Editor's note: This month begins a divergence from our usual format for Physician Spotlight features. In response to several requests, we are not only introducing readers to notable physicians in the Orlando area, but are also encouraging them to share their thoughts on issues in healthcare, research projects, charitable projects or anything else meaningful to our physicians. If you would like to share your thoughts with us, please let us know.
In January 2016, Asim A. Jani joined Orlando Health as Hospital Epidemiologist under Corporate Quality & Patient Safety, after several years as Director of the Preventive Medicine residency program at the Centers for Disease Control and Prevention (CDC). His specialty areas include Infectious Diseases, Public Health and General Preventive Medicine and Internal Medicine. He began his CDC career as an Epidemic Intelligence Service (EIS) officer in 2003 and served as a commissioned medical officer in the U.S. Public Health Service.
Over the last two decades, he has worked as an infectious disease clinician-educator, public health physician, consultant and medical epidemiologist. After EIS, he did his CDC Preventive Medicine practicum assignment in the Coordinating Office for Global Health (COGH), where he later worked as a medical epidemiologist on A/H5N1 and pandemic preparedness while being the Geo Team lead for India-CDC programs.
He also served in the role of physician advocate at the community level in Central Florida for vulnerable populations to reduce health disparities and promote health during his tenure at the Orange County Health Department.
His clinician-educator roles included service as teaching staff and ID consultative care at Orlando Health for over 10 years.
He has held numerous academic teaching appointments at USF, FSU and UCF, including most recently adjunct faculty in Epidemiology at the Rollins School of Public Health with Emory University. He is an invited speaker having given over 150 major presentations during his career, with over 30 abstracts, peer-reviewed articles, and book chapters and other scholarly products.
His consultative and scholarly interests primarily focus on population health, medical education, hospital epidemiology, and clinical infectious diseases but also include workforce development, systems-thinking and integrative medicine.
Dr. Jani obtained his degrees, BA in Psychology, MD and MPH as well as his ID Fellowship training at the University of South Florida Colleges of Medicine and Public Health and completed his Internal Medicine residency training at Orlando Regional Medical Center.
He has subsequently served in the role of Assistant Director of Medical Education at Orlando Health twice, when he was a founding faculty member of the Orlando Health Infectious Diseases Fellowship.
In 2010, he successfully completed the two-year Fellowship in Integrative Medicine, Univ. of Arizona Center for Integrative Medicine. In 2015, he finished the Population Health Academy training at the Jefferson College of Population Health in Philadelphia.
Dr. Jani: In other words...1978 - "What is Past is Prologue"
In front of the National Archives Building in Washington, DC, the statue by Robert Aitken, called "Future" bears the inspiration, "What is past is prologue." In that one Shakespearean line, we can see our past as an introduction to a greater future. And so it is with health care, when in 1978 global health leaders convened at Alma Ata (now Kazakhstan) to inspire urgent action by the "world community to promote and protect the health of all the people of the world." Through the famous Declaration of Health at Alma Ata (DHAA) - this International Conference on Primary Health Care heralded in a new era of health, characterized by the broad consensus that not only is health a "fundamental human right" but its attainment is "a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector." In other words, achieving health goes beyond the efforts of the individual, and yet like any right, there is an accompanying shared responsibility between patient and primary medical provider in that sacred space of trust and confidence they are supposed to mutually nurture.
Why is this relevant in 2017 especially in the U.S.?
The development of the current U.S. health care system, and related challenges and debates regarding access, quality and costs have many complex associated causes, interrelationships and events that are beyond the scope of this editorial. Three themes emerge for which there is almost universal consensus -current health care spending is unsustainable (=17% of GDP), the US population has poorer health outcomes and shorter lives relative to comparable affluent nations, and marked health disparities exist related to factors such as widening income inequality. Fragmentation of care, medical errors, medical litigation, workforce shortages and burnout compound the picture. Commodification of health will obligatorily continue to fuel apparently unresolvable debates on how best to pay for health care for all US populations. And yet social justice, equity, and community engagement are currently relevant principles that hearken back to those from Alma Ata and support some of the most progressive initiatives aligned with what has now become known as the Quadruple Aim: the prior three aims of improving population health outcomes, decreasing costs, strengthening patient experience of care plus improving the work life of providers and staff. Consumer engagement and population health are just two of the many emerging common strategic themes for health care leaders. In contrast to the tenets of any well-run industry, health care has more waste, harm and inefficiency than anyone finds acceptable. The challenges are great - with over 10,000 people turning 65 years old every day, and ~80% of our most common, chronic and disabling diseases being largely preventable through informed lifestyle choices (e.g., exercise, healthy diets, stress reduction, tobacco cessation, sugar consumption, etc.). So "health systems" (e.g., NashvilleHealth among many others) are obligated to proactively respond to community needs and go beyond caring for the sick and injured to preventing disease, promoting health and collaborating with public health entities. Sadly, only ~3% of our over $3.2 trillion national health expenditures is devoted to prevention activities, so for sure it's an uphill political climb but having healthier populations will truly bend the cost curve.
