International: Last year the Institute of Medicine (IOM) released its report The U.S. Commitment to Global Health. AGlobal health is the goal of improving health for all nations by promoting wellness and eliminating avoidable disease, disability, and death. It can be attained by combining population-based health promotion and disease prevention measures with individual-level clinical care. This ambitious endeavor calls for an understanding of health determinants, practices, and solutions, as well as basic and applied research on risk factors, disease, and disability.... The U.S. government, along with U.S.-based foundations, nongovernmental organizations, universities, and commercial entities, can take immediate concrete action to accelerate progress on the urgent task of improving health globally by working with partners around the world to scale up existing interventions, generate and share knowledge, build human and institutional capacity, increase and fulfill financial commitments, and establish respectful partnerships. U.S. leadership in global health reflects many motives: the national interest of protecting U.S. residents from threats to their health; the humanitarian obligation to enable healthy individuals, families, and communities everywhere to live more productive and fulfilling lives; and the broader mission of U.S. foreign policy to reduce poverty, build stronger economics, promote peace, increase national security, and strengthen the image of the United States in the world.@ As has often been said: AWhen you=re up to your neck in alligators, it=s hard to focus on draining the swamp.@ However, as we evolve into the 21st century and President Obama=s vision for implementing his landmark Patient Protection and Affordable Care Act (PPACA) takes hold, psychology (and the other health professions) must accept their societal responsibility for providing visionary leadership in addressing our nation=s and world=s most pressing needs. This is especially true for our professional schools. The alternative is to become obsolete, if not irrelevant. Protecting the status quo is not a viable option.
The IOM emphasized that health is inextricably connected to the broader goals of hastening development and reducing poverty. Significant progress has been made in the last 50 years with life expectancy increasing more than in the preceding 5,000 years. The creation, dissemination, and adoption of knowledge has been one of the main drivers of these health gains, delivering marked improvements in low- and middle-income countries that have invested in sustainable and equitable systems to deliver proven, cost-effective interventions. Our nation has an unprecedented opportunity to improve global health. The promise of potential solutions has captured the interest of a new generation of philanthropists, students, scientists, healthcare professionals, private sector leaders, and citizens B all eager to make a difference in this interconnected world.
The IOM identified five areas for action: * Scale up existing interventions to achieve significant health gains; * Generate and share knowledge to address health problems endemic to the global poor; * Invest in people, institutions, and capacity building with global partners; * Increase U.S. financial commitments to global health; and, * Set the example of engaging in respectful partnerships. The global health community has reached a critical juncture. The knowledge, innovative technologies, and proven tools to help millions of people in need are within reach. Yet even with demonstrated success in tackling certain health issues, a wide gap remains between what can be done with existing knowledge, and what is actually being done. Existing interventions are not widely used even though many are inexpensive and easy to administer. As the advocates for PPACA constantly pointed out, even within our own modern day health care delivery system, the lag between the discovery of more efficacious forms of treatment and their incorporation into routine patient care is unnecessarily long, in the range of about 15 to 20 years. The timeless health problems associated with poverty are now coupled with new challenges. Infectious diseases are emerging at the historically unprecedented rate of one per year. With airlines carrying more than 2 billion passengers annually, and systems of trade more interconnected than in any time in human history, the opportunities for the rapid international spread of infectious agents and their vectors have vastly increased. The rising tide of chronic diseases and injuries in low- and middle-income countries, where 80 percent of the world=s deaths from chronic, non-infectious diseases now occur, cannot be ignored.
One of the greatest contributions we can offer to the global campaign to improve health is to share America=s traditional strength B the creation of knowledge B for the benefit of the global poor. Not surprisingly, Americans traditionally focus upon conditions that affect people within our own borders and as a result, we often ignore or significantly neglect diseases or conditions that are overwhelmingly or exclusively incident in low- and middle-income countries. For example, globally more than 2 billion people are at risk of malaria each year. Despite dramatic reductions in malaria incidence and mortality in many parts of the world, approximately 500 million people still contract the disease, resulting in 1 million deaths annually. The IOM expressly noted that global health would greatly benefit from developing and disseminating a variety of novel behavioral and biomedical prevention strategies to combat infectious diseases. Focusing upon two disease entities for which the behavioral sciences clearly have particular expertise: Obesity is escalating worldwide at an alarming pace, along with rates of type 2 diabetes, hypertension, and lipid abnormalities associated with obesity. More than 1 billion adults are overweight; 300 million are clinically obese. Mental disorders affect millions worldwide; about 14 percent of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders, alcohol-use and substance-use disorders and psychosis.
