Beyond health care reform: immigrants and the future of medicine

Abstract

I first discuss the fundamental responsibilities of physicians and relate them to an increasingly fragmented medical system made even more complex by government regulations. I focus on trust as a vital component in the doctor–patient relationship, and note the difficult conditions surrounding the treatment of poor and marginal populations. Subsequently, I sketch the elements of a new vision to extend medical services to neglected populations. In that pursuit, the part played by physicians is only as important as the willingness of neighbourhoods and communities to support health as a public good.     

生物医学工程的精要、责任和展望

作为工程学的直属分支,建立生物医学工程学科的主要目的不是为了开辟一个新的科学研究领域,而是为了借助工程学的方法来解决生物医学领域所面临的实际问题,以及借助工程师们所接受的专业训练、所拥有的专业知识、所具备的工作技巧来提高医疗服务的质量和效果。工程学与生物医学的结合已取得了一些具有里程碑性质的成果。在中低收入国家,例如中国,生物医学工程有责任保证合理使用专业技术,为低廉、可靠、有效的医疗服务提供支持。本文将根据可预见和不可预见的学科发展限制和困难,对学科发展的现实目标和责任进行严肃、冷静地讨论。     

Advising Patients on the Use of Complementary and Alternative Medicine

Complementary and alternative medicine (CAM) is an area of great public interest and activity, both nationally and worldwide. Many alternative medical practices have existed for hundreds, even thousands of years. Patients and professionals are turning to CAM for a variety of reasons. Most have tried conventional medicine for a particular (usually chronic) medical condition and have found the results inadequate. Some are concerned over the side effects of conventional therapies. Some are seeking out a more “holistic” orientation in health care where they can address body, mind, and spirit. A continuing challenge will be how to address CAM services that are based on time, practitioner–patient interactions, and self-care, using modern standards of evidence, education, licensing, and reimbursement. For most CAM therapies, there is insufficient research to say definitively that it works and CAM research is especially limited in the area of cancer. Given that situation, the questions (but not answers) facing the medical practitioner are clear-cut. Should the practitioner await the definitive results of formal Phase III randomized clinical trials, or should the practitioner rely on limited data, seeking out evidence that makes physiological sense and small trials that seem to offer some benefit to the patient? When and at what point do you discourage, permit, or recommend an available alternative therapy? The answers are not simple. There may be differences of opinion and values among the patient, the practitioner, and the organizations that pay for a therapy. CAM areas should be approached with every patient who enters the office recognizing that there are precautions to consider when patients are using, or plan to use, such therapies. This paper presents a broad survey of what complementary and alternative medicine is from the perspectives of both the public as user and the conventional medical practitioner, as well as provides examples of issues pertinent to understanding and evaluating research in CAM. The past is back and the future will involve integration of modern and ancient ways.     

Healing across Cultures: Learning from Traditions

The health and wellness of an individual are reliant on the integrated effects of mind, body, and spirit. This triad is intricately set within a backdrop of the environment, our earth. Western cultures often disregard this holism, especially this fourth component, in its considerations of wellness as described by modern medicine. This practice is unlike that of many of the traditional cultures in the world. These cultures focus more on balance in the context of environmental respect. Varied cultures share remarkable similarities in their healing modalities, especially considering the relative isolation from one to another—evidence that there is truth to the healing knowledge they possess. We are not disconnected from the natural world in terms of health, but dependent and interconnected within ourselves and to everything around us. Social change is required to assure that the practice of modern medicine evolves to incorporate this integral aspect of health and wellness, and this can be done through partnerships with traditional healers.There is a growing demand for wellness and earthly responsibility. It is time to appropriately learn from age-old societies and their healing traditions for they do have answers we are seeking in sustainability and harmony, environmental stewardship and planetary respect, and holistic health. For thousands of years, our ancestors have known the secrets of long life—this knowledge needs to be preserved through the apprenticeship of future generations. We propose a collaboration that develops mutually beneficial learning partnerships combining modern medical knowledge with the wisdom of traditional healers around the world.     

The Sanctification of Dreams: Prevalence and Implications

Many scientists and practitioners have debated about the function of dreams. Though some researchers have described dreams as purposeless random neuronal firings, others have suggested that dreams serve an adaptive function with certain dream characteristics having positive implications. Drawing on other studies of sanctification, this study examines whether imbuing a dream with qualities of the sacred relates to beneficial outcomes. Examining a college student sample of 168, it was found that the more sacred the dream was perceived, the more beneficial the outcome reported from a stressful life event which related to the dream. These outcomes include less negative affect and more positive affect, psychological and spiritual growth. Sanctification of dreams predicted these outcome variables over and above other religious measures as well as dream measures. The implications of these findings are discussed.     

