1 December 2018

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Bush Healthcare and the Importance of Data

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I've been living and working in French West Africa since 2011. I spent the first three years as a Peace Corps volunteer in Benin, living in a small community, Ganikperou, in the north of the country (https://goo.gl/maps/mHBykgi1EVL2).

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There was a local health clinic in a community about 12 km from Ganikperou, and I heard about it through rumors of another foreigner, just like me, living there. One day, I decided to stop by the clinic and say hello. It was there that I met Dr. Crystal Faidherbe, who founded and runs the clinic Bodarima (https://bodarima.wixsite.com/site/le-dispensaire). Dr. Faidherbe is now one of my heros, and I have been holding up her work as a model of what a life of service to a greater good can really mean. She has tirelessly worked to build up a clinic in an area of the world that has enormous need of quality healthcare. During our first conversation, I hadn't really planned what I wanted to get from our first meeting, but I asked her if she might be in need of a volunteer who could assist her in managing her operations in some way. She asked a little bit about my background, at which point I told her that I majored in Evolutionary Biology and had taken some coursework on human physiology, genetics and had a particular interest in the various parasites that live inside of our bodies. Apparently, that was good enough for her and she thought I could fit in assisting her nurses in the main bloc conducting general consultations for the outpatients that came in every day.

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She gave me a room behind the hospital where I could sleep, and I started volunteering two days a week at the clinic. The routine was getting up at 6 AM and finding something to eat before the morning prayer. As a nun, she was pretty driven by the idea of serving God, so she had the staff meet every day at 7 AM for the morning prayer before opening up consultations immediately after. The first patients were usually already at the clinic by the time we finished up the prayer, and then they just kept coming.

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Probably half the time, patients were arriving with malaria accompanying a couple of other complications: malaria and diarrhea, malaria and bronchitis, malaria and infected skin lesions. It wasn't really hard to diagnose and treat these patients. Basically, you just look out for a maximum of 10 symptoms, and base any conclusions off of those suite of symptoms. The rapid test for malaria costs about $1, but our consultation fee was also $1 and the cheapest treatment we prescribed for malaria was around $1.20. Therefore, it usually would have added a significant cost burden to the patient to actually take the malaria test. Generally speaking, we didn't ask the patients to pay for a malaria test, and we diagnosed malaria and prescribed treatment skipping over this step. While this probably sounds crazy to people who haven't lived in malarial zones where there is also extreme poverty, to me it makes for common sense.

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For context, my village was 12 km away from the clinic, and most patients would come by hiring a motorcycle taxi and having two people sit on the back. We charged for consultations, and for any medicine we prescribed and sold in our pharmacy. If you take a typical outpatient, let's say with malaria and diarrhea, a typical cost breakdown for that patient's family would be:

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$2.80 = round-trip transport

$1.00 = consultation fee

$2.50 = medicine

$0.40 = food to consume while waiting in queue

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$6.70 = Total estimated cost of non-complicated treatment for common affliction

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This is extremely inexpensive medical care by any standard, and yet this dollar amount is high enough that families would have to think twice, three, or even four times before making the decision to bring a sick family member to the clinic for consultation. Ganikperou is a village that is extremely food-insecure. I remember every year during the hunger season, in which entire families would eat only a single meal per day of boiled corn flour mixed with watered-down sauce. It was heartbreaking to witness night after night, of children crying because of hunger and their parents unable to meet their desires. It took me a good year before I understood enough of the local language to interpret "I'm hungry" repeated over and over by a 3-year-old in the household next door. He wasn't just spoiled or manipulative, but was just reacting to a biological need to have more sustenance.

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When you have 6 kids and haven't quite achieved food security, a $6.70 unexpected expense now forces a potential outcome of either 1 of your kids dying of malaria or all 6 kids spending an additional week crying out for more food. Therefore, I couldn't really blame families for waiting a few days before finally making the decision to bring their child in for medical care. However, malaria isn't the kind of disease that young children can bear for very long before complications start coming on, so often the treatment required hospitalization, or more expensive still, a blood transfusion. Death is also a common occurrence after severe anemia sets in.

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Overall, I perceived a positive feedback loop occurring in front of my eyes, in which extreme poverty was making people hesitant to pursue medical care, and therefore waiting until the last minute, and then paying additional costs, which in turn would reinforce people's belief that medical care was too expensive, and making them hesitate to seek care again in the future.

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I'm still shocked by this reality that exists in clinics like Bodarima, and I've since seen a similar trend repeated in areas all over French West Africa, especially among the poorest populations.

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The question that I ask myself is, why is it that medical care can't be high enough quality and yet affordable by the poorest of the poor in our world? The cost of medicine is extremely low for most common diseases, and there are plenty of people in this world who are willing to work for next to nothing as long as they are making a positive impact on people's lives.

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Obviously, it's cheaper to treat people before they get too sick. In fact, a lot of the work that international development organizations have been doing over the years in this area of the world has been in educating the poorer populations on the importance of recognizing the symptoms of the most common diseases and encouraging them to seek medical care early on to reduce costs and improve outcomes. To be honest, though, I don't think that this is really the best way to solve the problem. Is the population's ignorance of the importance of their own lives and the value of their own money really the problem? No. I don't think it is the main problem. I think that healthcare itself, as it is being administered to and accessed by these populations, could be dramatically improved.

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I like the term "value-based healthcare". It makes me think of building systems that are the most efficient and therefore the most sustainable and long-term effective. But how do you go about building a value-based healthcare system if you're trying to provide medical care to the poorest people in the world? The first thing that comes to mind for me is data. More needs to be known about how healthcare is being administered to these populations. How many people are being treated, and for which diseases? What are the outcomes? What tests are they taking, what aren't they taking? What is measurably providing the most value to these populations as they interact with the healthcare system, and what isn't providing as much value?

 

I realized that without this data, it would be extremely difficult to build upon the healthcare systems in French West Africa. However, getting hospitals and clinics to start using electronic health records in this area of the world seems to be a very daunting task. There are already some clinics and hospitals, generally in wealthy urban areas, that are utilizing electronic health record databases. However, the vast majority of clinics struggle to maintain even paper health records for their patients. The major challenge with adopting electronic health records is the extremely limited financial means of the rural clinics that are treating the patients that we care most about. Any platform introduced to these clinics would need to be either free, extremely inexpensive, or present opportunities for the clinics to generate additional revenue in some way for it to stand a chance at adoption.

 

So that's really the challenge that we're looking to take head-on here at blockEHR. We aim to create a decentralized and distributed, open-source electronic health record database built on the blockchain. We intend on building the platform, and spear-heading the effort to convert entire health systems, one clinic at a time, to enable access to the data necessary to coordinate the multitude of actors involved to boost efficiency at all levels and ultimately drive down costs for the patient.

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We're taking a bold stance, and counting on evolving technologies and Web 3.0 to create a type of organization that is owned by the medical practitioners themselves and gives them full control of and the potential to generate revenue from their medical records.

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Sound interesting to you? Want to learn more or help continue the discussion?

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Leave us a message at the home page.

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