Public Health & Human Rights

Community health workers: (Part II) The five essential components of an effective CHW program

Reviews of community health programs have shown these five components are most important to a successful program:

1) Community Health Workers (CHWs) are chosen by the community in which they live and they maintain close ties with the community.

Some programs have allowed CHW positions to be "rewarded" positions based on local politics. When positions are simply political rewards or when the workers are not local, they may lack the needed motivation.

2) CHWs have clearly defined roles.

As stated in the Lancet, "CHWs will probably perform better with clearly defined roles and a limited set of specific tasks than if they are expected to undertake a wide range of tasks."

3) Effective training and ongoing supportive supervision.

Training is not enough. It has been shown that a plan for regular supportive supervision of CHWs is important to their success, their morale, and their continued satisfaction as CHWs.

Effective training focuses not on curative care but on health education and prevention. It has been found that most CHW trainings focus overwhelmingly on curative care despite their stated goal of providing preventive training, and this generally makes CHWs less effective than they can be. As a Lancet review paper states, "much greater attention should be given to practical, task-oriented training….Curative care provided by CHWs is unlikely to have a significant impact on mortality." Again, "CHW programs have often included simple curative care to create interest and meet felt needs, and there is a marked tendency to neglect the preventive and promotive services."

4) Incentive systems.

Most early studies of community health programs assumed that volunteers were best, but, since those early days, most studies have shown than an incentive system, monetary or otherwise, retains more workers and keeps them more satisfied in their role. High worker attrition destabilizes a program and can prevent it from gaining momentum because of the need for continuous replacements, the high training costs, and the increased difficulty of managing such a program. Some effective programs have salaried workers, others give honorariums, and others provide t-shirts, badges, bags, and other non-monetary incentives. Whatever is done, most effective programs provide their CHWs with some form of incentives.

5) Support for the CHWs and their work by health professionals.

Several studies have concluded that the single most important factor in determining the success of a CHW program is the support and respect that the workers receive from health professionals. Yet, the cultural gaps between the health professionals and the community workers are usually so great that this becomes the single biggest barrier to an effective community health program.

I will use the next post to further explain what the studies show about the relationship between community health workers and health professionals and how that relationship is so critical to an effective CHW program.

Community health workers: (Part I) Who are they and how have they been effective?

Community health workers, village health workers, lay health workers, these are all terms that describe similar roles and the literature has much to say about them. I want to summarize, in a several part series, what the literature says about community health workers and their effectiveness.

Today, in 2008, there is renewed energy about primary care and community health workers and there is wide-spread acceptance that they have the potential to make significant improvements in the health of individuals and communities, but there is also growing literature indicating that there are effective and less effective ways to use community health workers.

First, what are community health workers (CHWs) or village health workers?

Most common definitions of CHWs define them as members of the community with limited training to provide basic health and nutrition services. They usually work part time as health workers and may be paid or volunteer, however they are not usually civil servants or professionally employed by a ministry of health.

In what specific areas has the work of CHWs been found to be most effective?

Studies have show these benefits of CHWs:

• increase vaccination rates
• improve health in people with lung infections
• improve health in people with malaria
• increase breastfeeding
• decrease death in the elderly
• reduction in neonatal mortality
• improvement in neonatal care
• reduction in child mortality
• management of pneumonia and malaria
• improved community and personal hygiene
• improved diarrhea management
• effective treatment of HIV/AIDS and TB

Community health workers also bring with them benefits that are sometimes difficult to quantify in a study.  Dr. Paul Farmer calls community-based care the highest standard of care.  His organization's website, Partners in Health, states, "By improving adherence to treatment, monitoring medical and socioeconomic needs, empowering patients, and reducing the risk of hospital-acquired infections, community health workers make possible a model of comprehensive, community-based care that is the highest standard of care available anywhere."

But, what makes community health workers effective and what are the potential problems that need to be addressed?  These will be taken up in the following posts.

