Since the onset of the COVID-19 pandemic, face masks have become the accessory du jour. Because of the increased demand for masks and other types of personal protective equipment we are on the brink of a global shortage where we may not even have enough supplies for frontline health care workers.
Some savvy individuals have started making their own reusable cloth masks out of various fabrics such as cotton or scuba. Available in a variety of patterns, they’re stylish and cost-effective. But do they work?
People seem to think they do. I had to visit the Emergency Department recently and saw the majority of doctors and nurses wearing brightly coloured, simply designed reusable masks. They were made by a local dressmaker who was selling three masks for $1000 JMD. The purpose of buying three was to interchange the masks, ostensibly to minimize soiling. Still, members of staff wore these masks for hours, whether or not they were directly interacting with a coughing patient.
My gut instinct says they’re probably not as effective as a disposable medical mask, but what does the literature say?
The first thing I learnt is that there is limited research on the efficiency of reusable fabric masks. Cloth masks have been studied from as far back as 1905 and as recent as 2017, with ambiguous conclusions.
In 2013, this article in the Journal of Infection Control acknowledged the historical use of cloth masks in protecting healthcare workers from respiratory illnesses1, and highlighted the lack of evidence around the efficiency of cloth masks, calling for further research. They argued that in an outbreak developing countries would not be able to consistently afford disposable surgical masks and respirators, but policy guidelines made no reference to the use of cloth masks, possibly because there wasn’t enough evidence.
The authors go a step further and tease out recommendations to improve the efficiency of reusable cloth masks (higher thread count, more layers and muslin instead of gauze), but they point out that most of their evidence comes from studies conducted in labs with mannequins as opposed to actual healthcare settings.
A 2015 randomised trial of cloth masks compared to surgical masks in Vietnam compared the outcome of clinical respiratory illness, influenza like illness (ILI) and lab-confirmed viral illness between clusters wearing disposable surgical masks and reusable face masks2. They found that the rate of all infections was highest for persons wearing cloth masks, particularly the rate of ILI and lab-confirmed infection.
(This is the only randomized control trial of cloth masks. )
A 2017 study in the Journal of exposure science evaluated the efficiency of three types of cloth masks and one type of surgical mask commonly used in developing countries in reducing exposure to particulate matter3. The study compared the filtration efficiency of each mask to the gold standard – N95 respirators. They concluded that:
Compared with cloth masks, surgical masks are more effective in reducing particulate exposure
And finally, The Lancet recently published an article discussing the “Rational use of face masks in the COVID-19 pandemic”4. The authors compared the policies of eight different health authorities on the use of face masks. Notably, China was the only country that explicitly recommended cloth masks or ‘non-medical masks’, and the recommendation was for persons at ‘very low risk’ of infection (those who mostly stay at home or in well-ventilated areas).
One interesting observation is that none of the studies I found examined whether wearing cloth masks was harmful i.e. associated with increased risk of infection compared to no mask at all. Theoretical discussions suggest that wearing a mask without a medical indication could increase your risk of infection if the mask is used improperly or for long periods or if you develop a false sense of security and forego other preventative measures such as hand washing. But before the advent of mass produced disposable masks, cloth masks were our best protection against infection. Can they help us still?
There is a plethora of emerging research on all things related to COVID-19, an outbreak which has been described as the greatest clinical challenge of our generation. Now is the time to explore and evaluate cost-effective resources for health, especially as the pandemic threatens the health of the most vulnerable among us.
1 Chughtai AA, Seale H, MacIntyre CR. Use of cloth masks in the practice of infection control – evidence and policy gaps. Int J Infec Control 2013 9(3). doi:10.3396/IJIC.v9i3.020.13
2 MacIntyre CR, Seale H, Dung TC, et al. A cluster randomised trial of cloth masks compared with medical masks in healthcare workers. BMJ Open 2015;5:e006577. doi: 10.1136/bmjopen-2014-006577
3 Shakya, K., Noyes, A., Kallin, R. et al. Evaluating the efficacy of cloth facemasks in reducing particulate matter exposure. J Expo Sci Environ Epidemiol27, 352–357 (2017). https://doi.org/10.1038/jes.2016.42
4 Feng, S., Shen, C., Xia, N., Song, W., Fan, M., & Cowling, B. J. (2020). Rational use of face masks in the COVID-19 pandemic. The Lancet Respiratory Medicine. doi: 10.1016/s2213-2600(20)30134-x
You ever see something ridiculous and think ‘Really? Is this still happening in 2020?’. Like, men still can’t say the word ‘two’. . . in 2020? Hanover still doesn’t have a Burger King. . . in 2020? Jamaica still doesn’t have a sexual harassment bill. . . in 2020? We still gonna argue about climate change. . . in 2020?
