The Nation Newspaper

Category: Rethink Health

  • Healthcare for immigrants in 30 languages

    A pioneering program featuring cultural mediators and interpreters at Madrid’s Ramón y Cajal Hospital provides assistance to over 5,700 migrants and trains another 10,000 in TB and sex education.

    In many African countries, almost nothing related to healthcare is free.

    That’s why an offer of free medical tests and treatment upon an immigrant’s arrival in Spain can be met with skepticism.

    Recipients might wonder: will my fluids end up on the black market? Why do they need so much blood?

    When a doctor and a patient speak different languages, everything from explaining the reason for a pain to discrediting blood-trafficking rumors is a challenge.

    Salud Entre Culturas is a pioneering healthcare program that was born in 2006 within the Tropical Diseases unit of the Madrid-based Ramón y Cajal Hospital.

    Its mission is to provide healthcare to people who don’t speak Spanish, and who have limited English and French skills.

    These are mainly sub-Saharan young men, but the program is open to all nationalities. The focus is on breaking the language barrier while getting past cultural differences.

    “Many do not know what hepatitis is. You talk about malaria and some think it spreads by water, or that AIDS doesn’t exist.

    Explaining dormant tuberculosis, diagnosing a chronic disease or telling them they need blood tests every six months is a hurdle,” says director Rogelio López-Vélez, MD.

    López-Vélez leads a team of five regular professionals and several assistants. Translators participate in consultations with migrants who know only certain African languages.

    In this facility, up to 30 African languages have been spoken, as well as Romanian, Russian and Arabic.

    The immigrants’ most common countries of origin include Cameroon, Côte d’Ivoire, Guinea Conakry, Ukraine and most recently, Syria.

    Suleiman, age 25, attended his first doctor’s appointment in Spain with two friends.

    “We were concerned about whether they would understand us and be able to come up with a diagnosis,” he says.

    “Now that we’ve been through this, we really appreciate the interpreting service. Translators are of tremendous help.

    Without them this would be extremely difficult and unreliable.” All three of them come from Guinea Conakry and say that learning Spanish is their top priority.

    The program appeared at the same time as the cayuco boat crisis, when 39,180 people landed in small “patera” boats on the coast of the Canary Islands.

    Since then, healthcare professionals have treated more than 5,700 migrants and have created specialized workshops for nearly 10,000 people, raising awareness about issues such as TB, HIV-AIDS and sex education.

    In 2017, Madrid’s Health Council made the program official, recognizing the importance of cultural mediation and interpreting services.

    Alongside López-Vélez, psychologist Anne Guionet, interpreter Bárbara Navaza and Doctor Miriam Navarro bolstered the initiative. Navarro, who no longer practices day-to-day medical care, still remembers their first steps:

    “From the very beginning, we realized the unease it caused for these people to have a heap of tests done with no one able to explain them in their own language, and all the misconceptions such a situation entailed.”

    Migrants normally come for their first medical appointments thanks to the workshops they regularly attend, organized by members of Salud Entre Culturas at NGOs, shared flats or even local bars.

    The project started with sub-Saharan Africans and progressively opened up to other nationalities. “In these meetings we run quick HIV tests and organize themed talks based on the needs of our respective organizations,” Peña says.

    The team has started analyzing the impact of these workshops. Based on data collected by Navarro, at first only 47 percent of attendees acknowledged the existence of AIDS — a figure that rose to 95 percent at the end of the workshop.

    Over the years, the project has received financing from public sources such as the National AIDS Plan and European funds, as well as from private investors and donors.

    From university and jumping the fence

    In 2008, Entre Culturas trained a group of Africans to become health and cultural mediators. This year, they were able to train four more. Serigne Fall of Senegal was part of the first group; the second one included Serge Hoys, a Cameroonian who joined in June.

    Their stories have a rather different starting point but converged in this unit. While Fall came to Spain from France, where he studied French philology, Hoys literally jumped over the fence at Melilla. They both ended up working for the organization.

    “In Cameroon, there are over 187 official dialects,” Hoys says. “Imagine what it’s like to talk to people who only speak these languages. This is not just any job; the conditions in which the sub-Saharan Africans arrive here are tough.