Images of Public Health: Community health and primary care are the answer

 

(Source: WHO World Health Report 2008.  This is Monica Korir an outreach worker visiting a home in Kenya)

For many, the allure of curative medicine seems like the answer to public health.  However, while curative medicine has an important role in health, true advances in the health of the public will come most significantly through preventive community-based primary care.

The newly published World Health Report 2008 focuses on primary care and is an important document with a wealth of information.  Describing some of the key current pitfalls in health trends, the report notes three areas of concern:

1) Approaches to health that are focused on specialized curative care

2) Approaches to health that focus on short-term disease control

3) Approaches to health that encourage unregulated commercialization of health

As the report states, "these trends fly in the face of a comprehensive and balanced response to health needs."

What is needed?  According to the report, approaches to health that 1) contribute to equity and social justice, 2) reorganize services around people's needs and expectations, 3) contribute to healthy communities through integration with various services, and 4) replace short-term control with inclusive, participatory, negotiation-based leadership.

The report is well worth the read, and is full of a lot of practical evidence and guidance.

http://www.who.int/whr/2008/en/index.html

 

The rights and dignity of India's "untouchables"

There is a well-written and recent article in the UKs Sunday Herald that gives us a glimpse into the every-day plight of Dalits in India.  The writer also helps us understand some of the violence that has been taking place in India, and he helps us see the hope that many Dalits are finding.  The entire article is worth reading, and I’ve highlighted only several passages here:      

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Deekonda Tirupathi and his bride-to-be, Sucharitha, are converting to Buddhism because they are Dalits, members of society rooted below even the bottom rung of India's complex hierarchical system. Above them, four main Hindu classes, or varnas, occupy their own places in life: the priestly Brahmins; then the ruling class, the Kshatriyas; next are the Vaishyas, the artisans and traders; then follow the Shudras, labourers and servants. Those born without varna are seen as sub-human, or, as they used to be referred to, "untouchable", their lives restricted to menial jobs and duties deemed impure in Hinduism: they alone work leather, dispose of dead bodies, handle carcasses, clear human and animal excrement.

 

Our wedding couple are the latest in a long line of Dalits who hope to rid themselves of the stigma of "untouchability" and be accepted as equals by adopting a new religion. They follow in the footsteps of one of the country's greatest thinkers, Bhimrao Ramji Ambedkar, a Dalit lawyer and scholar who went on to become the main architect of India's constitution.

 

"Every day thousands of Dalits choose to embrace a new religion," says Dr Joseph D'souza, international president of the Dalit Freedom Network. "Dalits are primarily choosing Buddhism or Christianity, although some have chosen Islam. Changing their religion means they - and more important, their children - think of themselves differently. Instead of following holy texts which say they were created only for one role in life and are of lesser value than others, now they learn about a creator who made them equal and truly free. This mental change impacts on their behaviour as they attempt new careers or fight for dignity by embracing their legal rights."

 

Unsurprisingly, the talk over lunch at the wedding in Karimnagar is dominated by the topic of change. But any transition from such deeply entrenched positions may prove painful. If the caste system were to be abolished folowing next year's crucial elections then, according to Vattipalli: "There may be clashes with Hindu fundamentalists because the Hindu scriptures are everything for them."

 

His words seem to be have been born out after recent conflict in the states of Orissa, Karnataka, Tamil Nadu, Kerala and Madhya Pradesh. Trouble in Orissa alone left 13,000 people without homes when Anti-Christian violence flared up after local Hindus accused Christian Dalits of murdering a controversial holy man. Claims of forced conversions were also levelled at the Christians. (Both allegations have been vehemently denied). During the most recent clashes, one Christian woman was left dead and scores of others were injured.

 

So far the outbreaks have been relatively contained, given the size and population of the country, but Moses Vattipalli fears that Dalit empowerment may prompt reprisals.

 

"Dalits will be angry because of injustices and oppression spread over the last 3000 years," he warns. "There could be bloodshed, even civil war."

