tag:theconversation.com,2011:/nz/topics/health-care-access-35279/articlesHealth care access – The Conversation2024-03-13T12:45:24Ztag:theconversation.com,2011:article/2222472024-03-13T12:45:24Z2024-03-13T12:45:24ZBuyouts can bring relief from medical debt, but they’re far from a cure<figure><img src="https://images.theconversation.com/files/577693/original/file-20240223-20-aiwmsy.jpg?ixlib=rb-1.1.0&rect=0%2C15%2C5145%2C3462&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medical debt can have devastating consequences.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/stethscope-on-pile-of-us-banknotes-royalty-free-image/153349316">PhotoAlto/Odilon Dimier via Getty Images</a></span></figcaption></figure><p><a href="https://www.kff.org/health-costs/press-release/1-in-10-adults-owe-medical-debt-with-millions-owing-more-than-10000/#:%7E:text=Americans%20Likely%20Owe%20Hundreds%20of,who%20owe%20more%20than%20%2410%2C000.">One in 10 Americans</a> carry medical debt, while <a href="https://www.commonwealthfund.org/publications/issue-briefs/2022/sep/state-us-health-insurance-2022-biennial-survey">2 in 5</a> are underinsured and at risk of not being able to pay their medical bills.</p>
<p><a href="https://doi.org/10.1001/jamanetworkopen.2022.31898">This burden</a> <a href="https://www.commonwealthfund.org/publications/podcast/2023/oct/how-medical-debt-makes-people-sicker-what-we-can-do-about-it">crushes millions</a> <a href="https://doi.org/10.1377/hlthaff.2023.00604">of families</a> under mounting bills and contributes to the <a href="http://doi.org/10.1001/jamanetworkopen.2022.31898">widening gap</a> between rich and poor. </p>
<p>Some relief has come with a wave of debt buyouts by <a href="https://fortune.com/2023/03/10/local-communities-are-buying-medical-debt-for-pennies-on-the-dollar-and-freeing-american-families-from-the-threat-of-bankruptcy/">county and city governments</a>, <a href="https://apnews.com/article/business-georgia-nonprofits-2a5c3afc4a646d489242bd99eb6652fc">charities</a> and even <a href="https://www.wmdt.com/2024/01/chick-fil-a-pays-medical-debt-on-delmarva/">fast-food restaurants</a> that pay pennies on the dollar to clear enormous balances. But as a <a href="https://scholar.google.com/citations?user=cGZVMkoAAAAJ&hl=en">health policy and economics researcher</a> who studies out-of-pocket medical expenses, I think these buyouts are only a partial solution.</p>
<h2>A quick fix that works</h2>
<p>Over the past 10 years, the nonprofit <a href="https://ripmedicaldebt.org/">RIP Medical Debt</a> has emerged as the leader in making buyouts happen, using <a href="https://www.cnn.com/2020/03/01/us/medical-debt-campaigns-give-back-trnd/index.html">crowdfunding campaigns</a>, <a href="https://www.theguardian.com/us-news/2016/jun/06/john-oliver-medical-debt-forgiveness-last-week-tonight">celebrity engagement</a>, and partnerships in the private and public sectors. It connects charitable buyers with hospitals and debt collection companies to arrange the sale and erasure of large bundles of debt. </p>
<p>The buyouts focus on low-income households and those with extreme debt burdens. You can’t sign up to have debt wiped away; you just get notified if you’re one of the lucky ones included in a bundle that’s bought off. In 2020, the U.S. Department of Health and Human Services <a href="https://revcycleintelligence.com/news/hospitals-can-sell-patient-bad-debt-to-charitable-orgs-oig-says">reviewed this strategy</a> and determined it didn’t violate anti-kickback statutes, which reassured hospitals and collectors that they wouldn’t get in legal trouble partnering with RIP Medical Debt. </p>
<p>Buying a bundle of debt saddling low-income families can be a bargain. Hospitals and collection agencies are typically <a href="https://www.wbur.org/onpoint/2023/09/21/buy-and-sell-medical-debt-health-care">willing to sell</a> the debt for <a href="https://www.theatlantic.com/health/archive/2019/08/medical-bill-debt-collection/596914/">steep discounts</a>, even <a href="https://fortune.com/2023/03/10/local-communities-are-buying-medical-debt-for-pennies-on-the-dollar-and-freeing-american-families-from-the-threat-of-bankruptcy/">pennies on the dollar</a>. That’s a great return on investment for philanthropists looking to make a big social impact.</p>
<p>And it’s not just charities pitching in. <a href="https://www.npr.org/sections/health-shots/2024/01/23/1225014618/nyc-joins-a-growing-wave-of-local-governments-erasing-residents-medical-debt">Local governments</a> across the country, from <a href="https://arpa.cookcountyil.gov/medical-debt-relief-initiative">Cook County, Illinois</a>, to <a href="https://www.axios.com/local/new-orleans/2023/05/23/new-orleans-medical-debt-forgiveness">New Orleans</a>, have been directing <a href="https://apnews.com/article/health-care-costs-boston-toledo-e423c64c1322bc8e4254b7a70b1da50c">sizable public funds</a> toward this cause. <a href="https://www.nytimes.com/2024/01/22/nyregion/medical-debt-forgiveness.html">New York City</a> recently announced plans to buy off the medical debt for half a million residents, at a cost of US$18 million. That would be the largest public buyout on record, although Los Angeles County may trump New York if it <a href="https://www.latimes.com/california/story/2023-10-04/la-county-buy-forgive-medical-debt-how-work">carries out its proposal</a> <a href="https://www.cbsnews.com/losangeles/news/la-county-considering-plan-to-erase-medical-debt-for-residents/">to spend</a> $24 million to help 810,000 residents erase their debt.</p>
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<figcaption><span class="caption">HBO’s John Oliver has collaborated with RIP Medical Debt.</span></figcaption>
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<p>Nationally, RIP Medical Debt has helped clear more than <a href="https://ripmedicaldebt.org/about/">$10 billion</a> in debt over the past decade. That’s a huge number, but a small fraction of the estimated <a href="https://www.kff.org/health-costs/issue-brief/the-burden-of-medical-debt-in-the-united-states/">$220 billion</a> in medical debt out there. Ultimately, prevention would be better than cure.</p>
<h2>Preventing medical debt is trickier</h2>
<p>Medical debt has been a persistent <a href="https://files.consumerfinance.gov/f/documents/cfpb_medical-debt-burden-in-the-united-states_report_2022-03.pdf">problem over the past decade</a> even after the reforms of the 2010 Affordable Care Act <a href="http://doi.org/10.1056/NEJMsr1406753">increased</a> <a href="http://doi.org/doi:10.1001/jama.307.9.913">insurance</a> <a href="http://doi.org/doi:10.1001/jama.2015.8421">coverage</a> and <a href="https://doi.org/10.1353/hpu.2020.0031">made a dent</a> in debt, especially in states that <a href="http://doi.org/10.3386/w22170">expanded</a> <a href="http://doi.org/10.1001/jama.2021.8694/">Medicaid</a>. A recent <a href="https://www.commonwealthfund.org/publications/issue-briefs/2022/sep/state-us-health-insurance-2022-biennial-survey">national survey by the Commonwealth Fund</a> found that 43% of Americans lacked adequate insurance in 2022, which puts them at risk of taking on medical debt. </p>
<p>Unfortunately, it’s incredibly difficult to close coverage gaps in the patchwork American insurance system, which ties eligibility to employment, income, age, family size and location – all things that can change over time. But even in the absence of a total overhaul, there are several policy proposals that could keep the medical debt problem from getting worse.</p>
<p><a href="https://www.urban.org/sites/default/files/2022-06/Which%20County%20Characteristics%20Predict%20Medical%20Debt.pdf">Medicaid expansion</a> has been shown to reduce uninsurance, underinsurance and medical debt. Unfortunately, insurance gaps are likely to get worse in the coming year, as states <a href="https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision/">unwind their pandemic-era Medicaid rules</a>, leaving millions without coverage. Bolstering Medicaid access in the <a href="https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/">10 states</a> that haven’t yet expanded the program could go a long way.</p>
<p>Once patients have a medical bill in hand that they can’t afford, it can be tricky to navigate financial aid and payment options. Some states, like <a href="https://medicaldebtpolicyscorecard.org/state/MD">Maryland</a> and <a href="https://medicaldebtpolicyscorecard.org/state/CA">California</a>, are <a href="https://doi.org/10.1001/jama.2021.23061">ahead of the curve</a> <a href="https://medicaldebtpolicyscorecard.org/">with policies</a> that make it easier for patients to access aid and that rein in the use of liens, lawsuits and other aggressive collections tactics. More states could follow suit.</p>
<p>Another major factor driving underinsurance is <a href="https://www.npr.org/sections/health-shots/2022/06/16/1104679219/medical-bills-debt-investigation#:%7E:text=For%20many%20Americans%2C%20the%20combination,slightly%20lower%20than%20the%20uninsured.">rising out-of-pocket costs</a> – like high deductibles – for those with private insurance. This is especially a concern for <a href="https://www.chiamass.gov/assets/docs/r/pubs/2020/High-Deductable-Health-Plans-CHIA-Research-Brief.pdf">low-wage</a> <a href="https://www.ajmc.com/view/financial-burden-of-healthcare-utilization-in-consumer-directed-health-plans">workers</a> who live paycheck to paycheck. More than half of large employers believe their employees <a href="https://www.kff.org/report-section/ehbs-2023-summary-of-findings/#:%7E:text=As%20noted%20above%2C%2025%25%20of,a%20moderate%20level%20of%20concern">have concerns</a> about their ability to afford medical care.</p>
<p>Lowering deductibles and out-of-pocket maximums could protect patients from accumulating debt, since it would lower the total amount they could incur in a given time period. But if the current system otherwise stayed the same, then premiums would have to rise to offset the reduction in out-of-pocket payments. Higher premiums would transfer costs across everyone in the insurance pool and make enrolling in insurance unreachable for some – which doesn’t solve the underinsurance problem.</p>
<p>Reducing out-of-pocket liability without inflating premiums would only be possible if the overall cost of health care drops. Fortunately, there’s room to reduce waste. Americans <a href="https://www.pgpf.org/blog/2023/07/why-are-americans-paying-more-for-healthcare">spend more on health care</a> than people in other wealthy countries do, and arguably get less for their money. <a href="http://doi.org/doi:10.1001/jama.2019.13978">More than a quarter</a> of health spending is on <a href="https://www.brookings.edu/articles/reducing-administrative-costs-in-u-s-health-care/#:%7E:text=Cutler%20proposes%20several%20reforms%20to,in%20the%20health%2Dcare%20system.">administrative</a> <a href="http://doi.org/10.1111/1475-6773.13649">costs</a>, and the <a href="https://doi.org/10.1377/hlthaff.2018.05144">high prices</a> Americans pay don’t necessarily translate into <a href="https://www.doi.org/10.1001/jama.2019.13978">high-value care</a>. That’s why some states like <a href="https://www.milbank.org/publications/the-massachusetts-health-care-cost-growth-benchmark-and-accountability-mechanisms-stakeholder-perspectives/">Massachusetts</a> and <a href="https://hcai.ca.gov/get-the-facts-about-the-office-of-health-care-affordability/">California</a> are experimenting with <a href="https://www.chcf.org/wp-content/uploads/2022/04/HealthCareCostCommissionstatesAddressCostGrowth.pdf">cost growth limits</a>.</p>
<h2>Momentum toward policy change</h2>
<p>The growing number of city and county governments buying off medical debt signals that local leaders view medical debt as a problem worth solving. Congress has passed substantial <a href="https://www.cms.gov/priorities/key-initiatives/hospital-price-transparency">price transparency laws</a> and prohibited <a href="https://www.cms.gov/nosurprises">surprise medical billing</a> in recent years. The Consumer Financial Protection Bureau is <a href="https://www.consumerfinance.gov/about-us/newsroom/cfpb-kicks-off-rulemaking-to-remove-medical-bills-from-credit-reports/">exploring rule changes</a> for medical debt collections and reporting, and national credit bureaus have <a href="https://www.urban.org/urban-wire/medical-debt-was-erased-credit-records-most-consumers-potentially-improving-many">voluntarily removed</a> some medical debt from credit reports to limit its impact on people’s approval for loans, leases and jobs. </p>
<p>These recent actions show that leaders at all levels of government want to end medical debt. I think that’s a good sign. After all, recognizing a problem is the first step toward meaningful change.</p><img src="https://counter.theconversation.com/content/222247/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Erin Duffy receives funding from Arnold Ventures. </span></em></p>Local governments are increasingly buying – and forgiving – their residents’ medical debt.Erin Duffy, Research Scientist, University of Southern CaliforniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2064912023-05-30T05:16:35Z2023-05-30T05:16:35ZThe real cost of New Zealand’s two-tier health system: why going private doesn’t relieve pressure on public hospitals<figure><img src="https://images.theconversation.com/files/528947/original/file-20230529-24-y696dn.jpg?ixlib=rb-1.1.0&rect=76%2C728%2C4981%2C2674&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Getty Images</span></span></figcaption></figure><p>Ethicists argue that healthcare is special. Unlike other consumer goods, its availability and accessibility should be based on need rather than ability to pay.</p>
<p>In New Zealand, however, our tolerance of a two-tier health system – in which some services are only available for a price – suggests a degree of moral ambivalence. </p>
<p>Take, for instance, the recent Health and Disability Commissioner <a href="https://www.hdc.org.nz/media/6402/22hdc01310.pdf">report</a> detailing inadequacies in cancer treatment and management in southern parts of New Zealand. Alongside cases of patients seeking urgent cancer treatment in the <a href="https://www.odt.co.nz/news/dunedin/health/healthcare-delays-push-cancer-patient-private">private sector</a>, it raises questions of justice about our two-tier health system.</p>
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<p>Many seem to accept the argument that a two-tier public-private health system is not morally problematic, given most essential health services remain free to all. Some might go further and argue justice demands a two-tier system because health is only one public good the state is obliged to provide. Limiting non-essential healthcare services ensures it can meet those obligations. </p>
<p>The second private tier protects the liberty of those who want and can afford to purchase those services, while the first public tier focuses on meeting everyone’s needs to a sufficient level.</p>
<p>But the justice argument supports this conclusion only if the services and benefits provided in the first tier meet that threshold of sufficiency. Where exactly this threshold lies has been the subject of perennial debate. </p>
<h2>Eroding the public system</h2>
<p>We might start with the idea that a sufficient level of healthcare includes “<a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/769663">vital goods and services essential to human flourishing</a>”. </p>
<p>While this excludes some services (high-cost treatments with uncertain benefits), it demands more than what the public sector is currently providing to New Zealanders. It should include (at least) more comprehensive and universal access to primary and oral healthcare and timely access to cancer treatment.</p>
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<a href="https://theconversation.com/high-cost-means-more-than-half-of-nzs-young-adults-dont-access-dental-care-117494">High cost means more than half of NZ's young adults don't access dental care</a>
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<p>Our willingness to accept a second tier of healthcare accessible only to those who can pay depends on the sufficiency of the first tier. The worse the services in the first tier, the weaker the justification for the second tier.</p>
<p>Many also seem to accept the argument that the private sector plays an important, possibly even altruistic, role in supporting the public sector. A provider at a new private clinic in Dunedin recently <a href="https://www.odt.co.nz/news/dunedin/health/skipping-queue-placing-trust-somewhere-new">stated</a>:</p>
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<p>We’re proud to back up the public health system by providing an alternative service that will take some of the pressure off the public system.</p>
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<p>Patients are susceptible to the idea that by paying for private treatment they are “freeing up a bed” for someone in the public sector.</p>
<p>This argument is misleading at best. When the public system isn’t adequately resourced to meet the need, patients who receive their care privately do not have a bed or a spot to give up. The lack of a spot is often what drives them to the private system in the first place. </p>
<p>On the contrary, the proliferation of private-sector facilities and policies that favour this proliferation may either implicitly or explicitly aim to deplete the public sector. </p>
<p>Following the principle that every private bed is one the state does not need to provide, private beds don’t free up public beds, they replace them.</p>
<p>We should not be under any illusion that private insurance and private healthcare are altruistic in relieving pressure on the public system. They profit from failures of the public system to meet current needs and patients’ desperation to receive timely treatment.</p>
<h2>Eroding solidarity</h2>
<p>The Health and Disability Commissioner’s report on cancer treatment in the southern region highlights demonstrable harms for patients who did not receive timely treatment in the public system. In a particularly stark <a href="https://www.odt.co.nz/news/dunedin/health/public-private-health-divide-decides-brothers%E2%80%99-fate">recent case</a>, brothers who received cancer treatment in the public and private system respectively experienced tragically different outcomes. </p>
<p>Examples like this show a growing gap between the services available in the private and public tiers of our health system. This gap threatens social cohesion and solidarity. </p>
<p>When the worse-off are required to accept services below reasonable expectations of routine care (and the demonstrable harms that result), individuals are no longer in the same boat. The better-off live in a world of social goods and privileges inaccessible to the worse-off. </p>
<p>Why we accept this in health and not other sectors is an important question. It is hard to imagine school teachers only taking bookings months out to see parents seeking help for their troubled children, or denying entry to public schools due to limited capacity. </p>
<p>It is also doubtful we would accept teachers setting up private classes and consultation times to provide a timely service to those who can pay. </p>
<h2>Entrenched inequities</h2>
<p>The commodification of healthcare was built into the New Zealand system from the outset, with medical professionals demanding the freedom to charge fees for their services. The results are <a href="https://assets-global.website-files.com/5e332a62c703f653182faf47/5e332a62c703f6d08f2fdabe_content.pdf">evident in many of our health statistics</a> that reflect entrenched health inequities, particularly between Māori and non-Māori New Zealanders. </p>
<p>While we are likely stuck with a two-tier system for the foreseeable future, it can and should be made more just by ensuring all “vital goods and services” are securely provided in the public sector.</p>
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Read more:
<a href="https://theconversation.com/new-zealands-health-restructure-is-doomed-to-fall-short-unless-its-funding-model-is-tackled-first-179935">New Zealand's health restructure is doomed to fall short unless its funding model is tackled first</a>
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<p>Health is special. It preserves a range of opportunities people need to live flourishing lives. We should demand a health system that is committed to preserving those opportunities for everyone. </p>
<p>We need our political leaders to tell us whether they stand with us in support of this goal and indicate their commitment to universal healthcare. If so, we need them to acknowledge this can only be achieved with some fundamental shifts in how we think about the public-private divide.</p><img src="https://counter.theconversation.com/content/206491/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robin Gauld has received funding from the Health Research Council of New Zealand. He serves on the Board of Directors of Business South.</span></em></p><p class="fine-print"><em><span>Elizabeth Fenton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The argument that private healthcare relieves pressure on the public system is misleading. Private care profits from failures of the public system and patients’ desperation for timely treatment.Elizabeth Fenton, Lecturer in Bioethics, University of OtagoRobin Gauld, Professor; Co-Director, Centre for Health Systems and Technology, University of OtagoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2051652023-05-10T18:49:55Z2023-05-10T18:49:55ZWhat does ending the emergency status of the COVID-19 pandemic in the US mean in practice? 4 questions answered<figure><img src="https://images.theconversation.com/files/524939/original/file-20230508-197326-1kuk6o.jpg?ixlib=rb-1.1.0&rect=181%2C142%2C8465%2C5418&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">COVID-19 hasn't vanished, but at this point it's doing less damage.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/woman-erasing-red-covid-19-virus-with-paint-roller-royalty-free-image/1292684629?phrase=covid-19&adppopup=true">Klaus Vedfelt/DigitalVision via Getty Images</a></span></figcaption></figure><p><em>The COVID-19 pandemic’s public health emergency status in the U.S. <a href="https://www.npr.org/2023/04/11/1169191865/biden-ends-covid-national-emergency">expires on May 11, 2023</a>. And on May 5, the World Health Organization declared <a href="https://www.statnews.com/2023/05/05/who-declares-end-to-covid-global-health-emergency/?">an end to the COVID-19 public health emergency of international concern</a>, or PHEIC, designation that had been in place since Jan. 30, 2020.</em> </p>
<p><em>Still, both the WHO and the White House have made clear that while the emergency phase of the pandemic has ended, the virus is here to stay and <a href="https://www.washingtonpost.com/health/2023/05/05/covid-forecast-next-two-years/">could continue to wreak havoc</a>.</em> </p>
<p><em>WHO Director General Tedros Adhanom Ghebreyesus noted that, over that time, the virus has taken the lives of <a href="https://www.washingtonpost.com/world/2023/05/05/who-covid-global-health-emergency/">more than 1 million people in the U.S.</a> and <a href="https://doi.org/10.1038/d41586-023-01559-z">about 7 million people globally</a> based on reported cases, though he said the true toll is likely <a href="https://www.npr.org/sections/goatsandsoda/2023/05/05/1174269442/who-ends-global-health-emergency-declaration-for-covid-19">closer to 20 million people worldwide</a>. While the global emergency status has ended, COVID-19 is still an “<a href="https://www.who.int/news/item/05-05-2023-statement-on-the-fifteenth-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-coronavirus-disease-(covid-19)-pandemic">established and ongoing health issue</a>,” he said.</em></p>
<p><em>The Conversation asked public health experts <a href="https://cph.osu.edu/people/mjones">Marian Moser Jones</a> and <a href="https://cph.osu.edu/people/afairchild">Amy Lauren Fairchild</a> to put these changes into context and to explain their ramifications for the next stage of the pandemic.</em> </p>
<h2>1. What does ending the national emergency phase of the pandemic mean?</h2>
<p>Ending the federal emergency reflects both a scientific and political judgment that the acute phase of the COVID-19 pandemic crisis has ended and that special federal resources are no longer needed to prevent disease transmission across borders. </p>
<p>In practical terms, it means that two declarations – the <a href="https://www.phe.gov/emergency/news/healthactions/phe/Pages/2019-nCoV.aspx">federal Public Health Emergency</a>, first declared on Jan. 31, 2020, and the <a href="https://www.whitehouse.gov/briefing-room/presidential-actions/2022/02/18/notice-on-the-continuation-of-the-national-emergency-concerning-the-coronavirus-disease-2019-covid-19-pandemic-2/">COVID-19 national emergency</a> that former President Donald Trump announced on March 13, 2020, are expiring.</p>
<p>Declaring those emergencies enabled the federal government to cut through mountains of red tape to respond to the pandemic more efficiently. For instance, the declarations allowed <a href="https://aspr.hhs.gov/legal/PHE/Pages/Public-Health-Emergency-Declaration.aspx">funds to be made available</a> so that federal agencies could direct personnel, equipment, supplies and services to state and local governments wherever they were needed. In addition, the declarations made funding and other resources available to launch investigations into the “<a href="https://aspr.hhs.gov/legal/PHE/Pages/Public-Health-Emergency-Declaration.aspx">cause, treatment or prevention</a>” of COVID-19 and to enter into contracts with other organizations to meet needs stemming from the emergency. </p>
<p>The emergency status also allowed the federal government to make health care more widely available by <a href="https://aspr.hhs.gov/legal/PHE/Pages/Public-Health-Emergency-Declaration.aspx">suspending many requirements</a> for accessing Medicare, Medicaid and the Children’s Health Program, or CHIP. And they made it possible for people to receive free COVID-19 testing, treatment and vaccines and <a href="https://www.medicaid.gov/medicaid/benefits/downloads/medicaid-telehealth-services.pdf">enabled Medicaid</a> and Medicare to <a href="https://telehealth.hhs.gov/providers/billing-and-reimbursement/">more easily cover telehealth services</a>. </p>
<p>Finally, the Trump administration used the national emergency to invoke <a href="https://www.dhs.gov/news/2023/01/05/dhs-continues-prepare-end-title-42-announces-new-border-enforcement-measures-and">Title 42</a>, a section of the Public Health Service Act that allows the federal government to <a href="https://theconversation.com/a-trump-era-law-used-to-restrict-immigration-is-nearing-its-end-despite-gop-warnings-of-a-looming-crisis-at-the-southern-border-194971">stop people at the nation’s borders</a> to prevent introduction of communicable diseases. Asylum seekers and others who normally undergo processing when they enter the U.S. have been turned away under this rule. </p>
<h2>2. What domestic policies are changing?</h2>
<p>An estimated 15 million people are likely to lose Medicaid or CHIP coverage, <a href="https://aspe.hhs.gov/sites/default/files/documents/a892859839a80f8c3b9a1df1fcb79844/aspe-end-mcaid-continuous-coverage.pdf">according to the federal government</a>. <a href="https://www.kff.org/medicaid/issue-brief/how-many-people-might-lose-medicaid-when-states-unwind-continuous-enrollment/">Another analysis projected</a> that as many as 24 million people will be kicked off the Medicaid rolls.</p>
<p>Before the pandemic, states required people to prove every year that they met income and other eligibility requirements. This <a href="https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-growth-estimates-by-state-and-eligibility-group-show-who-may-be-at-risk-as-continuous-enrollment-ends/">resulted in “churning”</a> – a process whereby people who did not complete renewal paperwork were being periodically disenrolled from state Medicaid programs before they could reapply and prove eligibility. </p>
<p>In March 2020, Congress enacted a continuous enrollment provision in Medicaid that prevented states from removing anyone from their rolls during the pandemic. From February 2020 to March 31, 2023, <a href="https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-growth-estimates-by-state-and-eligibility-group-show-who-may-be-at-risk-as-continuous-enrollment-ends/">enrollment in Medicaid and CHIP grew by nearly 23.5%</a> to a total of more than 93 million. In a December 2022 appropriations bill, Congress passed a provision that ended continuous enrollment on March 31, 2023.</p>
<p>The Biden administration <a href="https://www.whitehouse.gov/wp-content/uploads/2023/01/SAP-H.R.-382-H.J.-Res.-7.pdf">defended this time frame as sufficient</a> to ensure that patients did not “lose access to care unpredictably” and that state Medicaid budgets – which received emergency funds beginning in 2020 – didn’t “face a radical cliff.” </p>
<p>But many people who have Medicaid or who enrolled their children in CHIP during this period may be unaware of these changes until they actually lose their benefits over the next several months.</p>
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<p>At least five states already <a href="https://ccf.georgetown.edu/2023/04/01/state-unwinding-tracker/">began disenrolling Medicaid members in April</a>. Other states are <a href="https://medicaid.ohio.gov/stakeholders-and-partners/covidunwinding/covidunwinding">sending out termination letters</a> and <a href="https://www.hhs.texas.gov/services/health/medicaid-chip/end-continuous-medicaid-coverage">renewal notices</a> and will <a href="https://ccf.georgetown.edu/2023/04/01/state-unwinding-tracker/">disenroll members starting in May, June and July</a>.</p>
<p>Only Oregon has set up a comprehensive program to minimize disenrollments. That state is running a <a href="https://www.oregon.gov/oha/HSD/Medicaid-Policy/Documents/2022-2027-1115-Demonstration-Approval.pdf">five-year federal demonstration program</a> that allows it to temporarily let people stay on Medicaid if their income is up to 200% of the federal poverty level and lets eligible children stay on Medicaid through age 6. Many other states are <a href="https://www.medicaid.gov/covid-19-phe-unwinding-section-1902e14a-waiver-approvals/index.html">trying more limited strategies</a> to improve the renewal process and decrease churning.</p>
<p>The array of telehealth services that Medicare began <a href="https://telehealth.hhs.gov/providers/billing-and-reimbursement/billing-and-coding-medicare-fee-for-service-claims/?">covering during the pandemic</a> will continue to be covered through December 2024. Medicare is also making coverage for <a href="https://telehealth.hhs.gov/providers/policy-changes-during-the-covid-19-public-health-emergency/policy-changes-after-the-covid-19-public-health-emergency">behavioral and mental telehealth services a permanent benefit</a>.</p>
<p>The end of the emergency also means that the federal government is no longer covering the costs of COVID-19 vaccines and treatments for everyone. However, in April, the Biden administration announced a new $1.1 billion <a href="https://www.hhs.gov/about/news/2023/04/18/fact-sheet-hhs-announces-hhs-bridge-access-program-covid-19-vaccines-treatments-maintain-access-covid-19-care-uninsured.html">public-private “bridge access program</a>” that will provide COVID-19 vaccines and treatments free of charge for uninsured people through state and local health departments and pharmacies. Insured individuals may have out-of-pocket costs depending on their coverage.</p>
<p>The end of the emergency lifts the pandemic restriction on border crossing. Large numbers of migrants <a href="https://www.cnn.com/2023/05/08/us/title-42-expires-border-immigration/index.html">have gathered at the Mexico-U.S. border</a> and are expected to enter the country in the coming weeks, further straining already overwhelmed staff and facilities. </p>
<h2>3. What does this mean for the status of the pandemic?</h2>
