Jordan Swanson. Originally published in the HIR Winter/Spring 2000 Issue.
On October 27, 1998, Hurricane Mitch slammed into the Caribbean coast of Central America. UN officials have classified Mitch as the worst natural disaster to hit the region this century. In Honduras alone, over 14,000 lives, billions of dollars worth of crops, and 45 years of infrastructural development perished in flash-floods and landslides." Those figures, however, are not capable of appraising the pain, the fear, and the insecurity people have suffered and are still experiencing," reports Mary de Flores, die First Lady of Honduras. Many Hondurans, whose already scarce property and employment were devastated by the hurricane, are slowly working to rebuild housing and businesses as they always have, with only a short-term focus. But a growing contingent is breaking away from the traditional mentality toward public reconstruction, especially in the field of health care. This group sees not only a destroyed country but also a newfound opportunity to rebuild a sustainable, modern medical system. These reformers recognize that Honduras's fundamental well-being rests on crafting an improved public health system with a long term focus.
For the past several decades, the public health system in Honduras has focused on treating communicable diseases as well as responding to natural disasters through heavy reliance on international aid. Since the late 1970s, low-income tropical countries including Honduras have waged a serious war against communicable diseases. The results are now becoming apparent: communicable diseases, even the most historically virulent killers malaria, dengue, and tuberculosis are receding, and Honduras now boasts 98 percent nationwide participation in its vaccination program. Poor health in the wake of Hurricane Mitch did not result in the anticipated outbreaks of malaria and tuberculosis, dispelling the conventional wisdom that these diseases are still catastrophic afflictions in Honduras.
The Ministry of Public Health, which both regulates and delivers national healthcare through a network of 28 hospitals, 214 physician-staffed health centers, 727 rural health centers, and nine maternal and child clinics, is the central figure in the Honduran health network. But the Ministry is in fact only one part of a multi-faceted system; many foreign non-governmental organizations (NGOs) complement the work of the Ministry by providing necessary specialized medical services. These groups organize vaccination drives for children and pets in rural villages, deliver necessary medicine and supplies, monitor nutrition, conduct follow-up checkups, and coordinate transportation to hospitals. Much of the innovative input comes through NGOs that draw on medical standards from developed countries but are willing to experiment with new approaches in Honduras.
Recently, however, the Honduran health system has been beset by instability. The frequent turnover of the Ministry of Health's management, which corresponds to the quadrennial election of a new national president, has disrupted continuity among programs and has barred attempts at large-scale modernization. Furthermore, the interface between the Ministry and the various NGOs is often ineffective. Both actors provide essential parts of the healthcare infrastructure, but in a nation plagued by unreliable technology, poor communication, and inhospitable terrain, coordination of tasks is disorderly and inefficient. The Ministry does its best to operate a complete health system, and NGOs become involved on a local level in areas not serviced by the government. This hierarchy does not explicitly rely on NGOs for specific functions. Thus the Ministry tries to operate all programs, but is spread so thin that it is unable to provide optimal services.
The second factor disrupting public health continuity is the high frequency of natural disasters. The El Niño phenomenon of oceanic heating cycles has been growing in intensity since the 1970s, and every seven to nine years a succession of hurricanes batters Central America, producing such infamous hurricanes as Fifi (1974), Hugo (1989), and Mitch. The central pressure of Hurricane Mitch, 905 millibars, was the most extreme value in history for a hurricane in the Caribbean basin. In the context of government programs that are slow to rebound from such events, a backdrop of disasters means that the public health system is taking on a rather permanent mission of short-term disaster-response. This "spincycle" condition renders Honduras incapable of developing the long-term plans to guide medical care.
Hurricane Mitch destroyed the Honduran medical system physically and socially. For the first several months following the disaster, all attention was focused on emergency and temporary treatment to prevent further loss of life and on bringing basic medical attention and living essentials to Honduras 's six million inhabitants. The corresponding reliance on international support has made it difficult for Honduras to gain the autonomy and skills to operate its own public health system. Before Mitch, total aid to Honduras was approximately US$415 million per year, and though the aid increased dramatically to over US$2 billion last year, much of it did not go toward long-term development projects. Paradoxically, however, the best way to provide disaster medicine is to focus not on the current disaster situations but on long-term development of the health system to serve overall health needs. In spring 1999, attention began to shift to assessing the reconstruction of a new and better healthcare system. This reconstruction was both necessary and opportune: by destroying the old system, Mitch provided an opportunity for fixing its problems.
