Chronic Conditions | Pittsburgh City Paper

Chronic Conditions

Pittsburgh's Global Links makes the best of a flawed health-care system

Earlier this year, the University of Pittsburgh Medical Center learned that it no longer needed 3,000 of its IV poles -- those wheeled, bedside metal stands from which nurses hang drip bags. The hospital had acquired new infusion pumps with bigger LED screens: The pumps would help prevent medical errors, but their weight risked toppling the old poles, which the hospital now had to dispose of.

In the U.S. health-care system, IV poles inhabit every hospital room, and they don't come cheap; these had cost $200 or more apiece. In much of the developing world, meanwhile, hospitals often don't have any IV poles. The only way to elevate an IV bag there is to nail it to the wall, meaning impoverished patients can't leave their beds. The lucky ones get relatives to hold the bags for them so they can move around.

Transferring America's medical surplus to developing countries is the mission of a growing nonprofit industry. Its oldest practitioners include Pittsburgh-based Global Links, which next year marks 20 years in the trade. The group encourages hospitals to set aside items they once threw out -- everything from near-weightless silk sutures to upholstered, steel-framed exam tables.

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Carnegie Mellon work-study student Angelina Gonzalez processes medical surplus for shipment overseas.

The IV poles came into Global Links' possession thanks to its long association with UPMC; a biomedical engineer knew to notify management of the newly surplus hardware. By late October, hundreds of the poles had already been cleaned and painted by Global Links' small army of volunteers, then shipped to hospitals in places like Honduras and Nicaragua.

The need for such items is great. Global Links co-founder and executive director Kathleen Hower says the 3,000-plus poles "will probably only hold us for about two years."

As one of roughly two dozen groups working full time to redistribute U.S. medical surplus, Global Links has a two-fold mission: improving health care in developing countries while keeping usable surplus from clogging landfills at home. And there is plenty of opportunity for growth. This year, Global Links will ship 34 40-foot-long cargo containers, holding 340 tons of supplies, a record for the group. Next year, it's aiming for 40.

Demand rose this year especially because of hurricanes Ike and Gustav, which wreaked devastation in Cuba. But the health-care industry's production of surplus seems as limitless as the demand for it: Here in the developed world, we simply have a lot extra. Yet, as a Global Links pamphlet puts it, "People overseas die for lack of what we throw away."

Most stories about nonprofit agencies end here: a heart-warming tale about sharing America's bounty with impoverished people in the developing world. But look closer, the way people like Hower do, and you may see that Global Links is responding not just to the problems in developing nations, but to symptoms of trouble in our own.

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Global Links volunteers process medical surplus for shipment overseas.

Asked her age, Hower says she's recently become a grandmother. She's low-keyed and businesslike, with a fondness for turquoise jewelry. She grew up in West View, worked in hospital administration, took time off to raise kids, and then went part time at the University of Pittsburgh's Center for International Studies. Conversations with students and professors there, some from Latin America, led her "to think about my place in the world," she says.

In the 1980s, Hower knew an ophthalmologist here who'd take big bags of surplus sutures on humanitarian trips to Pakistan. In 1989 she launched Global Links with two colleagues. Their first office was one of the ophthalmologist's tiny Downtown exam rooms.

Today, Global Links occupies the second floor of a former industrial laundry on Penn Avenue, in Garfield. It's across the street from Allegheny Cemetery, but rather than a graveyard, it's a kind of clinic in itself, reanimating discarded objects for life-enhancing work overseas.

Much of the high-ceilinged space holds metal shelves that bear cardboard boxes and plastic tubs full of unused syringes, specimen cups and items both mundane and specialized: Band-Aids, cotton balls and wash basins; endotracheal tubes, cervical scrapers and a box marked "saw blades, assorted."

