We often hear about the developed world assisting developing nations so it was refreshing to read the recent Wall Street Journal article that tells us it can also be the other way around. U.S. health programs are drawing lessons from medical practices in developing countries. When the AIDS clinic at the University of Alabama at Birmingham recognized that their patient no-show rates were growing, they looked far and wide for solutions. They found one in southern Africa.
Alabama's "Project Connect" has adapted a model developed in AIDS clinics in Zambia. Doctors see patients within five days of an initial call to clinic to gather psychosocial and medical history along with blood tests. A social worker also interviews new patients to try to identify and address issues (which often turn out to be complex and mutli-layered) that might prevent patients from coming back for ongoing care. The strategy is getting the job done. The Journal reports that "the no-show rate dropped from 31 percent in 2007 to 18 percent through June 2009."
I remember visiting an AIDS clinic in South Africa in 2004 and was shocked to see how empty it was. I asked a doctor why, and he said that they get patients in and out quickly by collecting all needed information before the patient actually saw a doctor. This was a stark difference from the AIDS clinic in San Francisco where my aunt worked, and where lengthy waits were the norm. I asked the same question many are asking today: "If they can do it, why can't we?"
As a student at Peking University in Beijing in 2005-06—China's version of Harvard, without the Ivy—I was honored to be amidst some of China's best and brightest minds. I often wondered whether the person I was sitting next to at the school cafeteria eating noodles and baozi would be a future finance minister or a scientist that will cure cancer. I never once thought that some of these students would be unemployed. And uninsured. But in today's economic climate, some of them are.
After China's revolution, people got a basic level of medical care for free. That system was dismantled in the 1980s amid the economic reforms. Now China has gaps between the quality and access of care in rural and urban areas. And China has uninsured people—about 200 million of them. And costs are rising, as they are here. (NEJM had a great brief history of modern China's health system called "Privatization and its Discontents.")
Growing up in Australia and working there, I never really worried about health care. Sure, you had to spend some time in the doctor's waiting room (as we do here), but you were never turned away because you lacked insurance. Australia's Medicare health care system covers everyone (not just the elderly and disabled, as the US Medicare system does). Australia's Medicare, financed through general taxes, gives everyone in the country access to free or low-cost medical, vision and hospital care. It gives you free or subsidized care at the doctor's office and a discount on many prescription drugs. But we also had choices. We could get supplemental private health services and, in special circumstances, allied health services like chiropractors. That private option gives us services like dental work, emergency ambulance transfers (which aren't exorbitant there), a private hospital bed and so on.
Twice in the last couple of weeks I've had conversations with non-Americans about our complex and costly health care system that leaves 46 million people uninsured. To put a highly technical spin on their conclusions: They think we're absolutely nuts.
The other night I had dinner with two German students interning at their embassy. Both were excited to be here during the early months of Obama's presidency; one had been at the Brandenburg gate when he went there as a Democratic candidate last summer. Both were pretty sophisticated, and were able to discuss some of the long-term economic challenges of rising health care costs and technology throughout the world. But as one of the young women told me, "When my grandmother got sick and her treatment cost 150,000 Euros, we didn't have to worry, it was all paid for. But I heard it wouldn't have been in America." Well, it depends. If she was 65, she'd have Medicare, which provides great coverage for some things but can leave patients with significant out of pocket costs for others. If she was younger than 65, it would depend on what kind of policy she had, what kind of services it covered, what kind of monthly, yearly or lifetime caps. And forget about it if she were one of the 46 million uninsured or 25 million underinsured. The grandmother, incidentally, is doing just fine now.
Your physical, cultural, and political environment has an unquestionable impact on your health and the course of your life. This is the clear and resounding conclusion from the World Health Organization's (WHO) Commission on Social Determinants of Health, which has released its final report, "Closing the gap in a generation: Health equity through action on the social determinants of health."
Not only does WHO make it clear that determinants of health vary from country to country, but there are vast inequalities within countries too.
"The development of a society, rich or poor, can be judged by the equality of its population's health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantages as a result of ill-health."
The commission lays out three recommendations for tackling this global phenomenon: