Building a grass-roots, citizens’ movement for health

This is a blog that I originally wrote for Medsin. It was written following a meeting of the Peoples’ Health Movement UK at the School of Oriental and African Studies on 31st March 2012.

By the time the Health and Social Care Bill passed into law, becoming an Act, on 20^th March, it had garnered almost universal condemnation, with unprecedented agreement between the medical Royal Colleges, the British Medical Association, the Royal College of Nursing, the Royal College of Midwives, and many others – not forgetting nearly 180,000 signatures on the ‘Drop the Bill’ Government e-petition (the second-most signed petition on the site) and nearly 600,000 signatures on 38 degrees’ ‘Save Our NHS’ petition.

The Bill, from a government that had promised ‘no top-down reorganizations of the NHS’ at the last general election, represented a glaring democratic deficit. But how did such widespread opposition fall on deaf ears?

Escape from Dhaka – and two new insights

We escaped Dhaka – just in time, as once again hartals shut down the country. The streets were jammed – clearly, we were not the only ones hoping to get out of the capital for the impending six-day weekend: strikes on Wednesday and Thursday called by the opposition party, and more on Sunday and Monday by a coalition of religious groups. But getting away at short notice was not so easy, and it took us eight hours of running between bus stations, phoning friends, and begging favours before we managed to get hold of the last seven tickets on what, at half past midnight, must have been one of the last buses out of Dhaka that night.

Field Journal Week 2: A circus act in Dinajpur

The daily journal clearly didn’t work out; having spent a week each in Rangpur and Dinajpur, and a whirlwind visit to Dhaka for a day, we are now in Mymensingh for our final field visit. This blog may seem a bit all over the place – while many of the reflections in this post and others are drawn from the internship, I’ve been pursuing the Community Health Worker research in our free time, and uncovering plenty more surprises as I go – but those will be for another post.

By Wednesday, it had become a farce.

We were visiting the WASH programme – water, sanitation and hygiene. In the morning, we joined a meeting where a WASH Programme Officer delivered hygiene lessons to village members – when to wash their hands, cleaning vegetables, covering food, using the latrine. We were shown two latrines provided by BRAC – one paid for with a loan from BRAC – and hopped in the auto-rickshaws that had brought us there, to move to our next stop.

Field Journal Day 2: On marriage, money, and human rights

We are in an Area Office – one of around 300 across the country, in turn served by over 2000 Branch Offices: BRAC really does reach the end of the trail, beyond even the Government’s services.

The woman speaks confidently – a sense of conviction in her voice – she knows her rights, and has come looking her for justice. Of course, that is my impression, listening to the opening conversation without translation; the truth is far more complicated. Faruq listens quietly, occasionally nodding or agreeing – ‘Ach-ch-ch’, ‘right, right, right’.

A long speech by Faruq – the woman leans her head to one side – ‘ji, ji’ – he seems to have summarised her case well. The woman is smartly dressed – with a new green bag, blue umbrella poking out the top. Clean, gold sandals with flowers adorning the straps. She certainly doesn’t look like she’s come in from the fields – is she a volunteer? Teacher? Shashthya shebika? English words intersperse the flow of Bangla – ‘service manager’; ‘business’.

Field Journal Day 1: Arrival

We leave Dhaka – crowded, crazy, dirty, overwhelming Dhaka – and head, at last, for ‘the field’. This is, I hope, where our internship with BRAC really begins – the point of departure from the powerpoint lectures on the air-conditioned 21st floor, to interviews through interpreters sat on the ground in the midst of a microfinance meeting – perhaps. At this stage, we are still largely in the dark as to what the field will hold for us.

It’s also a point of departure in other ways. For all its mania, Dhaka has many creature-comforts; our first two meals at BRAC’s Training and Resource Centre (TARC) in Rangpur certainly set the tone – we’ll be eating rice three times a day for the next three weeks, it seems. Dhaka is also more cosmopolitan: arriving in mid-afternoon, we go for a brief trip into Rangpur’s centre to look around – and attract a large crowd of intensely staring men wherever we stop. Poor Lisa, a petite blonde French girl in our group, definitely attracts much of the attention, but Rahil, part-Bengali part-Indian, and even Toni, our Bengali BRAC coordinator, are lumped with the outsiders as some kind of visiting circus.