Larger donated items -- beds, wheelchairs, exam tables -- go to Global Links' 23,000-square-foot warehouse, in Homewood. But it's here on Penn that some 1,500 volunteers annually contribute most of the 6,000 hours of labor on which the group depends to package material. Most of it is bound for Bolivia, Cuba, the Dominican Republic, Guatemala, Guyana, Haiti, Honduras, Jamaica and Nicaragua. (Sutures, which remain Global Links' signature item, are distributed in a couple of dozen additional countries worldwide.)

Most of the material comes from hospitals. The lion's share is from the sprawling UPMC system; other contributors include West Penn Allegheny, Jefferson Regional Medical Center, and clinics, private practices and individuals.

Items arrive in boxes and plastic bags that deliverymen stack nearly to the ceiling. Often, no one knows what's inside. A crew, typically college work-study students, sort through it all, piling gauze here, packets of antiseptic ointment there. Volunteers inspect items further, then box them for shipment. Expiration dates are crucial: Nothing past or even close to expiration is shipped -- except to Cuba, where a half-century U.S. trade embargo heightens need, and where the infrastructure exists to resterilize possibly contaminated items. (Global Links has a special federal license to donate to Cuba.)

The needs of clinics and hospitals in the developing world are often quite basic -- sometimes, they don't involve "medical equipment" at all. Much of what Global Links ships is furniture: waiting-room chairs, filing cabinets, exam tables and intensive-care beds, needed for administrative purposes or the simple goal of allowing patients and caregivers a measure of dignity.

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Photo: Courtesy of Global Links
In many developing countries, shortages require health-care workers to wash exam gloves for reuse.

But shipments of actual medical supplies are substantial. In 2008, Global Links sent overseas about 146,000 syringes and 293 walkers. Blood-pressure monitors are coveted. Every year, the group ships more than 100,000 exam and surgery gloves to facilities like the one in Haiti depicted in a photograph displayed in the office, where used gloves have been washed and hung to dry on racks, for reuse. (Once, at Nicaragua's largest women's hospital, Global Links head Hower saw a nurse mix toxic chemotherapy drugs bare-handed for lack of gloves.) In other pictures, Haitian nurses sit cutting bulk gauze into squares, and a kid lays on a rusty gurney whose sole bedding is a bath towel.

In 2007, Global Links sent 75,000 sutures to dozens of hospitals around the world, places that would have otherwise delayed life-saving surgery; asked patients to buy and bring their own suture; or risked infection by improvising with fishing line or nonsterile thread.

The group has 15 staffers and a budget of $1 million, funded by grants, recipient nations and individual cash donors. Overall, in 2007, the group sent 25 sea containers of materials worth more than $5 million to hospitals overseas. The 34 containers it shipped this year were worth close to $30 million, an unusual jump in dollar value due mostly to several manufacturers' one-time donations of surplus pharmaceuticals.

On a recent weekday morning at Global Links, with Latin guitar music sounding from a stereo, a half-dozen volunteers and a few staffers bustled about a big table stacked with surplus. Some filled Ziploc bags with surgical strips (for neurosurgery), then squeezed the air out to pack them in boxes. Others packed stretch briefs and sanitary napkins together, for new mothers somewhere in the global South.

Volunteers come from schools, churches and groups like Pittsburgh Cares; others are individuals. "Once you get here you just don't want to leave," says Cathy Nalesnik, a mom and former medical technologist from Shaler who's volunteered twice weekly since 2001. "All the stuff we packed would have ended up in a landfill in Pittsburgh."

Hospitals like Global Links, too. "The gap they fill is just fantastic," says David Hargraves, UPMC's supply-chain manager. "We want to throw away as little as possible."

UPMC oversees contracts for more than $500 million in goods annually. That's roughly one-sixth of all the health-care spending in Guatemala -- a nation of 13 million people.

Global Links works with hospital staff to improve awareness about setting surplus aside. Such efforts second the trend toward "greening" health-care facilities, which includes waste reduction, along with hospitals' desire to avoid per-ton disposal fees and do some good besides. Global Links, for instance, is part of UPMC's transition team for moving Children's Hospital to its new Lawrenceville complex.

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Photo: Courtesy of Global Links.
In Nicaragua, a donated opthalmoscope is used.

