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Tuesday, December 31, 2013

Healthcare Spending--moderating? David Blumenthal et al explain.

David Blumenthal and others recently published a paper in the New England Journal of Medicine entitled "Health Care Spending--a Giant Slain or Sleeping?" In it they look at the ongoing, and rarely discussed, phenomenon of slowing of healthcare spending, which has persisted over several years. Health care spending grew remarkably after the establishment of Medicare and Medicaid in the 1960's, resulting in the fact that health care costs now equal about 18% of our gross domestic product (GDP) when they were only 5% before these programs were introduced. This was no coincidence. A third party payer, even one we expect to value frugality such as the government, will increase utilization of services because they are already paid for, and will increase prices for the same reason unless the prices are negotiated. In Europe, prices for procedures and medications are frequently  negotiated, but in the US powerful drug companies and device manufacturers successfully resist this, resulting in relatively free floating prices. In the past few years, however, overall health care costs have slowed their growth considerably and now actually lag behind the increase in  GDP. We have had a much slower economy since 2008, which could be expected to slow health care spending, but this effect has been beyond what economists would expect based on this.

The authors discuss the many factors that may be involved in slowing healthcare costs, and also present some strategies that might help encourage this trend. They suggest that some of the provisions of the Affordable Care Act, including establishment of healthcare models that make providers of healthcare more financially responsible for the health of patients rather than profiting from their illness, may already be having a positive impact. Movement towards having patients be more involved in their own health, including making informed choices about treatment and testing may reduce unnecessary costs. The article is definitely worth reading. They conclude that healthcare, despite the encouraging trends, is still overpriced and can can stand to be more frugal without sacrificing patient care. This is true. In my experience, testing and treatments are still ordered without adequate attention to necessity or cost. Preventive strategies to reduce grave illness are still underutilized and drug companies still overcharge for their products and convince us that their value is higher than it really is. We continue to use the very newest and most expensive technologies to delay the moment of death for patients who are genuinely dying and ought to be allowed to do so in comfort and with dignity. All of these things come with huge price tags.

The article ends with a couple of very important points, and then misses a few more because the authors are most likely not practicing physicians. Dr. Blumenthal, the first author, is the president of the Commonwealth Fund, a philanthropic organization which researches social and health policy. He has been a primary care physician, but has been influential in policy and administration for many years, suggesting that he probably no longer takes care of patients in the hospital or clinic.  His coauthors, Kristof Stremikis and David Cutler are in public policy and economics, respectively, and are not MD's. The points that are particularly important  that they did mention in the article are that consumers can be a powerful force for improving both quality and in reducing costs if, and only if, they are given data about quality and costs. Also, that the way we presently pay for medical care, especially the way we bill, is incredibly inefficient (also, in its complexity, so prone to fraud and inaccuracies, though they didn't mention this.) What they did not mention is that physicians can be a powerful force in improving quality and reducing costs if they, also, are given data about these things. Doctors still do not know how much a given test or procedure costs, what portion will be paid by a patient out of pocket, and mostly do not have guidelines that help them not to order excessive testing or treatment. Billing is only a small part of the problem of administrative burden.The increasing demand on nurses' and other caregivers' time by electronic health records which appear to be endlessly hungry for valueless detail that must be entered on a computer not only reduces all of our abilities to do good bedside patient care but clouds our minds with trivia and chases experienced staff, both nurses and doctors, to early retirement because of inadequate (and irrelevant) data entry skills.

I commend the authors of this article for clear writing and excellent synthesis. The fact that healthcare spending is already going in the right direction is fascinating and almost entirely neglected in the press, probably because it doesn't support the more popular story that everything to do with healthcare in America is going rapidly to hell in a handbasket. I expect the ongoing vigorous debate about healthcare reform will keep people discussing costs which will make both physicians and patients more likely to pay attention and reduce frivolous expenditures.