    Some of them have never been to a medical practice, nor have they been admitted to a hospital or had a flu shot. This is what we need to be aware of,” he stresses.

    “We’re pushing for interpreters to become part of the public health system. A doctor shouldn’t have to draw a picture for a patient.”

    Now the service’s greatest challenge is to follow up on treatments. “It’s a very unstable demographic,” López-Vélez says, “because they can only stay in foster homes in Madrid for 90 days at most…and many of them leave afterwards.

    It is important to adapt protocols.” For the time being, at least, the program has managed to remove linguistic barriers, and to convince patients that their blood is in good hands.

  • Midwives could reduce maternal mortality rates in South Africa

    Could midwives be the solution to curbing South Africa’s dismal maternal mortality rate,currently among the highest in the world?

    The rheumatologist and health economist Dr.Brian Ruff seems to think so. He is the CEO of South African private healthcare management company PPO Serve.

    In order to make births safer and cheaper for women in the lowermiddle class who lack health insurance and are often unable to afford high quality private-sector deliveries, his company created in June 2017 The Birthing Team, an initiative based on midwifery.

    In South Africa, about 134 mothers die in childbirth for every 100,000 children who are born.

    Although this death rate has dropped by almost a third in public hospitals in recent years, according to research published by the peer-reviewed South African Medical Journal,specialists note that urgent interventions are needed to achieve the country’s goal of halving these losses by 2030.

    “In the United Kingdom, all low-risk pregnancy patients are managed by midwives,” said gynaecologist Dr. Howard Manyonga, who leads The Birthing Team. He noted that in South Africa, midwives employed by private hospitals are “underused and become de-skilled,”adding that the best ones often leave the country.

    Today, the Birthing Team’s initiative is underway at three private hospitals in Durban,Johannesburg and Pretoria.

    Obstetrician Dr. Selina Ramatsoso, one of the team’s members in Pretoria, said the initiative empowered these specialist caregivers.

    The Birthing Team’s care package covers mothers and babies starting at 20 weeks of pregnancy and until six weeks after birth, and comprises everything from tests to examinations, medication, three ultrasounds and delivery —including a C-section if necessary.

    It costs around 21,000 South African rands (USD 1,500).

    In contrast, women who have health insurance pay 38,000 rands on average for delivery and accommodation in a private hospital, according to Discovery Health Medical Scheme,the largest private health insurer in the country.

    At overcrowded public hospitals, uninsured women can spend up to 36 hours in labour waiting for an emergency cesarean. Such long waits can lead to babies being born with brain damage.

    Ruff’s holistic approach can bridge these gaps. In the private sector, which serves about 16percent of the population, obstetric specialists usually tend to all pregnant women, whereas a midwife supported by a team of doctors could manage uncomplicated pregnancies, saving time and money.

    That is why the Birthing Team’s model costs less; obstetricians treat patients only twice during their pregnancy (at their first appointment and at 36 weeks, unless they present complications) and a midwife manages most appointments and deliveries. The team’s scope does not include highly complex cases or patients who are likely to deliver prematurely —although so far they have only rejected five percent of all the cases.

    The patient’s medical files are discussed weekly among midwives and doctors, who remain fully available for telephone consultations.

    Dr. Ramatsoso, who now only attends patients who suffer complications, believes the system helps doctors to use their skills more efficiently.

    As a result, the initiative assisted 250 births in the past year, none of which resulted in maternal or child deaths.

    “One baby was born without enough oxygen but after a few days in intensive care, the baby recovered completely and had no lasting brain damage,” Dr.Manyonga said.

    And while about 62 percent of middle-class women with medical aid plans have C-sections,according to the latest Council for Medical Schemes report, the Birthing Team system has managed to drop C-section rates among its patients to only 40 percent. “We monitor women’s experiences. They enjoy being managed by a midwife who can afford to spend up to an hour with them at each appointment,” said Dr. Manyonga.

    A Johannesburg mother, Natascha Loubser, used the Birthing Team for her pregnancy and 14-hour labour.