Global Links takes pains to emphasize, however, that it's not about just shipping tonnage. "Giving people stuff isn't going to improve health care," says Hower. Too many charitable groups, she says, send donations overseas without knowing whether the items are needed, or even usable. "It's a terrible trend that's seen all over the developing world -- the U.S. just dumping things, basically," says Angela Garcia, the group's deputy director.

Hower and other staffers address that concern by working with the Pan American Health Organization (an affiliate of the World Health Organization), local ministries of health and individual hospitals to focus on needs. There are also frequent trips overseas.

Hower remembers her first trip to Nicaragua, where Global Links sent its first shipment in the early 1990s, just after the civil war ended. "The devastation of 10 years of war there was just pretty awful," she says. "People were just shell-shocked." At a women's hospital in Managua, "There was blood on the floor in the halls. Literally, women were dying of hunger and bleeding out," Hower says. "I just remember walking out in the hall and stepping around bloody gauze on the floor."

One recent recipient facility was Hospital Coatepeque, west of Guatemala City. The hospital, which lacked an intensive-care unit, was struggling with an increased load of critically ill patients. In 2007, Hower connected the hospital to Jefferson Regional, in the South Hills, which was replacing all its ICU patient monitors, and UPMC Shadyside, which was replacing its ICU beds. In October, Hower toured Hospital Coatepeque. "My visit, they were having the dedication of the new intensive-care unit," she says. At least three patients there were already waiting to use it.

None of what's donated to Global Links, of course, is "medical waste," the contaminated stuff that exits hospitals in red biohazard bags. But some would-be surplus is among the estimated 20 or more pounds of trash a day generated per hospital patient. (That's about five times what a nonhospitalized American produces.)

At U.S. hospitals, surplus is endemic, and its sources are many. Some, like UPMC's IV poles, is donated because the hospital has purchased a technological upgrade or other replacement. Some surplus comes available when a practice closes or downsizes, or a facility relocates. And some involves items that the hospital -- often motivated by liability concerns or federal safety guidelines -- simply chooses not to use: plastic-bagged surgery kits containing surgical drapes and other items, for instance, whose outer bag has been punctured although the inner, sterile seal is unbroken.

Or say a box of sutures is dented, but the internal sterile pack is undamaged. "We might not put it on the shelf, [but] the manufacturer wouldn't take it back for full credit," says UPMC's Hargraves. It's surplus. Even items that weren't sterile to start with -- boxes of latex exam gloves whose side flap is torn, for instance -- end up on Global Links' shelves.

Much medical surplus consists of the profusion of single-use items that have been introduced over just the past few decades. Once, ice packs, scalpels, even syringes were cleaned and reused. But as cheaper materials took over -- plastic for glass syringes, for instance -- even unused items are more likely to end up in the trash, or as surplus.

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Global Links volunteer Cathy Nalesnik seals a box of re-packed surplus.

"We used to have sterile drapes that were cotton, years and years ago," says Dianne Lataille, a radiology nurse at Allegheny General Hospital. "Now everything's paper." If only two of the three surgeon's gowns in a pack are used, she says, the third is thrown away. Stacks of unused (but resterilizable) gauze leave operating rooms in the trash, too.

Even seemingly durable items end up surplus: Bins and pegboards at Global Links bristle with stainless-steel hemostats (for compressing damaged blood vessels) forceps and vascular clamps, some of them heavy-duty and a foot long. "They never even had disposable" when she became a nurse, in 1976, says Lataille.

Other items, especially furniture, are discarded simply because they're no longer fashionable -- "like those things from the '80s that are orange," says Hower. Hospitals just don't want them in their waiting rooms, making the place look outmoded. Global Links' warehouse contains a small workshop for repairing the headboards of beds and fabricating parts for broken wheelchairs; one staffer reupholsters damaged furniture.

In addition, there is stuff that never even makes it to a U.S. health-care facility -- such manufacturer's overstock, for instance, as the 350,000 dialysis needles boxed up in Global Links' warehouse and bound for Jamaica.