Monday, December 16, 2013

This is what happened when I went to healthcare.gov to sign up for health insurance

Today in the mail I received a letter from my private health insurance company informing me that my current policy, which was being cancelled because it didn't meet minimum standards of the new healthcare law, would actually be available to me next year. In other words, I could keep my plan.

There has been a big kerfluffle about a presidential promise to allow people to keep their health insurance plans if they liked them, which turned out not to be true under the health care law. Having read the law I thought that was pretty clear. I figured that my plan wasn't compliant and I would therefore find myself signed up for some more expensive policy by my health insurance company when 2014 rolled in. I am not entirely sure why the president told people they could keep their non-compliant policies, and apparently he has been spanked soundly for saying it. The "Keep your health plan act of 2013" passed the house in November, but I cannot find anywhere that it passed the senate, and now I have received a letter that suggests I can keep my health plan. I find nothing online to explain this confusing set of contradictions.

But all of that aside, I decided today that I would plunge into what is supposed to be a horribly broken system for obtaining health insurance. The process sounded interesting a month or two ago, but I was way too busy to explore it. Today, though, my schedule cleared out a touch and I got the letter from my insurance company, so I decided to give it a whirl. And...

It was fine. There was no problem.

First I went to the website for Idaho's health exchange as the letter from my insurance company instructed. Since Idaho has been grouchy about anything to do with the healthcare law, we are not quite yet functional as a state exchange. The website routed me to the federal health insurance exchange via healthcare.gov. There I expected horrible bugs and delays. I don't doubt that people have had terrible bugs and delays, but today things went as smoothly as a greased watermelon in a warm lagoon. The website was attractive and uncluttered, the fonts were easy to read and the navigation was fast. I signed up for an account. I entered my name, the names of my children, social security numbers, and attested to our citizenship and the fact that we didn't smoke. I promised that I was telling the truth. I was then routed to a page of options for health plans, categorized by level of coverage. Coverage is either bronze, silver or gold, depending on how much the plan pays and how much I pay to have the plan. I went for bronze level since I expect to die suddenly after experiencing perfect health all of my life, and figure that my children will be well until they are kicked off my plan at age 26. I am willing to bet my $12,500 out of pocket maximum on it, and have a health savings account with something like that amount of money in it, should I lose my bet. I had 6 choices of plans, offered by a variety of different companies and chose the cheapest which was about $25 more expensive than this year's non-compliant health plan that I was invited to keep. My experience with my present insurance company involves a yearly price hike of around 20%, so this increase in cost was in no way disappointing.

Having signed up for insurance in the past, I'd have to say this experience was better. If I had been less financially well off, I would have also had a break on price, which would have been nice.

I don't know what to say about the failed roll out of the Affordable Care Act other than the fact that at this present moment it works fine. Will it destroy American health care as we know it or cause an already overburdened system to implode? That remains to be seen. Will coverage for preventive care dramatically reduce costs by improving the overall health of Americans? Not sure. But on Monday, December 16, 2013 at 5 PM the process of comparing and purchasing a health insurance policy was easy.

Rural Medicine: Idaho and Africa and elsewhere

Rural medicine, I guess, can be defined as health care that happens in places that aren't big cities or referral centers. The vast majority of the populated earth's crust that has any health care at all is served by rural practitioners. I have done a little bit of rural medicine in Haiti, in Mexico and now a bit more in South Sudan. I have also worked in a rural health care system in Idaho for nearly 20 years.  People benefit hugely from health care delivered to them in their less densely populated home turf, despite the fact that health care in such locations lacks technology and specialist services that are often available cities or university medical centers.

In the US, most rural health outposts are within an hour of a major medical center, either by ambulance or helicopter, so transfer to a high tech center is usually possible when there is an indication. In developing countries people are often grateful for any medical care that can be provided and transfer to a higher level of care is much slower or impossible.

