The Nation Newspaper

Tag: #rethinkhealth

  • The aftermath of reducing mental health stigma

    Over the past five years, the world has started talking more openly about mental health.

    The conversation about taking care of your mental health can be heard across the world in conversations among friends, all the way up to the highest levels of government.

    In Canada, from we’re I’m writing, an Ipos poll released in 2017 revealed that “85 percent of Canadians surveyed say they consider mental health to be as important as physical health – another 12 percent say it’s even more important.

    Half of Canadians (49 percent) say they’re personally more comfortable talking about their mental health when compared to two years ago.” Similar statistics have been popping up all over the world.

    In my own life, I have seen the same family members who shamed me for dealing with anxiety, depression and other issues, have started to open up about struggling with their own mental health.

    As a kid, I remember struggling to find the space to talk about how I was feeling. I was sad when others were happy and worried when others were excited.

    When I tried to ask for support from my family, school or community, I was often told how I should “be grateful for my life” or “pray to God to feel better and have my pain lessened,” or —on particularly bad days— that I was an “overdramatic attention seeker making things up.” I felt so alone, so burdensome.

    This reinforced the silence and led me to think I was the problem, and that committing suicide would be the answer.

    After my suicide attempt, I was lucky enough to be found on time and taken to a hospital, where a fellow patient and a nurse encouraged me to keep living.

    Thankfully, these experiences are in stark contrast to how things are like today. Thanks to the anti-stigma conversation, my family and friends now realize how harmful their prejudices were to me, how helpful it is to have access to the proper services and why such services should be available for everyone.

    For me, the most important change is to see that my parents, who survived trauma, war and abuse, are finally talking about it and processing it.

    That, as a family, we have come to realize that my struggles with mental illness reminded them of their own — and that’s why they tried so hard to ignore them. Together, we are ending the cycle of trauma that can follow one generation after the other.

    Destroying the stigma around mental health has been an amazing movement to be part of, but also a shortsighted one. As we have dismantled stigma, the wait lists for mental health services have increased, as funding to mental health services has not kept pace.

    We’ve fostered a conversation around mental health while lacking to boost the services needed to ensure its prevention and treatment, leading to the mental health crisis in young people so often portrayed in the media.

    And while more young people speak about their mental issues, our suicide rates keep growing, mainly because we have policies to track suicide but we lack the resources to fight it where and when we need them.

    A 2018 report by the Canadian O’Brien Institute for Public Health for the NGO Children First Canada illustrates the situation: “Over the last 10 years, there has been a 66 percent increase in emergency department visits, and a 55 percent increase in hospitalizations, of children and youth (age five to 24 years) due to mental health concerns.”

    The same report states that, in a year span, there was an eight percent increase in young people having thoughts of suicide.

    I have experienced this trend personally. As someone using her own story to educate people about mental health issues, I remember the first time people told me that my story had encouraged them to ask for help.

    I remember the pain in their voice when they told me they had thought that admitting they weren’t well was “the big step,” only to realize that the system that was supposed to walk along side them in the hard journey of recovery wasn’t there at all.

    I remember how betrayed they felt by me for selling them a dream of recovery and services that they could not access. This led me to walk away from public speaking for a while, and rather focus on creating services to send people to.

    So where do we go from here?

    We need to encourage economic leaders to fund mental health services — whether it’s government, family foundations, businesses or others. We have to focus on helping remove the financial gap and lack of mental health services.

    We also need to make sure the mental health funding goes to innovative services. With the increase in demand, we need to be smart about where we spend the money.

    We need to focus on resources that are lean, show positive changes, and that are accessible to as many people as possible.

    To me, this means directing the funds to mental health services that are operate online, on the phone or in comfortable community spaces rather than in expensive and overcrowded hospitals.

    Finally, we have to keep our leaders talking about mental health.

    We can encourage our local community to keep our political leaders honest about what they are doing to ensure that mental health is being addressed.

    Ask for education where needed, but also services and support for people who are now educated about this issue and realize something is wrong.

  • Screening to Identify Perinatal Depression

    Babies and mothers in the Western Cape of South Africa now have a brighter future, thanks to a provincial government’s decision in September 2018 to start screening the mental health of pregnant women and new mothers during routine checkups.

