Lost in Legislation: Barriers in Actualization of Post-Apartheid Healthcare Reform in South Africa and American Analogies
Abbie Marie Bender
A nation now defined by the intersection of the Western and Non-Western worlds, South Africa’s evolving healthcare system provides an invaluable reference for the perils that segregation and class control can create for large groups of a population. Under apartheid, the system propagated such separation in the availability and delivery of medicine to its peoples in a caste-like manner. To be of Western descent in South Africa was a ticket that admitted one to the amenities of Western medicine; those without the whiteness of such validating paper found themselves trapped in substandard care. As apartheid was dissolved with the inauguration of the African National Congress, or ANC, in 1994, a set of goals regarding healthcare reform reflected the burdens created by the inefficient and inconsistent paradigms of segregated care in the decades prior. Still, the inequalities and unpardonable restraints on human rights are not so easily ameliorated with legislature and some of the most critical divisions persisted as a division between the private and public sectors of healthcare. The United States often imagines itself as a model system for other nations to imitate, and we rarely assign equivalent value to the tactics of other nations—especially developing nations. It would be prudent to examine the strengths and pitfalls that other systems have in the development of a more recognizable healthcare plan for our own country and its peoples. It stands to reason that there is much to be gained from studying a country as extreme as South Africa—one that has evolved from developing to developed in a short time span—and one that is plagued by a problem with which America is hesitant to admit itself infected—the constraints of a traditionally hierarchal health care system that consistently favors certain racial and ethnic groups, even if we attempt to claim that the stratification is founded in socioeconomic standing alone, thus exempted from the propagation of “separate but equal” undertones in care.
“The tragedy is not that things are broken. The tragedy is that things are not mended again.
- Alan Paton
Kelsey L. Capron and Lara C. Weinstein, MD
Homelessness in the United States
- 630,000 homeless in the US in 2012, thousands in Philadelphia
- Over 3% of the US population has been homeless during the past 5 years
- Homeless = no stable residence
Temporary shelters, unsheltered locations (the street, transit stations, parked cars), etc.
- High rates of legal issues, substance abuse/dependency, & lack of stable employment
Severe mental illness = overrepresented & linked to severe health disparities
- Higher risk for all-cause mortality (primarily due to injuries, overdose, CV disease)
Mortality rates 3-4x higher than the general population
Chronic & acute mental & physical health conditions
HIV, tuberculosis, hypertension, diabetes mellitus, Hepatitis C
Life expectancy: 42-52 years for the chronically homeless
- Disproportionately low numbers / low quality of social supports
- The current “continuum of care” model:
Outreach à treatment à transitional housing à permanent supportive housing
Perceived by the homeless as a series of hurdles, often not possible to overcome
- No empiric support in favor of the practice of requiring individuals to participate in psychiatric treatment or to maintain sobriety before being housed
Poor health is a risk factor for homelessness, and homelessness is a risk factor for increased health needs.
What Are Multidisciplinary Care Rounds (MDR’s)?
MDRs are defined by the unique characteristic of incorporating a multitude of both physician and non-physician specialties into the conversation with the patient for the coordination of their care.
What is Discussed During an MDR?
Activities relating to the care of the patient that may be incorporated into the MDR include summarizing the treatment that the patient has undergone, discussing the treatment approach that is planned for the patient, working through potential issues that may arise from the treatments, and discussing the potential future therapy.
What is Telehealth?
Telehealth is the delivery of Health-care related activities or information via telecommunications technologies (eg. web conferencing). It is differentiated from telemedicine in that the focus is expansive and includes preventative as well as curative aspects.
- The number of participants in high school sports has increased since 1989 (National Federation of State HS Association).
- From 2000-2010 7% of public schools cut athletic programs while less than 1% added them (Sharp Center Univ. Michigan).
- Some estimates predict 27% of public high schools will not offer varsity athletics by 2020 (Sharp Center Univ. Michigan).
- School’s are dropping athletic programs (as well as music and theater programs) due to budget cuts.
