children of Latin American heritage who have immigrated to the U.S. during the last few decades when fast food options that are relatively inexpensive but calorie-dense have been more readily available. Gravitating towards this type of diet sets children up for devastating long-term health consequences. Research has found that children of Hispanic backgrounds have a greater genetic predisposition to damage from sugar-rich diets that can lead to obesity and, in the long run, increased rates of cancer—and even liver failure—necessitating liver transplantation in young adulthood.

As a researcher, my efforts to combat this epidemic have been shaped by the susceptibility of immigrant families, but also by my own diverse experiences growing up around the world and then immigrating to the United States.

In retrospect, I was fortunate to have an untethered upbringing. My family is from India, where I was born and spent my early years. But after that, we moved to follow my dad’s career, spending time in both the Middle East and Asia. These varied experiences helped make me who I am today: open to new ideas and to understanding how best I can help all people.

My basic medical education occurred in India, where we were challenged every day to achieve the best outcomes for our patients, even with resources that were sometimes limited.

After my medical training in India, I worked as a junior researcher studying pediatric liver disease before immigrating to the United States to get advanced training. I trained in pediatric liver disease management, including liver transplantation for children, at Northwestern University, then worked at Cincinnati Children’s Hospital. At the end of my tenure there I served as head of the liver transplant program for children. Today, I continue my work at Children’s Hospital Los Angeles, leading one of the top pediatric teams in the nation specializing in digestive disorders and liver transplantation. My work here falls into three main areas.

About one-third of my time involves the administration of our Gastroenterology division. Our healthcare infrastructure in the United States is complex and therefore can at times be expensive. In this role, I frequently lean on my early days of medical training in India where being respectful of resources was paramount. Using lessons from my past, I attempt to provide the best outcomes for children under our care today.

Another third of my time is spent being a clinician, treating patients and talking with their families. Many of the families I have the privilege of treating are immigrant families with limited resources. So, when I talk with a family about their child’s obesity-related liver disease, I am very aware of these limitations to their care and treat the 15–20 minutes I have with them with the utmost regard.

This time is extremely important to them. Years ago, I often gave people the whole textbook on what they were facing, but that didn’t work out so well. My wife, who is a social worker, convinced me that a physician needs to be understood, and that means not being so “clinical” in one’s message that you lose empathy. I’ve therefore learned to focus the information I share with each family to what is actionable and practical—I can’t tell them to go to the park if the parks where they live are not considered safe, and it’s hard to ask them to eat more fresh vegetables if they are in an area without grocery stores.

Instead, I focus on getting people—both patients and their families—to avoid sugar. Sports drinks, fruit juices, soda pop and any sweetened drinks should be avoided. “If it’s sweet and you can pour, kick it out the door,” is one of my adages. This is advice I know they can remember and hopefully use in their daily lives!

Photo courtesy of Juan Ocampo.

The final third of my time is spent on research: with other scientists, I study pediatric obesity and liver disease in the laboratory. In the laboratory, we work on understanding the mechanisms behind the damage caused by sugar and sugar substitutes in the development of obesity and its frequent association with other conditions such as fatty liver disease and diabetes. I take on this challenge to research the mechanisms of fatty liver diseases, not only to change outcomes of patients at a clinical level, but also to better understand the cellular mechanisms that result in weight loss and hopefully help lead to new treatments for fatty liver disease.

It is this research that truly breaks down the walls between different parts of my work life. When you are a clinician, you reach one person at a time, but from research I can take principles that apply all over the world, including to the children and neighbors across all the places I spent growing up.

All these roles have taught me to believe very strongly in advocacy and community partnership for effecting real, lasting change. Case in point: when science influences legislation and public policy to discourage consumption of sugar-sweetened beverages, children’s health improves. Another example: Children’s Hospital Los Angeles partners with federally qualified health centers to successfully serve diverse populations and apply science that shows us how to treat obesity and its related health problems.

And that, perhaps, is a perfect example of how all these nuances are linked–culture informing care, research influencing results, all in the embrace of public policy that recognizes not only problems but proven solutions–and in healthcare, nuances make all the difference. That’s something I understand as a doctor, a researcher, an administrator—and as an immigrant.

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I address this daily as a psychiatrist in my primary job at a children’s clinic in San Jacinto that is part of the Riverside University Health System. And I address this more generally by training medical students, residents, and fellows through my position on the clinical faculty in psychiatry and neuroscience at UC Riverside School of Medicine.

I believe that immigrant physicians, nurses, and other health care providers are starting to redefine the way medicine is practiced, simply because so many immigrants have found work in the American health care industry. My hope is that these immigrants, with their experiences of other health care systems, can help to improve the way we provide mental health care. In particular, we need to change the standards of how we define “productivity,” and the way that insurance companies define that for the health care industry. More personally, I think the health care industry ought to define productivity through the quality of the interaction between health care providers and their patients and not by the numbers that came through the door for the day. The relationship between the patient and the health care provider should be seen as sacred, and essential to the practice of medicine.