Jamaica is light years behind the rest of the Western world when it comes to LGBTQ+ rights and inclusivity. The closest we get is when the national HIV programme focuses on sexual risk reduction among key populations (as determined by international donors) like men who have sex with men and transwomen. In the past the government hasn’t put much effort put into understanding the lives of these individuals beyond getting them tested at workshops and lymes and ensuring they took their meds if diagnosed positive. This service gap encouraged the development of civil society groups like Equality Jamaica and Transwave, which advocate for the rights of LGBTQ-identifying folks in a holistic way, not just zooming in on their sexual practices.
The habit of defining people by their sexual practices has always rubbed me the wrong way. The intellectual defense put forward by many in my field is that not every man who has sex with men identifies as gay or bisexual. Which, fine, I understand that, but many more of them do identify that way. Or are afraid to identify as gay/bisexual because of the possible repercussions. And that’s important to acknowledge too. It is awkward as hell to have a conversation about sexuality with someone you’ve just met, and for most patients the revelation happens after building the therapeutic relationship, if it happens at all. But regardless of who my patients choose to have sex with, I try to create a space where they can feel accepted.
I’ve always taken the position of affirming people’s identities and respecting their life choices, while the rest of my colleagues politely tolerate the ‘alternative lifestyles’ of the people we work with. Do I wish we could all be a little more open-minded and accepting? Yes, but I’m also grateful that I haven’t heard any complaints from patients (yet) about being treated poorly by staff members based on their perceived sexual orientation. For the most part health care workers are getting better at customer service and professional behaviour, whatever their personal beliefs. And that’s major progress.
There’s still much more work to be done in erasing stigma and discrimination due to homophobia. A lot of it is systemic, related to our laws and policies. But so much more of it is cultural and community based. Recently my supervisor exhorted the team to see MSM as individuals, not just patients with high risk behaviours. At first I was annoyed because, Obviously. They. Are. People. That’s what I’ve been saying this whole time! But then I was grateful. Because this was the same supervisor who two years ago had advised me to refuse care to a transman seeking advice on transitioning. And if that isn’t progress I don’t know what is.
Our healthcare system has a lot of catching up to do. When I look at models of healthcare in other countries, I recognize the outdated practices and policies that are holding us back. Some of it is a broader cultural mindset of paternalism and individualism but who is to say which came first? What I hope for is a cultural and psychological revolution, what I work toward is effecting a little change every day in my circle of influence. The progress is heartening, a reassurance that we are moving in the right direction, however slowly. Huge changes don’t happen overnight, but they happen. Through the dedicated effort of committed people, change starts somewhere and then spreads across the world.
From time to time I get quizzical looks when I tell people that I work in primary care (aka clinic) in Hanover, one of Jamaica’s most rural parishes. The eyebrows climb even higher when I further explain that no, I don’t have a private office somewhere.
Fellow doctors wonder how I survive on the salary (and compared to my hospital colleagues it is meagre). Patients who connect with me are disappointed that I only work in hot, overcrowded government facilities and not some low-traffic office with an air-conditioned waiting room. Would-be mentors are perhaps bemused by my preference for this rural space that offers little in the way of career advancement.
But I continue to choose Hanover year after year, even though my feet itch with wanderlust and three years is the longest time I’ve stayed in one place since high school.
Well, the parish is beautiful. Lucea overlooks a picturesque bay of rolling blue sea. Cascade overlooks lush green hills of swaying bamboo. For almost the entire length of the highway that passes through Hanover the sea is a few scant feet away from the road, replete with stunning sunsets and the cool calm breeze of true island living. But that isn’t it.
