The Case for Primary Health Care

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 primary healthcare? 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.

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.

Primary care providers save lives

WHO, 2018

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.

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on Advocacy

In Jamaica, we have a lot of people with opinions. Having a loud mouth and strong convictions is instruction Number 3 in ‘How to be Jamaican’ (Number 2 is ‘always ask for curry goat gravy’). It’s no surprise then that we have so many organizations arguing publicly for a wide range of causes and policies.

We were practically born and raised to be advocates. Ask any frustrated community who block road and bun tire to protest bad road conditions. Look at any line of people waiting impatiently to access a service – somebody is going to start advocating for more staff and decreased waiting time (albeit in more colourful language).

Even though most Jamaicans advocate from cradle to grave, Advocacy with a capital A is often described in cultured tones, refined and pedestalized into colonial approval, consisting mainly of papers, workshops and civilized protest. Grassroots movements get lopped off at the tip: keep the pretty flower, leave the dirty roots behind.

Because most groups that Advocate are based in the Kingston and St. Andrew area, their Advocacy is limited to scavenging for policy change. But if civil society organizations incorporated grassroots strategies and engaged the wider Jamaican community, their advocacy (with a common a) would have more lasting impact.

Yes, this is another rant on decentralizing our socio-cultural landscape. Buckle up, kids.

Kingston/St. Andrew is home to only 25% of Jamaicans, but they have 100% of the headquarters for civil society organizations. Whether it’s environmental protection, social justice or human rights everyone is based in Kingston. Meetings, workshops and policy discussions happen mostly in Kingston. Organized protests happen in Kingston, letters to the editor are written to the Jamaica Gleaner (you guessed it, a Kingston-based national newspaper), and social media campaigns mainly reach urban demographics.

You might argue that these organizations are concerned with creating policy change and Kingston is where policies are created so that’s where they have to be. Yes, but policy change isn’t the only avenue for activism. And can policy change be sustainable without significant efforts at the local and individual levels?

No, no it can’t.

The problem with top down change is the same problem with trickle down economics. The benefits are rarely if ever felt by the people at the bottom of the ladder. Trickle down social justice might look pretty on paper, because we have all the right policies, but it won’t change the day to day realities of the average Jamaican because our realities are largely a consequence of our mindset.

For example, suppose Parliament actually decides to decriminalize abortion. Does that mean girls in rural communities will no longer face barriers like social stigma and cultural beliefs that encourage early and frequent child-bearing? No, those barriers will remain unless someone inside that community is advocating for a different way of doing things. I already said Jamaicans are born advocates, you just need to wind us up and point us in the right direction.

So it’s all well and good to rock the boat on a national level, but it has to be matched by an equally fervent (and I would argue stronger) campaign to effect behaviour change at the level of individuals and communities.

Too see this in action, look at our politicians. MPs excel at leveraging community advocacy into political power. They don’t campaign on policy (which they probably think flies over the head of their constituents), instead they campaign on personality. Their election hinges on whether or not the people believe in them, not their ideas. All that matters is that their voters believe they’re a man or woman of the people and then they can get into Parliament where they have the power to affect policy.

And if our politicians are out here getting elected in rural Portland because they can drop it low like Pamputtae and step into Gordon House the next day (get you a girl who does both) then our civil society organizations really have to step up their game.

Policy advocacy goes hand in hand with behaviour change advocacy. It’s not either/or. The civil society organizations that are doing the most in Kingston need to start doing the most in other parishes as well. This doesn’t mean new organizations, just a shift in the way things are done. Instead of locking up all that experience and expertise in Kingston, why not share it with the communities they advocate for?

Roll into Clarendon and Westmoreland with some of those lofty ideas. Expand your reach to St. James or St. Mary and get some fresh perspectives. Build momentum across the country with deliberate efforts, not just a symposium every couple of years because funding agencies mandate it.

Sustainable change can’t happen with an approach that’s strictly top down or bottom up. It’s top down and bottom up efforts that meet in the middle. Is it extra work? Will there be some uncomfortable conversations? Does it mean leaving behind the air-conditioned comfort of city life for that extra work and those tough conversations? Yes, yes and yes. But sustainable change is really the only change worth advocating for.