    Maternal depression and anxiety are estimated to affect roughly one-third of women in South Africa before or after the birth of a child. Routine mental health screening, integrated to primary care, will allow common conditions like these to be picked up and treated early, with benefits for both infants and mothers.

    The screening tool used in the initiative was developed by the Perinatal Mental Health Project (PMHP), led by Dr Simone Honikman, based on research conducted at a midwife obstetric unit in Cape Town.

    A nonprofit entity based at the Department of Psychiatry and Mental Health of the University of Cape Town, the PMHP was launched in 2002 and has been providing counselling services ever since, ensuring screening and support for pregnant women in low income areas dealing with psychological distress.

    “Our screening tool picks up depression and anxiety, and now it is part of the maternal case record. It is brief and simple to use,” Honikman said, describing its adoption by the Western Cape as a victory for mothers and babies.

    The tool consists of a standardised questionnaire, developed by the PMHP team and administered by nurses, midwives or counsellors at the first antenatal visit. The questionnaire is available in the four languages spoken by most of the project’s beneficiaries — English, Afrikaans, isiXhosa and French.

    Infant and child psychiatrist Dr Anusha Lachman, from Stellenbosch University, said the decision to adopt this screening tool was long overdue. “I hope it will be rolled out to the rest of the country,” she added.

    ”Maternal depression in Africa is about three times higher than the international average, which is around 10 percent of pregnant women. The reasons for the high prevalence are clear: people’s socio-economic situations, high levels of intimate violence and substance abuse, and not being able to access support,” said Lachman.

    Support for women’s mental health before and after birth is particularly lacking in underprivileged communities. The PMHP is run by a professional counsellor working at the maternity unit of the Hanover Park Community Health Centre, in Cape Town — an area notorious for gang violence.

    “We see patients whose partners have been killed in gang shootings, who have recently been diagnosed with HIV, who are unemployed, who deal with substance abuse and domestic violence at home, and teenagers whose parents have kicked them out,” said PMHP counsellor Liesl Hermanus.

    Sharmaine Miller, a government health promotion officer who has worked at the maternity unit for 29 years, has taken on the mental health screenings and Hermanus does the counselling. They have developed a positive relationship with the nursing staff.

    “They have really embraced what we do and tell us when they identify vulnerable patients, like a mum who is very tearful in the labour ward,” said Miller..

    Hermanus has worked at the midwife obstetric unit for the last eight years. She usually sees patients in her office, where her energy, organisation and a basket of toys make women feel they are in safe hands.

    “I do lots of listening and psycho-education about bonding, explaining the importance of touch and talking to babies. Later on in a pregnancy, I see patients start feeling better and getting excited about their baby,” she said.

    Since its creation, the PMHP has screened more than 37,000 women, and counselled nearly 7,000 mothers in distress. Miller screens up to 15 pregnant women and new mothers on a daily basis, and teaches them skills such as breastfeeding.

    Practical advice, like how to apply for a child support grant, is also provided to parents, some of whom do not have enough money for the next meal, let alone nappies.

    One of the women helped by the PMHP said she felt so desperate she thought of taking her own life, until her counsellor made her feel safe. “I feel better when I talk to her; she’s always active, taking the positive side,” she said during a consultation.

    Then she addressed her counsellor directly: “I’m here now, I’m fine, because I know I have you on my side. I’m very proud to be a mum.”

    The project also trains nurses and health care professionals from across Africa to respect and care for women before and after childbirth.

    One of its programmes, for instance, teaches patients and health workers to step into one another’s shoes through role play.

    Honikman said that it helped increase empathy and respect between the maternity staff and their patients, which is crucial to screening.

    Cassey Chambers, operations manager for the NGO South African Depression and Anxiety Group, said it was common to get calls from mothers who were overwhelmed months after their babies were born.

    “They are feeling stressed, depressed and anxious. Many feel like they don’t have any support but are too afraid to speak to anyone in case others think they are bad mums or that something is wrong with them,” she said.

    “Everyone assumes that having a baby is the best thing ever, but no one addresses the issue that it is also the most stressful, loneliest and scariest time,” she added, noting that postnatal depression was a serious condition and that new mothers should be encouraged to seek support and treatment.

  • Changing Society’s Assumptions about Mental Disorders

    “Leave me alone, let me die!” yells Hawah Abubakar*, a dozen pills in her hand, as she struggles to free herself from the clutches of a classmate. “I’m tired of this life.” Tears roll down her cheeks.