I stay in Hanover because I believe there is so much good I can do here.
Whether it’s running the parish’s first treatment clinic for persons living with HIV, or saying yes to every single patient that turns up at clinic in the hills no matter how full we already are, or spending the extra time to listen to an old man reminisce about his favourite son – there is so much good I have done, and so much that I can still do.
Clinics have a bad rap among patients. Somehow people developed the idea that hospital doctors are better (this is laughable because Hanover is so tiny that the same clinic doctors often also work at the hospital) and that clinics are not worth their time. But in the time that I’ve been working in Hanover (did I mention it’s been three years?) I’ve been so lucky to work alongside doctors and nurses who care passionately about the overall well-being of their patients, not only about their blood pressure or HbA1c.
The magic of primary care is really how one doctor or one nurse or one community health aide can make a dramatic difference in the outcome of a person’s health. The beauty and the privilege of my job is watching people not just improve their condition, but thrive with care and support.
The fulfillment that I get from my daily work reminds me why people look at medicine as a calling and not just a job. And while I won’t always work at the level of individual patient care, the purpose of my duties will always remain the same: to bring quality healthcare to the people who truly need it. They say you never forget your first love; and wherever I work in the world whether elsewhere in Jamaica or further abroad it is and always will be Hanover that has my heart.
trigger warning (n): a statement at the start of a piece of writing, video, etc. alerting the reader or viewer to the fact that it contains potentially distressing material
Back when I worked in an urban clinic there one doctor would be rostered to cover ‘police cases’ i.e. cases of sexual assault. I dreaded this duty. We all have our weak spots, and sexual assault is one of those scenarios where it’s impossible for me to maintain professional detachment. But it was part of the job at that clinic, and it didn’t seem like an opt-out deal.
I wondered, what if I was a survivor of sexual assault? I was already so uncomfortable, how would I have managed if this was actually a trigger for me? Do our supervisors check to make sure we’re psychologically prepared for this kind of duty? Or is graduation from medical school supposed to guarantee a certain level of psychological fitness?
Recently I participated in a training session for healthcare workers on mental health. The group was discussing self-harm and suicide, a topic that was bound to come up in any kind of training around mental health. But the attitude of a few group members caught me off guard; they were dismissive and flippant. When someone used the phrase “attention-seeking” I had to step outside.
The debate around trigger warnings has gained in velocity and vitriol in recent years. Opponents of trigger warnings label and shame people with mental illnesses as weak. Social media has watered down the phrase so that it’s become a joke, a meme or a gif. Still survivors and their supporters try to carve out safe spaces, where people coping with trauma and depression can exist without sudden and painful reminders.
Should work be a safe space?
For healthcare workers, that would be impossible. We can’t predict what issues the next person will have. The patient is our first priority and we create safe spaces for them.
But what if we could create a work environment that protected the mental health of patients and stafftoo? What if we went to work acknowledging that other people might be dealing with trauma? What if we recognized the impact of trauma and proactively tried to reduce harm?
I don’t think trigger warnings are the best way forward. Jamaican society exists in a constant state of high tension, repeated trauma and triggers. Trigger warnings at work would be undermined by newspaper headlines, radio talk shows and social media. The added stigma against mental health would make the suggestion laughable at best and condemned at worst. But there might be a middle ground.
The mental health training session wrapped up with an introduction to trauma-informed care, a novel approach that will hopefully change the way we do things. Trauma-informed care emphasizes psychological and emotional safety for providers and survivors. A trauma-informed system realizes the widespread impact of trauma, recognizes signs and symptoms of trauma in patients, families, staff; integrates knowledge about trauma into policies, procedures and practices and avoids re-traumatization.
In a world besieged by natural disasters, civil wars and states of emergency, we need healthcare that is attuned to the realities of our experiences. If we are traumatized as a society we need a system that supports everyone, patients and providers, in achieving good health. Ensuring our organizations are trauma-informed is the best way forward.
My old high school has a past student association with chapters all over the world. There’s a chapter right here in Montego Bay, one in Kingston, one in New York, and one in Florida. Mobay High girls probably make up 90% of the diaspora, trekking all over the world with our brilliance.
