The convergence of international aid and community-based health

The convergence of international aid and community-based health care opportunities and challenges of practicing family medicine in rural Ethiopia Jeff Panzer, MD October 14, 2011

Etalem’s story • 3 yo girl, presented in Oct 2009, with pneumonia & malnutrition • Did not improve with malnutrition feeds • Started on TB meds. Not improving, & sent to university hospital where she was formally diagnosed with TB • Showed marked improvement (see pic from March 2010), & finished TB meds • Died from diarrheal illness just months after finishing her TB meds

Overview • Intro to Ethiopia • Lalmba & Chiri Health Center • Medical & Public Health Issues • Aid Gone Awry?

Ethiopia – Culture • Food – injera, wat • 80 different languages • Kafa zone – the birthplace of coffee!

WHO data Ethiopia United States Total population: 81, 021, 000 302, 841, 000 Gross national income per capita: $630 $44, 070 Life expectancy at birth m/f (years): 55/58 75/80 Probability of dying under five (per 1, 000 live births): 123 8 Probability of dying between 15 and 60 years m/f (per 1 000 population): 358/294 137/80 Total expenditure on health per capita: $22 $6, 714 www. who. int

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• “La – lam – ba” • NGO started in Eritrea in the 1960’s by a married couple • Lalmba’s focus is “to help the poorest of the poor” in East Africa in three areas – orphan care – medical care – public health • Current programs in Eritrea, Ethiopia, and Kenya • Locally-driven, sustainable focus

Population # of doctors Region SNNPR 15 million Zone (state) Kafa 1 million 3 Woreda (county) Decha 130, 000 2 (us) Kebele (village) ? 10, 000 Chiri U. S. has 26. 7 physicians and 98. 2 nurses & midwives per 10, 000 www. who. int

Chiri Health Center (CHC) • Built in late 1990’s by Lalmba • Run in collaboration with Government in Public-Private Partnership • The health center and orphan program is staffed by – 4 -5 expatriates – 40+ Ethiopians • Ethiopian medical personnel including – – 6 -8 nurses & health officers 1 pharmacist 1 -2 laboratory technician 4 -5 nurse assistants.

Chiri Health Center • Clinical services – – – • Public health – – • Outpatient (>100 pts/day) 15 -bed inpatient unit 2 -bed labor & delivery room Antenatal care clinic ART clinic for HIV patients DOTS program for TB patients Inpatient malnutrition refeeding program with 4 beds Anti-rabies vaccination program wound care & dressing changes Family planning Childhood vaccinations ‘minor’ surgical procedures vaccine outreach community meetings onsite TB & malnutrition education Community health worker education Social programs (financial aid) for TB patients, malnutrition families, and some referral patients.

Obstetrics • 4 -5 laboring mothers/week • Most women deliver at home • Patients requiring C-sections were driven 45 minutes away to Bonga (during daylight hours)

Makeshift ambulance and x-ray lightboard

Medical Cases

Malnutrition

Severe Malnutrition Program • Refeeding program at CHC since 2007. – F 75, F 100, & Plumpy Nut donated from UNICEF • Only program in all of Kafa Zone. (1 million people) • 10 -15 admissions each month. Average child stays about 2 weeks.

Kwash girl, on presentation After Malnutrition formula & feeds for 24 weeks

TB “The doctor in me insists that no one should die of tuberculosis today; it’s completely curable. Yet it is, at the same time, the world’s leading infectious cause of death among young adults…Exacting its toll among the world’s poor, tuberculosis has ceased to occasion much interest, either in scientific circles or in the popular press. ” Farmer, Paul. Infections and Inequalities • In 1 year at our clinic, we diagnosed around 150 patients with active TB. • DOTS = 2 months intensive phase / 6 months continuation phase • Our nutrition & housing program – “compliance” vs. access • New TB education program

Admasu – before & after (several months of) TB meds

Aid Gone Awry? • “Because the efforts this [international aid] money is paying for are largely uncoordinated and directed mostly at specific high-profile diseases—rather than at public health in general—there is a grave danger that the current age of generosity could not only fall short of expectations but actually make things worse on the ground. ” - Laurie Garrett “The Challenge of Global Health. ” Foreign Affairs Jan/Feb 2007, Volume 86, No. 1

HIV vs. other diseases HIV Other diseases 30 patients on ART Active TB=150 patients/year Staff paid by larger NGO: Case manager Community counselor Data Clerk No extra staff: No case manager No community counselor No data clerk Nurse trainings – about one week per month Nurse trainings – 1 malnutrition training for the entire year Free meds delivered to our doorstep; regularly expire Need to pick up all other meds (and buy most) and regular shortages occur Lab techs paid to transport CD 4 counts No other labs are transported

UNICEF refeeding supplies • Jimma – 4 hours • Addis – 10 hours • Awasa – 14 hours

Per Diem • Nurse salary = 2000 birr/month • Training = ____ birr/day • Transport = ____ birr/day (To be completed prior to lecture)

Measles Money • WHO funds transit of blood specimens of suspected measles patients to Addis (10 hours by bus) – First five specimens – both transit costs and per diem allowance • Measles outbreak – February 2010 – 1 st case – health officer leaves with specimen – Next 4 cases – nurses argue over who transports. Local government’s solution = both go with the specimen they collected.

Benefits of Community-based International Work • Community-based approach – Meeting the local needs comprehensively vs. • Top-down approach – one-size-fits-all – Surrogate end points

Lessons Learned • Aid work is tricky • “First, Do No Harm” • How can family doctors help? – Patient perspective – Population perspective

Questions?

References • Collier, Paul. The Bottom Billion. • Easterly, William. The White Man’s Burden. • Ethiopia: Demographic and Health Survey 2005. http: //www. measuredhs. com/pubs/pdf/FR 179. pdf • Farmer, Paul. Infections and Inequalities. • Lalmba Association. http: //www. lalmba. org/ • www. thelancet. com Vol 370 September 22, 2007 • WHO Ethiopia profile http: //www. who. int/countries/eth/en/

Contact info: jpanzer@gmail. com The End Questions? Check out: • Lalmba’s website - www. lalmba. org • The White Man’s Burden by William Easterly • The Bottom Billion by Paul Collier