    A student in her early twenties, Abubakar’s wish is to sleep away her ordeals and never wake up. Perhaps if she dies, she says, she’ll cease to be an object of scorn.

    Abubakar has a mental disorder. Sometimes she loses control, closing her eyes and clenching her fists, making sudden, unpredictable moves and destroying things around her.

    She once attempted to jump from a two-storey building in the middle of a classroom lecture – it took half a dozen men to stop her. When she finally calms down and others tell her about her actions, she remembers nothing.

    In northern Nigeria, where she lives, people believe that she is possessed.

    But this time Abubakar isn’t out of her mind. She says her intention to commit suicide is genuine. “Every man who asks me out jilts me as soon as he finds out about my condition.

    No man wants to marry a girl like me,” she sobs, adding that her friends and classmates have begun to avoid her, afraid her insanity might visit her unexpectedly and make them victims of her violent displays.

    People with mental disorders actually have two conditions to cure: their ailment, and society’s misconceptions about it – also known as stigmatisation.

    According to Aishatu Yushau Armiyau, a lecturer at the Department of Psychiatry, Jos University Teaching Hospital, stigmatisation deprives mental illness victims of their human dignity and participation in society, by undermining social support and compromising opportunities for treatment.

    She notes that stigmatisation is due to “misconception, prejudicial stereotypes, and negative public (and professional) attitudes about mental illness,” owing to the assumption that “persons with psychotic disorders are unpredictable and incapable of being managed, even by the best efforts of the health system.”

    Stigmatisation cuts across social class and demographics. Educated and non-educated people, laymen and even health professionals have been guilty of attaching stigma to persons with mental disorders. Such discrimination is particularly widespread in Nigeria.

    A study published in the South African Journal of Psychiatry in 2010 revealed that 52 percent of respondents believed that witches were responsible for mental illness, 44.2 percent held that it is due to demon possession, and close to one-third felt that it is a consequence of divine punishment.

    Meanwhile, in 2013, a survey of nursing professionals conducted by researchers from the University of Ibadan showed that 26 percent preferred to distance themselves from mentally ill persons.

    The World Health Organization (WHO) observed that mentally disabled people are often excluded from community life, denied basic rights such as shelter, food and clothing, and are discriminated against in the fields of employment, education and housing.

    Many are denied the right to vote, marry and have children. “As a consequence,” WHO says, “many people with mental disabilities are living in extreme poverty which in turn, affects their ability to gain access to appropriate care, integrate into society and recover from their illness.”

    While WHO says that mental health policies and laws are critical to improving conditions, they point out that these are “absent or inadequate in most countries of the world.”

    In Nigeria, where the health budget dedicates only three percent to mental health, the sole available mental health care document is of colonial origin and includes obsolete laws, such as one providing for the imprisonment of suicide survivors.

    In 2003, a Mental Health Act bill was introduced in the National Assembly that would protect the rights of people with mental disorders, ensure equal access to treatment, and discourage stigma. It was withdrawn in 2009. In 2013, the bill was re-introduced, and has been hovering in the House ever since, yet to be passed into law.

    In the meantime, a handful of nonprofit organisations, such as the Mentally Aware Nigeria Initiative (MANI), provide support for people with mental illness and conduct awareness campaigns that have educated thousand of Nigerians.

    While urging Nigerians to challenge the “taboo, stigma and misconceptions about mental health among the general population,” MANI also appeals to the government and other decision-makers to provide necessary legislation, policies and budget allocation to boost mental health services in the country, particularly to ensure mental health first aid and suicide prevention services.

    Also advocating for stronger and more up-to-date policies is the Abuja-based Smart Suicide Prevention Initiative (SSPI), established in 2013.

    It focuses on preventing suicide by raising awareness, provides resources to those affected by suicide, and advocates for policies that will save lives.

    SSPI uses a variety of media to get its message across – for example, it produces a TV show, “Whispers of the Hurting,” to encourage discussion on the subject of suicide.

    The Lagos-based Mental Health Foundation has been operating in Lagos for the past 10 years, bringing together psychiatrists, clinical psychologists and dynamic young volunteers who coach and inspire the numerous depressed and stigmatised people in Nigeria.