<p><a href="https://www.ncbi.nlm.nih.gov/books/NBK143061">A pandemic declaration</a> represents an assessment that human transmission of a disease, whether well known or novel, is “extraordinary,” that it constitutes a public health risk to two or more U.S. states and that controlling it requires an international response. But declaring an end to the emergency doesn’t mean a return to business as usual.</p>
<p><a href="https://www.who.int/publications/i/item/WHO-WHE-SPP-2023.1">New global guidelines for long-term disease management</a> of COVID-19, released on May 3, 2023, urged countries “to maintain sufficient capacity, operational readiness and flexibility to scale up during surges of COVID-19, while maintaining other essential health services and preparing for the emergence of new variants with increased severity or capacity.”</p>
<p>Former White House COVID-19 response coordinator <a href="https://fortune.com/well/2023/04/29/covid-antiviral-paxlovid-evade-deborah-birx-double-deaths/">Deborah Birx recently warned</a> that the omicron COVID-19 variant continues to mutate and may become resistant to existing treatments. She called for more federally funded research into therapeutics and durable vaccines that protect against many variants. </p>
<p>Birx’s warnings come as <a href="https://www.krem.com/article/news/health/coronavirus/washington-covid-final-press-conference/293-3f109a05-5e8a-4c80-8868-18f8cd9d3fbe">remaining states have ended their COVID-19 press briefings</a> and <a href="https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/CANotify/CANotifyMain.aspx">shut down their exposure notification systems</a>, and the <a href="https://apnews.com/article/covid-home-test-78960c4c36422907a2eab3eb0dcdfadd">federal government has ended its free COVID-19 at-home test program</a>. </p>
<p>With the end of the emergency, the CDC is also changing the way it presents its COVID-19 data to a “<a href="https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html">sustainable national COVID-19 surveillance” model</a>. This shift in COVID-19 monitoring and communication strategies accompanying the end of the emergency means that the virus is disappearing from the headlines, even though it has not disappeared from our lives and communities.</p>
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<h2>4. How will state and local pandemic measures be affected?</h2>
<p>The end of the federal emergency does not affect state-level or local-level emergency declarations. These declarations have allowed states to allocate resources to meet pandemic needs and have <a href="https://telehealth.hhs.gov/providers/policy-changes-during-the-covid-19-public-health-emergency/telehealth-licensing-requirements-and-interstate-compacts/">included provisions</a> allowing them to respond to surges in COVID-19 cases by allowing out-of-state physicians and other health care providers to practice in person and through telehealth. </p>
<p>Most U.S. states, however, have ended their own public health emergency declarations. Six states – Delaware, Illinois, Massachusetts, New York, Rhode Island and Texas – still had emergency declarations in effect as of May 3, 2023, that will expire by the end of the month. So far, <a href="https://nashp.org/states-covid-19-public-health-emergency-declarations/">Massachusetts Gov. Maura Healey</a> stands alone in having indicated that she will “extend key flexibilities provided by the public health emergency” related to health care staffing and emergency medical services.</p>
<p>While some states may choose to make permanent some COVID-era emergency standards, such as looser restrictions on telemedicine or out-of-state health providers, we believe it could be a long time before either politicians or members of the public regain an appetite for any emergency orders directly related to COVID-19. </p>
<p><em>This is an updated version of an article that was <a href="https://theconversation.com/bidens-plan-for-ending-the-emergency-declaration-for-covid-19-signals-a-pivotal-point-in-the-pandemic-4-questions-answered-199060">originally published</a> on Feb. 3, 2023.</em></p><img src="https://counter.theconversation.com/content/205165/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marian Moser Jones receives funding from the National Endowment for the Humanities and The American Public Health Association. In the past she has received funding from the National Institutes of Health and the American Association for the History of Nursing, as well as the State of Maryland.</span></em></p><p class="fine-print"><em><span>Amy Lauren Fairchild has received funding from NIH, NSF, NEH, the RWJ Foundation, and the Greenwall Foundation. </span></em></p>The emergency status allowed the federal government to cut through a mountain of red tape, with the goal of responding to the pandemic more efficiently.Marian Moser Jones, Associate Professor of Health Services Management, Policy and History, The Ohio State UniversityAmy Lauren Fairchild, Dean and Professor of Public Health, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1902572022-09-09T08:23:32Z2022-09-09T08:23:32Z5 essential reads on migrant access to healthcare in South Africa<figure><img src="https://images.theconversation.com/files/483525/original/file-20220908-24-jfkrlw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Members of Operation Dudula sing and chant slogans during their protest outside the Kalafong Hospital in Atteridgeville township, west of Pretoria, restricting undocumented migrants from accessing healthcare.</span> <span class="attribution"><span class="source">Photo by Phill Magakoe/ Getty Images</span></span></figcaption></figure><p>The hostility against foreign nationals that has been <a href="https://www.dailymaverick.co.za/article/2022-09-01-operation-dudula-calls-off-protests-at-kalafong-hospital-after-fruitful-meeting-with-health-minister/">displayed</a> outside some of South Africa’s hospitals is not new or isolated. South Africa is home to <a href="https://www.sahrc.org.za/index.php/sahrc-media/opinion-pieces/item/1422-ensuring-health-and-access-to-health-care-for-migrants-a-right-and-good-public-health-practice">about 2 million</a> immigrants, many of whom struggle to access a variety of public services, including healthcare. </p>
<p>The question of whether migrants place unnecessary pressure on the health system must be put into perspective. Two realities need to be highlighted. </p>
<p>The first is that South Africa’s health system has been plagued by problems and it functions poorly as a result of poor governance. It is a highly unequal system which places significant pressure on public healthcare. There are general shortages of nurses and doctors, high workloads, low morale among staff and multiple burdens of disease. Corruption also plays a role.</p>
<p>The second is that migration – the movement of people into and across South Africa – is a reality and must be planned for.</p>
<p>Experts writing for The Conversation Africa have explored these issues in a number of articles: we’ve collected five of them here. </p>
<h2>Good relationships with migrants</h2>
<p>Small, organised groupings of South Africans have pushed an anti-migrant sentiment which is closely linked to the country’s dire economic situation, partially caused by increased poverty, scarcity of resources and high unemployment rates. </p>
<p>There is evidence that the statements that fuel these sentiments are false and that South Africans and migrants can live together in good relationships. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/xenophobia-does-not-tell-the-full-story-of-migration-in-south-africa-182784">Xenophobia does not tell the full story of migration in South Africa</a>
</strong>
</em>
</p>
<hr>
<h2>Medical xenophobia</h2>
<p>The health minister for South Africa’s Limpopo province was recorded on video berating a Zimbabwean woman for crossing the border to access healthcare in South Africa.</p>
<p>This is not the only case. There are often reports of healthcare providers indiscriminately practising “medical xenophobia”. But this dominant, single narrative around migrants and health care is misleading.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/telling-the-complex-story-of-medical-xenophobia-in-south-africa-127040">Telling the complex story of 'medical xenophobia' in South Africa</a>
</strong>
</em>
</p>
<hr>
<h2>Better system design</h2>
<p>The public health system isn’t engaging adequately with migrants and this has an effect on the way the system operates.</p>
<p>What South Africa needs is a health system that considers population movement in the way that policies and interventions are designed.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/south-africas-healthcare-system-cant-afford-to-ignore-migration-120797">South Africa's healthcare system can't afford to ignore migration</a>
</strong>
</em>
</p>
<hr>
<h2>The law allows migrants access</h2>
<p>South Africa has a collection of laws that set out exactly how healthcare services should be provided. This includes the constitution, the National Health Act and the Refugee Act. </p>
<p>The state must provide free care to everyone, except for people covered by private medical aid schemes.</p>
<p>The blame on migrants is misplaced. The real issue is health system management and governance. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/migrants-in-south-africa-have-access-to-healthcare-why-its-kicking-up-a-storm-189574">Migrants in South Africa have access to healthcare: why it's kicking up a storm</a>
</strong>
</em>
</p>
<hr>
<h2>Healthcare at the border</h2>
<p>Although most immigrants come to South Africa in search of work opportunities and better living conditions, they inevitably need healthcare. </p>
<p>A study by Doctors Without Borders (MSF) around the South African-Zimbabwe border sets out what services foreign nationals seek most often, and how. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-migrants-who-move-between-zimbabwe-and-south-africa-access-healthcare-in-border-towns-189822">How migrants who move between Zimbabwe and South Africa access healthcare in border towns</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/190257/count.gif" alt="The Conversation" width="1" height="1" />
Small, organised groups of South Africans who are stopping undocumented foreigners from using hospitals bring the issue of migrants accessing healthcare into the spotlight.Candice Bailey, Strategic Initiatives EditorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1898222022-09-05T18:34:50Z2022-09-05T18:34:50ZHow migrants who move between Zimbabwe and South Africa access healthcare in border towns<figure><img src="https://images.theconversation.com/files/482793/original/file-20220905-2133-3fqstw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Refugees and asylum seekers move through this refugee camp in Musina, South Africa.</span> <span class="attribution"><span class="source">Photo credit should read Luca Sola/AFP via Getty Images</span></span></figcaption></figure><p><em>Zimbabwe and South Africa share a <a href="https://www.britannica.com/place/Zimbabwe">225 km common border</a>. There is only one official border crossing, at Beitbridge. An estimated <a href="https://www.msf.org.za/news-and-resources/patient-and-staff-stories/zimbabwe-sharing-msf-experiences-beitbridge-reception">15,000 migrants</a> and refugees from Zimbabwe and other countries cross daily either through the official border post or at illegal crossing points. Migrants’ access to healthcare, particularly in the two towns along this border – Beitbridge and Musina – has come into sharp focus after the health minister of Limpopo province made <a href="https://www.bbc.co.uk/news/world-africa-62677577">disparaging remarks</a> to a Zimbabwean woman seeking help at a South African hospital. Doctors Without Borders has been <a href="https://www.msf.org.za/news-and-resources/patient-and-staff-stories/zimbabwe-sharing-msf-experiences-beitbridge-reception">providing healthcare to displaced populations</a> at Beitbridge for 22 years. The Conversation Africa spoke to Doctors Without Borders’ regional migration advisor Vinayak Bhardwaj about their research into migrants’ healthcare needs in the area.</em> </p>
<h2>What’s known about people crossing into South Africa?</h2>
<p>In 2019 we did a <a href="https://www.msf.org.za/sites/default/files/2021-03/Migration_history_tool_Limpopo_Mobility_Survey.pdf">survey</a> to produce reliable evidence on the way migrants move and what the links are to their health outcomes. </p>
<p>In the survey we interviewed just over 1,600 migrants in the border towns of Beitbridge in Zimbabwe and Musina in South Africa. </p>
<p>For most migrants, Beitbridge was a transit site en route to South Africa. The main reasons they gave for leaving their countries of origin were to search for jobs and for better living conditions. </p>
<p>These economic motivations were coherent with the main difficulties many respondents faced in Zimbabwe as their last place of residence. Many respondents had travelled from countries further north and had spent some time in Zimbabwe en route to South Africa.</p>
<p>These difficulties were mainly unemployment, financial challenges and food insecurity. Although they were aware of the alarming levels of political persecution and civil unrest in Zimbabwe, none of the participants cited political-related factors as the main reasons for leaving Zimbabwe.</p>
<p>Men and women said they came searching for jobs. But the search for better living conditions was a more predominant reason to leave the country for men than for women. Motivations involving family, such as a family gathering or starting a new family, were more common among female respondents. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/482475/original/file-20220902-25-hm5l3f.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/482475/original/file-20220902-25-hm5l3f.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=493&fit=crop&dpr=1 600w, https://images.theconversation.com/files/482475/original/file-20220902-25-hm5l3f.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=493&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/482475/original/file-20220902-25-hm5l3f.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=493&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/482475/original/file-20220902-25-hm5l3f.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=620&fit=crop&dpr=1 754w, https://images.theconversation.com/files/482475/original/file-20220902-25-hm5l3f.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=620&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/482475/original/file-20220902-25-hm5l3f.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=620&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The number of migrants at the Beitbridge border post and their reasons for leaving their countries of origin.</span>
</figcaption>
</figure>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/482476/original/file-20220902-24-mzz866.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/482476/original/file-20220902-24-mzz866.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=463&fit=crop&dpr=1 600w, https://images.theconversation.com/files/482476/original/file-20220902-24-mzz866.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=463&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/482476/original/file-20220902-24-mzz866.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=463&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/482476/original/file-20220902-24-mzz866.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=582&fit=crop&dpr=1 754w, https://images.theconversation.com/files/482476/original/file-20220902-24-mzz866.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=582&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/482476/original/file-20220902-24-mzz866.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=582&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The number of migrants in Musina and the reasons for leaving their countries of origin.</span>
</figcaption>
</figure>
<p>Our survey was initiated before the COVID pandemic and the data collection was concluded and published just as the pandemic began. Some of these findings may therefore be different now. </p>
<h2>What are the biggest insights about their health needs?</h2>
<p>For a long time there has been insufficient information about migrants’ medical needs in this area. </p>
<p>In Beitbridge, the health needs often related to chronic or infectious diseases such as hypertension and malaria. There was also high HIV prevalence among women. And there was a significant need for mental health services. </p>
<p>Our results showed that Central Africans coming from countries such as Burundi and Democratic Republic of Congo were particularly hampered from accessing medical care, primarily due to language barriers. Because their primary language was French, accessing care in English was difficult.</p>
<p>The survey also showed that sexual violence was a reality for migrants. An estimated 36% of single female Malawian migrants residing at a safe house in Beitbridge said they had experienced sexual violence. </p>
<p>In Musina, there was evidence of high levels of sexual violence and abuse among male migrants. There was also a significant need for mental health services. Burundian migrants and asylum seekers in particular reported poor mental health indicators. </p>
<h2>What facilities are available?</h2>
<p>On the Zimbabwean side, there is one hospital and four government clinics: Beitbridge Hospital, and Dulivadzimu, Nottingham, Shashe and Tshikwarakwara council clinics, which offer primary health services. </p>
<p>These facilities are all in the town of Beitbridge. The clinics are strategically located in the Beitbridge urban district. The Beitbridge district hospital caters for both local and mobile populations. </p>
<p>These facilities are geared towards providing services around chronic conditions. Their capabilities to provide mental health and sexual and reproductive health services are more limited. At the Dulivadzimu council clinic, Doctors Without Borders supports the facility with human resources, filling in gaps for the pharmacy, and providing laboratory support. </p>
<p>In addition to these facilities, Doctors Without Borders has set up a small mobile clinic at the Beitbridge Reception Centre, which provides primary healthcare to Zimbabweans who are deported and to people moving through to South Africa. </p>
<p>In the town of Musina, there are three state-run facilties: Musina Hospital, and Nancefield and Musina clinics. </p>
<p>Recently a quick needs assessment by Doctors Without Borders in the area showed inappropriate water and sanitation facilities at the site, as well as difficulties in accessing healthcare in the public clinics and hospitals. </p>
<p>On the back of these insights Doctors Without Borders established an emergency project in the so-called men’s shelter in Musina town. </p>
<p>The organisation also established the “Musina model of care” – a strategy which targets agricultural workers based at distant farms. The idea was to create a mobile approach with core minimum services, including antiretroviral treatment and tuberculosis treatment for those who could not access clinics. </p>
<p>Having achieved successful rates of treatment continuation, the activities have been handed over to the South African authorities.</p>
<h2>What did you learn about the scale of migration in the area?</h2>
<p>Historically, the flow of migration in southern Africa is towards South Africa, as shown by the International Office for Migration’s <a href="https://reliefweb.int/report/zimbabwe/southern-africa-monthly-flow-monitoring-registry-report-july-2022">flow trends data</a>. </p>
<p>But consolidated data has not been consistently collected for the last two years, due to the COVID pandemic. The International Office for Migration, which tracks this information closely, <a href="https://zimbabwe.iom.int/news/more-200000-people-return-zimbabwe-covid-19-impacts-regional-economies">reported</a> that during the pandemic (2020-2021), over 200,000 Zimbabwean migrants returned to Zimbabwe mostly because of the lack of economic opportunities in South Africa during the pandemic. </p>
<p>The closure of the Beitbridge border for several months (on the Zimbabwe side) during the pandemic, as well as the further restrictions on legal movement, such as the requirement to provide a negative PCR test, further reduced legal migration. This affected irregular migration in ways that haven’t been tracked yet. </p>
<p>More recent data is available on a month-to-month basis, documenting the flow across the Beitbridge border. But this has not yet been analysed to assess whether the scale of migration has returned to pre-pandemic levels.</p><img src="https://counter.theconversation.com/content/189822/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vinayak Bhardwaj is affiliated with PRICELESS, a health economics thinktank based at the Wits School of Public Health. I work there as a researcher. They did not, however, any editorial input in this article.</span></em></p>Beitbridge and Musina are two border towns in Zimbabwe and South Africa that see many migrants pass through – with different health needs.Vinayak Bhardwaj, Regional Migration Referent, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1577502021-05-04T12:16:13Z2021-05-04T12:16:13ZTwo classes of trans kids are emerging – those who have access to puberty blockers, and those who don’t<figure><img src="https://images.theconversation.com/files/398409/original/file-20210503-19-4w4g9v.jpg?ixlib=rb-1.1.0&rect=17%2C37%2C1915%2C1411&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Transitioning is possible after going through puberty, but it's much more difficult for trans people to look the way they want to look.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/illustration-of-the-question-of-belonging-to-royalty-free-illustration/1311856269?adppopup=true">Elena Medvedeva/Getty Images</a></span></figcaption></figure><p>For people who have never thought about it before, it might sound reasonable to require trans kids to wait until they’re adults before they can receive certain forms of care known as <a href="https://theconversation.com/im-a-pediatrician-who-cares-for-transgender-kids-heres-what-you-need-to-know-about-social-support-puberty-blockers-and-other-medical-options-that-improve-lives-of-transgender-youth-157285">gender-affirming treatment</a> – which is what <a href="https://www.nbcnews.com/feature/nbc-out/arkansas-passes-bill-ban-gender-affirming-care-trans-youth-n1262412">legislation that just passed in Arkansas</a> does.</p>
<p>But this type of legislation actually prevents kids from accessing treatment before and during a crucial period of development: puberty. </p>
<p>When I was researching my book “<a href="https://nyupress.org/9781479885794/the-trans-generation/">The Trans Generation: How Trans Kids and Their Parents are Creating a Gender Revolution</a>,” I observed how not all trans kids can access the care they want or need during this critical stage of life. This unequal access to gender-affirming health care, which occurs across state lines and socioeconomic divides, could cause two “classes” of transgender people in the United States to emerge – those who are able to take hormone blockers, and those who aren’t able to do so. </p>
<p>Those in the latter group can endure more <a href="https://www.businessinsider.com/transgender-medical-care-surgery-expensive-2019-6">financial hardship</a>, <a href="https://www.medicalnewstoday.com/articles/326590#recovery">physical pain</a> and <a href="https://doi.org/10.1542/peds.2019-1725">mental anguish</a> later in life, while becoming much more vulnerable to discrimination and violence.</p>
<h2>A paradigm shift in trans treatment</h2>
<p>For decades, kids who didn’t conform to the gender expected of them were forced to endure treatments designed to “cure” their gender nonconformity. <a href="https://www.aacap.org/aacap/policy_statements/2018/Conversion_Therapy.aspx">This form of therapy</a>, called “reparative” or “corrective,” typically involved instructing parents – and sometimes teachers – to subject children to constant surveillance and correction. If a child acted in ways that didn’t align with gender-expected behaviors, psychologists told caregivers to withhold affection and mete out punishments.</p>
<p>For example, in the 1970s, <a href="http://edition.cnn.com/2011/US/06/07/sissy.boy.experiment/">a boy with the pseudonym Kraig</a> was a patient at UCLA’s “<a href="https://www.washingtonpost.com/blogs/blogpost/post/family-of-kirk-murphy-says-sissy-boy-experiment-led-to-his-suicide/2011/06/10/AGYfgvOH_blog.html">feminine boy project</a>,” a government-funded experiment that sought to evaluate ways to reverse feminine behavior in boys. </p>
<p>Kraig <a href="http://www.doi.org/10.1901/jaba.1974.7-173">was subjected to shame-inducing treatments</a>, with therapists counseling his father to beat Kraig when he failed to conform to masculine norms. </p>
<p>He ended up committing suicide as an adult. </p>
<p>In recent years, however, there has been what transgender studies scholar Jake Pyne <a href="https://doi.org/10.3138/cjhs.23.1.CO1">has called</a> “a paradigm shift” in treatment. An ever-expanding <a href="https://doi.org/10.1080/00918369.2012.653305">body of research</a> <a href="https://pubmed.ncbi.nlm.nih.gov/27046450/">shows</a> that family support, social acceptance and access to supportive health care produce the best outcomes for transgender kids. </p>
<p>In 2011, the World Professional Association for Transgender Health <a href="https://www.wpath.org/publications/soc">took a position against gender-reparative therapy</a>, stating that any therapy that seeks to change the gender identity of a patient is unethical. Changes to the law have followed suit. For example, in 2014, California passed the <a href="http://transgenderlawcenter.org/wp-content/uploads/2013/03/PublicFAQ.pdf">Student Success and Opportunity Act</a> to ban reparative therapy and require schools to permit transgender children to participate in activities and to access spaces and facilities according to their self-determined gender categories.</p>
<h2>Buying time</h2>
<p>As corrective or reparative programs have lost legitimacy, publicly and privately funded gender clinics featuring <a href="https://theconversation.com/im-a-pediatrician-who-cares-for-transgender-kids-heres-what-you-need-to-know-about-social-support-puberty-blockers-and-other-medical-options-that-improve-lives-of-transgender-youth-157285">affirming models of treatment</a> for trans kids have sprung up across the U.S.</p>
<p>Affirming treatment focuses on enabling kids’ families to embrace their child’s gender identity, and supporting them in dealing with any resulting discrimination or mental health issues. </p>
<p>This treatment model doesn’t steer patients toward any particular gender identity. However, if a child makes the decision to transition to another gender, a number of medical interventions are available. </p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/18667644/">According to the clinical literature surrounding gender-affirming practice</a>, the first goal of medical treatment is to buy time for the child or young person.</p>
<p>This is done through puberty-suppression therapy, via hormone blockers. The thinking goes that by delaying the onset of puberty, gender-nonconforming kids won’t be rushed into a decision before they experience the irreversible development of secondary sex characteristics. </p>
<p><a href="https://doi.org/10.1136/jme.2007.021097">The second goal</a> is a more “normal” and satisfactory appearance.</p>
<figure class="align-center ">
<img alt="Four kids sit on a bed playing video games." src="https://images.theconversation.com/files/397910/original/file-20210429-13-76k4wm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/397910/original/file-20210429-13-76k4wm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/397910/original/file-20210429-13-76k4wm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/397910/original/file-20210429-13-76k4wm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/397910/original/file-20210429-13-76k4wm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/397910/original/file-20210429-13-76k4wm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/397910/original/file-20210429-13-76k4wm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Four friends who are transitioning from male to female hang out together.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/lilly-curran-aged-11-who-is-transgender-and-is-part-of-a-news-photo/1055671872?adppopup=true">Adam Gray/Barcroft Media via Getty Images</a></span>
</figcaption>
</figure>
<p>To accomplish both goals, access to hormone blockers is crucial. </p>
<p>For example, most children who have been assigned female at birth and take hormone blockers <a href="https://uihc.org/health-topics/top-surgery-transmen">will not need top surgery</a>. Meanwhile, children who have been assigned male at birth and take hormone blockers won’t need to later mitigate or reverse characteristics spurred by puberty: a deeper voice, facial hair, and a visible Adam’s apple and other results of male puberty that cannot be reversed.</p>
<p>Having the opportunity to take hormone blockers <a href="https://pubmed.ncbi.nlm.nih.gov/20461468/">has been linked</a> to reduced mental health vulnerability in transgender adults. </p>
<p>Children who are taking hormone blockers can decide to stop doing so at any time. They will then go through puberty consistent with their assigned sex at birth.</p>
<h2>A divide emerges</h2>
<p>Transitioning is possible after going through puberty, but it’s much more difficult for trans people to look the way they want to look. It’s also a lot more expensive.</p>
<p>This is where the divide opens up. Not everyone has supportive parents, good health insurance or doctors who are able to provide puberty-suppression therapy. Nor does everyone live in a state with progressive legislation. </p>
<p>When conducting research for my book, access was a big theme that emerged.</p>
<p>At the age of 16, Nathan, for example, hated his post-pubescent body so much that he engaged in self-harm. (The names used in my book are pseudonyms, as required by research protocol.) The top surgery he so desperately needed was out of reach because his family simply couldn’t afford it. His mom, Nora, describes being terrified that Nathan would kill himself because of this lack of access. </p>
<p>“It’s all because of this damn top surgery,” she told me. “And I am literally terrified, because I know for a fact that once he gets this done he’s going to be a totally different child. And it kills me that I can’t do anything.”</p>
<p>Seven-year-old Esme, on the other hand, knew very clearly from a young age that male puberty was not what she wanted and felt able to communicate this to her parents. And because of her parents’ support and access to affirming health care, she told me she’s planning to take hormone blockers when she’s old enough. Later, she’ll take <a href="https://www.issm.info/sexual-health-qa/what-is-cross-sex-hormone-therapy/">cross-sex hormones</a>, which will result in the development of secondary sex characteristics consistent with her self-defined gender identity.</p>
<p>Whether Esme chooses to be openly transgender or not as an adult will be mostly up to her; her physical appearance won’t mark her as trans.</p>
<p>Then there are the ways poverty and race are intertwined. Because Black, Native American and Latino trans kids <a href="https://www.census.gov/library/stories/2020/09/poverty-rates-for-blacks-and-hispanics-reached-historic-lows-in-2019.html">are disproportionately likely</a> to be living in poverty, <a href="https://read.dukeupress.edu/tsq/article-abstract/1/3/402/24758/The-Technical-Capacities-of-the-BodyAssembling">they’re less likely to have access to crucial treatments at a young age</a> that will make it easier to be a transgender adult.</p>
<p>And trans kids <a href="https://transequality.org/issues/resources/understanding-non-binary-people-how-to-be-respectful-and-supportive">who are nonbinary</a> – meaning they don’t feel like they’re strictly male or female – also face challenges in accessing affirming health care. Many medical professionals continue to see trans health care within a binary model: Patients are transitioning to either male or female. </p>