Margy Heldring=s vision of establishing a senior-scientist/practitioner U.S. Public Health Service Corps is most timely. As she points out, many of our colleagues are entering the twilight years of their careers. They want to make a difference and are not yet ready to fully retire. How can their considerable expertise be effectively utilized? The vision expressed by President Lyndon Johnson at the University of Michigan comes to mind: AThe challenge of the next half century is whether we have the wisdom to use that wealth to enrich and elevate our national life, and to advance the quality of our American civilization.... This is the place where the Peace Corps was started.... Will you join in the battle to build the Great Society, to prove that our material progress is only the foundation on which we will build a richer life of mind and spirit? There are those timid souls who say this battle cannot be won; that we are condemned to a soulless wealth. I do not agree. We have the power to shape the civilization that we want.... Those who came to this land sought to build more than just a new country. They sought a new world.@ The following year Medicare became the law of the land.
Unlike the United States, in low- and middle-income countries, universities, science academics, and the research community are often absent from public policy engagement. Our government, which is the largest funder of many international organizations and a significant donor of bilateral aid, carries considerable influence in shaping the global health environment and thus possesses the opportunity to be a good steward for health at both the national and global levels. AHealth is a highly valued, visible, and concrete investment that has the power to both save lives and enhance the image of the United States in the eyes of the world.... Working with partners around the world and building on previous commitments, the United Stateshas the responsibility and chance to save and improve the lives of millions; this is an opportunity that the [IOM] committee hopes the United States will seize.@
Integrated/Co-located Care: Retired Rear Admiral Chris Bruzek-Kohler recently shared her vision for the health care environment of the 21st century. AOne place to look to as an encouraging story of health care delivery transformation and a way forward for civilian mental health professionals is the Navy. Navy Medicine has successfully implemented two programs providing mental health care in non-traditional settings: on the battlefield with Marines and in primary care practice. A primary component of the Navy=s promotion of a >Culture of Fitness= is mental health. Recognizing their responsibility to effectively prevent, identify, and treat all psychological health conditions and the ill effects of war, Navy Medicine mental health stationed with the Marines developed Operational Stress Control and Readiness (OSCAR) Teams, which embed psychologists, psychiatrists, psychiatric nurse practitioners and psychiatric technicians as organic assets in operational units. The goal of the OSCAR teams is to be as far forward and to spend as much time as possible with the Marines to build the trust, cohesion, and understanding necessary to break the stigma of mental health care with military patients.
AThe concept of OSCAR is to demystify the whole process of psychiatric treatment. The Marines often call the mental health provider >the wizard.= The origins of this term were not only because the mental health provider could >make people disappear,= i.e., suddenly remove them from their units without warning, but it also provoked the image of the mysterious Wizard of Oz pulling the smoke levers behind the mirror. This is not the case with OSCAR. The mental health provider interacts with the Marines in the normal routine of the day. In this way the mental health provider becomes a real person that the Marines can trust and get to know. Being a full member of the Marine Corps unit, the Marines are more likely to ask questions about minor issues without the stigma of being seen as patients and before the>minor= issue becomes something major. The OSCAR provider is also highly effective when they are a trusted advisor to mid-level leaders who can gain perspective from the provider, thereby helping them to become better leaders. There is a heightened sense of trust and awareness on both sides and a profound improvement in communication among the warfighters, their leaders, and medical.
