August in Africa- Blog IV

Written August 12, 2008

Today I will write about a remarkable young woman I met in a remote area of Africa. However, I will first describe the context of our meeting.

I asked my friend Tewodrose Adhanom Ghebreyesus, Minister of Health for Ethiopia, to show me the system of Health Extension Workers (HEWs). Our government, through our HIV/AIDS, Malaria and USAID funds, has helped build the system. We need to ensure our money is building capacity for ultimate sustainability and not just creating an endless dependency.

To understand the design of this effort, one must first remember the starting place. This is a nation estimated to have 80 million people. Statistics don’t do the level of poverty justice, but the average annual income is $700, although the majority of people earn less than $100 a year. The entire gross domestic product of the nation is about 80% of the non-entitlement budget of HHS. Vast numbers of the people live in villages where the word remote is inadequate. The average life expectancy of a male is less than 46 years old.

The Prime Minister and Minister Twedorose properly concluded that improved health was a pre-requisite to improved economic vitality. They also concluded that with the resources they had available to them, improving health through normal methods was impossible. They had to build something unique, and they had to start basic. They concluded the first objective was to build a primary health system that was within the reach of every Ethiopian citizen. They created a construct that calls for training 30,000 public health workers known as health extension workers.

HEWs are almost all woman and typically young, generally 18 to 25 years old. The Ethiopian government sought to identify high school educated woman from every area of the country and set up a training course that lasted one year, during which the women were taught to provide a surprising and impressive array of services, and a limited number of medical treatments.

By design, HEWs live in their communities, work in pairs, and cover 1,000 households. Their job is to know the people in their community on a personal enough basis that they are able to teach, persuade and enable the adoption of improved personal health practices in a way that will attack the problem of poor health at the root.

The Ethiopian government has undertaken (again with help from HIV/AIDS money from the United States) to build a series of health centers; one for every 250,000 people. These health centers have the capacity to provide basic curative service and have around 15 beds capable of managing a patient for up to 48 hours. These are typically managed by the equivalent of what we know as physician assistants. When needs go beyond what the health center can manage, they aspire to get patients into a system of larger hospitals.

The Ethiopian government reports considerable progress on fulfilling this vision. They will have recruited and trained 24,000 of the needed 30,000 health workers, for example. They admit to being a little behind on opening new health centers, but the reality is all systems like this have weak spots and break downs, and the goals of starting with prevention and focusing on the basics seem logical and admirable.

The Minister accompanied my delegation, which included Dr. Julie Gerberding and Tim Ziemer, the Coordinator of the President’s Malaria Initiative, to Axum, Ethiopia, a small city on the northern border. Our purpose was to accompany a HEW into homes and watch her work.

In that setting, I met Abrehet Tarekegne, an attractive and smart 20-year-old woman, who has been working since she was 18 years old as a HEW. Together, we visited a family that lived in a dwelling that appeared to be typical to the area. It was made of a collection of materials including mud, stone and straw. The family had seven children ranging in age from late teens to three years old (my estimate). They cultivated the land around them with some corn and wheat. They had some chickens and three cows, which they yoke and use to plow and cultivate their fields. They told me proudly about bees they raise. It is the one crop they have that generates cash. They get the equivalent of $50 per hive. Last year they generated eight hives.

Abrehet told me privately about the conditions in which the family was living when she first visited them two years earlier. There was no separation between themselves and their animals. They had no latrine system, no malaria nets and little idea of personal hygiene. My visit revealed they had rearranged their living quarters to separate the animals, though not as completely as she hoped. The living quarters were small, maybe 14 feet by 14 feet. There were two beds, both with bed nets. They had a latrine system built so that the waste was kept away from the house. She insisted I go inside the latrine to show me the way it worked. It was slightly more information than I wanted, but it demonstrated to me how committed these health workers are. She had a list of over 250 homes she was working with.

I asked how many visits she is able to make. She told me her goal is to spend considerable time with 10 families a week. She said, “I like to spend enough time with each one so that I can make real progress. Sometimes I have to help them do things.”

Two important things to put into context here: First, she walks everywhere she goes and the families often live a long ways apart. Second, all this is on top of the routine other work she does as she moves about. I asked her if she keeps records on her work. She reached into a black bag she carries with her and produced a paper summarizing her work during the past year. During the past 12 months, working on her own, Abrehet has:

• Tested 1,100 people for HIV/AIDS
• Counseled the 9 people who tested positive
• She is currently tracking 105 pregnant woman
• She delivered 7 babies herself
• Trained 152 mothers on breast feeding
• She follows 152 woman with family planning
• Distributed 1,001 vitamin A capsules
• Vaccinated 219 children against tuberculosis
• Distributed more than 3,000 condoms

This was done by a 20-year-old woman walking from home-to-home with a canvas bag as her office.