<p>Stef, who’s 14 years old and nonbinary, told me they had a far easier time accessing puberty blockers when they were asserting that they were a girl than when they subsequently adopted a nonbinary identity.</p>
<h2>A matter of life or death</h2>
<p>Ultimately, these disparities in access have repercussions. </p>
<p>For example, <a href="https://pubmed.ncbi.nlm.nih.gov/20461468/">research indicates</a> a significant improvement in quality of life among adult transgender women who have undergone facial feminization surgery, which involves surgically altering facial bones and soft tissue to conform to female gender norms.</p>
<p>However, this is an expensive and painful procedure that transgender girls can forgo by simply undergoing puberty suppression treatment. Of course, some trans people don’t understand themselves to be trans early enough to advocate for themselves. And that’s OK. But the majority of transgender children <a href="https://www.researchgate.net/publication/46569010_Transgender_Children_in_Schools">remain invisible</a> – unable to articulate their feelings and longings because of unwelcoming and unsupportive environments.</p>
<p>[<em>Over 100,000 readers rely on The Conversation’s newsletter to understand the world.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=100Ksignup">Sign up today</a>.]</p>
<p>Now, the availability of gender-affirming health care for teens is under threat in ways that go beyond insurance, cost and familial support. </p>
<p>In states like Arkansas, it’s a societal rejection of treatment that is, for some trans teens, a matter of life or death.</p><img src="https://counter.theconversation.com/content/157750/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Travers receives funding from the Social Sciences and Humanities Research Council of Canada and the Simon Fraser University Office of the Vice President, Research.</span></em></p>Puberty-suppression therapy gives trans teens the gift of time and the ability to attain a more desirable appearance.Travers, Professor of Sociology, Simon Fraser UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1525252021-01-27T22:01:04Z2021-01-27T22:01:04ZFalling through the safety net: Youth are at the heart of Canada’s mental health crisis<figure><img src="https://images.theconversation.com/files/379913/original/file-20210121-21-pufey2.jpg?ixlib=rb-1.1.0&rect=0%2C194%2C4493%2C3251&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Significant reform of youth mental health care in Canada is needed to address the high rates of mental illness in young people.</span> <span class="attribution"><span class="source">(Unsplash/Devin Avery)</span></span></figcaption></figure><p>Canada is grappling with a <a href="https://www.cihi.ca/en/child-and-youth-mental-health-in-canada-infographic">major youth mental health crisis</a> characterized by high rates of mental illness, suicide, hospitalizations and considerable delays in access to services. These issues are <a href="https://doi.org/10.1177/0706743720943820">exacerbated by the COVID-19 pandemic and opioid overdose epidemic</a>. With limited signs of progress, <a href="https://doi.org/10.1177/0706743718758968">significant reform</a> of youth mental health care in Canada is paramount.</p>
<p>As mental health researchers in the field of prevention and early intervention, we recognize the importance of youth engagement in mental health issues, and present here not only our own opinions but the lived experiences and perspectives of youth. </p>
<p>Our national youth advisory team informs multi-site research trials and supports the development and use of evidence-based youth mental health interventions. Through this collaboration, we present key challenges within the Canadian mental health-care system for youth, and offer novel solutions and recommendations for progress.</p>
<h2>Funding prevention and early intervention</h2>
<p>A key issue is the continued limited government funding for mental health, especially prevention. The <a href="https://www.budget.gc.ca/2019/docs/plan/budget-2019-en.pdf">2019 federal budget</a> prioritizes mental health literacy, harm reduction treatments for opioid use and a suicide crisis hotline. </p>
<p>Because <a href="https://www.camh.ca/en/driving-change/the-crisis-is-real/mental-health-statistics">70 per cent of adults with mental health issues</a> begin experiencing symptoms in adolescence, greater investment in youth mental health and prevention is vital. Specifically, evidence-based early intervention and prevention — such as the <a href="https://www.preventure.ca">Canadian PreVenture program</a> — can reduce the prevalence of <a href="https://doi.org/10.3389/fpsyt.2018.00770">youth mental health and substance use disorders by about 50 per cent</a>. Despite the science, current funding for prevention <a href="https://www.ccsa.ca/sites/default/files/2019-05/ccsa-011332-2006.pdf">represents less than one per cent of all costs to society related to substance use disorders</a>. </p>
<p>Another ongoing issue is affordability and accessibility of services. Although free psychological help is available, <a href="https://cmha.ca/wait-times-2">waiting times are notoriously long</a>. For youth, such delays can make the difference between the need for preventive services versus treatment. </p>
<p>The alternative — privatized care — is largely unaffordable. Fees often <a href="https://mps.ca/psychologist-fees/">range from around $100</a> to <a href="http://www.psych.on.ca/About-Psychology/Getting-help/What-to-expect-when-seeing-a-psychological-profess">$225 per hour</a>, preventing access for many youth, especially those exercising their right to privacy and agency by seeking care without a guardian. </p>
<p>Giving youth access to privatized mental health care for free would reduce the strain on the public system. A step in the right direction would be for Canada’s public health plan to include <a href="https://www.assnat.qc.ca/en/exprimez-votre-opinion/petition/Petition-8629/index.html">universal access to mental health services</a>, particularly preventive and early intervention supports, at least until age 25. </p>
<h2>Accessibility of services</h2>
<p>However, our youth advisers noted the importance of addressing concerns beyond affordability. They list services’ efficiency — wait times and staff capacity, for instance — as well as functioning hours, inclusiveness, appropriateness to youth needs and location as significant obstacles to accessing care. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/380744/original/file-20210126-19-1m69gh6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A young woman with her head in her hands" src="https://images.theconversation.com/files/380744/original/file-20210126-19-1m69gh6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/380744/original/file-20210126-19-1m69gh6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/380744/original/file-20210126-19-1m69gh6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/380744/original/file-20210126-19-1m69gh6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/380744/original/file-20210126-19-1m69gh6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/380744/original/file-20210126-19-1m69gh6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/380744/original/file-20210126-19-1m69gh6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Young people are falling through the cracks in Canada’s mental health system.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Adapting evidence-based programs, including cognitive behavioural therapies and peer support services, to be <a href="https://doi.org/10.1001/jamapsychiatry.2020.1640">distance/virtually delivered</a> offers a new way to rapidly reach under-served youth. This is particularly pertinent in light of <a href="https://doi.org/10.1177/0706743720940562">recent reports of deteriorating youth mental health</a> and substantial disruptions in access to mental health care during the ongoing COVID-19 pandemic.</p>
<p>While youth may have access to mental health professionals in schools, our youth advisers found such personnel were often heavily focused on academic concerns. Indeed, school psychologists’ time and effort may be diverted towards educational assessments and evaluations of learning disabilities and behavioural problems more than other mental health conditions and research. </p>
<p>The ratio of students to psychologists also tends to be higher than the recommended <a href="https://cpa.ca/docs/File/Sections/EDsection/School_Psychology_TFpaper_Aug2014_Final.pdf">1,000 youth per professional</a>, reaching <a href="https://doi.org/10.1177%2F0829573516654585">2,000 to 8,000 students</a>. Furthermore, many school-based drug education programs delivered to students have <a href="https://doi.org/10.1016/S0140-6736(09)60744-3">limited evidence of effectiveness</a>. </p>
<p>To address this, national standards are needed for school psychologists, focused on providing clinical support to students and participating in research that will help further mental health services for youth. </p>
<h2>Towards new models of care</h2>
<p><a href="https://doi.org/10.1001/jamapsychiatry.2020.3905">In response to the need for reform</a>, new, more holistic models of care are emerging, which include a greater consideration of a persons’ developmental stage in life, and the severity of their diagnosis. </p>
<p>For example, youth-focused and integrated services like <a href="https://foundrybc.ca/who-we-are/">Foundry BC</a> and <a href="https://youthhubs.ca/en/about/">Youth Wellness Hubs Ontario (YWHO)</a> follow a similar model to <a href="https://headspace.org.au">Australia’s Headspace</a> and Canada’s <a href="https://accessopenminds.ca">ACCESS Open Minds</a> to provide fast access to evidence-based, innovative mental health services incorporating in-person, virtual and outreach care. They also seek to delay transitions to adult services by extending care to young adults. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/380745/original/file-20210126-21-1lxz67q.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A group of young people at a PreVenture workshop" src="https://images.theconversation.com/files/380745/original/file-20210126-21-1lxz67q.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/380745/original/file-20210126-21-1lxz67q.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=306&fit=crop&dpr=1 600w, https://images.theconversation.com/files/380745/original/file-20210126-21-1lxz67q.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=306&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/380745/original/file-20210126-21-1lxz67q.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=306&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/380745/original/file-20210126-21-1lxz67q.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=385&fit=crop&dpr=1 754w, https://images.theconversation.com/files/380745/original/file-20210126-21-1lxz67q.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=385&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/380745/original/file-20210126-21-1lxz67q.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=385&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Youth at a PreVenture workshop. A number of research-informed services are paving the way for reform by engaging youth in program development and promoting a more holistic approach to youth mental health.</span>
<span class="attribution"><span class="source">(PreVenture)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>However, these services remain largely dependent on young people actively seeking help and contacting them independently, which introduces biases in the type of young person served. In this regard, partnerships with schools could be beneficial. Schools can provide clinics with the opportunity to reach more youth (potentially all youth), and clinics can assist schools in addressing mental health demands that they cannot manage on their own.</p>
<h2>Engaging young people</h2>
<p>Finally, despite growing evidence of the benefits of <a href="https://www.health.ny.gov/community/youth/development/docs/jphmp_s079-s087.pdf">engaging youth in research and services</a>, there is a <a href="https://doi.org/10.1186/s12913-018-3219-2">lack of sustained opportunities</a> for youth to inform mental health care.</p>
<p>Notably, our youth advisers expressed some reticence about openly discussing mental health because they feared stigmatization and had doubts that service providers, researchers and policy-makers would listen to their views. Overall, however, most felt that raising awareness of young people’s mental health experiences could be beneficial, and could contribute to the creation of appropriate and relevant services. </p>
<p>While we engage youth in research, YWHO and Foundry BC involve youth in service development and delivery via <a href="https://youthhubs.ca/en/engagement/">advisory committees, outreach work and peer support</a>. <a href="https://www.camh.ca/en/camh-news-and-stories/youth-have-a-voice-in-projects-aimed-at-them">By integrating these different youth engagement platforms into their institutions</a> and committing to gathering youth feedback in accessible and meaningful ways, service providers can shape their resources to better serve the needs of youth. Co-ordination between service providers and schools may also create new avenues for youth participation.</p>
<p>The pandemic and the opioid crisis highlight the urgency of developing a more adaptable mental health-care system that reaches youth across the country. Canadian youth deserve affordable and accessible mental health care that’s backed by science, informed by their own voices and co-ordinated and funded nationally and provincially. </p>
<p><em>This article was also authored by Marion Audet, research assistant in psychology at the Conrod Venture Lab, Centre de Recherche, CHU Ste-Justine. It was also co-authored by the CUSP/OPfS National Research Youth Advisory Group (including Joseph McAndrew, Neave Allen, Hans Ang, Kyla Neville, Jackie Relihan, Laila Stewart).</em></p><img src="https://counter.theconversation.com/content/152525/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ranmalie Jayasinha is affiliated with the Conrod Venture Lab, Centre de Recherche, CHU Ste-Justine, which hosts the PreVenture program. </span></em></p><p class="fine-print"><em><span>Patricia Conrod works for Universite de Montreal and CHU Ste Justine. She receives funding from Canadian Institutes for Health Research to evaluate the impact of early and targeted intervention strategies on youth mental health and substance use outcomes. She has also received consultation fees from government organizations when advising on how to develop evidence-based drug and alcohol prevention. </span></em></p>High rates of youth mental illness show the urgent need for accessible, affordable and research-backed mental health care. It’s crucial to include young people’s voices in shaping these resources.Ranmalie Jayasinha, Postdoctoral Research Fellow, Faculty of Medicine, Université de MontréalPatricia Conrod, Professor of Psychiatry, Faculty of Medicine, Université de MontréalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1485172020-10-22T21:03:34Z2020-10-22T21:03:34ZJoyce Echaquan’s death: How a decolonizing approach could help tackle racism in health care<figure><img src="https://images.theconversation.com/files/364618/original/file-20201020-13-1009kr7.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1353%2C667&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Demonstrators hold a vigil marking the death of Joyce Echaquan, who recorded insults hurled at her by staff at the Joliette, QC, hospital while she was there for treatment.</span> <span class="attribution"><a class="source" href="https://www.cpimages.com/">The Canadian Press/Paul Chiasson</a></span></figcaption></figure><p>The <a href="https://www.ctvnews.ca/health/joyce-echaquan-s-death-highlights-systemic-racism-in-health-care-experts-say-1.5132146">horrific death of Joyce Echaquan</a>, from the Atikamekw Nation in Manawan, has sparked conversations on systemic racism in Canada. Echaquan heard racist and degrading comments from health-care workers at a hospital in Joliette, Que., north of Montréal, in the moments before she died on Sept. 28. </p>
<p>Systemic racism is a blatant problem in the health-care system. The circumstances surrounding Echaquan’s death provide a poignant example of the racism Indigenous people experience in the health-care system. It lies at the interface of interactions between patients, health-care providers and institutional structures. But a solution — <a href="https://www.nccih.ca/docs/emerging/RPT-CulturalSafetyPublicHealth-Baba-EN.pdf">cultural safety</a> — does exist. </p>
<p>Since 2018, the research partnerships that I have developed with the Manawan community have made it possible to document the racism faced by Atikamekw in the health-care system. Together we are trying to define and implement solutions based on cultural safety, an approach that places Indigenous culture at the centre of health care.</p>
<h2>A colonialist system</h2>
<p>In September 2019, retired Superior Court justice Jacques Viens released a report on the treatment Indigenous people by the public service in Québec. The <a href="https://www.cerp.gouv.qc.ca/fileadmin/Fichiers_clients/Rapport/Final_report.pdf">Viens Commission report</a> made it clear that the Québec health system is built on colonial policies that perpetuate power imbalances and social exclusion. Colonialism is embodied in the organization of health-care programs and practices, which are built on the values, principles and perspectives of the dominant western culture and are poorly adapted to the needs of Indigenous people.</p>
<p>Western medicine, for example, is based on a biomedical model of health, while many Indigenous cultures <a href="https://www.fnha.ca/wellness/wellness-and-the-first-nations-health-authority/first-nations-perspective-on-wellness">view wellness holistically</a>, integrating the spiritual, emotional, mental and physical dimensions of health.</p>
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<img alt="People marching and holding a banner that says Justice for Joyce" src="https://images.theconversation.com/files/365071/original/file-20201022-14-5ekq11.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/365071/original/file-20201022-14-5ekq11.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=396&fit=crop&dpr=1 600w, https://images.theconversation.com/files/365071/original/file-20201022-14-5ekq11.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=396&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/365071/original/file-20201022-14-5ekq11.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=396&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/365071/original/file-20201022-14-5ekq11.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=497&fit=crop&dpr=1 754w, https://images.theconversation.com/files/365071/original/file-20201022-14-5ekq11.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=497&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/365071/original/file-20201022-14-5ekq11.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=497&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">People participate in a demonstration against systemic racism in Montréal.</span>
<span class="attribution"><span class="source">The Canadian Press/Graham Hughes</span></span>
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</figure>
<p>Health services in Canada are built and managed in accordance with western worldviews, reinforce western cultural supremacy, socially and politically disavowing the traditional, millennia-old health practices and knowledge of Indigenous Peoples. As a reflection of the structural racism embedded in social institutions, interactions between Indigenous people and health-care providers are often characterized by stigma, discrimination and racism.</p>
<h2>The effect of racism on health</h2>
<p>Racism has disastrous consequences on the health of Indigenous people, whose communities already face more health challenges than others due to precarious social conditions.</p>
<p>The scientific literature shows that people who experience racism and discrimination <a href="https://pubmed.ncbi.nlm.nih.gov/18425710/">tend to anticipate encounters with health-care professionals</a>, underutilize health-care services and <a href="https://pubmed.ncbi.nlm.nih.gov/28246155/">under-report their symptoms</a> to doctors and nurses. This increases health inequalities by hindering disease detection and the provision of appropriate care. </p>
<p>Racism in health care comes in addition to other micro-aggressions and environmental stressors, which affect individual capacity to adapt and to cope with social and contextual challenges. This chronic exposure to various stressors precipitates a decline in biological functions, increasing the risk of disease for Indigenous people. This is a phenomenon described by research as “allostatic load,” which has been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6946095/">documented for several racialized and minority groups</a>.</p>
<h2>Reversing the power imbalance</h2>
<p>Culture has long been recognized as a fundamental element in promoting healing and improving health in Indigenous communities. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC188521/">Cultural safety is a transformative approach to health-care that was developed by Irihapeti Ramsden, a Māori nurse</a>. It refocuses health care on the needs, values, rights and cultural identity of Indigenous people. Its goal is to dismantle the colonialism that underlies the health-care system by taking into account the social, cultural, economic and political factors that influence the health of Indigenous people. </p>
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<p>Cultural safety requires the development of equal partnerships between health professionals and Indigenous communities. This approach implies that patients and professionals engage respectfully and actively participate in health-care delivery, while aiming to protect the cultural identity of the patients. In keeping with this perspective, the core characteristics of culturally safe care must be defined by the communities receiving the care, in accordance with their own values and cultural norms. The goal is to reverse existing power relations by giving a central place to the historically marginalized voices of Indigenous populations.</p>
<h2>Reducing barriers</h2>
<p>Cultural safety can be deployed in health care in several ways. For example, a greater prominence of Indigenous doctors, nurses and other health-care workers. Cultural safety also requires improving professionals’ cultural competencies and their skillset for implementing safe and respectful treatments. Professionals must learn to recognize the influence of their own culture on the care they provide, be aware of their privileges and their position of power within the health-care system. </p>
<p>In addition, a number of efforts aim to reduce the barriers to care for Indigenous people by providing interpreters, liaison and co-ordination services for patients. A popular model in the literature is the “<a href="https://bmjopen.bmj.com/content/8/3/e019252">patient navigator</a>” model, where peers or health professionals act as intermediaries between the patient and the health-care system. </p>
<p>Navigators can fulfil a variety of roles, booking appointments, arranging transportation, accompanying patients to consultations and translating or disseminating professional recommendations. They may also provide emotional support or refer patients to community support resources.</p>
<p>From an organizational point of view, other interventions might involve to increase services offered to Indigenous populations, such as anchoring Indigenous spirituality in traditional health practices. Another way to promote cultural safety is to change organizational structures so they include the voices of the communities served, so they are better positioned to support changes in practices.</p>
<p>In short, this concept applies at different levels, with the ideal being the implementation of various strategies that act in synergy. All of these solutions require strong partnerships with the communities concerned, as well as sustained political will. This political will must begin with the formal recognition of the existence of systemic racism and the right of access of Indigenous people to health services free of discrimination — as proposed by the Manawan Atikamekw Council in what they have named <a href="https://www.youtube.com/watch?reload=9&v=xlYEvIqr7CA">Joyce’s Principle</a>.</p><img src="https://counter.theconversation.com/content/148517/count.gif" alt="La Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marie-Claude Tremblay receives funding from the Canadian Institutes of Health Research to conduct research on cultural security in health care. </span></em></p>Joyce’s Principle seeks to shift the way health services are provided to Indigenous communities and ensure they are free of discrimination.Marie-Claude Tremblay, Professeure adjointe, Département de médecine familiale et de médecine d'urgence, Chercheuse à VITAM, centre de recherche en santé durable, Université LavalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1408992020-10-07T18:13:36Z2020-10-07T18:13:36ZLack of ID can endanger already vulnerable people during COVID-19 pandemic<figure><img src="https://images.theconversation.com/files/360403/original/file-20200928-24-11pmtkm.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3594%2C2596&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">COVID-19 restrictions like physical distancing and cashless payment are making life more difficult for those already vulnerable. </span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span></figcaption></figure><p>Rod Maxwell, a young Indigenous man from northern British Columbia, was forced to live on the streets of downtown Vancouver last March <a href="https://www.cbc.ca/news/canada/british-columbia/indigenous-man-stranded-dtes-1.5504544">after his personal identification was stolen</a>. Maxwell had travelled to the city to access health-care services unavailable in his rural community. After his identification was stolen, he was left with no alternative but to live on the streets of downtown.</p>
<p>He now lives and sleeps in close proximity with other people experiencing homelessness and unable to practise effective physical distancing. He doesn’t have the money to replace his personal ID. Even though family members want to purchase a transportation ticket for him, without identification he is unable to get on a bus or train. There are organizations in Vancouver that would normally help with replacing his ID, but due to COVID-19 these services have been temporarily suspended. </p>
<p>This case sheds light on the issue of personal identification for marginalized and underserved people who are made further vulnerable because they lack forms of official identification. Ultimately he is a bureaucratic hostage. An apt metaphor for someone rendered exceedingly vulnerable and marginalized due to being without identification at a time when it is vital to have but nearly impossible to obtain.</p>
<h2>Surviving COVID-19 without ID</h2>
<p>Individuals living without personal identification are unable to access most, if not all, of the health, social and economic supports available during the current pandemic. There are many individuals living without forms of essential identification like a birth certificate, health card, social insurance number (SIN) and driver’s licence. Without these forms of ID <a href="https://doi.org/10.3390/ijerph16040567">it is nearly impossible to access necessary income and health supports.</a></p>
<p>Government agencies like <a href="https://www.theglobeandmail.com/politics/article-ottawa-considers-shutting-down-service-canada-centres-as-employees/?utm_source">Service Ontario and Service Canada have reduced their hours in response to COVID-19 restrictions</a>. Non-profit organizations that <a href="http://neighbourhoodlink.org/partners-for-access-and-identification-paid/">normally hold ID clinics,</a> cover the costs of obtaining personal identification or provide a mailing address have been forced to reduce or altogether eliminate their services during the pandemic. </p>
<p>To avoid creating more bureaucratic hostages in a time of crisis, policy and emergency responses must deal with the needs and circumstances of the most marginalized people in our society.</p>
<p>Businesses and essential services have implemented physical distancing rules to limit person-to-person contact. Notably, many are <a href="https://www.bnnbloomberg.ca/covid-19-could-accelerate-shift-to-cashless-experts-say-1.1442318">asking customers to pay using debit and credit cards or e-transfers</a> instead of cash. This comes along with increased efforts by government agencies to transition to e-banking for the distribution of income supports during the current pandemic. </p>
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<img alt="A phone being used to make a cashless payment" src="https://images.theconversation.com/files/348995/original/file-20200722-30-1gaa5z3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/348995/original/file-20200722-30-1gaa5z3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/348995/original/file-20200722-30-1gaa5z3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/348995/original/file-20200722-30-1gaa5z3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/348995/original/file-20200722-30-1gaa5z3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/348995/original/file-20200722-30-1gaa5z3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/348995/original/file-20200722-30-1gaa5z3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Many businesses have moved to cashless payment due to the pandemic. But that often disadvantages those whose only option is paying by cash.</span>
<span class="attribution"><span class="source">(Jonas Leupe/Unsplash)</span></span>
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<p>Discouraging the use of paper money and unnecessary face-to-face contact during the pandemic is reasonable. However, there are many people who are unable to go cashless. Such measures risk excluding individuals who are already vulnerable. </p>
<p>Many people live without access to financial institutions for a variety of reasons including a lack of birth certificate or other forms of personal identification. In Canada, for instance, <a href="https://www.canada.ca/en/financial-consumer-agency/services/banking/opening-bank-account.html">financial institutions require two pieces of personal identification to open an account</a>: a photo ID with signature (not including a health card) and a SIN. However, a birth certificate is required to obtain the required forms of ID. To get a SIN, for example, individuals need at least a birth certificate and access to a broad range of parental information that some may not have, <a href="https://www.canada.ca/en/employment-social-development/services/sin/before-applying.html">including primary documents (not photocopies)</a>. Without these forms of ID it is virtually impossible to obtain a bank card, effectively barring people from the cashless economy.</p>
<p>Many individuals and families who are experiencing economic hardship during this period rely on food banks. <a href="https://vancouversun.com/news/local-news/starting-april-1-food-bank-users-will-need-to-prove-low-income-status-and-address/">Most food banks in Canada require personal ID for individuals to access their services</a>. While it is difficult to know exactly how many Canadians are without ID, <a href="https://this.org/2017/03/31/what-it-means-to-be-a-canadian-living-without-id/">reputable sources conservatively estimate the number to be in the thousands.</a> </p>
<p>Our preliminary research suggests the numbers may be much higher in the territories and northern areas of provinces, where there is limited access to health-care resources and social services. Many people simply do not have access to those documents and information, cannot afford the added cost of a personal ID application or lack a fixed address to receive the documents, all of which means that it is nearly impossible to obtain personal identification now that they need it most. A lack of ID and the systemic barriers that make it difficult to acquire identification operate within a <a href="https://doi.org/10.3390/ijerph17124227">structure of existing social and economic inequalities in our society</a>.</p>
