Tuesday, August 19, 2008

my response to being-self-righteous-know-it-all-yeavou

Colleen, my partner in crime this past year as co-president of GlobeMed at NU and the one who will be spending 9 months at the HOPE Center this year working to develop an HIV VCT (voluntary testing and counseling center), has some important analysis of her experiences so far at the Center. See here for her blog post.

I completely agree with the fact that the HOPE Center is not the community transforming, daily life-saving medical center to which people flock from miles around. It's not Zanmi Lasante. But I think that it is important to remember that the HOPE Center is still new, just a little over a year old, and in reality, we are still working to put the routine systems into place such as patient intake and record keeping that I've mentioned earlier. And although the HOPE Center is not an all encompassing primary health care clinic where people can be treated for all ranges of infectious diseases and injuries, it is still providing treatment for Anthony's open sores, antimalarial medication for hundreds of local villagers, antibiotics for babies with diarrheal diseases, and family planning for many local women.

This not nearly enough, the poor communities surrounding the HOPE Center deserve much more to address their human right to health. But I think that the HOPE Center is an important start and first step towards health equity for these communities.

I remember Joia Mukherjee's (medical director of Partners in Health) talk at the 2007 GlobeMed Global Health Summit, where she discussed the challenges PIH faced when trying to scale up the services offered at their new hospital in rural Haiti, Zanme Lasante. She discussed the frustration she felt when, despite a brand new, beautiful building, with modern medical tools and trained doctors and staff, only a small trickle of patients entered on a daily basis. She knew that there were thousands of desperately sick patients in the surrounding communities. What was stopping them?

Her thesis was that PIH had not yet addressed the immense barriers which blocked poor rural Haitians from seeking medical attention. Barriers that required dialogue and anthropological research to unearth. They realized that most of their patients lived several hours walk from the hospital. In many cases, it was simply impossible for the peasant farmers to pull themselves from their fields, on which they depended for their next meal. Structural economic barriers blocked their health equity.

While many health NGOs have stopped at that point - not wishing to address the more pernicious issues of social and economic rights in addition to the right to health - PIH dove in to tackle the economic barriers which were preventing their patients health from improving. While interviewing a patient with TB about his/her symptoms, they would also ask: How much do you eat? Do you have a roof over your head? Do you sleep on a dirt floor? In addition to treating the TB patients with complex chemotherapeutic regimens, they attacked poverty by building homes and providing food assistance. To address the barrier of large rural distances, they hired a small army of community health workers. These health workers - all Haitian, and hired from a population with greater than 50% unemployment - were able to go to the distant towns and villages, check on patients receiving ARV, and directly observe TB patients receiving their medicine.

Obviously, PIH is in a different stratosphere with regard to scale and scope. But, I think that their hard learned lessons will be instructive as we ask: "Where do we go from here?"

We too, need to address the barriers which are preventing sick patients from surrounding communities to come to the HOPE Center. First, what are we charging for use of the medical services provided by the Center? I know that we accept the Ghana Health Service's National Health Insurance Service (GHS NHIS), which is highly subsidized for the rural poor, and only costs the equivalent of $7 per year for an adult. Perhaps the answer is a push to get all people in the communities that we serve covered by the NHIS, those who could not afford it would be offered coverage paid for by the HOPE Center. Even better, would be to provide completely free service to those who could not pay. While this would cost a significant amount of money, I think that the alternative is worse. Children and adults continuing to die of preventable diseases.

Another barrier to the health of these communities is the limitation of the Center's currently offered services. We currently lack a diagnostic lab to diagnose infectious diseases, so the nurses must refer most patients to the district or regional hospital, which too are underfunded and understaffed. We must ask, why would patients come to our clinic if they thought they would likely just be referred? Once the lab is installed and functioning, a doctor would enable the clinic to greatly expand the scope of disease treated at the Center.

Over the next year, with Colleen here and able to work collaboratively with Margaret (the head nurse), Joseph, and Dr. Eleeza (the regional health director), I hope that we can draft a 5 year plan with interventions aimed at addressing the barriers to health for the communities around the HOPE Center. It will be a long process, and one that should have been done before the Center opened. But, working through our progress to this point as a stepping stone, I believe that the HOPE Center can become a true access point for health equity.

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