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Further reading: Jamaica Observer Letter of the Day: The Undoing of Civil Society in Jamaica

Women’s Bodies Make the News (again)

Lately I’ve been spending my time taking deep dives into the arena of gender analysis. Holed up in a small classroom for 3 hours a week in a recurring debate on the privileges of the penis may not sound like your idea of fun, but to me it’s absolute heaven. Feminist intellectual stimulation, stinging repartee and a whole bunch of new words to add to my vocabulary. It doesn’t get much better than this.

But the perspective comes with a shadow, cynicism. The niggling fear that the status quo (which is far more pervasive and sinister than I realized) won’t ever change because so many people are invested in keeping it the same. The concern that despite our promises as a country and despite our claims as a society, the day to day culture of Jamaica thrives on the subordination of women and other non-masculine groups.

Close to my heart, the topic of healthcare: reproductive rights and abortions. Recently in the news again thanks to MP Juliet Cuthbert-Flynn (In 2018 I learnt a bunch of useless US politician names, maybe 2019 is the year I learn Jamaican ones) who tabled a bill to decriminalize abortion.

Not a bill to let women kill their children.

Not a bill to give women an excuse to be promiscuous.

Not a bill to hasten the decay in Judeo-Christian morals and values.

(all points that were raised and shot down)

The bill was tabled to allow easier access to safe abortions – because women are literally dying.

As I read the discussions helpfully Tweeted out by groups in attendance (the revolution will not be televised because there is no revolution), the points raised by pro-lifers kept circling back to the idea that women do not own their bodies. Their bodies must be offered up for the greater good ie having babies and if they die in the process well it would have been a worthy sacrifice. The MPs who responded challenged the speakers to provide data to back up their claims (they couldn’t) and questioned the right of the Church to make decisions for a pluralist society.

I happen to follow mostly ‘woke’ people on Twitter: feminists, LGBTQ folks and advocates, pro-choice supporters. So my news feed lulls me into the false sense of feeling like maybe the progressive bunch scored a win.

But then I see pictures of the pro-choice stand/march that happened before the debate started – a handful of lovely women (and men, and I think maybe non-binary persons too) clad in black with shirts and placards bearing slogans like ‘NO WOMB FOR PATRIARCHY” and “MIND YOUR OWN UTERUS”. Catchy slogans, very clever, but not a big crowd.

And then I take note of the Members of Parliament who they Tweeteed about actively participating in the discussion. Again, lovely people, but only three maybe four names are repeated.

And then I realize something. It’s great to feel like a part of a movement. It’s great to have people who agree with your values and outlook on life. It’s nice to be included (I get such a thrill when WE-Change retweets me). But the shadow, cynicism, clouds the warm fuzzy feelings.

Culture, society, Parlimentarians in the majority aren’t ready to allow women full control over their own bodies. We might get ideas. The road to change is long and hard, and it will probably continue long after we’ve passed on the torch. This ‘gender thing’ is a huge obstacle to human rights, social development and nation building. We gotta start looking at these problems fully cognizant of the biases and privileges we bring to the table. We have to stop accepting the status quo and start challenging it.

I gotta get off woke Twitter and start changing the world around me.


Just in case anyone was wondering (I was) – the only news article that spoke about this debate was a brief piece in the Gleaner that basically recounted an emotional story from a Catholic nun about overriding women’s choices for the patriarchy. You can read it here.

Rape Culture Thrives in our Churches

On September 23, Dionne Smith and her teenage daughter were brutally murdered in their home by Fabian Lyewsang, Smith’s common-law husband. It was a vicious act, carried out by a man against the women he should have been protecting.

This is the kind of gender based violence that Jamaicans encounter every single day, but we simply pretend it is something less sinister, less insidious. We pretend, as two prominent pastors have argued, that this act of violence and others like it are the result of women. Women choosing the wrong partners, women choosing to stay instead of leave (never mind that they have nowhere to run), women choosing men who murder them in their beds and then drive off a bridge into the Rio Cobre.

In the words of a Parkland shooting survivor, I call BS.

This is victim blaming.

This is the patriarchy.

This is misogyny.

This is rape culture.

This is the church leading the flock astray. Where I would have expected Pastor Glen Samuels (president of the West Jamaica Conference of Seventh-day Adventists (WJC)) and Pastor Joel Haye to lead the charge in holding men accountable for their actions, they have failed us all miserably. And they have failed the women in their congregations worst of all.