<p>Policies should not be implemented if they render people <a href="https://www.cbc.ca/news/canada/british-columbia/indigenous-man-stranded-dtes-1.5504544">bureaucratic hostages</a> and make it almost impossible for those who most need assistance to get help. </p>
<h2>Modest interventions can make a big difference</h2>
<p>Relatively straightforward bureaucratic fixes can have a meaningful impact. Governments should <a href="https://www.ontario.ca/page/get-or-replace-ontario-birth-certificate">reduce or eliminate fees associated with birth certificate applications</a>. <a href="https://doi.org/10.3390/ijerph17124227">Our research finds</a> that even birth certificate applications fees as low as $25 still present a major barrier for many low-income individuals.</p>
<p>Why not waive fees altogether? Providing people with birth certificates should not be a fee-driven service as this unintentionally imposes yet another obstacle to possessing ID for many people, particularly low-income people.</p>
<p>Governments should also reduce bureaucratic requirements for obtaining a birth certificate especially during crisis periods. Some requirements for birth certificate applicants — like mother’s maiden name at time of birth or physical signatures — also present major barriers, particularly for people with deceased or estranged parents. </p>
<p>In light of COVID-19, agencies like the Canada Revenue Agency are enacting <a href="https://www.canada.ca/en/revenue-agency/campaigns/covid-19-update/covid-19-electronic-signatures.html">alternatives to physical signatures</a> in order to accommodate Canadians during this challenging time. The same must be done to help people attain vital documents at a time when having access to personal identification is more important than ever.</p><img src="https://counter.theconversation.com/content/140899/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kristin Burnett receives funding from SSHRC</span></em></p><p class="fine-print"><em><span>Chris Sanders receives funding from Social Sciences and Humanities Research Council (SSHRC).</span></em></p>The outbreak of the COVID-19 pandemic has exposed gaps in the health-care system that leave those without identification documents vulnerable.Kristin Burnett, Profesor in the Department of Indigneous Studies, Lakehead UniversityChris Sanders, Associate Professor of Sociology, Lakehead UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1373752020-06-26T12:31:48Z2020-06-26T12:31:48ZRethinking what research means during a global pandemic<figure><img src="https://images.theconversation.com/files/343588/original/file-20200623-188916-uocweh.jpg?ixlib=rb-1.1.0&rect=51%2C0%2C5760%2C3785&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Farmworkers are essential workers who must decide every morning whether they will leave their home to work the fields to provide for their families and the nation.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/health-worker-takes-the-pulse-of-a-mexican-farm-worker-at-a-news-photo/167824121">John Moore/Getty Images News via Getty Images</a></span></figcaption></figure><p><em>The Conversation is running a series of dispatches from clinicians and researchers operating on the front lines of the coronavirus pandemic. You can <a href="https://theconversation.com/us/topics/covid-19-front-lines-84846">find all of the stories here</a>.</em></p>
<p>“Doctora,” a community health worker yelled from across the room. “People are lined up along the fence. Under the sun. Do we have water for them?” </p>
<p>I was standing in the middle of an air-conditioned room in April at a COVID-19 testing site for Latino farmworkers and their families in the eastern part of Southern California’s Coachella Valley. Outside was an ever-increasing line of symptomatic patients, individuals who either reported having a cough, fever or difficulty breathing, or who had been in contact with someone with the virus in the past two weeks. They were all waiting to get tested.</p>
<p>In the days before, a team of promotoras – trusted community leaders with expertise in community organizing who act as connectors to the community – had fielded call after call from concerned community members. The community members were calling about their eligibility to get tested and whether Social Security numbers and health care insurance coverage would be required. Some farmworkers shared that they couldn’t return to work without getting the test and producing evidence that they were COVID-free to their farm managers. Often ineligible for employment benefits, loss of employment can comprise their ability to survive.</p>
<p>As an <a href="https://profiles.ucr.edu/app/home/profile/acheney">anthropologist at the University of California, Riverside</a>, I have a doctorate of anthropology not medicine. So I never imagined myself as “Doctora Ana,” serving on the front lines of a global pandemic and leading efforts to disseminate public health information and set up COVID-19 testing sites for essential workers. But, when I was asked in April to lead a team of medical students and promotoras in COVID-19 testing, I was ready, thanks to a conversation I had three years prior that inspired me to think about research differently.</p>
<h2>Gaining trust</h2>
<p>I remember vividly the first time I met Conchita, a known advocate for her Purépecha community, an indigenous group from the Mexican state of Michoacán. I had been looking for a trusted member of the community with whom I could partner to carry out a project on health care access among Latinos in farm-working communities in Southern California. Through an existing partnership with a community-based organization serving the Eastern Valley, I had been put in touch with Conchita.</p>
<p>I had traveled nearly 100 miles from the University of California, Riverside School of Medicine, to her home in the eastern Coachella Valley. When I arrived, Conchita was sitting outside waiting for me and invited me to sit down under the shade of her carport. It was spring in the desert, and the sun shone brightly. I was anxious. I feared my broken Spanish and the community I represented, the academy, would create barriers to our communication. I worried that she, like so many from indigenous communities, might mistrust research. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/344180/original/file-20200625-33569-1je626c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/344180/original/file-20200625-33569-1je626c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/344180/original/file-20200625-33569-1je626c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/344180/original/file-20200625-33569-1je626c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/344180/original/file-20200625-33569-1je626c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/344180/original/file-20200625-33569-1je626c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/344180/original/file-20200625-33569-1je626c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/344180/original/file-20200625-33569-1je626c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">From left: The author, medical student Cinyta Beltran Sanchez and Congressman Raul Ruiz.</span>
<span class="attribution"><span class="license">Author provided</span></span>
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</figure>
<p>As an anthropologist conducting community-based participatory research, the voice of the community guides my work – from the development of research questions and study design to data analysis, interpretation and use of data. My approach is to place the voice of the community at the center of research and create in collaboration with community members meaningful evidence for public health advocacy. While this looks different for each community, in the Eastern Valley, this approach informed the design and implementation of a free clinic.</p>
<p>The Eastern Valley is a 45-mile long rift valley bounded by mountain chains and one of the richest agricultural regions in the world. It is also one of the most impoverished areas of California and home to a large <a href="https://www.ncbi.nlm.nih.gov/pubmed/30223174">undocumented and underinsured foreign-born Latino population</a> living in poverty and working in the fields. About a third are migrant farmworkers. </p>
<p>The area is also home to the largest Purépecha community in the United States. Many from this community live in rundown trailer parks on Native American lands in the Eastern Valley. While these lands protect the residents from local border patrol agents, it also sets them up for abuses from landowners. Over the years, outside entities such as <a href="https://www.nytimes.com/2007/10/21/us/21land.html">federal judges</a> have filed lawsuits to shut down trailer parks with makeshift infrastructures that they thought presented extreme public health risks but that were home for the workers. Thus, among the immigrants in this region, there is a general mistrust of outsiders, including researchers, who have flown in and out, taking information from them but never sharing the results.</p>
<p>My biggest concern that hot spring day with Conchita was: Would I reproduce this injustice? </p>
<p>Our conversation was both a “meet-and-greet” and partnership negotiation. We discussed the research at hand, the work involved and the role of the community investigator in engaging community members in the study. Conchita listened attentively and asked questions. As we neared the end of the conversation, it was unclear whether we would move forward. Then, with directness, she laid out her terms for partnership. She agreed to partner on the research, but only if study findings were used to directly benefit the community. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/343596/original/file-20200623-188931-17ayu73.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/343596/original/file-20200623-188931-17ayu73.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/343596/original/file-20200623-188931-17ayu73.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/343596/original/file-20200623-188931-17ayu73.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/343596/original/file-20200623-188931-17ayu73.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/343596/original/file-20200623-188931-17ayu73.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/343596/original/file-20200623-188931-17ayu73.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/343596/original/file-20200623-188931-17ayu73.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">At the core of Global Health at Home are promotoras who disseminate information throughout their networks and facilitate access to free health care services via pop-up clinics in safe spaces in the Eastern Valley.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Fast forward a couple years. The research inspired <a href="https://in-training.org/global-health-home-18397">Global Health at Home</a> (GH@H), a student-led effort to provide free health care to underserved and vulnerable populations in rural farmworking communities in the Eastern Valley. At the core of this infrastructure are promotoras who share information throughout their networks and help people gain access to free health care services via pop-up or mobile clinics in safe spaces in the Eastern Valley.</p>
<p>The students, bilingual UCR medical and pre-med students and California Baptist physician assistant students, refer to the clinic, which is held the third Saturday of every month, as the <a href="https://coachellavalleyfreeclinic.weebly.com/">Coachella Valley Free Clinic</a>. For the past year, I have supervised this team of students and promotoras on the design, implementation and delivery of free health care services based on our <a href="https://healthycommunities.ucr.edu/usmex-united-states-mexico-unidos-por-salud">study’s findings</a> that fear of deportation and limited access to bilingual providers prevent many foreign-born Latinos from seeking and getting health care. </p>
<p>It was this team who saw the need to provide COVID-19 information and how to prevent its spread in both Spanish and Purépecha, the primary languages of our patients. Our outreach efforts have focused on communities in the Eastern Valley with particular attention to the <a href="https://www.latimes.com/california/story/2020-04-21/coronavirus-coachella-valley-farmworkers">Oasis trailer park</a>, located in the community of Thermal, where we hold our pop-up clinic.</p>
<h2>In the wake of COVID-19</h2>
<p>Our patients are essential workers. They must decide every morning whether they will leave their home to work the fields to provide for their families and the nation. They make this decision in the context of increasing cases of COVID-19 in the country and the very communities in which they live. Riverside County, where the Coachella Valley sits, has the <a href="https://www.latimes.com/projects/california-coronavirus-cases-tracking-outbreak/riverside-county/">second-highest number of coronavirus cases and deaths in the state</a>. In Thermal, the infection rate is <a href="https://www.desertsun.com/story/news/health/2020/04/29/coronavirus-california-targeted-testing-needed-eastern-coachella-valley-ruiz-says/3029957001/">five times higher</a> than any other city or unincorporated community in the valley.</p>
<p>The infrastructure and network of GH@H enabled us to rapidly organize and engage the community in <a href="https://noticiasya.com/los-angeles/2020/04/30/pruebas-gratuitas-del-coronavirus-en-mecca/">COVID-19 testing clinics</a>. Through a grant to one of our partners, <a href="https://cvvim.org/">Coachella Valley Volunteers in Medicine</a>, and an anonymous donation, 200 tests were made available to farm workers and their families in the valley, enabling us to hold the first two clinics in May. Within days, the network of promotoras had spread news of the testing site through their social networks, and student leaders organized themselves to assist at the clinics. In May, we held our first two clinics. We have since been preparing for additional clinics and handing out public health material.</p>
<p><a href="https://www.newyorker.com/news/q-and-a/how-pandemics-change-history">Pandemics change history</a>. They force us to reconsider what we once thought as natural and normal. In the wake of COVID-19, researchers can become trusted figures of authority who can purposely use their institutional privilege and re-appropriate their research networks, skills and knowledge to better the lives of vulnerable populations during a pandemic. Pandemics can change the meaning of research.</p>
<p>[<em>You need to understand the coronavirus pandemic, and we can help.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=upper-coronavirus-help">Read The Conversation’s newsletter</a>.]</p><img src="https://counter.theconversation.com/content/137375/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ann Cheney receives funding from the National Institutes of Health and the Patient-Centered Outcomes Research Institute. </span></em></p>In the wake of COVID-19, researchers can become trusted figures of authority who can re-appropriate their networks, skills and knowledge to better the lives of vulnerable populations.Ann M. Cheney, Assistant Professor, Department of Social Medicine Population and Public Health, University of California, RiversideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1316042020-06-25T19:38:34Z2020-06-25T19:38:34ZMaking health care more affordable and accessible for the elderly: insight from the US and France<figure><img src="https://images.theconversation.com/files/344028/original/file-20200625-33511-1phclg9.jpg?ixlib=rb-1.1.0&rect=67%2C101%2C7500%2C4547&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Given the current health crisis, seniors are highly vulnerable, yet can face significant costs for health care. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-senior-man-wearing-facemasks-during-1679644147">Yuganov Konstantin/Shutterstock</a></span></figcaption></figure><p>A significant number of OECD countries have recently experienced a steep increase in the percentage of older residents due to the baby-boom wave hitting the 65-year-old barrier. In the United States and in France, the vulnerable population aged 65 and over will increase due to population aging, growing prevalence of long-term conditions and effects of Covid-19 on health.</p>
<p>Despite the immense differences between the two countries’ health care systems, the establishment in 1966 of the <a href="https://en.wikipedia.org/wiki/Medicare_(United_States)">Medicare program</a> for those 65 years and older moved the US health insurance level closer to that of France and other countries with universal health care.</p>
<p>However, as the costs of health and long-term care (LTC) have continued to rise in both countries, the direct costs for those covered – what remains to be paid after reimbursement by public and private health plans – have also risen. Moreover, stubborn inequalities in access to care remain, depending on the US state or the department in France. Reducing direct payments for the vulnerable, elderly residents thus constitutes a common policy challenge for the United States and France.</p>
<h2>Common challenges</h2>
<p>In 2018, residents 65 years and older made up 20% of the population in France and 16% in the United States. By 2060, it is projected to reach <a href="https://www.prb.org/wp-content/uploads/2019/06/PRB-PopBulletin-2020-Census.pdf">23% in the US</a> and 27% in France. As that proportion rises, so will the demand for care and long-term care. In 2018, the share of the gross domestic product (GDP) dedicated to government health care spending reaches 14.3% in the United States and 9.3% in France. The proportion of GDP devoted to public spending on long-term care remains relatively low, <a href="https://www.oecd.org/health/health-systems/health-at-a-glance-19991312.htm">0.5% in the US and 1.9% in France</a>.</p>
<p>The high price of innovative drugs is a concern for all developed countries. In the last two years, the first cellular and gene therapies were approved in the United States and Europe. These medications are costly and concern only a small number of people, making cost-sharing difficult. A significant increase in the <a href="https://novamedica.com/media/theme_news/p/9362-the-changing-landscape-of-research-and-development-innovation-drivers-of-change-and-evolution-of-clinical-trial-productivity">number of products/indications from gene and cellular therapies</a> is expected in the coming years along with new challenges in terms of financial sustainability and access to care for the most vulnerable.</p>
<p>Significant international differences have been shown for <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3185-8">direct health care spending</a>. In 2018, such payments represent 9% of the health spending in France, the lowest proportion in OECD countries, and 11% in the United States. Despite this low average level, access to health and long-term care for those 65 and over remains poorly coordinated and integrated, and is inefficient in both countries.</p>
<h2>Long-term care affordability is a serious challenge in France</h2>
<p>In France, a specific program (<a href="https://www.ameli.fr/medecin/exercice-liberal/presciption-prise-charge/situation-patient-ald-affection-longue-duree/definition-ald">“Affections de longue durée”</a>) offers full, no-cost care at the point of service for chronic and costly diseases. It accounts for 70% of the health spending for statutory health-insurance payments. It represents 17% of the French population in 2017, while the population 65 and over represents 53% of all recipients. But this mechanism does not prevent high direct payments, due to the <a href="https://www.tresor.economie.gouv.fr/Articles/2015/04/15/tresor-eco-n-145-quel-avenir-pour-le-dispositif-de-prise-en-charge-des-affections-de-longue-duree-ald">lack of annual capping</a>.</p>
<p>This is even more the case for people over 60. The long-term care policy relies on a home-care scheme targeted at the elderly disabled, <a href="https://www.service-public.fr/particuliers/vosdroits/F10009">“Allocation personnalisée d'autonomie”</a>, which was shifted to local authorities (departments) in 2004, and on disability allowance, <a href="https://www.service-public.fr/particuliers/vosdroits/F12242">“Allocation aux adultes handicapés”</a>. While there are advantages to local management, it can also lead to <a href="https://drees.solidarites-sante.gouv.fr/IMG/pdf/dd37.pdf">inequalities in direct payment for a given health status and care needs</a>. In all, the average monthly direct payment for home care represented <a href="https://drees.solidarites-sante.gouv.fr/IMG/pdf/ddd1.pdf">300 euros in 2011</a> (337 dollars).</p>
<h2>… and care affordability is an immense problem in the US</h2>
<p>The US health care system is characterized by problems of high direct payment and unequal spatial access to health and long-term care. In 2018, 94.1% of adults 65 and over were covered by a public plan. Medicare covers <a href="https://www.census.gov/library/publications/2019/demo/p60-267.html">57.8 million people</a>, namely 17.8% of the population compared to 15.6% in 2013. Total Medicare expenditures represent <a href="https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/TR2019.pdf">741 billion dollars in 2018</a>. Two thirds of older Medicare recipients use long-term care or report they experience <a href="https://www.commonwealthfund.org/publications/issue-briefs/2019/jan/financial-hardship-older-americans-ltss">difficulties in performing daily activities</a>. Long-term care comes out of the <a href="https://en.wikipedia.org/wiki/Medicaid">Medicaid program</a>, and the eligibility requirements, services and cost-sharing policies vary state by state.</p>
<p>To reduce the burden of drug expenditures, <a href="https://www.medicare.gov/drug-coverage-part-d">Medicare Part D</a> was introduced in 2006. The program has <a href="https://www.sciencedirect.com/science/article/abs/pii/S0167629617300577">decreased elderly mortality by 2.2% annually</a>, which in turn has been estimated to provide welfare benefits from lives saved of <a href="https://www.journals.uchicago.edu/doi/abs/10.1162/ajhe_a_00107">between 1.5 and 4.8 billion dollars</a>. Part D has also resulted in a <a href="http://europepmc.org/article/med/25666229">15% decline in depressive symptoms</a>. It has <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3165176/">cut in-patient admissions</a> and <a href="https://repository.upenn.edu/hcmg_papers/78/">increased prescription-drug use</a> through a <a href="https://www.ajmc.com/journals/issue/2008/2008-11-vol14-n11sp/nov08-3702psp14-sp21/">reduction in out-of-pocket payments</a> (OOPs).</p>
<p>Despite the benefits provided by the Medicare program, in 2017 <a href="https://www.ncbi.nlm.nih.gov/pubmed/29140737">23% of Americans 65 and older had to forgo care because of cost</a> – nearly five times the rate in France, just 5%. The difference is a direct consequence of the cost of care in the United States. For instance, treatment for cardiovascular disease can require a <a href="https://www.ncbi.nlm.nih.gov/pubmed/31539389">direct payment of 317 dollars per year</a>. For diabetes, the figure is 237 dollars, and for hypertension, 150 dollars. This in turn has an impact on Americans’ financial health: A <a href="https://www.kff.org/report-section/the-burden-of-medical-debt-section-3-consequences-of-medical-bill-problems/">2016 Kaiser Family Foundation study</a> found that medical bills were a key factor in at least 1 million personal bankruptcies in 2015, and estimated that 52 million US residents had difficulty paying medical bills.</p>
<p>Due to the growth in the number of people 65 and older and the <a href="https://www.nber.org/papers/w16011">appeal of Medicare Part D option</a>, it is estimated that the program’s costs will rise 7.3% over the next five years. The out-of-pocket costs for health and long-term care for the elderly are not only rising, but there are also high regional inequalities for long-term care – in particular, enforcement of the expansion of the Medicaid eligibility mandated under the <a href="https://www.healthcare.gov/glossary/affordable-care-act/">Affordable Care Act</a> varies greatly from <a href="https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/">state to state</a>.</p>
<h2>Understanding vunerability</h2>
<p>The definition of vulnerability in health is neither universal nor absolute. Nevertheless, it lays down the rules for financial responsibility. Vulnerability can rely on an objective definition such as a medical approach (France’s chronic-disease scheme). The recognition of vulnerability can also be defined by reaching a key age – 65 for Medicare recipients in the United States, 60 for the home-care program in France.</p>
<p>Vulnerability can also refer to individual financial ability, measured either in absolute terms (<a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.W4.546">means testing</a> for Medicaid in the United States or the <a href="https://www.ameli.fr/assure/droits-demarches/difficultes-acces-droits-soins/complementaire-sante/complementaire-sante-solidaire">“Complémentaire santé solidaire”</a> in France) or in relative terms (such as the capping of direct payments). The latter system exists in several countries, notably in Germany, Belgium and Switzerland, and to a certain degree in France and the United States. In France, the capping of annual direct payment <a href="https://www.vie-publique.fr/rapport/29331-mission-bouclier-sanitaire">was discussed in 2007 but not implemented</a>. A <a href="https://solidarites-sante.gouv.fr/IMG/pdf/rapport_grand_age_autonomie.pdf">recent French report</a> calls for a direct payment cap, which would reduce out-of-pocket costs and improve care for dependent elderly residents.</p>
<p>In the United States, the weak limits on drugs prices and the absence of capping in Medicare Part D could further deteriorate access to care. Prescription drug costs are a significant problem given that <a href="https://www.ncbi.nlm.nih.gov/pubmed/29140737">55% of older Americans take four or more prescribed drugs</a>, versus 22% for the French. Among other factors, this difference is driven by high rates of medical conditions such as obesity, dementia, respiratory illnesses and rheumatoid arthritis, an overprescription of antipsychotics, and relatively fast access to new treatments.</p>
<p>A set of managed care plans foster Medicare-Medicaid integration for those who qualify for both, known as <a href="https://www.medicareresources.org/glossary/dual-eligible/">“dual eligibles”</a>. About 20% of those eligible for Medicare also qualify for Medicaid, approximately <a href="https://www.medicareresources.org/faqs/can-i-be-enrolled-in-medicare-and-medicaid-at-the-same-time/">12.1 million individuals</a>. This is innovative, as those who qualify for both will typically have no out-of-pocket health-care costs.</p>
<h2>Political hurdles</h2>
<p>Widening Americans’ access to affordable health care has long been a subject of political debate, and one proposal is the <a href="https://joebiden.com/healthcare/">public health insurance option</a> proposed by the former vice-president and current presidential candidate Joe Biden. Among the provisions, it would use the wider coverage to negotiate lower prices with drug corporations to reduce the overall cost of care as well as lower patients’ out-of-pocket costs. The <a href="https://www.whitehouse.gov/issues/healthcare/">White House website</a> indicates that if re-elected, President Donald Trump would continue to seek to repeal the Affordable Care Act, but gives no specifics on what it would be replaced with.</p><img src="https://counter.theconversation.com/content/131604/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thomas Barnay ne travaille pas, ne conseille pas, ne possède pas de parts, ne reçoit pas de fonds d'une organisation qui pourrait tirer profit de cet article, et n'a déclaré aucune autre affiliation que son organisme de recherche.</span></em></p>Despite significant differences in their systems, both countries share the challenge of having to reduce the cost of health and long-term care for older citizens.Thomas Barnay, Full Professor of Economics, Director of ERUDITE Unit research (Équipe de Recherche sur l’Utilisation des Données Individuelles en lien avec la Théorie Economique), Université Paris-Est Créteil Val de Marne (UPEC)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1394302020-06-10T18:54:35Z2020-06-10T18:54:35ZCOVID-19 is deadlier for black Brazilians, a legacy of structural racism that dates back to slavery<figure><img src="https://images.theconversation.com/files/340716/original/file-20200609-21230-1ojep5e.jpg?ixlib=rb-1.1.0&rect=0%2C16%2C3741%2C2469&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Protesters in São Paulo declare 'Black Lives Matter' at a June 7 protest spurred by both U.S. anti-racist protests and the coronavirus's heavy toll on black Brazilians. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/protestors-hold-a-banner-during-a-protest-against-brazilian-news-photo/1218336349?adppopup=true">Marcello Zambrana/Anadolu Agency via Getty Images</a></span></figcaption></figure><p>The United States and Brazil have much in common when it comes to the coronavirus. </p>
<p>Both are among the world’s <a href="https://www.nytimes.com/interactive/2020/world/americas/brazil-coronavirus-cases.html">hardest-hit countries</a>, where hundreds die daily. Their like-minded presidents, Donald Trump and Jair Bolsonaro, have both been <a href="https://www.vox.com/policy-and-politics/2020/3/14/21177509/coronavirus-trump-covid-19-pandemic-response">widely criticized</a> for their <a href="https://theconversation.com/brazil-jair-bolsonaros-strategy-of-chaos-hinders-coronavirus-response-136590">poor handling</a> of the pandemic. </p>
<p>And in both countries the virus is <a href="https://www.americanprogress.org/issues/race/news/2020/03/27/482337/coronavirus-compounds-inequality-endangers-communities-color/">disproportionately affecting black people</a>, the result of structural racism that dates back to slavery. </p>
<h2>Legacy of slavery</h2>
<p>Brazil forcibly brought some 4 million enslaved Africans into the country over three centuries, <a href="https://www.bbc.com/news/world-latin-america-30413525">more than anywhere else in the Americas</a>. About <a href="https://www.bbc.com/news/world-latin-america-15766840">half its 209 million people are black</a> – the world’s second largest African-descendant population after Nigeria. </p>
<p>Modern Brazil never had legalized racial discrimination like Jim Crow, but race-based inequalities are deeply entrenched. Despite a <a href="https://theconversation.com/assassination-in-brazil-unmasks-the-deadly-racism-of-a-country-that-would-rather-ignore-it-94389">persistent myth</a> of Brazil as an integrated “racial democracy,” <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863696/">employment discrimination and residential segregation</a> limit opportunity for black people. </p>
<p>These and other factors translate into <a href="https://www.amazon.com.br/Solid%C3%A3o-Ensaios-Desigualdades-Raciais-Brasil/dp/8581922481">lower life expectancy, education and standards of living</a> for <a href="https://journals.sagepub.com/doi/10.1177/0021934704264003">Afro-Brazilians</a>. Black Brazilians live, on average, 73 years – three years less than white Brazilians, according to the <a href="https://www.nexojornal.com.br/grafico/2019/06/10/A-expectativa-de-vida-no-Brasil-por-g%C3%AAnero-ra%C3%A7a-ou-cor-e-estado">2017 National Household Survey</a>. The U.S. has a <a href="https://www.cdc.gov/nchs/data/hus/2017/015.pdf">nearly identical life expectancy gap between races</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/340727/original/file-20200609-21226-3a9ocg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/340727/original/file-20200609-21226-3a9ocg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/340727/original/file-20200609-21226-3a9ocg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/340727/original/file-20200609-21226-3a9ocg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/340727/original/file-20200609-21226-3a9ocg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/340727/original/file-20200609-21226-3a9ocg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/340727/original/file-20200609-21226-3a9ocg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/340727/original/file-20200609-21226-3a9ocg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Residents of the Aglomerado da Serra favela, or slum settlement, register for food aid, June 4, 2020, Belo Horizonte.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/poor-residents-of-the-aglomerado-da-serra-favela-register-news-photo/1247238628?adppopup=true">Pedro Vilela/Getty Images</a></span>
