Tuesday, May 29, 2012

Time to Take Hygiene Issues Seriously

I published the following opinion piece in The New Times on 21 May 2012.

Around the world, it is well understood that catastrophic medical expenditures are a leading cause of destitution, driving some families from stability into poverty and preventing others from pulling themselves up.

One of the most common causes of hospitalization and mortality for young children in Rwanda is diarrhea and associated digestive diseases, causing tremendous suffering among the most vulnerable and hindering national development. Many of all of these cases are the result of poor hygiene and inadequate sanitation, a set of issues that we have all the tools and knowledge to solve. Vision 2020 and the Millennium Development Goals, toward which Rwanda has made strong progress in recent years, identify improved hygiene as a top priority for very good reason.

Digestive diseases pose both immediate and long-term health risks to children and families in Rwanda. Not only do the acute symptoms of diarrhea and dehydration threaten the child's health, but these can lead to malnutrition before long when the child is unable to eat. Acute malnutrition is compounded by severe diarrhea, and chronic malnutrition exacerbated by recurrent diarrhea can lead to developmental delays.

Diarrhea leads to more hospitalizations among children than any other individual cause, and is responsible for a significant portion of out-of-pocket expenditure by families in both rural and urban areas. While mutuelle de santé covers 90% of all medical costs for enrolled families, even the 10% contribution can add up very quickly with lengthy or repeated hospitalizations. Families have had to borrow and draw on help from neighbors in order to manage these expenses due to diarrhea, but sometimes this is not enough.

Through the payment of 100% of medical bills when families in Ubudehe category 1 and 2 are unable to pay, the government spends a significant amount of both the domestic and development budget to provide care for multiple hospitalizations for children with digestive diseases. This money should be used for the economic development of the nation - to build more hospitals in remote areas, to construct high quality schools to educate our youth, and to provide families with greater opportunities to build better lives for themselves and for the next generation.

Furthermore, the opportunity costs of having a parent accompany and remain with a child to the hospital are enormous. Other children who stay at home are often neglected (not by parental irresponsibility but because they must give their full attention to the sick child), placing them at risk for poor school attendance, malnutrition, and depression. Additionally, that parent cannot perform their usual income-generating activity, rendering their family more vulnerable to catastrophic medical expenditure and making it less likely they will have the resources to continue improving hygiene and sanitation at home, so all of their children are at even higher risk for future digestive diseases. A vicious cycle of poverty and disease is perpetuated, undermining development and trapping families in a state of constantly trying to respond to the next health or financial crisis.

Our most powerful tool in the struggle against digestive diseases among children in Rwanda would be a widespread change in mindset around the importance of better hygiene. The hygiene committees that already exist at the district and umudugudu levels should be sensitized around the threat poor hygiene poses to local and national development. Communities should be supervised by local leaders for the construction of adequate toilets that follow sanitation guidelines from the Ministry of Health. Families across the country must be remind by all of us at all occasions about the importance of washing hands after using the toilet and before cooking or eating. Each man, woman, and child must use potable water - whether from an improved water source or through boiling or filtering or using pharmaceutical. Every household should take pride in maintaining a clean home, with separate safe places for clothing, cooking, and eating. Finally, families must serve children food that is well prepared - not cooked too little so that dangerous bacteria remain, but not so much as to remove important vitamins.

These actions are simple and urgent. The Ministry of Health and our colleagues across the Government Institutions are availing resources for continued scale up of behaviour change communication, improved water and sanitation infrastructure, and prevention and treatment of diarrhea (including the new rotavirus vaccine), but these will mean nothing if not accompanied by a major shift in day-to-day hygiene practices by the population. As a nation, we must stand together ready to confront poor hygiene as a serious but solvable threat to our development.

Sunday, May 13, 2012

Global Health Delivery in Rwanda Course Featured in New York Times

The New York Times published an article today about the Global Health Delivery in Rwanda course, which resulted from a collaboration between Harvard Medical School and the Rwandan Ministry of Health. You can read it by clicking HERE or reading below.

Harvard Offers New Global Health Program

The success of Rwanda in providing health care to its poor has drawn the attention of the international community and has inspired a new program at Harvard University.

Rwanda was one of the poorest countries in the world in 1994, after a genocide claimed more than 500,000 lives and left the country with little or no access to medical services. In 2005, it began to rebuild its infrastructure. Now, according to the Rwandan Ministry of Health , the country provides health care and insurance to more than 90 percent of its population, inspiring medical leaders from around the globe to visit the African country to study its transformation.

Now, the Harvard School of Public Health is working with the Rwandan Ministry of Health to teach a course called Global Health Delivery in the village of Rwinkwavu twice a year.

“Rwanda is honestly starting to change the face of global health,” said Dr. Paul Farmer, one of the founders of Partners in Health , a nongovernmental organization that works in Rwanda and other poor countries. He is also the chairman of Harvard’s Department of Global Health and Social Medicine and one of the faculty members for its course in Africa.

In February, 30 African medical leaders met with Harvard faculty at the training and research center in Rwinkwavu to discuss the challenges of delivering health services in resource-poor settings. Six of these students were trained to become faculty members who will teach future classes, with the next sessions scheduled for July.

