Immigrants, an at risk populations

Immigrants

According to the World Health Organization, there are an estimated 1 billion migrants in the world today (214 million international migrants and 740 million internal migrants). The collective health needs and implications of this sizeable population are considerable. Migration flows comprise a wide range of populations, such as workers, refugees, students, undocumented migrants and others, with each different health determinants, needs and levels of vulnerability.

In our current globalized world defined by profound disparities, skill shortages, demographic imbalances, climate change as well as economic and political crises, natural as well as man-made disasters, migration is omnipresent. Migration is also essential for some societies to compensate for demographic trends and skill shortages and to assist home communities with remittances.

Inequities

"There is substantial evidence of inequities in both the state of health of these groups and the accessibility and quality of health services available to them. However, differences from the majority population vary according to the specific group being studied, the health problems or services involved, and the country concerned. Some groups may in certain respects enjoy health advantages (The healthy immigrant effect), but it is mainly disadvantages that have been documented.
With rare exceptions, migrants and ethnic minorities tend to occupy a less-favorable social position and research indicates that this is strongly linked to their health problems. Statistically speaking, many health discrepancies are reduced or disappear when socioeconomic status is controlled for. Some, however, do not; even when they do, it may be more plausible to regard socioeconomic status as an intervening variable rather than as the root cause of ill health. Social disadvantage is reinforced by the manifold processes of social exclusion to which migrants and ethnic minorities may be exposed. Discrimination at individual and institutional levels, as well as the limited social rights accorded to many migrants, must be regarded as the fundamental cause of many health problems." (How health systems can address health inequities linked to migration and ethnicity. Copenhagen, WHO Regional Office for Europe, 2010.)

 A political climate of fear

To tackle health inequities, it is necessary for health systems not only to improve the services available to migrants and ethnic minorities, but also to address the social determinants of health across many sectors. A wide range of policies and practices needs to be critically examined in the light of their consequences for the health and wellbeing of migrants and ethnic minorities.

The current political climate of fear and anger has led to more closed door policies and is restricting access of health services to those who need them the very most. The refugee populations find themselves especially vulnerable with elevated numbers of mental disorders, such as PTSD (Post Traumatic Stress Disorder).

While the fear of terrorism and drug violence is real and understandable, governments, medical professionals, and health systems must strive to provide equal and quality care to all, while continuing to improve the those situations that are causing the need for care.

Health for all

 

More Information here:

How health systems can address health inequities linked to migration and ethnicity. Copenhagen, WHO Regional Office for Europe, 2010

http://www.who.int/hac/techguidance/health_of_migrants/en/



 

El juego de la farmacoeconomía

Espero me permitan hablar de este tema con estos términos. Menciono la palabra juego, porque así lo tratan. Se hacen fullerías y se pasa a la siguiente casilla sin responder las preguntas de las cartas; porque muchas instrucciones están definidas y se hace caso omiso de ellas.

España introdujo en la legislación la evaluación económica como un modo de financiación selectiva de medicamentos, siendo pionero en la elaboración de guías de estandarización metodológica, y aumentando significativamente el número de estudios de evaluación económica. Sin embargo no hay una verdadera voluntad política de utilizar éstos métodos para la introducción de nuevos fármacos en la financiación con fondos públicos.

Existe un creciente interés por los estudios de evaluación económica, pero éstos no se acompañan de un aumento de la calidad ni de rigor metodológico. Hay mucha confusión en los términos que se utilizan y poca experiencia de los editores e investigadores de revistas que incluyen esto estudios, perpetuando así la mala calidad. Por ello es necesario conocer algunos conceptos básicos de una evaluación económica, debiendo profundizar más, aquellos profesionales que se relacionan con estos estudios. 

Nos situamos en un marco, en un tablero de juego llamado farmacoeconomía. Se gana al cumplir el siguiente objetivo: determinar qué fármaco produce mejores resultados para la salud según los recursos invertidos, una vez identificados, medidos y comparados los costes riesgos y beneficios de los programas, servicios o terapias.

