HIV solution: decentralizing treatment & patient empowerment

At the core of successful health programs are powerful community systems. Whether they are strong local governments, community-based organizations, or just informal groups of individuals – these types of community centered systems keep health programs focused on serving people and meeting needs in ways that will be most effective for the community.

In what has been called a model for Africa and US health programs by CDC Dr. Kebba Jobarteh, Mozambique is leading the way in restructuring how HIV treatment and support is delivered. Most countries in southern Africa have very high HIV prevalence rates as well as difficulties in providing treatment to those who need it. While there are many people in need of HIV treatment, there is a critical lack of adequate health infrastructure, clinics, hospitals, and health workers, to deliver the necessary services.

Providing treatment is just the beginning of the battle. Once an individual starts treatment with antiretrovirals (ARVs) they need to continue to adhere to a regular regimen of ARVs. Access to the medications and clinics along with regularly taking ARVs present a two-fold problem in areas where health services have long been weakened by a plethora of misfortunes: apartheid, structural adjustment programs, lack of development, under-investment, etc.

The new model developed by Doctors without Borders (MSF) puts communities at the forefront. By creating “patient groups,” treatment is decentralized to small health clinics in communities. This model spreads the responsibility to communities where there is the greatest need. The patient groups act as both a delivery system for ARV drugs as well as a support network for those with HIV. In many rural areas, people don’t have the time to travel long distances for extended periods of time to get their ARV drugs. The members of a patient group take turns traveling the distance to the health clinic. Likewise, members record whether each member of their group has taken their ARVs regularly and on time, which is then reported to the health clinic.

The model is very similar to that of “community health workers” (CHWs), who are members of the community that share knowledge and provide services when health systems can’t. As a solution to the inadequate health systems seen around the world, the “patient group” model puts those who need health services in control of their own treatment with the backing of a support network from their community. This may be a more effective model than CHWs since those who need treatment are providing the treatment. What better way to understand patient needs than to listen to the patients?

The CHW model has been popularized by organizations such as Partners in Health working in communities in developing countries. The model has now spread to urban areas and “developed” countries around the world. The patient model is yet another example of rural solutions from developing countries setting the bar for gaps in health care treatment in developed countries. A patient-centered/ people-centered approach to health delivery will make health systems more effective and successful around the world.

Featured on the Americans for Informed Democracy Blog, where I’m writing as a Global Health Analyst and reposted by Partners in Health.

the universal currency of being under the weather

Review of Healing and Curing: Issues in the Social History and Anthropology of Medicine in Africa
by: Megan Vaughan

Everyone everywhere gets sick whether it is a common cold, a serious disease, or even a life-threatening virus. Likewise, communities across the world work to heal these illnesses and afflictions. Megan Vaughan reminds us that illness and healing are everywhere; there are unwell bodies everywhere and always attempts to heal those bodies. Illness and healing are regular, even normal, features in our lives. However, as Vaughan notes, illness and healing have different definitions and meanings in different areas of the world and within different cultures. How then can we unite the rhetoric into one common topic for academics to discuss?

One of my first thoughts goes to the international organization, Medecines Sans Frontiers (MSF, Doctors Without Borders), and their work across the globe conducting medical missions. How are they able to work towards comprehensive fighting of illness and healing when there are so varied ideas of illness and healing? Do they have anthropological training? Are they equipped with a cultural guide?

Vaughan notes that in Feierman’s article he cited Gilbert Lewis’ work in Papua New Guinea.

Lewis had defined the universe of misfortune by determining who was and who was not ill according to scientific criteria, and then observed how illness was diagnosed and treated within the community. As Feierman pointed out, this was a radically different anthropological approach to that taken by Victor Turner in The Drums of Afflication, a study in which illness appeared to have little independent biological reality, but was described as an important stage in a social drama. (284-5)

Lewis’ work was both innovative and radical in that he worked to apply his Western scientific knowledge well at the same time watching and learning how local communities treated illnesses.
I’d have to say this idea is no longer so radical and more likely than not has become the norm for those working in organizations like MSF.

Among ordinary people in cases of illness caused by sorcery, or in other words by one person’s aggression against another, the course of treatment developed into a contest of power between the medicine men working for and against the sick person. The patient could not recover unless his supporting healer proved fully dominant, and therefore capable of ending the contest of strength. (286)

An issue often arises between separating metaphor and symbol from biological reality in discussions of illness and healing. This is an especially important context in Africa where illness and sickness can refer to actual disease as well as spiritual imbalances or curses. Recognizing the overlaps of science and culture within medical practice is key to effective healing. If culture is ignored in scientific medical realities there can be terrible consequences. But, where is the boundary of biological science in medicine?

More often we have to choose between approaches, since we simply do not have the textured evidence which might allow us to trade both the extent of biologically defined illness and the cultural experiences and constructions of that illness. I would like to argue, then, that we might want to learn something from the new well-documented pluralism of African healing systems. (287)

Something that I have studied and seen is this pluralism of African healing systems. Most notably in Ghana the traditional healers and birth attendants are integrated into the formal health care system. They are provided training and certification and often work alongside those practicing Western orthodox medicine.

