Journal, February 11

            Over the last two weeks, CEDEMUNEP has been preparing to run health workshops in four Afro-Peruvian communities in Lima.  It has been interesting for me to work alongside my co-worker, Ada, who has volunteered as a community health promoter in Lima for over 10 years, and has a wealth of on-the-ground knowledge about public health in Lima.  On a quiet afternoon at work last week, I had the chance to interview her about her work, and it was an incredible opportunity for me to learn about the complexity of international development in the health sector.

In my 2^nd year urban planning course, People and Plans, we discussed the Social Determinants of Health (SDOH).  The World Health Organization (2013) defines the SDOH as “the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.”  When it comes to diseases like Tuberculosis (TB), there is a strong direct correlation with unemployment, inadequate housing, malnutrition, social exclusion, and other dimensions of poverty.  In fact, when I asked Ada about the causes of TB, she never mentioned bacteria.  While she acknowledges that the most important part of her job is to take patients their medicines every evening, and supervise them to ensure that they never miss a dose, there is much more to her visits.  First, she observes her patients’ living conditions and communicates her observations to the health centre.  Second, she ensures that they have enough food, and provides them with baskets of rice, milk, and other staples if they are not receiving proper nutrition.  Third, she teaches them how to make simple handicrafts in order to take their minds off their disease, make them feel useful, and provide them with basic income-earning opportunities.  Fourth, she makes friendly conversation and provides emotional support and encouragement, as many patients are quite socially isolated and suffer from a lack of self-esteem.  Finally, she talks to patients’ families to dispel the myths and stigma around TB, and offer recommendations for how to prevent illness and support their family members through treatment.  All of these efforts contribute to a patient’s ability to complete their treatment regimen and recover. 

Socios de Salud in Lima, 2011

Ada's account of her daily work in community-based Directly-Observed Therapy, Short-Course (DOTS) illustrates the complexity of TB and its treatment.  For decades, the Peruvian government struggled to deal with the growing TB epidemic because of their simplistic, top-down approach. Not only did treatments fail in more than half of cases—many patients that failed to complete their treatment regimens developed cases of Multi-Drug Resistant TB (MDR-TB).  Fortunately, in 1994, the not-for-profit organization Socios en Salud (the Peruvian sister organization of Paul Farmer, Jim Yong Kim, and Ophelia Dahl’s Partners in Health) began to offer assistance to Peru’s Ministry of Health, based on their experience of successful community-based TB treatment in rural Haiti.  Socios first worked with poor residents of Lima’s shanty towns to conduct community surveys, which revealed many of the aforementioned social barriers to effective treatment.  The organization then began to train community health promoters in DOTS, and design individualized treatment plans for MDR-TB patients to help surmount these barriers.  These initiatives were highly successful, and went on to revolutionize TB treatment in Peru and around the world. 

The history of TB treatment in Peru, along with Ada’s account of her experience as a community health promoter, serve as important reminders that complicated solutions do not work for complex problems in international development.  When the Peruvian government and the WHO relied on best practices in TB treatment, they were unsuccessful in treating patients who faced more significant social challenges, and they were unable to respond to the unexpected emergence of MDR-TB.  It was Socios en Salud’s innovation that finally led to a solution for outlying cases.  Furthermore, Socios proved that treatment must be holistic, considering an array of medical and social factors that lead to sickness and impede treatment. They also demonstrated the importance of approaching complex problems from the bottom-up, treating cases on an individual basis so that people do not fall through the cracks of a large, impersonal health system.  And finally, they showed us that TB treatment requires constant attention and monitoring, because people’s lives and health are always in flux. Community health promoters must constantly collect information about their patients and their environments, in order to respond effectively to their situation and determine an appropriate course of treatment.  These lessons in solving complex problems are crucial for international development practitioners to understand, and they will stay with me as I continue to work in this field.

References

World Health Organization. (2013). Social determinants of health.  Retrieved 7 February 2013 from http://www.who.int/social_determinants/en/