</figcaption>
</figure>
<p>Because government data in Brazil is not automatically collected by race or ethnicity, though, the health impacts of racism can be hard to measure. Bolsonaro’s administration did not require the <a href="https://noticias.uol.com.br/saude/ultimas-noticias/redacao/2020/05/04/justica-determina-coleta-de-registros-de-raca-e-etnia-em-casos-de-covid.htm">collection of COVID-19 racial data</a> until late April, well into the pandemic, after much pressure. It has yet to release that information. </p>
<p>Regardless, by April the <a href="https://g1.globo.com/bemestar/coronavirus/noticia/2020/04/11/coronavirus-e-mais-letal-entre-negros-no-brasil-apontam-dados-do-ministerio-da-saude.ghtml">Brazilian Health Ministry</a> had already flagged high COVID-19 death rates among Afro-Brazilians, a category that includes people who identify as “black” or “brown” in the census. Officials in <a href="https://www.prefeitura.sp.gov.br/cidade/secretarias/upload/saude/PMSP_SMS_COVID19_Boletim%20Quinzenal_20200430.pdf?fbclid=IwAR0mNVdNtmO7ODqPCAqH0QfkzsX1hpMKNkvmgySqi1k2XD42E3F8vjz2OjU">hard-hit São Paulo</a> had also announced that mortality rates among COVID-19 patients were higher among black residents. </p>
<p>Now, <a href="https://drive.google.com/file/d/1tSU7mV4OPnLRFMMY47JIXZgzkklvkydO/view">data collected in May</a> by outside researchers for over 5,500 municipalities shows that 55% of Afro-Brazilian patients hospitalized with severe COVID-19 died, compared to 34% of white COVID-19 patients. </p>
<h2>Health and racism</h2>
<p>We are health researchers – one American, one Brazilian – who for many years have <a href="https://www.ethndis.org/edonline/index.php/ethndis/article/view/878">studied</a> how <a href="https://www.scopus.com/scopus/inward/record.url?partnerID=10&rel=3.0.0&view=basic&eid=2-s2.0-85035756709&md5=329eac49bd35f8a77849586b7daae38b">racial disparities</a> in Brazil affect black people, looking at everything from sickle cell anemia to reproductive health. </p>
<p>Our research over the past two months finds <a href="https://www.sciencedirect.com/science/article/abs/pii/S0277953617304410">structural racism</a> – in the form of high-risk working conditions, unequal access to health and worse housing conditions – is a major factor shaping Brazil’s COVID-19 pandemic.</p>
<p>For over a decade, black activists and public health researchers have been pointing out that <a href="https://www.scielo.br/pdf/sausoc/v25n3/1984-0470-sausoc-25-03-00535.pdf">institutional racism</a> creates <a href="https://www.sciencedirect.com/science/article/abs/pii/S0277953617304410">worse health outcomes for Brazil’s black population</a>. Black Brazilians experience higher rates of <a href="http://portalarquivos2.saude.gov.br/images/pdf/2019/julho/25/vigitel-brasil-2018.pdf">chronic illnesses</a> like diabetes, high blood pressure, and respiratory and kidney problems due to food insecurity, inadequate access to medicine and <a href="https://ethndis.org/edonline/index.php/ethndis/article/view/878/1199">unaffordable prescriptions</a>.</p>
<p>Racism itself also takes a severe physical toll on black people. Studies in the United States demonstrate that daily experiences of racism and discrimination can lead to <a href="https://theconversation.com/coronavirus-deaths-and-those-of-george-floyd-and-ahmaud-arbery-have-something-in-common-racism-139264">dangerously high stress hormones and diminish the body’s ability to fight disease</a>. <a href="https://www.nationalgeographic.com/history/2020/04/coronavirus-disproportionately-impacts-african-americans/">Racial bias from medical professionals</a> then compounds poor outcomes for black patients. </p>
<p>Unlike the U.S., Brazil has free, universal health care. But its public hospitals have been <a href="https://www.theguardian.com/world/2016/dec/13/brazil-approves-social-spending-freeze-austerity-package">woefully underfunded since a deep recession that began in 2015</a>. </p>
<p><a href="https://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2020000500101">Intensive care beds are now in short supply</a> at public hospitals in several cities fighting coronavirus outbreaks. This is especially detrimental to black COVID-19 patients, since Afro-Brazilians rely more <a href="https://nacoesunidas.org/quase-80-da-populacao-brasileira-que-depende-do-sus-se-autodeclara-negra/">heavily on the public health system</a> than white Brazilians, who often have private health insurance through their jobs.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/340729/original/file-20200609-21238-1plqfsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/340729/original/file-20200609-21238-1plqfsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/340729/original/file-20200609-21238-1plqfsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/340729/original/file-20200609-21238-1plqfsn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/340729/original/file-20200609-21238-1plqfsn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/340729/original/file-20200609-21238-1plqfsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/340729/original/file-20200609-21238-1plqfsn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/340729/original/file-20200609-21238-1plqfsn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The intensive care unit of the Gilberto Novaes Municipal Field Hospital in Manaus, Brazil, June 4, 2020.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/june-2020-brazil-manaus-view-into-the-intensive-care-unit-news-photo/1217563284?adppopup=true">Lucas Silva/picture alliance via Getty Images</a></span>
</figcaption>
</figure>
<h2>Poverty and exposure</h2>
<p>Extreme economic inequality is another critical factor <a href="https://temas.folha.uol.com.br/global-inequality/brazil/brazils-super-rich-lead-global-income-concentration.shtml">shaping the general health of Afro-Brazilians</a>. With the top 10% of the population earning 55% of domestic income, Brazil trails only Qatar in concentration of wealth, according to a 2019 <a href="https://nacoesunidas.org/relatorio-de-desenvolvimento-humano-do-pnud-destaca-altos-indices-de-desigualdade-no-brasil/">United Nations report</a>. </p>
<p>Few, if any, Afro-Brazilians rank among Brazil’s super-rich. <a href="https://biblioteca.ibge.gov.br/visualizacao/livros/liv101681_informativo.pdf">National household survey data</a> shows that black and brown Brazilians make far less money than white Brazilians, even with equivalent educational background. The racial wage gap in Brazil actually <a href="https://biblioteca.ibge.gov.br/visualizacao/livros/liv101681_informativo.pdf">outweighs the gender wage gap</a>: White women earn up to 74% more than black men. </p>
<p>Generally speaking, the higher the salary, the less likely Afro-Brazilians are to have a job. Many work in the informal and service sectors, as <a href="https://theconversation.com/in-brazils-raging-pandemic-domestic-workers-fear-for-their-lives-and-their-jobs-138163">house cleaners</a> or street vendors. Others are self-employed or unemployed. </p>
<p>During the pandemic, this economic insecurity severely lessens Afro-Brazilians’ ability to <a href="https://www.hypeness.com.br/2020/03/coronavirus-e-a-inabilidade-social-do-governo-ameacam-negros-e-pobres/">socially distance</a> and makes them highly dependent on staying in their jobs despite the health threat. </p>
<p>Maids, for example – most of whom are black women – are proving to <a href="https://theconversation.com/in-brazils-raging-pandemic-domestic-workers-fear-for-their-lives-and-their-jobs-138163">be a high-risk group</a>. Domestic workers were among Brazil’s <a href="https://g1.globo.com/rj/sul-do-rio-costa-verde/noticia/2020/03/17/idosa-de-63-anos-morre-por-suspeita-coronavirus-em-miguel-pereira-diz-secretaria-municipal.ghtml">first COVID-19 deaths</a>.</p>
<h2>Neighborhood risks</h2>
<p>Brazil’s coronavirus outbreak originated in wealthy neighborhoods whose residents had traveled to Europe, but the disease is now <a href="https://nacla.org/news/2020/03/31/brazil-favelas-covid19">spreading fastest</a> in its poor, dense, long-neglected urban neighborhoods. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/340730/original/file-20200609-21230-1e1ti2t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/340730/original/file-20200609-21230-1e1ti2t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/340730/original/file-20200609-21230-1e1ti2t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/340730/original/file-20200609-21230-1e1ti2t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/340730/original/file-20200609-21230-1e1ti2t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/340730/original/file-20200609-21230-1e1ti2t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/340730/original/file-20200609-21230-1e1ti2t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/340730/original/file-20200609-21230-1e1ti2t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A protest sign reading, ‘They say to wash your hands, but how to do that without water?’ on May 18, 2020.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/residents-of-paraisopolis-one-of-the-citys-largest-slums-news-photo/1213517036?adppopup=true">Miguel SCHINCARIOL / AFP via Getty Images</a></span>
</figcaption>
</figure>
<p>Just over 12 million Brazilians, most of them black, live in such informal urban settlements, from Rio de Janeiro’s favelas to the “peripheries” of São Paulo. These areas have inadequate access to <a href="https://theconversation.com/megacity-slums-are-incubators-of-disease-but-coronavirus-response-isnt-helping-the-billion-people-who-live-in-them-138092">water and sanitation</a>, making it difficult to follow basic hygiene recommendations like washing one’s hands with soap. </p>
<p>So while the <a href="https://www.theguardian.com/world/2020/jun/09/enormous-disparities-coronavirus-death-rates-expose-brazils-deep-racial-inequalities?emci=94d478d2-52aa-ea11-9b05-00155d039e74&emdi=45829873-54aa-ea11-9b05-00155d039e74&ceid=4606001">disparate impact of COVID-19</a> on black Brazilians was not inevitable, our research explains why it’s unsurprising. </p>
<p>The racism that pervades nearly every facet of Brazilian society increases black people’s exposure to the virus – then reduces their ability to get to quality care. </p>
<p>[<em>You need to understand the coronavirus pandemic, and we can help.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=upper-coronavirus-help">Read The Conversation’s newsletter</a>.]</p><img src="https://counter.theconversation.com/content/139430/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In Brazil, black COVID-19 patients are dying at higher rates than white patients. Worse housing quality, working conditions and health care help to explain the pandemic’s racially disparate toll.Kia Lilly Caldwell, Professor, African, African American, and Diaspora Studies, University of North Carolina at Chapel HillEdna Maria de Araújo, Professor of Public Health and Epidemiology, Universidade Estadual de Feira de Santana (UEFS)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1377352020-05-11T14:41:02Z2020-05-11T14:41:02ZHow coronavirus is threatening the equal access principle at the core of the NHS<figure><img src="https://images.theconversation.com/files/332297/original/file-20200504-83775-h5k652.jpg?ixlib=rb-1.1.0&rect=264%2C253%2C6687%2C3735&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/london-uk-4th-march-2017-editorial-597255296">Shutterstock/JohnGomez</a></span></figcaption></figure><p>The NHS was <a href="https://www.kingsfund.org.uk/blog/2019/12/five-reasons-why-nhs-winter-may-be-different">under strain</a> long before the COVID-19 pandemic risked it becoming <a href="https://www.theguardian.com/world/2020/mar/21/doctors-warn-coronavirus-could-overwhelm-nhs-intensive-care">overwhelmed</a>. But it still guaranteed equal access to the health system for all British residents. In fact, during its 70 years of existence the NHS has always honoured this <a href="https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england#principles-that-guide-the-nhs">core principle</a>. However, the rapid growth in coronavirus cases and the limited resources available has led to the implementation of a <a href="https://blogs.bmj.com/medical-ethics/2020/03/26/dont-let-the-ethics-of-despair-infect-the-intensive-care-unit/">patient ranking system</a> and <a href="https://www.cambridge.org/core/journals/european-journal-of-risk-regulation/article/will-covid19-mark-the-end-of-an-egalitarian-national-health-service/1B020BDA3E5426039C614FC4CE84273B">my research</a> shows that these measures could be putting equal access at risk.</p>
<p>Infected people with a greater chance of regaining good health were given priority for treatment through an emergency measure introduced on March 21 by the National Institute for Health and Care Excellence (Nice), making equal access to the NHS the lesser objective. The <a href="https://www.nice.org.uk/guidance/NG159">COVID-19 rapid guidelines</a> suggested that doctors consider the medical benefit, including the patient’s likelihood of recovery, when deciding on their admission to an intensive care unit.</p>
<p>The advice required a certain level of speculation from clinicians on how well patients might respond to critical care. These guidelines were heavily criticised by <a href="https://www.mencap.org.uk/press-release/mencap-responds-deeply-troubling-new-nice-covid-19-guidance">disability protection groups</a>, as it seemed the criteria on which resource allocation was based was skewed in favour of younger and healthier patients.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/332299/original/file-20200504-83764-14x4qkm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/332299/original/file-20200504-83764-14x4qkm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/332299/original/file-20200504-83764-14x4qkm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/332299/original/file-20200504-83764-14x4qkm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/332299/original/file-20200504-83764-14x4qkm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/332299/original/file-20200504-83764-14x4qkm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/332299/original/file-20200504-83764-14x4qkm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">COVID-19 has forced a change in the way patients are assessed for critical care.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/critical-care-sign-hospital-1707858304">Shutterstock/SimonWayPhoto</a></span>
</figcaption>
</figure>
<p>Indeed, long-term disabled or elderly patients tend to have a greater likelihood of having multiple medical conditions (comorbidities), and may be assessed as being less likely to recover from critical care. </p>
<p>The guidelines were <a href="https://www.nice.org.uk/news/article/nice-updates-rapid-covid-19-guideline-on-critical-care">amended in part on March 25</a> reflecting concerns that applying the score to people with learning disabilities, autism and other stable long-term disabilities “would put them at a disadvantage when decisions were made about admission to critical care in this time of intense pressure”.
Despite this change, the guidelines still recommend some form of priority assessment, suggesting that not all patients could equally have access to critical care. </p>
<p>Unfortunately, the reality of the pandemic has not allowed the NHS to spread resources to preserve equal access to services. For example, patients can’t be rotated to share ventilator time or bed days in hospital. Instead – under the new emergency system – patients are given priority when clinicians believe they have a better chance of making a good recovery. And this indirectly favours <a href="https://www.theguardian.com/commentisfree/2020/mar/14/coronavirus-outbreak-older-people-doctors-treatment-ethics">younger and healthier people</a>. </p>
<p>The new model also puts the needs of infected people ahead of others, such as the chronically ill (diabetics, cancer patients) or people suffering from mental health issues. This is creating a backlog that will be difficult to eliminate when regular NHS operations resume and it is likely to have a significant impact on the <a href="https://www.hsj.co.uk/coronavirus/nhs-england-gearing-up-to-restart-routine-care/7027488.article">overall organisation of care</a>. Patients holding back from seeking treatment during the pandemic could also require more extensive and costly interventions or even <a href="https://www.researchgate.net/publication/340984562_Estimating_excess_mortality_in_people_with_cancer_and_multimorbidity_in_the_COVID-19_emergency">die prematurely</a>.</p>
<h2>Healthcare rationing</h2>
<p>Granted, even in non-pandemic times, clinicians run an assessment of outcomes for their patients to determine whether the treatment is in their best interest. But they usually do not have to factor in critically limited resources. </p>
<p>As the entire system comes under pressure, the reality of <a href="https://blogs.bmj.com/bmj/2020/03/09/covid-19-triage-in-a-pandemic-is-even-thornier-than-you-might-think/">triage has changed</a>. Rationing of resources is no longer just operated at the macro-level where resources are allocated to the NHS by the government. Difficult rationing decisions are now being imposed on clinicians who are being asked to make <a href="https://blogs.bmj.com/bmj/2020/03/20/daniel-sokol-the-life-and-death-decisions-of-covid-19/">dramatic choices about patients</a> not just on medical need but on how a proposed treatment might effect resources.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1252194047562670080"}"></div></p>
<p>As I’ve noted in my <a href="https://www.bloomsburyprofessional.com/uk/justice-and-profit-in-health-care-law-9781509902705/">previous research</a>, when the NHS is not dealing with a public health emergency, the allocation of healthcare generally follows a model of egalitarian justice. But going back to equal access for all after the COVID-19 crisis may be impossible.</p>
<p>Once emergency measures are suspended, the NHS will need to address the delays in treatment that occurred during the pandemic. Only vital services have <a href="https://www.telegraph.co.uk/politics/2020/04/27/nhs-restore-vital-servicessuch-cancer-care-tuesday-matt-hancock/">so far resumed</a> and many more interventions and treatments still need to be rescheduled. The cost of having scaled up critical and intensive care on the entire territory and having purchased services and hospital beds <a href="https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/ihpn-partnership-letter-25-march-2020.pdf">in the independent sector</a> will also have long-term effect on the NHS finances. </p>
<p>Adding to these costs, investments in the <a href="https://www.ft.com/content/09897050-13bc-4ebe-99af-25b8d2ab5781">under-utilised seven Nightingale hospitals</a> will have to be absorbed. Finally, the public health strategy will have to be reassessed to prepare for a potential future pandemic. All of which will affect available resources and will jeopardise equal access to healthcare for all. Inevitably, the NHS will have to adopt a new model that will have to again prioritise some patients, maybe those in need of urgent care or those more likely to benefit from these resources.</p>
<p>If it is to return to its founding premise, the NHS will require more than just a round of applause and good will. It will need sustained and guaranteed financial support from the government.</p><img src="https://counter.theconversation.com/content/137735/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sabrina Germain does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The core egalitarian principle of the NHS could be under threat in the wake of the COVID-19 pandemic.Sabrina Germain, Senior Lecturer at The City Law School, City, University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1285832019-12-13T13:42:43Z2019-12-13T13:42:43ZAs rural Americans struggle for health care access, insurers may be making things worse<figure><img src="https://images.theconversation.com/files/306472/original/file-20191211-95111-1gzbdtm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Dr. Kyle Parks, the only surgeon at Evans Memorial Hospital in Claxton, Ga. The hospital struggles to stay in business while serving large numbers of rural poor.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Health-Overhaul-Rural-Health/ed9860bfc26e44678cc9dc4ab0c138be/53/0">Russ Bynum/AP Photo</a></span></figcaption></figure><p>Living in rural America certainly comes with a number of benefits. There is <a href="https://www.moving.com/tips/6-proven-benefits-of-country-living/">less crime, access to the outdoors, and lower costs of living</a>.</p>
<p>Yet, not everything is rosy outside the city limits. Rural communities face growing infrastructure problems like <a href="https://www.wvpublic.org/post/stirring-waters-inside-appalachia-how-drinking-water-systems-are-failing-rural-residents#stream/0">decaying water systems</a>. And they have more limited access to amenities ranging from <a href="https://www.pewsocialtrends.org/2018/05/22/views-of-problems-facing-urban-suburban-and-rural-communities/">grocery stores to movie theaters, lower quality schools, and less access to high-speed internet</a>. </p>
<p>Yet perhaps most daunting are the tremendous <a href="https://www.ruralhealthinfo.org/topics/rural-health-disparities">health disparities rural Americans face</a>, in terms of both their own health and accessing care. </p>
<p>As a number of <a href="https://scholar.google.com/citations?hl=en&user=QY68LSIAAAAJ">my recent studies indicate</a>, these disparities may be exacerbated by insurance carriers and the networks they put together for their consumers. </p>
<h2>A sick system that’s getting worse</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/306711/original/file-20191212-85412-nnbxnh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/306711/original/file-20191212-85412-nnbxnh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/306711/original/file-20191212-85412-nnbxnh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/306711/original/file-20191212-85412-nnbxnh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/306711/original/file-20191212-85412-nnbxnh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/306711/original/file-20191212-85412-nnbxnh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/306711/original/file-20191212-85412-nnbxnh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Rural hospitals such as this one in Belhaven, N.C., have closed in unprecedented numbers in recent years, leading also to doctor shortages. Insurers face challenges in developing networks of doctors to care for patients.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Rural-Hospitals-Hard-Times/41b657c309f74405af5db2a4f83dd3dc/13/0">Gerry Broome/AP Photo</a></span>
</figcaption>
</figure>
<p>At the turn of the last century, cities were known to be <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4829a1.htm/">cesspools rampant with disease</a>. Much has changed since then. Today, health care disparities between urban and rural America have <a href="https://www.nber.org/papers/h0134">indeed reversed</a>. And they are <a href="https://journalistsresource.org/studies/government/health-care/rural-urban-health-care-disparities/">growing wider</a>.</p>
<p>Part of the problem is demographic. Over the last several decades, many rural areas have <a href="https://www.ers.usda.gov/amber-waves/2010/december/the-two-faces-of-rural-population-loss-through-outmigration/">lost a large share of their residents</a>. In many areas, <a href="https://w3001.apl.wisc.edu/pdfs/b03_16.pdf">the young are moving away</a>, leaving an aging population behind. </p>
<p>Besides being older, those staying behind are <a href="https://www.kff.org/uninsured/issue-brief/the-affordable-care-act-and-insurance-coverage-in-rural-areas/">poorer</a> and have <a href="https://www.kff.org/uninsured/issue-brief/the-affordable-care-act-and-insurance-coverage-in-rural-areas/">lower levels of education</a>. To make things worse, they are also more likely to <a href="https://www.cdc.gov/nchs/data/hus/2018/047.pdf">be uninsured</a>. And they tend to be sicker, exhibiting <a href="https://stacks.cdc.gov/view/cdc/43149">higher rates of cancer, heart disease, stroke and chronic lower respiratory disease</a>. It comes as no surprise that their <a href="https://dx.doi.org/10.21106%2Fijma.236">life expectancy is generally lower</a> as well.</p>
<p>The demographic challenges are made worse by the limitations posed by the health care system. For one, rural areas are experiencing tremendous <a href="https://www.ruralhealthinfo.org/assets/1275-5131/rural-urban-workforce-distribution-nchwa-2014.pdf">health care provider shortages</a>. Access is often particularly limited for <a href="https://www.ruralhealthinfo.org/resources/topics/specialty-care">specialty care</a>. But much more mundane health care services that most of us take for granted, like <a href="https://www.ruralhealthweb.org/news/nearly-700-rural-hospitals-at-risk-of-closing">hospitals</a> – including <a href="https://doi.org/10.1215/03616878-7277356">public hospitals</a> and <a href="https://www.commonwealthfund.org/blog/2019/rural-maternity-care-crisis">maternity wards</a> – are also affected. </p>
<p>Politics have made rural access challenges worse in many places. Partisan opposition to the Affordable Care Act has led many states with large rural populations, like Texas and Kansas, to <a href="https://doi.org/10.1215/03616878-2882219">refuse to expand their Medicaid programs</a> or support enrollment in <a href="https://doi.org/10.1111/puar.12065">Affordable Care Act marketplaces</a>. This stance is particularly damaging because the program provides a crucial lifeline to rural providers. </p>
<h2>A stark divide</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/306645/original/file-20191212-85404-1p5wat2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/306645/original/file-20191212-85404-1p5wat2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=433&fit=crop&dpr=1 600w, https://images.theconversation.com/files/306645/original/file-20191212-85404-1p5wat2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=433&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/306645/original/file-20191212-85404-1p5wat2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=433&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/306645/original/file-20191212-85404-1p5wat2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=544&fit=crop&dpr=1 754w, https://images.theconversation.com/files/306645/original/file-20191212-85404-1p5wat2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=544&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/306645/original/file-20191212-85404-1p5wat2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=544&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Nikki Kessler in a July 2014 photo is shown in a Lumberton, N.C. hospital. The closure of rural hospitals has not only resulted in fewer hospitals but also narrower insurance networks.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Medicaid-Hospitals/87289cb3c844406d9c628eec454cdb65/21/0">Gerry Broome/AP Photo</a></span>
</figcaption>
</figure>
<p>Rural communities across the country face tremendous health care access issues. And as recent study my colleagues and I did of <a href="https://doi.org/10.1377/hlthaff.2019.00116">access to cardiologists, endocrinologists, OB-GYNs and pediatricians</a> shows, insurance plans may further complicate the issue.</p>
<p>Focusing on California, we compared access between plans sold under the Affordable Care Act and commercially available plans. We also made comparisons to a hypothetical plan that included all of the state’s providers. In theory, this would be the plan available to consumers under various <a href="http://www.milkenreview.org/articles/life-and-politics-beyond-the-affordable-care-act">Medicare-for-All proposals</a>.</p>
<p>Overall, we found that consumers living in large metropolitan areas faced only very limited access challenges. However, as distance from cities increased, access worsened significantly. Consumers had fewer providers to choose from, and had to travel further to see them.</p>
<p>One of our starkest findings was the existence of what we called <a href="https://doi.org/10.1377/hlthaff.2019.00116">“artificial provider deserts</a>” – areas where providers are practicing and seeing patients, but insurance carriers do not include any of them in their networks. Without access to local providers, some rural residents are forced to travel 120 miles or more to reach in-network care.</p>
<p>Our findings hold for both Affordable Care Act plans and those commercially available, which fared only slightly better. </p>
<p>The problems we found in this study extend well past plans sold on the Affordable Care Act marketplaces. Two of my other studies found similar, if not worse problems, for rural consumers of <a href="https://doi.org/10.1002/wmh3.309">Medicare Advantage plans in New York</a> and <a href="https://doi.org/10.1177%2F2333392818824472">California</a>. </p>
<h2>More protections for rural Americans</h2>
<p>There are many reasons for the growing disparities between urban and rural America. Many of these aren’t always easily or quickly remedied through government intervention. Indeed, some may be inherent to living outside of metropolitan areas.</p>
<p>Yet when it comes to health care access, our recent work indicates that decisions by insurance carriers may further worsen the situation. Conceivably, insurers may limit access to providers to push sicker populations to enroll with other insurers. </p>
<p>However, the fault may not exclusively lie with insurers. Rural providers may also demand large fees to enter into <a href="https://www.healthaffairs.org/do/10.1377/hblog20190603.704918/full/">contracts with insurers</a>, leading insurers to exclude them from their networks. </p>
<p>While <a href="https://doi.org/10.1215/03616878-7785835">regulating provider networks comes with a slew of challenges</a>, it seems apparent to me that our current approach is not working for Rural America. It is time to rethink how we provide and regulate health care access to millions of Americans living in rural areas.</p>
<p>[ <em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://theconversation.com/us/newsletters/weekly-highlights-61?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=weeklysmart">You can get our highlights each weekend</a>. ]</p><img src="https://counter.theconversation.com/content/128583/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder is a Fellow in the Interdisciplinary Research Leaders Program, a national leadership development program supported by the Robert Wood Johnson Foundation to equip teams of researchers and community partners in applying research to solve real community problems. </span></em></p>Americans who live in rural parts of the country have fewer doctors, specialists and hospitals than those who live in cities. It also appears that insurers are working against them.Simon F. Haeder, Assistant Professor of Public Policy, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1286342019-12-11T12:57:51Z2019-12-11T12:57:51ZHow South Africa can build a child-centred health care system<figure><img src="https://images.theconversation.com/files/306094/original/file-20191210-95130-812jgm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Child health care remains uneven in South Africa and varies between provinces and districts.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>It is more than 20 years since the South African constitution first guaranteed children’s “right to basic health care services”. This is part of a broader commitment to ensure children’s rights to optimal survival, health and development. The question is how close South Africa is to realising these rights in practice. </p>