I’m not even exaggerating. People I graduated with already have PhDs, incredible careers and families, or they’re getting paid to travel (in a legit way, not like a pyramid scheme way).
MBHS graduates have a reputation for being pretty awesome. Which is why it’s so rewarding to join an association whose main purpose is giving back to the school that nurtured us. Or at the very least provided a pit stop on the way to our success. Giving back in the form of construction projects, financial support, scholarships and mentoring has been a rewarding experience over the last two years, and this year we’re continuing the trend.
Any past student can volunteer to be a big sister to one of the students who sign up. We’re usually understaffed with volunteers – last year some of the mentors had to double up on mentees (yikes), and this year some of them dropped out because of time constraints (double yikes). Even though we never seem to have enough big sisters for the number of excited little sisters , the committee behind the mentorship programme stays so darn determined to help however many girls they can. It’s truly a motivation.
We usually find girls from first form all the way up to sixth form, paired with mentors who graduated from as early as the 1970s. The age gap can make some of the interactions more parental than sisterly, but to their credit the mentors have been getting rave reviews, and many big and little sisters choose to stay in touch beyond the one year time frame.
Sometimes it feels like I’m too young to have anything of real value to offer someone who’s only 10 years younger than me (and some of them more than 10 years – I am getting old). But what these girls need more than grey-haired wisdom is support and encouragement and a listening ear. They want what we all wanted in high school: to feel like we mattered and like someone (a grown-up) was listening to what we had to say.
And that’s so easy to give. The time spent chatting on social media, the drives home, the movie nights, the mixes and mingles; just being present in their lives as a positive influence can have so much impact.
I know not everyone is cut out to be a mentor. And some people are still working through the trauma of their high school experience so they might not be in a good place to reach out. But if you feel like you’re too young, or too old or too busy I invite you to think differently. You have a lot to offer a younger person, just by having their best interests at heart. And if you prioritize giving back, no matter what age you are, you’ll get a good old-fashioned buzz of warm, fuzzy fulfillment.
If you’re a past student of Montego Bay High, help us reach more girls! If you’re not, maybe find an organization that does something similar and see how you can get involved. Whether it’s mentoring at risk kids, volunteering at an infirmary or donating to a drop-in centre there are so many opportunities to give. And there’s no age limit whatsoever.
This was meant to be a book review.But it got bigger.
Book:The Other Side of Paradise Author: Staceyann Chin Genre: Memoir
Staceyann Chin writes her memoir with painful honesty. The Other Side of Paradise sometimes trips over uneven dialogue and wobbles with a mostly unreliable narrator (how accurately do any of us remember our youth?) but the story it carries is all too familiar.
Recounting her early childhood and adolescence in Montego Bay, Jamaica, Chin takes us slowly and deliberately through her memories of growing up with her grandmother (a quintessentially Jamaican way to be raised), and receiving instruction on how to move through the world as a girl-child in possession of that most sacred body part – the “cocobread”. This is standard socialization for Jamaican girls. The minute we are born and our gender declared, we receive ear piercings, skirts (with tights) and endless repeated admonishments to ‘keep yuh legs close’ and ‘don’t mek nobody touch yu dere’.
Unfortunately, as Chin discovers in her prepubescent years, there are too many people (usually men) who want us to do the opposite. Who, as soon as backs are turned and doors are closed, are only too eager to “get the first sample” and “pick mi fruit when it ripe”. I call her memoir painfully honest because by revealing the unpleasant reality of her life in Jamaica, Chin has catapulted the familiar trauma of black girlhood into the bright lights of the world stage. And it’s not a flattering sight.
My reaction to the book is necessarily tangled in years of social conditioning and the normalization of trauma. I read Chin’s recitation of events with a matter-of-fact outlook, empathizing with her sexual assaults but consoling myself (rather emptily) that she is lucky to have escaped with relatively little harm.
On the other hand, accustomed as I am to books where the protection of white girls is paramount (and the slightest brush of a hand invites Child Protection Services), I’m acutely aware that this mistreatment of young girls’ bodies is not normal. When I read Staceyann Chin’s memoir through the eyes of an international audience that I imagine to be privileged and protected, alarm and outrage butt heads with my pragmatic resignation.
