Discuss Diagnosis and Natural History

Differences in Healthcare: Somalia versus the United States

There are several differences concerning healthcare between Somalia and the United States. The table below lists the main variations in policies for each country. The countries have differing laws regarding specific practices such as newborn screening. In the United States, the newborn screening process requires sickle cell disease screening in every state, and thus the majority of cases are discovered early after birth (Department, 2009). Despite a high incidence of consanguinity and hemoglobin disorders in the general area of the world that includes Somalia, there has been slow progress in implementing newborn screening programs in many countries in the Middle East and North Africa (Saadallah, 2007). According to the International Society for Neonatal Screening “there is no newborn screening in Somalia” (J.G. Loeber, personal communication, July 21, 2009). There are also differences regarding appointments and expectations. The Somali culture’s concept of time is relaxed, therefore appointment times are viewed more as general suggestions. A family may arrive an hour early or late to the health care appointment. Variations on physical examinations are also present. In Somalia, many women cover their body based on religious beliefs. Special care must be taken to preserve their modesty during a physical examination. United States health care providers must be careful to respect their modesty while not compromising the necessary exam (Adams & Assefi, 2002).

Somali Health Care System

United States Health Care System

Government owned/managed system

Combined public/private system

Centralized system

Decentralized

Focus on curative medicine

Focus on preventive medicine

On-the-spot diagnosis & treatment

Complex referral and triage systems

Few diagnostic tests

Many diagnostic tests used

Questions pertain to current illness

Many questions re: history & family

Medications usually prescribed

Medications not always prescribed

Prescriptions free while in hospital

Prescriptions never free

Payment for services: low cost/free

Services typically expensive

No appointment necessary

Appointments required – weeks or months ahead

Predictable waiting times

Unpredictable waiting times

No forms to fill out: oral culture

Many forms: literacy required

No insurance needed

Insurance necessary

Spirituality acknowledged

Body, mind & spirit usually separated

Sickle Cell Disease

Clinical effects of sickle cell disease include variable degrees of hemolysis and episodes of vascular occlusion resulting in tissue ischemia and chronic organ dysfunction. Hemolysis can cause jaundice, chronic anemia, delayed growth and sexual maturation, and other crises. Tissue ischemia can cause injury to all organs of the body especially the brain, kidneys, lungs, and spleen. Typically, the earliest signs of sickle cell disease are the swelling of hands and/or feet and severe pain in the extremities, back, chest, abdomen, and head. The pain is what most often brings sickle cell patients into the hospital and causes the greatest disruptions to the activities of daily living (Vichinsky & Schlis, 2006).

Sickle cell anemia is inherited in an autosomal recessive manner. Parents of patients with sickle cell anemia must have both passed on the affected Hb S gene for their child to be affected. For other types of sickle cell disease, parents must pass on different hemoglobin, beta mutations. Each sibling born to parents who are carriers has a 25% chance of being affected, a 50% chance of being a carrier, and a 25% of being unaffected and not a carrier (Vichinsky & Schlis, 2006). These percentages also apply to any subsequent pregnancies a family may have. Sickle cell disease is most common in persons of African, Mediterranean, Middle Eastern, and Indian ancestry although it can affect people of any background. In African-American populations, a mutated copy of Hb S is found in 8-10% of people. Therefore, every year in the United States, about 2,000 African-Americans are born with sickle cell anemia.

It is essential to have lifetime care for this disease to prevent early death, morbidity, and to increase quality of life. Parents, providers, and the affected individual all need to be properly educated in order to make appropriate use of medical care. All families need to understand the importance of medications and maintenance visits, be aware of warning signs, have access to a 24 hour medical facility, and develop plans to deal with episodes of pain based on the severity. Patients should know to avoid dehydration, extreme temperatures, and physical exhaustion. Most affected individuals benefit from routine screenings that assess developmental and/or neurocognitive progress, nutritional and dental health, and assessments regarding support systems, lifestyle, and availability of resources. Several tests including liver function tests, assessments of iron status, a cbc and reticulocyte count, BUN, urinalysis, and serum concentration of creatinine must be administered yearly to monitor the disease (Vichinsky & Schlis, 2006).

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