During the weeklong course, students and professors discussed case studies and conducted field visits throughout Rwanda. Because all the students are currently health workers — most are employees of the Rwandan Health Ministry — they are able to immediately apply what they learned in the Harvard course to their daily work.

Initially, the course was held only on Harvard’s campus, where students would discuss case studies on the difficulties of delivering medical services internationally.

But the course changed in February. A world away from Cambridge, Massachusetts, health professionals in Rwinkwavu discuss the same case studies. They also participate in live cases, in which students and faculty members interview doctors, nurses or other health workers, like the head of an organization working to deliver AIDS medications to the poor in Rwanda, to ask them about the challenges of their work. Visits to Rwandan clinics and hospitals allow students to see health care in action, and give them the opportunity to collaborate with other professionals to discuss solutions.

“To be a good global health provider, it’s good for students to see what others have done,” Dr. Agnes Binagwaho, who is both the Rwandan health minister and a Harvard faculty member, said by telephone.

Seeing potential for the course outside of Massachusetts, Dr. Binagwaho worked with Partners in Health to bring the Harvard curriculum to her home country.

“We hope to have students come from around the world and learn from them as well, and also have the students learning from each other, because they are all coming from countries where there are things ongoing,” she said.

There is now also a new Harvard degree, a Masters in Medical Sciences and Global Health Delivery, which will begin this autumn. Plans to offer a similar degree in Rwanda are under way.

“Above all, you need people who actually do the delivery to tackle the problems,” Dr. Farmer said. He stressed the importance of working not only in Africa, but also with African health care leaders. “Not everyone has the privilege to make it to Harvard — and we needed to reach out,” he added.

The Harvard course is one of the first that focuses exclusively on the challenges of delivering health care. It encourages students to think about how politics, economics and other social factors affect health.

“I don’t know many other groups that are looking at health care delivery as a field of study and bringing that to collaboration with African ministries of health,” said Dr. Joseph Rhatigan, the director of the Global Health Equity residency program at the Brigham and Women’s Hospital, a teaching hospital affiliated with Harvard in Boston.

Partnerships between medical schools and the developing world are increasingly common, but the majority focus on practicing medicine as opposed to delivering care and understanding the effect of social factors, he said.

Dr. Corine Karema, director of the programs for malaria and neglected tropical diseases at the Rwanda Biomedical Center and one of the students in the Harvard course who trained to become a faculty member, said the course made her change the way she looked at medical treatment.

“I’ve been working for a long time in public health, and we used to decide on intervention and strategies if they were cost effective without looking at how the strategy will best affect the patient,” she said.

She said she now had higher expectations. The course taught her to advocate the best treatment available, regardless of cost.

“Too many people in public health have been socialized for scarcity, the idea that we just have to make do with less,” said Dr. Farmer. “That socialization for scarcity has prevented innovation. That’s really what the course is about: confronting the socialization to scarcity and combating it.”

Dr. Farmer and other faculty members drew on their experiences at Partners in Health. For more than 20 years, the organization has worked in Haiti, Lesotho, Mali, Peru and other countries to make once-costly treatments for medical conditions like H.I.V. and tuberculosis available to the poor.

Although professors bring Harvard expertise to the table, they say they take as much away from the course as the students.

“I learn a lot more when I teach experienced people,” said Dr. Joia S. Mukherjee, the medical director of Partners in Health and a Harvard professor who helped organize and teach the course. “They are all saying, ‘Well, this is what we did here, this is what we did in Haiti.’ The students are learning more from one another than from professors.”

Dr. Farmer recalls students saying in a group discussion, “‘You mean that happened to you, too? Well, we had the same problem in Burundi.”’

“Within five minutes you had five people discussing a very specific problem that they had all faced,” he said. “That kind of exchange you can’t get out of a classroom, textbook or article. Watching hard-working African health care professionals sharing experiences, just for that hour session alone would have been worth the course.”

The students from Rwanda stay in contact via an online portal , and the case studies are available online as open source information.

“We agreed that in six months, we will all have a case study about something we have done in our daily work and use them as new materials for the Harvard lectures,” Dr. Karema said.

“It’s an outstanding initiative because it relates what is being done in the States to what the needs are overseas,” said Eldryd Parry, founder of THET Partnerships for Global Health, a British organization that works to improve health care in Africa and Asia. “There is so much in international aid and health that is decided in Washington, and that’s not the mind behind this program. It’s a catalyst for further interest.”

Faculty members have said that the main challenge will be maintaining funding, which is currently supported by Partners in Health, Harvard and philanthropies.

Dr. Pat Lee, who teaches at Harvard but is not affiliated with the course, said, “We have some interesting work to do as educators to adapt to the needs of different learners and tailor the curriculum so that it can be accessible to a variety of audiences.”

That will be critical if Dr. Binagwaho’s vision comes to light. In the future, she hopes to invite health professionals from around Africa and other developing countries to participate.

“We can be the example,” she said, “not teaching in theory, but teaching in practice. If you want the developing world to develop, you have to develop teaching. Courses like this have to grow.”