On human nature, and an abundance of people

Speaking to some of the other interns, I think it’s probably worth writing more frequently and less lengthily – this blog is meant to serve as a journal while in ‘the field’, and hopefully will let me mull over my Bangladeshi experience – but in order to do so, I do actually need to write – it’s very easy to store up tonnes of ideas, and never get them down on paper.

We’ll be writing more formal blogs for BRAC as part of the internship – free labour for the Communications department – so I hope to keep these more informal – more stream-of-conscience – more flowing. That will remain to be seen, I guess.

An inevitable subject for a blog here is the sheer volume of people. Bangladesh is the most densely populated country in the world (if you exclude city-states like Singapore and Monaco) – and it certainly feels like it. There simply isn’t space for privacy; though I’m staying with a well-to-do family, who even have a spare room with en suite bathroom for guests like me, there’s a constant stream of faces peering in the window or knocks at the door – ‘can we come in?’. For the first week, every time I left my room there was a new face in the house. I think I’ve narrowed it down: the father and mother; their grown-up daughters who come and go; their maid and her two children (Jack and Cindy); the doorman, Imam, who seems to have adopted me; and a number of others who work in the workshop on the top floor next to my room, hand-making saris for the ’boutique’ on the ground floor. Imam is a regular – whenever he is off duty in the evening, he will come and sit on my floor. With little English, and even less Bangla on my part, it’s a strange friendship – and not a little awkward, as he smiles and makes himself comfortable. We talk, or exchange nouns, but after a while, when I return to my emails or book, he’s quite happy to remain, and others come and join too. It’s only late at night (like now), when everyone has eventually retired to bed, that any thought of getting some work done is possible. At least in the field, when the real research begins, the BRAC centres should be a bit more conducive to work.

I’m probably being very unaccommodating and grouchy – at least, when it comes to my personal space. But if the house seems to be constantly full, the streets are heaving. Every possible nook and cranny has someone sitting, working, sleeping, begging; every road is congested with rickshaws weaving between CNGs bumping bumpers with cars. Even between the houses and the streets, the slums proliferate to fill the gap to house all these countless souls – so much so that they extend over the lake beside BRAC’s centre, on precarious stilts. I fear it wouldn’t take much of the monsoon rains to undermine them.

Despite the huge population, Bangladesh can seem incredibly small – the Bangladeshi interns with us all seem to know each other, or at least each others’ schools; one of the daughters of the family (the investment banker) I am staying with told me a story of a deal she was brokering (or whatever the jargon is), which almost went wrong but for the fact that it was a friend of her brother-in-law who was on the other end of it. Of course, it will be a small world within a certain social strata, and the vast majority of Bangladeshis no doubt did not go to the kind of schools that end you up as an investment banker – or an intern with BRAC. But another man on the street – one of the many who grab your hand and ask you where you are trying to go – led me on a merry circle round the block (for a fee), and seemed to know every person we passed. Even in the heaving, choking, urban Dhaka, it would be nice to think community is far from dead. But that’s probably being nostalgic for something that never was – getting by on who you know is human nature.

While buses burn…

… I have had a lazy day at the home of the family I’m staying with in Bangladesh. The working week being Sunday to Thursday, today should have been full of presentations and plans, but a hartal, or strike, called by the main opposition party has brought the city to a stand-still and, for fear of violence on the streets, we’ve been warned to stay inside. Apparently, the main concern is bus prices – ten had been set on fire by this morning.

I should probably explain what I’m doing here. I’m in Bangladesh. That wasn’t originally the plan. Intending to follow up my literature review (‘Project A’) in January on community health workers delivering family planning in Sub-Saharan Africa, I had hoped to go to Tanzania to carry out some field research (‘Project B’). Of course, things never quite work out as planned, especially when it involves coordinating with a host you’ve never met in a country far from home. Tanzania fell through, and my supervisor recommended I try BRAC, a development NGO in Bangladesh. Fortunately, family planning is relevant the world over, not least in one of the most densely populated countries in the world (whose land is up to 50% underwater some years), and community health workers are a concept pioneered by the grass-roots BRAC; I applied for an internship, and, some weeks later, was aboard an Emirates flight to the Indian subcontinent.

Given the enforced confinement to the house today, I’ve tried to read some more about BRAC. It’s a fascinating organization, one that goes far beyond my limited focus on health – from micro-finance to agriculture to education. This is really important, even through the lens of health, as none of these can be taken in isolation – but trying to keep my project focussed on their health programme is not the easiest when the internship programme aims to cover them all. BRAC has been training volunteers from villages throughout Bangladesh from its inception, and their health programme takes a few key interventions which can be provided by these community health workers – or shasthya shebikas - and delivers them as an ‘Essential Health Care’ package. The particular component I am interested in relates to family planning – what methods they provide, to whom, and how.