 

But Dalit campaigner D'souza takes a different view.  “Of course, any group of people that has been oppressed for thousands of years is tempted to take revenge, but I'm confident that Dalit leaders will follow the example of Gandhi and, even more so, BR Ambedkar," he says. "They will respond with a firm but peaceful defence of their rights and human dignity."

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See here for the entire article:

The oppression of ‘untouchables’ is modern India’s shame

Thousands of Indians have found a way of escaping their destiny as an outcast

Sunday Herald

By Andrew Duke

Oct. 12, 2008

http://www.sundayherald.com/life/people/display.var.2459708.0.the_oppression_of_untouchables_is_modern_indias_shame.php

Vision, hope, and dreaming of what has never been

Human beings suffer
They torture one another
They get hurt and get hard.
No poem or play or song   
Can fully right a wrong
Inflicted and endured.
History says, Don’thope
On this side of the grave,  
But then, once in a lifetime
The longed-for tidal wave 
Of justice can rise up
And hope and history rhyme.

by Seamus Heaney

 

I’ve been thinking a lot recently about conflict and health.  When one is aware of bombings, riots, stampedes, political and religious violence, and other forms of violence that are taking place around the world, it’s difficult to act as if those things don’t matter.  But, how does one respond?

 

One of the foremost experts on issues of war and peace and health and rights is Barry S. Levy.  In an article he wrote back in 2002, he stated,

"Without peace, there can be no health, basic human needs cannot be fully met, health care and public health services cannot be optimally provided, and healthy and safe physical and socio-cultural environments cannot exist. Therefore, peace, by definition, is part of public health.

 

Likewise, public health is part of peace. Without physical, mental, social, and spiritual health, there can be no peace. Without health, there can be no peace within an individual, within families, within communities or among nations."

Reading and hearing the experiences and thoughts of well-respected people and those much closer to these issues than I, several themes begin to emerge regarding violence and conflict in general, and one in particular resonates strongly within me.  Vision.  We must be people with a vision of what can be but is not yet.  People who hope, not fleetingly but with certainty.  These are what I read and see in Paul Farmer, Barry S. Levy, Joseph D’Souza, and Alexander Solzhenitsyn, all people with a personal understanding of the impacts of violence on people’s lives and how to effectively respond.

 

Last week, I had the privilege of hearing Dr. Paul Farmer speak.  He is one of those people who, impressive as are his credentials and work, portrays himself humbly.  He also is passionate about his work for the poor, for human rights and justice, and for health equity.  Paul Farmer is familiar with conflict both from his decades of work in Haiti and with his more recent work in Rwanda.  And, although the talk I heard was not specific to conflict, he said several things that are relevant here.  First, that we in public health are too often the skeptics and nay-sayers, and that we instead need to be the ones open to new ideas and open to not always basing decisions on gold-plated science.  He talked about the need to ask tough questions and that by asking those tough questions we can begin to change the status quo.  That we need to ask the questions that others can’t or won’t ask because of political or other sensitivities.

 

Barry S. Levy made a similar point in an article he wrote when he quoted President John F. Kennedy who stated in an address to the Parliament of Ireland in 1963, “The problems of the world cannot possibly be solved by skeptics or cynics whose horizons are limited by the obvious realities. We need men who can dream of things that never were, and ask why not.”  Levy continued by saying that public health leaders need to “call forth leadership in others,” people who will not simply continue doing what they’ve always done, but people who will do what is needed and what is right, regardless of whether it has ever been done before.

 

Alexander Solzhenitsyn spoke of this in a speech he gave after receiving the Nobel Prize for literature in 1970.  A man who spent many agonizing years in Russia’s state prison camps spoke of seeing “beauty” in the mundane.  And, he spoke of the power of written truth in realizing visions and in changing the world for the better.

“In agonizing moments in camp, in columns of prisoners at night, in the freezing darkness through which the little chains of lanterns shone, there often rose in our throats something we wanted to shout out to the whole world, if only the world could have heard one of us.