- Alternative approaches schools are taking include “pay to play” which increases the financial burden on students and families.
- In 2011, 3 out of 4 school districts in PA planned to decrease the number of extracurricular activities to deal with increasing budget cuts (Hardy).
- Despite increased participation, high school sports programs are threatened by budget cuts.
Emma Howard-Young and Jordan Howard-Young, MA
History of the Pasteur Clinic Đà Lạt
The Pasteur Clinic is associated with the Institut Pasteur, part of the international network of research institutes dedicated to the prevention and treatment of infectious diseases. The Đà Lạt branch of Vietnam’s Institut Pasteur was built between 1930 and 1936 under the direction of Dr. Alexandre Yersin, a physician remembered for identifying Yersinia pestis as the causative agent of Plague and a student of the eponymous French chemist and microbiologist Louis Pasteur. While many overt references to the French colonial tradition have been supplanted in Vietnam by nationalist sentiments, the Institut Pasteur retains its reputation thanks to a history of serving the needs of the Vietnamese population. Yersin, who lived out the final years of his life in Vietnam after overseeing the acclimatization of the quinine-producing Cinchona tree for the treatment of malaria, is remembered as a friend to the Vietnamese people. Since its founding, the Institut Pasteur in Đà Lạt has conducted infectious disease research and served as a major hub for vaccine production in central Vietnam.
Prior to 2014, the Pasteur clinic was located inside the Institut Pasteur complex and focused primarily on the administration of vaccines. The clinic’s medical director, Dr. Nguyễn Thị Thủy, began to explore ways the clinic could serve the significant health needs of the community in a broader way and subsequently received permission to build a free standing clinic within the Institut compound to provide an expanded array of services to the populace. Using loans, grants, and the clinic staff’s own finances, the newly independent clinic opened its current facility and officially began its expanded operations on October 24, 2014. A dedicated staff of physicians, nurse practitioners, nurses, medical assistants, and clerks now oversee the administration of the clinic and its daily provision of health services to patients from Đà Lạt and the surrounding areas.
Marlee Madora and Molly Klores
Philadelphia FIGHT is a comprehensive HIV/AIDS service organization providing primary care, consumer education, advocacy, and research on potential treatments and vaccines. FIGHT was formed as a partnership of individuals living with HIV/ AIDS and clinicians, who joined together to improve the lives of people living with the disease. Today, FIGHT serves an even broader patient population and recently received designation as a Federally Qualified Health Center. FIGHT strives to address not only HIV-infected patients, but all at-risk populations through education, outreach, and preventative medicine.
The annual Bridging the Gaps interns are responsible for several projects, including a client satisfaction survey, a “FIGHT Stories” client portrait project, and this year, projects on smoking cessation and Preexposure Prophylaxis (PrEP) use.
DEMOGRAPHICS OF CRAWFORD COUNTY1,2
- Population – 87,600
- Population density – 86.5 per mi2
- Ratio of patients to PCPs – 1,685:1
- Number of hospitals – 2
- Population 65 and older – 17.4%
- Overweight – 65% Obesity – 32%
- Population with Diabetes – 12%
- Heart disease death rate – 200 deaths per 100,000 people.
The above percentages and rates of disease are either equal to or higher than the averages for the state of Pennsylvania.
Amanda Nemecz, Alexander Rowan, and Talia Stark
Teaching Community Health Workers
In rural Rwandan villages, the communities are linked to healthcare through Community Health Workers (CHW). CHW are appointed based on village election and the requirement that they can read and write. The Rwandan Ministry of Health provides general health training to the CHW so that they can educate and advise the village on health related matters. CHW administer educational sessions at village meetings about prevalent health issues, and advise members of the village when they should go to the Health Center. JeffHEALTH’s teaching aims to supplement the Ministry of Health training. Topics are chosen and approved by the Project Director Andre Munyantanage, village leadership, and head of the local Health Center. The topics are in accordance with the Rwandan government development program Vision 2020.