My approach to medicine, both in my clinic and in training medical students, residents, and fellows, is deeply informed by my experiences in both Nigeria and the US. My parents are Nigerians who were graduate students in San Francisco when they met. They took me back to Nigeria shortly after I was born. We returned to Nigeria during the oil boom (in the late 1970s) and I grew up in the southeastern city of Owerri. I then studied medicine in Port Harcourt, which is the hub of Nigeria’s oil industry.

One requirement of my medical school training was a community rotation. I ended up in a rural town about fifteen miles from Port Harcourt city, an area called Ogoni, which is home to a minority ethnic group in Nigeria. It was also the site of many oil wells. Doing my community medicine rotation in Ogoniland—which had been devastated by the environmental impacts of the oil industry, ongoing violence (from both local groups and the militants), and also by extensive human rights violations—was mind-blowing. With a colleague, I began to study the positive and negative effects on the area’s youth of growing up amidst the oil—and learned that many had traumatic experiences, were not able to go to school, or were seduced by the money available because of the various illicit economies that had sprung up around the oil. I have remained particularly fascinated by the combination of psychological and medical effects of these influences on communities in the Niger Delta, and continue to collect data there.

Shortly afterwards, I relocated to the US. At this point, I had my medical degree from Nigeria; an MBBS. To practice in the US, I had to take series of examinations and fulfill requirements to complete the process of acquiring the doctor of medicine (MD) degree. My interest in medical and public health issues affecting communities has made me a community-oriented provider. Hence as I pursued the MD degree, I also studied for a master of public health (MPH) degree. I eventually completed my general psychiatry residency training at Loma Linda University and then child psychiatry fellowship training at USC. I have remained a community-oriented health care provider and I still stay connected with organizations that advocate for the right of individuals and their communities to quality health care and especially mental health care. These organizations include the American Psychiatric Association as well as National Alliance for the Mentally Ill.

In my job in San Jacinto, I have the opportunity to serve people who have no other ways of getting mental health care. Most of my patients have Medi-Cal. Some of them drive over an hour, from farmlands and very rural areas, for care. In many ways, this community reminds me of where I come from because there is so little access to mental health care.

At my clinic, our team includes psychiatrists, therapists, parent partners, and administrative staff. The average child or teen who comes to me has many psychosocial issues. I have to get through so many layers before I get to the core, and this takes time—time we often don’t have in American medicine. Maybe it has something to do with my Nigerian background or just being raised in a different environment, but—when somebody comes in and says they are depressed I just can’t say “OK, here’s your medication for depression. See you in one month.” I always have to deal with the core issues. I ask a lot of questions. We have Maslow’s hierarchy of needs, with the basics like food and shelter at the bottom and other things at the top. I feel I have to get to the basics first, before prescribing.

In the American system, health insurance companies and billing issues drive the way psychiatrists interact with patients. The norm is that the psychiatrist is the pill-pusher and a therapist does the therapy. While I think that specialization is important, it is also important to take a wholistic approach—especially when it comes to emotional issues or psychosocial issues that could be interacting with mental health issues. I will not shy away from something that is staring me in the face, especially when I know that it is a hindrance to the patient. I am not sure if this mindset comes from my Nigerian background or medical school training or even from the specific experiences that have shaped my life, but I just think that looking at an individual as fragments does not work for me. I believe that we should look at the individual in a more comprehensive way. I have to allow my patients to tell me how they feel in a way that is meaningful to them. My job is to grant them the space they need to explain to me what is going on.

I really believe that my work with underserved communities is my calling. I think of it as a great privilege because I could work just about anywhere. However, to have an impact on someone’s life that truly transforms him or her is just extraordinary.

The fact that I am an immigrant helps some parents relate to me. Parents are a huge part of child psychiatry, which is really more like family psychiatry. They often ask me where my accent is from. Even my Spanish-speaking parents who communicate with me through the help of translators may also identify with me as a parent. I think my young female patients also see me as a role model and someone who might inspire them to achieve loftier goals.

But at the same time, my experiences in Nigeria mean I’ve had to make some adjustments to the way I think. When I first started my residency in a more affluent community, I struggled with accepting people’s stressors for what they were. My teenage patients would get admitted following a suicide attempt and during interviews I would learn, ‘Oh, yeah, my boyfriend put this song about me on his phone and everyone laughed at me!’ I had thought of this comment as trivial and not a reason for a suicide attempt. In my mind, I was comparing this young girl to the kids I had seen during my rotation in Ogoniland. I had judged this girl and a few others as not really having problems. I was judging them in a way that was inappropriate. So for me, the biggest change was the way that I had to transform myself to be ready to work with people and their stressors at their level.

I started working with medical students two years ago. Understanding some of the expectations was initially challenging. I learned that the primary goals of the residents’ rotation were to have them get comfortable around psychiatric patients and be able to take a history.

