healthcare

What Determines our Well-being?

Robyn, , , , Leave a comment

She is blind. Cataracts, or maybe glaucoma. Maybe diabetic retinopathy or some other word she will never be able to pronounce or even see. Her prescriptions are filled by a relative, at a pharmacy that only provides half the medication she needs, and brought home to her fumbling fingers. She makes her way to clinic unaccompanied, navigating footpaths and public transportation by memory if not sight. Arrives to hear that her blood pressure is elevated, and her sugar is out of control. Insulin, the doctor says. Never mind that she has not been able to get her Metformin pills for weeks and weeks. Never mind that she has no refrigerator. Never mind that she cannot see. Your sugar is too high and there are no more pills we can prescribe for you. Insulin.

He has HIV. Contracted from some faceless sexual contact long ago; he rages at the diagnosis, a short-sighted anger that settles on his most recent partner. But CD4 cells are warriors, and do not drop to 50 overnight. How could this happen to him? He disappears for months. Changes his number. Skips town. Grows a beard to hide the tattoos. Loses himself in alcohol and cannabis. Cannot forget. He returns on a hospital gurney, face drawn, spiking fevers. Newly diagnosed, the internist says. Never linked to care, the social worker corrects him. If he lives, he will join the clinic. Fire spent, bitter and resigned. If he lives.

What are the social determinants of health?

According to the World Health Organization, these are the conditions into which people are born, grow, work, live and age and the wider set of forces and systems that shape daily life.

In other words, everything. Your world as you know it determines how healthy you can or cannot be. If we were fish, social determinants would be our fish tank and everything in it. Which would be great, because we could just upgrade to a bigger tank with better water and a more efficient pump/filtration system and most of our problems would be solved. Except for food, I guess. I don’t know, I’m getting out of my depth.

Social determinants of health can be thought of as any feature of life that supports people being well or makes it more likely for them to get sick. Things like employment, finances, food supply, housing, education, clean air and water, transportation, and access to healthcare. The list goes on. If we take a curative approach and think of health as treating disease then the social determinants are all the things that get in the way of someone reaching the doctor, getting an accurate diagnosis, getting the right treatment and recuperating successfully. If you stop to think about it, there are a million ways this process can be thwarted.

As a field of significance, social determinants have been on the health agenda for decades, since the 1940s. But they were relegated to the back burner in favour of alternative (read: neo-liberal) approaches to public health. Finally in the early 2000s they were revived and examined more closely, giving us hard science on health inequalities across the globe. This is a prime example of the gap between people who make health policies and the people who live with them. I’m sure the man or woman walking into a doctor’s office could easily have easily told you that the reason they ignored that suspicious lump for so long was that they couldn’t get time off work to visit the doctor and they were trying to save up money to buy the medication but the children had to go to school. Social determinants impact health in real time.

When we think about our roles as medical practitioners (and here I can only speak for doctors) we imagine waving a stethoscope and pen to make people healthy. With the right investigations and the right remedies blood pressures will be controlled, diabetic feet will heal and that infection will clear up in no time. But the reality is that our ten-minute consultation is merely a blip in the busy lives of the people who access healthcare. Our brief contact can only do so much and no more. In medical school we are told in not so many words that you can lead a horse to water, but you can’t make him drink. But our patients are nowhere near the pond. They are on the other side of the hill, separated by hot coals, barbed wire and quicksand.

There just isn’t much exposure to the social determinants in medical school. Public health and primary care docs try to explain this complex and layered concept on two short Community Health rotations to students who care more about cramming for exams than pondering the barriers to care for Miss Ivy in rural St. Mary. But this feels like a failure of the medical education system. I’ve mentioned before that we can’t all be paediatric neuro-oncologists, yet medical schools consistently emphasize the rote memorization of esoterica as the most important part of being a doctor. We graduate into hospitals that perpetuate this idea of health as a binary: either you are ill (in the hospital) or well (not in the hospital), failing to recognize that health exists on a continuum that is constantly shifting in relation to the environment.