    Throughout my pregnancy and checkups they were wonderful,” she said,adding that she’s grateful to everyone who assisted in bringing her “princess” into the world- particularly to her midwife.

    This year, the Birthing Team bid for a South African government tender that would enable the approach to enter the country’s planned National Health Insurance system and assist with high-risk pregnancies.

    If granted, the teams would “assist in 11 districts across the country with antenatal care and high-risk deliveries,” noted Dr. Manyonga, adding that discussions with low-cost insurance providers were also underway.

    Over time, the team aims to roll out the programme nationwide.

  • The promise of eHealth for rural India

    As a scientist at the New Delhi-based Institute of Genomics and Integrative Biology (IGIB),Dr. Anurag Agrawal often ponders the links between genes and lung disease.

    Could there be a connection between height, weight and a propensity to develop asthma? How might diet affect chronic obstructive pulmonary disease?

    In the winter of 2013, he started thinking: What if there was a way to use shipping containers to collect and mine people’s health records, thereby gaining insights into disease to provide treatment?

    One such container eventually made its way to a village in Uttar Pradesh. Here, villagers could gain access to a paramedic, deposit blood samples and have a qualified doctor advise them by monitor.

    They could submit a cardiogram, have a doctor look at it within days and,if necessary, sound an alert.

    The IGIB is one of 39 state-funded Council for Scientific and Industrial Research laboratories.
    As a government establishment, it had limited scope to expand.

    But five years ago, IGIB partnered with Narayana Health (NH), a renowned Indian multi-specialty hospital chain, and the American IT giant Hewlett-Packard, to install more than 40 such ‘eHealth’ centres in various parts of the country.

    The NH network now uses these shipping containers as part of its rural health outreach,which includes electronic medical records (EMR), bio-metric patient identification and integrated diagnostic devices.

    The HP cloud-enabled technology allows for the monitoring of clinical and administrative data.

    With one doctor for every 11,000 people, India falls far below the World Health Organisation standards, which specifies one doctor per 1,000 patients.

    The problem is particularly stark in villages, where access to primary healthcare centres is a major challenge, and where it is difficult to attract qualified doctors.

    In theory, the spread of mobile phones, falling internet data rates and inexpensive healthcare lodging facilities (such as shipping containers) can lead to significant penetration of eHealth into villages.

    In the field of radiology, for instance, telemedicine has been a game changer. It’s possible for remote eHealth centres to beam MRIs or cardiograms into well-equipped hospitals in cities to be studied by experts.

    But Agrawal, who now heads the IGIB, says that success is still limited.

    “The time of qualified doctors is still a huge cost,” he noted, “and while telemedicine has certainly made access to second opinions and to international consultation easier in urban areas, I’m not sure whether rural India has benefited as much.”

    Ajoy Khanderia, CEO of Gramin Health Care (GHC), an Indian startup that provides health services in underserved areas, believes rural India is where the potential of providing affordable health care can be maximised.

    His team has set up more than 100 clinics across six states and conducted over 4,800 health camps.

    The startup says it earned 10 million Indian rupees (USD 138,461) in 2017 and expects a five-fold increase in 2018.

    Unlike NH’s shipping containers, GHC has established its health centres in bazaar shops provided by the Indian Farmers Fertilizers Cooperative Limited (IFFCO), which holds a 26percent stake in the company.

    These centres are staffed and digitised healthcare clinics where, according to the company, “anyone can walk in, get a proper diagnosis, a subsidized doctor consultation and gain access to branded high-quality reliable medicines through its advanced assisted medicine technology platform.

    ” In the kiosks, a nurse conducts physical examinations and contacts a doctor using a live audio or video feed. Patients can submit their vital signs via a tele-diagnostics kit.

    The whole process doesn’t take more than 15 minutes, according to GHC. But difficulties remain.

    “The hardest is to change patient behaviour and get them to come to institutional healthcare instead of the traditional village quack and building,” Khanderia said.

    “The other important aspect is that we are not an NGO and we have to be affordable yet cost effective.”

    In villages where GHC has a presence, penetration is less than 20 percent of the population.

    It’s higher in the states of UttarPradesh and Haryana, where the company reaches up to 15 villages per operational centre and about 20,000 patients in total each year.