The idea of Community Health Workers is one that I’ve read much about over the last year. When I began the International Health BSc course, I felt a bit of a misfit – purposeless. Not for want of enthusiasm – I had finally rediscovered the reason why I entered medicine. But many of my classmates – and friends through the student global health network, Medsin – had become interested in global health through some particular passion for an issue – refugee health, or HIV/AIDS, or climate change. I came to first Medsin, and then the International Health course, more through mobilising students for global health – i.e. through Medsin – than in a particular area of interest. I felt this was something I lacked; I found myself looking more generally, at systems problems, for my niche.

I think I first came across Community Health Workers as a concept when reading a paper from Haiti, by some researchers from the organization Partners in Health. My reason for reading the paper wasn’t entirely academic – a friend had lent me Tracy Kidder’s Mountains Beyond Mountains the summer before, and I had become enamoured with PIH – a part of me hoped to focus on their work so that I might end up undertaking my Project B under their auspices. This was highly optimistic – the friend who had lent me the book had had similar aspirations at one time, and emailed the organisation for an entire year before eventually getting through (and accidentally seeing the email from head office: ‘I know we don’t normally accept volunteers, but this guy doesn’t seem to want to give up’).

The essay for which I read that paper turned out as can be expected from an ardent fan – far from critical or balanced, my references were largely from a small group of authors, and I failed to go beyond the conclusions they offered – which the marker took no small pleasure in highlighting to me. Nonetheless, the central concept – that community health workers can be a cornerstone in providing or increasing uptake of primary healthcare amongst the poorest and most vulnerable groups – stayed with me.

I read more. For another assignment, I produced a poster on community health workers delivering TB treatment in Bangladesh (not knowing that I would end up meeting some of them). For our non-communicable disease assignment, I wrote about lay mental health workers in India. Interestingly, as much as CHWs can be crucial in overcoming the human resource crisis in health facing many developing countries, much of the literature came from the USA: there was something about the concept which was more than simply a cheap stop-gap for missing health personnel. CHWs are a unique resource that have valuable qualities in themselves: they are of the communities they serve, and so are familiar with both the people and the problems. They are far from perfect, but in a world with rising healthcare costs, increasing co-morbidities, and a renewed emphasis on the Alma-Ata principles of Primary Health Care, there are few people better placed to tackle these challenges.

Community Health Workers can challenge our preconceptions of how a healthcare system should run, sometimes in quite awkward ways: in some studies, they have been shown to achieve the same and, sometimes, better results for particular (limited) interventions than their physician counterparts. While their diagnostic and technical skills are necessarily limited, given their short training, CHWs can effectively screen for common ailments that have safe, evidence-based treatments – for example, pneumonia in infants. They can also promote healthy practices – including family planning – and deliver the means to do so – for example, condoms or the oral contraceptive pill. For treatment of long-term conditions, whether for six- to nine-months, as for TB (which requires medication to be taken under direct observation every day), or for life, such as for hypertension, diabetes, or HIV, CHWs can support patients in adhering to their medications, ‘accompanying’ them through their treatment (a concept promoted by PIH, who called their CHWs ‘Accompagnateurs‘).

For BRAC, who started out by organising the poor into Village Organisations, training some of their members to become community health workers was a natural step to take. In line with much of their work, they focused on women, and the empowerment that such training could give: the shashthya shebikas were sold the EHC medicines at cost from BRAC, and were able to sell them for a small mark-up to their patients, earning themselves both an income and the respect of their communities.

Much like my first essay, in which I sang the praises of Partners in Health, my reading today has all been disseminated from BRAC; while a rigorously self-critical organisation (again, by its own account), there can be no doubt that there remain barriers to their programme. In the coming weeks, I hope to talk to some of the shashthya shebikas in person, as well as their supervisors and the health programme managers, in order to get a fuller picture. With the Bangladesh Ministry of Health and Family Welfare moving away from community-outreach towards a facility-based service (reviving the previously dilapidated network of Community Clinics), whether BRAC steps up to fill the gap or follows the same pattern remains to be seen.

In the meantime, I’ll sit out the hartal, and read some more.