We have to shift our thinking to come up with new and better ways to preserve and promote wellness. We have to train new generations of physicians and allied health workers to look beyond the confines of their facilities to the communities where people live and work. Meaning the places where health actually happens (or doesn’t). We have to ask hard questions and be open to the answers. Until we are ready to grapple with the consequences of our societal systems and structures, we will never be able to reach our vision of “Health People, Healthy Environment”, not in 2030 or ever at all.

on Universal Healthcare

Robyn, , , , , 4 Comments

I believe that healthcare is a human right. No one should have to suffer from a treatable disease because they cannot afford to access treatment, and no one should end up in debt after surviving illness. Jamaica is one of the few countries in the world that offers universal healthcare: Jamaican citizens pay no user fees when they access healthcare in public facilities. We also have the advantage of an extensive primary care network of health centres (clinics) that can be easily accessed by most communities.

There are many people for whom this type of healthcare is the only option. And there are many people for whom this type of healthcare is a last, last resort. Because I spend most of my time working closely with the former group, the disdain of the latter group always takes me by surprise.

I enjoy my work. I and humbled and gratified to watch people come into clinic worried or in pain and leave feeling calm and pain-free. I am delighted to complete an application form to the National Health Fund (NHF) so that my patients with chronic illnesses can access much-needed medication for a fraction of the cost. I am happy to sit and listen to the hard stories of their life, knowing they don’t often get the kindness of a friendly ear. I am excited to teach them about nutrition and how their medications work – even better when they actually heed my advice.

But there is still so much more that can be done, and that is why Jamaicans who can afford to will always choose private healthcare.

After I see a three-year old with an ear infection and write a prescription for antibiotics, the nearest public pharmacy is too far away for the parent to consider making the trip. In Hanover where I work, there is only one public pharmacy in the capital town of Lucea. Not to mention, the NHF only covers drugs for chronic conditions like diabetes, hypertension and asthma. Antibiotics and painkillers, which cost thousands of dollars, are not included. Private health insurance is not a feasible option for most of my patients either. If it was, I’m certain they wouldn’t be lining up in the clinic.

Another issue is the wait time. It’s a running joke, a widely known fact and a painful embarrassment that the waiting time in public health facilities is really, really long. Visiting the health centre for a routine visit can take hours, if not all day. Getting an appointment at the specialist clinic in our nearest tertiary hospital takes months. Waiting on an elective operation like a hernia repair can take years. Then after waiting for so long to have their concern dealt with, patients often encounter burnt out and unsympathetic health care providers who are tired and stressed from seeing too many patients with too few resources.

When it comes to diagnosing diseases the wait time gets even more sinister. Waiting for a Pap smear result in the public system takes anywhere from three to nine months, if it ever comes back at all. Privately? That takes two weeks. Screening mammograms (recommended annually) aren’t offered in the public system in Western Jamaica any at all. Biopsies (for example, when we’re suspecting cancer) in the public system have to be expedited by paying for them, otherwise the result could take months to return.

Photo by Nikko Tan on Pexels.com

Contrast the crowded, hot waiting area of a public health centre with the air-conditioned insularity of a private office. A doctor or nurse who smiles with you instead of frowning at the added workload at the end of an already long day. The appeal of private healthcare goes beyond shorter wait times to the perception that having to pay for something automatically means it is higher in quality. But that’s a discussion for another day.

Today I only want to wonder what public healthcare would look like if it received the lion’s share of resources. What if we had enough space in our waiting areas so that people didn’t have to sit outside? What if we had enough staff so that essential tasks didn’t have to be neglected? What if we had enough vital, essential and necessary drugs so that people didn’t have to choose between buying food and buying their medication? What if we injected resources into preventative services (health education, screening programmes, behaviour change) so that we could ease the burden on our hospitals? What if our policies ensured that staff could take proper vacation leave (not this minuscule two weeks a year that most people save up to take two months at once)? What if we had enough money to pay people so they wouldn’t need to add second and third jobs to try and make ends meet, further contributing to their burnout?

What if there was no one who benefits from an arrangement that strips the powerless and poor of their dignity while literally condemning them to die?