However, as time went on I realized that the rotation was not just about the students showing up just to fulfill their psychiatry obligation. These students are individuals with different stories and different backgrounds. I have encouraged them to see their own strengths, and see the things that they may take for granted. I have asked them to challenge the status quo about stigmas related to mental illness. I have encouraged them not to be scared of mental illness.

In a competitive field like medicine, medical students and trainees go through grueling experiences—they do rotations, deal with all kinds of personalities and expectations, some of which are quite high-handed. They have high rates of suicide. I have observed some undergo a tremendous transformation as they allow themselves just to open up to the process of what happens in their different interactions with the patients and their families. About a year ago, I was pleasantly surprised when the students named me their favorite psychiatry instructor.

In time, I think perspectives like mine will shape health care. I think that “the checklist thing”— where you treat every patient the same—does not work. I’m not just talking about making patients feel good. Productivity is not just how much money you’re bringing in. Productivity should be measured by whether we are keeping this patient out of the hospital. How are you increasing the productivity of this patient?

When a patient comes to me, I cannot find out in 15 minutes why they have been on benzodiazepine for 20 years. And if I could spend maybe an extra five, ten minutes over the next two or three months, I could get this person off benzodiazepine and get them back to work. How can we stay connected to people so that we can really get to the bottom of the problem and solve the problem in a meaningful way, instead of just this superficial treatment we do all the time that’s not getting us anywhere?

The post Seeing Patients as More Than a Collection of Body Parts appeared first on Zócalo Public Square.

Because I’m from an immigrant family in this part of California, I had the desire to serve the agricultural community in Gonzales and across the Salinas Valley. Throughout my entire life—growing up in Watsonville and East Salinas, and working professionally in a local hospital and federally-funded clinics—I have seen firsthand what it’s like not to be able to get medical care during an illness. This experience has inspired me to work harder and differently to make sure health care is accessible, affordable, and high-quality.

Lack of accessibility to health care has been an issue in my family for decades. My grandmother died in Mexico from “sick sinus syndrome,” a heart rhythm problem related to the cardiac sinus node. Living in poverty, she didn’t have access to a cardiologist, and couldn’t get the pacemaker and specialty care that would have given her an opportunity to live longer.

My interest in medicine dates from my childhood and adolescence. I happen to have been born in Santa Cruz to migrant farmworker parents who then lived in a farmworker camp in Watsonville. Transportation, and thus access to care, were problems for them; they had to ask for a ride to reach the nearest hospital that accepted the state Medicaid program, 45 minutes away. Consistency of care was also a challenge. Our family—my parents and their five children—were binational; we would live six months in Mexico and six months in the United States, as my parents couldn’t afford to stay here in the winter when the strawberry season and lettuce harvesting were over.

On long family trips to Mexico by car, we would encounter accidents on the roadside where people were injured, and I remember wishing I had the skills to help the wounded. Seeing the complications of diabetes in family members and friends—including premature deaths that could have been prevented with prescriptions, diet changes, and other medical care— strengthened my own desire to become a medical professional.

My interest also stemmed from having had a younger sister who was born with congenital anomalies. She only lived 9 months—three months longer than my parents were told she would survive. My parents at the time were accused of causing the congenital malformation from exposure to drugs or alcohol, but they didn’t use such substances at the time. The more likely cause of her malformations, I later learned, was exposure to pesticides in the fields.

Education was not a priority in our family. My parents, who only had first and second grade educations, wanted me to stop school at the eighth grade. When I didn’t, they stopped supporting me economically, so I had to work, to support myself—and, as the oldest, to support my siblings. Work meant picking strawberries. During the summers, the shifts were 10 hours a day, seven days a week.

As a first-generation high school student, I lacked mentors or even a good counselor; I didn’t know about college prep, honors, or AP classes, and the counselor enrolled me in general education classes during my freshman year at Alisal High School in East Salinas. But I was blessed with having a teacher, Mr. Terry Espinoza, who took an interest in me during his world history class. He asked to look at my schedule, and then he picked up the phone in his classroom, called the counselor, and insisted I be put in college prep and honors classes.

In high school I applied to the Monterey County Youth Program, which placed low-income students in summer jobs. I was lucky to be selected and matched to a job in the x-ray department at Natividad Hospital, a county hospital that provides care to the underserved and uninsured. I found I liked being part of serving these patients; I would go down to the emergency room to pick up x-ray films and translate between doctors and Spanish-speaking patients. The x-ray staff was very supportive, keeping me on after the summer so I could work there for the rest of my high school years.

I married during my junior year of high school, and was pregnant with my son as I applied to four UC schools. I got accepted at each and was offered a full ride at UC Berkeley (I would have paid just $90 a year). But I didn’t have much guidance from the school and didn’t understand my options. In May of my senior year, my son was born prematurely, at just 32 weeks, and my husband underwent back surgery. In support of me, he suggested that I leave my son behind with him so I could continue my education, but as a mother I couldn’t do this, even in pursuit of the dream of becoming a physician. I turned down Berkeley (I wish I had deferred admission, but didn’t understand how that worked), and took care of my premature baby and my husband.