Some surplus seems to make even less sense. Global Links sometimes receives nearly full cases of product samples (pharmaceuticals, say) because even when UPMC requests just one or two samples, "The manufacturer sends a case," says Garcia, the deputy director. "It's easier for manufacturers to distribute by the case lot."

Then there's the matter of expiration dates, which accompany essentially every product, even things that you wouldn't think could "expire." While Global Links withholds expired items from its shipments, many donations these days arrive in kit form -- like a pediatric/infant lumbar-puncture kit. The kit (used to test for things like meningitis) is packaged by the manufacturer in a molded plastic tray about 18-by-10 inches, with a sealed paper lid. A recent donation of the kits at Global Links was expired -- many hospitals would have just trashed it -- but that designation really applied to only a single item inside: a 2 ml glass ampoule of lidocaine. Almost everything else, including gauze pads and three test tubes, could be culled and repackaged.

One obstacle to intercepting all this surplus is that hospitals have such complex waste streams: "regular" trash, "regular" recyclables, biohazardous materials and items that are reused -- like linens and stainless-steel OR trays. Often, it's just easier for staffers to err on the side of throwing things away. "It might seem faster or easier to do something that's a little wasteful," says Janet Brown, director of sustainable operations for Practice Greenhealth, a nonprofit whose membership includes 600 hospitals nationwide. "To me, it's just a lack of attention."

UPMC's David Hargraves says the hospital has gotten results by emphasizing to employees, "don't ever throw that thing away if there's anything you can do to keep it out of the waste stream."

Despite its rapid growth, says Hower, Global Links can't collect enough donations to satisfy the wish lists of its clients. It can fill only a fraction of the up to 1,000 requests for beds each year, for instance.

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A Global Links shipping list.

Ten years ago, says Nick Hallack, CEO of Dallas-based humanitarian nonprofit Medisend, it was estimated that 16,000 cargo containers of medical surplus would meet the needs of the developing world -- and that only 4,000 were being shipped. The developing world's population growth likely means that ratio hasn't improved much since.

Still, if a modestly sized outfit like Global Links, operating mostly in Pittsburgh, can glean millions of dollars' worth of materials annually, how much surplus is there in the country?

In 1994, two Yale anesthesiologists estimated that U.S. operating rooms alone discarded $200 million of usable materials. And Hallack used to say that U.S. health care -- a $2 trillion-a-year industry -- generates almost $10 billion a year in medical surplus. Today he no longer cites the figure, simply saying instead that the amount of surplus is "an enormity."

For some critics of America's health-care system, the vast quantities of surplus are just one aspect of a larger problem -- mainly, that there is no American health-care system. Instead, says financial journalist Maggie Mahar, we have "laissez-faire chaos." One result is that, if the developing world has too little of the right kind of health care, we have too much of the wrong kind.

"Our whole health-care system is designed largely for the benefit of people who make profit off it, rather than patients," says Mahar, author of the 2006 book Money-Driven Medicine: The Real Reason Health Care Costs So Much.

That creates overspending in several ways, she says. One is overcapacity: Too many hospitals compete for too few patients, whom doctors then hospitalize more than is necessary. "Once the beds are there, we fill them," says Mahar, by phone from New York.

Mahar -- whose earlier books include a study of Wall Street called Bull! A History of the Boom and Bust 1982-2004 -- describes a "medical arms race" between health-care providers that leads to rapid turnover of hardware. "Doctors like toys, and it's easy to sell doctors toys," she says. And in general, she adds, "It's not benefiting patients, certainly not in a cost-effective way."

In Money-Driven Medicine, Mahar concludes that "up to one out of every three dollars [spent on health care] is squandered on unnecessary tests, unproved procedures, and overpriced drugs and devices that too often are not better than the less expensive products that they have replaced." The media's fascination with new technology and "miracle cures" drive this equation -- even though numerous studies suggest that decades of new gear, for instance, have failed to improve diagnosis rates for terminally ill patients.

