Developing generalism in the South African context

The largest impact on the South African burden of disease will be made in community-based and primary healthcare (PHC) settings and not in referral hospitals. Medical generalism is an approach to the delivery of healthcare that routinely applies a broad and holistic perspective to the patient’s problems and is a feature of PHC. A multi-professional team of generalists, who share similar values and principles, is needed to make this a reality. Ward-based outreach teams include community health workers and nurses with essential support from doctors. Expert generalists – family physicians – are required to support PHC as well as provide care at the district hospital. All require sufficient training, at scale, with greater collaboration and integration between training programmes. District clinical specialist teams are both an opportunity and a threat. The value of medical generalism needs to be explained, advocated and communicated more actively.

Scaling community-based services in Gauteng, South Africa: A comparison of three workforce-planning scenarios

Background: The introduction of community-based services through community health workers is an opportunity to redefine the approach and practice of primary health care. Based on bestpractice community oriented primary care (COPC), a COPC planning toolkit has been developed to model the creation of a community-based tier in an integrated district health system. Aim: The article describes the methodologies and assumptions used to determine workforce numbers and service costs for three scenarios and applies them to the poorest 60% of the population in Gauteng, South Africa. Setting: The study derives from a Gauteng Department of Health, Family Medicine (University of Pretoria) partnership to support information and communication technology (ICT)-enabled COPC through community-based health teams (termed as ward-based outreach teams). Methods: The modelling uses national census age, gender and income data at small area level, provincial facility and national burden of disease data. Service calculations take into account multidimensional poverty, demand-adjusted burden of disease and available work time adjusted for conditions of employment and geography. Results: Assuming the use of ICT for each, a health workforce of 14 819, 17 925 and 7303 is required per scenario (current practice, national norms and full-time employed COPC), respectively. Total service costs for the respective scenarios range from R1.1 billion, through R947 million to R783 million. Conclusion: Modelling shows that delivering ICT-enabled COPC with full-time employees is the optimal scenario. It requires the smallest workforce, is the most economical, even when individual community health worker costs of employment are twice those of current practice, and is systemically the most effective

Towards housing first and harm reduction : addressing opioid dependence and homelessness in Tshwane during the COVID-19 pandemic

Pandemics can increase mortality and drug-related harms among people experiencing homelessness. The Housing First approach prioritises housing and service access. Harm reduction, a principle of Housing First, minimises the consequences of drug use. This chapter presents lessons learnt from the application of Housing First and harm reduction principles with homeless people in Tshwane, South Africa, between April 2020 and March 2021. Quantitative service delivery data were retrospectively reviewed and analysed using descriptive statistics. Accounts by authors who participated in the COVID-19 response were collectively discussed in relation to the Housing First and harm reduction actors and process. Issues were synthesised in relation to two six-month periods. A task team was established to co-ordinate Tshwane’s response. In the first six months, 1 440 temporary bed-spaces were created at 25 shelters, and 2 066 people at shelters received food, social support and on-site healthcare services. Across shelters, 1 076 residents were started on methadone to manage opioid withdrawal. By the second six-month period, many gains were lost. Changes in political leadership stalled plans to reintegrate people housed in temporary shelters, and reduced funding led to shelter closures. By April 2021, more shelters operated than in pre-COVID-19 times, harm reduction capacitation for shelter staff continued, and local government committed to establish a street homelessness unit.Through a combination of funding and collaboration, progress was made towards Housing First and harm reduction for homeless people in Tshwane. A national policy on homelessness should be developed, funded and implemented. This should be informed by additional research, developed in partnership with affected populations, and built on a common understanding of Housing First and harm reduction.http://www.journals.co.za/content/journal/healthrFamily Medicin

Psychosocial implications of tubal ligation in a rural health district: A phenomenological study

<p>Abstract</p> <p>Background</p> <p>Tubal ligation is the most popular family planning method worldwide. While its benefits, such as effectiveness in protecting against pregnancies, minimal need for long-term follow-up and low side-effects profile are well documented, it has many reported complications. However, to date, these complications have not been described by residents in Congo. Therefore, the study aimed at exploring the experience of women who had undergone tubal ligation, focusing on perceptions of physical, psychological and contextual experiences of participants.</p> <p>Methods</p> <p>This qualitative study used a semi-structured questionnaire in a phenomenological paradigm to collect data. Fifteen participants were purposefully selected among sterilized women who had a ligation procedure performed, were aged between 30 and 40 years, and were living within the catchment area of the district hospital. Data were collected by two registered nurses, tape-recorded, and transcribed verbatim. Reading and re-reading cut and paste techniques, and integration were used to establish codes, categories, themes, and description.</p> <p>Results</p> <p>Diverse and sometimes opposite changes in somatic symptoms, psychological symptoms, productivity, ecological relationships, doctor-client relationships, ethical issues, and change of life style were the major problem domains.</p> <p>Conclusions</p> <p>Clients reported conflicting experiences in several areas of their lives after tubal sterilization. Management, including awareness of the particular features of the client, is needed to decrease the likelihood of psychosocial morbidity and/or to select clients in need of sterilization.</p

Developing generalism in the South African context

The largest impact on the South African burden of disease will be made in community-based and primary healthcare (PHC) settings and not in referral hospitals. Medical generalism is an approach to the delivery of healthcare that routinely applies a broad and holistic perspective to the patient's problems and is a feature of PHC. A multi-professional team of generalists, who share similar values and principles, is needed to make this a reality. Ward-based outreach teams include community health workers and nurses with essential support from doctors. Expert generalists - family physicians - are required to support PHC as well as provide care at the district hospital. All require sufficient training, at scale, with greater collaboration and integration between training programmes. District clinical specialist teams are both an opportunity and a threat. The value of medical generalism needs to be explained, advocated and communicated more actively

Identification of CMTM6 and CMTM4 as PD-L1 protein regulators

The clinical benefit for patients with diverse types of metastatic cancers that has been observed upon blockade of the interaction between PD-1 and PD-L1 has highlighted the importance of this inhibitory axis in the suppression of tumour-specific T-cell responses. Notwithstanding the key role of PD-L1 expression by cells within the tumour micro-environment, our understanding of the regulation of the PD-L1 protein is limited. Here we identify, using a haploid genetic screen, CMTM6, a type-3 transmembrane protein of previously unknown function, as a regulator of the PD-L1 protein. Interference with CMTM6 expression results in impaired PD-L1 protein expression in all human tumour cell types tested and in primary human dendritic cells. Furthermore, through both a haploid genetic modifier screen in CMTM6-deficient cells and genetic complementation experiments, we demonstrate that this function is shared by its closest family member, CMTM4, but not by any of the other CMTM members tested. Notably, CMTM6 increases the PD-L1 protein pool without affecting PD-L1 (also known as CD274) transcription levels. Rather, we demonstrate that CMTM6 is present at the cell surface, associates with the PD-L1 protein, reduces its ubiquitination and increases PD-L1 protein half-life. Consistent with its role in PD-L1 protein regulation, CMTM6 enhances the ability of PD-L1-expressing tumour cells to inhibit T cells. Collectively, our data reveal that PD-L1 relies on CMTM6/4 to efficiently carry out its inhibitory function, and suggest potential new avenues to block this pathway