Fortunately, Salinas has an excellent community college, Hartnell College, which I attended before transferring to UC Santa Cruz, where I earned a biology degree.

I have lasting regret that I never became a doctor. I was pre-med and, after graduation, I attended a post-baccalaureate program at UC Davis that was supposed to guarantee med school admission to all 24 students in the program. But it didn’t happen. I recommend UC Davis to people, but, unfortunately, while at the post-bacc program, I was aggressively discouraged from applying to medical schools, and even told by one official that I would be insulting medical schools to think I would get in with my MCAT scores. I was heartbroken, stopped the application process, and didn’t even open the envelopes I received from med schools. Years later, when I did open those envelopes, I discovered that the medical schools at USC and UCLA wanted me. It still brings tears to my eyes when I think about it, and it taught me a lesson that I share with students today: don’t let anyone tell you you’re not good enough, don’t be discouraged, apply and pursue your dreams.

My own dream was shattered, but I did return home to serve families like my own, as a physician’s assistant. My family’s own doctor said I could do much of the work a physician does with more flexible hours to raise a family. I now have three children, the youngest of whom is six. (That premature baby is now a strong and healthy Santa Cruz police officer). I worked at the local federally-funded community clinic for over a decade, about 10 miles away from Gonzales, where I live.

The problem in small towns like this is that it is difficult to attract physicians, physician assistants, and other medical professionals. It’s even harder to get them to stay; most leave after a few months. To have reliable providers and continuity of care, we need physicians and physician assistants who have roots in the community and the drive to serve the people here.

At the clinic, I saw many patients who came from Gonzales to my clinic, so, since I live there, I started a project to open up a family practice clinic in Gonzales to provide affordable medical care and ultrasound services. I approached a local doctor, Ignacio Guzman, who grew up in Gonzales in an immigrant family, and shared my vision of providing medical care in our agricultural community at an affordable price. We have started with one examination room and a small waiting room, and we offer affordable ultrasound and lab services inside the pharmacy.

We organize everything here to the benefit of those patients who are hardest to serve. We stay open until 6 p.m., and we don’t take a lunch break until 2—so that we can see people during their own lunch. Our small clinic is open to everyone who needs and seeks medical care, including the uninsured and those on almost any kind of insurance, including Medicare, Medi-Cal, and Central Coast Alliance, a regional nonprofit health plan. (In addition, I helped open and staff a local federally-funded clinic that was about to lose their funding because they couldn’t find a local provider.)

We also advocate for our patients. We don’t offer immunizations yet: We’d like to, but need funding for the refrigerator required for vaccine storage. In the meantime, families seeking vaccines have to drive to Salinas, which is 20 to 30 minutes away, depending on traffic, or take a bus, or pay $50 for a ride to the local public health department.

I also advocate for local students to become medical professionals. I’ve been disappointed that universities like California State University Monterey Bay don’t accept more local students into their physician assistant programs. This contributes to the shortage of medical professionals in the area, and adds to the challenges of providing accessible care and continuity of care, with long-term relationships between the providers and patients. We also need ultrasound technicians and well-qualified medical assistants.

With financial assistance from the city of Gonzales, we were able to purchase the ultrasound machine that now sits inside the Gonzales pharmacy. Our services are open for patients from other medical facilities and open to doctors from other medical practices. We prefer to provide ultrasound in the pharmacy because, in Mexico, people are used to seeing doctors and getting whatever else they might need at the pharmacy. (The local pharmacist, Jimmy Eitoku, shares the vision of making medical services as affordable and accessible as possible).

Before we offered ultrasound services, it was difficult for patients in the south part of Monterey County to access medical imaging at affordable prices. (The cheapest was an hour north, in Gilroy). Because we’re not in a hospital with all that overhead, our ultrasounds are cheaper. While they charge $1,600 in King City for a pelvic ultrasound, here in Gonzales we charge $400. We offer testicular ultrasounds at $180 and abdominal ultrasounds at $225.

But staffing the ultrasound site, and our clinic, has been an issue. We are hurting for local medical staff that are bilingual and invested in the community. We need certified sonographers who are trained in vascular ultrasounds, carotid ultrasounds, and ultrasounds of other body parts.

In other words, we need more people who dream of building a new health system, starting in this small agricultural community.

The post We Put the Ultrasound Machine in the Local Pharmacy appeared first on Zócalo Public Square.

I’ve devoted my life and career to trying to create an integration of American and traditional Chinese medical approaches, with the goal of making people all over the world healthier.

Coming from my native Hong Kong to the United States has been crucial to my ability to do this work.

