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Now for this post. Seeing as health care is still such a hot topic in the states, I thought I’d share a little about a health care system half a world away.
Nepal’s health care system is pretty unique. At the minimum, each village has a health post or sub-health post, staffed with couple of health workers and nurse-midwives. In cities, there are larger government hospitals, mission hospitals, and private hospitals. My primary health center in Shreegaun is somewhere in the middle: it has over 20 staff including a doctor, staff nurse, three health workers, five nurse midwives, two lab assistants, and a psychosocial counselor. The impressive (at least, for rural Nepali standards) building houses a clinic, emergency clinic, psychosocial counseling, a pharmacy, lab testing, antenatal care unit, and birthing center. About 18,000 patients receive services at the center each year, almost all of which are free. In fact, the health center actually gives out money for use of some of its services. For example, women get paid for giving birth in the health center. Patients also receive some money for undergoing family planning procedures like tubal ligation or vasectomy. Of course, a large portion of the funding for these services comes from foreign governments and non-governmental organizations, but it seems to be working quite well.
Nepal also has a unique approach to community health. Two or three women in each village serve as female community health volunteers, whose primary responsibility is to monitor mother-child health. Each organizes a monthly mothers’ group meeting in her village. They deliver trainings (on breastfeeding, HIV/AIDS), distribute tablets (deworming, vitamin A, zinc, iron, folic acid), offer counseling (on family planning, hygiene, nutrition), and encourage visits to the primary health center for checkups. The female community health volunteers are also the primary distributors of medicine for national health campaigns, such as the recent Nepal-wide program to prevent filariasis, the disease that causes elephantiasis. As volunteers, they receive no salary but earn some money by completing reports and often receive an allowance when they attend trainings. Since the program’s conception in 1988, these social servants have had an enormous impact on the health of Nepalis, especially in remote areas.
Still, a wide range of diseases that no longer affect many Americans remain a big problem in Nepal: malnutrition, tuberculosis, hepatitis, typhoid, leprosy, malaria, and many more. In my district, the central health office has programs geared toward the monitoring and reduction of just about every one, and many of them have been successful. For instance, thanks to a national eradication program, Nepal was recently declared polio-free. As another example, NGOs and the government are collaborating to curb the spread of HIV/AIDS through awareness campaigns and condom distribution, in addition to offering free testing, counseling, and treatment. Much of the recent progress in health is remarkable: more babies and mothers are surviving childbirth, more children are reaching adulthood, and more people are living longer. What may not be clear to the average person, however, are the causes of the improvement and the next steps to take. In other words, the public doesn’t always know best.
When I ask local leaders how the community’s health status might be improved, most point to the health center. Recently, the health center held a meeting with community members to hear suggestions for improvement. Those in attendance requested more free medicine, more surgical services, a video x-ray machine, and post-mortem examinations. While these things would indeed improve the treatment of some diseases (except for post-mortem exams—even the hospital staff thought that was a strange suggestion), I found these requests to be indicative of a pervasive, skewed, and unfortunate mindset about community health needs. Because when you consider that most people in my village cook over open flames, drink untreated water straight from ground wells, don’t wash their hands with soap, don’t brush their teeth, and occasionally eat meat that’s been sitting around unrefrigerated for several days, it’s obvious that there are much greater needs than video x-rays. Greater needs even than more medicine.
Let’s take a step back and look at America’s medical history; how have we come to live longer, generally healthier lives? The timeline is marked with countless small innovations that, together, have gradually led developed countries to conquer (or at least control) some pretty substantial challenges to their wellbeing. But the pattern isn’t random; often the earliest, greatest strides have come from social developments, while more recent, biomedical advances have only shown diminishing marginal returns. Take diarrheal disease: whether necessarily or serendipitously, our ability to prevent its spread (through things like sewer systems, water treatment facilities, and flush toilets) preceded our ability to treat it (using antibiotics and other targeted pharmaceuticals). As a result, diseases like typhoid are no longer a major problem in the U.S.; in the rare cases that they do arise, we can treat them. In general, initiatives in public health have had a far greater impact on human health and longevity than have the countless medical innovations of more modern times. Even looking at just the 20th century, it’s estimated that public health efforts increased the life expectancy of Americans by 25 years, compared to 4 years from medical advances.
In the globalized world, however, there is little order to “new” technologies (comprising hundreds of years of previously unheard of advancements, suddenly made available almost all at once) raining down upon less developed countries. As such, often the quick, shiny fixes look more attractive than the predecessors that made the future innovations possible. In some cases, this is just fine—who needs a landline when cell phones are available? But playing catch-up in fast-forward can be problematic. For a patient, a doctor, or a government health official, providing free care has a more immediate, tangible effect that building latrines or hand washing stations. In most cases, however, medicine alone can’t eliminate a disease.
Some Nepalis still hold to traditional beliefs about health, superstitions that witches can invoke illness that a medicine doctor or an odd home remedy can cure. They may be suspicious of medical care; during the national filariasis campaign, for instance, we encountered a number of people who refused to be immunized, alluding to vague stories of people who’d died after taking the pills. Others (increasingly, it seems) jump straight to biomedicine, looking to medications to keep their blood pressure in check and antibiotics to cure their stomach pain. What is largely missing is the in-between—an understanding that disease comes from how we interact with the natural world, and that, as such, to protect ourselves from disease we need look no further than our own behavior. Sometimes medicines can cure us, but they aren’t a proactive way to deal with disease. Limiting a disease’s spread with more basic solutions, such as encouraging children to wash their hands, training mothers how to treat water, or teaching about nutrition, can have a much greater impact.
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