Show me your neighbourhood and I’ll tell you how healthy you are and how long you’re likely to live. In Germany, when it comes to health and illness rates, huge inequalities exist. In many underprivileged districts, where income levels are particularly low, people die on average five years earlier than in wealthier districts.
But this is starting to change in the East Hamburg districts of Billstedt and Horn. Income in these areas is 40 percent lower than the average for Hamburg, and a large number of residents live below the poverty line. Education levels are relatively low and everyday life is fraught with troubles.
This was certainly the case for Samira Afalid*, age 31, who saw her gynecologist several times a month in recent years, in an effort to have children. She experienced three stillbirths, all before the 23rd week of pregnancy, for no apparent physical reason other than that she was overweight, which can interfere with both conception and pregnancy.
According to her doctor, Afalid needed someone to treat her, support her and help her lose weight over a period of time, which would also boost her self esteem. The gynecologist could not afford the time because her practice was located in the Billstedt and Horn area, where people tend to seek medical attention more frequently than the average, due to a lack of knowledge about everyday health matters. For this reason, a growing number of doctors are leaving the district, looking to settle somewhere less stressful and where patients can afford to pay higher fees. Those who stay behind are left with more patients to tend to, and even less time to treat them and educate them on health issues.
Afalid’s gynecologist was able to help her after all. She referred her to a new health kiosk in the heart of the district, part of the Health for Billstedt/Horn project, founded in August 2017. “The healthcare kiosk is one of the core elements of the project,” says Alexander Fischer, who was involved in developing the concept. It was launched by a physicians’ network, the health management company OptiMedis AG, and the local district hospital, and supported by the city of Hamburg.
Staffed by healthcare professionals, including nutrition advisors, nurses and midwives, the kiosk does not have any doctors on its payroll. Anyone can walk in without an appointment and get a first consultation right away. “We want to make the healthcare system as accessible as possible,” says Fischer. And with a high concentration of immigrants in the area, the staff can speak several languages, notably Turkish.
At one appointment, Afalid spent 45 minutes reviewing her case with a midwife – something that would have been unimaginable with her gynecologist — and designing a plan to see a nutrition counselor once a week at the health kiosk. Four months later, she had lost 25 kilogrammes.
Healthcare professionals taking on the workload of doctors is increasingly prevalent in Germany. In rural areas, doctors’ assistants conduct routine house visits now. But the Health for Billstedt/Horn project is the most comprehensive program of its kind so far. It aims to fill in the gaps left by overloaded physicians, by providing basic health advice and information, free of charge. “We often have to explain things that seem obvious,” says Fischer, quoting the example of a patient who thought that replacing sugar with butterscotch syrup would help him control his blood sugar levels.
Gerd Fass, a surgeon involved with the project since its launch, says it changed his life. “Sometimes I would feel overwhelmed by the expectations of the same patients asking the same questions,” he says. One of his patients used to come to his practice often, complaining about back pain. After referring him to the health center, the man’s consults became less frequent. “He’s got a completely different attitude now – less ‘The doctor will make me well’ and more ‘How can I contribute towards making myself well?’” notes Fass.
The project’s scope goes beyond the healthcare kiosk. “We offer regular training sessions for staff from more than 100 medical institutions in the area,” says Fischer. These include doctors’ practices, care facilities, sports associations and parental education establishments, and aim to guide people through the healthcare system. Thanks to its many activities, Health for Billstedt/Horn has developed a reputation throughout the district.
The project’s founders’ long-term goal is for their work to influence life expectancy and burden of disease rates in these areas, and hopefully, to see the concept applied across Germany. But although the Hamburg Center for Health Economics (HCHE) will evaluate the effectiveness and transferability of the project to other regions, there aren’t any relevant statistics available yet.
Germany’s Federal Joint Committee’s innovation fund has provided the financial support to run the project for three years, but future funding is uncertain, and it’s not yet clear that the additional public health costs will pay off in the end. The project could ultimately be classified as “nice but not fundable,” and simply disappear.
But it doesn’t look like it will. People are happy with the project – and more enthusiastic about taking responsibility for their own health. Since overhauling her approach to nutrition, Samira Afalid hasn’t become pregnant yet. But, in better health and feeling optimistic about her future, she’s ready to try again soon.
*Not her real name