January 26, 2012 | Health and Well-Being
Medicine at the Margins
Two Doctors Overcoming Obstacles to Accessing Healthcare
By Anna Louie Sussman
NEW YORK CITY— As doctors absorbed in caring for other people’s hearts, Amy Lehman, who was training in cardio-thoracic surgery in Chicago, and Sania Nishtar, Pakistan’s first female cardiologist, had to slow down and tune into their own to realize what they really wanted to do: help the most marginalized people access care.
Dr. Lehman was drawn to the isolated coastal communities along Lake Tanganyika, where 3 million people live with almost no health care infrastructure. Dr. Nishtar sought to leverage telecommunications technology to put vital treatments within reach of Pakistan’s poorest citizens, who often fall into a cycle of further debt and poverty when faced with unexpected health care bills.
Dr. Nishtar, who graduated at the top of her class at medical school in 1986, was practicing in an Islamabad hospital when a circular went around advising doctors to wash out used catheters and reuse them on poor patients.
“I was very perturbed by that differential level of care,” she said. “That day I decided, ‘I’m not going to spend the rest of my life doing this.’ If I can’t treat people equally, then let me try to at least educate them to protect themselves from disease.”
She launched Heartfile in 1998 and became a public health advocate, raising awareness about heart disease through newspaper columns, pilot projects and public service campaigns. But after a decade of research and advocacy, including substantial pro bono advising to the Pakistani government, she concluded that access to health care takes more than a well-designed and implemented policy.
In her 2010 book “Choked Pipes,” she writes that of Pakistan’s 170 million citizens, only 26.2% are covered by insurance or can avail themselves of subsidized medical care. The World Bank estimates that 32.6% of citizens live under the poverty line, and the average person earns $570 a year. For these people, paying user fees and other costs at a government-funded hospital could qualify as a “catastrophic expenditure,” one that demands more than 40% of the household’s discretionary income.
“Ever since I was in clinical practice I was very aware of medical poverty. I used to give all my pocket money to the poor, because their plight was so compelling,” she said.
“In 2010, as I was looking at the last proof for my book, I saw a patient who had been in an accident. He had to cut his leg off, rather than wait for year to recover, because that was a quicker way of going back to work. He couldn’t afford that long drawn out treatment. I thought ‘Oh my god, I don’t want to be remembered as that person who wrote policy papers and briefs all her life.’”
Catastrophic expenditures are not unique to Pakistan. In the United States, where over 50 million Americans had no health insurance in 2010 and where advanced technology and the high cost of training make health care relatively expensive, an unexpected medical emergency can easily tip a household into poverty. The World Health Organization estimates that paying for health services causes around 150 million people to experience a “financial catastrophe,” and 100 million fall below the poverty line because of health care expenditures. Over 90% of these cases happen in low-income countries.
With the royalties from her book, Dr. Nishtar launched the Heartfile Health Financing fund, to help subsidize health care costs for Pakistan’s poorest. But in a country with an international reputation for corruption, graft and patronage,she needed to ensure the money would go only to those who needed it.
With a grant from the Rockefeller Foundation, she developed an innovative IT platform that allows doctors and administrators from six participating hospital wards to verify a patient’s economic status based on data stored by the National Database Registration Authority, within a span of 48 hours. Once verified, the patient’s medical costs will be covered by Heartfile. The IT platform permits donors to trace where, when and how the money moves through the system, down to the last penny.
“The focus on transparency has a special relevance for Pakistan,” she said. “The level of transparency we required was unprecedented, so we had to build the technology ourselves.”
To date, Heartfile Health Financing has served over 400 patients, with cash transfers averaging around $700, a sum that’s 123% of gross national per-capita income. Her next step is speeding up the verification process, which will permit emergency care, an issue of particular relevance for women who may need C-sections or other urgent natal care. With more funding, she intends to expand the program to allow for regular cash transfers to treat chronic conditions, and is also considering implementing health-related loan options.
Dr. Lehman's patients are among the poorest people in the world, a fact that is exacerbated by their extreme geographic isolation. Consider that worldwide, nearly half of the population lives in rural areas, but only a quarter of physicians serve rural areas. Where Dr. Lehman works, “ultra-rural” areas along the banks of Lake Tanganyika, cellphone connectivity, health infrastructure, and even basic infrastructure like roads or running water, are all scarce to nonexistent. So are healthcare workers and clinics; instead, malaria, obstetric fistula, and cholera abound.
“The average lifespan is around 43. The average income is like $150. These women have extremely hard lives; it’s a place where maternal and child health are really dismal,” she said.
Her solution? The Lake Tanganyika Floating Health Clinic, a custom-built, 200-foot hospital aboard a boat that will travel the length of the lake providing services and training to the ultra-rural communities along the lake’s shores.
Since high school, Dr. Lehman had been drawn to post-colonial African history. In 2006, while in residence at University of Chicago, she vacationed with a college friend in Tanzania, and decided to visit Lake Tanganyika, where she got trapped in a typhoon.
“As we were driving away from the lake on muddy roads at three kilometers an hour in a Land Rover, I thought of the idea of bringing medical services by boat,” she said.
“It was obvious to me that this was the poorest part of Tanzania; they're geographically and socio-politically isolated, but there’s also been this overlay of real social upheaval, particularly on the Congo side. So because of supply chain issues, a boat is the best way of actually reaching these populations.”
The design of the boat -- the naval architecture and engineering using green technology – is expected to be completed next month. While Dr. Lehman fundraises furiously to build the boat, she visits the region regularly to conduct outreach missions. Her trip last October focused on maternal health, and in particular obstetric fistula, a hole in the birth canal usually due to obstructed labor.
The patients she sees often become pregnant in their early teens; one 18-year-old woman she recently treated had gotten pregnant when she was 12.
“She had a fistula, and had been living with it for six years. We see so many women in their 20s who have been living with these fistulas for years already,” she said. “The majority of fistulas are actually not caused by sexual violence, but by obstructed labor, and I think that tells you just what it means to be a woman in this part of the world.”
With a medical team that included a well-known fistula surgeon, obstetric gynecologists from the U.S. and Tanzania, and several nurses and a doctor from Congo and Tanzania who were there to learn, they performed 44 operations. They also distributed catheter kits, and trained their local colleagues in how to use them to treat acute fistula. Working side-by-side with local health care workers not only builds up their technical capacity, but engages them in discussions about, as she puts, “why even having a pregnant 12-year-old is something that’s no good.”
Now, she can rely on her staff around the lake, many of whom are returned refugees, to carry on that conversation when she's back in her home base of Chicago. She describes her colleague Vincent, for example, as “a quintessential feminist.”
“If there’s someone talking about how somebody’s wife shouldn’t be able to go get family planning and take it in secret, he’ll go bananas,” she said. “I don’t even need to be much of a mouthpiece, because I have my guys on it!”
Anna Louie Sussman is a writer and editor for the Women in the World Foundation website, and a frequent contributor to major U.S. magazines and newspapers.