In its Dartmouth Atlas of Health Care 2008, The Dartmouth Institute for Health Policy and Clinical Practice confirms that regions of the country with lots of hospital beds and medical services tend to overtreat chronically ill Medicare patients. This wastes resources, especially because regions that provide more treatment actually experience worse patient outcomes than regions providing more modest services. One possible reason: Unnecessary hospital visits increase the risk of hospital-acquired infections.

Meanwhile, Americans spend nearly twice as much per-capita on health care ($5,711, according to 2006 World Health Organization figures) as the nearest rival, Germany ($3,204). For years, health-care spending here has risen at more than twice the rate of inflation. It now accounts for more than 16 percent of the Gross Domestic Product -- up from 7 percent in 1970.

"For a very long time, this country's had a feeling there's really no limit to what we can spend on health care," says Mahar. Yet despite the spending, American rates of infant mortality and chronic disease, and even longevity, compare unfavorably with those in other rich countries.

Consider, too, how the profit-driven model affects something like expiration dates. Hallack, the Medisend CEO, contends that for many items, manufacturers' expiration dates -- which prompt hospitals and even humanitarian groups to trash donations -- are nothing more than marketing.

Sealed, nondegradable goods like syringes can remain usable for decades, Hallack says. Their "expiration" has less to do with sterility than with an arbitrary five-year "rotation date," he says. "That's the American marketing system."

But the "expiration-date" mythology has such a strong hold that some developing countries will no longer accept "expired" goods, Hallack says -- even if they test sterile.

What's the solution to a money-driven health-care industry? "Basically, we need to contain costs," says Mahar. She suggests adopting practices of other developed nations, most of which have some form of national health insurance. Such practices include tighter review of new drugs and devices so we don't overpay for minimal benefit. It would also help to reward providers for good outcomes -- getting patients to quit smoking; reducing readmittance to hospitals -- rather than for how many people get very sick.

But this line of thinking leads to a terrible irony, one seldom noted amidst (well-deserved) praise for the good works done by groups such as Global Links.

In 2007, Global Links received six bins of sutures from Boston Children's Hospital -- sutures that might "save hundreds of lives" -- simply because the hospital replaced one type of suture or another. The old sutures were shipped abroad, meaning that if the hospital had been more efficient, lives outside the country might have been lost.

Additionally, as Hower points out, the high standards of the United States mean our surplus is often of better quality than what developing countries could get buying new from, say, China. And putting that surplus to use saves landfill space and the damage done by manufacturing new products.

Yet surely, something's amiss when 2.6 billion people -- those who survive on less than $2 a day in the developing world -- have to rely on items other countries simply throw away. Moreover, the current model of medical-surplus donation and distribution scarcely seems efficient. It's highly labor-intensive and dependent on relatively affordable supplies of fossil fuel for shipping.

Perhaps not surprisingly, Global Links' Hower agrees that our health-care philosophy is deeply flawed.

Ideally, of course, health care would generate no waste at all; as with the rest of our unsustainable consumer economy, the health-care system's cost to the planet is too great. But to Hower, the problem isn't the surplus itself -- which she sees as the result of the high-tech care Americans expect and the health-care industry's fear of litigation. The problem is that we're setting a bad example for the developing world.

"People expect the United States to be cutting-edge," she says. But "the way we live and consume, even in the medical community, cannot be transplanted into these other communities. This is not a model they should be following."

Even in the United States, we're treating symptoms rather than causes. "Prevention and maintenance is what we need here," Hower says.

What's more, helpful surplus isn't the only thing we're shipping overseas. As diets change around the world, for instance, we're also exporting the lifestyle diseases of obesity and diabetes to places like China and India.

A better world, Hower contends, would be economically fair enough for all countries to acquire the medical goods they needed, without depending on surplus, or groups like hers. But as much as she abhors waste -- and as much as hospitals in a tight economy try to reduce it -- Hower doesn't anticipate its disappearance. "There's always gonna be surplus here," she says. "Always."