Para salir de la casilla de salida primero hay que formular una pregunta bien definida, que incluya las alternativas comparadas, la perspectiva (a quién interesa la respuesta a la pregunta planteada) y las características de los pacientes (edad, sexo, tipo…) y de su patología (criterios diagnósticos, subtipos, gravedad…)

En este primer punto de alternativas comparadas, los participantes suelen hacer trampas al evaluar sin comparación. Lo correcto sería hacer una comparación considerándose todas las alternativas relevantes. Esta tarea puede representarse gráficamente a través de árboles de decisión o modelos de tratamiento. Es muy recomendable el uso de análisis de decisión donde se calculan las distintas probabilidades de éxito con las diferentes alternativas, junto con el cálculo de sus costes.

El análisis de la perspectiva es uno de los puntos más importantes. La perspectiva puede ser a través del paciente, la sociedad, el hospital, las autoridades sanitarias o los comités terapéuticos. Y ésta determinará el tipo de estudio farmacoeconómico a utilizar y tendrá coherencia con la pregunta planteada.

Si el jugador cumple estos requisitos, podrá pasar a la siguiente casilla para realizar la medida de los beneficios y los costes, que dependerá de la perspectiva. La información puede tomarse prospectivamente a través de ensayos clínicos o restrospectivamente a través de datos de literatura, opinión de expertos y otros. Lo más frecuente es utilizar ambos, y su calidad determinara la calidad de la evaluación económica. Al medir beneficios, si se carece de datos, se puede recurrir a modelos basados en suposiciones. Las unidades de medida pueden ser en términos monetarios, en unidades clínicas habituales o en indicadores que midan el estado de salud como puede ser los años de vida ajustados por calidad. Al medir los costes hay que diferenciar tres tipos: costes directos: derivan de los servicios médicos y se clasifican en “médicos” y “no médicos”; costes intangibles: miden aproximadamente el coste del dolor o del sufrimiento; costes indirectos: se trata de los cambios en la capacidad productiva del individuo.

Una vez terminado este paso, el participante ya sabrá la casilla a la que deberá dirigirse, según el tipo de análisis farmacoeconómico que le corresponda:

• Coste-beneficio: los costes del tratamiento y los resultados se expresan en unidades monetarias.
• Coste-efectividad: el más utilizado. Los beneficios se miden en unidades de morbilidad y mortalidad, debiendo ser las mismas unidades para las opciones de tratamiento comparadas, los cuales tendrán que ser similares.
• Coste-utilidad. La medida de los beneficios se realiza mediante escalas que deben estar validadas, ser reproducible y específicas. Estas escalas miden la salud asociada a la calidad de vida.
• Minimización de costes: se utiliza cuando la efectividad clínica de las distintas terapias es idéntica. De esta forma basta con comparar los costes de cada una de las alternativas y elegir la de menor coste.

La siguiente actividad consiste en realizar el análisis de los resultados. Lo ideal sería medir los resultados (prevención de muerte...) pero muchas veces no es posible, por lo que se miden variables intermedias que den una aproximación del resultado final. Los resultados se deben expresar en términos de incrementos, utilizando el cociente del incremento de los costes dividido por el incremento de la efectividad (Ej.: C₂-C₁ / E₂-E₁). En este momento no hay que olvidar incluir los efectos adversos que puedan influir en los resultados.

En el caso de querer aspirar al bonus, se deberá incluir un apartado con las limitaciones, suposiciones y posibles sesgos. Es muy útil el análisis de sensibilidad que valora la solidez de las conclusiones del estudio cuando se modifica el valor de las variables cuyo valor se ha asumido previamente. Es decir se analizan todos los posibles resultados del estudio considerando todos los posibles valores que pueden tomar estas variables. 

Para ganar la partida se tienen que extraer las conclusiones, las cuales deberán tener validez interna y externa.

Ahora hablemos en serio porque, realmente, esto no es un juego. Un alto porcentaje del presupuesto sanitario del Sistema Nacional de Salud se gasta en medicamentos. Por lo tanto es lógico pensar en la necesidad de llevar a la práctica real la correcta realización de estos estudios. Hay que conocer bien los medicamentos: el coste-efectividad, el impacto presupuestario... Debería utilzarse de manera sistemática, siempre que sea posible, la evidencia científica a la hora de introducir y retirar fármacos, ya que éstos se financian con dinero público.

Bibliografía:

Sacristán JA, Soto J, Reviriego J, Galende I. Farmacoeconomía: el cálculo de la eficiencia. En: Dilla T, Sacristán JA. Evaluación Económica de Intervenciones Sanitarias. Doyma: Barcelona. 2006, p.p. 43-49. 