<p>We address this issue in a <a href="http://www.ci.uct.ac.za/sites/default/files/image_tool/images/367/Child_Gauge/South_African_Child_Gauge_2019/CG2019%20-%20%281%29%20Prioritising%20child%20and%20adolescent%20health.pdf">chapter</a> of the <a href="http://www.ci.uct.ac.za/sites/default/files/image_tool/images/367/Child_Gauge/South_African_Child_Gauge_2019/ChildGauge_2019_final_print%20%28sm%29.pdf">South African Child Gauge 2019</a> report. </p>
<p>Unlike adults’ right to health, children’s right to basic health care services is not subject to progressive realisation. Children should therefore be prioritised within the health care system. Yet the state has still not defined an essential package of health care services for children. This makes it difficult to determine what they are entitled to and what the state should be held accountable for. </p>
<p>Without a defined package, there’s a danger that the drive for efficiencies and cost saving may result in a limited basket of care that doesn’t address the complex needs of children. This is particularly true for those with chronic (long term) health conditions. </p>
<p>This essential package of care needs to be supported by a set of norms and standards. These need to specify the infrastructure, equipment, medicines and staff needed to meet the unique needs of children and adolescents. A clear package will also make explicit how health care establishments need to be equipped. These would include neonatal and paediatric wards as well as emergency medical services and primary health care services, where children currently have to compete for attention with sick and injured adults. </p>
<p>In other facets of the health system, too, budgets, building of infrastructure and medicine supplies need to consider children’s unique needs. </p>
<p>A child rights approach to health requires health professionals to treat children and their caregivers with respect and communicate effectively. Health care providers also need to build children’s and adolescents’ capacity to take responsibility for their own health and include them in decision making. </p>
<p>These fundamental shifts in the balance of power between adult and child, doctor and patient have been found to relieve pain and suffering. They also improve diagnosis, compliance with treatment, patient satisfaction and health outcomes. </p>
<h2>Training health workers</h2>
<p>The United Nations Committee on the Rights of Child has called for children’s rights to be integrated in the curriculum and performance criteria of all professionals working with children. These include health and allied professionals, teachers and social workers. The aim is to ensure that they are better attuned to children’s needs and rights. </p>
<p>For example, the <a href="http://www.lincare.co.za/?m=2019">LinCARE</a> programme, where a team of health workers provides mother and child health care in Limpopo province, aims to reduce neonatal mortality. It does this by improving the quality of care during pregnancy and labour. The programme is aimed at ensuring that all women have a positive pregnancy and birth experience. It includes antenatal classes and ensures that women have practical and emotional support from a birth companion and kind, respectful and technically competent clinical staff.</p>
<p>As part of current preparation for a <a href="http://www.health.gov.za/index.php/nhi">national health insurance</a> system, which is aimed at extending universal health care to all South Africans, bolstering the primary health care system offers three opportunities to strengthen the child health workforce and improve the quality of care: </p>
<ul>
<li><p>Community health workers play a central role in bringing health care services close to home, particularly for children living in poor or remote households. It’s therefore encouraging to see the national department of health’s commitment to employing them and paying them the minimum wage. This should improve supervision and support and ensure greater continuity of care between community-based services and health care facilities. </p></li>
<li><p>School health teams are another essential ingredient of the child system, helping to screen older children and address barriers to learning. Yet coverage reaches only one third of pupils in their first year of schooling and 20% of grade 8 learners. Its effectiveness is compromised by the shortage of health and other social service professionals, such as social workers, oral hygienists and dentists, psychologists, physiotherapists, speech and language therapists and occupational therapists.</p></li>
<li><p>Finally, district clinical specialist teams provide essential leadership for child and adolescent health at district level. For example, neonatal mortality has dropped by 30% in districts where there are paediatricians and paediatric nurses, yet less than half of specialist teams have a full paediatric team.</p></li>
</ul>
<h2>What needs to be done</h2>
<p>The progress for child health has been uneven in South Africa with significant variation between provinces and districts. For example, immunisation varied from 90% in Mpumalanga to 69% in the Eastern Cape – signalling persistent inequities in access and coverage of care.</p>
<p>Given these challenges, greater investment is needed to strengthen systems and build a workforce for child and adolescent health. National health insurance provides an important opportunity to ensure universal health coverage and financial risk protection for the poor, as well as to improve the quality of care. </p>
<p>This requires leadership for child health at every level of the health care system – from individual encounters with children and their families, to ensuring that child health is adequately represented on key decision-making structures that will decide how resources are allocated.</p>
<p>Very importantly, it requires that the health sector works with and alongside other sectors. Interventions such as sufficient good quality food, good quality education, safe water and sanitation, good housing, safe roads and safe communities can significantly promote the health and well-being of children.</p>
<p><em>The South African Child Gauge 2019 report is published by the Children’s Institute at the University of Cape Town. The theme of the 2019 issue – “Child and adolescent health: leave no one behind” – is a call to prioritise child and adolescent health and put children at the heart of the health care system.</em> </p>
<p><em>Lori Lake, a co-editor of the Child Gauge report, also contributed to this article.</em></p><img src="https://counter.theconversation.com/content/128634/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maylene Shung-King does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Children’s right to health is paramount: here’s what needs to be done to build a child-centred health care system.Maylene Shung-King, Professor, Health Policy, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1219062019-08-30T13:12:24Z2019-08-30T13:12:24ZWhen religious ideology drives abortion policy, poor women suffer the consequences<figure><img src="https://images.theconversation.com/files/290145/original/file-20190829-106517-1y8p1v1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Abortion rights supporters in Missouri take part in a protest, after state lawmakers passed rules aimed at closing Missouri's only abortion clinic, May 30, 2019.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Abortion-Missouri/d2a0ab33b7004567b365150c4b4be22a/10/0">AP Photo/Jeff Roberson</a></span></figcaption></figure><p>In Northern Ireland, Catholics and Protestants are frequently segregated, with some neighborhoods <a href="https://99percentinvisible.org/episode/peace-lines/">divided by barbed wire fences</a>, reflecting deep historical <a href="https://www.theguardian.com/housing-network/2017/oct/03/northern-ireland-shared-communities-economic-inequality-religion-neighbourhood">conflicts between the faiths</a>. </p>
<p>Ninety percent of Northern Ireland’s 1.87 million people are Christian, with Protestants, once the solid majority there, now <a href="https://www.irishtimes.com/news/ireland/irish-news/two-tribes-a-divided-northern-ireland-1.3030921">slightly outnumbering Catholics</a>. But members of these faiths remain divided decades after a 1997 <a href="https://www.cfr.org/backgrounder/northern-ireland-peace-process">peace agreement</a> meant to end sectarian violence in the region.</p>
<p>Northern Irish politicians do agree on one thing lately, The New York Times <a href="https://www.nytimes.com/2019/08/10/world/europe/abortion-northern-ireland-roe.html">reports</a>: banning abortion.</p>
<p>It is illegal in Northern Ireland to end a pregnancy unless it endangers the mother’s life, though <a href="https://www.nytimes.com/2019/08/10/world/europe/abortion-northern-ireland-roe.html?searchResultPosition=6">65%</a> of Northern Ireland’s population <a href="https://www.cnn.com/2018/10/09/health/northern-ireland-abortion-polls-intl/index.html">supports abortion</a>. As a result, women who seek abortions typically go to England, where abortion is legal. </p>
<p>But, as my <a href="https://buffalo.academia.edu/GretchenEly">research on cases of low-income abortion patients shows</a>, not everyone can afford abortion expenses. That includes women in the United States, where restrictive abortion laws mean the nearest clinic may be many miles away.</p>
<h2>Unaffordable abortion</h2>
<p>In one <a href="https://www.ncbi.nlm.nih.gov/pubmed/28812525">2017 study</a>, I examined data of over 2,300 patients in Ireland, Northern Ireland and <a href="https://www.bbc.com/news/world-europe-18251379">Isle of Man</a> who had received financial assistance from <a href="https://abortionfunds.org/about/">abortion funds</a>, charitable organizations that help people access abortions they can’t afford.</p>
<p>Though the Republic of Ireland <a href="https://www.theguardian.com/world/2018/may/26/ireland-votes-by-landslide-to-legalise-abortion">legalized abortion in May 2018</a>, leaving Northern Ireland as the only nation on the British Isles with an abortion ban, our research took place when abortion was illegal in both nations. </p>
<p>The average abortion expense for our sample was US$585, while patients had on average just $307 at their disposal to pay for the procedure. Eighty-four percent of these abortion-seekers were single, 34% were age 21 or under, and 8% were minors. They had, on average, two children each.</p>
<p>This profile is comparable to that of the almost 4,000 abortion fund service recipients in the United States whose data we also studied. In the U.S., abortion is legal nationally but <a href="https://www.newsweek.com/tennessee-considers-abortion-ban-when-pregnancy-detected-1453882">highly restricted in some states</a>. </p>
<p>We found many similarities between the patients. The American patients had, on average, $422 to contribute to abortions that cost around $1775. They were also young, single parents of two. These American low-income abortion-seekers traveled, on average, <a href="https://www.tandfonline.com/doi/abs/10.1080/19317611.2017.1316809">140 miles</a> for their procedure. </p>
<h2>Penalizing the poor</h2>
<p>Recent changes to U.S. <a href="https://www.hhs.gov/about/news/2019/02/22/hhs-releases-final-title-x-rule-detailing-family-planning-grant-program.html">family planning policy</a> highlight another parallel between Northern Ireland and the United States: the influence of <a href="https://www.reuters.com/article/us-usa-pence-hhs-special-report/as-trump-rewrites-health-rules-pence-sees-conservative-agenda-born-again-idUSKCN1T0176">religion in reproductive health policy</a>.</p>
<p>In mid-August, Planned Parenthood announced its <a href="https://www.nytimes.com/2019/08/19/health/planned-parenthood-title-x.html">withdrawal from Title X</a> – a Nixon-era family planning program for <a href="https://www.hhs.gov/opa/title-x-family-planning/about-title-x-grants/funding-history/index.html">low-income patients</a> – due to a new requirement that Title X medical providers cannot also offer abortions.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/290149/original/file-20190829-106517-14ld5aj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/290149/original/file-20190829-106517-14ld5aj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/290149/original/file-20190829-106517-14ld5aj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=839&fit=crop&dpr=1 600w, https://images.theconversation.com/files/290149/original/file-20190829-106517-14ld5aj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=839&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/290149/original/file-20190829-106517-14ld5aj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=839&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/290149/original/file-20190829-106517-14ld5aj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1054&fit=crop&dpr=1 754w, https://images.theconversation.com/files/290149/original/file-20190829-106517-14ld5aj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1054&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/290149/original/file-20190829-106517-14ld5aj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1054&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Anti-abortion protesters outside the U.S. Supreme Court, April 22, 1992.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Watchf-AP-A-DC-USA-APHS479827-Abortion-Demonstration/9e44bfee54bc4fb6b70bcc7e5d8cda79/10/0">AP Photo/Barry Thumma</a></span>
</figcaption>
</figure>
<p>Title X funds <a href="https://www.hhs.gov/about/news/2019/02/22/fact-sheet-final-title-x-rule-detailing-family-planning-grant-program.html">have never been used to pay for abortion services</a>. But by eliminating funding for facilities that offer abortions in addition to other reproductive services, the Trump administration rule may leave <a href="https://time.com/5655500/planned-parenthood-title-x-funding/">millions of low-income Planned Parenthood patients</a> without family planning care. </p>
<p>The new rule is part of an old American effort, <a href="https://www.thegospelcoalition.org/blogs/evangelical-history/christian-right-discovered-abortion-rights-transformed-culture-wars/">promoted by Christian activists and lawmakers</a>, to make legal abortions as difficult as possible to obtain. </p>
<p>The new Title X rule builds on the <a href="https://www.nytimes.com/2019/06/07/us/politics/what-is-the-hyde-amendment.html">1976 Hyde Amendment</a>, which prevents federal dollars from paying for abortion expenses. Low-income women relying on programs like Medicaid for health insurance must pay out-of-pocket for abortion, reallocating money <a href="https://www.guttmacher.org/sites/default/files/article_files/gpr100112.pdf">that would otherwise go to food and rent</a>. </p>
<p>While most manage to <a href="https://www.guttmacher.org/sites/default/files/article_files/gpr100112.pdf">access a wanted abortion</a>, research shows, some poor American women end up <a href="https://s27589.pcdn.co/wp-content/uploads/2016/09/OP_hyde_9.28.3.pdf">carrying unwanted pregnancies to term</a> against their will.</p>
<p>Many states in the southern U.S. – a conservative region where <a href="https://www.pewforum.org/religious-landscape-study/region/south/">76% of residents identify as Christian</a> – require <a href="https://www.guttmacher.org/state-policy/explore/counseling-and-waiting-periods-abortion">a waiting period of up to three days</a> for patients to “reflect” on abortion decisions. In practice, that means two mandatory in-person trips to the clinic and <a href="https://www.sciencedirect.com/science/article/abs/pii/S1049386715001619">higher medical costs</a>. </p>
<p>In Tennessee, where there is a 48-hour abortion waiting period, my <a href="https://www.jstor.org/stable/10.5406/jappastud.25.1.0087?seq=1#page_scan_tab_contents">recent research</a> found that abortion-seekers from the mountainous Appalachian region reported financial and personal strain, as well as problems arranging child care and transportation. Appalachia is a rural, remote region where <a href="https://www.arc.gov/research/researchreportdetails.asp?REPORT_ID=101">health care access is already compromised</a>. The <a href="https://www.guttmacher.org/fact-sheet/state-facts-about-abortion-tennessee">48-hour waiting period</a> likely puts legal abortion <a href="https://www.whijournal.com/article/S1049-3867(16)30060-3/pdf">out of reach</a> for some.</p>
<h2>Religion in health policy</h2>
<p>Many nations in Europe can be classified as predominantly Christian, much like the American South and Northern Ireland. But few allow religious ideology to influence their reproductive health laws.</p>
<p>In France, <a href="https://www.worldatlas.com/articles/religious-demographics-of-france.html">60% of people identify as Christian</a>, abortion is legal, and 80% of the French support the procedure in <a href="https://www.pewforum.org/2018/10/29/eastern-and-western-europeans-differ-on-importance-of-religion-views-of-minorities-and-key-social-issues/pf-10-29-18_east-west_-00-05/">all or most circumstances</a>, according to the Pew Research Center. </p>
<p>Legal abortion is similarly acceptable throughout Western Europe, Pew polling finds, with public support at <a href="https://www.pewforum.org/2018/10/29/eastern-and-western-europeans-differ-on-importance-of-religion-views-of-minorities-and-key-social-issues/pf-10-29-18_east-west_-00-05/">60% in Portugal, 65% in Italy and 72% in Spain</a> – all <a href="https://www.pewresearch.org/fact-tank/2018/12/19/5-facts-about-catholics-in-europe/">majority Catholic</a> nations. </p>
<p>Catholic Ireland, where even condoms used to be banned, recently voted to <a href="https://www.pewresearch.org/fact-tank/2018/05/29/ireland-abortion-vote-reflects-western-europe-support/">legalize abortion in the first trimester</a>. The momentous decision was spurred by the <a href="https://www.nytimes.com/2018/05/27/world/europe/savita-halappanavar-ireland-abortion.html">death of a 31-year-old woman</a> who was denied an abortion after miscarriage.</p>
<h2>Evidence-based policies</h2>
<p>Irish voters’ willingness to modernize abortion laws against Catholic teaching reflects a reality that my research lays bare: Reproductive health policies based on ideology rather than scientific evidence fail to serve the public. </p>
<p>Studies show that abortion rates across countries are similar <a href="https://www.guttmacher.org/news-release/2018/new-report-highlights-worldwide-variations-abortion-incidence-and-safety">regardless of legality</a>. So making abortions illegal or inaccessible generally does not stop women from getting them. </p>
<p>Wealthier abortion patients with adequate resources will overcome costs and other barriers that restrictive abortions law throw in front of them. Poor abortion-seekers are more likely to seek <a href="https://www.who.int/news-room/fact-sheets/detail/preventing-unsafe-abortion">unsafe, even deadly, procedures</a>. </p>
<p><a href="https://theconversation.com/abortions-rise-worldwide-when-us-cuts-funding-to-womens-health-clinics-study-finds-112491">Research from Latin America</a> confirms this. This socially conservative, heavily Catholic region has the <a href="https://time.com/5358823/argentina-abortion-vote-latin-america/">world’s most restrictive abortion laws</a>. It also has the <a href="https://theconversation.com/in-latin-america-is-there-a-link-between-abortion-rights-and-democracy-85444">highest rates of clandestine abortions</a>.</p>
<p>Religious freedom is critical in any free society, and faith provides a vital source of comfort for many people. But evidence shows that religion can be a burden, not a blessing, when it comes to reproductive health. </p>
<p>[ <em><a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=thanksforreading">Thanks for reading! We can send you The Conversation’s stories every day in an informative email. Sign up today.</a></em> ]</p><img src="https://counter.theconversation.com/content/121906/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gretchen E. Ely has received grant funding from the Society of Family Planning and the International Network for the Reduction of Abortion Discrimination and Stigma (inroads). </span></em></p>Young, poor, single and a mother of two: This is the profile of most women in the US and Northern Ireland who seek financial assistance to help pay for an abortion.Gretchen E. Ely, Professor and Associate Dean for Academic Affairs, University at BuffaloLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1127072019-03-03T07:28:46Z2019-03-03T07:28:46ZSouth Africa is failing the rights of children to education and health<figure><img src="https://images.theconversation.com/files/261625/original/file-20190301-110150-p6fmpr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Children who aren't South African citizens struggle to access affordable health and education.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Is South Africa regularly denying children their right to access education as well as health care on the grounds either of petty bureaucracy or by a misinterpretation of the country’s laws and international obligations?</p>
<p>The answer is yes. </p>
<p>The country places limitations on children’s access to education and affordable health care. This is particularly true of migrant children. These limitations are, in my view, unconstitutional and in violation of South Africa’s international obligations. For example, South Africa is bound by the International Covenant on Economic, Social and Cultural Rights. In the interpretation of this convention, the United Nations Committee on Economic Social and Cultural Rights <a href="https://www.refworld.org/docid/4a60961f2.html">has emphasised that</a>:</p>
<blockquote>
<p>all children within a state, including those with an undocumented status, have a right to receive education and access to adequate food and affordable health care.</p>
</blockquote>
<p>However, South Africa isn’t living up to this promise. </p>
<p>What’s clear is that South Africa’s current school admission policy has a <a href="https://city-press.news24.com/Voices/thousands-of-undocumented-children-being-deprived-of-basic-right-to-education-20190206">serious effect</a> on the access to basic education of both children who are South African citizens and those who are foreign nationals or stateless.</p>
<p>The challenges for those who are not South African citizens and don’t have the required permits are compounded by section 39 of the <a href="https://www.halfloop.com/immigration-visa-rsa">Immigration Act 13 of 2002</a>. This states that a “learning institution” may not provide “training or instruction” to an “illegal foreigner”. Principals of schools that enrol a child who is an “illegal foreigner” can be charged and may face penalties.</p>
<p>Children who are not South African citizens often also struggle to access affordable health care through what’s been called <a href="https://www.dailymaverick.co.za/article/2018-03-29-medical-xenophobia-public-hospitals-deny-migrants-health-care-services-sahrc/">“medical xenophobia”</a>. </p>
<p>A recent Constitutional Court ruling gives some hope that the requirements of birth certificates and study permits for children to enrol in school will eventually be relaxed. However, litigation is still ongoing and as with access to affordable health care, there’s often a discrepancy between what the law provides and the actual situation on the ground.</p>
<h2>Denial of rights</h2>
<p>On 10 December 2018, the Grahamstown High Court gave an order dismissing an urgent application by the Centre for Child Law that 37 children should be admitted to a public school pending final determination of a <a href="https://eduinfoafrica.files.wordpress.com/2016/11/application-vol-1.pdf">case instituted by the Centre in 2017</a>, in which the applicants, among others, requested an order that: </p>
<blockquote>
<p>no learner may be excluded from a public school on the basis that he or she does not have an identity number, permit or passport. </p>
</blockquote>
<p>The 37 children were among the many children whose guardians have not managed to secure the <a href="https://www.msn.com/en-za/news/featured/the-undocumented-children-denied-the-right-to-go-to-school/ar-BBSyU50?li=BBqfWMJ">paperwork needed</a> to be allowed to register in a school under the 1998 Admission Policy for Ordinary Public Schools. </p>
<p>On 15 February 2019 the Constitutional Court granted leave of appeal against the High Court order and overturned it, ordering that the children should be admitted and enrolled in school by 1 March. However, this order does not finally decide the issue of requirements for enrolling in school as the case instituted in 2017 is still pending before the High Court. </p>
<p>The right to health care is provided for in article 27 of the Constitution. The <a href="https://www.gov.za/sites/default/files/gcis_document/201409/a61-03.pdf">National Health Act 61 of 2003</a> provides for free health care at public facilities for children under six years old, unless a child is covered by private medical insurance. </p>
<p>According to the <a href="http://www.health.gov.za/index.php/uniform-patient-fee-schedule/category/108-u2012">Uniform Patient Fee Schedule</a> all non-South African citizens – except those with permanent or temporary residence and citizens of the member states of the Southern African Development Community who “enter the (the republic) illegally” – are classified as full-paying patients. Children without the required permits who are over six years old, who lack medical insurance and are not from a Southern African Development Community member state therefore lack access to subsidised health care.</p>
<h2>International obligations</h2>
<p>The <a href="https://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/73/195">Global Compact for Safe, Orderly and Regular Migration</a> was adopted in December 2018 with South Africa’s support. Among other things, the global compact calls on states to adopt child sensitive migration policies. It also promotes international legal obligations in relation to the rights of the child, and upholds the principle of the best interests of the child at all times.</p>
<p>The principle of the best interest of the child was first set out in an international treaty 30 years ago in the <a href="https://www.ohchr.org/en/professionalinterest/pages/crc.aspx">United Nations Convention on the Rights of the Child</a>. It was reiterated in the <a href="http://www.achpr.org/files/instruments/child/achpr_instr_charterchild_eng.pdf">African Charter on the Rights and Welfare of the Child</a>. South Africa is party to both these treaties. In addition, the <a href="http://www.justice.gov.za/legislation/constitution/SAConstitution-web-eng.pdf">South African Constitution</a> provides that: </p>
<blockquote>
<p>a child’s best interests are of paramount importance in every matter concerning the child.</p>
</blockquote>
<p>A child is defined as anyone below the age of 18.</p>
<p>The right-holder in the bill of rights in the Constitution, is with few exceptions “everyone”. Clearly this includes not only South African citizens but everyone who is in the country. Most rights are not absolute and may be limited under section 36 </p>
<blockquote>
<p>in terms of law of general application to the extent that the limitation is reasonable and justifiable in an open and democratic society based on human dignity, equality and freedom. </p>
</blockquote>
<p>The Immigration Act is a “law of general application”. However, the child’s best interest is “of paramount importance”. </p>
<p>In my view, the rights of children to basic education and affordable health care in South Africa can’t be limited and “everyone” must be read to include every child, irrespective of their immigration status. When it comes to access to health care the situation is even clearer as there are no limitations set out in the country’s laws. The Uniform Patient Fee Schedule should therefore be revised to provide for subsidised health care for all children whose guardians cannot afford medical insurance.</p><img src="https://counter.theconversation.com/content/112707/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Magnus Killander receives funding from the National Research Foundation. </span></em></p>South Africa is violating its own Constitution, and international obligations when it comes to undocumented children.Magnus Killander, Professor, Centre for Human Rights in the Faculty of Law, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1089772018-12-21T16:49:43Z2018-12-21T16:49:43ZCelebrating solutions that chip away at big problems: 3 essential reads<figure><img src="https://images.theconversation.com/files/251644/original/file-20181219-45394-rklicz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">No longer tangled and pointing in the right direction</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/thinking-about-structuring-business-process-solutions-1028847439">turgaygundogdu/Shutterstock.com</a></span></figcaption></figure><p><em>Editor’s note: As we come to the end of the year, Conversation editors take a look back at the stories that – for them – exemplified 2018.</em></p>
<p>Slowing the pace of climate change, increasing access to health care and comprehensively covering the news are very different but worthy goals with some things in common. </p>
<p>One is gridlock. The <a href="https://www.cnn.com/2018/12/10/world/climate-change-us-coal-cop24/index.html">nation’s leaders</a> are <a href="https://www.cbpp.org/sabotage-watch-tracking-efforts-to-undermine-the-aca">doing little</a> to <a href="http://www.governing.com/topics/politics/gov-trump-cuts-public-radio-broadcasting-rural-lc.html">solve these problems</a>.</p>
<p>Another is sticker shock: Holding the line at <a href="https://www.nationalgeographic.com/environment/2018/10/ipcc-report-climate-change-impacts-forests-emissions/">2 degrees Celsius</a> of global warming – <a href="https://www.sciencenews.org/article/global-warming-limit-degrees-ipcc-climate-change">or less</a> – would cost trillions of dollars and require <a href="https://www.wri.org/publication/transforming-agriculture-climate-resilience-framework-systemic-change">systemic change</a>. The same goes for securing adequate <a href="https://www.politifact.com/truth-o-meter/article/2017/jul/21/how-expensive-would-single-payer-system-be/">medical treatment</a> for <a href="https://www.thebalance.com/how-does-health-insurance-work-3306069">all Americans</a>. <a href="https://www.knightfoundation.org/public-media-white-paper-2017-levin">Reporting the news</a> costs billions, but nobody knows how to <a href="https://doi.org/10.1080/21670811.2016.1246373">pay that tab</a> either.</p>
<p>To see how disheartening this is, search the internet for the terms “<a href="https://350.org/overcoming-despair/">climate change</a>,” “<a href="https://www.boswellbooks.com/book/9781595985941">health care</a>” or “<a href="https://www.cjr.org/analysis/crisis-of-trust-inside-newsrooms.php">newsrooms</a>” and “despair.” You’ll generate hundreds of thousands of hits or more.</p>
<p>That’s why I like to pause, especially at the year’s end, to celebrate innovations and encouraging trends that chip away at huge challenges.</p>
<h2>1. Bypassing drug shortages</h2>
<p>For example, the emergence of <a href="https://theconversation.com/nonprofit-drugmaker-civica-rx-aims-to-cure-a-health-care-system-ailment-104744">Civica Rx</a> is encouraging. The nonprofit generic drugmaker, which launched in 2018, will soon begin producing 14 hospital-administered generics. Most of them are too scarce to meet demand. </p>
