Trained in Internal Medicine at the American University of Beirut (AUB) back home in Lebanon, Mona Haidar, MD, was quickly drawn to social medicine and caring for patients in community-based programs. From joining Partners In Health (PIH) in Lesotho in 2006 to developing the first social medicine curriculum for the Lebanese American University (LAU), she shares her journey with us and explains why she did not hesitate to join GHDonline as a co-moderator of the “Adherence” community.
GHD Blog: How do you view your role as a doctor?
Mona Haidar: Back when I did my pre-medical and medical training, many of us students claimed that we knew why we chose medicine. Like in most universities focused on western medicine, my training was mainly cure-oriented. You get trained to treat the disease, not the patient. But I always felt that there was something lacking – that medicine and the role of a doctor could be more than that. I always liked this quote: “It matters more what kind of patient has a disease, not what kind of disease has a patient.”
The more I progress the more I’m convinced that medicine really is a tool to achieve social justice. This is how I see medicine: it’s an interaction with people, and as a doctor I try to approach the whole person and the roots of the problem. For example in Lesotho you cannot treat HIV/AIDS without addressing, and “treating” in a way, some of the social and economic barriers and difficulties that impact health such as poverty, unemployment and food insecurity.
Dr. Haidar with a patient in one of the Lesotho clinics.
GHD Blog: Tell us more about your experience with PIH in Lesotho?
Mona: While doing some research for my grand round, I encountered the PIH model. My first reaction was “Wow, this is great!” And it just happened that they were looking for a doctor in Lesotho so I applied.
When I arrived there in 2006, the program had just started. I was based in Bobete, the second clinic PIH-Lesotho rolled out. There was scarcely any electricity - the solar power was not as reliable as it is now. Not having light was a major challenge because many times we would have to operate emergencies at night, either trauma cases or to deliver babies with candles or gas lamps. But you do your best. And it’s not only the clinic; the whole community has the same conditions.
Roads or lack thereof are also a major challenge. Patients walk for hours on end to reach the clinic, being sick, and sometimes they even ask us, “What time do you close?” Of course, we do not close!
While there, I saw firsthand the quality of care that the staff brings and the determination they put into doing so even in very rural and resource-poor areas such as Lesotho. PIH combines field work with academic, research and advocacy. They bring the lessons learned in the field to classrooms and vice-versa.
GHD Blog: How did PIH adapt its model of care, with Community Health Workers, in Lesotho?
Mona: Village health workers, or CHWs, already existed in Lesotho; they are part of the community structure and are appointed by the chief of the village. Usually well-regarded and respected in the village, health workers know how to read and write. Also, most of them are women though recently we’ve noticed more men joining. When there’s a need to increase the number of health workers per village, for example, we consult the chief of the village. This is also a sign of respect to the community and its traditions.
In our clinics in Lesotho, being a health worker is a full- time, paid job. Health workers accompany at least five patients from their own villages and do a lot of home-based care. They check on them twice a day and make sure that medication is properly taken. They also go with their patients to appointments, including follow-ups and medication refills every two weeks at first and then monthly. Last, they report to us when one of their patients cannot come to the clinic, and they come along with us on home visits for their patients.
Before PIH started, there was scarcely any training for health workers. They would have random trainings now and then from the Ministry of Health or other organization. They were not paid either: it was more of a social status in the community. Once a month, PIH Lesotho organizes a training day during which, in addition to providing professional training, we hand out monthly salaries and transportation stipends. It’s also a day to thank health workers for their work so we organize a lunch all together. The last time I was there, more than 150 attended.
Village Health Worker Training in Nohana
From health workers we always get a sense of how we’re doing. A health worker once said to me, “Since this project started we’re witnessing less death.” In Lesotho, unfortunately, funerals are daily activities because of the high prevalence of HIV among other things. So the fact that grossly they are witnessing less funerals and that it is bringing hope to the people is very rewarding.
Also, and that’s very important, they really care because it’s their community. It’s in their hands; it’s not only us providing care. It reminds me of an anecdote that clearly exemplifies this dedication. Once we had to admit a sick baby whose mother had died. The village health worker stayed overnight to watch over him. When we went to check on him and administer his medications including ART, she [the community health worker] had already prepared some of the medications and was carefully looking at the watch so as not to miss the exact time - 7 pm - to administer ART. There are many memorable moments like this one and I hope that as time goes by there will be many more.
Supervising village health workers is still a challenge – ideally there should be a supervisor per village for example. But it is not easy in this kind of settings because of transportation issues. We rely on feedback from patients and also from indirect ways – patients’ health and village health workers meetings.
