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Doctor devotes practice to Pacific cancer programs

“There are times when we can’t see the forest for the trees, when it comes to the enormous problems of health care in America.” So stated Dr. Neal Palafox, MD, MPH, a professor of Family Medicine and Community Health at the University of Hawaii John A. Burns School of Medicine, who was here in the territory last week to speak to the Cancer Coalition Board.

 

He also addressed their general membership meeting held on Thursday, and spoke to LBJ hospital staff for their Continuing Medical Education session.

 

Dr. Palafox, who grew up in Hawaii and has visited the territory many times, oversees a vast network of Pacific cancer control programs and partners in his capacity as a UH professor and medical doctor.  Years ago, he made it his mission to find funding for health centered Pacific programs, and to date, has located and secured several million dollars in grants to fight cancer and other Pacific health problems.

 

 While here, he was able to update the local organization on the current structure of health care in the Pacific, and ways it can be improved.

 

He also works with Non Communicable Disease (NCD) coalitions, because several risk factors for NCDs — such as tobacco use and obesity— contribute to the incidence of cancer.

 

HEALTH OUTCOMES AND THE BIG PICTURE

 

In terms of health services, Dr. Palafox made a startling statement.  He said, “If health services worked perfectly in any country—any country— it would only affect a maximum of 20% of health outcomes.  The other 80% comes from social determinants, with a very small percentage associated with genetics and gender.”

 

That is because doctors and the medical system can only do so much; lifestyle choices also matter.  The determinants, which have the biggest impact on health, according to Dr. Palafox, are education, income and the general environment (i.e. clean air and water).

 

Stated another way, education level and level of poverty determine choices. For example, If good food is more expensive than less healthy food, choices are made which have nothing to do with the doctors and the medical system, but everything to do with what people can afford, their level of education and their understanding of nutrition and healthy eating.

 

He said the NCD epidemic, particularly obesity, which is a huge risk factor in many other diseases, is being driven by two main factors:  demographics (as we move from pre-industrial to industrial societies, we are living longer); and lifestyle, which is determined by levels of education and income.

 

Working with policy-makers is vital, he noted.  Creating anti-tobacco laws, subsidizing healthy foods, creating community gardens, granting time off for exercise and recreation—all vitally important. He cautioned that we need to see the big picture, the long term. The unintended consequence of short term policies is that funding is diverted to the worst possible place—that place is where we are treating the end result of diseases such is diabetes, coronary heart disease and cancer.

 

We build bigger and better dialysis clinics, cancer wards and emergency rooms when we should be focusing on prevention and primary care.

 

PRIMARY, SECONDARY AND TERTIARY CARE

 

Dr. Palafox says that the U.S. health care system has it exactly backwards when it comes to where we spend our money. We should be emphasizing prevention rather than focusing on the complications of disease at its end stages. (He did note that the ACA, or Obamacare has addressed this issue, and placed greater emphasis on prevention with extra funding for such measures.)

 

 The way we organize our economic structure matters, and funding should center on Primary, Secondary and Tertiary Care (in that order) and the impact of social determinants on health outcomes.  Otherwise, NCDs (obesity, cancer, diabetes) will drain the health system of its resources.  “Even the United Nations has said that NCDs will prevent development in countries, because they are a bottomless pit—there is no end to the medical costs that come about because of NCDs.  A case in point is the need to expand the LBJ dialysis clinic, an expensive undertaking and a drain on limited resources.

 

He likened the situation to a cliff, with the population pushed to the edge. Without a fence, or a barrier, they go over. The barrier is prevention and Primary Care, and the higher the education and income levels, the further back from the edge the people will be. Midway down the side of the cliff is a net —that is Secondary Care and disease management.  At the bottom of the cliff is the ambulance (Tertiary Care), which is the last place we want to be. “Best to set up the barriers at the top of the cliff, while improving education and income, which helps people stay away from the edge.”