Education Topics Include:
Family Planning, Teenage Sexual Health, HIV/AIDS Prevention, Dental Hygiene, Breast and Cervical Cancer, Prevention and Detection, Nutrition, Prenatal Care, Soil Helminths,Drug and Alcohol Abuse Prevention
Rebecca Newbrander, MD Candidate
Maternal and Child Health in Iganga District Uganda
Maternal and child health outcomes in the East Central Region of Uganda are especially poor compared to the rest of Uganda :
- Only 32% of women (50.7% nationally) informed about signs of pregnancy or delivery complications
- Only 12% of women (62% nationally) received malaria prophylaxis during pregnancy
The “Three Delays Model” of barriers to care:
- Knowing when to seek care and making the decision to do so
- Access to care once decision is reached to seek it
- Receiving quality care at a health center or hospital
Maternal and Child Heath Care in East Central Region:
- Husbands and mother-in-laws frequently make decisions of whether to seek care
- Prenatal care is considered to be only for sick people
- Tiered health centers mean women often are referred multiple times to receive adequate care or receive care a given health center is not equipped or trained to give
The Intersection Between Medication Tablets and Electronic Tablets: Determining the Usability and Acceptability of a Patient-Centered Cardiovascular Risk Assessment (PCCRA) iOS App
Nisha Patel, MS2; Geoffrey Mills, MD, PhD; Marianna LaNoue, PhD; and Amy Cunningham, MPH
One American dies from cardiovascular disease (CVD) every 40 seconds. Risk factor awareness, assessment, and communication has been shown to improve efficacy of patient treatment and also decline overall risk in the population over time. Traditional cardiac risk assessment tools (e.g. Framingham risk assessment, FRA) generate a risk score in a format that may not appreciated or easily understood by all patients. A new patient-centered approach, in which the patient becomes an active participant in the decision-making process, has shown significant increase in patient-provider communication and diagnosis/management.
Kaitlyn Petruccelli, BS and Rickie Brawer, MPH, PhD
The Center for Urban Health (CUH) and the Office for Student Life and Engagement at Thomas Jefferson University (TJU) are working with two public elementary schools in Philadelphia – Southwark School and Independence Charter School – to create a culture of health in the schools. Both schools wish to establish an environment that promotes health and safety and assists children in developing life-long healthy habits. The offices at TJU set out a plan to
(1) Assess the current policies and climate at the schools,
(2) Identify priority weaknesses to address,
(3) Connect TJU’s various health professional schools and student organizations with the elementary schools.
The goal is for TJU students to assist in addressing the schools’ needs by developing health promotional programs and volunteering their time to implement the programs. Our project was to address the first step of this plan: to develop a wellness assessment to evaluate the health policies and practices in the schools.
2LT Tyler Walker
Dr. Jonathan Letterman was the medical director for the Army of the Potomac during the American Civil War. Dr. Letterman graduated from Jefferson Medical College in Philadelphia in 1849. With his appointment to the largest portion of the Union Army, Dr. Letterman was tasked with improving what would today be called a population health nightmare. Soldiers lived in filth, ate food devoid of nutrition, were forced to train beyond what was necessary no matter the conditions, and worst of all, were not provided with an organized medical department to treat them if they were wounded or became ill. He focused his attention on improving the healthcare soldiers received, bettering the culture of army medicine, and teaching individuals healthy and sanitary behaviors. His innovative ideas not only saved the lives of thousands of soldiers wounded on the battlefield, they prevented disease, increased the fighting strength of the Union Army, and ultimately aided the United States in winning the Civil War.
To view older posters click on the following link: http://jdc.jefferson.edu/ph/. College within the College (CwiC) is a four year academic area of concentration designed to enrich the Jefferson Medical College curriculum for those students who seek additional training in Population Health. This program aims to step beyond the individual-level focus of mainstream medicine by addressing a broad range of factors that impact health, such as environment, literacy, ethnicity, social structure, resource distribution, health systems and health education/promotion. This collection consists of posters and presentations developed by Jefferson CwiC-PH medical students in their exploration of service, research/evaluation, and policy analysis in local, regional and international settings.
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