Rethinking the deserving body: altruism,markets, and political action in health care provision

Abstract

I seek to understand two dimensions in the evolution and practices of medical institutions in the USA. First, I ask, how and why do medical organizations limit, suspend, or redirect profit-oriented functions to abide by principles of altruism and still survive in a competitive market economy? Reaching out to poor and immigrant populations entails non-economic factors, including the deployment of religious and humanitarian narratives. Conversely, the extent and character of legislative actions supporting philanthropic endeavours is closely related to mobilization at the grassroots level. I investigate the ways in which community organizations bring about changes to support practices that confound, at least to some extent, market expectations and underscore the significance of political action to secure health care services on behalf of low-income populations, including immigrants.     

Structural violence and compassionate compatriots: immigrant health care in South Florida

Abstract

Based on more than twenty in-depth interviews with health care professionals in Miami-Dade County clinics and hospitals, this study explores immigrant access to health care. We focus on some of the debates that took place during the 2009–10 process of US health care reform, which uncovered a pervasive public fear that immigrants illegitimately access health care. This study found the opposite: immigrants in South Florida often avoid primary health care even when offered freely and legally. This is because of bewilderment about bureaucratic requirements, fear of deportation and bills, and cultural folkways. We present the former two barriers as forms of structural and symbolic violence. We conclude by describing South Florida's compassionate compatriots, as a means by which immigrants can be guided through the health care system.     

American acupuncture and efficacy: meanings and their points of insertion

By its very definition, efficacy's meanings remain fluid, their particularities contingent on context. The change seen as significant may occur on a symbolic level or through the removal of physical symptoms. It may address conditions of a social body. Some discussions differentiate between "healing" and "curing." Many of these meanings surface when examining what efficacy means in the practice of acupuncture in the United States. This complex phenomenon is possible largely because acupuncture draws on the qi paradigm on the one hand, allowing for the most ephemeral dimensions of experience to be included in considerations of efficacy. On the other hand, in the most material sense, acupuncture is also susceptible to being conceptualized as a device, independent of that same paradigm, allowing for the insertion of biomedical models and criteria. Pluralism within acupuncture itself intersects with, and even embodies, the medical pluralism of U.S. culture.     

The safety net of the safety net: how federally qualified health centers "subsidize" Medicaid managed care

In this article, I examine the impact of neoliberalism and welfare reform on the delivery of Medicaid, specifically how the advent of Medicaid managed care (MMC) has been wrought with contradictions, placing increased burdens on primary safety-net organizations and impacting the many communities they serve. I argue that federally qualified health centers (FQHCs) operate as a primary safety net among safety-net providers, supporting and subsidizing New Mexico's MMC program financially and administratively. By presenting ethnographic data, I will demonstrate how FQHCs pay many of the hidden financial and institutional costs of the shift to managed care. Such findings uncover paradoxes inherent to neoliberal ideologies and privatization, raising questions about the efficacy of a managed care system for Medicaid as well as the future of the health care safety net and access to health care for the diverse populations it serves.     

Integrating mental health into primary health care in Iraq

The Ministry of Health in Iraq is undertaking a systematic programme to integrate mental health into primary care in order to increase population access to mental health care. This paper reports the evaluation of the delivery of a ten day interactive training programme to 20% of primary care centres across Iraq. The multistage evaluation included a pre- and post-test questionnaire to assess knowledge, attitudes and practice in health workers drawn from 143 health centres, a course evaluation questionnaire and, in a random sample of 41 clinics, direct observation of health workers skills and exit interviews of patients, comparing health workers who had received the training programme with those from the same clinics who had not received the training. Three hundred andseventeen health workersparticipated in the training, which achieved an improvement in test scores from 42.3% to 59%. Trained health workers were observed by research psychiatrists to have a higher level of excellent skills than the untrained health workers, and patient exit interviews also reported better skills in the trained rather than untrained health workers. The two week course has thus been able to achieve significant change, not only in knowledge, but also in subsequent demonstration of trained practitioners practical skills in the workplace. Furthermore, it has been possible to implement the course and the evaluation despite a complex conflict situation.     

Reform of mental health care in Serbia: ten steps plus one

Disastrous events in the country and the region caused a 13.5% increasein the prevalence of mental and behavioral disorders in Serbia in the lastfew years, thus making them the second largest public health problem. Dueto prolonged adversities, the health system has deteriorated and is facingspecific challenges. However, the reform of mental health care has been initiated,with a lot of positive movements such as the preparation of a national policyfor mental health care and a law for protection of mentally ill individuals.The transformation of mental health services has started, with an accent oncommunity care, antistigma campaigns and continuing education. Based on anassessment carried out by the National Committee on Mental Health, serviceprovision, number of professionals working in services, funding arrangements,pathways into care, user/carer involvement and other specific issues are reported.     

