Fog

HIV in America: Why you should get tested

From the Huffington Post on June 28, 2010.

Yesterday was National HIV Testing Day, a reminder for all of us to get tested for HIV. Among the one million Americans living with HIV, twenty percent do not know they are infected. This is despite Centers for Disease Control guidelines that recommend testing for all Americans between the ages of thirteen and sixty-four.

The consequences of not knowing one's HIV status can be devastating. I saw this firsthand a few months ago as a doctor on call at my local hospital.

Michelle was an Asian woman in her forties who had been hospitalized overnight. It was thought that she had a mild pneumonia. I took over her care the next morning and set off to check in on her before meeting my team for morning rounds.

Upon entering her room, I noticed that she was was thin-appearing and sleeping comfortably. I approached her gurney. Suddenly, the alarms went off. Her oxygen level was dropping dangerously low. This was unusual for a mild pneumonia. Could she have asthma or a clot in her lung instead? A list of alternative diagnoses ran through my head as I dialed up her oxygen.

Her nurse rushed into the room. "Someone from the lab is on the phone," she said. "Michelle's HIV test just came back positive."

She had PCP pneumonia, a rare fungal infection of the lungs that is seen when HIV cripples the immune system. If not recognized and treated promptly, it can be fatal.

Michelle's case reminded me that our country has not yet overcome AIDS. In fact, the rates of HIV infection in some American populations actually rival those in sub-Saharan Africa, the center of the global epidemic.

In Washington D.C., for example, one in thirty individuals is infected, a higher rate than in Ethiopia or Rwanda. New York City has the most infections in the country, with alarmingly high rates among specific populations: one in forty African Americans, one in eight injection drug users, and one in ten men who have sex with men. Increasingly, heterosexual women, not traditionally considered 'high risk,' are being diagnosed with HIV.

Despite such startling numbers, HIV is not part of our national consciousness as it was even a decade ago. In a 2004 debate, former Vice President Dick Cheney was criticized for not knowing that HIV is the largest killer of young African American women. Five years later, a Kaiser Family Foundation poll confirmed that fewer Americans thought that HIV was a serious problem domestically. Not infrequently, patients admit to me that they engage in risky sexual behavior without fear of contracting the virus. Many have not been tested.

Physicians bear responsibility for this trend as well. Despite universal screening guidelines, only seventeen percent of respondents in the Kaiser poll said that their doctor offered them an HIV test.

Thus, it is not surprising that a full one-third of Americans with HIV are diagnosed late in their disease. These are people that miss out on life-saving treatments and are likely to infect their partners without even knowing it.

Michelle was one of these people. By the time she was diagnosed, her immune system was irreversibly damaged. She was battling a life-threatening PCP infection. Fortunately, with intravenous antibiotics and steroids to reduce the swelling in her lungs, she eventually overcame the pneumonia. However, she had to endure a fifty-day long hospitalization in which she was nearly put on a breathing machine. All this could have been prevented had she been tested even once during the previous five years.

It is time that we all acknowledged the reality of HIV in our country. It is time for a renewed commitment to bring our domestic epidemic under control. We need a commitment from elected officials to increase funding for HIV programs, especially ones that expand testing. We need a commitment from doctors to offer testing to their patients. Most of all, we need a commitment from every American to understand their own risk of infection and get tested.

All of us have a role in overcoming HIV in America.

Identifying information has been changed to protect patient confidentiality. This piece was written as part of the Partnership for Physician Advocacy Skills program at UCSF.

Yosemite

Healthcare reform: Giving up now is not an option

From a speech given at a health reform rally on February 19, 2010.

This week, President Obama will meet with Congressional leaders to take up the topic of healthcare reform once again. As a physician who works on the front lines, my message for them is simple: giving up now is not an option.

I am fortunate to work with dedicated doctors and nurses, and in them I see the strength of our health care system. Yet, like so many of my colleagues, I also see what is wrong with our healthcare system.

I see the patient with asthma, merely in his twenties, who runs out of inhalers and suddenly can't breath. I see him connected to a breathing machines in our intensive care unit.

I see the small business worker who could never afford insurance, now requiring dialysis because high blood pressure damaged his kidneys beyond repair.

The single mother of two who showed up for her mammograms every year. Then she lost her job and with it her insurance. I see her, three years later, to confirm that indeed that lump on her breast is cancer.

I see this and so much more. And like other physicians, I know that healthcare reform cannot be pushed back any more.

For those of us who support reform, the last few weeks have been difficult. We are so close to passing a bill that, while imperfect, is still a significant step in the right direction. After the election in Massachusetts, however, the media thinks that we cannot pass health reform. Some in Congress are afraid. There is talk of giving up.

This talk reminds me of a conversation I had with another physician a few months back. He was taking call, working all day and then admitting new patients to the hospital that same night. He was on his feet, taking care of patients, responding to pages, talking to families, checking labs, writing notes. Finally at 2:30 in the morning, twenty hours into his shift, there was a lull, a chance for a quick nap. He made his way to the call room in the basement of our hospital. Just as his head touched the pillow, his pager went off again. There was another patient waiting to be admitted.

I asked him, "What keeps you going? You have a wife and kids at home. You could be spending time with them or getting a full night's sleep in your own bed." He looked at me and asked? "You think we have it tough? Our patients are the ones who are going through real struggles. They have to cope with illness and the thought of burdening their loved ones. Yet, they don't give up. So who am I to give up on them?"

It is tempting, when things get difficult, for us to give up. It is tempting, when the political winds change course, for members Congress to give up on those who need healthcare, to move on to something easier.

For us who work in healthcare, we know that giving up won't cure our patients' asthma. It won't make cancer go away. Giving up won't relieve the pain of a lady with a fracture or that of a family that just lost a loved one.

The mother undergoing chemotherapy for breast cancer while also holding down a job is not giving up.

The wife who prays at the bedside of her husband injured in an accident is not giving up.

The alcoholic with cirrhosis, having resisted a drink for four years and now patiently waiting for a liver transplant, is not giving up.

The nurse who eases the pain of a patient with a stroke, the physical therapist who gets him to walk again, the doctor who works to prevent another one -- they are not giving up.

Our patients do not give up. Because of them, we cannot give up. Neither should our elected officials, until every American has access to the affordable and quality healthcare that is their right.

Marin headlands

Fixing healthcare: Primary care is job No. 1

"The Senate and House are inching closer to extending health insurance to millions of Americans. Access to insurance, however, does not necessarily mean access to healthcare. What is also needed is a sufficient supply of primary-care doctors. As an internal-medicine physician who works in multiple clinical settings, I repeatedly witness the consequences of patients not having that access."

Read more in the Los Angeles Times.

Perspective

Perspective

California Academy of Sciences