When a person in the US discovers that he or she is very sick they usually call an emergency medical service team which sends at least 2 trained medical technicians within a few minutes to evaluate the patient and transport them to a hospital if that is necessary. In some areas like the Alaskan bush and truly isolated parts of the US this is not true, but the vast majority of non-city dwelling Americans have access to emergency medical services. In rural South Sudan a person who is very sick will first receive any folk remedy available and if that is not effective, will begin the long journey, on foot or carried on a litter by relatives, to the nearest health care facility. Such a trip may take days.

On arrival at a rural emergency room in the US, patients will usually immediately see a well trained doctor who will respond appropriately to their life threatening needs with interventions that are similar to what they would get at a hospital in a larger city. Specialists will be called if appropriate and often will be at the bedside in close to no time. Testing, including CT scanning, ultrasound, advanced lab testing and x-rays, is completed quickly and a likely diagnosis and treatment strategy is determined usually within a few hours. An IV line is usually placed and, if in doubt, the patient is put on oxygen by nasal cannula. If appropriate treatment for the patient's condition isn't available, transfer to a larger facility is arranged. If the patient is sick but can safely be managed in the rural hospital, admission is arranged. The patient is then taken to a moderately comfortable electrically controllable bed with clean sheets and a pillow, with a pitcher of water and toiletries on the bedside table. In a very good rural hospital in South Sudan, like the place I worked, testing is limited to a fingerstick test of glucose and creatinine (for kidney function), vital signs such as blood pressure and oxygen saturation, if the machine is working, possibly a bedside ultrasound if the health care provider has been trained and the machine is available. Very sick patients are placed on a mattress on an ancient bed in the ward, if a bed is available, and may be given intravenous fluid or medications if their condition warrants it. There is no oxygen, water pitcher, bedside table, sheets or pillows. The medications available are limited, and if what we have is not what the patient needs, they might get whatever is closest to what they need, or nothing at all. Transfer is sometimes possible, but usually delayed by days and sometimes longer. If the problem is one of several tropical diseases which are common, treatment is rapid and appropriate and miraculously life saving at a tiny overall cost compared to treatment of anything in the US. If the patient's breathing stops or the heart ceases to beat, that is usually the end, without resuscitation unless the cause is clearly quickly reversible, like having choked on a peanut. Blood transfusion is possible and sometimes life-saving, since many of the worst tropical diseases are associated with severe anemia. Although blood typing can be done, a full screen for transmissible organisms and minor blood incompatibility is not possible, so potential donors must be people for whom there are very few risk factors which mostly means medical staff. The blood comes out of the donor and is immediately infused into the recipient, relieving symptoms of weakness and heart failure. There are no facilities for processing the blood so it is fresh whole blood that is transfused, which actually has some theoretical advantages over the stored packed cells most patients receive in the US. Some women with problems of labor and delivery can receive life-saving help, based on the expertise of the attending physician or healthcare worker and people with wounds or injuries can often be patched up or splinted or casted. Abscesses can be drained. Sores, including tropical ulcers can be cleaned and dressed and often healed.

In the US, detailed and scrupulous records are usually kept, often in digital format which can be searched if you know how to do it. Records in the tiny hospital in South Sudan are very brief and often inadequate to communicate the course of events without the additional input of the caregivers who may remember what happened and what everyone was thinking. The lack of complete records of medications given was particularly frustrating for me. There were, however, twice daily vital signs most of the time, which are often not available in less excellent hospitals. In order to make an impact on a person's disease it is necessary to know what is happening with the person, thus vital signs such as blood pressure, temperature and pulse are important, as are changes in a patient's symptoms and signs of disease. If we don't know whether the treatments we order are actually being given, our ability to adjust therapy to achieve a desired result is extremely limited. The excessive and almost obsessive data gathering that we suffer from in the US can overload us, but the ability to have some objective data regarding a patient's physical state is extremely helpful. I longed for more documentation in my visits to Haiti, Mexico and Africa. On the other hand, there was something beautifully basic and adequate in the concise paper records in South Sudan. Patients had a card, half of a standard size piece of printer paper, which documented all of their inpatient and outpatient complaints, diagnoses and treatments. They knew to keep these cards and brought them with them for each visit with a health care worker (or received a scowl if they didn't.) The more extensive records from a hospitalization were just thrown away when the patient left the hospital, but a brief summary stayed on the card. The cards were often dirty and wrinkled, but people kept track of them, which made a huge difference in being able to find a way to cure patients persistent or new ills.