It’s also more than a little embarrassing to think about first world country citizens reading her book and finding out that this is actually how children are treated in Jamaica.
Despite great personal struggles against the fabric of a society that would have loved nothing more than to strangle her voice, Chin made her own happy ending – emigrating to New York and becoming a poet and activist (and now, a mother).
I loved the representation in this book – it’s honestly the first time I’ve ever felt ‘seen’ in any kind of literature. The depictions of Montego Bay and its surrounding communities, the classism inherent in Jamaican society, the racial tensions that simmer just below the surface, the burgeoning sexuality of an adolescent girl in a country where female sexual expression is anathema – everything resonated with my life up to this point. I am grateful to Staceyann Chin for putting this uncomfortable, familiar, strangely hopeful book into the world, and I can’t wait for her next.
I did not like this book when I first read it. Not one bit. I thought Queenie was irresponsible and needy, I thought the descriptions of her Jamaican grandparents came across as condescending, and the vividly described sex scenes were more than a little gratuitous. The narrative tense kept switching between past and present, sometimes in the same paragraph (this might just be my electronic copy) which is a huge pet peeve of mine. Not to mention the gallons of infuriatingly casual racism that went totally unchallenged until the third act. Nothing about this book recommended itself to be read a second time.
That being said, I think Queenie should be required reading for every second generation immigrant black girl struggling to straddle two cultures and losing her footing in both.
Through her eponymous main character, Candice Carty-Williams pulls us along for a treacherous ride through a year in the life of a woman on the brink of self-destruction. While hinting clumsily(/skillfully?) at the ruins of a traumatic past, the events that have shaped Queenie into the shell of a woman she is today aren’t fully revealed until the last few chapters. This is a deft delivery that evokes less shock value and more cathartic release, which at the end of the book is really what we’re hoping Queenie can achieve.
Most of my grievances with Queenie are easily smothered when she finally accepts that she has a problem. In mental health examinations, we call that insight: a person’s ability to acknowledge that they are, in fact, not well. Carty-Williams should be applauded for her realistic portrayal of the therapeutic process because no one magically gets better once they identify the source of their trauma; the work gets lighter, but usually not easier.
I give Carty-Williams another nod for her determined activism. Overtly, Queenie tries repeatedly to convince her editor to let her write serious pieces about the Black Lives Matter movement, but more subtly Carty-Williams uses sleight of hand to declare her stance on boundaries around black women’s hair, body positivity and the fetishizing of black bodies.
As for my reactions, for the second time in a fortnight I am left reeling from warring emotions. When Queenie finally divulges the incidents of her past, including abuse by her stepfather, my reflex thought is “Thank God it was just verbal/emotional abuse, that’s not so bad”. But when her therapist is appalled by the revelation I realize I too am a victim of generational trauma bleeding into our culture.
So we don’t have another generation of trauma passing itself off as culture.
The collective Jamaican perspective on the care and wellbeing of children is completely fucked. And we have yet to accept that there is a problem.
The local news reported on two separate cases involving the assault of underage girls by police officers. In one case, the girl-child was in police custody, removed from an unstable home situation for care and protection. Care. And. Protection.
Weekly, almost daily in Jamaica, there is another story of a child being raped, murdered; a woman being assaulted, killed. The onslaught of reports on violence, graphic headlines and news segments that are way too detailed raises feelings of helplessness, anger and apathy. We become preoccupied with trauma (“have you heard/seen the latest story of another broken black body”), we withdraw, we increase our vigilance.
We are traumatized, vicariously, from witnessing the trauma endured by a person who looks like us, who inhabits our skin. The repeated pummeling of women’s bodies, girls’ bodies splays open the widely-held notion that girls and women are little more than chattel, our bodies commodities to be used and ultimately discarded.
Black women from birth have historically been branded and boxed. We’ve been slapped with labels like angry, aggressive, slutty, bitchy. We’ve been forced into rigid expectations for body type, fertility level and faithfulness, and when social sanctions fail to “keep us in line”, we’re dragged back into bounds by peer-approved physical violence.
It has to stop.
