For the next few weeks, I’ll be writing about an idea that can make people healthier while bringing down health care costs, both in poor countries and in the United States.
The strategy is to move beyond doctors — to take the work of health care and shift down from doctors and nurses to lay people, peers and family. In the United States and other wealthy countries, lay people can fill in the gaps in left by doctors’ care. In poor countries, people with no or little formal medical training are successfully substituting for doctors and nurses.
This is fortunate, as villagers in many developing countries rarely see doctors or nurses. Especially in English-speaking parts of Africa and south Asia, doctors and nurses are often poached by better pay and conditions offered by Canada, the United States, Britain and Australia. Half the doctors trained in Ethiopia or Zambia, for example, have emigrated. (And each doctor who goes from, say, Kenya to Britain represents a transfer of about $600,000 from a poor country to a wealthy one.)
Even doctors who don’t leave the country tend to stay in cities, where they treat patients who can pay. The distribution of nurses is only slightly more equitable. Rural villages do not tempt them.
But are doctors and nurses necessary to improve rural health? Two very successful programs in desperately poor parts of India’s Maharashtra state say no. SEARCH (the Society for Education, Action and Research in Community Health), in the district of Gadchiroli, and the Comprehensive Rural Health Project, in the district of Jamkhed, both recruit ordinary women to take care of their villages’ health. They have had a huge impact on the health and prosperity of their villages.
The Jamkhed program works with India’s most downtrodden people. Its trainees are women, many of them members of the Untouchable caste, many illiterate. When I visited the program in 2008, I met Jamkhed health workers who are lepers and those who were married at the age of two and a half.
While Leelabai Amte is a higher-caste Maratha, not an Untouchable, she was totally illiterate when she became a village health worker — she has since learned to read and write. She was married at 10 and had her first son at 13. Today, however, she is a respected authority figure in her village of 6,000 people, Halgaon. Amte was 60 when I met her, a very thin woman with thick glasses and no front teeth.
Twice a day, at nine in the morning and six at night, she set off through the streets of Halgaon, carrying a blood pressure cuff and a baby scale in her black shoulder bag, along with a log book. She visited the newborns she had delivered, pregnant women, old people. Her first stop one morning in January was the home of a three-day-old baby boy. Amte watched the baby suckle and then tied him in a cloth sling and hooked it to her scale. He was three and a half kilos, nearly eight pounds — a remarkable gain over his three-kilo birth weight. She murmured approvingly. “Don’t put anything on the umbilical cord,” she said. “And keep the child in the sunlight in the morning.”
“Twenty years ago, mothers waited three days to breast-feed their babies,” she said – a superstition that deprived babies of valuable colostrum and reduced the mothers’ supply of milk. Today, Amte has banished this and dozens of other superstitions from Halgaon. When she started working in Halgaon in 1977, families had six or seven children. The children often had scabies and other skin diseases. They were unvaccinated and often sick. Night blindness due to Vitamin A deficiency was everywhere. Tuberculosis and leprosy were common, and their sufferers were ostracized. People attributed illness to curses from the gods.
Today there is no more infant mortality, and TB and leprosy are gone. Mothers eat better — the average birth weight of a baby has gone from about four and a half pounds to six and a half. New mothers are taught how to feed and care for their babies. Children get regular immunizations. Now almost every mother knows how to treat diarrhea and fever.
At a busy corner in the center of town, Amte was in the middle of a crowd of about 20 men, talking about installing toilets in Halgaon’s houses. Village women in India do not speak out to men, but Amte does. In the street she saw the husband of one of her pregnant patients — a woman overdue for her prenatal visit to the program’s hospital. “Why is your wife not coming to the hospital?” she scolded him. “We’ll check everything, give her blood tests.” The man had the grace to look sheepish. “I’ve been busy with farming,” he told Amte. “Next month I’ll bring her.”
All of the Jamkhed women say that the most important thing they do is teach others. Amte has trained three village women to deliver babies. At one house she quizzed a high-school girl. “If a child has a fever, what do you do?” Amte asked.
“Cold compresses,” said the girl promptly.
“And diarrhea?”
“You give oral rehydration mixture.”
“Do they teach you about health in school?” asked Amte. “Do they tell you about safe drinking water and keeping yourself clean?”
“No,” the girl replied. “You are the one who talks about that.”