Austerity, health, and lessons from history

1929

Hoovervilles

On ‘Black Tuesday’ October 29th the US stock market crashed beginning an economic crisis known as ‘the Great Depression’. In the 1930s the great depression put millions of Americans out of work; business and industry were heavily affected. Hundreds of Americans found themselves homeless, and began congregating in shantytowns (Hoovervilles) that began to appear across the country. Citizens lived in difficult sanitary conditions. The total debt of the country was over 200 per cent of GDP and suicide rates increased markedly among the unemployed between 1929 and 1933.

The newly elected of the day, President Roosevelt, closed all the banks only reopening them only after they were stabilized. The US Congress created the Federal Deposit Insurance Corporation to insure deposits up to US$5000. President Roosevelt started programs that came to be known as the ‘New Deal’. Major objectives included putting people back to work and re-housing those who had lost their homes, however he also pushed for the creation of the 'Social Security Act'. It established a system of old-age benefits for workers, survivor benefits for victims of industrial accidents, unemployment insurance, and aid for dependent mothers and children, the blind and the physically disabled.

The money expended in New Deal programs was well invested, as every additional $100 per capita reduced suicides by 4 per 100 000 and reduced infant deaths too. Not all States of the US implemented the New Deal with equal rigor. Thus, differences can be observed: States that fully implemented the programs had better health outcomes. 

1948

NHS

A second historical example appeared after World War II. The United Kingdom (UK) mounted an ambitious plan to bring good health care to everyone. It created a National Health Service (NHS) in 1948. For the first time, hospitals, doctors, nurses, pharmacists, opticians and dentists were brought together to provide services free for all at the point of delivery. The central principles are clear: the health service will be available to all and financed entirely from taxation; people pay into it according to their means . When the UK created the NHS, it was still struggling with effects of World War II. Its economy had yet to recover, having lost huge amounts of absolute wealth. The winter of 1946–1947 proved to be very harsh; it curtailed production and led to shortages of coal, that again damaged the economy. At the time, the currency (British pound) was over valued – and subsequently devalued. The US initiated Marshall Plan grants (mostly grants, also a few loans) thereby pumping $3.3 billion into the European economies. The health conditions for British people were as difficult as in all other European post-war countries.

1873

Gründerkrise

One final historical case here is creation of the Germany social insurance program – the first in the world. In 1873, Germany and much of Europe and America entered an economic slump – the so called ‘Long Depression’ or Gründerkrise. This downturn was the first to hit the German economy since industrial development began to surge in the 1850s. The states of the German Reich had waves of emigration of their population – primarily for economic reasons and primarily to the US. In 1870, German-born farmers outnumber native born in the state of Pennsylvania who were born native to the US.

In this setting that a socialist movement developed in Germany – and the founding of Germany’s Social Democratic Party. As a result of a major depression’ that swept Europe and the US in the mid-1870s, Bismarck initiated economic policy change in 1878–1879. He tried to constrain the rise of social democrats by any means. While undergoing economic, social and political unrest, Germany (Prussia) became the first country in Europe to offer compulsory social health insurance (1883), accident insurance bill (1884) and an old-age and disability bill (1889). It was chancellor Bismarck who introduced them, usually after serious debates in the Reichstag and much opposition from the liberals. Despite his impeccable right-wing credentials, Bismarck would be called a socialist for introducing these programs, as was President Roosevelt 70 years later (see New Deal above).

Read more here:

www.palgrave-journals.com/jphp/journal/v35/n2/full/jphp20147a.html
www.ourdocuments.gov/doc.php?flash=true&doc=68
www.nhshistory.net/shorthistory.htm
www.historyhome.co.uk/europe/bisdom.htm

Healthier Cities

“Where people live affects their health and chances of leading flourishing lives. Communities and neighbourhoods that ensure access to basic goods, that are socially cohesive, that are designed to promote good physical and psychological wellbeing, and that are protective of the natural environment are essential for health equity.”

- Closing the gap in a generation, WHO headquarters, 2008

"Two thirds of the population of the European Region live in towns and cities. Urban areas are often unhealthy places to live, characterized by heavy traffic, pollution, noise, violence and social isolation for elderly people and young families. People in towns and cities experience increased rates of noncommunicable disease, injuries, and alcohol and substance abuse, with the poor typically exposed to the worst environments. However, there are ways to tackle these challenges."

- Urban health was the theme of World Health Day, 7 April 2010.