Black and brown children are supposed to feel safe and enjoy their childhood. That can’t happen if eleven year old girls keep reading newspaper articles about eleven year old girls being kidnapped and murdered. Children should be nurtured and protected and allowed to flourish in their own time. That can’t happen if we keep using their bodies as excuse and punishment. Chin and Carty-Williams have given us books that reflect the fractured and failing state of our society.
It’s 4:30AM. The sun isn’t up yet but Miss Dee is already making her way up the rocky lane to the main road of her community where she will catch the first ride going into town. In her purse she carries enough money for taxi fare both ways, two mint balls and a wrapped up piece of plastic with her tattered clinic appointment card and her last prescription. She will reach the clinic by 6AM so that she can collect one of the first numbers. When she arrives she is the third person there. They settle in to wait until 7:30 when the first security guard will open the gate.
Forty-one years ago in the city of Almaty, Kazakhstan, when Miss Dee was still a bright young girl, leaders from all over the world gathered to make a decision about keeping people healthy. The Declaration of Alma Ata, as it would come to be known, states firmly that primary health care is the key to achieving ‘Health for All’ – the universally accepted goal that promotes the health of all people.
Before we get into the nitty gritty, let’s get a few definitions out of the way. What is health, exactly? The World Health Organization defines health as “a state of complete mental, physical and social well-being, not merely the absence of disease or infirmity”. And they should know. This sounds like something everyone should have, right?
Health is a state of complete mental, physical and social well-being, not merely the absence of disease or infirmity
World Health Organization
‘Health for All‘ is the slogan for universal health coverage: no person or population gets left behind. Women, LGBTQ+, disabled individuals, persons living with HIV – everyone is included! Unfortunately, in some places, not everyone gets included all the time.
Now what is primaryhealthcare? This is a way of thinking about and organizing the different aspects of health care. Definitions of primary healthcare often make reference to essential health care and primary care (not the same thing). A primary health care system has a few key characteristics.
It’s based on principles that are scientifically sound, and socially acceptable
Primary healthcare is universal – it includes every single person
Primary healthcare aims to provide improved access to health services, financial risk protection and improved health outcomes
And finally primary care refers to those services that are delivered in the community (usually at a clinic or health centre) by doctors, nurses and allied health workers (also called primary care providers). These services are often someone’s first point of contact with the health care system.
So if primary health care is the key to achieving #HealthforAll, and if healthy people live better, stronger lives then investing in a strong primary health care system is the best and most cost-effective way to ensure a healthy, productive population.
Remember Miss Dee from earlier? She’s not real, but her story is. This clinic-before-daybreak sojourn is the reality for a majority of citizens who access services at health centres (clinics) in Jamaica. People leave home early hoping that they will get through the clinic quickly. But in reality reaching clinic by 6AM doesn’t guarantee that Miss Dee will be finished before 10AM or even before noon. Depending on the type of clinic, number of patients, availability of staff or occurrence of emergencies, Miss Dee may end up waiting until 3PM or later before she’s seen by a medical doctor (her primary reason for going to clinic in the first place). And remember she only brought enough money for transportation – not for lunch – and she left home too early to have a proper breakfast.
Public health care in Jamaica is a running joke. Meaning, the kind of joke people run from. Letters to editors, prime time news stories, and overheard conversations complain about common themes like long wait times, rude staff, lack of resources, lack of space and limited accessibility. The feeling of the man on the street (who only complains to overburdened health care staff and never to his chair-cushioned and air-conditioned MP) is that average people, poor people, who need and use these services are grossly neglected. Politicians and the well-to-do get private, highly resourced health care but the woman on the street gets what the duck got.
So what actually is the situation? The Layman’s Doctor recently posted a guide for people accessing care at their local health centres, in which she specifically addressed the notoriously long wait times and cautioned patients to prepare for it. For people who don’t work in or don’t access care in these clinics, it can seem like another world.
There are large crowds on days when a doctor is present at the clinic, and often the seating provided is inadequate. As we approach the summer months, there is no air conditioning, and clinics in the country don’t always have fans installed. The patient to staff ratio is usually high, which further prolongs the wait time, and to top it off most health centres do not have a pharmacy attached. This means that after seeing the physician patients have to get their medication at another (sometimes inaccessible) location, that may or may not have all the drugs they need.