So...rural medicine is such a very different thing in different settings, and so incredibly important. It is fraught with huge challenges, especially in the most remote places. These can look like the hospital I saw in the South Sudan, or even smaller primary care health centers, staffed only by a single community health worker trained to treat only a few specific diseases out of the myriad that people have, with a very small formulary of remedies. It can be so very rewarding to see patients who work hard and never ask for medical resources be cured of diseases that stop them in their tracks and threaten to ruin not only their, but their entire family's livelihood. And this does happen, using very basic tools. A few packets of oral rehydration solution or a course of amoxicillin can be lifesaving. In my rural hospital in Idaho we can't transplant a kidney or bypass the blood vessels whose blockage causes a heart attack, but we can care for nearly all of the sick people who come to us, and we do a really good job.  And the community health workers in Africa also do a really good job, treating malaria in children with fevers who might otherwise die, pneumonia in infants who are desperately ill, identifying and treating malnutrition and referring the worst affected to appropriate nutrition programs. After all of the American volunteers leave the hospital I visited in South Sudan and the rains fall, turning roads to impassible mud, South Sudanese health care workers treat patients who continue to present with life threatening illnesses. There is so much that they can't do, but, much more importantly, so much that they can do.



Tuesday, December 10, 2013

Medical Care in Old Fangak, South Sudan



Two days ago I got back from Old Fangak, a tiny town in Jonglei province on the banks of the Zaraf River, a branch of the Nile. Because I am on a self proclaimed sabbatical, and because I have wanted to visit my friend Jill Seaman who treats tuberculosis and Kala Azar in South Sudan for years, I just took off and went there, and now, many mosquito bites later, I am back.

South Sudan is the newest country in the world, having achieved independence July 9, 2011 after decades of civil war in the Sudan. The politics of independence are complicated, involving routine marginalization of the sub-Saharan population of the south by the Arab north. There are also rich oil reserves in South Sudan which may help fund infrastructure improvements eventually. I visited Juba, the capital city, briefly and spent the vast majority of my time there in the town of Old Fangak where the hospital and medical clinic are located. Two weeks and a bit and basically one small town do not make me a South Sudan expert. Still, it was quite the trip and both interesting and valuable on so many levels.

The Hospital and the Diseases
Jill Seaman has worked as a physician in Sudan for decades, originally for Doctors Without Borders (Medecins sans frontieres--MSF) and then through her own organization, Sudan Medical Relief. She works as an emergency physician and family practitioner in Bethel Alaska to help fund the project and is supported by various governmental and nongovernmental organizations including the Alaska Sudan Medical Project which arose in Bethel in response to her work. I had the opportunity to work alongside the Alaska volunteers, who help out with medical projects as well as construction of buildings and bore-hole water wells.

Jill has become one of the worlds experts on the treatment of Kala Azar, also called Visceral Leishmaniasis, a usually fatal parasitic disease caused by an organism transmitted by the bite of the sandfly. Kala Azar causes an intermittent high fever, an enlarged spleen, weight loss, swollen liver and then death, often due to other diseases such as pneumonia or tuberculosis. Two years ago the hospital was treating close to 300 new cases a week, delivering shots to 1000 people a day of primarily the injectible Sodium Stibogluconate, an antimonial, with another antibiotic called paromomycin. The standard course of treatment lasts about a month and makes the patient feel sick, but usually cures the infection which mostly does not recur. Severe cases and ones coexisting with tuberculosis or HIV are treated with every other day liposomal amphotericin B for 6 doses, which is significantly more expensive and also much easier to tolerate. During the time I was in Old Fangak, there were few new cases of Kala Azar, only about 1 a week. Apparently sandfly numbers and bugs in general are lower this year, but nobody is sure why or if this is a trend that can be expected to continue.