In the end, when we say “community-based” at PIH, it’s not only the care that is community-based, we become part of the community. In a way, we live with them. This and the interaction with health workers were really touching to me.
GHD Blog: What is the role of home visits?
Mona: We do home visits for a wide range of reasons, not just to follow-up on medical conditions. Sometimes we go to assess the socio-economic conditions. And even though it’s not really difficult to assess these, we do it out of solidarity for the patient and to see what’s going on. For example one time I had a patient who was doing very well and then I started seeing that she was becoming depressed, sad. The health worker told me that she was facing difficulties with food: she has several children and her husband had just passed away – typical scenario in Lesotho. So we went to her house and talked with her. Since she had a baby on formula that was being followed in our clinic, she had knowledge and experience on safe formula preparation. So we decided to hire her to assist in the formula program and to help other women. We try to hire patients as much as possible.
GHD Blog: You are currently developing the social medicine curriculum of the Lebanese American University (LAU). Can you tell us a little more?
Mona: I was asked by the founding Dean of the Lebanese American University Medical School (LAUMS), Dr. Kamal Badr, to lead the formation and direction of their social medicine program. LAU was founded as the first school for women in the entire Middle East in 1831, and became a university in 1924. The LAU Medical School is being established in collaboration with Partners Harvard Medical International, and expects to launch its first class in the fall of 2009. Over this next academic year, I will be involved in structuring the curriculum for social medicine at LAUMS which will include both a didactic component and national and international fieldwork. LAUMS regards social medicine as an integral curricular requirement and a central theme that will be introduced in a structured way throughout the four years of the medical school. I am very eager to learn from the tremendous experience of the faculty at the Department of Global Health and Social Medicine at Harvard Medical School, where I am a Research Fellow, in designing, developing, and teaching social medicine curricula.
GHD Blog: How do you see your role as a co-moderator of the “Adherence” community on GHDonline, the “Communities of Practice” website of the Global Health Delivery project (GHD)?
Mona: To me, the GHD project is like an umbrella for many things that I want to be involved in or that I am already doing. It’s a place to share and learn from others’ experiences, tested and tried practices. When you’re in the field, you encounter a lot of questions for which you do not have answers. Sometimes you cannot even follow-up on these but when you can it’s really hard as you work in isolation more often then not – you do not have a colleague next to you to inquire for a second opinion or advice. Some of these questions are everyday-type issues, but others are critical and getting answers can really impact your practice.
As a clinician in Lesotho, I quickly realized that adherence to ARV is a complex issue that needs to be carefully addressed. So having an online community to address this, where there are practical resources and people who share a common interest and goals, is a great idea. To me, GHDonline is focused on delivery of health care: it’s the tools, methods and concepts that translate in the field – equate inventions if you want and make it accessible, available, and deliverable to the people who need them.
Hopefully GHD will become a science by itself, with its own methodology, key areas, frameworks and applications because this is the need today for health care. Delivery of health care is challenging and critical everywhere, not just in resource-poor settings. Every day there is something new happening but the challenge is how to bring it to where we need it.
Epilogue: Challenges ahead in Lesotho
PIH launched its Lesotho project in 2006 following an invitation by the Government of Lesotho, and by its partners in Rwanda and the Clinton HIV/AIDS Initiative (CHAI). Partners In Health Lesotho (PIHL) employs over 900 community health workers (CHWs) based at six remote mountain clinics, trained to provide Directly Observed Therapy (DOTS) to HIV and TB patients in their homes. PIHL also provides family planning services and has established effective prevention of mother-to-child transmission programs for HIV positive mothers. The six clinics are currently logging over 100,000 patient visits annually, including weekly Under 5 clinic days which are specifically geared toward vaccinations and child health.
In addition to an extremely high prevalence of HIV, the country is ravaged by a second epidemic with the fourth highest TB rate in the world. In July 2007, PIHL launched the country’s first community-based multidrug-resistant tuberculosis (MDR-TB) treatment program in Africa in partnership with the Ministry of Health and Social Welfare and other partners PIHL renovated an old government leprosy hospital into a 24-bed MDR-TB referral hospital with infection control, laboratory, and pharmacy. However, most of the MDR-TB patients are treated in the community by a specialized clinical team and supervised by carefully selected, monitored, and trained community health workers. The program currently treats MDR/XDR-TB patients in all ten districts of the country. Read more about PIH Lesotho here.