The worlds population is in a state of migration. More and more people are moving to towns and cities in search of jobs that can support a higher quality of life. This migration will lead to 70% of the worlds population in cities by 2050 according to the World Health Organization. We need "to tackle these challenges" related to water, environment, violence and injury, noncommunicable diseases and their risk factors like tobacco use, unhealthy diets, physical inactivity, harmful use of alcohol as well as risks associated with disease outbreaks. We need smarter cities that promote healthier living.

What needs to happen now:

• Confirm that the urban poor have access to basic public services, such as safe water, sanitation, and health services

• Design cities to promote physical activity (bike lanes, green spaces, etc. . .)

• Make healthy food available and affordable (community gardens, farmers markets, etc. . .)

• Improve public transportation and road safety

• Environmental and noise pollution controls (limit access to city roads)

• Build inclusive cities that are accessible and age-friendly (community events, community sports, and special needs friendly walkways and building)

• Make urban areas resilient to emergencies and disasters

The future hold all sorts of exciting possibilities for cities, especially as we transition from the vehicle centered model that has gripped urban planning for the last 50 years. One of the new focus will need to be health and healthy living. Public health professionals with have to step forward and make their voices heard as we push to create cities that not only provide the items listed above, but imagine up new and better ways of providing health and happiness to all of the city dwellers of tomorrow. 

For more information visit, http://www.who.int/topics/urban_health/en/

 

Zika. What else have we been missing?

Mosquito (Zika vector) 

I am very excited to be a father one day. It is something I have looked forward to my whole life. It is also something that I worry about a lot. I really want my children to be happy and healthy. I want them to be able to learn and grown and experience all the amazing things that this life has to offer.

That is why the news of the last few months has been so frightening. A mosquito born RNA virus called Zika has been potentially linked recently to congenital defects like microcephaly, which can mean severe neurological impairment and death of the fetus or newborn. Zika has also potentially been linked to autoimmune complications like Gillian-Barré syndrome, which effects individuals of all ages.

Zika virus was first identified all the way back in 1947 in the Zika forest in Uganda in the rhesus macaque population. Since that first isolation the virus has popped up in tropical areas throughout western and central Africa, in Asia, and in several islands of the pacific region.

Zika was mostly ignored up through 2007. Infections only present symptoms in around 1 of 4 people infected and those symptoms were usually minor (low grade fever, maybe a rash, myalgia, or a headache). Zika was categorized by most within the family of neglected tropical diseases, because it was not considered worth researching by drug companies.

In 2007 things began to change. There was an outbreak on the island of Yap and then in French Polynesia in 2013 and 2014. This began to prompt concern from health experts, but still nothing changed till this last year when Zika made it to the northeastern states of Brazil. Within the large populations in Brazil Zika's, heretofore, hidden secrets are being revealed.

In October of last year health professionals in Brazil looked through their health data and realized that something was wrong. In northeastern states like Pernambuco, Rio Grande do Norte, and Sergipe there had been a ten fold increase in the number of births presenting with microcephaly.

To their credit, these health professionals kicked things into gear. On November 11, 2015 the Brazilian ministry of health declared a public health emergency in relation to the number of children born with microcephaly. On November 17, 2015 The Pan American Health Organization and The World Health Organizations also issued an epidemiological alert, which was followed by the title of , "Public Health Emergency". That title gives researchers and health experts access to the $15 million dollar budget of the World Health Organization to study and mitigate the negative health impact of Zika.

It saddens me to think of how long this virus has been overlooked. We had no idea what it might be capable of. How many millions of people have been infected over the last 68 years since Zika was discovered, and because of those infections how many babies have potentially been born with microcephaly or died in the womb?

It truly is exciting to see a world wide public health machine kicking in into gear to work on this  public health emergency. Daily there is news coming out the with updates in the research on the virus and it's transmission, there are advisories and educational material to inform people and slow the transmission, and there are speeches from world leaders and health professionals. However for me, a man preparing to have a family, the fear remains in the back of my mind. What else are we missing? Almost 70 years after finding this virus we are realizing its terrible potential. It took the infection of millions in Brazil before we realized what Zika was capable of doing.



For more information about the Zika virus click here

Information used in this article about Zika virus was taken from rapid risk assessment reports issued by the European Center for Disease Prevention and Control on 24 November, 2015 and 21 January, 2016

 

Bienvenido

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