The other diseases that were common were Tuberculosis, Malaria and Brucellosis, with a few cases of HIV as well as infectious complications of starvation, snake bites, spear wounds, tropical ulcers, pregnancy complications and cancers. The hospital complex has several buildings including brick and cement structures that have become more dirty and broken down over the years, a new building that is made out of various prefab building materials and is easier, so far, to keep clean and several mud huts. There is a laboratory, a pharmacy and a dispensary, a construction compound a short distance away and a compound where tuberculosis patients stay for the 8 months they are in directly observed therapy.

Since this clinic is a primary health care delivery site, it has a formulary of drugs that is considered to be basic for treating common illnesses. Depending on what diseases are trending upward, drugs sometimes run out, and patients can't get the optimal treatment for their disease. Chronic diseases such as lung disease, diabetes and congenital heart disease were difficult to treat, since they required ongoing medications or surgery, which is not available anywhere close. We saw cancers too, and these cases were agonizing because there was nothing we could give to treat the disease, and strong pain medication was nonexistent. While I was there we saw a 23 year old woman with advanced ovarian cancer and a belly full of ascites. She had been to a regional hospital where surgery was felt to be impossible and had returned to us, so full of fluid she could barely breathe. She felt better after a few gallons of liquid were drained, and was able to walk around the village a bit, but her disease would eventually progress to the point that nothing could be done and she would die, with very little in the way of pharmacological comfort. There were also two very old people, one with a swollen leg from a blood clot, with multiple masses in her liver on ultrasound suggestive of advanced cancer. Anticoagulation with heparin was not possible since heparin is not considered an essential drug and is not in the formulary. Treating the clot when nothing could be done about the cancer would probably have been silly in any case and she passed away on her way home from the hospital. An old man who knew he was dying, but not why, had a huge tumor mass in his abdomen and chest and was able to return home by boat to die in a familiar place. A little boy who had trouble swallowing had what appeared to be a nasopharyngeal cancer. It may be possible to raise money for him to be transported to a center where radiation can be done, but that is very expensive and it is far from certain that it will happen.

Tuberculosis in rural South Sudan often presents with disease outside the lungs, and when it is in the spine can cause painful deformities which are often associated with paralysis of the legs. Therapy for tuberculosis can prevent death from overwhelming infection but often the spinal deformities are well established before patients even get to a doctor and they end up unable to walk.  Donors sometimes arrange for wheelchairs which are wooden scooters with hand pedals, well designed for the terrain and the patients' needs. There is plenty of pulmonary TB as well, and patients often expose others by coughing before their disease is confirmed and they can move to quarters with other TB patients. Respiratory isolation is just not practical in this setting. I saw several patients with severe spinal deformities, some of whom were dealing with the complications of paralysis--infected ulcers on weight bearing areas and restrictive lung disease which was complicated by pregnancy. I saw a couple of cases of likely tuberculous pericarditis which bedside ultrasound confirmed to be causing heart failure. In the US, pericardial tamponade (impairment of filling of the heart due to fluid in the bag that holds the heart) usually presents as a life threatening emergency. In the cases I saw, the fluid had been present in a diseased pericardial sac for quite a long while and the patient only presented when their tolerable chronic shortness of breath became intolerable due to some other event. Usually fluid in the pleural (lung) space or pericardial sac will decrease in volume when patients are treated with steroids in addition to their TB drugs, though one of these patients did die within a few days of arrival since she was also stressed by the recent delivery of a child and a 4 day trip in the hot sun to get to the hospital as well as other chronic medical problems. In the US both of these patients would have been in the intensive care unit with cardiologists in attendance, but in Old Fangak there was very little we could do acutely besides provide a comfortable place to sleep and a few cardiac medications that may or may not have been effective.