If you’re frustrated just reading this, you aren’t alone. Experts the world over have agreed that accessible and universal primary care is critical to improving health outcomes. That means that people with diabetes won’t get their legs chopped off, and people diagnosed as obese can be prevented from getting diabetes in the first place.
In their technical series on primary health care the WHO reviewed systematic reviews and meta-analyses from a broad sweep of countries. The results were unanimous. When it comes to people dying (all-cause and specific-cause mortality), there is strong evidence that supplying primary care providers (ie clinic staff) leads to less people dying overall. Primary care providers save lives, y’all. And strong evidence that continuity of care (meaning the same doctor, same facility or strong linkages between doctors and facilities) also leads to less people dying.
For people who care more about the bottom line, the same review also examined health system efficiency (ie best bang for the buck). They found strong evidence that a supply of primary care providers reduces the number of avoidable hospitalizations, and evidence that case management programmes (think social workers) could reduce the number of total hospitalizations as well.
And for the social justice warriors (because health care is a human right), there is evidence that primary care, as compared with other types of health care, can improve access to health services, especially for disadvantaged adults.
Full disclosure – most of these studies took place in English-speaking high income countries but the evidence can be translated universally. Read the full 28-page review here: The Economic Case for Primary Care.
So if you were Minister of Health and you had to decide how to spend the meager Health budget, how would you allocate the funds? In Jamaica there are no user fees for nationals at public facilities (this does not mean health care is free!), so all the money comes from you (and a few donor agencies). You have to keep hospitals open, keep clinics running, pay your staff, provide medication, refurbish and maintain equipment, buy resources and develop media campaigns that remind people to “love yuh body, treat yuh body right“.
What’s your number one priority?
If you guessed hospitals – then you’d be right. . . Right on the side of our current Health Ministry, which is the wrong side.
Hospitals are undeniably important to the delivery of health care. Secondary and tertiary centres (smaller and larger hospitals) are vital and necessary, but they are vital and necessary in the way that having a spare tire is necessary. They’re super important if you get a flat tire, but it’s way simpler and easier to invest your time in avoiding a flat tire in the first place.
Now I know what you’re thinking – “But I can’t control when I get a flat tire!!”. And I hear you, shit happens. You drop into a pothole on the North South highway and pow! Yuh haffi draw fi di spare. But suppose you were using your spare tire every single day? If you had to choose between keeping your tires in good condition and avoiding potholes or buying a really expensive spare tire (complete with repairing the damaged tire, and the loss of work time that it’s going to take you to get the tires sorted out) which would you choose?
I really want to know, so leave a comment with your pick. And if you’re one of those brilliant minds out there thinking that this wouldn’t have happened if the roads were properly maintained in the first place then congratulations, you’ve just hit on another pillar of primary care – multi-sectoral policy and action. Because there are a lot of other things in the world that impact a person’s health, not just access to health services.
What I’m trying to say in my long rambling way is that investing the bulk of health budgets into hospitals isn’t going to yield any long-term improvement in the health of the population. Hospitals are necessary to deal with emergencies but, as we’ve shown, having a strong primary care system means there won’t be as many emergencies. A robust primary care system can handle minor emergencies and prevent major ones, reducing the burden on the hospitals and other referral centres.
So back to Miss Dee. By pouring more time and energy and investment into making primary care stronger, better and more effective Miss Dee won’t feel compelled to leave her house in the pitch-dark pre-dawn, risking ankle and foot injury on the uneven road. She could get to clinic at 8:30 or even 9 for her appointment, do her checks and see the doctor by 10, then get her medication (for free) at the same facility and return home in time for lunch. If we invested the right way, with the needs of the patient at the heart of our activities then even if Miss Dee was a 16 year old lesbian seeking advice on safe sex, or an 80 year old blind woman in a wheelchair she would have the same access, protection and positive outcome.
Health isn’t just for the good of the individual, it’s for the good of the country. Healthy people are more productive, and more healthy working people means more GDP. It’s time for all our leaders to make good on their promise – ‘Health for All’ is a human right.