I asked if the family had been resistant to change. She said, “Almost everybody is, but if you just keep coming back and explaining why it is important, they ultimately begin to change.”

I asked the husband about his reaction to this young woman asking him to change the way he and his family lived. He confessed to the resistance but said, “We knew her for a long time, and also believed it was the right thing.”

Minister Tewodrose told me that choosing the HEWs from the local village is a critical part of the formula. They have relationships they can build on. It was clear to me that Abrehet has begun to develop a fair amount of trust and stature by virtue of the personal service she provides. “What are your aspirations for the future?” I asked her.

“I want to get more education, maybe become a nurse or doctor,” she said. She told me she rarely takes a day off, because the needs are so abundant, but also made clear how satisfying she finds her work.

Abrehet Tarekegne, a Health Extension Worker, demonstrating how she uses one of her tools to listen to Secretary Leavitt’s heartbeat.

The Minister of Health told me they expect HEWs will provide an ongoing source of motivated medical students. He said, “We have told them, if they produce results, we will help them get an education.”

Perhaps one of the most interesting parts of our time together, was when I asked her to open her black bag and show me what was inside. It was a mini clinic. She had vaccines, malaria medication, vitamins, etc.

Abrehet Tarekegne showing Secretary Leavitt supplies she carries on her visits to families.

I have seen public health systems used like this in many other places around the developing world. El Salvador is one recent example (blog on Health Promoters). I find this system to be such a practical and efficient formula to make progress in this incredibly difficult situation.

The health system of the United States deals with a much different set of problems than a developing nation like Ethiopia, and nobody would trade our outcomes for theirs. However, there are things we can and should learn from these systems. One is that basic health care, provided by trained care extenders, in spartan facilities, is vastly superior to nothing and will produce substantial benefit to people.

Comments

My brother-in-law recently gave me a copy of a book about how the Chlorine Dioxide Ion has been tested with patients in Africa to kill malaria, but that the discoverer of the simple and affordable treatment has been unable to get it further tested with safety and efficacy studies. The ion is apparently released when Stabilized Oxygen is combined with vinegar for three minutes and taken with water...

I am a former hospital administrator from county teaching hospital in Fort Worth. I also worked with a major drug company to train their research associates...I can see why there would be little interest from drug companies for so simple a treatment...but I would think other humanitarian groups would at least investigate it...given the enormous need the Secretary is seeing on his trips in the area.

After reading the book, I contracted the flu and decided I felt so bad...why not try the drops sent to me with the book..The next morning I was completely recovered. We keep it on hand now for just such occasions and have had the same results--whether respiratory or gastro-intestinal flu! Stronger doses are reported to have caused recovery from patients in Malawi who tested positive for malaria and then their blood tested negative for malaria after the simple treatment within days.

Has anyone ever checked the treatment out?

Posted by: Marion Pattillo | August 22, 2008 at 06:23 PM

Secretary Leavitt Thank you for standing up for what is right.

Posted by: M/M W. A. Klein | August 22, 2008 at 06:31 PM

DEAR SEC. LEAVITT,
THANK YOU FOR THE COURAGE TO STAND UP AND SUPPORT THE RIGHT OF PHYSICIANS AND OTHER MEDICAL PERSONNEL TO REFRAIN FROM PARTICIPATING IN ABORTIONS.
GOD BLESS YOU. ALYSA

Posted by: ALYSA | August 22, 2008 at 07:24 PM

Thank God we still have people in government who will stand up
for those who still have solid religious beliefs. We're tired
of getting trampled. God Bless you royally, keep up the good work, we love you!!

Posted by: June | August 22, 2008 at 09:32 PM

thanks for taking a stand in support of our medical community and the community they serve. A physician or their assistants, working contrary to conscience, cannot provide the best care possible of their patients - regardless of your feelings about the procedure in question.

Posted by: John Kassouf | August 23, 2008 at 09:15 AM

Thank you for your wise decision and speaking out on protecting people's rights of choice regarding performing abortions when it goes against their beliefs and comfort levels. Please don't ever give up on things like this ever, no matter what happens!!
May God bless you and provide you with the wisdom and knowledge you need to do the right thing for us all.
Respectively,

Posted by: Carol | August 23, 2008 at 02:43 PM

Dear Secretary Leavitt,

Thank you for defending the choice of health care professionals NOT to violate their conscience.

Sincerely,

Sam and Sylvia Costanzo

Posted by: Sam and Sylvia Costanzo | August 23, 2008 at 05:35 PM

Dear Sec. Levavitt -
THANK YOU!!! for defending the choice of health care professionals NOT to violate their conscience. I pray that more medical personnel will be emboldened to do what they know is right.

