Addressing health challenges in a resource-poor setting

If a health care system is viewed as confined (ie, inside a “box”) and assessed only through examination of its internal components, the interactions of its components will be poorly understood. Applying this principle to a resource-poor nation — by focusing on the plight of the people in the villages, townships, clinics and hospitals, and the need for money for staff education and improved resources — we may see few outcomes and feel frustrated by our inability to meet public need. A greater understanding comes from looking outside the box, to see its inputs from and outputs to the wider world.

In this article, I reflect on my experience in Pari, a resource-poor village in Papua New Guinea (PNG), near Port Moresby. Robert Black, Professor of Tropical Medicine, University of Sydney, visited PNG in 1966 and gave a lecture titled, “My God, what have we done?”.1 He noted that health workers had no way of knowing the effect of their efforts. There were no data, and we did not know whether we were making a difference.

Changes will not always be due to the efforts of health workers. In the 1970s, there was an epidemic of cut feet in Pari. The number of patients presenting for care rose from fewer than 100 per 3 months to a peak of over 300 per 3 months.2 At the same time, glass from broken beer bottles had been increasingly littering the beach. Some time earlier, pressure from the local brewery had encouraged the national parliament to repeal a regulation that placed a small recoverable fee on beer bottles. Empty bottles now had no value. The only satisfaction they offered was to be hurled at something solid and smashed. Parades to clean the beach and bins in which to safely store the broken glass were ineffective. Only when data showing the increased prevalence of cut feet in Pari became available was an accessible member of parliament convinced of the problem. The fee was restored and the epidemic fell away.

Few challenges can be addressed with such a direct legislative action or demonstrable effect. Legislation to ban the baby bottle and protect small children from infantile diarrhoea and malnutrition was passed in PNG, but it was difficult to enforce. A ban on tobacco advertising received parliamentary support, but its effect was not dramatic (Sir Isi Kevau, Dean and Professor of Medicine, University of Papua New Guinea, personal communication).

Many of the challenges faced in resource-poor settings are complex and intractable. Over a 10-year period in Pari, there were mean increases of up to 7 kg in body weight in young adults.2 Such increases, which often follow changes in activity, employment and diet accompanying urbanisation, underlie an increased prevalence of hypertension, diabetes, stroke and myocardial ischaemia — diseases previously virtually unknown in Pari, but now increasingly evident there.

Tuberculosis (TB) is an even more complex challenge. Patients often have a poor understanding of its nature and of the need for consistent and long-term therapy. TB smacks of sorcery in its insidious onset and wasting characteristics. If, after initial treatment, a patient feels much better, he or she may see no need to continue with therapy. There is a threat of persistent infectivity, spread of the disease to others, and increasing drug resistance (a major problem in PNG).

In Pari, patients who attended regularly for TB treatment had no superior understanding of the disease. Their culture recognised tension and anger as potent causes of misfortune, and many came simply to avoid upsetting me.

Complex challenges call for action inside and outside the health care box. Inside the box, health workers can manage hypertension and diabetes and beat TB. But they need support from outside the box — leadership and adequate tools for their work. PNG lacks adequate leadership at many levels. At the highest level, 21st century PNG relies on a legislature and bureaucracy that are notoriously corrupt and inefficient, as frequent articles in the national press testify. The example of decisionmakers encourages the same behaviour at all levels of society. In PNG’s main teaching hospital, I found that the basic anti-TB drug isoniazid was not available, even though it was listed on the medical stores computer. It had been stolen for sale outside the hospital.

New medical graduates in PNG — potential health care leaders — are expected to take postings in rural provinces. But the provincial administration moves slowly, if at all: salaries for new graduates are not paid, postings are not offered, and accommodation is not available (Sir Isi Kevau, personal communication). Young doctors lose heart and take up private practice in already over-doctored towns. This is common in resource-poor communities, and rural health teams flounder without direction.

What can be done to meet the challenge? Inside the box, doctors can offer advice on diet and exercise, and they can prescribe statins, hypoglycaemics and available hypotensives and anti-TB drugs. But drug costs, the discipline of taking medications and the need for repeat prescriptions make compliance unlikely and outcomes uncertain.

Outside the box, there is no simple measure comparable to legislation for returnable beer bottles. In Australian Indigenous communities, health-promoting measures prescribed by legislation have included pensions paid partly in healthy food items, proclamation of alcohol-free areas and removal of highly processed foods from local stores. There is marginal evidence of benefit, but few administrations claiming a democratic basis can countenance such direct intervention.

Leaders of resource-poor settings need to be aware of their vital roles in health care. Without informed understanding and commitment, health care flounders. Often, there seems little hope of change. But improvements to health care can be promoted by gathering facts to fuel persistent and effective advocacy, and by leaders in health care building alliances with decisionmakers who can remove impediments and create new possibilities. It is a demanding and sometimes thankless task. But in the words of Australian physician John Billings, “We must be prepared to live dangerously, and can expect to die tired”.