<p>The venture has not disclosed its business model. But “should it choose to do so, Civica Rx could theoretically set the price at or near the cost of production,” writes <a href="https://scholar.google.com/citations?user=ckOu9WsAAAAJ&hl=en">Stacie B. Dusetzina</a>, a Vanderbilt University health policy and cancer scholar. That would make a big difference in a country where pharmaceuticals can sell for <a href="https://www.vox.com/science-and-health/2016/11/30/12945756/prescription-drug-prices-explained">triple what they cost elsewhere</a>.</p>
<p><iframe id="CMBR7" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/CMBR7/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>If Civica Rx succeeds at making treatment in hospitals cheaper and better, there will be fewer excuses for not fixing the rest of the health care system’s broken pieces. </p>
<h2>2. Scrapping emissions</h2>
<p>Just as Civica Rx makes it possible to feel more optimistic about the future of U.S. health care, the industrial-scale repurposing of steel and aluminum holds promise regarding climate change.</p>
<p><a href="https://www.isri.org/recycling-commodities/recycling-industry-yearbook">Scrap metal gets recycled</a> the way cans and boxes from <a href="https://www.citylab.com/city-makers-connections/recycling/">your household</a> do, only on a bigger scale. <a href="https://theconversation.com/how-recycling-more-steel-and-aluminum-could-slash-imports-without-a-trade-war-97766">Repurposing metal</a> from demolished buildings and nonroadworthy cars saves money, tempers landfill problems and uses much less energy than starting from scratch.</p>
<p>Because the process requires less power, it “has a much-smaller carbon footprint,” explains <a href="https://scholar.google.com/citations?user=4XQeuikAAAAJ&hl=en&oi=ao">Daniel Cooper</a>, a University of Michigan mechanical engineer. “The greenhouse gas emissions for recycling steel are around one-quarter of what they are for making new steel, and recycling aluminum cuts emissions by more than 80 percent.”</p>
<p><iframe id="fX2LY" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/fX2LY/10/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Granted, <a href="https://www.nbcwashington.com/news/business/US-Struggles-With-What-to-Do-With-Tons-of-Recycled-Material-489971551.html">China’s unwillingness to import</a> as much American junk as it used to due to <a href="https://waste-management-world.com/a/tariffs-creating-more-problems-than-they-solve-for-metal-recyclers">trade tensions</a> is disrupting global scrap markets.</p>
<p>But the U.S. could potentially use all of steel and aluminum it throws out right here, Cooper contends. That would cut down on emissions even more by bypassing the <a href="https://theconversation.com/cargo-ships-are-emitting-boatloads-of-carbon-and-nobody-wants-to-take-the-blame-108731">carbon released into the atmosphere from hauling cargo</a> across oceans.</p>
<h2>3. Teaming up between newsrooms</h2>
<p>The traditional way to cover the news is inefficient. Many journalists often report on the same events and scandals, working in isolation and duplicating efforts. </p>
<p>That’s starting to change, observes <a href="https://scholar.google.com/citations?user=n_3ICpcAAAAJ&hl=en&oi=sra">Magda Konieczna</a>, an assistant professor of journalism at Temple University. </p>
<p>A growing number of news organizations “are sharing their high-quality journalism with other outlets,” she explains. “By teaming up, they can inform bigger audiences about the problems like corruption, environmental dangers and abusive business practices.”</p>
<p>Most of the time, the <a href="https://theconversation.com/nonprofit-newsrooms-are-reaching-bigger-audiences-by-teaming-up-with-other-outlets-102293">sharing involves news nonprofits</a> without big audiences, Konieczna finds. This collaborative approach helps “elevate the quality of the media where people are already going for news: newspapers and newscasts, whether directly or through Facebook and Twitter.”</p><img src="https://counter.theconversation.com/content/108977/count.gif" alt="The Conversation" width="1" height="1" />
Fixes for small pieces of massive problems show that overarching crises may be less hopeless than they appear.Emily Schwartz Greco, Philanthropy + Nonprofits Editor, The ConversationLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/921352018-02-28T13:47:50Z2018-02-28T13:47:50ZHealthy outrage: the story of a pioneer of community healthcare in South Africa<figure><img src="https://images.theconversation.com/files/207736/original/file-20180224-108125-15qi4hz.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A younger Dr Trudy Thomas engaging with a community in St Mathews en route to visit a clinic. </span> <span class="attribution"><span class="source">Supplied</span></span></figcaption></figure><p><em>Healthy Outrage</em> is an apt title for a story that describes the journey Dr Trudy Thomas travelled during the various stages of her life. Thomas was the pioneer of community health programmes in South Africa. Her work spanned more than half a century, stretching through the dark years of apartheid and into the democratic era when she was asked to run the department of health in the Eastern Cape province after the 1994 elections.</p>
<p>Thomas entered the public health arena at a time when <a href="http://www.sajbl.org.za/index.php/sajbl/article/view/216/194">health services were heavily skewed</a> towards white people under the apartheid government. This meant that resources were disproportionately allocated by the state and the vast majority of black South Africans received poor quality and inferior services. </p>
<p>In 1994 the dawn of democracy brought the constitutional promise of healthcare for all. But the optimism of the time was soon to wear thin: for Thomas too. Even before the new government’s first term was up, she had begun to express her disdain at the deterioration of healthcare.</p>
<p>And two decades later the public health care system remains in shambles. In the Eastern Cape, the health care system has collapsed. A report <a href="https://www.timeslive.co.za/news/south-africa/2013-09-12-health-report-brings-tears-to-judges-eyes/">released by the human rights lobby group Section 27</a> revealed severe doctor shortages, a lack of ambulances and hospitals without water or essential equipment. Thomas contributed to the report when it was researched. </p>
<p>In <em>Healthy Outrage</em>, she describes how many of her experiences, particularly as a doctor dealing largely with children, provoked outrage. But her response was a “healthy” and constructive one. When faced with a problem she would sum up the key issues and then to go about addressing them, often with very limited resources. </p>
<p>The book is well written and is a fascinating read about one of the relatively unsung South African heroes of the past half-century. One of its main messages is how, with relatively few resources, a few people with integrity, commitment and hard work can achieve so much.</p>
<h2>Her story</h2>
<p>Thomas was born in 1936 and describes her early life of growing up in a working class family in Krugersdorp where her father was a miner on the gold mines. She excelled at school and went on to study medicine at the University of the Witwatersrand.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/207738/original/file-20180224-108150-i1upw8.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/207738/original/file-20180224-108150-i1upw8.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=882&fit=crop&dpr=1 600w, https://images.theconversation.com/files/207738/original/file-20180224-108150-i1upw8.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=882&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/207738/original/file-20180224-108150-i1upw8.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=882&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/207738/original/file-20180224-108150-i1upw8.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1108&fit=crop&dpr=1 754w, https://images.theconversation.com/files/207738/original/file-20180224-108150-i1upw8.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1108&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/207738/original/file-20180224-108150-i1upw8.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1108&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Receiving an honorary doctorate from Rhodes University.</span>
</figcaption>
</figure>
<p>She soon struck up a relationship with Ian Harris. After they’d completed their studies they got married and went on to do their internships at what is now Chris Hani Baragwanath Academic Hospital in Johannesburg. </p>
<p>This proved to be a valuable preparation for the next phase of their lives as they learned practical skills in most areas of medicine. Thomas was struck by the enormous burden of preventable diseases that she saw in children, both infectious and nutrition related. </p>
<p>During this time <a href="http://www.sahistory.org.za/topic/sharpeville-massacre-21-march-1960">the Sharpeville massacre</a> took place and many of the injured were brought to Baragwanath Hospital where she was part of the team treating them. This had an important influence on her political outlook.</p>
<p>She and her husband moved to a remote health facility called St Matthews Mission in the Eastern Cape where they took over as the medical team. Thomas concentrated on the children’s ward; her training at Baragwanath Hospital stood her in good stead.</p>
<h2>Serving the community</h2>
<p>Thomas put enormous energy into travelling throughout the community providing primary health care. </p>
<p>She had very limited resources but used them to maximum effect with the full buy-in of the community. As she states in her book, this was community outreach long before the term was coined. It was only in 1978 that an International Conference on Primary Health Care in the Soviet Union led to the well known <a href="http://www.who.int/social_determinants/tools/multimedia/alma_ata/en/">Declaration of Alma Ata</a> which emphasised that effective primary care is fundamental to the health and well-being of any community. Thomas was well ahead of her time.</p>
<p>In 1974, the family moved to East London and it was here that Thomas’s political profile developed further. She got involved with the human rights organisation, the <a href="https://www.blacksash.org.za/index.php/our-legacy/our-history">Black Sash</a>, and also struck up a solid relationship with the charismatic black consciousness leader <a href="http://www.sahistory.org.za/people/stephen-bantu-biko">Steve Biko</a> and his immediate family and associates. </p>
<p>I first met Thomas in 1976 while working at Cecilia Makiwane Hospital in what was then the Ciskei homeland. As a young doctor, I was enormously impressed with her clear views on how primary healthcare and community health complemented curative hospital care.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/208011/original/file-20180227-36696-1pgiddv.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/208011/original/file-20180227-36696-1pgiddv.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=823&fit=crop&dpr=1 600w, https://images.theconversation.com/files/208011/original/file-20180227-36696-1pgiddv.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=823&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/208011/original/file-20180227-36696-1pgiddv.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=823&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/208011/original/file-20180227-36696-1pgiddv.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1035&fit=crop&dpr=1 754w, https://images.theconversation.com/files/208011/original/file-20180227-36696-1pgiddv.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1035&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/208011/original/file-20180227-36696-1pgiddv.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1035&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p>Thomas was put in charge of community health at the hospital and its 14 clinics. Despite her political opposition to the homeland policy she typically decided to make the most of the situation. For example, she coordinated an immunisation campaign that virtually eliminated measles in the region in the early 1980s, something the country hasn’t managed to achieve 35 years later.</p>
<h2>At the helm</h2>
<p>Thomas was full of hope and optimism when the first democratically elected government took over in 1994 and, somewhat to her surprise, was appointed to run the provincial health department in the Eastern Cape.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/207737/original/file-20180224-108113-8vklv3.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/207737/original/file-20180224-108113-8vklv3.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=384&fit=crop&dpr=1 600w, https://images.theconversation.com/files/207737/original/file-20180224-108113-8vklv3.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=384&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/207737/original/file-20180224-108113-8vklv3.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=384&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/207737/original/file-20180224-108113-8vklv3.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=482&fit=crop&dpr=1 754w, https://images.theconversation.com/files/207737/original/file-20180224-108113-8vklv3.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=482&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/207737/original/file-20180224-108113-8vklv3.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=482&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Eastern Cape Health MEC Dr Trudy Thomas with then president Nelson Mandela at the opening of the Umtata Academic Hospital.</span>
</figcaption>
</figure>
<p>As one of the poorest provinces in the country, the challenge of developing an integrated and effective health system was enormous. She travelled the length and breadth of the province and achieved a great deal. </p>
<p>But her honesty and inability to toe the party line eventually led her into political disfavour and she was not appointed to a second term in 1999.</p>
<p>This didn’t stop her. She took up the fight against HIV and AIDS. She resigned from the African National Congress because of the government’s <a href="https://www.timeslive.co.za/sunday-times/opinion-and-analysis/2016-05-08-dear-mbeki-now-is-the-time-to-apologise-for-aids-denialism/">attitude</a> to HIV and AIDS but continued to set up structures to assist and support AIDS orphans.</p><img src="https://counter.theconversation.com/content/92135/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Cooper received funding in the past for contract research from companies for research on nutrition and antibiotics. He also received funding from the SA Medical Research Council. None are related to this review.</span></em></p>The tale of an unsung South African hero in the field of community health.Peter Cooper, Professor Emeritusin the Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/886822017-12-11T11:51:15Z2017-12-11T11:51:15ZThere’s more to evidence-based policies than data: why it matters for healthcare<figure><img src="https://images.theconversation.com/files/197968/original/file-20171206-926-sjv2uv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A nurse weighs a baby at a clinic in Accra, Ghana. </span> <span class="attribution"><span class="source">Kate Holt/MCSP</span></span></figcaption></figure><p>A critical part of reaching the <a href="https://sustainabledevelopment.un.org/sdg3">United Nation’s Sustainable Development Goals</a> in 13 years’ time is to ensure that everyone can access equitable and affordable healthcare – more commonly known as universal health coverage.</p>
<p>The idea of “Health for All” was first put on the global agenda in 1978 at the <a href="http://www.who.int/publications/almaata_declaration_en.pdf">International Conference on Primary Health Care at Alma Ata</a>. It called for primary health care to be introduced as the first step to making sure that everyone has access to health care.</p>
<p>Since then, primary healthcare has been a feature of health systems across the world. But 40 years later, universal health coverage remains a challenge. About 400 million people <a href="http://www.who.int/mediacentre/factsheets/fs395/en/">do not have access to one or more essential health services</a>. This is because they are too far, too expensive, of low quality or non-responsive to patient needs. </p>
<p>The big question is: how can countries strengthen their health systems to deliver accessible, affordable and equitable care when they are often under-financed and governed in complex ways? </p>
<p>One answer lies in governments developing policies and programmes that are informed by evidence of what works or doesn’t. This should include what we would call “traditional data”, but should also include a broader definition of evidence. This would mean including, for example, information from citizens and stakeholders as well as programme evaluations. In this way, policies can be made more relevant for the people they affect. </p>
<p>Globally there is an increasing appreciation for this sort of policymaking that relies of a broader definition of evidence. Countries such as South Africa, Ghana and Thailand provide good examples.</p>
<h2>What is evidence?</h2>
<p>Using evidence to inform the development of health care has grown out of the use of science to choose the best decisions. It is based on data being collected in a methodical way. This approach is useful but it can’t always be neatly applied to policymaking. There are several reasons for this.</p>
<p>The first is that there are many different types of evidence. Evidence is more than data, even though the terms are often used to mean the same thing. For example, there is statistical and administrative data, research evidence, citizen and stakeholder information as well as programme evaluations. </p>
<p>The challenge is that some of these are valued more than others. More often than not, statistical data is more valued in policymaking. But both researchers and policymakers must acknowledge that for policies to be sound and comprehensive, different phases of policymaking process would require different types of evidence. </p>
<p>Secondly, data-as-evidence is only one input into policymaking. Policymakers face a long list of pressures they must respond to, including time, resources, political obligations and unplanned events.</p>
<p>Researchers may push technically excellent solutions designed in research environments. But policymakers may have other priorities in mind: are the solutions being put to them <a href="http://onlinelibrary.wiley.com/doi/10.1111/puar.12475/pdf">practical and affordable?</a> Policymakers also face the limitations of having to balance various constituents while <a href="https://www.nature.com/articles/s41599-017-0046-8">straddling the constraints of the bureaucracies they work in</a>. </p>
<p>Researchers must recognise that policymakers themselves are a source of evidence of what works or doesn’t. They are able to draw on their own experiences, those of their constituents, history and their contextual knowledge of the terrain. </p>
<p>What this boils down to is that for policies that are based on evidence to be effective, fewer ‘push/pull’ models of evidence need to be used. Instead the models where evidence is jointly fashioned should be employed.</p>
<p>This means that policymakers, researchers and other key actors (like health managers or communities) must come together as soon as a problem is identified. They must first understand each other’s ideas of evidence and come to a joint conclusion of what evidence would be appropriate for the solution. </p>
<p>In South Africa, for example, <a href="https://www.odi.org/publications/10603-evidence-and-policy-south-africa-s-department-environmental-affairs">the Department of Environmental Affairs</a> has developed a four-phase process to policymaking. In the first phase, researchers and policymakers come together to set the agenda and agree on the needed solution. Their joint decision is then reviewed before research is undertaken and interpreted together. </p>
<h2>Joint efforts</h2>
<p>Integrating research into government policies and programmes can result in meaningful engagement between policymakers, researchers and other actors. </p>
<p>Increasingly, governments and researchers are partnering in various ways to ensure that research can feed into the policymaking process as results emerge. In this way, policymakers are part of the research design as well as the actual research and its interpretation, – known as embedded research. </p>
<p>Ghana’s <a href="http://www.ghanahealthservice.org/chps/category.php?chpscid=98">community-based Health Planning and Services</a> is a good example. By embedding the research in the Ghana Health Service, what started as a pilot in one part of Northern Ghana became national policy in 2005 to improve primary health care. </p>
<p>As part of scale-up efforts, policymakers, health managers and academic researchers worked hand-in-hand to design studies and analyse routine data to improve the programme. </p>
<p>Today the service is a key part of Ghana’s universal health coverage strategy. And importantly the primarily rural model is being adapted for urban areas. </p>
<h2>The journey to accessible health care</h2>
<p>As the Ghana example shows, when there is collaboration between governments and researchers, good results are achievable. This means focusing on long-term engagement and building a comprehensive view of evidence. </p>
<p>When evidence is better sourced and better understood, it can be deployed more effectively. This means that there should be investment in people who are at the front line of finding solutions and implementing change.</p>
<p>Policymakers, researchers, practitioners and communities need to come together to share their understanding of what evidence means, and how it can be used to strengthen health systems. This will help us chart a course to achieving universal health coverage.</p><img src="https://counter.theconversation.com/content/88682/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Aku Kwamie does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>For healthcare to be accessible, affordable and equal, policies and programmes that promote universal health coverage need to be based on evidence.Aku Kwamie, Health systems researcher, University of GhanaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/797682017-06-22T15:04:41Z2017-06-22T15:04:41ZWhy competition is key to cutting the cost of cancer drugs in South Africa<figure><img src="https://images.theconversation.com/files/175155/original/file-20170622-11971-1xbml5b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Shutterstock</span> </figcaption></figure><p>South Africa’s Competition Commission has launched an <a href="http://www.gov.za/speeches/media-statement-commissioner-investigation-manufacturers-cancer-drugs-13-jun-2017-0000">investigation</a> into excessive pricing by three major pharmaceutical companies that have the sole rights to distribute cancer drugs in the country. </p>
<p>The commission’s job is to protect ordinary South Africans from abuse by dominant players. It has <a href="http://www.compcom.co.za/">powers</a> to investigate and evaluate restrictive business practices, abuse of dominant positions and mergers. </p>
<p>Its investigation into the drug companies is vital as cancer treatment is <a href="http://www.cansa.org.za/competition-commission-investigating-pharmaceutical-companies-for-cancer-medicine-prices/">unaffordable for most South Africans</a>. Many medical schemes – which offer medical cover to 16% of the population or 7 million people – refuse to pay for the medication because of the cost. </p>
<p>In South Africa all drug prices are approved and signed off by the medicines pricing committee in the National Department of Health. But our hope is that the commission’s investigation could still drive competition among suppliers, and in turn more affordable prices for cancer treatment. This should result in better access to affordable drugs, particularly for poor people.</p>
<h2>The drugs in question</h2>
<p>Three companies are being probed: Swiss-based <a href="http://www.roche.co.za/home/about-roche/companyprofile.html">Roche</a>, US-based Pfizer and South African company Aspen Pharmacare.</p>
<p>The cancer drugs in the spotlight are used mainly to treat lung and breast cancer but they can also be used in the treatment for other types of cancers.</p>
<p>One of the drugs is trastuzumab which is supplied by Roche and <a href="http://www.who.int/bulletin/volumes/94/10/15-163998/en/">recommended</a> by the World Health Organisation to treat breast cancer and can be used in combination with other drugs for some types of stomach cancer. Roche’s branded versions of the medication is Herceptin. This is the only trastuzumab product currently available in South Africa.</p>
<p>Pfizer provides the only crizotinib product to South Africa for the treatment of lung cancer. Its product, Xalkori, is not yet registered in South Africa, and is only accessed through a special application process under the Medicines Act which enables clinicians to prescribe and use medicines not yet registered by the MCC to treat patients.</p>
<p>Aspen is being investigated for three of the oncology drugs it supplies: Chlorambucil (Leukeran), Melphalan (Alkeran) and Busulfan (Myleran). All are generic drugs but Aspen is the only pharmaceutical company in the country that’s registered with the Medicines Control Council to sell the drugs in South Africa.</p>
<p>Competition authorities in a number of European countries, including the European Union, are also <a href="http://europa.eu/rapid/press-release_MEX-17-1326_en.htm">investigating Aspen</a> for alleged excessive pricing on these and other products. </p>
<h2>Why are they so expensive?</h2>
<p>The cost of a drug is related to its development. Before a cancer drug reaches the market there is a complex clinical research process and an expensive administrative process that requires millions of dollars of investment. This includes regulatory studies and three phases of clinical trials. </p>
<p>In the pharmaceutical industry, the initial patent holder is usually the pharmaceutical company that researched and developed a drug . </p>
<p>Although the patent life from the date that it is filed is 20 years, the average time to bring a cancer drug from the start of clinical testing to regulatory approval is between eight and 12 years. </p>
<p>This means that the actual patent life of a drug from the time of initial marketing can be limited – often less than 10 years. In addition, only 16% to 19% of cancer drugs that enter clinical trials successfully make it to market.</p>
<p>There’s an added challenge in cancer treatments. Even with the arrival of “new and improved” versions of a previously approved drug, the older (and by now generic) drug tends to be viewed as substandard treatment. This perpetuates the situation. And in the last 59 years the health sector has increased its knowledge of cancer and treatment immensely. But it’s not yet at a curative phase. Faced with the seriousness of the diagnosis, patients, family and physicians are often willing to pay the high price of treatment even for marginal improvements in someone’s health.</p>
<p>Drug companies also have to go through a lengthy process before they can start selling a drug. Once a drug is approved by a regulatory authority it needs to be registered with a country’s medical control council before it can be prescribed by oncologists. This registration process can take a long time. </p>
<h2>What needs to be done</h2>
<p>The biggest problem with the price of cancer drugs is that there is no competition among truly effective cancer drugs to lower their cost. Healthy competition between different drugs would drive lower prices and keep prices reasonable for the consumer.</p>
<p>One way that competition has been achieved for other pharmaceutical drugs has been through the generic route. Once the patent expires, manufacturers of generic versions can produce more cost-effective versions. This is happening for some cancer drugs. But there are two limitations: one is that it takes a long time to develop cancer treatments. And generic versions of cancer drugs are much higher than those used to treat non-malignant (non-cancerous) diseases. </p>
<p>So what can be done? There are three options:</p>
<ul>
<li><p>encourage oncologists to prescribe drug treatment that isn’t as expensive,where possible. </p></li>
<li><p>reduce prices by introducing a form of generic price control, where predetermined pricing limits are prescribed, and </p></li>
<li><p>promoting a non-profit generics model, where certain designated generics would be made available at cost, as opposed to be sold at a profit.</p></li>
</ul>
<p>The competition case in South Africa is also an important part of the campaign to make sure that cancer drugs are more affordable. As incidence of cancer <a href="http://www.cansa.org.za/category/recent-posts/cope-with-cancer/about-cancer/statistics/">continue to rise</a>, massive resources are being poured into cutting-edge research and biotechnology to successfully treat this dread disease. But these benefits aren’t being felt by the vast majority of people in the world.</p><img src="https://counter.theconversation.com/content/79768/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Natalie Schellack does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The high cost of cancer drugs in South Africa has come under the spotlight with an investigation by the Competition Commission in the country.Natalie Schellack, Associate Professor and Course Leader: Post Graduate Programmes in Clinical Pharmacy in the Department of Pharmacy, Sefako Makgatho Health Sciences UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/745872017-04-28T01:51:12Z2017-04-28T01:51:12ZThe patients we do not see<figure><img src="https://images.theconversation.com/files/167035/original/file-20170427-15097-qum4s3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An empty wheelchair – or is there a person there we do not see?</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/wheelchair-241479589?src=db1N4Q-k6RxRNBvcOjFW0w-1-35">From www.shutterstock.com </a></span></figcaption></figure><p>In medicine, we speak of “seeing patients” when we are rounding in the hospital or caring for those who come to our clinics. But what about those people who may be sick but do not seek care? What is our responsibility to the patients we do not see?</p>
<p>This question takes on greater urgency in the current political climate, as patients face the threat of losing health insurance. <a href="http://www.vox.com/policy-and-politics/2017/4/26/15437560/ahca-house-moderates-freedom-caucus">Renewed efforts</a> to repeal and replace the Affordable Care Act leave millions wondering whether they will be covered.</p>
<p>For me, as a physician practicing in the safety net, abstract numbers evoke the very real stories of my uninsured patients. One of my patients, whom I’ll call Elsa, had not seen a doctor since immigrating to the United States 15 years ago. That abruptly changed one morning: She awoke to find the room spinning around her and, terrifyingly, she could not articulate the words to explain to her husband what was going on. She was having a stroke. </p>
<p>There are many reasons that patients like Elsa may not seek care – until they have no choice. Although she felt no symptoms before her stroke, Elsa was one of about <a href="https://www.cdc.gov/features/undiagnosed-hypertension/">13 million U.S. adults with undiagnosed high blood pressure</a>. I wondered if making her aware of her blood pressure would have been enough to avoid her suffering. </p>
<p>But even if high blood pressure may sit atop the list of problems I write out, from his or her perspective it may not crack the top five. Food security, job stability, child care and affordable housing understandably feel more urgent. Time and again, I have learned that taking care of my patients starts by trying to walk a mile in their shoes.</p>
<h2>Why patients may not seek care</h2>
<p>Sometimes, forgoing care is a symptom of social isolation. I asked another patient of mine – whom I had recently diagnosed with uncontrolled, likely longstanding diabetes – about his eating habits. I learned that in his routine, he would go for days at a time without interacting with another person; he did not have any family nearby and worked from his home computer. </p>
