Forty-something years ago, when I was born in Pittsburgh, Pa., I was a sickly thing. I weighed only 6 pounds. I had a strep infection and wouldn't eat. The doctors put me in an incubator and treated the infection, and within a few weeks I was well enough to go home to my family's split-level in the suburbs.
A few years ago, a 9-year-old boy named Samson came down with strep. But he lived in rural Rwanda, not suburban Pittsburgh, and his family did not have the pennies needed to take him to the clinic to be treated. He developed rheumatic heart disease that damaged his heart valves, and for years he was too ill even to attend school.
After spending 10 years of my career in global health, five of them in Rwanda, I know the numbers. Samson is just one of hundreds of thousands of children in Africa whose minor illnesses go untreated every year. Worldwide, a child under 5 dies about every three seconds. Up to a third of those die within weeks of birth. The rest die primarily from pneumonia, measles, malaria and diarrhea — all preventable or treatable illnesses. It's an overwhelming tragedy, all the worse because it's avoidable. Rwanda's child mortality rate has shown remarkable improvement in recent years, but more than 10 percent of babies still don't make it to age 5.
How is it possible that in 2009, a baby just like me would likely not survive if she had the bad luck to be born somewhere like Rwanda? How can it be that even in the United States we have yet to put into practice the simple logic of making sure sick people get treatment so they don't get sicker?
Solid primary health care isn't really hard; in fact, it's kind of boring. Most ailments are routine. Many can be prevented. It's only when the little things don't get managed that things become — disgracefully — interesting.
Thirty years ago, the International Conference on Primary Health Care in Alma-Ata, in what was then the USSR, adopted the Declaration on Primary Health Care, a sweeping document that launched a movement to make primary health care "a fundamental human right." Last October, back in the same city — now known as Almaty, Kazakhstan — another international gathering marked the publication of a World Health Organization report titled "Primary Health Care: Now More than Ever." In her introduction to the report, WHO Director-General Margaret Chan acknowledged that "despite enormous progress in health globally," the failure to make primary health care essentially universal was "painfully obvious."
The classic indicators of health have certainly improved worldwide in the past three decades, but progress has been desperately uneven: Gaps between rich and poor have widened, and some of poorest countries have actually lost ground. Although the global under-5 mortality rate has been cut in half since 1970, the United Nations reports that 27 countries in the world, most of them in Africa, made no progress from 1990 to 2006 in reducing child death. In 1977, life expectancy at birth in sub-Saharan Africa was 48. By 2006 it had only risen to 50. Even in places that are better off overall, such as India and the United States, health disparities within countries remain stark. The American Cancer Society reported in December that African Americans are 48 percent more likely to die of colon cancer than white Americans. The Institute of Medicine estimated that 18,000 people died in the United States in 2000 because they didn't have health insurance; an update a year ago by the Urban Institute reported that the figure has risen steadily, reaching 22,000 a year in 2006.
It doesn't have to be this way. Whether the solution for preventing serious disease is cancer screening, the prompt treatment of malaria, blood pressure pills or a measles shot, the most logical place to provide it is through a functioning system of primary health care that is accessible - geographically and financially — to everyone. Over the years, policy wonks have defined primary health care in many ways and rebaptized it many times: It's been called close-to-client care, patient-centered care and, more recently, medical home. At the simplest level, though, commitment to primary health care is as an approach that starts with preventing and treating the easy stuff and only gets more sophisticated when the patient needs it.
Where Samson lives, in Rwanda's Bugesera district, the clinic was barely functioning a few years ago. Mayange Health Center had a solid building but no power, almost no medicine and an unmotivated, poorly compensated staff. The center saw only a few patients a day, and every month almost all the expectant mothers in the area delivered at home rather than pay the cost of delivery at the sparsely equipped maternity room. Throughout the country, health centers were called death centers.
Then, in late 2005, the government of Rwanda selected Mayange as the site for a new integrated development initiative, the Millennium Villages project, which aims to show that the U.N. Millennium Development Goals can be met even in the poorest parts of Africa. Over a few months, the Mayange Health Center acquired basic equipment, a supply of medications and more nurses. More important, the center received management assistance and tools: simple things like plastic folders to maintain patient records, and training for the nurse in charge of managing the drug supply. The project worked with the government to connect the health center to the power grid a few hundred yards away.
Needs-based subsidies and management help for the community health insurance system gave thousands of people financial access to health care, and bed nets were distributed to prevent malaria. Attendance at the health center rose from just over 6,000 patient visits in 2005, before the improvements, to more than 14,000 in 2006. After co-payments were eliminated in early 2007, the numbers soared again, reaching 40,000 visits by the end of 2007. Mortality dropped. In 2007, one woman told a visitor, quite simply, "Our children don't die anymore."
Samson could have been — should have been — treated for strep right away in one health center visit by a low-cost antibiotic. Instead, thanks to some dedicated volunteers and donors who learned of his case and contributed thousands of dollars, he received heart valve surgery in South Africa. Today, Samson is becoming a normal teenager. That he needed a miracle to do so tells us the system wasn't working.
Nothing in the transformation of the Mayange Health Center required fancy technology, name-brand drugs or highly trained doctors. It was a matter of simply helping the center function well enough to provide basic services and making sure people could afford the care. In the years since, a related initiative, the Access Project, has helped dozens of health centers in Rwanda improve services by addressing basic management issues like financial management, pharmacy operations and work planning. Installing shelves in a pharmacy storage room or teaching an accountant to better manage a clinic's books are not sexy activities; you won't see either on an episode of Grey's Anatomy. Building basic health care is just not prime-time material.