The strong presence of immigrants in medicine is inspiring a reevaluation of medicine and the development of new ideas. Immigration, after all, is a risk, and we need to see more risk-taking to make health care safer, more effective, more affordable, and more accessible.

I see my own journey as a miracle. I arrived at UCLA in late 1968 to study chemistry, with the goal of introducing the Western world to a new drug derived from the Chinese herbal pharmacopoeia. The 2015 Nobel laureate Tu Youyou achieved this in her discovery of artemisinin, the anti-malarial drug derived from a Chinese herb used for fever and chills.

Instead, I decided to dream bigger than just the discovery of new drugs and pursue the vision of establishing an integrative health model of East-West medicine, with an emphasis on health promotion, disease prevention, treatment, and rehabilitation. My method of integrative medicine, established through the UCLA Center for East-West Medicine, which I founded more than 25 years ago, is not like an international buffet, where a provider picks randomly from a disjointed assortment of therapies, such as adding acupuncture or massage to a drug therapy. Instead, it is like a carefully curated dinner menu, with the most appropriate therapies working together to address the specific needs of each patient.

We combine Western biomedicine’s strengths in disease detection, acute condition management, and vital system stabilization with Traditional Chinese Medicine’s concept of balance and emphasis on the body’s innate ability to heal. This approach has been embraced—by hundreds of Western-trained doctors who refer their patients to us, by the thousands of students who have joined our educational programs, and ultimately by medical journals and institutions with which I have worked, from the U.S. Food and Drug Administration and the National Institutes of Health to the World Health Organization.

Coming to the U.S. was a challenge, but pursuing this approach was even a bigger gamble. In my early decades as a doctor, Chinese medicine was seen as quackery, but my mentor, Dr. Sherman Mellinkoff, who was dean of UCLA’s School of Medicine, encouraged me and believed in me as I dug more deeply into the subject and applied the knowledge I learned. I also faced skepticism about the possibility of integrating Traditional Chinese Medicine with Western biomedicine. And I’ve had to reassure the people who work with me as they took career risks to build this field.

My late wife, Shirley Hui, who married me when I was in medical school because of my aspirations to change our system of health, allowed me to devote my full energy to realizing this dream, including using our own money to launch the Center before philanthropic support became available. (I also relied on gifts from friends and patients; our first folding massage table at the Center was donated by a patient). I believe that stress related to this early work contributed to her developing metastatic breast carcinoma that took her away from me, but integrative medicine kept her going for 11-and-a-half years to enjoy our five beautiful grandchildren.

One irony is that, to get to China and understand its traditional medicine, I had to leave Hong Kong for the U.S. Since arriving here, I’ve been able to travel to China, where the government has provided Western-trained medical doctors in China with education in traditional medicine and encouraged Chinese medicine practitioners to pursue Western medical training. China deserves more consideration as a medical model—since it has been able to care for 22% of the world’s population with only 1% of the world’s health care budget.

Traditional Chinese Medicine embraces many approaches to forms of prevention. By teaching moderation, body-mind balance, and lifestyle modification it is, in effect, promoting health and wellness. As such, the Traditional Chinese Medicine approach complements the crisis intervention model of biomedicine familiar to Americans.

In my career, I’ve seen an increasing interest in this integration of medicines—including the development of new drugs and approaches to the epidemic of diabetes, the emphasis on considering the natural and social environment of patients, a greater interest in balance and the flow of energy (as opposed to the Western focus on drugs), and the ways we reckon with aging.

This integration is not merely a response to the failures of American medicine, which is not only the world’s most expensive but also engenders high rates of medical errors and produces inadequate beneficial outcomes. Instead, this integration represents a movement to a truly global system of medicine that integrates different healing traditions from around the world.

To draw upon these different traditions, I feel it is crucial to combine rigorous research with treatment. In 1995, we launched our education programs, which seek to learn from each patient we treat, while generating questions for our research. Our goal is that what we learn from each patient will enhance the quality of care of subsequent patients. This generates an educational ripple effect: the physicians and nurses we train become change agents in the transformation of our health care system.

Our progress has been accelerated by greater evidence of efficacy, safety, and cost effectiveness, including studies that that show that acupuncture and body-mind approaches (like meditation or yoga) reduce pain and mood disorders.

We often see patients who have been unable to solve their problems with state-of-the-art Western medicine. First, we assess the diagnostic work-up and treatment they’ve had so far. Then, we do a more complete history of their health, looking at psychosocial, nutritional, and lifestyle factors, and do a conventional physical exam supplemented with a Traditional Chinese Medicine diagnosis that looks at acupoints and the tongue. Treatment might include anything from changes in nutrition or medication to the use of acupressure or tai chi exercises.

Here’s what this looked like for a 72-year-old who came to us with left hip and lower back pain. Medicare had spent $34,000 over 18 months administering six epidural steroid injections, doing several neuroimaging studies, and implanting spinal catheters for morphine infusions four times. At our center, she had seven treatments over three months, which included acupressure massage and education in self-massage and exercise. She experienced complete relief of her pain; Medicare paid $600 for the all of this. (This was the difference in cost in 1999. Now the gap is even greater.)