[…] we neither have to be totally biologically ‘blinkered,’ focusing exclusively on the disease vector, nor do we have to go so far down the road of social constructionism as to render ‘biology’ totally passive. (287)

Beyond various relative understandings of illness and healing it is important to break into the realm of colonial medicine in order to understand certain inadequacies in response to illness and failures of healing. Vaughan notes that the study of colonial medicine has been one of the areas that has illuminated most clearly the limits of colonial power (288). In Africa, she writes how, “colonial medics were simply too thin on the ground and their instruments too blunt to be viewed either as agents of oppression or as liberators from disease, and studies of African demography confirm this view.” (288)

Although colonial medicine may have been more an inadequate colonial department, it is important to look further and apply the past to the present. The impacts of Western diseases brought by colonial powers ravaged Africa. Because of perceptions of Africans and lacking colonial medical systems, these new diseases were not addressed. A history of disease patterns doesn’t reflect on colonial medicine, but the responses to disease patterns in Africa does. Colonial responses to illness reflected problematic representations of Africa and Africans and so the historical medical accounts are filled with issue.

[…] of course there are many important differences between theories and practices of twentieth century biomedicine, and those of African healers, but in order for us to understand these differences the practice of scientific medicine in its various forms needs to be specified with the same attention to detail as are those of its African counterparts. (291)

To conclude, I applaud Vaughan’s call for medical practice to reflect the pluralism found in Africa health care systems. She writes a compelling piece and hopefully her ideas are heeded at least in medical work conducted in Africa.

the week in african health


Ethiopia a scene of over-grazing and desertification, making it difficult for both people and animals to survive. (From the MSF Photo Blog)

’There’s no reason only poor people should get malaria’

In an action that surprised many audience guests, Bill Gates, released a small number of mosquitoes into the crowd at the TED conference. Gates quit Microsoft last year to focus more on his philanthropic work. He spoke of the need, and his commitment, to put more funding towards developing drugs to combat malaria, one of the highest killers in the ‘developing’ world.
Watch the video:
Mosquito Genes Linked To Insecticide Resistance May Be New Target in Fight Against Malaria,
Insecticide malaria impact clue

When there is no village doctor

It is estimated that every fourth medical doctor and every twentieth nurse trained in Africa leaves the continent for better job prospects and better pay in wealthier countries. The UN Global Health Workforce Alliance warns that the economic crisis could further increase the medical workforce crisis across Africa.

For David Werner, who wrote the widely-translated 1970s village health care manual, “Where There is No Doctor,” medical specialization is not the best answer. “Experts come in and think they have all the answers, and end up drowning out solutions villagers could devise themselves.”

Need to Focus on Maternal, Child Health – Top AU Official

As the African Union meets in Addis Ababa, Commissioner for Social Affairs Biencé Gawana said in regards to the AU’s proposed launch of a continent-wide program,

“We will launch a movement to promote maternal and child health in the continent,” she told reporters. “It will be an advocacy campaign… together with partners like UNFPA [the UN Population Fund] and UNICEF [the UN Children’s Fund].

With 500,000 women dying in childbirth each year, Africa has some of the highest rates of maternal, infant, and child mortality. As part of the solution the AU report noted: “One of the main challenges in the promotion of maternal, infant and child health and development is access to health care facilities and services, especially at primary health delivery level and [in] rural areas.”

Zimbabwe: Cholera Infection Rate Climbs As UN Cleared to Assess Crisis

On Monday the WHO reported an increase of 2000 cholera deaths in Zimbabwe. The report was released just as President Mugabe agreed to allow a top level UN assessment team to tour the country to find solutions to curb the cholera pandemic as well as the current hunger crisis. Food security continues to plummet in may areas of Zimbabwe as many worry they will not receive aid in time.
More: Zimbabwe Cholera Statistics Rise Again As New Malaria Fears Grow,
Zimbabwe Diary: fighting cholera

South Africa: The Quiet Water Crisis

There is great concern with the cholera outbreak in Zimbabwe, but what the South African government may be missing is its very own growing water crisis. With an aging infrastructure and rising demand, the potential for deadly bacteria to be released into its water systems is high. When Mandela’s government took power in 1994, an estimated 14 million South Africans lacked access to clean water supply and 21 million people lacked proper sanitation. Although the numbers have changed drastically, the Department of Water Affairs and Forestry (DWAF) reported in 2008 that 5 million people still lacked access.

Twestival and Charity: Water

Last year SCOUT BANANA conducted a ‘Year of Water’ Project to benefit the work of Charity: Water. The organization is now utilizing the social media tool, Twitter, to raise a large amount of money to build wells across the world. Charity: Water began its work by supporting well projects across the African continent.

South Africa: ‘Development Must Adapt to Water Resources We Have’

98% of water resources are being used in South Africa. Water security is becoming an issue as pollution from mining has been difficult to clean up and no other water resources remain unused.

Obama Lifts “Global Gag Rule”

Also known as the Mexico City Policy, this move is being applauded by women’s and productive rights groups across the globe.
More: Obama Reverses U.S. Ban on Abortion-Linked Aid

University Partnership Aims to Fight HIV/AIDS More Effectively

Backed by an almost $5 million grant from the Bill & Melinda Gates Foundation, John Hopkins University is growing a partnership with Makerere University in Uganda in an attempt to combat the growing HIV/AIDS epidemic. The partnership is only in its initial steps.

Originally posted on the SCOUT BANANA blog.