Monday, May 12, 2008

Shadowing an Accompagnatuer and Community Health Worker

Rural HIV Care House Visits

Whether you look left or right, banana trees consume your view. Intermittingly along the rough and rocky dirt road women will be walking with their cultivated produce balanced on their heads, children with their family’s yellow containers preparing to fetch water from the nearest well, and men with three bushels of bananas strapped to a bicycle that they are pushing. This has been the view for much of the 45-minute ride for rural HIV care house visits. This day I am shadowing an accompagnatuer and a community health worker – two mainstays and vital parts of Partners in Health’s (PIH) framework.

The idea is simple. A person in a community is trained to “accompany” another in their treatment of HIV/AIDS and their general wellbeing. It fosters a strong link in the community, acts as a referral process to the clinics, and has incredible results for adherence to treatment. It is a highly organized system in which accompagnatuers are responsible for their individual clients and then the community health workers monitor the progress with periodic joint visits. This day is one such visit. The accompagnatuer has six patients that she visits once a day at the same time to directly observe their morning antiretroviral dose and give them the medication for the afternoon. The furthest one lives 2km from her house, approximately a fifteen minute walk.

Our driver stops the creaking truck at a narrow path cut into sectioned off vegetation patches and at first I see no houses (see photo). As we continue down the path children begin to gather wondering what a “muzungu” is doing in their tiny and secluded rural community. A smile, a wave, and a greeting in kinyarwandan will be returned with brighter smiles, enthusiastic waves, and increasing curiosity. It is a recurring event that breaks initial barriers and reminds one of the simple beauties in life. We arrive at the desired mud house and exchange greetings, handshakes, and laughs at my attempts at the local tongue. The husband and wife give us the wooden bench and bring in a dried leaf mat for them to use on the floor. It is a simple gesture but it speaks volumes about the culture here and also the importance of the health workers in the eyes of the people.

The community health worker goes through a three page comprehensive questionnaire. The format is heavily geared for check marks and numbers therefore allowing me to follow along quite well. The husband and wife are both HIV+ and their first five kids have tested negative. There is a hesitancy to test the two-year-old child, which both workers attempt to address. The wife tested positive during a prenatal check up with that child, and the husband followed suit. This particular visit is evaluating the husband’s health. The questionnaire also contains other factors that are fundamental to health and are valuable resources for PIH’s social workers. Some of the alarming issues are that he eats one maybe two meals a day and that there are no mosquito nets over the three beds in the house. Positives are also noted, such as the house and metal sheet roof are in good condition and the cooking is done outside of the house. This last note is important because everyone cooks with coal, which when used inside living quarters can create numerous health risks. There are no complaints or illnesses reported and the community health worker neatly writes her findings and conclusions at the end of the last sheet.

After fifteen minutes the house visit is over. More importantly this family of eight in the deep rural areas of Eastern Rwanda has received attention that is potentially life changing. It is difficult for these people to get to a clinic so instead PIH branches out deep into the surrounding district in a proactive fashion. In essence they are trying to find the problems and bring the people in before they get worse. It is vital to understand that the mentality, which is common in many developing countries, is a visit to a doctor or clinic is only after ailment has become a serious problem. For instance the husband’s first CD4 count, the measure of the immune system’s strength, was 35 and he only got tested because his wife tested positive. To put this number into perspective HIV treatment starts at 200 and as high as 350 in malnourished populations. Less than two years later, his count is 1056, which is well within the range of an HIV negative adult. This is two more years that six children had a father and a family had a breadwinner – intangible positives that some times do not make it in statistics or reports.

The success of the accompagnatuers program has proven to be beneficial to the patient through varying areas – medical, social, and even psychological. The effect of the system and the relationship between the people in the room are highly visible. However, the meeting cannot go on too long because there are more houses to visit. After the thank yous we turn outside and are greeted by an even larger group of children. The path back to the truck is lined with string beans, bananas, and potatoes. A look around will show mud houses and endless cultivation. This is the setting, and this is the future of healthcare in rural areas of Rwanda.

