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Saturday, November 18, 2006

Of Health, Public and Private

Public health considers the well-being of the community. As we work to improve antenatal care, we hope that the impact is community-wide, with more mothers and babies surviving and thriving. Measuring the impact requires scientifically sound sampling and careful follow-up. So we have Carol delving into an ambitious project, a case-control study of sorts, choosing systematically (every other name) nearly a hundred HIV+ women who delivered babies 1 and 1/2 years ago, and then randomly choosing two controls for each one who are matched by age, parity (how many pregnancies) and village. After she collected these names from the clinic registries, the tricky part begins: finding almost 300 women with only names and villages to identify them over a year after they have delivered their babies. We want to know how many of the mothers and babies survive and are collecting some data on their nutrition and overall health. For the HIV positive mothers, we are able at a year and a half to find out if the virus was transmitted to their babies. While we do this every time we have a food distribution and every time we see people in clinic . . . That only tells us about the health of the small percentage who choose to remain in contact, which may skew our assessment, because we’re seeing the ones who live near, or like medical care, or are organized enough to get help, and therefore more likely to have good outcomes. For weeks now Carol and her trusty research assistant Ndyezika have been combing the community with their list of names. Take into account that there are no addresses, almost no roads, no phone numbers, no computers, no files. Then consider that names in this culture are rather unimportant and fluid, and a nervous mom at antenatal care may say the first thing that comes into her head when asked for her name. I have frequently asked husbands and fathers the names of their wife or child and seen them struggle unsuccessfully to come up with the name! Many times the name on a child’s immunization record bears little resemblance to what he’s called at home. Then consider the fact that marriages are very impermanent. If a woman registers while living in one village, nearly two years later she may have moved on, back to her parents or on to another husband. So after weeks of struggle they had found less than 20 people. We like the approach of going to the patient .. . But thought we’d try to lure the patients to us one more way. For four days a list of 60 names was announced on the radio. On Friday morning 13 of those women showed up. Not bad, not great. Still slogging on. Private health considers the well-being of the individual patient. One of the mothers who came on Friday was among the HIV positive group (obviously for reasons of confidentiality, the study is being billed as a general antenatal follow-up with no mention of connection to HIV status). Her 18 month old son was a strapping and healthy looking boy. She had dropped out of any follow-up and was still breast-feeding the toddler. We tested him, and he was not infected! What joy to share this news with her. But then we advised her to wean the child right away. His nutrition was good, and the small risk remained of transmitting the virus through breast milk. She tucked her breast back in her dress, and we gave him sweet biscuits to distract his crying. Maybe one little life saved? It’s possible. Both public and private health are important. Jesus fed 5000, taught principles of community cooperation. But he also raised one widow’s dead son, or healed one bleeding woman in a crowd. So we continue on, trying to change policies and reach thousands with teaching and testing, while also touching the one toddler who can be saved from infection.

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