Such an integration is not radical. Indeed, our center merely matches the broader definitions of health that are starting to take hold around the world. The World Health Organization’s current definition of health is “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Desire for change is strong in many other countries. And we are developing several collaborative projects abroad.

Locally, we collaborate with the Los Angeles County health system to share what we learn in online courses to help health professionals. We also share our knowledge with the Tzu Chi Foundation, an international humanitarian and non-governmental organization that provides medical services in El Salvador, Sri Lanka, Haiti, and Honduras and operates free and mobile clinics, a large bone marrow bank, and hospitals in Taiwan.

I believe that the full potential of this integrated model has not been seen yet, because we are still limited by inadequate financing for its development. But systematic change is possible—I know this as a researcher, educator, clinician, and immigrant. In the future, health care should be people-centered and community-centered, and should solve problems at their roots—whether those roots are biomedical, or psychosocial, ecological, and spiritual.

The post Defining Health as a ‘State of Complete Physical, Mental, and Social Well-Being’ appeared first on Zócalo Public Square.

Some answers to that question lie in the story of a San Francisco campaign against hepatitis B.

Americans of Asian heritage have by far the highest rates of chronic hepatitis B virus infection; while less than 1% of the total U.S. population has “hep B,” one in ten Asian Americans are infected. And San Francisco, with a large population of residents of Asian heritage, has the highest rate of liver cancer in the country, reflecting in part high levels of undetected chronic hepatitis B infection.

More than a decade ago, activists and community members in San Francisco launched a major media campaign that portrayed people of Asian heritage as heroes for getting tested, screened, and vaccinated. It was the very first time that I had seen Asian Americans who looked like me in a mainstream ad.

By engaging Asian Americans as messengers to the community, including hard-to-reach immigrants, to change perceptions of the infection, the campaign offers broader lessons for how to address other hard-to-discuss public health issues.

The campaign started in 2007, with AsianWeek Foundation organizing diverse Asian Americans and immigrants to focus on ending hep B disease. Ted Fang, then AsianWeek’s executive director, brought together health leaders, including Samuel So, MD, of the Asian Liver Center at Stanford University, and Janet Zola (then with the San Francisco City and County Department of Public Health), to form a coalition called San Francisco Hep B Free (SFHBF). Mitch Katz at the San Francisco Department of Public Health put his full support behind the effort.

This coalition also included immigrants and leaders in Asian American organizations, as well as in the media, government, community, and business sectors. The campaign’s goals were to move Asian Americans to get screened and to convince public and health care providers to test and vaccinate Asian Americans for hep B.

This coalition set out to develop communication strategies that would break the silence about hepatitis B and normalize discussion of it. Without funds to start, organizers began by soliciting strong public statements of support from then-Mayor Gavin Newsom, who proclaimed the goal of making San Francisco free of hepatitis B.

San Francisco Supervisor Fiona Ma, then the only Asian American on the board of supervisors, wrote and led the passage of legislation calling for testing and vaccinating all Asian Americans in San Francisco, and also talked publicly for the first time about her own chronic HBV infection.
Having broken the ice through effective communication, the coalition soon got funding for bus signs and billboards introducing the campaign. In 2007, bus ads featuring Newsom encouraged testing for hepatitis B.

In 2008, an ad campaign called “B a Hero” featured Asian Americans with drawings of capes and Superman costumes superimposed on their everyday clothing, with a “B” appearing in place of the Superman “S.” The concept: getting tested for HBV and talking to friends and family about being tested would make anyone a hero. This upbeat approach, designed by a team of Asian Americans, proved very effective.

Courtesy of Grace Yoo.

The 2010 ad strategy was tougher because it focused, in a very personal way, on the statistical likelihood of developing cancer by having an undetected infection. Featuring local volunteers of various Asian ethnicities and backgrounds as beauty pageant contestants, one ad noted that one in 10 Asian Americans were infected with hep B, the leading cause of liver cancer, and posed the question, “Which One Deserves to Die?” A second ad asked the same question over a tableau of an inter-generational Asian family gathering for a photo.

Courtesy of Grace Yoo.

As a medical sociologist, I researched the roles of Asian Americans, their leaders, and celebrities in this San Francisco effort—the first study of such health promotion campaigns. I was particularly interested in how “narrative communication”—official stories, invented stories, and personal stories—can educate the public about a particular health issue. Such narratives had shown results in the Witness Project, a program in which local African-American breast and cervical cancer survivors talk about, or “witness,” their cancer experiences.

What I learned from San Francisco’s campaign was that breaking the silence and using personal narratives from respected Asian-American leaders helped destigmatize hep B. While the disease had previously been associated with “bad people” or “bad behavior,” the campaign repositioned it as something that the community could act to confront, in the service of greater health for all. In many Asian countries where hep B is common, infected patients are acculturated to feel ashamed or fearful, and consequently hide their disease. A common perception in Asia is that those infected somehow deserve it.