Measuring and improving the quality of mental health care: a global perspective

Mental disorders are common worldwide, yet the quality of care for these disorders has not increased to the same extent as that for physical conditions. In this paper, we present a framework for promoting quality measurement as a tool for improving quality of mental health care. We identify key barriers to this effort, including lack of standardized information technology‐based data sources, limited scientific evidence for mental health quality measures, lack of provider training and support, and cultural barriers to integrating mental health care within general health environments. We describe several innovations that are underway worldwide which can mitigate these barriers. Based on these experiences, we offer several recommendations for improving quality of mental health care. Health care payers and providers will need a portfolio of validated measures of patient‐centered outcomes across a spectrum of conditions. Common data elements will have to be developed and embedded within existing electronic health records and other information technology tools. Mental health outcomes will need to be assessed more routinely, and measurement‐based care should become part of the overall culture of the mental health care system. Health care systems will need a valid way to stratify quality measures, in order to address potential gaps among subpopulations and identify groups in most need of quality improvement. Much more attention should be devoted to workforce training in and capacity for quality improvement. The field of mental health quality improvement is a team sport, requiring coordination across different providers, involvement of consumer advocates, and leveraging of resources and incentives from health care payers and systems.     

Oral health care issues in aged care facilities in Western Australia: resident and family caregiver views

Objective: To investigate resident and family perceptions and attitudes towards oral health care and access to dental services for aged care facility residents. Method: Focus groups and individual interviews with residents and family caregivers were conducted at aged care facilities in the Perth Metropolitan Area, Western Australia. Results: There were 30 participants from twelve aged care facilities (21 residents and nine family caregivers). Five focus groups comprising both residents and family caregivers were conducted in addition to three face‐to‐face interviews with residents. Both groups considered oral health very important to overall health and quality of life. Family caregivers noted a lack of dental check‐ups and specialised professional oral care, particularly in high‐care facilities. Low care residents were more likely to have regular dental check‐ups or dental treatment and off‐site dental visits were straightforward due to their mobility and family member assistance. Family caregivers noted time limitations and lack of expertise in oral health care amongst staff in high‐care facilities, and the challenges of maintaining oral care for residents with poor mobility or cognitive impairment. It was considered important that staff and management liaise with family caregivers and family members in provision of oral care. Conclusion: Regular oral care, assessment and treatment were considered limited, particularly for residents in high care. There is a need for comprehensive, ongoing oral health programmes involving appropriately trained and empathetic dental health professionals and staff to improve oral health care in Perth’s aged care facilities.     

Lessons learned in developing community mental health care in Africa

This paper summarizes the findings for the African Region of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Implementation of Community Mental Health Care. We present an overview of mental health policies, plans and programmes in the African region; a summary of relevant research and studies; a critical appraisal of community mental health service components; a discussion of the key challenges, obstacles and lessons learned, and some recommendations for the development of community mental health services in the African region.     

Oral health care in private and small long-term care facilities: a qualitative study

Objective: Elderly people who are institutionalised receive qualified care. Among the services supplied, oral health care has not always been a priority. The aim of this study was to identify the characteristics of oral health care provided to the elderly residents in long‐term care facilities (LTC) in Porto Alegre/RS city. Methods: Twelve private and small‐size LTCs (less than 20 residents) participated in this study. All supervisors and 36 carers were interviewed. The data obtained were organised according to the offer of oral health under the following categories: responsibility for oral care, oral care routines, difficulties carrying out oral care routines. Results: The procedures used most often in order of frequency were tooth brushing, prostheses cleaning, use of mouthwashes, soaking of prostheses and cleaning of the tongue. Among the difficulties mentioned were the high cost of dental assistance, the lack of co‐operation both by family members and by the elderly themselves, the oral and general health status of the elderly and the limited time available for carers to carry out the tasks. Oral care is conducted empirically, and the responsibility is left to the carers. Conclusions: Analysis of the statements given reveals that oral care does not follow any kind of protocol or standardisation. The persistence of this situation could lead to unsatisfactory oral health care in private and small LTC facilities.     

The power of local autonomy: expanding health care to unauthorized immigrants in San Francisco

Abstract

I analyse the mechanisms through which an inclusive local policy environment in the integrated city-county of San Francisco operates to improve unauthorized immigrants’ access to and utilization of health care. Within – but not outside – the bounds of this inclusive local context, committed providers reported being able to provide attention to unauthorized immigrants without worrying about the direct costs of doing so; to buffer, marshal resources, and advocate for individual unauthorized patients; and to exert substantial autonomy in deciding how to approach lack of legal status in their patient–provider interactions. These results highlight the potential and limitation of sub-national policies seeking to ameliorate unauthorized immigrants’ health vulnerability in a hostile US federal context.