 

We will be told: What can literature (words) do against the pitiless onslaught of naked violence? …The simple act of an ordinary courageous man is not to take part, not to support lies. Let that come into the world and even reign over it, but not through me. Writers and artists can do more: they can vanquish lies!"

Joseph D’Souza, a person well-familiar with violence, speaks too of hope and of not giving up.  And, he too knows the power of the written word and of truth in dispelling lies and promoting justice and rights.  He writes “Sometimes the task seems too formidable.  Sometimes success seems like nothing more than a dream.”  D’Souza quotes one of the Chinese leaders of the Tiananmen Square uprising from 1989, “I dream of a day in China when the ideas of freedom, democracy, human sympathy, tolerance and equality have pervaded people’s hearts and minds…”

Dreaming for justice and “seeing” what is yet unseen are deeply Biblical concepts.  Those of us who claim a Biblical faith cannot simply see the world as it is and as it happens, but rather must view with a perspective and with questions that go beyond the boundaries of the obvious.  There is an expectation about what will be but is not yet, and there is a realization that people are more than the flesh and bones we so easily mistake for the person.  

 

Hopes, visions, expectations… these are the things I read and hear that we must hold to and work toward in spite of the nay-sayers and skeptics and keepers-of the-status-quo around us.  It seems to me that these concepts are critical to health and justice in both war and peace.

Images of Public Health: World's largest smoking ban begins on October 2

 

The world's largest ban on smoking in public places begins on October 2 throughout India.  Images similar to those found above will soon begin appearring on cigarette boxes in that country as a way to inform people of all literacy levels of the dangers of smoking.

Similar images are used on tobacco products in Australia, Canada, and several other countries and studies have shown them to be effective at motivating people to quit smoking.

How well the smoking ban in India is followed or enforced is another matter, but there is no question that the new rules have the potential to save millions of lives.

Improving health and protecting rights through culturally intelligent living

I was talking recently with a public health colleague who works with First Nations communities in Canada, and the conversation turned to the importance of cultural sensitivity and understanding when working with people of other cultures. As she stated, we need to make sure that our "programs fit the people" rather than making the people fit the program.

Having spent a lot of time outside the borders of the U.S., culture and the impact it has on our lives and the way we see the world is a topic that greatly interests me. From the footpaths of Kalimantan to the dusty village roads of Gujarat to the mountain trails of Yoro to the subways in Singapore, the culture in which we live profoundly affects the way we see the world. And, in this increasingly interconnected world, our ability to effectively talk to each other has a direct impact on the work we do to improve health and protect rights.

Respect for culture and for people of different nations is fundamental to public health and human rights work, but this respect goes far beyond a simple affirmation of differences or the teachings one can receive in a half-day training. More than knowledge, we need to think differently. The relatively new field of cultural intelligence (CQ) provides a helpful framework for understanding the complexity of effective cultural interaction.  It is troubling that many excellent organizations send people to other cultures with little to no training, yet the evidence is clear that cultural intelligence is vital for anyone working, or planning to work, in a cross-cultural setting (and, of course, you don’t even need to leave your country to encounter cross-cultural differences). 

A person who is culturally intelligence, is able, as an outsider, to interpret unfamiliar gestures and actions as if they were from that culture. The study of cultural intelligence focuses on four key factors:

Knowledge CQ: this is a person’s understanding of the differences between cultures. Knowledge about economics, laws, politics, religious beliefs, values, customs, social norms, and worldview all come under this CQ factor. One example of a question to ask is how well you know the rules for expressing non-verbal behaviors.

Interpretive CQ: this is how a person makes sense of cultural experiences and includes judgments they make about their thoughts and the thoughts of others. A person strong in this area will mentally check their assumptions as they are engaging others and they will adjust if their experience differs from what they expected. One example of a question to ask is how well you check the accuracy of your cultural knowledge when you are with people from other cultures.