Brucellosis, which is carried by cows, was very common. It presents with fever and joint pains early in its course, but can have a myriad of presentations as it becomes more chronic, including stiffness and pain in the lower back. When it causes severe arthritis it is rarely completely reversible and the treatment for it is in no way benign. In rural South Sudan cows are currency and they are more often held as wealth rather than used for meat or milk. Piles of cow dung are everywhere and cow dung is mixed with clay to make houses.

The hospital is staffed by Jill Seaman, an American doctor, any volunteers (and there aren't many) from overseas as well as local health workers with varying degrees of experience and skill. The health workers use protocols for testing and for treating common symptoms and diseases and do an admirable job of treating those diseases that are most common, including malaria, tuberculosis and Kala Azar which would require the attendance of multiple specialists in an American hospital and much head scratching to be appropriately managed. Diseases that don't fall into common categories may not be treated well, either because they are difficult to diagnose or because treatment is not available. We saw 3 cases of newly presenting symptomatic congenital heart disease, one atrial septal defect and two ventricular septal defects, which may be eligible for free surgery if the patient can get to Khartoum where there is a heart surgery institute. There were also a reasonable number of worried well patients who had symptoms that bothered them a great deal, usually pain of some kind, but no red flag signs to suggest any more than muscle strains from chronic hard work.

Being a woman--not such a great deal
There is very little industry in rural South Sudan and, beyond building houses, gathering wood, cleaning fish and working on farms. A woman's value lies in her ability to have babies. South Sudan has the highest maternal death rate, with 2 women dying for every hundred babies born. Most of these women die at home, but some of them come to the hospital at Old Fangak with their birthing difficulties. When I arrived at the hospital the very first day, a woman was waiting in the minor surgery room on the floor in a pool of blood. She had come to the hospital with bleeding in her 24th week of pregnancy, stayed as an inpatient at bedrest with a threatened miscarriage, then returned home (walked, of course) to deliver her preterm infant who died, then came back to the hospital with a post partum hemorrhage because of a retained placenta. She was anesthetized and Dr. Jill manually extracted the placenta and the patient, though rather anemic, survived and thrived and returned home. The family buried the baby with the placenta. She was a young mother but this wasn't her first child. I saw several miscarriages and threatened miscarriages while I was there and one complication in which the mother lost her life. Unlike some developing countries where girls are devalued and even selectively aborted or killed at birth, in South Sudan a man wishing to marry must pay the family of the girl he chooses with cows, the most trusted local currency. Raising a girl baby to maturity is thus a money maker for a family. Men may keep several wives and women do not appear to have any rights. Domestic violence and fighting of all types was strictly forbidden on the hospital grounds, but not at all uncommon in the community. It would be better, I think, to be born a cow than to be born a woman in Old Fangak. Still, the women I met were often intelligent, assertive and sometimes clearly treasured by their husbands and families.

Tribes and cultures
There are many tribes with their own distinct languages and cultures in South Sudan, but the main 3 are the Nuer, the Dinka and the Shilluk, all of whom I met in the hospital. Those who have had education may speak Arabic or English, but if they do not, they cannot communicate with each other and exist in Old Fangak in what appears to be a fragile peace. Nuer people were in the majority and I picked up a smidgen of Nuer language. The usual greeting "male" means peace, which is a nice thought. Nuer boys have a distinctive scarification on their foreheads which is part of a coming of age ceremony in which the forehead is inscribed with parallel lines with a sharp object by an elder of the tribe. If the boy squirms or cries, the lines are not straight and he is marked as a coward. I didn't see any complications of the procedure while I was there, though I imagine there must be some. Girls also have decorative scars on their face and chests, more often patterns of dots. Occasionally the scars grow thick on the chest and women would complain of pain and itching when this happened. They often pull their own teeth and train the remaining teeth to splay in the front which is considered to be beautiful.

