Raj Panjabi was nine years old when his family fled the civil war in Liberia. Nearly three decades later, the medical instructor at Harvard University is rushing to improve access to health care in his home country and other developing countries, as CEO and founder of the NGO Last mile of health.
The success of his approach, focused on community health, catapulted him to the list of the 100 most influential people in the world according to the magazine Time in 2016. This year, he has served as a front-line physician against the pandemic. Although covid-19 vaccines point to the end of the tunnel, they can take years to reach millions of people in vulnerable populations around the world.
question: How is coronavirus affecting rural communities in low- and middle-income countries?
Answer: Rural communities have already had to face such challenges. If we look at every pandemic in human history, we know that the poor and marginalized are the last to access laboratory tests, treatments, and vaccines. This has been the story of every pandemic historically. And, unfortunately, the covid-19 pandemic is strengthening 1 viral apartheid, In which only the rich have access to adequate services and treatments. For example, access to test it is lower in rural areas than in cities. Treatment is delayed because there is no availability of oxygen therapy or Dexamethasone. In addition, rural areas are the last to receive some of the new medicines.
Raj Panjabi, medical professor at Harvard.
As for vaccinations, the experience of previous campaigns shows us that poor and rural regions are the last to receive them.
As for vaccines, the experience of previous immunization campaigns shows us that poor and rural regions are the last to receive them. We know from current information on global immunization that 13 million children under the age of one do not receive a single dose of vaccine. We are talking about measles, polio and other vaccines that are already known and used, but are out of reach in remote rural areas and sometimes in urban areas where the limitation is not geography but poverty and lack of health services. I think because of all this, the communities are not well prepared at the moment.
P: He mentions that some rural communities have already faced challenges similar to covid-19. What lessons do these experiences teach?
A: One of the keys is to incorporate community health workers and coordinate their action with teams of doctors and nurses. Countries that opted for community health before the pandemic are relatively better today. A good example is Liberia, where it was founded Last mile of health.
Years ago, we had the Ebola epidemic which caused a lot of pain and suffering in our country. About 11,000 people lost their lives in the region and nearly 30,000 became infected. But it could have been much worse.
At some point, the projections were that a million people could have become infected, of which half or more could have died. Then, when Ebola was doubling humanity and Liberia, the role community health workers played was huge. They were the ones who, in team with nurses, examined patients.
In one district, we examine 10,000 people; just 42 door-to-door workers were paying attention to the symptoms. These same workers also tracked contacts and connected patients with health system services. These same workers, who serve about 80% of Liberia’s rural population, are now being trained in the identification of coronavirus cases and contact tracking to ensure the health system does not collapse completely.
P: You insist a lot on the importance of the community health, With community workers proactively attending to families, in low-income countries. Do you think that this model deserves to be strengthened high-income countries like Spain?
A: Think so. For example, in Brazil, community health workers have helped with chronic diseases that afflict many rich countries and rich areas of poor countries, such as hypertension and diabetes; diseases that end up causing heart attacks or strokes that severely disable patients and even result in deaths. In fact, the Brazilian family health program contributed to a 15 to 20% reduction in mortality related to strokes and heart attacks. We could get similar results in rich countries, but we do not devote the necessary resources. For example, the Bureau of Labor Statistics reports that here in the United States, there are only 56,000 community health workers. We need at least 300,000. Sometimes people believe that the labor cost of the health service is an expense, not an investment.
Raj Panjabi, medical professor at Harvard.
Half of the world’s population, 3.7 billion people do not have access to essential health services. Within this group, the worst offenders are the billion who live in the most remote communities.
P: Beyond the covid-19 pandemic, what do you think are the challenges for access to a universal health service around the world including rural areas?
A: As long as there is a patient out of our reach, it means we haven’t done enough. Unfortunately, there are many patients out of our reach. For me, this is the biggest problem that, in addition to being generally ignored, the information we have about it is insufficient.
We talk frequently about the lack of attention to specific diseases. People do not have enough access to the treatment of HIV, tuberculosis, hypertension, insurance parts … But if a cross-sectional cut is made of all these diseases and one wonders which population is most at risk of acquiring- and do not receive medical attention, we will find rural and remote populations at the forefront.
Half of the world’s population, 3.7 billion people do not have access to essential health services. Within this group, the worst offenders are the billion who live in the most remote communities. Then, we build a primary health care system that is within the reach of every child and every family.
P: How can technology, including Artificial Intelligence and telemedicine, help increase access to health care in poor social settings?
A: To build a robust health system requires four pillars: staff; medical supplies and medicines; a space to provide the service and, finally, technology.
When we watch programs around the world, the most successful ones invest in these four areas. Technology can improve training, with virtual tools, assist in diagnosis, improve monitoring and facilitate access to health services, as with telemedicine. However, there is a painful paradox: there are many places in the world where technology can make a big difference, such as in rural areas, but it is precisely where there is no infrastructure to take advantage of technology. That’s why, among other things, we need better infrastructure models that reduce energy requirements.
About Artificial Intelligence (AI): I think there’s a lot of advertising noise around it. But for a community health worker who has to diagnose 20 different pathologies, AI is relevant only when one of those 20 things is very rare and AI can identify it. If not, it is not so relevant.
In my opinion, we must start to guarantee the technological infrastructure, take advantage of telemedicine and offer tele-education. AI only makes sense if you accompany other areas of health care technology.
P: Beyond technologies, do you think primary care and community health should encompass mental health?
A: Of course, I find it crucial. One of the studies we did in Liberia was after the civil war which lasted 15 years and caused a lot of trauma. We surveyed 1,600 households in 2008, with the Government of Liberia. Between 40 and 44% of the adult population had symptoms that were described as severe depression or post-traumatic stress.
It is unthinkable that community health can ignore a problem of this magnitude. Community health is underfunded. Therefore, the community mental health too.