Wednesday, May 7, 2008

Partners in Health

The Approach, the Vision, and the Results

It is difficult to explain everything that Partners in Health (PIH) does in Rwanda. The simple reason is their programs are too vast and comprehensive to fit in one, two, or ten blog entries. I think the better way to explain what is being done here – in the rural countryside of Eastern Rwanda – is through the philosophy and the approach that has made this non-governmental organization world renowned. PIH is an organization that functions under a human right based, development driven, and comprehensive approach. Now let me clarify that statement through tangible examples.

To call PIH a healthcare or HIV/AIDS non-governmental organization would be limiting. It is very true that they provide unparalleled healthcare, especially with treatment of HIV/AIDS, in research poor settings, such as Haiti, Rwanda, and Lesotho, but their real gains are in addressing the root of many of the problems they encounter – poverty. How do they tackle such a large yet critical component of the human condition? Of course the answer is through healthcare, but that is only the beginning. Healthcare is not only a basic human right in this organization because they don’t stop at the “standard” or the international expectation. Whether it is the successful chemotherapy treatment for pediatric Hodgkins Lymphoma (perhaps a first in the rural districts) or the mixed cocktail antiretroviral therapy that is criticized as not being cost effective, the standard here is that patients deserve everything possible just as if a member of the doctor’s staff where in the same predicament.

Of course there are other human rights that are vital in establishing a just life; education, a livable wage, housing, food are but a few. Many of these key rights are included in the practices and programs on the ground. It fits accordingly to the vision of development. If we talk about education, PIH pays for over a 1000 primary school fees for area children. If we talk about a just wage, the absolute majority of the paid staff (ranging from doctors to cooks) are Rwandan and paid above what the established wage would “normally” be (such as the same position with the Ministry of Health). The concept here is human capacity building. Above all, the over arching goal is to create a model and system that can be run completely by Rwandans in the future, much like PIH’s renowned Haiti program. To attain such a goal, training of local personnel becomes a high priority. It does not stop with medical training. They also run several income generation programs, such as teaching and providing tools for carpentry and sewing. When it comes to a dignified living space, PIH utilizes it many social workers to identify the most vulnerable or needy cases and then works to fill the need, such as a coagulated tin roof or an entire home from scratch. One doctor put it so bluntly that I had to write it down. To paraphrase - if some one has TB and they have a roof that is leaking then the TB is never going to go away. We go in, patch the roof or cover it with a plastic tarp, and now the patient gets better. So simple, yet unfortunately deemed “radical”.

The last example I will provide is perhaps one of the most essential of basic human rights – access to food. It is a topic of international importance and tragedy as the global food crisis continues to plague the world’s poorest. An extra 50 cents for a bagel gets a full page in a Connecticut newspaper, but the impact of the raising of prices effect in the developing world is the difference between eating twice a day to once or worse. In a country that is ravaged by malnourishment, PIH runs several food programs that are aimed at providing the life saving nutrients needed for survival. For instance, the pediatrics ward estimates half its patients are a result of malnourishment. The visible symptoms are so common they have a local name – “Kwashiorkor”. The eyes get puffy, the cheeks get overly chubby, and belly swells. The treatment – food of course – is two months supply and then revaluation after that period expires.

The comprehensive aspect is illustrated through the “accompagnateur” system that first made PIH “famous” in the public health world. It is best explained as a person who the organization pays to daily visit a set group of people in their community to directly assist and make sure the patient is taking their HIV or TB medications. This direct approach has many benefits. First, it accounts for an amazingly high adherence and successful continual treatment rate. Secondly, it creates a leader and a network within the community. Thirdly, it provides as a mechanism for referring someone to the clinic or hospital if they are having complications or other illness. This same practice, which started on the central plateau of Haiti, is now being used thousands of miles away in the rural countryside of Eastern Rwanda.

The Health Ministry has realized that the philosophy and approach of PIH is not only addressing healthcare needs, but in the process it is conducting development initiatives through empowering the locals. The two have partnered to scale up the rural health care sector of the country. It is a new endeavor and challenge for PIH, but not many organizations have the vision or approach to accomplish such a task.