Universal healthcare implies some kind of equity, but there are too many gaps in our system that people can fall through. The burden of filling these cracks is carried by people who are already struggling under a system that does harm to their well-being. Perhaps when we emerge from this public health crisis, the government will finally recognize the undervalued role of public health and primary care and make meaningful efforts to improve the quality of health we offer our people.

____________________________________________________________

If you’re interested in more readings like this, check out my post on The Case for Primary Healthcare. For a more poetic take on this rural doc life, you can read Why Hanover.

Is your DIY face mask working?

Robyn, , , , 5 Comments

Since the onset of the COVID-19 pandemic, face masks have become the accessory du jour. Because of the increased demand for masks and other types of personal protective equipment we are on the brink of a global shortage where we may not even have enough supplies for frontline health care workers.

Some savvy individuals have started making their own reusable cloth masks out of various fabrics such as cotton or scuba. Available in a variety of patterns, they’re stylish and cost-effective. But do they work?

People seem to think they do. I had to visit the Emergency Department recently and saw the majority of doctors and nurses wearing brightly coloured, simply designed reusable masks. They were made by a local dressmaker who was selling three masks for $1000 JMD. The purpose of buying three was to interchange the masks, ostensibly to minimize soiling. Still, members of staff wore these masks for hours, whether or not they were directly interacting with a coughing patient.

My gut instinct says they’re probably not as effective as a disposable medical mask, but what does the literature say?

The first thing I learnt is that there is limited research on the efficiency of reusable fabric masks. Cloth masks have been studied from as far back as 1905 and as recent as 2017, with ambiguous conclusions.

In 2013, this article in the Journal of Infection Control acknowledged the historical use of cloth masks in protecting healthcare workers from respiratory illnesses1, and highlighted the lack of evidence around the efficiency of cloth masks, calling for further research. They argued that in an outbreak developing countries would not be able to consistently afford disposable surgical masks and respirators, but policy guidelines made no reference to the use of cloth masks, possibly because there wasn’t enough evidence.

The authors go a step further and tease out recommendations to improve the efficiency of reusable cloth masks (higher thread count, more layers and muslin instead of gauze), but they point out that most of their evidence comes from studies conducted in labs with mannequins as opposed to actual healthcare settings.

A 2015 randomised trial of cloth masks compared to surgical masks in Vietnam compared the outcome of clinical respiratory illness, influenza like illness (ILI) and lab-confirmed viral illness between clusters wearing disposable surgical masks and reusable face masks2. They found that the rate of all infections was highest for persons wearing cloth masks, particularly the rate of ILI and lab-confirmed infection.

(This is the only randomized control trial of cloth masks. )

A 2017 study in the Journal of exposure science evaluated the efficiency of three types of cloth masks and one type of surgical mask commonly used in developing countries in reducing exposure to particulate matter3. The study compared the filtration efficiency of each mask to the gold standard – N95 respirators. They concluded that:

Compared with cloth masks, surgical masks are more effective in reducing particulate exposure

And finally, The Lancet recently published an article discussing the “Rational use of face masks in the COVID-19 pandemic”4. The authors compared the policies of eight different health authorities on the use of face masks. Notably, China was the only country that explicitly recommended cloth masks or ‘non-medical masks’, and the recommendation was for persons at ‘very low risk’ of infection (those who mostly stay at home or in well-ventilated areas).

One interesting observation is that none of the studies I found examined whether wearing cloth masks was harmful i.e. associated with increased risk of infection compared to no mask at all. Theoretical discussions suggest that wearing a mask without a medical indication could increase your risk of infection if the mask is used improperly or for long periods or if you develop a false sense of security and forego other preventative measures such as hand washing. But before the advent of mass produced disposable masks, cloth masks were our best protection against infection. Can they help us still?

There is a plethora of emerging research on all things related to COVID-19, an outbreak which has been described as the greatest clinical challenge of our generation. Now is the time to explore and evaluate cost-effective resources for health, especially as the pandemic threatens the health of the most vulnerable among us.

