Nearly every night after dinner, Sarah, Catherine, Tanya and Karen and I sit for what can sometimes be hours and discuss the work we’re doing and what it means. It is one of my favorite times of day, because the conversation helps direct me to be mindful of the place I’m in and the way we interact with the community.
It appears that the Poly may have a less direct connection to those global health challenges so apparent in Queens, because we’re tucked away in our lab building prototypes instead of witnessing sickness or death firsthand. In reality, our team is working towards solving the same problems that you can see so clearly in the hospital, and therefore the problems and underlying challenges in the clinic are actually very relevant to our work. Even beyond the direct problems of global health, it is important for me to remember that themes of development and outreach are still related to me, even if they don’t always feel entirely tangible in the lab. With that logic, the observations I’ve had about common misperceptions within the development community around Blantyre may not be prevalent in my daily interactions but they are a fibre of my work. Here are the two largest misconceptions I have started thinking about from our dinner conversations and my general observations:
Misconception #1: Sustainability = education.
A large focus of groups intending to provide medical or public health interventions is to be sustainable in whatever service they supply. Leaving medical supplies is a short-term intervention. People don’t want to simply drop off materials or donations and leave; they want to ensure that the things they bring to the community have impact after they leave. The trouble is when that sustainability is equated wholly to education.
It is often true that educating people about a new health practice or educating healthcare workers about device maintenance can go a long way towards really helping a community. Education often has a long half life, so if you can effectively teach a new skill to someone it is unlikely that their new knowledge will deteriorate much over time. But oftentimes the largest obstacles to an intervention in global health aren’t as straightforward as a lack of education. Maybe it’s not worth teaching a community how important it is to wash their hands if they don’t have consistent access to clean water. Knowing how to repair a device can only go so far if the clinic you work at cannot afford replacement parts. These may seem like obvious examples, but in my experience it is much harder to make these kinds of observations when you aren’t removed from the setting. Sometimes frustration about an unexpected condition or excitement about a new project can impair vision about what the real issues are.
To avoid falling into this misconception it is absolutely essential to have a solid understanding of the environment you are working in. In engineering terms, the process of understanding the problem and forming theoretical design criteria for every educational service or new skill you try to offer is one of the most important steps in the process. In my case, I am lucky to have six other interns that I work with who can help ground my judgement and come to a more complete understanding of the global health problems we are trying to address. Staying conscious about my own perceptions helps me self-regulate and stay diligent about getting all the facts straight.
Misconception #2: There is only one type of solution that works.
This one came mostly from some of the books I’ve been reading on health and economic development interventions in Africa in the past. A lot of experts will argue either entirely in favor or completely against some kind of program- either aid cripples an economy and it must be stopped, or it is necessary to prevent countless deaths and cannot be stopped in the near future. Either hospitals must indefinitely depend on supplies from the US and other foreign entities to keep patients alive, or they should try an immediate reduction in dependance on donations of supplies to stimulate their own medical markets. One article will say that low-resource settings cannot develop without the help of others, and the next will argue that they never can develop while being handicapped by others’ interventions.
In my experience, these macroeconomic assumptions hold less water when tested on the ground. Malawian mortality rates and disease prevalence cannot be attacked with a straightforward, unidimensional approach. The best strategy is different for each circumstance, and it depends on the long-term goals and the urgency of the need being addressed.
As an example, consider the need for pulse oximeters in many of the wards I visited this year and last year. The lack of available pulse oximeters is and has been a large problem in Queens and I’m sure in other healthcare facilities in the area. An all-or-nothing approach from some of the authors I’ve read may be to not intervene in any way in order to supply these devices to the clinics. The lack of adequate technology would spurn the start of a market to locally manufacture or find pulse oximeters. If the need is present, eventually healthcare workers and government officials will find a solution, and because that solution won’t have depended on outside entities it will be much more self-sufficient than any other kind of intervention. However, this kind of sustainability is achieved at the expense of the patients in the wards today, those who are in conditions critical enough to where they cannot wait for the needs to drive the market. There’s no way of knowing how long it would take before the pulse oximeters started appearing sustainably, and in the meantime there is still suffering and mortality.
The other extreme is to look more at the short-term needs in a setting. Pulse oximeters tend to be extremely expensive, especially the type that are small enough to be used on infant patients. They’re also relatively delicate- they require maintenance and repair, as well as a periodical battery change. If an NGO delivered one hundred pulse oximeters to the nurseries at QECH, immediate patient care would improve. However, as those pulse oximeters slowly deteriorated over time, as more and more broke or were lost or ran out of battery power, the intervention would become less effective. In a few years, the hospital may be back in the same situation of not having all the tools necessary to deliver a high standard of care. Therefore the approach of indiscriminate aid or donations is also impractical, because it fails to attack the heart of the problem.
Pulse oximetry is a unique example because it highlights an area where neither method of international involvement is ideal. Other strategies like BTB’s to deliver pulse oximeters that are affordable by the hospitals try to straddle the opposing issues of providing a service while also encouraging local sustainability. There are also many other areas where one side of the argument may be better for the community than the other. The point I want to make is that the underlying issues faced in global health are multifaceted, dynamic and deeply rooted in history, economics, culture, and geography. Because of their complexity, it is impossible to make blanket statements about whether or not interventions in low-resource settings are good or bad. Each circumstance must be observed with respect to the unique setting and context that defines it.