    To access their services, patients buy a health card that costs 120 rupees, or less than two dollars, per year.

    GHC focuses mainly on pathology services, since surgery requires centralised facilities.

    Analysts from the George Institute for Global Health, while optimistic about the potential of eHealth to provide health care delivery, say there’s a long way to go.

    In 2017, the institute’s eHealth review pointed out that regulation is needed: “Most of the apps have been developed by independent developers rather than by healthcare organizations.

    The clinical value and health benefits of these apps are inadequately documented, leaving uncertainty about their effectiveness and efficacy.”

    In the same way that Agrawal saw the potential for gathering health data, via rural healthcare, to uncover clues to diseases, GHC hopes to benefit from this information too.

    The team has collected more than 150,000 patients’ health records across the country, and plans to open 4,000 more kiosks and 1,000 health centres (polyclinics) in the next five years.

    A state-funded insurance programme that aims to allocate 500,000 rupees worth of coverage a year to every poor family—about 40 percent of India’s population—could be helpful to eHealth initiatives.

    “Given that cost of access is a major hurdle, I would expect insurance schemes to play their role,” said Agrawal.

  • A Visit to the Health Center

    Access to health services in Germany is unevenly distributed. In disadvantaged neighborhoods you’ll find far fewer doctors then in wealthy areas. A new concept in a district of Hamburg could be a model for a nationwide solution.

    Show me your neighborhood and I’ll tell you how healthy you are and how long you’re likely to live. In Germany, when it comes to health and illness rates, huge inequalities exist.

    In many underprivileged districts, where income levels are particularly low, people die on average five years earlier than in wealthier districts.

    But this is starting to change in the East Hamburg districts of Billstedt and Horn.

    Income in these areas is 40 percent lower than the average for Hamburg, and a large number of residents live below the poverty line.

    Education levels are relatively low and everyday life is fraught with troubles.

    This was certainly the case for Samira Afalid*, age 31, who saw her gynecologist several times a month in recent years, in an effort to have children.

    She experienced three stillbirths, all before the 23rd week of pregnancy, for no apparent physical reason other than that she was overweight, which can interfere with both conception and pregnancy.

    According to her doctor, Afalid needed someone to treat her, support her and help her lose weight over a period of time, which would also boost her self esteem.

    The gynecologist could not afford the time because her practice was located in the Billstedt and Horn area, where people tend to seek medical attention more frequently than the average, due to a lack of knowledge about everyday health matters.

    For this reason, a growing number of doctors are leaving the district, looking to settle somewhere less stressful and where patients can afford to pay higher fees.

    Those who stay behind are left with more patients to tend to, and even less time to treat them and educate them on health issues.

    Afalid’s gynecologist was able to help her after all. She referred her to a new health kiosk in the heart of the district, part of the Health for Billstedt/Horn project, founded in August 2017.

    “The healthcare kiosk is one of the core elements of the project,” says Alexander Fischer, who was involved in developing the concept. It was launched by a physicians’ network, the health management company OptiMedis AG, and the local district hospital, and supported by the city of Hamburg.

    Staffed by healthcare professionals, including nutrition advisors, nurses and midwives, the kiosk does not have any doctors on its payroll. Anyone can walk in without an appointment and get a first consultation right away.

    “We want to make the healthcare system as accessible as possible,” says Fischer. And with a high concentration of immigrants in the area, the staff can speak several languages, notably Turkish.

    At one appointment, Afalid spent 45 minutes reviewing her case with a midwife – something that would have been unimaginable with her gynecologist — and designing a plan to see a nutrition counselor once a week at the health kiosk. Four months later, she had lost 25 kilograms.

    Healthcare professionals taking on the workload of doctors is increasingly prevalent in Germany. In rural areas, doctors’ assistants conduct routine house visits now.

    But the Health for Billstedt/Horn project is the most comprehensive program of its kind so far. It aims to fill in the gaps left by overloaded physicians, by providing basic health advice and information, free of charge.

    “We often have to explain things that seem obvious,” says Fischer, quoting the example of a patient who thought that replacing sugar with butterscotch syrup would help him control his blood sugar levels.