The San Francisco campaign successfully reframed this discourse among Asian immigrants and Asian Americans by providing factual information on transmission, emphasizing medical solutions, and creating positive emotions and feelings of empowerment. In effect, as then-San Francisco Board of Supervisors President David Chiu told me in an interview for my study, what the study did was to bring hep B “out of the closet.”

Destigmatization is a first step, but it is also a process that needs to be continually reiterated. Jason Liu, an activist who was a premedical student at the time, told me that even when he told Asian Americans that their primary mode of hepatitis B infection was from fluids transferred during the birthing process, the stigma is still difficult to eradicate given that hepatitis B can be transmitted sexually or through drug use.

One of the most important strategies to counter the persistent stigma was to have well-known and respected Asian Americans speaking out. Personal disclosures by Supervisor Ma and Alan Wang, then a news anchor at the local ABC affiliate, were particularly helpful. In an on-air piece, Wang, who said he was inspired by Ma’s disclosure, described the discovery of his own infection status and his ongoing monitoring and treatment to prevent liver cancer. He has proven to be a key resource and voice for the campaign by talking about his hepatitis B infection openly.

Jeanette Tam, who worked for a health plan focused on Chinese Americans at the time, told me that the campaign had broken a barrier. “This is not something that Chinese people and Chinese families discuss: weaknesses. And so with Fiona Ma coming out and talking about that, it was an eye opener to me.” That a public figure would risk her public image by coming forward impressed Tam enough to encourage her to speak up as well. Tam said, “And even if you choose to tell someone to get prevention, get tested, and get vaccinated, that’s good. And if it goes as far as, ‘You know what? I’m going through it too,’ it puts a human face on it so that people don’t have to feel secretive.”

Focusing on the upbeat message that this problem could be solved encouraged greater involvement by members of the community—especially since up to two-thirds of infected Asian Americans who are infected are unaware of their disease and the potential for liver cancer. SFHBF’s “B a Hero” campaign was built around the idea that addressing hepatitis B is a heroic cause and that “we,” everyday people, can make a difference.

Another successful strategy involved shifting the paradigm of the disease away from the impression that it is a death sentence by refocusing attention onto solutions such as vaccination and treatment. Thus, the taboo against discussing “bad news,” especially news related to death, was subverted by the message that by working together the community can prevent hepatitis B disease and liver cancer. Community activist Mary Jung said this gave participants a positive outlook: “Isn’t it nice to work on something that’s preventive? … Instead of always raising money for research like for cancer, or something like that.”

Many respondents to my surveys cautioned that it has been easier to destigmatize hep B among Asian Americans born or raised in the U.S., compared to those who are first-generation adult immigrants. But it appears that the San Francisco campaign, by having U.S.-born Asian Americans as leading figures, was able to communicate across the generations to these adult immigrants. And in establishing this precedent the campaign also broke new ground.

Even though this landmark campaign occurred over a decade ago, its lessons continue to resonate. The San Francisco campaign was culturally appropriate. It ran the first major U.S. market ad campaign featuring all Asian American models. Ethnic and general media campaigns were closely coordinated in five languages, but primarily in English and primarily through general market outlets. In addition to getting the cultural aspects right, the campaign used the right messengers and offered the right sorts of messages.

All told, the San Francisco campaign provided a model for communicating and organizing around health issues in the Asian American community—or in any community suffering from a stigmatized illness or condition.

The post To Stop a Deadly Cancer, Turn Everyone Into a ‘Hero’ appeared first on Zócalo Public Square.

I’m the state dental director in the California Department of Public Health. Our team collaborated with the California Department of Health Care Services and a number of partner organizations to create a roadmap for improving oral health in the state through the year 2028. Improving oral health requires not only enhancing dental care but also promoting healthy habits that help prevent tooth decay, gum infections and cancer—such as tooth brushing with a fluoride toothpaste, eating a healthy diet, and avoiding tobacco and sugary substances.

While studying dentistry in India I saw many patients suffering from oral cancer. In India, oral cancer is a common cancer because many people chew tobacco products. Unfortunately, most of these cancers were detected in late stages; people hadn’t sought care early because it wasn’t painful. When the cancer is already late-stage, treatment is not likely to be successful.

I wanted to find a way to prevent and detect these cancers in early stages, so I started thinking about studying public health. I chose to go to the Johns Hopkins School of Public Health because the United States had an impressive record of improving oral health through public policy.

Interestingly, America had developed a strong public health intervention for addressing tooth decay. In 1941, when the military was recruiting young men for the armed forces in the U.S., dental problems were the number one reason for rejecting young men entering the armed forces during World War II. This and other such reports about dental diseases led President Harry Truman to sign a law that created the National Institute for Dental Research for addressing dental diseases. As a result of the research conducted in several communities, the U.S. Public Health Service decided to support a national effort to add fluoride to the drinking water as a form of mass protection against tooth decay. This intervention does not require conscious effort on the part of individuals to get the benefit of fluoride.

