Tuesday, January 4, 2011

It Takes a Community to Treat an Epidemic

Women and their children wait to receive maternal child health services at a health center in Tanzania. Photography by Nathan Golon.
It was a long trip from Dar es Salaam, due north then west, first on paved roads and then on dusty country paths that meandered through the fields. Few fields were planted with corn or bananas while large tracts of land were open fields with little evidence of agriculture. Clusters of thatched huts passed by quickly as we made our way to the health center. In small villages along the way, women assiduously swept the earth in front of their households as children ran around pushing a ball or playing with small sticks. Men, some old, some young, sat around in circles on low stools or tree trunks in animated conversations.

It was late in the afternoon when we finally arrived at the health center. A jubilant clinical officer came out to meet us followed by two dozen peer educators, all singing and dancing in a heartfelt welcome. I was proudly informed that this small health center had already engaged close to 300 persons with HIV in care and had close to 200 already started on HIV medicines. These are just a few of the millions who have benefited from the HIV scale-up, a historic public health achievement. While only about 100,000 individuals with HIV in low and middle income countries were able to access treatment in 2002, by the end of 2009 this number has skyrocketed to close to 4 million. Most remarkably, sub Saharan Africa is the region that has had the most dramatic increase.

How was this achieved in a region plagued with weak health systems and a multitude of health crises? Shortage of skilled health care workers, lack of continuity model of healthcare for a chronic condition like HIV, dilapidated facilities, inadequate laboratories, entrenched stigma, and poverty are just some of the challenges that faced the HIV response. As I walked around the health center, I kept pondering the question, “how was this accomplished and what does it teach us?” I visited the cramped room where the clinical officer saw all her patients, where the 44 charts of the ones she had seen that day lay on the rickety table. I opened one chart and saw the neatly filled rows of information. I followed her to the pharmacy, a tiny room where the precious medications are kept under lock and key, then passed by the laboratory where a technician proudly showed me his new equipment and his impeccably organized registers.

Dr. Wafaa El-Sadr (second from left) with ICAP Tanzania staff.
The answer to my question dawned on me when I finally sat down to talk with the staff and the peer educators, themselves living with HIV. The answer lay in the fact that they were one, one team that worked together hand in hand. No hierarchy was evident, no sense of the provider as the source of wisdom and the patient as the passive recipient. The staff described the needs of the community, the gaps in services and the innovations they had come up with to cope with impediments. The peer educators astutely asked about nutrition and poverty. They shared their need for new bicycles to be able to make home visits to check on the patients assigned to them. All were passionate about their community, all were adamant on achieving high quality of care, all were cognizant of their individual value as well as their collective power.

Many years into the future, when the history of the HIV response is written, some will credit the billions of dollars of resources for the achievements. Yet, a most important factor might be overlooked. The secret of this remarkable success may lie in the partnership that I witnessed between passionate and committed staff members with knowledgeable and empowered patients.

Wafaa El-Sadr, MD, MPH, is director of ICAP at Columbia University and director of the Center for Infectious Disease Epidemiologic Research (CIDER) at Columbia University’s Mailman School of Public Health. Dr. El-Sadr also is professor of clinical medicine and epidemiology at Columbia University.