AThe power of having providers embedded is unmistakable. Retired Navy Medical Corps Officer, Captain William P. Nash: >OSCAR builds a bridge across the cultural gap between the warfighter and the mental health professional the only way a bridge can be built B by drawing the mental health professional as fully as possible into the culture and life of the military unit to be supported.= OSCAR=s success is evident in the enthusiasm surrounding the program in the Marine Corps and the desire of military commanders outside of the regimental level to expand it to air wings, logistics groups, and reserve forces for the benefit of their service members.
ANavy Medicine is also utilizing mental health professionals in innovative ways on the home front. To improve quality and access to care, Navy Medicine has created integrated Medical Home Teams within its Internal Medicine and Primary Care clinics to provide personalized, coordinated, and proactive care to patients. The Medical Home initiative is unique because it is an integrated care model where primary care services and behavioral health assets are together in the same clinic space. The embedded behavioral health consultant provides health assessment and intervention expertise to primary care managers and their patients. Clinical Psychologists are ideally suited for the Navy=s Medical Home Team model.
AA report from a 2007 DoD Task Force on Mental Health suggested that the integration of mental health providers within the Medical Home would improve access and decrease stigma by maximizing the number of interventions that can be conducted in a primary care setting. Research supports the Task Force=s assertion and provides evidence of significant improvement in clinical outcomes and reduced psychological stress among service members served by behavioral health providers in primary care settings. The Medical Home Model with integrated behavioral health specialists was first implemented at National Naval Medical Center (NNMC) in Bethesda, Maryland in2008, followed by Naval Medical Center inSan Diego and Naval Hospital Pensacola. Building on early successes, the Navy will roll out the Medical Home Model at all remaining treatment sites this summer.@
Innovative Practices: One of the more visionary provisions contained in the President=s Health Care Reform legislation (PPACA) authorized demonstration programs to train or employ alternative dental health providers in order to increase access to dental health care services in rural and other underserved communities. This Fall the W. K. Kellogg Foundation released its report on the Alaska Dental Therapists program, which was strongly opposed by organized dentistry essentially proffering that these providers would be Apublic health hazards,@affirmatively harming their patients if allowed to practice. The Kellogg Foundation found that: Adental therapists practicing in Alaskaprovide safe, competent and appropriate dental care. The two-year, intensive evaluation is the first independent evaluation of its scale to assess care provided by dental therapists practicing in the United States. It confirms for us what numerous prior studies of dental therapists practicing in other countries have already shown: that dental therapists provide safe care for underserved populations.@
Dental therapists have been providing preventive and basic dental care to children and families in remote Alaska Native villages since 2006. Although new to the U.S., dental therapy has been well-established for decades in more than 50 countries, including those with advanced dental care systems similar to ours. The evaluation assessed the work of dental therapists in five communities, as well as the experience of hundreds of patients. They were directly observed performing sealant placement, composite and amalgam preparations, stainless steel crown placement, and oral health instruction. The evaluation relied on examination standards used for assessing clinical competency for board certification of U.S. dental school graduates. Alaskan dental therapists are technically competent to perform the procedures within their scope of work and do so safely and appropriately. After graduating and completing a 400-hour externship under the direct supervision of a dentist, dental therapists are certified to provide a limited scope of dental services under the general supervision of a dentist. They successfully treat cavities and help to relieve pain for people who often had to wait months or travel hours to seek treatment; patient satisfaction with their care is very high; and, they are will-accepted in tribal villages. The report further noted that severe shortages of dentists disproportionately affect low-income communities and communities of color; that lack of affordable dental care is putting sorely needed dental services out of reach for nearly 50 million Americans, particularly those in rural and underserved areas. Hawaii=s federally qualified community health centers have been particularly supportive of this (r)evolution as access to dental care and/or behavioral health care has continued to be their top priorities over the past decade. The dental therapists are well respected in their communities. Because many dental therapists return to practice in their home communities, they typically have the cultural skills and language fluency needed to educate and motivate people towards behavioral change. As role models they serve as important oral health advocates. ASimply training more dentists will not solve this problem. TheAlaska model is a community-driven solution that can work in communities across the country.@ Aloha,
Pat DeLeon, former APA President BDivision 29 B November, 2010