 

AMERICAN SAMOA’S CANCER COALITION

 

American Samoa’s Cancer Coalition, now in their 10th year, has received several awards for their work. Their outreach, screening programs, education, and registry are all an indication that they are doing really well said Dr. Palafox.

 

The Cancer Registry, which is a vitally important statistical tool, is up and running here, through CDC funding; “but legislation must also be in place; data keeping, software, training for registrars needs to occur,” he said. “Some of the first data has come out, and this is something we never had before.  We have a U.S. Certified Cancer Registrar here, one of only two in the USAPI.”

 

The data is there to inform policy, as well as how hospitals set up their systems. For example, if breast cancer is the biggest issue, then data will show that, and policies and programs can be adjusted accordingly, he explained.

 

“The Cancer Registry can be used at the planning levels, and legislators can look at the levels and ask how to apply funds to prevent the cancer.” He noted that there are very strict rules about entering the data.

 

Dr. Palafox said that we have many challenges here in the Pacific. The Western lifestyle is here and influences the way we eat and what we eat.  “Yet, are healthy foods available? Do we exercise enough? Can we return to a more traditional diet?” he asked.

 

There are myriad problems with not understanding what constitutes healthy eating, he said, “And even if you know what healthy foods are, people must have those foods available.”

 

The real challenge is to change behavior, he concluded—and the question for leaders and legislators is this:  What does the government have to put in place policy-wise to make that happen?

 

“The fallacy is, we believe that the hospital and DOH are responsible for our health, that we’re all sick because they didn’t do their job. That’s the fallacy.” In the end, he said, it is our job to do everything we can personally to take care of our health, and health care providers, legislators and educators then become partners in a vibrant and healthy community.

 

BACKGROUND

 

Dr. Palafox told Samoa News that his decision to focus on cancer control was largely due to the fact that he spent ten years in the Marshall Islands, where he developed a tremendous interest in the health care of Pacific peoples. He said that in spite of the high incidence of cancer in the Marshalls— associated with the twelve year history of nuclear testing there by the U.S. government— there was precious little cancer data from the North Pacific being recorded.

 

(According to UHMed Now, a University of Hawaii news site, from 1998 to 2008, Dr. Palafox was principal investigator, looking into the health effects of the U.S. nuclear weapons testing program in the Marshall Islands, focusing on the lingering health impacts from nuclear tests conducted in the Pacific during World War II. In 1999 and again in 2010, Dr. Palafox was invited to testify in Washington, D.C. to the President’s Cancer Panel on cancer-related challenges in the US Associated Pacific. His grants through the University have directed over 20 million dollars to Pacific related health programs.)

 

He spent several years knocking on doors, and finally was able to secure funding from the National Cancer Institute to build the Cancer Council of the Pacific Islands. From there, he was able to obtain money from the Centers for Disease Control which enabled him to build programs and coalitions that would show how to screen and prevent cancer, as well as keep data and create registries.

 

Through his efforts, and those with whom he partnered, each jurisdiction of the U.S. Affiliated Pacific Islands (USAPI) now has a Cancer Coalition and a comprehensive cancer plan developed by that coalition.

 

He regularly visits each USAPI jurisdiction to facilitate the development and implementation of those plans.

 

For this particular trip, he had received a request to help the Department of Health, LBJ Hospital, and the Cancer Coalition to work together.  Although the Coalition is a Non-Government Organization outside the DOH, it was DOH director Motusa T. Nua, who had asked the Cancer Coalition to be their partner and help design and structure their ongoing cancer prevention programs.

 

The Cancer Coalition has the best idea of what is happening in the community with regard to cancer, the DOH director had explained.

 

Dr. Palafox’s presentation at LBJ Continuing Medical Education centered on data keeping and the correct coding and processing of death certificates. He explained, “When death certificates are filled out properly it gives people a way to track predominant causes of disease in a country. When they are not filled out properly, that information is lost.”

 

To put it another way, “You don’t know where you’ve been, and you don’t know where you’re going,” if death certificates are too general, too vague, or do not contain pertinent details.