David Ziehr and Matthew Growdon
Harvard Medical School, Class of 2014
Nearly half of the Guatemalans we diagnosed with diabetes already knew they had el azúcar. Weeks, months, or years prior, many had traveled miles and waited hours for a hurried consultation with a physician at a free, government-run centro de salud only to receive a referral to the same physician’s private clinic. They later returned home even poorer, but now with a diagnosis and a month’s income worth of oral hypoglycemics – medications to lower blood sugar.
Miles from a pharmacy, too poor to buy more drugs, or believing they had been cured, the patients experienced little more than a holiday of controlled disease. They had pursued medical care, yet were just as sick as the men and women we diagnosed with diabetes for the first time.
How must the delivery of health services adapt as the burden of chronic disease swells in resource-poor nations? Community health workers (CHWs; promotores de salud) may represent the greatest hope for patients with – or at risk of – chronic diseases in such settings.
CHWs are laypeople with basic medical training who educate and assist members of the community to maintain or improve their health. While conventionally entrusted with episodic care, CHWs have emerged as reliable advocates for patients with HIV and tuberculosis in Haiti and Rwanda. PIH trained these CHWs to teach about prevention, acquire and administer medications, and provide careful follow-up. This model, by which local leaders accompany patients to navigate poverty, stigma, and a fragmented health care system to achieve effective care, has inspired efforts to find and treat patients with chronic non-communicable diseases (NCDs) in Guatemala.
Empowering local health advocates
This past summer, Dr. Daniel Palazuelos, clinical director of PIH projects Guatemala, worked with us to train CHWs in Santa Ana Huista, Guatemala, to help patients with diabetes and hypertension manage their illness. The CHWs are members of el Equipo Técnico de Educación en Salud Comunitaria (ETESC; Technical Team for Education in Community Health). Refugees of the Guatemalan civil war returned home and banded together to form the organization, which provides legal and medical accompaniment to rural Guatemalans.
Themselves victims of atrocities and speakers of local languages, ETESC CHWs are uniquely positioned to assist indigenous Guatemalans, a population subjugated during the war and neglected in its wake on the basis of race, poverty, language, education, and geographical isolation.
Familiarity bonds CHWs to their communities and distinguishes them from outside doctors, nurses, and volunteers. Accordingly, we designed a course with a flexible curriculum to encourage discussion and analysis of local barriers to care. Twelve daylong sessions emphasized basic disease etiology, symptoms, diagnostic tests, treatment regimens, lifestyle modifications, prevention, and integration of care with reliable physicians and nurses.
Basic lessons in pathophysiology reinforced the CHWs’ understanding of chronic disease. For instance, one game had the CHWs perform the roles of the parts of the body necessary to absorb glucose from a meal: the intestines accepted sugar from a meal and passed it to the blood, which visited the pancreas to receive a “key” (insulin), which the blood needed to deliver sugar to the hungry cells.
With diabetes, the pancreas tired and stopped giving insulin to the blood, causing sugar to accumulate, pass through the kidneys to the urine, and damage vessels in the hands, feet, and eyes. Though simplified, this exercise organized the CHWs’ approach to patient education and treatment: “excess sugar,” which can be controlled with healthy diet or medication, causes the symptoms and long-term effects of diabetes.
Chronic diseases, acute challenges
The damage many chronic diseases cause is insidious and progressive; symptoms may not present until late in the course of the disease. But, as prevention and early treatment are most valuable, one must learn to educate patients about a disease they do not (yet) outwardly experience.
Widespread, often justified, skepticism of the medical establishment in Guatemala further complicates the diagnosis and treatment of a patient’s chronic disease. A man with a first-time diagnosis of stage-two hypertension is at an elevated risk of stroke and heart attack, yet the health care provider must approach diagnosis and treatment delicately. The man will not pursue treatment if he does not trust the provider’s assertion that the disease is serious and incurable but controllable with diet and medication.
Moreover, salesmen in pickup trucks with bullhorns regularly hawk suspicious and expensive “natural cures.” We distanced the legitimate care of the CHWs, which might require patients to purchase drugs, from such exploitation.
Remarkable turnouts at active case-finding missions
Through word of mouth alone, the CHWs attracted long lines of residents who had skipped breakfast in anticipation of free measurements of their fasting blood glucose and blood pressure. In five communities, the CHWs tested over three hundred men and women.
Dr. Palazuelos confirmed diagnoses and prescribed medications, while CHWs logged each patient with diabetes or hypertension to begin follow-up. We visited pharmacies throughout the region and alerted the CHWs to those with the lowest prices and largest selections. Each CHW supplemented his or her botiquín (community medicine chest) with essential drugs for diabetes and hypertension, which he or she could then sell—at cost—to patients.
With patient records, inexpensive medications, and tools to monitor blood pressure and blood glucose, the CHWs were prepared to assist in the long-term management of patients’ diabetes or hypertension.
Meetings with government clinic doctors alerted the CHWs to referral options for patients needing advanced care. No CHW should be left alone to take care of patients; only with well-supplied and supported teams can patients acquire the care they deserve.
After our departure in late July, nurse Maggie Sullivan arrived to monitor and support the CHWs. They capably documented follow-up visits with patients and replenished their botiquines. As the program expands, CHWs will need routine access to a physician or nurse to start and adjust medications.
Community health workers may be our greatest hope to coordinate patients’ care in the absence of a functioning health care system, thereby helping to control the increasing burden of diabetes and hypertension in resource-poor settings. With our support, community leaders committed to the health of their neighbors can begin to overcome the many and evolving challenges of NCDs.