Critters and the natural world
I arrived at the end of the wet season and if I had stayed longer the weather would have gotten cooler, possibly down into the 60 degree range during the night. As it was, it was mostly in the mid 90s during the day, with very high humidity, and I was sticky sweaty all the time. In the evening before I retired to my tent under the big tamarind tree I would take a bucket bath which was delightful, but which would wash off the mosquito repellent, making lounging with friends around the campfire less attractive. Nights were long, as much as 10 hours in my tent reading and writing and thinking, which was a delightful luxury that I don't allow myself very often at home. Night sounds were frogs on the shore of the river, squeaks of bats, sometimes an owl and packs dogs working out their issues in the distance. I mostly slept through the sounds of cats eating overconfident rats. Early morning roosters would crow starting about 4 AM and then doves would begin to coo in the trees and kites and ibis would call. Honey bees would buzz in the trees. They are said to be aggressive but I never had problems with them. There were monitor lizards in the yard and a python in the latrine, cobras in the pantry trying to help with the rat problems and various poisonous snakes that were unlikely to take me unawares since I wore good solid shoes and carried a headlamp. The insect life was fascinating, with huge beetles and praying mantis and evil biting carnivorous ants who attacked our thanksgiving feast leftovers while we slept. Mosquitoes were plentiful, though not as plentiful as they are some times, I'm told. Some of them carry malaria. There are big flat spiders and spiders with long legs but none that seemed particularly threatening. There was a crocodile, but I never saw him. The diversity of birds was amazing and I can imagine bird watching tours might make the area some money eventually. The water of the river is not bad, though it carries schistosomiasis which, if untreated, can cause various major organs to malfunction. There is a treatment for it, though, a single pill of Praziquantel, so I went swimming and enjoyed it very much. Both men and women bathe in the river often and are good swimmers. It looks like they are having fun.

Food, or lack thereof--
Starvation continues to be a major health issue in the area I visited. As the civil war has ended people are starting to farm and garden which increases the variety and abundance of food. People can grow their own corn and sorghum which are major staples. Cows milk supplements their nutrition. They grow a small amount of tobacco which people smoke in pipes in the evenings. The people stuck in the hospital cook their own food, but many of them depend on bags of sorghum and oil from the world food program, as well as bags of "plumpy nut," which is provided to some categories of malnourished people. Plumpy nut is expensive and is provided by aid organizations for patients with severe malnutrition. It is just peanut butter with sugar and milk powder and vitamins added, but the little serving size bags make it easy to eat and it resists spoilage. Women and girls make sorghum cereal by grinding the sorghum on boards or stones with a rounded piece of wood, then cooking it over tiny cook fires. This is usually breakfast, lunch and dinner for people at the hospital. Very occasionally meat supplements their diet. Nobody was fat.

Safety issues
I'm back now, safe and healthy, and I didn't even lose much weight. Stories of Sudan and South Sudan in the news made me and my family and friends worry that there would be gunboats and AK47's and raids with burnt villages and child soldiers and machete attacks. Although this is not impossible in a country where violence has been common and widespread for decades, there has been peace in Old Fangak for 2 years and there was never any hint of danger to me personally from anyone armed or angry. The generation that is now in its teens and twenties has grown up without much of the values that keep communities strong, but still there are communities and people who value them and wise people who act as role models. There are still cattle raids which lead to conflict with physical violence of various kinds. There are many less guns in circulation, and the area where I stayed is disarmed of its guns, though they are still available at the police station should war break out again. Mostly people injure each other with fists and spears, and there is less danger of bystanders getting unintentionally harmed. The most vulnerable I felt during the whole trip was when I was at the airport in Juba flying in and out of the country. It is crowded and inefficient and contrary and seems designed to make transit as difficult as possible. Still, thousands of people every day make it into and out of the country and in fact I had no trouble.

Jet lag is fading, but every morning I wake up finding myself trying to diagnose mysterious tropical disease syndromes and cure the incurable. I am thankful for cold weather and a warm house and a well fed dog who does not expect me to throw a rock at her. I learned a huge amount in a short period of time and met wonderful wise people, both African and American. It was difficult, time consuming and expensive to get to South Sudan and, despite all that I will probably go back.