Focusing first on primary health care doesn't, of course, mean denying poor people advanced care when they need it. Any good primary health care system needs a referral system to hospitals and specialists, services that are still lacking in much of the developing world and remain inaccessible to many in richer countries.
But when primary health care functions well, secondary and tertiary care are needed far less often. Unfortunately, when basic health care doesn't work, the reverse is true.
In 2007, a 10-year-old girl named Jeannette showed up at a health center in Rwanda with kidney failure. There's no way to know now what caused Jeannette's illness — a diagnosis would have required tests that are almost unimaginable in a country with one pathologist for nearly 10 million people. But her kidney problem may well have been a complication of a treatable infection like strep.
In Jeannette's case, a local doctor managed to get her advanced treatment at the single dialysis machine in the country, paying out of his own pocket. Her case came to the attention of a Canadian benefactor, who began making plans to bring her to Toronto for a kidney transplant. Despite these efforts — extraordinary for a child in Rwanda — complications set in and Jeannette died, for lack, perhaps, of one early clinic visit, and one course of antibiotics.
A study published in The Lancet in 2003, "How many child deaths can we prevent this year?," concluded that 63 percent of child deaths worldwide could be avoided if simple, proven interventions were available to all. The recent WHO World Health Report points to countries around the world that reduced child mortality by more than 80 percent from 1975 to 2006; all had increased access to basic health care. In Thailand, where primary health care has been a priority since the 1970s and immunization and skilled attendance at birth is now virtually universal, under-5 mortality dropped by 8.5 percent a year from 1990 to 2006, more than any other country. In Brazil, the right to health was enshrined in the 1988 constitution. The public health system, which offers free immunization and early treatment for many diseases, is cited as the main reason why infant mortality is down 60.5 percent since 1990 and life expectancy up from 67 years in 1991 to 72 years in 2007.
Funding for global health has soared in the 21st century, with massive programs such as the Global Fund to Fight AIDS, Tuberculosis and Malaria; the U.S. President's Emergency Plan for AIDS Relief; and the Global Alliance for Vaccines and Immunization. But the new money has gone disproportionately to selective programs or diseases. These investments are vitally important, but in too many countries, such programs actually damage the primary health care system by diverting funds, attention and trained staff away from basic health care. A growing international movement is working to integrate the big initiatives into countries' primary health care systems — using the funding flows to improve, rather than erode, overall health care.
In the United States, once someone gets very sick, he or she will probably get care eventually, when it's extremely expensive and sometimes too late to do much. In a comprehensive series on diabetes in 2006, The New York Timesnoted that insurers often refuse to pay for a diabetic to see a podiatrist who can help prevent common complications but will almost always pay tens of thousands of dollars for a foot or leg amputation. Not all disease prevention or early treatment is cost-effective — some interventions cost a lot and don't work well enough. But using methods that weigh the value of improved health against the expense of a service, researchers can develop good evidence of what works and what doesn't. In any case, interventions don't work if there is no system to deliver them, or if the system is unaffordable.
The familiar drivers of rising health care charges in the United States include hospital-centered care focused on disease instead of health; the extraordinary costs of end-of-life care; a bloated and inefficient payment system; high pharmaceutical prices; the cost of malpractice litigation; and the expense of caring for millions of uninsured people. In a 2003 report, "Hidden Costs, Value Lost: Uninsurance in America," the Institute of Medicine estimated that we spend $98.9 billion a year on care for uninsured people, including $35 billion in uncompensated services that hospitals and other providers have to absorb. Covering them with insurance under the current system would require an additional $34 billion to $69 billion a year, but that calculation does not include the annual cost of the diminished health and shorter life spans of the uninsured, estimated at $65 billion to $130 billion per year.
The sheer volume of research on the benefits of primary health care is overwhelming — so much so that one has to wonder what could be left to study. Late last year, the American College of Physicians published a review of 100 studies on the relationship between primary care availability and health care quality and costs. Some of the findings:
- Among developed countries, the United States ranks lowest in the strength of its primary care system and lowest in health care outcomes, yet highest in health care spending.
- States with higher ratios of primary care physicians to population have better health outcomes, including fewer deaths from cancer, heart disease and stroke.
- In 2000, an estimated 5 million admissions to U.S. hospitals — costing more than $26.5 billion — could have been prevented with high-quality primary care.
In the past few years, an approach to primary health care known as the "medical home" has been endorsed by the American College of Physicians, the Institute of Medicine, the American Academy of Pediatrics and, in November, the American Medical Association. Its basic principles amount to classic primary health care: The medical home would include a personal physician, have a whole-person medical orientation, provide coordinated care and offer a payment scheme that supports the system. A pilot project using the medical home concept at Geisinger Health Systems, which serves 2.5 million people in central and northeastern Pennsylvania, showed encouraging results in the first year: A 20 percent reduction in hospital admissions and a 7 percent decrease in overall costs.
Buried under all of the research, the meta-analyses and the demonstration projects, the concepts and elements of good primary health care remain pretty simple. Putting them into place will be more complicated, but it can be done.
For a start, change the system in the United States to ensure everyone gets the basic health care that — for all our high-tech machines and slick pharmaceutical ads — tens of millions of uninsured people currently cannot afford. Build better health centers in the developing world and make sure they have enough trained staff and medicine, so the next Samson or Jeannette will be just another kid who gets sick and then gets better. Let primary health care serve up medical miracles by the million, as a matter of earnest, boring, lifesaving routine.
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