    Gerd Fass, a surgeon involved with the project since its launch, says it changed his life.

    “Sometimes I would feel overwhelmed by the expectations of the same patients asking the same questions,” he says.

    One of his patients used to come to his practice often, complaining about back pain. After referring him to the health center, the man’s consults became less frequent.

    “He’s got a completely different attitude now – less ‘The doctor will make me well’ and more ‘How can I contribute towards making myself well?’” notes Fass.

    The project’s scope goes beyond the healthcare kiosk. “We offer regular training sessions for staff from more than 100 medical institutions in the area,” says Fischer.

    These include doctors’ practices, care facilities, sports associations and parental education establishments, and aim to guide people through the healthcare system. Thanks to its many activities, Health for Billstedt/Horn has developed a reputation throughout the district.

    The project’s founders’ long-term goal is for their work to influence life expectancy and burden of disease rates in these areas, and hopefully, to see the concept applied across Germany.

    But although the Hamburg Center for Health Economics (HCHE) will evaluate the effectiveness and transferability of the project to other regions, there aren’t any relevant statistics available yet.

    Germany’s Federal Joint Committee’s innovation fund has provided the financial support to run the project for three years, but future funding is uncertain, and it’s not yet clear that the additional public health costs will pay off in the end.

    The project could ultimately be classified as “nice but not fundable,” and simply disappear.

    But it doesn’t look like it will. People are happy with the project – and more enthusiastic about taking responsibility for their own health.

    Since overhauling her approach to nutrition, Samira Afalid hasn’t become pregnant yet. But, in better health and feeling optimistic about her future, she’s ready to try again soon.

    *Not her real name

  • It’s time to reshape the way we think about health issues

    Imagine a world where Alexander Fleming’s discovery of penicillin 90 years ago remained unknown to most of the planet. Millions of lives would have been needlessly lost.

    Sharing knowledge of the many different and innovative ways to solve major health issues can have immeasurable benefit.

    Over the next three weeks, Sparknews is proud to invite five leading newspapers from five different countries (Der Spiegel, El Pais, The Sunday Times, The Nation & The Hindu) to explore stories of solutions that are having an impact on today’s most pressing healthcare challenges.

    These challenges have evolved since Fleming’s time. We have made important progress against infectious diseases, but studies reveal that our way of life has become an even greater threat to our health.

    Stress, junk food, substance abuse, pollution and endocrine disrupting chemicals have paved the way for the growth of noncommunicable diseases such as cancer, cardiovascular disease, respiratory disease and diabetes.

    Noncommunicable diseases are now responsible for more than 70 percent of deaths globally, mostly among lower income communities.

    The same way of life that’s impoverishing our physical condition is prompting a decline in our state of mind.

    According to the World Health Organization, suicide is the second leading cause of death among 15-29-year olds, and death due to dementia more than doubled between 2000 and 2016.

    The stigma surrounding mental illness and treatment renders this issue even more complex.

    Considerations such as age, gender, sexual orientation and migration status tend to exclude certain populations from the healthcare system, leaving them vulnerable to various types of disease and psychological distress.

    As the articles published in The Nation show, there is reason for hope. Even if medical research has traditionally focused more on curing disease than preventing it, we’re at the dawn of a more open-minded approach to medicine and health.

    Researchers, scientists, individuals and organizations all over the world are working on new ways to prevent noncommunicable diseases, to provide universal access to healthcare, and to address and destigmatize mental illness.

    The medical community and the general public are increasingly embracing alternative approaches to prevent what’s preventable and live our fullest possible lives with what’s not.

    For example, telemedicine services can address overcrowded hospitals, while providing healthcare access to people in remote locations. Affordable nasal filters could prevent pulmonary disease linked to air pollution.

    Training refugees to provide psychological counseling to their peers might help the latter to overcome traumatic events.

    Solutions such as these have the potential to save lives and reshape the way we think about healthcare. They can offer us better, longer, healthier lives, no matter our differences or socio-economic status.

    You can be a part of the solution – reading and sharing these stories so that they reach every corner of the globe.

    Let’s rethink health together.