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Dr. Ann Settgast on travel medicine and health care policy

Minnesota Health Care News, August 2012

Dr. Ann Settgast, an assistant professor of internal medicine at the University of Minnesota, is a primary care physician at HealthPartners Center for International Health and practices travel medicine at HealthPartners Travel and Tropical Medicine Center.

You earned a diploma in tropical medicine and health (DTM&H). How did you become interested in that field and in international health in general? I'm fascinated by other countries and cultures, and love to travel. Most Western medical education doesn't provide extensive coverage of diseases encountered in developing countries (malaria, leprosy, malnutrition, etc.). I obtained my DTM&H to be better prepared to work in parts of the world, and with populations, where these conditions are common.

Many of your patients are foreign-born. Is working with them different than with U.S.-born patients? It's a privilege to work with people from entirely different backgrounds than my own. I'm fascinated by my patients' histories and perspectives, and learn a great deal from them. For many, coming to the U.S. from, say, a refugee camp, preventive medicine and chronic disease management are foreign concepts. I enjoy the opportunity to improve health by building relationships that allow me to promote these concepts, working with patients to combine their non-Western approaches to health with our own in order to obtain the best outcomes.

Some travel requires advance medical planning, such as immunizations. How can a traveler find out what is needed?The best way is to visit a travel clinic. Many patients think the only thing we do at travel clinic is give shots, but there is much more. Significant time is spent reviewing malaria risk and prevention. Malaria is an illness that can be fatal quickly in patients who are not immune to it. Choice of prophylactic medication is individualized based on side-effect profile, patient medical history, and other factors. We discuss prevention and management of traveler's diarrhea, which is very common, and review travel risks.

Some preexisting conditions require special planning for travel abroad. Please give us some examples. Changes in diet, activity, and time zone can all affect diabetes control and may require readjustment during travel. Risk of altitude illness can be affected by various cardiopulmonary conditions. Patients who are immunosuppressed, whether due to a disease like AIDS or to medication, require special management.

Have you found an effective way to handle jet lag? Starting a trip well rested helps. People are typically affected when crossing more than three time zones, and traveling west is easier than going east. For example, someone traveling west across six time zones can expect to feel well within two or three days. But the same distance going east can require double that time to feel synchronized with local time. In addition to circadian rhythm disturbance, sleep loss itself common during travel contributes to jet lag. I advise patients to use daylight, outdoor activity, and intense activities during the day of arrival when going east to help them stay awake at their destination until local bedtime. Some providers recommend melatonin or zolpidem to help with sleep the first few nights.

Recently, you had a short-term teaching appointment in Tanzania. Please tell us about that. I taught on the internal medicine service at Selian Hospital outside Arusha, Tanzania, which serves northern Tanzania's rural Masaai. My students were training to be assistant medical officers, mid-level providers who lessen Tanzania's profound physician shortage. They were among the most eager and motivated learners I have ever met; teaching and learning from them was fun and inspiring. They requested multiple topics for lectures, and would attend any time of day for as long as I would teach!

What can the United States learn about health care delivery from other countries? The U.S. has much to learn from other wealthy democracies, all of which have truly universal health care systems, most at less than half the cost of ours. There is a constant search in American medicine for the "holy grail" of cost control. We often try to do this via mechanisms to reduce care based on the misperception that our system is so expensive because we provide too much care. However, if one looks at discrepancies in spending between us and these countries, it's not because the U.S. provides too much unnecessary care (although this problem certainly exists). Rather, our huge spending is on the administrative side due to our fragmented, multipayer, for-profit system.

Please tell us about Physicians for a National Health Program and this group's reaction to the June 28 Supreme Court ruling on the Affordable Care Act (ACA). Physicians for a National Health Program (PNHP) is a national non-profit research and education organization dedicated to implementing a single-payer health care system in the U.S. Our Minnesota chapter, with nearly 1,000 provider and medical student members, works toward a single-payer solution at the state level. While the ACA will help some patients, it will not solve our crisis. More than 200,000 Minnesotans will remain uninsured while many more will be under-insured without proper access to health care. Single-payer still provides the only means to cover everyone at reduced cost. More information is at www.pnhpminnesota.org.

What are obstacles to implementing single-payer health insurance? The main obstacle is the private health insurance industry. Another obstacle is lack of education about what "single payer" really means. Some erroneously confuse it with socialized medicine or think it would lead to reduced care. However, the savings come not from reducing care but from streamlining the administrative side of the system. The Lewin fiscal analysis of a Minnesota single-payer system, published in March 2012, revealed that Minnesota could reduce health care spending by 9 percent and cover ALL Minnesotans with comprehensive coverage if single payer was enacted here.

PNHP-MN has introduced legislation for single-payer insurance. What can you tell us about this? PNHP-MN has worked closely with Sen. John Marty, chief author of Minnesota's single-payer legislation. The bill made progress during the first few years after introduction, passing through several legislative committees. However, since the 2010 election and subsequent changes in House and Senate leadership, the bill has stalled. Single-payer is not a partisan issue. It is the most fiscally conservative approach to health care reform.

http://issuu.com/mppub/docs/mhcnaug12