It Takes a Village: Community and Enduring Health
Have you ever heard the expression "it takes a village to raise a child"? Well, I always personally thought the saying was a little lack luster. Don't get me wrong, the meaning is not lost on me - nor is the importance of a plethora of support for the advancement of children - but does the value of a "village" decrease once that child becomes a young man, a new mother, or an elderly woman? Of course not! Call it what you will (village, tribe, etc), their support will always matter.
In much the same way that the village raises the child, communities of healthcare workers are integral to the advancement of population health. More importantly though, individuals from your "village" - whether it be Community Health Volunteers, trained personnel, or even other individuals with similar diagnoses - are the timeless, invaluable support system without which the maintenance of population health is impossible. This analogy might be a bit of a stretch, but I've already taken it this far! What I'm saying is this: where healthcare workers intervene for a short period of time, one's community is the enduring context within which we live - and it should therefore be the focus of any truly sustainable population health program.
Now you're probably not here to read my thoughts on local-global health practices, but this introduction is important to the stories I want to share with you. Moreover, it is a tangible way to demonstrate the effect that a short time at AMPATH can have on anyone lucky enough to work here. After 5 weeks at MTRH and out in rural communities, the power of community-contextualized care has fundamentally changed the way I see the practice of medicine.
The first story is about a young Clinical Officer (kind of like a Physician's Assistant) named Robert and a small community in Sonoko. Daktari Robert, as he is called, comes from the Sonoko area and works with BIGPic - which is a large, multi-faceted effort to take healthcare out of the clinic and into the community. Beyond speaking local languages, he understands the needs and interests of the population with which he works. So we show up, van full of meds and wazungu (white people), while Daktari Robert addresses an assembled group.
This group is a collective of individuals, many with Hypertension(HTN)/Diabetes and many without. As a cohort they form a microfinance GISHE group that works to support wealth-care, meaning the members collect funds form their own income and pool it together to produce small loans for group members. That's the most basic version of the story. It also just so happens that this group is made up of many individuals with similar diagnoses, ensuring stigma and discrimination of group members based on health status is minimalized. Robert's job then is to provide health literacy and interventional medical care during these GISHE meetings.
This brings us to a patient I'll call E. E is an elderly woman who came complaining of a severe headache - as she described it, the worst of her life. She had been off HTN medications for 8 months by the time she came to see us. Disclaimer: HTN and headaches are a really, really bad combination. Take into account that E's blood pressure was 225/150, her breathing was increasingly labored, and she had been under added stress due to recent deaths in her family? That's the recipe for a stroke/MI right there. Oh, and the only facility performing ECHO/ECG/CT is Moi - which is 2 hours away by car. So there was no time to lose! Yet despite all of this information, and the urgency with which Daktari Robert explained the situation, E refused to come back with us to MTRH. What good is our medical training when the patient refuses care?
And that's when her community got involved. The group of women who had been attending the GISHE group and collecting their meds gathered around E, convinced her to come back with us, and promised to take care of her home/family while she was away. You see her greatest concern was not her health, it was her family and their funeral arrangements - concerns even Robert couldn't qualm. But her community understood the barriers preventing her from seeking care, and so they overcame them by coming together. That's the village at work.
The next story is of Elias. He is a tall, lanky, middle-aged man with a great smile and funny mannerisms who also just happens to be HIV positive. Because of his status, Elias works as an HIV Peer Navigator/Counselor for the HIV Resistance Clinic. His job is to be a village-of-one for the most difficult patients - those with poor adherence, those facing stigma and discrimination, those who need a little extra support. How can someone with no medical training be such a critical member of the medical team? He speaks a language that none of the physicians can, and I don't mean Swahili or Kalenjin. It is one that he shares with our patients - both because of their mutual diagnosis and because he understands the sociocultural context of HIV as well as the unique difficulties our patients face. It is absolutely not an overstatement to say that Elias has been and continues to be the gateway to care for hundreds of people.
The first patient I saw in clinic was a severely wasted young woman who had seemingly given up hope. She presented with partial right-sided paralysis due to a ring-enhancing lesion in her brain - probably crypto, maybe TB. Elias told me that she had worked as an engineer in Mombasa and feared discrimination from her coworkers so much that she'd almost let it kill her. Now she had come for her second visit at AMPATH, with her family by her side, and the whole gang lit up when Elias entered the room. In a mix of Kalenjin, Swahili, and English they shared their joy at her recent improvements: weight gain, recovered movement, and so on. At the same time, Elias cautioned her about allowing fear to take her backward. As she left he wrote his personal number on a card, handed it to her, and said: "take heart, sister" - to which she smiled broadly. He then turned to me, smiled, and asked Dr. Adrian Gardner: "Who's next?"
"But, Grant," you might be thinking, "what does this have to do with that longwinded intro??" - which is a totally fair criticism. I could have just told you these stories and let them impact you in their own way, and maybe I should have. But I want you - whoever you are - to ask yourself these questions: what comparison do we have to Elias in the United States? Where are the individuals with well-managed diabetes who work with our newly diagnosed patients? Why don't we have group medical care to inspire support and openness amongst individuals with similar diagnoses? Where are the volunteer healthcare workers caring for others in need?
I know there are people who would be willing to do exactly that, but our current system has no place for them. Instead, our patients hear what we, as physicians, have to say and then immediately go home to scour the internet for resources written by - you guessed it - people with their disease/disorder! There are foundations and support groups and retirement homes and billions of dollars in healthcare expenses, so what is stopping us from having the healthiest population on Earth? In my opinion, the answer lies in our inability to learn from Kenya. These stories embody the lessons we must take back home with us to the United States. So often people think that we've come here to bequeath some elite system onto a needy population. Instead, I challenge you to see Kenya as an example from which Americans can learn the true meaning of population health - and, of course, the invaluable contribution of your own village. As it is said in Swahili: mtu ni watu - a person is people.