The overarching influence of Alma Ata was seen in the way primary health care was considered the backbone of a strong health system, nationally, regionally or locally, with a natural interdependence with the patients' communities. Participating nations were expected to build an effective network of primary care providers (e.g., strong medical education, incentives and relative status) and mobilize community development, engage community health workers, develop a "health-in-all- policies" view, and use "practical, scientifically sound technology" (DHAA). David Kindig's work shows that 80% of the determining factors contributing to one's health map to one's socioeconomic status, behavioral choices, and environments, with only 20% in the clinical care domain. The medical profession can still have profound impact on the other domains through new approaches - preventive medicine, social medicine, geomedicine, lifestyle medicine, and integrative medicine.
Rishi Manchanda (from www.healthbegins.org) makes the case for providers to go more "upstream" and address social determinants of health. The current Robert Woods Johnson "Culture of Health" movement reinforces this message and more. Moving forward, upstream oriented providers can accelerate their efforts through a broader deeper knowledge of their communities as derived from Community Health Needs Assessments and accompanying Community Health Improvement Plans, now widely mandated in the U.S. Alternative payment models and innovation have enabled advancements such as the medical home, medical neighborhood and accountable health and accountable care communities, all close philosophical siblings of the ground-breaking Community Oriented Primary Care (COPC) and Communities of Solution (CoS - 1967 Folsom Report) models. The CoS is a "powerful, motivating framework because of its ability to balance the often competing philosophies of social and individual responsibility."[i] Whole community approaches can often transcend differences in the local political arena. And recent studies unequivocally show county-level geographic disparities in life expectancy, reinforcing the mixed reality that communities are where people work, pray, eat, live but also prematurely die. Fortunately, evolving thought in both health care and public health are arriving at similar conclusions, i.e., that community integrated prevention and care models linking medical and social services can improve outcomes, increase access, and reduce costs.
The Alma Ata Declaration of Health was just that "a declaration on health, how it arises, how it is promoted and how it is protected. It was not a manifesto on disease management, nor relevant policy guidance on how disease management systems can be created. It was instead an affirmation in and of itself. Our health professions education systems for medicine, nursing and even public health have traditionally focused on disease and pathogenesis, identifying risk factors and natural history pathologic processes that culminate in disease, injury and death. And yet wholeness and wellness across the dimensions" body, mind, spirit, relationship, environment, occupation and social context are what we need to create for our patients and for ourselves as healers. This is the contrasting model of salutogenesis (saluto = health/wellness; genesis = creation), as coined by Aaron Antonovsky. Don Berwick and other luminaries have extended the concept that salutogenesis must be aspired for as the basis of any true health system.
As our patient's pursue happiness and joy even as they reclaim their health from disease, injury or even near-fatal events, they also have responsibilities, as we all do "since in the realm of health we are all at risk for being patients, getting ill, and having varying levels of imbalance throughout our lives. But medical and nursing providers can reassure people they are not alone in creating and maintaining health. We can try to mitigate risk and promote our own well-being through our individual, collective and social realms. The Declaration is duly diligent to the themes of "self-reliance" and "self-determination" (DHAA). Once again, we find our future course charted in past wisdom via the futuristic and yet perennial words of Alma Ata, "people have the right and duty to participate individually and collectively in...their health care" (=patient engagement).
Recent evidence-based monographs have artfully speculated about the future of primary care, health and health care, and even public health in 2-3 decades (www.altfutures.org). Reflecting on those monographs may well be touchstones for that inscription and statue by Aitken, and most of all for the year 1978, when the global community came together to shed light on how we can have a functional health system - a system that is itself healthy and just, flexible and informed, proactive and efficient, frugal and strategic to ensure people are healthy.