Sunday, March 2, 2008

Deja-vu...all over again

The first time I ran into a Macalester student a few weeks ago here in Hyderabad, it wasn't a huge surprise. Mac students are always trying to save the world, so I only expected to find one in India. I didn't expect to find two in Hyderabad though. Last night, a girl approached me somewhat hysterically outside a night club, saying she recognized me from the States. Sure enough, she has seen me at Mac. In a city where you can eat street food wrapped in newspapers advertising jobs with Google, globalization is becoming very tangible.

Apart from that, work is good. Last week, we started dispatching mobile health teams to a large slum area, and needless to say, they were popular. Not surprising, as free quality healthcare can never fail in India. However, while the mobile team was doing its job, I went on a walking tour of the basti, Dewarconda. Home to about three thousand, the residents of the locality are tucked away behind the posh apartment blocks and villas of some of Hyderabad's wealthiest residents. My stated intention was to spread word about the mobile health team's timing and services, but the jaunt was more of a needs assessment/case finding trip. A community's needs, particularly when it comes to health, can be devastatingly obvious, but easily overlooked if you never bother to make first hand observation (the more I learn, the more it seems this happens in health development projects). On this trip, I found a diabetic who'd had both big toes amputated (and a rather gruesome abscess), as well as a hydroencephalic baby. I referred both of them on to the mobile team, but they evidenced a broader need: case finding. The residents of these slums are under a lot stress, and tend to work 10-14 hours a day, so it can be easy to overlook what appears to be a relatively innocuous symptom (e.g. the hydroencephalic child could suffer brain damage if the condition is not dealt with; to the eye, the kid only looks like he has a slightly swollen head and the mom didn’t think it was serious).
Case-finding also ties into other programmatic objectives. Since our goal is ultimately enable communities to achieve greater control over their own health (and in turn, health services), we provide training to community members in health. A significant avenue is through the training of community health workers, a paradigm pioneered in rural areas of the developing world (China having taken the lead several decades ago, with their "barefoot doctors"; you can read about it here: Essentially unpaid volunteers, and usually women, at a minimum these people end up serving as first contact points in rural community health systems, and can even act as "mini-doctors" who deliver many curative services. Essentially, this community health model is a response to chronic shortages of healthcare staff. In countries like India, where a very significant portion of the healthcare staff are recruited to developed nations (cruelly ironic, since many are trained in institutions supported by the Indian govt. It amounts to Indian-subsidization of Western health care), it can have a devastating impact.
The latest iteration of this migration involves a reverse migration: instead of our healthcare staff traveling abroad, patients are coming to India, as part of the much-lauded medical tourist industry. Although the odd source of pride for many in India, it's ultimately just a variation of the theme, as few of the medical staff serving foreign medical tourists would ever cater to the needs of destitute local communities.

So the innovate response of community health workers. If as a country, you’ve lost your doctors and nurses, you might as well train community members at the local level. Although it leads to some deskilling of the work force, community members offer immense benefits due to their local networks. Yet, the paradigm was initially, and still largely is, one of rural settings. The project I visited in Jamkhed was a spectacularly successful example based in such a setting. As the populations of developing countries increasingly urbanize, urban health development is becoming increasingly important. Porting the model is proving interesting. The urban poor enjoy much greater access to health services than their rural brethren, but I'm not sure if this is always a good thing. Indian healthcare has succumbed to rampant commercialism, and many hospitals' (and doctors') primary focus is not patients, but profits. Mix this with poor, relatively uneducated poor slum dwellers who often seek out care in emergency situations, and you have a prime recipe for exploitation. It also makes it tougher to operate low-cost, or no-cost health services, because we are in essence, competing with these institutions for patients, and because we don't charge a lot (or at all), we risk being perceived as inferior.
So where do community health workers fit in the urban paradigm? I'm not quite sure; I've searched the literature, and the body of work is minor compared to rural community health. However, I’m convinced that community health programs, and the community health workers that are integral to them, are needed as a counterpoint to the divergent nature of the Indian healthcare system, in which two systems are evolving. One to serve the needs of an elite, wealthy urban upper class, and another for everybody else (I’ll let you guess which one is far better resourced and staffed).
All this to say, case-finding, and accompanying referral protocols, could be a vital role for urban CHW’s. Although they might not directly deliver the vital curative services of their rural counterparts, by identifying impending illness, and in turn, referring such cases to institutions that provide quality, patient-centered care, such CHW’s might be able to help their communities make the best of a somewhat misdirected health system.
It’s a work in progress, which involves reasoning from first principles. Wish us luck ;).

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