The Next Generation is a CRN column penned by residents, fellows and post-docs. Alexi Matousek, MD, MPH, an Arthur Tracy Cabot Fellow and Global Health Equity in Surgery resident, reflects on his experience taking part in the training program managed by BWH’s Center for Surgery and Public Health.
The cornerstone of global health at Brigham and Women’s Hospital is the longstanding connection with Partners In Health (PIH) – the NGO founded by Paul Farmer. A key component to the mission of PIH is to “do whatever it takes to make [our patients] well – just as we would do if a member of our own families or we ourselves were ill.”
This philosophy is what drew me to the Brigham and to the Department of Surgery, which established a specialized residency track in global surgery. I have spent more than 20 years working on development projects in Haiti with my family, and finding a training program where I could further develop skills in public health and surgical practice among the poor was extremely important to me. I was fortunate to land a research fellowship at the Center for Surgery and Public Health, affording me the opportunity to return to Haiti and bring a new skill set to bear on the problems of access and outcomes measurement in global surgery and begin to discover what it truly means to do “whatever it takes.”
I returned to Hôpital Albert Schweitzer (HAS) in rural Haiti in July 2013, where I had lived as a child because it offered an opportunity to do the research I thought could help the most.
The hospital has a nearly 60-year history of delivering high quality health care to the population in its district. The demand for services is extremely high, and the hospital is nearly always over capacity. Unsurprisingly, when I arrived, we found that the Haitian staff surgeons and nurses knew better than I did how to treat the patients they encountered. However, they lacked both the skills and time to measure results in order to prioritize improvements. While anyone could walk around the wards and point out numerous deficiencies in staffing, supplies and organization, it was very difficult to prioritize potential solutions that would bring the most benefit. Especially lacking was any measurement of outcomes at the community level.
I set out to determine if outpatient outcomes measurement could be done in the remote mountains surrounding the hospital. While nearly all Haitians struggle in poverty, people living in the mountains face challenges that are orders of magnitude greater than their neighbors living in the plains. Accessing health care is much more difficult for mountain patients. Despite available financial assistance, the mountain people receive fewer than half as many operations as people living in the plains.
I had first-hand experience with the conditions in the mountains because my family has lived and worked in a mountain village each summer since 1997. I’ve carried water, walked to market, bathed in the river and slept in their houses. Despite these experiences, I was still at a loss to explain the large disparity in access, especially given that any financial costs could be covered by the hospital.
The more I delved into the problem, the more I discovered. The mountain people are almost universally illiterate. Any mountain child whose parents are able to sacrifice enough for them to complete school moves away to find employment. Those who are left never could afford enough school to learn to read. In addition, they are not socially connected to the hospital or the valley towns and have no one who can explain the correct process to follow at the hospital. When they enter the hospital, they are embarrassed and timid as they can’t afford to dress as well as others and are easily identified as very poor. Lines are long, and busy clerks don’t have time to explain where to go. I realized we needed to do more than just tell them where to go. They needed an advocate, someone to accompany them to the services they needed.
To address this issue, I borrowed from Paul Farmer again, using community health workers (CHWs) to guide mountain patients through the hospital. We went into the mountains and held screening clinics where anyone who thought they needed surgery could be seen by a physician and partnered with a CHW who would do “whatever it takes” to ensure they received the surgical care they needed.
Using the rich network available through my research fellowship at BWH, I was able to collaborate with Sana, a mobile solutions group based out of MIT to design a smart phone application for our CHWs. The app stores GPS location data, guides the CHWs through a simple survey looking for symptoms of infection and allows them to submit a photograph of the surgical incision for review by the surgeons and research team. The CHWs visited patients’ homes at least three times after surgery to check on them and track their results with this app.
Over a period of one year, the community health workers have successfully guided approximately 100 patients through the hospital, increasing the elective surgical rate four times for the mountain population. They also complete 30-day follow up, perform visits on time and submit high quality photographs in greater than 90% of cases. With these early promising results, we are confident that community health workers can help overcome access barriers and perform outcome measurement in the mountains of rural Haiti. We are working to expand and further study mHealth as a method of outcome measurement in global surgery.
This effort relied heavily on the tenacity of the CHWs and their desire to serve their community. To our knowledge, it is the first program to use CHWs for surgical follow-up, and the first to use smart phones for surgical outcomes measurement at the community level.
I envision a time when patients in developing countries can be assured a high quality surgical outcome because they receive focused attention to outcomes monitoring and quality improvement through the use of mobile technology in the hands of community health workers. I am extremely grateful to the Brigham and my collaborators throughout Boston for the opportunity to start this journey toward equitable surgical care, and I will continue to do “whatever it takes” to advocate on behalf of those in need.
Matousek will complete the Center for Surgery and Public Health’s two-year Arthur Tracy Cabot Fellowship for the Center for Surgery and Public Health in July. The fellowship is one of the only programs in the country designed to provide surgical residents with the resources to develop their health services research skills while pursuing a master’s degree in public health at Harvard School of Public Health. Matousek was also one of the first two residents to inaugurate BWH’s residency track in academic global surgery in 2012. If you’re interested in learning more about Matousek’s experiences, you can visit his web site or watch his video, “Disfavored: Bringing Surgery to a Forgotten People.”