Oh yeah, that school thing...part two
From January to May, we take three five-week blocks chosen from a variety of classes that have more or less to do with infectious disease. In the first block, I took a course called Primary Health Care in Developing Countries, and another called Conflict & Health.
The first one I chose largely because there wasn't a whole lot else on the list that I was terribly excited about taking, Mostly, I was avoiding the continuation of the epidemiology/statistics series, which would probably be very helpful but is not something I can see using enough to put myself through the unpleasantries of the actual course. Primary Health Care seemed like an apt enough course, being that this is probably where my intended career will take me anyway. Or so I thought.
The idea behind the PHC concept is something of a strange one. In nations where health infrastructure is minimal if at all existent, alternate systems of health care workers with minimal but specific training in local problems have been developed. In China this is called the "barefoot doctor" movement; other regions have different names for it. In theory, this is a good idea; it doesn't take four years of medical school to recognize the periodic fevers of malaria in places where most the population gets it more than once, and it doesn't take a doctor to hand out chloroquine at the appropriate time. And for simple matters like that, this sort of system works - if it has sufficient support to keep facilities and drug supply lines running.
But the whole concept has taken on the aura of religion. What started as a quick-and-dirty way to provide basic care in severely marginalized communities has managed to take on a following of true believers, among them the instructors of this class. Community-based health care is not seen as a service or a stop-gap until professionalized medical infrastructure can be built, but as a golden path to liberation - a way that a community can rise up out of poverty and achieve heath, wealth, and, apparently, the pursuit of second-rate medical care.
Which is, indeed, where I start to object. The evidence for the PHC actually improving health outcomes is minimal - or, if it is out there, this course directors failed to cite any of it. Far from presenting evidence on what sorts of programs have yielded better outcomes for the people involved targeted by these programs, the focus lies on how well a program adheres to the concepts of PHC - a rather circular bit of logic that neatly skirts the question of whether PHC actually provides reasonably improved medical care and health outcomes.
On top of that, there is an open hostility toward the "biomedical model" - that is, the notion that drugs and hospitals and health professionals are the key to improved health. In some part, this is true - much of the burden of disease in developing nations is tied up in conditions of poverty, and demand a system-wide solution that includes the alleviation of crowding and other such factors that drive the transmission of disease. PHC presumes to help out in that field including community development schemes as an integral part of the program.
But there's a couple of problems with all this. The obvious one is that health care provided by untrained or minimally educated local workers is bound to meet with unsurmountable technical limitations. Periodic fevers may look like malaria, but pneumonia also presents as acute fever, and these two are somewhat difficult to tell apart where both are common; additionally, they require two very different drugs which have absolutely no effect if the diagnosis is the reverse of what the local care provider guesses it might be. There's no way to fix this without at least a stethoscope and a microscope to run blood slides on, but that would take an investment in training and equipment that the PHC crowd looks down on. Apparently, they find it disempowering to inflict such technology and diagnostic precision on people.
The second objection I raise is that this system is touted not as a stop-gap until a modern health care can be installed, but an ultimate goal. Funny that wealthy nations - those with enough cash to create whatever kind of health care system they want - do not choose to venerate untrained locals over doctors, hospitals, and established clinics. And I have a strong suspicion that the course directors themselves - including one Brit and one American - do not go to half-trained community health workers when they get sick. I feel quite sure that they engage exactly the kind of system - one with university-trained professionals and well-equipped laboratories and well-stocked pharmacies - that they deplore in the developing world. It comes off as a kind of reverse snobbery: putting on a pedestal the kind of second-rate system that they have no obligation to depend on when push comes to shove.
This underlying attitude breeds some weird responses to health care professionals themselves, which probably made up a majority of the sixty or so students in the class. One doctor from Africa finally asked in exasperation what exactly her role should be in such a system. The American course director exclaimed that of course health professionals have a role! They should be serving in outreach and training positions. This struck me (and a number of others) as very odd. As a future doctor, I am not educated in either of those activities, and though I think either might be fun or interesting, it would be a total waste of my education to become a doctor only to do outreach activities, which do not take a four-year investment in expensive education to perform. In my opinion, doctors in these systems should be doing the things that community health workers should absolutely not be doing - things like cesarean sections and treatment of malignancies and management of complicated patients and surgical fixes to trauma.
There are other problems too, much of it rooted in a strange aura of naivete about what actually goes on in the developing world. One of the course directors once declared that no government ever objects when community development advocates try to build these kinds programs - which makes me think these people never read a word about Central America in the 1980s, when any sort of community development was violently quashed in nations like Guatemala and El Salvador under the guise of stamping out communism. Another time the same instructor mentioned that aid projects should be careful never to overwhelm the local capacity that has been built - an assertion that, if carried out, would mean that vital projects like mass measles vaccination should wait until each community can get it together to do it themselves. In other words, the desires of first-world PHC advocates to see a certain sort of work be done according to their dogma outweighs the objective of keeping kids from dying of measles. PHC can also be a victim of its own success - where straight-forward problems like malaria have been brought under control by community-based health projects, all that's left is the really ugly stuff that community health workers can't deal with: cancer and diabetes and neonatal sepsis and post-partum hemorrhage and the like.