In the 1960s, New York State started to take this public health approach to address tooth decay. While studying public health at Johns Hopkins, I came to learn about their impressive record, which led me to pursue a dental public health residency training program in the New York State Department of Public Health.

As it happened, I started my career in public health just as the AIDS epidemic started. At that time, no one knew that AIDS was caused by the HIV virus, but dentists were seeing people who had unusual ulcers and tumors called Kaposi sarcoma in the mouth. Dentists were really perplexed to see this outbreak among their patients, and they didn’t know how to manage or treat this condition.

I was part of the New York state health department’s team studying this problem and addressing the transmission of the disease. The department ultimately recommended that all dentists should wear gloves, masks, and eyewear for treating patients. Beforehand, dentists were not wearing gloves while treating patients. A guideline was issued initially, and then it became a requirement through regulation. Now, you’ll never go to a dentist’s office and find them not wearing gloves, masks, and eyewear.

I was able to see the impact of this policy, which within a short period of time made all dental offices improve their infection control practice—not only for HIV and AIDS, but also for other diseases like hepatitis B. The policy really transformed the way infection control is practiced in dentistry and dramatically reduced the transmission of infection in dental settings.

That experience exposed me to the power of making big, system-wide changes in dental care. System-level interventions, like the infection control practice, and environmental changes such as adding fluoride to drinking water, have impressed me the most.

After that, I was involved in an effort to work on public health approaches for high risk groups, including pregnant women who had difficulty obtaining dental care during their pregnancies. When I was in dental school, we were told it was too risky to provide dental care during pregnancy. In 2000, while I was at the New York State Department of Health, a physician wrote a letter describing the terrible experience of a pregnant woman who didn’t get dental care in a timely manner. This woman took pain killers and had to be airlifted to treatment for liver toxicity and lost her baby. This, and other such reports, prompted us to assess the problems encountered by women seeking dental treatment during pregnancy and identify solutions. We convened an expert panel and discovered that contrary to the prevailing belief, it was safe to treat women who were pregnant. I led the efforts to develop guidelines for oral health care during pregnancy that are now adopted in many states.

I held multiple positions in New York State, including the position of state dental director, before coming to California in 2015. We published a report in 2017 that found that national reviews consistently ranked California in the lowest quartile of states with respect to children’s oral health. Tooth decay is a childhood condition more prevalent than asthma or hay fever. It is reported that children in this state miss approximately 874,000 days of school a year because of dental problems. Additionally, there are disparities within the state—some populations experience more oral diseases than others, some places have lacked fluoridated water, others have shortages of dental professionals, and some racial/ethnic groups are more likely to die of oral cancers that can be treated if detected earlier.

Interestingly, when it comes to the oral health of adults overall, California is ranked closer to number one. We don’t know exactly why this is, but we have a hypothesis. One of the indicators of oral health is whether people over 65 have lost all their teeth. If you look at all the states in the U.S. with higher rates of tobacco use—by that I mean West Virginia, Kentucky, Tennessee, Alabama—they have higher prevalence of tooth loss. When you look at states like California, Utah, Connecticut, New York, where the prevalence of smoking is very low, the tooth loss rate is lower. That tells us that it’s at least as important to address habits and lifestyle as to address dental care itself.

In 2015, when we started planning a roadmap for improving oral health in California, we wanted to tap into the potential of communities to transform themselves. The California Oral Health Plan 2018-2028 offers a structure for collective action by partners and stakeholders to assess and monitor disparities in oral health and the oral health status of children and adults, prevent oral diseases, and increase access to dental services, not only in traditional settings, but also in places where it can really make a difference, like schools—while also promoting best practices and advancing evidence-based care. These actions will promote healthy behaviors, including preventive care, and reduce oral diseases.

In the last four or five years, many parts of the state have come together to address oral diseases and promote policies and programs. For example, there’s a requirement called Kindergarten Oral Health Assessment. All children entering school should have an oral health assessment so they are healthy and without pain when they attend school. This will reduce school absenteeism and help children learn and perform better. Also, we are promoting dental programs in schools—either linking children to dental care providers by screening and identifying a source of dental care for those who need it, or providing preventive services directly in schools and, in some cases, even offering treatment services in schools.

At the same time, other initiatives have been implemented. The California Department of Health Care Services has launched an awareness campaign called “Smile, California” about dental services available through the Medi-Cal dental program. There is a new initiative, called the Dental Transformation Initiative, that aims to get more children into preventive services and dental treatment. Also, Covered California has increased dental insurance coverage for children and families.

This is an exciting time for all Californians to engage in this transformational effort to improve oral health, and I am fortunate to be part of this effort.

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