The Jamkhed program was founded in 1970 by Raj and Mabelle Arole. Mabelle (who died in 1997) and Raj were first and second in their class respectively at a prestigious Indian medical school. They shared not only medical talent, but a dissatisfaction with the kind of medicine they were being taught — curative medicine, the kind useful for wealthy countries.
They moved back to Jamkhed, near where Raj was born, a location they chose largely for its desolation. They decided that doctors were not the way to help rural villages. The vast majority of sickness in rural areas could be prevented with clean water, waste-disposal systems and more diverse farming. Villages need to end deadly superstitions about health. They need to end discrimination against women and Untouchables, and to learn about hand-washing, nutrition, breast-feeding and simple home remedies. Doctors do none of these things.
“Rural problems are simple,” Raj Arole told me. “We do not need experts. An array of women like village health workers is enough, properly trained and supported.” The very prestige and distance of doctors worked against them. The Aroles found that lack of education was an advantage for village health workers. They knew how their neighbors lived and thought.
The Aroles went to various villages and asked each to choose a woman to send to the program’s headquarters in Jamkhed, which is also the name of the district’s major city, to learn to be a health worker. Mabelle and the couple’s daughter, Shobha, now a doctor who runs the program, conducted the training.
Teaching the women health skills was the easy part. Illiteracy was not an overwhelming problem. The real problem was the women’s complete absence of confidence. Their entire lives had been lessons in keeping their heads down. They had to gain confidence from each other.
Amte and many of the other active health workers gather at the Jamkhed campus every Tuesday. They discuss problems in their village and learn about new health subjects. New health workers go in groups of three or four to stay with more experienced peers in their village for a week. They watch their mentor as she greets her neighbors with assurance, works with local all-men farmers clubs, sees patients and teaches mothers about breastfeeding or purifying water.
Starting out, none of the women could imagine that their neighbors would ever listen to their advice. There was no magic in it. The answer turned out to be the expected factors: time, demonstrable success and support. There were months, sometimes years of frustration, tempered by the soothing words of more experienced health workers who had gone through the same thing. But eventually, mothers of sick children called the Jamkhed worker out of desperation, when going to the temple didn’t work. Their success in curing a child’s diarrhea or delivering a baby after a difficult labor was the turning point. After that, people started listening when they talked about clean water, breastfeeding and nutrition as well.
Indian statistics have long shown that Jamkhed villages are far healthier than their neighbors. A new study published in the Bulletin of the World Health Organization found that Jamkhed’s program has reduced child deaths by 30 percent but had no significant effect on neonatal deaths — those in the first month of life.
SEARCH, by contrast, focuses on more traditional medicine. Like Jamkhed, SEARCH was founded by a husband-and-wife team of Indian doctors who studied public health at Johns Hopkins University in Baltimore, Abhay and Rani Bang. But there are differences. SEARCH is newer, founded in 1985. It requires its health workers to have more education —literacy at least, and some of the women have finished 10th grade. SEARCH trains them to work with mothers in their homes to have healthy children. The health workers visit pregnant women repeatedly, attend births, teach mothers about how to keep their babies healthy and check in on the children often. They diagnose and treat illnesses, and even administer injectable antibiotics to treat blood infections.
The Bangs carry out numerous studies of their work. In 1999, they published an article in the medical journal Lancet, showing that their home-based care program reduced neonatal and infant mortality by 50 percent.
That caught the attention of the Connecticut-based humanitarian agency Save the Children. “Neonatal mortality was an important and neglected health issue,” said David Oot, associate vice president for health and nutrition at Save the Children. “But the deaths occur at home without exposure to the formal health system. So people thought there was little you could do.”
SEARCH proved there was a lot you could do. For the past 10 years, SEARCH has worked with Save the Children to study new ways community health workers can work with mothers, and teach these methods to others. On Saturday, I will look at what makes Jamkhed and SEARCH so successful when similar programs have failed elsewhere, and how their ideas are now reaching millions of people around the world.
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Tina Rosenberg won a Pulitzer Prize for her book “The Haunted Land: Facing Europe’s Ghosts After Communism.” She is a former editorial writer for The Times and now a contributing writer for the paper’s Sunday magazine. Her new book, “Join the Club: How Peer Pressure Can Transform the World,” is forthcoming from W.W. Norton.