But most of all, this approach demands that the poorest people in the world - those who work the hardest, those who have the least food to eat - take on the additional burden of running their own health care system. This is not something we ask wealthy people to do; wealthy people walk into a clinic or hospital built by some kind of health care system, they pay their bills through insurance or pocket cash or nationalized funds, and then they go about their lives. They are not asked to pitch in to build the clinic and create income-generating projects to finance the doctors' salary before they can access any care. And yet the PHC philosophy believes that it is entirely appropriate to ask the most poverty-stricken people of the world to do this themselves.
That was one class. The other one, Conflict & Health, was just about the most opposite in philosophy and subject matter. On one hand, the approach to the problem of providing health care in conflict zones (or "fragile states," as the current lingo goes) is the reverse of PHC: in camps for refugees and internally displaced people (refuges who are still within the borders of their home nation), there is little effort giving to building community capacity and more given to just getting people fed finding enough water and housing to provide a bare minimum of life quality. But more than that, this class covered the spectrum of approaches (from top-down aid to community-based efforts), noting the advantages and disadvantages of each and allowing for discussion for where different tactics are most appropriate for the provision of care to those most in need. Philosophically this was much more palatable than the narrow and dogmatic approach of the PHC class. And it made for some interesting discussion about what relief work is about these day - humanitarian workers used to have a somewhat protected status, and they could feel pretty safe even on the ground in some very conflict-ridden areas. Not so anymore. Because of the publicity and attention that arises when aid workers are affected, in places like Iraq and Afghanistan they have become intentional targets for any faction wanting front-page coverage in the western news media. There is much discussion about how this has evolved in Iraq, because with the recent incursion, the military has specifically encourage aid agencies to participate in the rebuilding - which certainly makes aid workers look like they are in collusion with the invading military. In other regions the situation is even worse - in Chechnya, it is estimated that fully one half of foreigners who land on the ground are kidnapped. Fifty percent. Any agencies wishing to do aid work there go in under heavily Russian military guard - which keeps them somewhat protected, but puts them squarely in the position of seeming to approve of or even aid the violent faltering Russian control over the region.
In any case, the two courses together made for an interesting (if not uncontroversial) look into health care in the developing world.
The first one I chose largely because there wasn't a whole lot else on the list that I was terribly excited about taking, Mostly, I was avoiding the continuation of the epidemiology/statistics series, which would probably be very helpful but is not something I can see using enough to put myself through the unpleasantries of the actual course. Primary Health Care seemed like an apt enough course, being that this is probably where my intended career will take me anyway. Or so I thought.
The idea behind the PHC concept is something of a strange one. In nations where health infrastructure is minimal if at all existent, alternate systems of health care workers with minimal but specific training in local problems have been developed. In China this is called the "barefoot doctor" movement; other regions have different names for it. In theory, this is a good idea; it doesn't take four years of medical school to recognize the periodic fevers of malaria in places where most the population gets it more than once, and it doesn't take a doctor to hand out chloroquine at the appropriate time. And for simple matters like that, this sort of system works - if it has sufficient support to keep facilities and drug supply lines running.
But the whole concept has taken on the aura of religion. What started as a quick-and-dirty way to provide basic care in severely marginalized communities has managed to take on a following of true believers, among them the instructors of this class. Community-based health care is not seen as a service or a stop-gap until professionalized medical infrastructure can be built, but as a golden path to liberation - a way that a community can rise up out of poverty and achieve heath, wealth, and, apparently, the pursuit of second-rate medical care.
Which is, indeed, where I start to object. The evidence for the PHC actually improving health outcomes is minimal - or, if it is out there, this course directors failed to cite any of it. Far from presenting evidence on what sorts of programs have yielded better outcomes for the people involved targeted by these programs, the focus lies on how well a program adheres to the concepts of PHC - a rather circular bit of logic that neatly skirts the question of whether PHC actually provides reasonably improved medical care and health outcomes.
On top of that, there is an open hostility toward the "biomedical model" - that is, the notion that drugs and hospitals and health professionals are the key to improved health. In some part, this is true - much of the burden of disease in developing nations is tied up in conditions of poverty, and demand a system-wide solution that includes the alleviation of crowding and other such factors that drive the transmission of disease. PHC presumes to help out in that field including community development schemes as an integral part of the program.