When two clergymen can feel comfortable getting behind the pulpit to chastise women for the “bad decisions” that put them in the path of dangerous men we have a problem. When the congregation listens and agrees, when a major news outlet (yes, the Jamaica Gleaner) blasts the story on the front page with the headline “Pastors urge women to choose partners carefully” we have a problem.

And the problem is the systemic, pervasive and frankly disgusting idea that if women would dress right, speak right, act right, choose right then men would not be able to hurt them. The problem is holding women accountable for the behaviour of women AND men, and holding men accountable for nothing. And it has to stop.

Fabian Lyewsang was responsible for his actions, not Dionne Smith. If it had not been Dionne it would have been some other woman. This fact is indisputable. Men alone – not women, not circumstance, not peer pressure, MEN – are responsible for their own behaviour.

When we fail to hold men accountable we fail to notice that 1) our women are in dire need of protection and 2) that our men are suffering from deep emotional and psychological scars. Until we can address these two issues – protect the women while healing the men – our society will stay stuck in this desperate pit of rampant murder/suicides.

When you realize you’re in a hole, the first step is to stop digging. Pastor Samuels and Pastor Haye need to stop digging and work with our elected leaders to find a way out that doesn’t involve climbing on the bodies of murdered women.

on the question of choice

Time and again we debate our debating of the A word in Jamaica. In Parliament. On the streets. In churches. In the bedroom. In doctor’s offices. In back alleys. With hangers, with pills, with blood.

The ‘A’ word. Abortion.

The idea is castigated by our ‘Christian-minded’ nationalism and people get very upset whenever it’s brought up. Words like ‘murder’ and ‘human life’ get thrown around. Women are accused of being careless and cruel.

I think too often we get caught up in Christian morals to the detriment of our fellow citizens. As if we forget that slavery too was sanctioned by ‘God’. And I’m not saying that people shouldn’t read Bible, praise Jesus and pray to their Lord but the same way I stay out of Christian people churches is the same way the Church-State should stay out of women’s bodies.

Much like the buggery law it’s simply embarrassing that abortion continues to be a debate in government in 2018. Not even a debate, an issue so taboo we don’t even talk about it. Like sex education. Come to think of it, maybe abortion would be less of an issue if there was more sex ed. I digress.

It’s high time we doctors stopped pussy-footing around while women suffer. And it’s high time Parliament stopped ignoring the issue just because it makes the Church uncomfortable. If you not going to clamp down seriously on rape, stop bawl out when the victims are forced deal with the consequences.

Give women the choice, and get your damn hands off our wombs.

a word on checkpoints and the assailing of women’s bodies

The State of Emergency is now in its tenth month. Violent crime levels appear unabated. Every issue of the Western Mirror carries a front page headline on some gruesome murder or gunfight.

Twice daily checkpoints are my new normal, since I live and work in two separate parishes. I drive through, waving to the unlucky soldiers assigned to stand in the middle of the road in the grueling summer heat, and smile.

At first I would approach each checkpoint with a sense of trepidation. Would they stop me to search my car? And then annoyance. Would they stop me to try and get my number? My experience was getting harassed by soldiers and police officers alike who appeared to have no other reason to stop me than to chat me up like a man in a bar. It was unprofessional and frustrating.

I used to slow and stop so that the officer or soldier could peer into the car, but these days I slow down just enough to give a brisk wave unless I’m told otherwise. This is just another way one learns to navigate social conventions as a person of the feminine gender.

After a while, when my frustration had faded to good-natured acceptance, I started to notice female soldiers now deployed to man the line. One day while cruising through at my snail pace, I overheard a bus driver call out a raunchy greeting to the lady soldier standing in the road. I cringed, and questioned.

Beyond the sexism that exists among one’s professional colleagues, a sexism that can potentially be challenged and eroded by professional success, is there a deeper and more pervasive sexism in society at large that undermines the execution of professional ‘gender roles’?

Is there a certain level of respect accorded to soldiers and police officers? Do we accord that same respect when the soldier or police officer is a woman? And does the change in tone when addressing a female member of the armed forces imply a lack of respect, or is it simply a neutral cultural phenomenon?

I’m pretty sure that woman was used to getting catcalls in her line of duty, and many women are. Some find it annoying, some find it flattering, and for some it’s just a part of life, neither good nor bad. In my culture there are many things that my liberal ideology struggles to accept, and this is one of them.