<p>Aside from deterring access to care, loneliness and social isolation have direct effects on health. One <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000316">review of 148 studies</a> showed that the influence of social relationships on the risk of death was comparable with risk factors such as obesity and alcohol use.</p>
<p>In other cases, the health care system must take responsibility for barriers to patients that we ourselves erect. Beyond costs, structural barriers include inadequate language interpretation services and the assumption of health literacy when conveying information. Meanwhile, <a href="https://www.ncbi.nlm.nih.gov/books/NBK220343/">historical inequities often underlie wary attitudes</a> toward health care.</p>
<p>Dr. Mary Bassett, the health commissioner of New York City, <a href="http://www.huffingtonpost.com/entry/racism-as-cause-of-poor-health_us_581a1376e4b01a82df6406d6">has spoken plainly</a> about this: “We must explicitly and unapologetically name racism in our work to protect and promote health…We must deepen our analysis of racial oppression, which means remembering some uncomfortable truths about our shared history.” </p>
<p>In the same vein, new immigration policies may have <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1700829">a chilling effect</a> on the willingness of people like Elsa to see a doctor, if they perceive negative repercussions for themselves or their families.</p>
<p>Many patients with the greatest unmet needs are therefore marginalized, with only glancing interactions with the health system – or none at all, in the most wrenching cases of suicide, drug overdose and other chronic illnesses that end in catastrophe.</p>
<p>When they do seek care, it is sporadic. They may show up in the ER, but not to a primary care follow-up appointment. If an ensuing phone call goes unanswered, or their phone is out of service, we label them as “<a href="https://www.ncbi.nlm.nih.gov/pubmed/22493465">lost to follow-up</a>” and move on to the next patient on the list. </p>
<h2>What needs to change</h2>
<p>Doing better by these patients will require moving the locus of accountability for health further into communities. It means <a href="http://healthaffairs.org/blog/2016/04/11/milestones-on-the-path-to-population-health/">bringing more of a public health mindset</a> to health care; that is, not reflexively restricting our purview to those who happen to cross our clinic’s threshold. </p>
<p>Hospitals and health systems must have the humility to reach across boundaries and partner with local institutions that are sometimes more trusted, and often more relevant, in people’s daily lives, including churches, schools, food pantries and parks. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/167040/original/file-20170427-15086-kl53hi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/167040/original/file-20170427-15086-kl53hi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=391&fit=crop&dpr=1 600w, https://images.theconversation.com/files/167040/original/file-20170427-15086-kl53hi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=391&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/167040/original/file-20170427-15086-kl53hi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=391&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/167040/original/file-20170427-15086-kl53hi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=491&fit=crop&dpr=1 754w, https://images.theconversation.com/files/167040/original/file-20170427-15086-kl53hi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=491&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/167040/original/file-20170427-15086-kl53hi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=491&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Librarian Joan Limbert is shown in this 2013 file photo from a Spring, Texas library. The library was one of hundreds across the country where people could sign up for insurance coverage in the health care exchanges.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/Search?query=health+care+in+library&ss=10&st=kw&entitysearch=&toItem=15&orderBy=Newest&searchMediaType=excludecollections">David J. Phillip/AP</a></span>
</figcaption>
</figure>
<p>In one recent example, the 54 branches of the Free Library of Philadelphia <a href="http://content.healthaffairs.org/content/35/11/2030.abstract">were shown to be vital community nodes</a> for health-related services like literacy programs, healthy eating initiatives, job fairs and food preparation courses. Public libraries are particular safe havens for those experiencing mental illness, substance use disorders and homelessness – as well as youth and recent immigrants. We should consider how the these locations are therefore already a part of our health ecosystem.</p>
<p>Doctors and other clinicians may balk at trying to take care of the patients we do not see. After all, with the harried pace set by the <a href="http://khn.org/news/15-minute-doctor-visits/">15-minute office visit</a>, it is hard enough to keep up with the patients we do see. But the goal is not to schedule doctor’s appointments for all library-goers, but rather to equip them to be better stewards of their own health, which sometimes involves health care providers, sometimes not. While physicians can’t do it alone, we can lend our voices to those calling for greater outreach, less stigma and protection of the most vulnerable. </p>
<h2>Prevention, not regression</h2>
<p>In Elsa’s case, when she had her stroke, she was rushed to the ER and received excellent care from the hospital team. Neurologists treated the blocked vessels in her brain and diagnosed her with a narrowed heart valve and high blood pressure. </p>
<p>As a doctor in a system that accepts all patients, regardless of ability to pay, I was proud to be a part of her follow-up care. She underwent heart valve surgery, and we put her on blood thinners and blood pressure medicines to reduce her risk of another stroke. Her rehabilitation, all things considered, was going well. The health care system had reacted to Elsa’s crisis with swift competence.</p>
<p>At our last clinic visit, my mind turned to what could have been done to prevent her stroke. But the chances to intervene were too few. She and her husband made a living as bottle-pickers; they spent hours every day sifting through trash for bottles to recycle. Elsa told me they made enough money to get by, since they lived with her nephew. But visiting me in clinic, not to mention a cardiologist, neurologist and physical therapist, cost her time and thus cash. </p>
<p>And so for every Elsa who walks into our clinic I know there is another patient we do not see. </p>
<p>With health coverage for millions of Americans in limbo, we must speak out and organize just to keep seeing the many patients who have been newly brought into care. And at the same time, we must develop better ways to find and support people like Elsa – even before we see them as patients.</p><img src="https://counter.theconversation.com/content/74587/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr. Chokshi is a physician and health system executive at New York City Health + Hospitals.</span></em></p>For many of the nation’s poor, food and shelter are more important than health care. Questions of insurance coverage loom broadly, but another question lingers: how to treat the poor we do not see.Dave A. Chokshi, Physician, New York UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/701062017-02-07T15:43:53Z2017-02-07T15:43:53ZSouth Africa’s child support grant should start in pregnancy. Here’s why<figure><img src="https://images.theconversation.com/files/155160/original/image-20170201-12656-xiuhgo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Pregnancy and childbearing reduces women’s income-generating potential and introduces a host of new expenses. These include needing to eat well and the cost of transport to access antenatal services.</p>
<p>Poor women find it difficult to meet these additional costs, which is why many countries provide grants to mitigate the impact of poverty during pregnancy.</p>
<p>South Africa’s child support grant has been hailed as one of its most successful national <a href="https://theconversation.com/south-africa-does-child-support-grants-well-but-not-other-welfare-services-64696">poverty alleviation strategies</a>. It has significantly <a href="https://www.unicef.org/southafrica/SAF_resources_csg2012findings.pdf">improved the lives of young children</a>. But the country has yet to consider extending support grants to women who are pregnant. The fact that South Africa does not distribute a pregnancy grant means irreversible but avoidable damage to children and mothers from poor families is not addressed. </p>
<p><a href="http://www.samj.org.za/index.php/samj/article/view/11604/7752">Our study</a> looked at pregnancy support grants in 27 countries to see what South Africa could learn about implementing similar programmes.</p>
<p>Based on the experiences of countries at similar levels of development we concluded that introducing pregnancy support grants to women in South Africa would improve health outcomes for babies and mothers. They would help women access interventions that improve health and nutrition during pregnancy. This in turn would reduce stillbirths and infant deaths, and improve the growth of children from the foetal period through the first year. </p>
<h2>How other countries work</h2>
<p>Several countries that are considered to be less well off than South Africa provide pregnancy support to mothers-to-be. Their programmes show three benefits for these mothers and their children. </p>
<p>Firstly, it has encouraged women to get access to health care facilities during their pregnancies. Poor attendance is still a key cause of maternal and infant deaths globally. In South Africa, about one in 10 women do not attend health services during pregnancy and one in 20 deliver without trained personnel. </p>
<p>Eight of the studies showed an increase in the number of women accessing health services. Grants distributed to pregnant women in Cambodia acted as an incentive for them to visit health care centres. And in Peru, for example, there was a 65% increase in the number of women who accessed care. </p>
<p>Secondly, grants help women deliver their babies in health facilities rather than at home with a traditional birth attendant. In Bangladesh, hospital births rose more than three fold after grants were introduced.</p>
<p>The third effect the grants had was that they reduced poverty and food insecurity by mitigating the intergenerational effects of poverty. The health and development of a generation improved as a result of the grant. Their long-term accumulation of social and economic capital increased which in turn enhanced the next generations’ life chances. </p>
<h2>Misguided view</h2>
<p>In South Africa the child support grant is given to 12 million guardians of children under the age 18. They receive about US$ 27 (R360) a month. </p>
<p>The grant has been distributed since 1996. It was initially only for children younger than five but eligibility has progressively expanded to older children over time. </p>
<p>But the existing grant is inadequate because it fails to undo the harms of maternal deprivation during pregnancy. </p>
<p>The government’s reluctance to begin the grant in pregnancy might be based on the view – commonly held in the broader society – that it would encourage women to become pregnant. </p>
<p>This is a misguided belief. <a href="http://dx.doi.org/10.2307/799658">Several studies</a> have shown that child support grants do not induce poor women to become pregnant. Instead, according to the research, women spend the money on food, transport to health facilities and preparations for the child. They don’t spend the grant on <a href="http://www.jstor.org/stable/2134493?origin=crossref&seq=1#page_scan_tab_contents">luxury goods</a>.</p>
<p>There are several ways that the South Africa’s government’s concerns could be addressed. For example:</p>
<ul>
<li><p>the policy could allow women to receive the grant for only their first two pregnancies,</p></li>
<li><p>the grant could be given only to pregnant women over the age of 19.</p></li>
</ul>
<p>Women who fell pregnant before they turn 19 would not be eligible for the pregnancy grant but would still qualify for the child support grant after their babies were born.</p>
<p>Over time, as policy makers developed confidence in the policy, the grant could be extended to pregnant women younger than 19 as well as to women with more than two children.</p>
<p>And pregnancy support could automatically become a child support grant once the child was born and a birth certificate or proof of delivery within a health facility was provided.</p>
<h2>Disadvantaged for life</h2>
<p>A pregnancy grant would compensate women for their increased costs, as well as their lost wages during pregnancy and after the baby is born. These costs are generally borne by women, as men in South Africa are very often absent. </p>
<p>In the formal sector this financial burden is covered for women through maternity benefits. But women in the informal sector or those who are unemployed are excluded. South Africa has an unemployment rate of <a href="http://www.gov.za/sites/www.gov.za/files/Status_of_women_in_SA_economy.pdf">29% among women</a>. </p>
<p>Beginning a support grant while women are pregnant means that the critical period before a woman gives birth is covered. Even under the present system women often only access their child support grant a year after their child is born because of processing delays. This is a most critical time in a child’s development.</p>
<p>The child support grant is one of the most effective interventions to enhance child health and development in South Africa but it could be way more effective.</p><img src="https://counter.theconversation.com/content/70106/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Wits University's School of Public Health received funding from the South African Department of Social Department to do background research on the viability of the pregnancy grant.</span></em></p><p class="fine-print"><em><span>Matthew Cherisch does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Across the world many countries issue pregnancy grants to support mothers-to-be. South Africa has a progressive social security grant system, but it does not support this vulnerable group.Matthew Cherisch, Associate Professor at the Wits Reproductive Health & HIV Institute, University of the WitwatersrandSharon Fonn, Professsor of Public Health; Co-Director Consortium for Advanced Research Training in Africa; Panel Member, Private Healthcare Market Inquiry, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/697562017-01-20T02:56:42Z2017-01-20T02:56:42ZRural America matters to all Americans<p>President-elect Donald Trump has nominated former Georgia Gov. Sonny Perdue to lead the Department of Agriculture.</p>
<p>Many Americans may feel like this particular Cabinet nomination doesn’t impact their everyday lives, but that is a misconception. USDA is responsible for areas beyond agriculture, including food, nutrition and rural development. </p>
<p>Rural America is important to all Americans because it is a primary source for inexpensive and safe food, affordable energy, clean drinking water and accessible outdoor recreation.</p>
<p>Almost three-quarters of the United States is considered rural, but <a href="https://www.ers.usda.gov/webdocs/publications/eib162/eib-162.pdf">only 14 percent</a> of the population lives there. As more <a href="http://www.npr.org/2014/10/21/357723069/millennials-continue-urbanization-of-america-leaving-small-town">people have moved away from rural areas</a>, many have lost an understanding or appreciation of what rural communities contribute to the nation. </p>
<p>As an attorney who focuses on agriculture and food law and policies, I’d argue that these communities’ unique challenges are even more dimly understood.</p>
<p>Rural Americans voted in <a href="http://www.politico.com/story/2016/11/hillary-clinton-rural-voters-trump-231266">high numbers</a> and helped propel President-elect Donald Trump to victory. Now, people in rural parts of the country are waiting to see if Trump’s promise to make America great again will include them.</p>
<p>Of course, the administration’s first challenge lies with figuring out what rural areas need. That’s a difficult task because there’s not just one “rural voice,” unified on all issues. Rural communities relying on recreation tourism may support increased environmental regulations while those relying on farming or manufacturing may be opposed. Farmers may support international trade agreements that open markets to crops, while those in manufacturing fear the loss of jobs. The concerns of rural West Virginia will not be the same as those of rural Wyoming.</p>
<p>In nominating Perdue to head the USDA, the key agency charged with supporting rural America, Trump has picked someone with strong agricultural and rural roots. Perdue has years of experience in the agriculture and trade sectors. As governor of Georgia, he oversaw a state in which <a href="https://dch.georgia.gov/sites/dch.georgia.gov/files/related_files/document/Georgia%27s%20Rural%20Counties-Sept%202014.pdf">108 of 159 counties</a> are designated rural because they have populations under 35,000. </p>
<h2>Providing food and energy</h2>
<p>The USDA is the nation’s sixth-largest federal agency. Most Americans know that the agency is responsible for agriculture, farming, livestock, forestry and natural resources. However, most of its budget supports <a href="http://www.obpa.usda.gov/budsum/fy17budsum.pdf">numerous nutrition programs</a>, including supplemental assistance (SNAP) and the school lunch program. It’s not a stretch to say the department’s programs touch every American.</p>
<p>Farming and agricultural production are obvious examples. Agriculture makes up approximately 6 percent of the overall economy and provides almost <a href="https://www.ers.usda.gov/data-products/ag-and-food-statistics-charting-the-essentials/ag-and-food-sectors-and-the-economy.aspx">10 percent of U.S. employment</a>. U.S. agricultural exports are <a href="https://www.ers.usda.gov/webdocs/publications/aes97/aes-97.pdf">expected to reach more than US$130 billion</a> in 2017. </p>
<p>The safety and low cost of the food that U.S. farmers provide is often taken for granted. Americans spend less of their income on food than any other country – <a href="https://www.ers.usda.gov/webdocs/DataFiles/Food_Expenditures__17981//table97_2014.xlsx">just over 6 percent of household income</a>. That compares to Canada – 9.2 percent, Germany – 10.22 percent, France – 13.3 percent and Italy – 14.2 percent. </p>
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<p>But rural America is about more than farming. Rural communities are also the home of many of the country’s <a href="http://www.iatp.org/files/2016_04_01_CleanPowerPlan_TR.pdf">energy production resources</a>, such as coal mining, renewable fuels like ethanol and biodiesel, wind and solar energy, and gas and oil production. Approximately <a href="https://www.brookings.edu/wp-content/uploads/2016/06/0509_locating_american_manufacturing_report.pdf">20 percent of the manufacturing industry</a> is located in rural America. </p>
<h2>Rural challenges</h2>
<p>Rural communities face real and unique challenges. While many of these same issues exist in cities, programs designed to work in urban areas often <a href="https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Rural%20Policy%20Learnings%20Memo.pdf">do not translate well to rural areas</a>. </p>
<p>Substance abuse, for example, is just as common in rural areas as in cities, but rates among certain groups, like teenagers and the unemployed, are higher. Most recently the issue of rural opioid abuse has been of key governmental concern. Before leaving office, former USDA Secretary Tom Vilsack was leading <a href="https://www.usda.gov/wps/portal/usda/usdahome?navid=opioids">an interagency initiative</a> focused on finding ways to fight an increase in abuse and overdoses. This initiative recognized the <a href="http://scholars.unh.edu/cgi/viewcontent.cgi?article=1006&context=carsey">hurdles of providing treatment in rural areas</a>, including transportation, public funding shortfalls and high costs.</p>
<h2>Lack of professionals</h2>
<p>It’s also difficult to recruit professionals to rural areas, an issue that impacts health care services, education and the law. </p>
<p>Not only is attracting <a href="https://www.ruralhealthinfo.org/topics/healthcare-access#barriers">health care professionals</a> to rural areas a challenge, but facilities, transportation, privacy concerns and access to specialists are major concerns. Access is a significant issue as rural Americans have higher numbers of chronic illness, including <a href="https://www.ruralhealthweb.org/about-nrha/about-rural-health-care">heart disease and diabetes</a>. Rural youth commit suicide at twice the rate of urban teens, and <a href="https://www.ruralhealthweb.org/about-nrha/about-rural-health-care">access</a> to mental health care is a significant problem. </p>
<p>Rural education also poses <a href="http://files.eric.ed.gov/fulltext/ED556045.pdf">unique challenges</a>. Student populations tend to be smaller. That translates to less funding. Rural schools are seeing a need for increased support related to early childhood development and education to provide needed programs, and recognition of unique problems they face. <a href="http://www.ruraledu.org/user_uploads/file/EarlyChildhood.pdf">Rural children</a> are less prepared for school than urban kids, in part due to lack of early education programs, and lower income and education levels of parents.</p>
<p><a href="http://www.abajournal.com/magazine/article/too_many_lawyers_not_here._in_rural_america_lawyers_are_few_and_far_between">Not having a local attorney</a> available impacts the ability to build a defense if charged with a crime or handle issues like child custody disputes, divorce or preparing a will. Local attorneys also play a role in community development and civic organizations.</p>
<p>And affecting many of these other issues is this harsh reality: When compared to urban areas, rural areas have higher rates of unemployment and poverty. Recent USDA numbers show <a href="https://www.ers.usda.gov/topics/rural-economy-population/employment-education/rural-employment-and-unemployment/">rural unemployment</a> averaged 5.4 percent, while urban unemployment was 4.8 percent. In 2014, <a href="https://www.ers.usda.gov/topics/rural-economy-population/rural-poverty-well-being/poverty-overview/">rural poverty rates</a> were 18.1 percent, compared to 15.1 percent in urban areas. <a href="https://www.ers.usda.gov/topics/rural-economy-population/rural-poverty-well-being/poverty-overview/">Child poverty rates</a> average 4 percentage points higher in rural areas than in urban areas. </p>
<h2>USDA can’t act alone</h2>
<p>By some measures, parts of rural American have seen improvement over the past few years. </p>
<p>Vilsack and the Obama administration successfully created programs and directed millions of dollars to rural development. An <a href="https://www.ers.usda.gov/webdocs/publications/eib162/eib-162.pdf">annual USDA survey</a> indicated that in 2016 rural unemployment decreased, fewer rural Americans lived in poverty, rural incomes rose, populations were steady and the number of children without access to sufficient food was at an all-time low. </p>
<p>Yet even with these improvements, the election results indicate that rural Americans still feel underrepresented and unhappy with the federal government. </p>
<p>Many in rural areas want the government to look at trade, health, tax, commerce, environmental, education, labor, immigration and other policies and ask, “How does this impact or improve rural America?” For example, many rural Americans believe they were overlooked when considering the impact of international trade agreements. They argue that is what caused rural areas to <a href="https://www.ers.usda.gov/topics/rural-economy-population/business-industry/">lose 25 percent</a> of their manufacturing jobs in the 2000s.</p>
<p>Of course, rural issues go beyond the scope of USDA. Immigration policies can impact farm labor and food prices. Environmental regulations effect energy production. Trade policies have an influence on manufacturing and agricultural production. </p>
<p>What rural America demanded with this election is a seat at the table. Getting one may be a challenge considering approximately 80 percent of elected officials <a href="http://www.usatoday.com/story/news/nation/2013/01/12/rural-decline-congress/1827407/">do not represent rural areas</a>. What they and the new president need to understand is that strong rural communities benefit us all.</p><img src="https://counter.theconversation.com/content/69756/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer Zwagerman is affiliated with the American Agricultural Law Association, Iowa State Bar Association, Polk County Bar Association and NALP.</span></em></p>Are you part of the 86 percent of Americans who do not live in rural America? Here’s why Trump’s choice to lead the USDA matters to you.Jennifer Zwagerman, Associate Director of the Agricultural Law Center; Director of Career Development (Law School), Drake UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/493012015-10-26T04:34:19Z2015-10-26T04:34:19ZUniversal health coverage means more than access and affordability – quality matters too<figure><img src="https://images.theconversation.com/files/99486/original/image-20151023-27619-7wsg42.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Although health care has become more accessible and affordable, quality at the facilities is still a problem.</span> <span class="attribution"><span class="source">Reuters/Siphiwe Sibeko</span></span></figcaption></figure><p>Moderate strides have been taken to make South Africa’s public health services accessible and affordable. But problems of quality persist. Evidence of this is that people still prefer private healthcare providers. </p>
<p>Post-1994, the emphasis has been on making healthcare services more available, and payment systems have been redesigned to increase affordability. This has seen an increasing share of government spending channelled into public health care. </p>
<p>But this fiscal shift has not made big improvements to South Africa’s health. Many critical health indicators, such as <a href="http://apps.who.int/gho/data/view.main.200">infant mortality rates</a> and <a href="http://apps.who.int/gho/data/node.main.3?lang=en">life expectancy</a>, are below those of other middle-income countries that spend much less on health care.</p>
<p>Availability and affordability interventions are largely aimed at achieving universal health access. “Health for all” is one of the goals of South Africa’s <a href="http://www.gov.za/issues/national-development-plan-2030">National Development Plan</a>. It is the main aim of South Africa’s pending major health reform – a <a href="http://www.bowman.co.za/FileBrowser/ContentDocuments/NHI.pdf">national health insurance plan</a>.</p>
<p>The government has taken a supply-focused approach to reducing health inequities – an appropriate approach in view of the extreme polarisation of the country’s private and public healthcare systems. But the focus on availability and affordability has overshadowed an equally critical issue – the demand side of access. In other words, what do people want? Do South African consumers find the public health services acceptable?</p>
<h2>Acceptable levels of service</h2>
<p>About 60% of those who attended public health facilities were satisfied with the service they received, irrespective of their illness, injury or socioeconomic status. However, acceptability is subjective and therefore hard to measure. Differing expectations of service levels, based on prior exposure to private health care, make economically empowered individuals more likely to complain than their less affluent counterparts. This bias could skew the findings of the analysis.</p>
<p>The “very satisfied” responses in the GHS data showed that the poor were apparently more satisfied with services than the more affluent. But because these data are self-reported and subject to bias they should be interpreted with caution. More rigorous analytical techniques and research methods are needed if we are to understand patient satisfaction levels.</p>
<p>Some people preferred to consult a private doctor rather than go to a public health facility. Clearly they opted for what they perceived to be better quality. The validity of this perception is debatable though. It can be argued that public health facilities are better equipped and their staff more experienced than private doctors when it comes to tuberculosis and HIV/AIDS treatment. </p>
<p>Levels of acceptable service could be gauged by complaints in the GHS about dirty facilities and rude staff. This was the subject of less than 15% of the complaints about public health facilities, with incivility being a bigger issue than uncleanliness. </p>
<p>These complaints came more from the affluent than the poor, perhaps implying different expectations about cleanliness and friendliness and different norms for the appropriateness of complaining about a “free” public service.</p>
<h2>The private sector</h2>
<p>More than 95% of the respondents felt public health facilities were affordable. This was expected, as primary health care is free for all and public healthc are is free for children under five and pregnant women. Other public health services are billed according to ability to pay, and certain services are offered free of charge to select groups. </p>
<p>Yet a <a href="http://etd.uwc.ac.za/xmlui/handle/11394/4211">study</a> of the general household survey data showed that public health care is perceived as an inferior good. Even some of the poorest and most marginalised are prepared to spend their own money to see a doctor, although the services of their nearest clinic are virtually free. </p>
<p>While affordability remains an issue, it was not the main reason that stopped people from consulting a healthcare provider when ill or injured. But it was clearly more of a barrier for black people than for white. This highlighted a disturbing public-private split along race lines.</p>
<p>Affordability was the main reason why people did not join a medical aid. A large proportion – irrespective of socio-economic status – still paid personally for health care, albeit very small amounts proportional to household income. Encouragingly, this trend decreased for all race and socioeconomic status groups during the period under review.</p>
<h2>Change is needed</h2>
<p>A multi-dimensional approach to interpreting access to health care has gained traction in recent years. But most of the interventions to improve access remain supply oriented.</p>
<p>Access to public health facilities seems to be fairly equitable and well targeted in terms of affordability. The same cannot be said of availability, and particularly acceptability, which are lagging behind. </p>
<p>The government must continue to increase physical access to health care, especially in rural areas. Public health role-players must use resources efficiently to deliver a high quality service that all consumers will find acceptable. </p>
<p>Failure to do so could undermine health policies designed to achieve “health for all”. Particular attention must be paid to the overlooked and under-researched issue of acceptable levels of service. The current scenario does not bode well for South Africa’s major health reform – the implementation of the national health insurance plan.</p><img src="https://counter.theconversation.com/content/49301/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Carmen S. Christian does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The government has put a lot of effort into making health care in South Africa more accessible, but the quality of the service still lags behind.Carmen S. Christian, Lecturer in Economics, University of the Western CapeLicensed as Creative Commons – attribution, no derivatives.