But there's a couple of problems with all this. The obvious one is that health care provided by untrained or minimally educated local workers is bound to meet with unsurmountable technical limitations. Periodic fevers may look like malaria, but pneumonia also presents as acute fever, and these two are somewhat difficult to tell apart where both are common; additionally, they require two very different drugs which have absolutely no effect if the diagnosis is the reverse of what the local care provider guesses it might be. There's no way to fix this without at least a stethoscope and a microscope to run blood slides on, but that would take an investment in training and equipment that the PHC crowd looks down on. Apparently, they find it disempowering to inflict such technology and diagnostic precision on people.
The second objection I raise is that this system is touted not as a stop-gap until a modern health care can be installed, but an ultimate goal. Funny that wealthy nations - those with enough cash to create whatever kind of health care system they want - do not choose to venerate untrained locals over doctors, hospitals, and established clinics. And I have a strong suspicion that the course directors themselves - including one Brit and one American - do not go to half-trained community health workers when they get sick. I feel quite sure that they engage exactly the kind of system - one with university-trained professionals and well-equipped laboratories and well-stocked pharmacies - that they deplore in the developing world. It comes off as a kind of reverse snobbery: putting on a pedestal the kind of second-rate system that they have no obligation to depend on when push comes to shove.
This underlying attitude breeds some weird responses to health care professionals themselves, which probably made up a majority of the sixty or so students in the class. One doctor from Africa finally asked in exasperation what exactly her role should be in such a system. The American course director exclaimed that of course health professionals have a role! They should be serving in outreach and training positions. This struck me (and a number of others) as very odd. As a future doctor, I am not educated in either of those activities, and though I think either might be fun or interesting, it would be a total waste of my education to become a doctor only to do outreach activities, which do not take a four-year investment in expensive education to perform. In my opinion, doctors in these systems should be doing the things that community health workers should absolutely not be doing - things like cesarean sections and treatment of malignancies and management of complicated patients and surgical fixes to trauma.
There are other problems too, much of it rooted in a strange aura of naivete about what actually goes on in the developing world. One of the course directors once declared that no government ever objects when community development advocates try to build these kinds programs - which makes me think these people never read a word about Central America in the 1980s, when any sort of community development was violently quashed in nations like Guatemala and El Salvador under the guise of stamping out communism. Another time the same instructor mentioned that aid projects should be careful never to overwhelm the local capacity that has been built - an assertion that, if carried out, would mean that vital projects like mass measles vaccination should wait until each community can get it together to do it themselves. In other words, the desires of first-world PHC advocates to see a certain sort of work be done according to their dogma outweighs the objective of keeping kids from dying of measles. PHC can also be a victim of its own success - where straight-forward problems like malaria have been brought under control by community-based health projects, all that's left is the really ugly stuff that community health workers can't deal with: cancer and diabetes and neonatal sepsis and post-partum hemorrhage and the like.
But most of all, this approach demands that the poorest people in the world - those who work the hardest, those who have the least food to eat - take on the additional burden of running their own health care system. This is not something we ask wealthy people to do; wealthy people walk into a clinic or hospital built by some kind of health care system, they pay their bills through insurance or pocket cash or nationalized funds, and then they go about their lives. They are not asked to pitch in to build the clinic and create income-generating projects to finance the doctors' salary before they can access any care. And yet the PHC philosophy believes that it is entirely appropriate to ask the most poverty-stricken people of the world to do this themselves.
That was one class. The other one, Conflict & Health, was just about the most opposite in philosophy and subject matter. On one hand, the approach to the problem of providing health care in conflict zones (or "fragile states," as the current lingo goes) is the reverse of PHC: in camps for refugees and internally displaced people (refuges who are still within the borders of their home nation), there is little effort giving to building community capacity and more given to just getting people fed finding enough water and housing to provide a bare minimum of life quality. But more than that, this class covered the spectrum of approaches (from top-down aid to community-based efforts), noting the advantages and disadvantages of each and allowing for discussion for where different tactics are most appropriate for the provision of care to those most in need. Philosophically this was much more palatable than the narrow and dogmatic approach of the PHC class. And it made for some interesting discussion about what relief work is about these day - humanitarian workers used to have a somewhat protected status, and they could feel pretty safe even on the ground in some very conflict-ridden areas. Not so anymore. Because of the publicity and attention that arises when aid workers are affected, in places like Iraq and Afghanistan they have become intentional targets for any faction wanting front-page coverage in the western news media. There is much discussion about how this has evolved in Iraq, because with the recent incursion, the military has specifically encourage aid agencies to participate in the rebuilding - which certainly makes aid workers look like they are in collusion with the invading military. In other regions the situation is even worse - in Chechnya, it is estimated that fully one half of foreigners who land on the ground are kidnapped. Fifty percent. Any agencies wishing to do aid work there go in under heavily Russian military guard - which keeps them somewhat protected, but puts them squarely in the position of seeming to approve of or even aid the violent faltering Russian control over the region.
In any case, the two courses together made for an interesting (if not uncontroversial) look into health care in the developing world.
posted by skylanda at 3:03 PM
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