References

1 Chughtai AA, Seale H, MacIntyre CR. Use of cloth masks in the practice of infection control – evidence and policy gaps. Int J Infec Control 2013 9(3). doi:10.3396/IJIC.v9i3.020.13

2 MacIntyre CR, Seale H, Dung TC, et al. A cluster randomised trial of cloth masks compared with medical masks in healthcare workers. BMJ Open 2015;5:e006577. doi: 10.1136/bmjopen-2014-006577

3 Shakya, K., Noyes, A., Kallin, R. et al. Evaluating the efficacy of cloth facemasks in reducing particulate matter exposure. J Expo Sci Environ Epidemiol 27, 352–357 (2017). https://doi.org/10.1038/jes.2016.42

4 Feng, S., Shen, C., Xia, N., Song, W., Fan, M., & Cowling, B. J. (2020). Rational use of face masks in the COVID-19 pandemic. The Lancet Respiratory Medicine. doi: 10.1016/s2213-2600(20)30134-x

Doctors and Mental Health

Robyn, , , , , , , 6 Comments

The lives of medical professionals (at least the part of our lives that we choose to share with the public) are a lot like Instagram posts: lots of happy, successful moments to build the image of being competent and caring. But just like Instagram, real life is never as perfect as that carefully curated snapshot.

If you remember my last post about the things we don’t talk about, there was one really important topic I left off that list:  mental health. Just like physical health, our psychological well-being is integral to the way we function. But while we won’t hesitate to get ourselves checked at the first sign of illness, we balk at the idea of talking about our feelings or worse, spending time in therapy.

Sometimes we don’t talk about it because we feel our patients need to believe that their doctor is operating at peak performance. Discussing our mental health issues openly, or even acknowledging them can have a detrimental impact on the physician-patient relationship. Patients tend to think of doctors as superhuman, somehow immune to the struggles that plague the average person. In reality, doctors have the same problems as everyone else. But we don’t like to be reminded of that. We buy into the con, believing that we are somehow capable of feats no one else can do.

Sometimes that’s allowed, even expected – not everyone can perform brain surgery or resuscitate newborn babies – but other times we overreach. Doctors frequently pull stunts like trying to function normally after 36-48 hours with no sleep. We sweep treatable issues like depression under the rug because of course we can handle it, self-medicating with substance use or else ignoring the problem entirely until it can no longer be contained.

The medical profession carries one of the highest rates of suicide (1.4-2.3 times the rate of the general population). But discussing an issue that can call into question your fitness to practice is absolutely off-limits. In the most ideal and ethical situation, doctors would put the patient’s interest ahead of their own security, but we are human first, driven by the same fears and needs as everyone else. And there is a very real fear that any perceived disability will end or permanently blight our careers.

On top of this is the associated stigma of mental illness that is so very rampant in Jamaica and the Caribbean. No patient wants to see the “mad” doctor who “tried to kill himself”. But if any progress is to be made in erasing this stigma we physicians have to be the pioneers. And since this stigma persists even among doctors, we are the first hurdle we have to clear. After that, education and sensitization of the wider society.

Even though no one seems ready to talk about it* (Megz over at Barefoot Medz is one of the few, doing a really great job) mental health is a discussion we need to have. In such an emotionally draining and psychologically demanding profession it isn’t fair to anyone to have doctors fumbling to look after their mental health alone.

We need to catch mental health issues among physicians from early, as early as medical school even. Mandatory psychological screening for depression, anxiety and PTSD among others should be instituted for all the high risk professions: doctors, police officers, firefighters. We shouldn’t have to wait until a doctor commits suicide or a policeman kills his spouse before doing something. Prevention or at least early detection is paramount.

There’s a lot of work to be done. Efforts have started but they’re halfhearted at best and the government offers little in the way of support. We must be our own advocates and work with other key players to remind the public that there is no good health without good mental health.

*

Further reading: a pediatrician’s experience with psychosis, and a GP’s experience with depression.

*After writing this post, I discovered Dr. Eric Levi an ENT surgeon who is also making strides in the discussion on mental health in doctors.