Motivational CQ: this is a person’s interest in experiencing other cultures and interacting with people from those cultures. A person strong in this area will put a lot of energy toward learning about another culture and learning how to live in that culture. They also will be able to empathize with others and will want to have a strong desire to connect, even though the differences are great. It has been said that this is the most difficult factor of cultural intelligence, yet the one that can lead to the biggest cultural gains. One example of a question to ask is whether you enjoy interacting with people from other cultures.

Behavioral CQ: this is a person’s ability to adapt their behavior in ways that are culturally appropriate, and this includes both verbal and non-verbal behavior. One example of a question to ask is whether you change your verbal behavior (tone, speed, use of silence and pauses) when talking to people from another culture.

The cultural intelligence framework adds richness to the concept of culture and allows us to be more relationally effective. It brings a sense of humility to our interactions with others as it forces us to realize that we may not be the experts we think we are, and it forces us to ask uncomfortable questions about our beliefs and assumptions. In the end, cultural sensitivity is not simply about being successful in our work. It is about living intentionally and missionally with a focus on others.

Barack Obama's closest policy advisors (see previous post for McCain's advisors)

As I mentioned here before, politics, human rights, and public health are closely interwoven. And, knowing those who are most closely advising the candidates and who may well continue their roles with the next president helps me to better understand who I’m voting for and potential implications.

The information here is all public and published information and was compiled by a non-partisan health policy group. I’m going to focus here solely on the key health and foreign policy advisors of these candidates since both issues say much about how the future president may impact health and rights globally.

These are Barack Obama's closest health policy advisors:

David Cutler

• Economics professor and dean of social sciences at Harvard
• Member of the Institute of Medicine
• Has been a primary developer of Obama’s health plan
• Thinks that the primary goal of health care should be to improve quality, and feels that most healthcare spending is good.
• Author of "Your Money or Your Life: Strong Medicine for America’s Healthcare System"

Stuart Altman

• Healthcare economist and Dean of Brandeis University Social Policy and Management School.
• Worked on health care proposal for John Kerry and played a central role in the writing of Obama’s plan.
• Author of "A Cure for Spiraling Healthcare Costs"

Gregg Bloche

• Professor of law at Georgetown and adjunct professor at John Hopkins School of Public Health.
• Visiting fellow at the Harvard Program on Ethics and Health
• Consultant on South Africa’s Truth and Reconciliation Commission on human rights in the healthcare sector.
• Author of several books including "Consumer Directed Healthcare and the Disadvantaged"

Tom Daschle

• Former Senate majority leader.
• Consultant for a law firm advising on healthcare and other issue.
• A senior fellow at the Center for American Progress
• Co-Chair of ONE Vote ’08, which aims to address health and poverty in developing countries.
• Author of "Critical"

David Blumenthal

• Professor of Medicine and Healthcare Policy at Harvard
• Has worked on past presidential candidates’ healthcare proposals including Obama’s plan.
• A strong advocate of health information technology.
• Author of "Health Information Technology: What is the Federal Government’s Role?"

These are Barack Obama's closest foreign policy advisors:

Denis McDonough

• Senior fellow at the Center for American Progress
• A former foreign policy advisor to Tom Daschle, including work on HIV/AIDS, war on terror, and other topics.
• Author of "Balancing our Climate Debt: The Group of Eight have an Obligation"

Greg Craig

• Partner at a law firm who has represented several high profile clients including former U.N. secretary Kofi Anan.
• Advised Senator Edward Kennedy on defense and foreign policy in the 1980s and a former director of policy during the Clinton administration.

Susan Rice

• Was recently a senior fellow at the Brookings Institution
• A senior advisor on the Kerry campaign
• Author of "The Threat of Global Poverty"

Tony Lake

• Professor of diplomacy at Georgetown.
• National security advisor to President Clinton

Richard Danzig

• Bioweapons consultant to the Pentagon
• Former Secretary of the Navy from 1998 – 2001.
• Believes the overall US strategy should be to reduce the amount of armed conflict in the world.
• Author of "The Big Three: Our Greatest Security Risks and How to Address Them"

Dan Shapiro (Middle East policy advisor)

• Vice president of a lobbying and consulting firm
• Former legislative advisor

Dan Restrepo (Latin American policy advisor)

• Director of the Americas Project at the Center for American Progress
• Author of "The United States and Latin America: After ‘The Washington Consensus’"

Scott Gration (national security advisor)

• CEO of Millennium Villages, a project to assist African nations out of poverty based on the U.N.’s Millennium Development Goals.
• Retired 2-star general in the Air Force.