Posted by: JAN DRAKE | August 24, 2008 at 04:57 PM

Secretary Leviatts,

Thank you for your support of a bill to protect health worker in the procedures that violate their conscious.

This is true freedom.

Posted by: Ron Westover | August 25, 2008 at 12:10 PM

Thank you so much for defending the choice of health care professionals NOT to violate their conscience, and let's hope that more medical personnel will be emboldened to do what they know is right. This really shouldn't even be an issue, but these days, so many decisions seem to be made in 'Bizzaro Land',instead of the USA that was founded on Christian principles.

Posted by: K O Harrison | August 25, 2008 at 10:35 PM

Thank you for taking a stand in support of our medical community and the community they serve. Thank you for defending the rights of the unborn who have no other voice but those of us who speak the words of life for them. I believe you have more support in this decision that you know. It only takes one voice to turn the tide in favor of the application of wisdom.

Posted by: Phil Stadtlander | August 26, 2008 at 12:29 PM

Physician’s conscious? What happen to patient’s RIGHTS and patient’s consent?

If you DO NOT like your scope of practice, change the specialty.

Posted by: SC | August 26, 2008 at 07:05 PM

Thank you for taking a stand to support personal freedom for health care professionals to not be forced to violate their own conscience.

Posted by: Linda H | August 29, 2008 at 12:45 PM

I am truly dismayed by the proposed regulation from the U.S. Department of Health and Human Services (HHS) that would permit health providers to refuse to provide health care based on religious or moral objection even though they are receiving federal funds. This is a clear violation of the separation of church and state, as well as a threat to anyone—woman or man—seeking reproductive health care. As a tax payer, I will not tolerate this.

Posted by: Zenas Van Slyck | September 11, 2008 at 03:51 PM

As a medical student, I have often been faced with the straight forward ridicule of my faith, especially when it dictated my response to hypothetical training scenerios in treatment of patients around hot topic issues such as abortion and physician assisted suicide. I know that this will probably not change in the future, but I also know that at this present, my opinions and actions are justified under the constitutional rights of freedom of speech. I strongly hope in the future that I will not have to face the choice of loosing my license or being forced to preform abortions or assisted suicide. In both areas, I know that there is many more options that people think that they have. I also know the power of God's grace to see patients through life's difficulties having faced many of my own. Many patients who are faced with the option of abortion are not informed well about alternatives and unfortunately, social stigma has made some of those options less attractive (adoption namely). I also know that in the case of suicide, many people chose that route as a cry for help and that is really what they need - a stronger social network and psychological and psychiatric help. So, please continue to fight for future physicians like myself who entered medicine hoping to save life and improve life and not to be forced to take it away.

Posted by: Joy Ruff | September 17, 2008 at 02:13 PM

Dear Sec. Leavitt:

Some people seem to feel threatened by your determination to protect the rights of those in the healthcare profession. Some are saying you are actually trying to discriminate against patients. Having read the rule, I know this to be untrue. I sincerely hope people will see through the propaganda being put forth by those who oppose the rule. Thank you for reminding us that those who work in healthcare have rights, too.

Posted by: Jill Beach | September 18, 2008 at 05:26 PM

Back in 1967 I was a PCV in Ethiopia and stayed at a health clinic for a few days on my way to visit Lalibela. Then the special project was against malaria - that was before HIV/AIDS. At that time the HEWs were young men (I suppose now the men are in the military). It is very sad to see how the Ethiopian government has squandered its funds on war and international bickering with Eritrea, instead of building up the country. There is a movie called "Black Gold" about coffee growers in southern Ethiopia - whose children are malnourished because they grow cash crops instead of food crops. I have seen on the news that famine is returning to Ethiopia.

In reading the comments above, I was surprised to see all the entries on your proposal to limit women's health options (and not on Ethiopian Health Workers!). The comments mostly support the rights of medical personal to refuse women the care they need. How about all the women who will be injured by such lack of care. If these people really wanted to reduce the number of abortions, they should be more than glad to have more women's health options.

I agree with the person who commented:
"I am truly dismayed by the proposed regulation from the U.S. Department of Health and Human Services (HHS) that would permit health providers to refuse to provide health care based on religious or moral objection even though they are receiving federal funds. This is a clear violation of the separation of church and state, as well as a threat to anyone—woman or man—seeking reproductive health care. As a tax payer, I will not tolerate this."

Posted by: Rose Araya | September 19, 2008 at 07:24 PM

I enjoyed reading about your trip to Africa.......the people in the United States should be very thankful that they have such high quality health care

Posted by: ArabBible | September 22, 2008 at 10:22 AM