    All of these initiatives work with minimal funding and little government policy to guide them. But that hasn’t prevented them from trying to bring about deeper awareness of mental health and help those who suffer.

    * Not her real name

  • An air pollution filter to prevent heart and lung diseases

    Delhi is one of the most polluted cities in the world. But the Indian capital is also the birthplace of an innovative device that aims to prevent people from suffering the consequences of air pollution, a major contributor to noncommunicable diseases such as cardiovascular and chronic respiratory conditions.

    The invention is called a Nasofilter – literally a filter that covers the nostrils and uses nanofibre-based technology. Its creators claim this is the first device of its kind to prevent up to 90 percent of PM2.5 (particulate matter under 2.5 millimetres in diameter) and 95 percent of PM10 from getting into our lungs through the nose.

    The product was developed by Nanoclean Global, a local startup founded by a team of graduates and faculty members from the Indian Institute of Technology in Delhi.

    It launched in November 2017, just days before a toxic blanket of smog covered the Indian capital. “As soon as we launched we got thousands of inquiries from schools, hospitals and companies in Delhi and across the country,” said one of the company’s co-founders, Prateek Sharma.

    Sharma had grown up watching his mother struggle with asthma and was determined to help her protect her lungs. “No mask seemed to work,” he said. He had the idea for an air pollution filter during his last year of studies.

    In 2016, he joined with fellow graduates Tushar Vyas, Jatin Kewlani, Sanjeev Jain, and faculty members Ashwini Agrawal and Manjeet Jassal to develop the first Nasofilter prototype.

    The filters can be used for up to 12 hours. They are barely noticeable, since the edges that stick to the bottom of the nose are almost transparent.

    “The concept is fairly simple,” Sharma explained. “The fibres allow surface filtration and, when you exhale, the filters clear out all the accumulated harmful particles.”

    Today, the device sells for 10 Indian rupees (USD 0.14) a pair, and the startup is receiving bulk orders nationally and internationally from countries such as Iran, Dubai and Vietnam.

    “The response is very encouraging and we are growing”, said Sharma. “Of course demand grows when we have bad air days.”

    It is no surprise that the product found a growing market in India.

    Between May 2015 and October 2017, Delhi saw only two days of “good” air quality, with the monsoon season bringing some relief, according to the Indian Central Pollution Control Board.

    In 2018 the capital enjoyed a few more precious days of good air quality, only thanks to the rain. But for most of the past 900-odd days, the city’s air quality has varied from severely polluted to very poor to satisfactory, even in the best weather.

    Delhi’s doctors are alarmed about the damage this is causing to lungs and hearts.

    “There has been a huge rise of young, women and non-smoker patients coming in with lung cancer, which previously affected mostly smokers and adult men,” said Dr. Arvind Kumar, Founder and Trustee of Lung Care Foundation and Chairman of the Centre For Chest Surgery at the Sir Ganga Ram Hospital in New Delhi.

    A recent study conducted by the hospital links this trend to air pollution. “The occurrence of the disease in patients under 50 or even under 30 years of age, an increase in the proportion of women, and a nearly 1:1 ratio of non-smokers to smokers all point towards environmental factors such as air pollution as a major causative agent. These are trends that indicate something is terribly amiss,” noted the report.

    But the scope of the problem goes far beyond lung cancer. According to the World Health Organisation (WHO), around seven million people die every year from exposure to fine particles in polluted air.

    As cities’ air quality declines, the risk of stroke, heart disease, lung cancer, and chronic and acute respiratory diseases, including asthma, increases for the people who live in them.

    In 2016, a report in The Lancet noted that air pollution was responsible for 9.8 percent of the total disease burden in India, the second leading risk factor in the country after child and maternal malnutrition.

    Sharma believes the Nasofilter could bend the curve. “People who suffer from allergies and asthma use it year-round,” he said. So far, his company has been recognised by the South Korean government as one of the top 50 technical startups in the world.

    In 2017, it received the Indian government-sponsored Startups National Award, and was the only Indian startup among the 100 finalists of the Elevator Pitch Competition, in Hong Kong.

    Meanwhile, the Nasofilter team is developing another device that could prevent bacteria from entering the body’s system. “We’re hoping to maybe even keep TB and other diseases at bay,” said Sharma. “Work is underway and we are very hopeful.”

  • 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.