John McCain's closest policy advisors (see next post for Obama's advisors)

As I mentioned here before, politics, human rights, and public health are closely interwoven. And, knowing those who are most closely advising the candidates and who may well continue their roles with the next president helps me to better understand who I’m voting for and potential implications.

The information here is all public and published information and was compiled by a non-partisan health policy group. I’m going to focus here solely on the key health and foreign policy advisors of these candidates since both issues say much about how the future president may impact health and rights globally.

These are John McCain’s closest health policy advisors:

Douglas Holtz-Eakin

• President of DHE Consulting
• Former director of the Congressional Budget Office
• Chief economist for President Bush’s Council of Economic Advisors
• Argues that health reform is needed and advocates relying on market forces.
• Author of "Healthcare Reform in the U.S: How, When and Why"

Stephen Parente

• Professor of finance at the University of Minnesota and a professor at the Bloomberg School of Public Health.
• Helped craft McCain's health care plan.

Raissa Downs

• A partner at a lobbying firm that specializes in healthcare. Client include AARP, Amgen, Sanofi-Aventis, and Blue Cross Blue Shield.
• Former Deputy Assistant Secretary for Health at the U.S. Department of Health and Human Services.

Tom Miller

• A resident fellow at the American Enterprise Institute for Public Policy Research
• A former senior health economist for the joint Economic Committee of the U.S. Congress
• His research focuses on transparency for health services, regulation, and consumer-driven health care.
• Author of "Measuring Disparities, Improving Health: Closing the Gap"

Regina Herzlinger

• Professor at Harvard Business school known as a strong supporter of consumer-driven healthcare. She has published books and articles about health care and the need for a consumer-driven system.
• Author of "Who Killed Healthcare?"

Dan Crippen

• Member of the 2007 Google Health Advisory Council and a healthcare consultant. 
• Helped found the lobbying group, the Duberstein Group.
• Former director of the Congressional Budget Office and was a domestic policy advisor to President Reagan.

These are McCain's closest foreign policy advisors:

Randy Scheunemann

• Founder of Orion Strategies, a lobbying firm.
• Co-founder of the Committee for the Liberation of Iraq, a NGO seeking support for the democratization of Iraq.

Richard Williamson

• Serving as the U.S special envoy to Sudan.
• Served as the ambassador to the U.N. for special political affairs and as the ambassador to the U.N.’s Commission on Human Rights.
• A senior foreign policy advisor for Presidents Reagan, Bush, and Bush.
• Author of "Seeking Firm Footing: America in the World in the New Century"

John Lehman (national security advisor)

• Member of the 9/11 Commission
• Former Navy Secretary in the Reagan administration.

James Woolsey (national security advisor)

• Director of CIA from 1993-1995
• Main focuses are energy policies and their role in national security.  An advocate of clean energy, electric transport, and biofuels.

When the free market isn't always the best answer

When the actions of the free market lead to a near-global economic collapse, it's time to begin seriously considering whether the free market is the answer for health care.

The free market is not the answer to lowering health care costs (which is greatly needed) nor the answer to better health care for everyone.  In fact, the closest example of market-based health insurance, Health Savings Accounts (HSAs), cannot fairly be called health insurance at all.  Nonetheless, market-based solutions to health care are the politically popular ones and the only options that continue to receive serious consideration.

Greed, lack of transparency, and complex sets of rules are what people are agreeing has brought the economic market to its critical point today in need of rescue, and there is no reason to think that a free-market solution to health care will have better results.