American Medicine Through the Looking Glass

What Alice would see on American Samoa:

After the September 29th, 2009 tsunami hit American Samoa, I took a leave of absence from my job as a policy adviser in the California Senate to offer medical relief to the tiny Pacific island. But nothing I did in the Legislature prepared me for what I found in Pago Pago.

I've had a few "Alice Through the Looking Glass" moments working as a surgeon in American Samoa for the past month. 

Lewis Carroll's 1871 follow-up novel to "Alice in Wonderland" describes a world that is the mirror image of the known world. Time runs backwards. Books can be read only when held up to a reflective glass. Alice is offered advancement if she plays well as a pawn in a chess game. She becomes a queen by capturing the Red Queen.

When I left Sacramento, there was an argument raging in the Capitol -- and in states across the nation -- about the drastic funding cuts to health care programs necessitated by overdrawn state bank accounts and declining revenues.

I listened to enraged lobbyists from around my state lecture me on the evils of cutting "our critical health care safety net." Without instant restoration of this funding from unspecified sources, people would die.

One of the programs aggressively defended was Healthy Families, a form of Medicaid for Californians who have too much money to qualify for Medicaid.

"It's for the children," I was asked to convey to my boss, Senator Sam Aanestad, who is also an oral surgeon in rural northern California.

I thought that critical services for children include things like visits to pediatricians, asthma medications, and hospital stays. It surprised me to learn that the "critical" unmet health needs of children covered by Healthy Families also included inpatient drug rehabilitation, acupuncture, biofeedback, and elective abortion. 

The desperate need for funding to cover these services was used to justify $97 million in new taxes that would be passed on to Californians who bought their own health insurance.

Fast forward to the LBJ Tropical Medical Center in American Samoa, one month later.

One of my patients, a cheerful gentleman in his early 60s with a very sick gallbladder, needed to stay on the ventilator the night after his three-hour operation. To check the position of his breathing tube, I requested a portable chest x-ray in the Intensive Care Unit where he was taken after surgery.

Thirty minutes later, after spending time with my patient's worried family, I walked into the ICU to check the x-ray.

"I'm sorry, Dr. Halderman," the nurse caring for the man informed me. "The portable x-ray machine broke this afternoon. We cannot do any portable films. Maybe it will be fixed tomorrow. Sometimes they have to order a part. It may take time to get it." [Note: there are only two flights per week from the U.S. into American Samoa.]

Enter Alice's mirror world. A portable x-ray machine is among the most basic pieces of equipment in modern medicine. Transporting a critically ill, ventilated patient to the Radiology Department for a non-portable x-ray is risky. The breathing tube can dislodge, intravenous lines can be pulled out accidentally, and the resources for resuscitating a patient who "crashes" in the x-ray suite are limited.

I remember having the same "this can't be real" thought this morning when I noticed that the magnesium blood level I ordered wasn't reported by the lab. The lab had run out of the chemical reagent that allows magnesium levels to be tested.

Magnesium is a critical co-factor in over 300 processes in the human body.  Both a deficiency and an overdose can be lethal. 

I could only guess at my sick patient's magnesium needs.  The reagent might be shipped next week.

It was in a conversation with the Chief of Surgery here that I learned what it was like to work every day in a place where "critical" health care needs were defined very differently from in the California Capitol.

"You know all those women we sent to you to diagnose breast cancer?" he asked. Dr. Kamlesh Kumar, a talented surgeon, referred to five women I'd seen in the last three weeks. All were under age 50. Two were in their 30s. 

I was pleased to offer minimally invasive biopsies just like I did when I served a rural central California community for five years. I wanted to raise the standard of care for American Samoan women with breast disease.

All of the biopsies revealed invasive breast carcinoma. With no chemotherapy or radiation treatments or equipment to stage the cancer, I knew I would be arranging for their cancer treatment off the island.

"I don't know what we'll tell them when they come back for the diagnosis," Dr. Kumar said to me. "This year, the off-island referral program wasn't funded."

80% of the island's population lives below 200% of the Federal Poverty Level. Poverty here does not mean cell phones and cable TV but no health insurance. It is subsistence. 

There is no economic base to create jobs. One of the only major employers on American Samoa, a tuna cannery, closed on October 1st of this year. It could not compete with companies that used non-U.S. cheap labor. 

These U.S. Nationals, who enlist in the United States military at a per capita rate higher than any other state or territory, have said little to me about the conditions they face. No one complains when told that essential equipment and testing will be unavailable indefinitely.

"It's American Samoa, that's how it is," is the phrase I've heard repeatedly. The shock I've expressed is usually met with shrugged shoulders, occasionally with a smile. "Fa'afetai (thank you) for trying anyway."

I asked Dr. Kumar how long it had been this way on the American territory.

"I've been here 14 years, Linda. I used to cry when I came home after telling a patient the diagnosis was breast cancer or prostate cancer that could be cured in Minnesota or Texas or southern California. I had to tell a patient that I knew what she needed to get better but I could do nothing to provide it.

"I used to cry," the Fijian surgeon told me in his beautiful British accent. "But my tears have dried. Those of us who have to face the patient sitting in our exam rooms can do nothing to change it. So I do what I can with what we have."

So if I hold a mirror to the flags of this remote U.S. territory, one of which is the American flag, I see Alice's strange world -- a world in which cancer treatment is a luxury and biofeedback is a critical need.

Linda Halderman, MD, FACS
Department of General Surgery
LBJ Tropical Medical Center
Pago Pago, American Samoa
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