Is it inappropriate and unacceptable for a man to calls out ‘Psst, babes‘ when a woman walks by? Is it only inappropriate when he does it to certain Women, or in certain Spaces? Does the acceptability depend on the man’s intention: to objectify and assault, or to compliment and affirm? If the action is allowed, is there an expected response? Is it rude to ignore them? It certainly seems that way.

And is it really such a big deal?

In some spaces it can be. As a general rule I ignore the leaking air and the catcalls, but on certain streets I make damn sure to respond with a polite greeting. At issue here is the concept of danger. On main roads I feel safe enough to ignore the calls; on side streets I am too aware of my vulnerability to invite an uncertain threat. I fear, so I conform. But does this make me complicit in a social norm I desperately wish would change?

I don’t have the answers, but I think it’s important that we start talking somewhere. A catcall on a lonely avenue isn’t the same as being sexually assaulted, but the threads of gender-based violence run deep. Until we can pick up the ends, wherever they are scattered, we will never begin to untangle that knot.

Inventing Language

I have two entirely different and diverging spiels to divulge about this topic. The first, which I’ll probably (forget to) talk about later, is inspired by Dr. Eric Levi’s post about changing the culture of medicine by changing the words we use when we talk to each other.

The second, which I’ll talk about now, has to do with the way we produce and consume Jamaican literature. I say Jamaican specifically, because I think the Caribbean on a whole is doing much better with producing stories that are told in the language of the people. But I can’t shake the feeling that as Jamaicans we aren’t quite there yet.

Prolific writers like Erna Brodber and Kei Miller (among many, many others) must be commended for following the ample footsteps of Miss Lou and putting our dialect on an international stage. But when I read The Last Warner Woman (Miller) or Nothing’s Mat (a recent release by Brodber) I don’t feel like I’m hearing the voice of the man or woman on the street. The dialogue and narration tend to feel like a weirdly off-brand version of Jamaican dialect, the distinction growing when they employ the use of Patois. It’s not that they use Patois wrong (because it’s a language with its own rules and I’m very adamant about that but I should probably leave that argument for another time) it’s just that it doesn’t feel right.

Of course I might be judging their writing too harshly. It’s much easier for me to say that Tamika Gibson captures the essence of the Trini accent perfectly in her YA novel Dreams Beyond the Shore because I don’t live in Trinidad and have no reference for the nuances of their everyday conversations. But I know what I expect Jamaicans to sound like, and the bar I set might be too high to realistically reach on the page.

Another reason for my discomfort with our language in print might be that the sounds and phrases I hear in Montego Bay are noticeably (albeit only slightly) different from the turns of phrase used in Kingston or other parts of the island. So maybe Miller and Brodber are staying true to their own ears, while alienating mine.

In either case the point remains that I have yet to read a Jamaican novel that rings true with authenticity*. It either feels like I’m watching Jamaica through the eyes of a foreigner or like I am the foreigner with strange and altered expectations for the writing. It doesn’t help that most Jamaican writers live abroad, and I have often wondered if it is easier to write home from the Diaspora or if the distance does something to the translation. As if in their habit of making our language and culture more palatable for the foreign audience it loses the vivre that makes it appeal to the local one.

Where does all of this thinking leave me? Tamika Gibson mentioned in an interview that she wrote the award-winning manuscript because she wanted Trinidadian youngsters to have a book that was in their language. Growing up all the stories she read were about foreign places and foreign people and she didn’t want that to continue.

Neither do I. But as I grapple with the idea of writing an authentically Jamaican story I recognize that my struggle is in the physical act of putting one word after the other. Having read so many novel and stories and poems generated by a largely cosmopolitan author base certain phrases and descriptions spring readily to mind. Certain combinations of words naturally trip out of my fingers, but none of these fit our local setting.

There’s no set or pre-defined way to describe Montego Bay because it just hasn’t been described often enough. So the task that rests with the writer who talks about home is really to build the language brick by brick in a slow meticulous operation. Because it’s never really been done before so you have to pay attention to get it right.

It’s the difference between moving into a densely populated neighbourhood where all the houses have been around for centuries and moving into a neighbourhood where all your neighbours are still building the houses from scratch. It’s grunt work, fantastic work, and it will take elbow grease, grit and determination. Luckily, we’ve got those in spades.