Hurricane Mitch represented a key transition point for the Honduran medical system in three respects. First, it became apparent that the acuity of disasters in Central America is increasing and that a new model of long-term, rather than short-term, relief must be implemented to prevent a cyclical state of permanent disaster response. Second, Honduras realized that screening international aid is an important feature of sustaining its own health infrastructure, and that a future medical system could only utilize aid that fit specific needs. Third, new information indicates that medical needs will reflect a shift from communicable to noncommunicable diseases, and the medical system must similarly change from one of medical intervention to one of preventive health.
The pre-disaster miscommunication between NGOs and the government reached crisis levels during Mitch, as the disadvantages of a non-collaborative relationship were manifested by a slow, uncoordinated disaster response. Some tasks were repeated several times while others were completely neglected; there was little accountability, and the two groups got in each other's way. Vagrants who lost their illegal shacks in the capital city of Tegucigalpa received medical care and housing instantly, while farming villages received care slowly and sporadically. In response to this inefficiency, the Ministry stepped forward and required that incoming aid be aligned with the needs of the disaster response.
Foreign aid was called into question during the disaster response to Hurricane Mitch. On one notable occasion, a European organization planned to send a donation of medication and a delegation of doctors to manage its distribution in Honduras. The medication was badly needed, but coordinators in Honduras politely declined the offer of foreign medical personnel. The European organization was outraged that while Honduran medical students were being sent on horseback to deliver care, their elite, European-trained physicians were excluded from helping. But the reason for the refusal, reported Honduran sources, was that the positive impact of foreign doctors is severely limited by their typical lack of familiarity with common tropical ailments and the local medical system. The doctors also expected a large degree of support including translators, nurses, guides, transportation, and tourist-grade accommodations and food, items already in high demand during the disaster. The Honduran government judged that the burden of foreign doctors during the disaster outweighed their positive contribution. Refusal of external medical support during the disaster was an unprecedented event, an example of the Hondurans' embracing a local-level critical examination of the role of international aid. The Pan-American Health Organization (PAHO) commended this bold stance, advocating that "countries and organizations should only send medical teams or health workers at the request of the affected country, and should be equipped with logistical and technical support."
At the same time that disasters and international policy are altering the course of medicine in Honduras, so, too, is a change in medicine itself. Mitch confirmed that communicable diseases are on the decline, but pointed toward a new health crisis: rapidly growing non-communicable diseases. Non-communicable diseases now account for 81 percent of illnesses in developed countries, and for these nations there is a critical need to combat noncommunicable diseases, including the world's top three killers: heart disease, stroke, and respiratory infections. As the World Health Organization (WHO) 1999 annual report suggests, it is crucial for less-developed countries such as Honduras to focus on noncommunicable diseases before they reach the epic proportions that have occurred in North America and Europe. This will require a change in the structure of healthcare, but more significantly a complete change in the public mentality; the traditional association between poorer countries and communicable diseases is not necessarily true anymore, especially in Latin America. Non-communicable diseases are on the rise because of increasing lifespans, explains WHO Director-General Gro Harlem Brundtland.
A Cooperative Affair
The three major implications of the medical response to Mitch that Honduras needs to focus on a long-term model for medicine, that certain aspects of the system need to be developed for specific aid, and that the focus must shift to preventive medicine to defeat noncommunicable disease have sparked a vigorous effort to build a new health system with two new characteristics. First, the new system will be independently sustainable. While it will still rely on international NGO participation, both the Ministry and NGOs hope to articulate plans to align that involvement to specific needs as part of an overall health program. Second, the new structure will utilize specialists rather than general physicians in hospitals and embrace a mission of prevention.
This effort has been spearheaded by an alliance between various NGOs and the Ministry of Health. The Ministry, under the inspirational but unofficial leadership of the First Lady, is focusing on remodeling public hospitals and regional health centers throughout the country, creating the first-ever pediatric intensive care unit, and organizing staff training to accompany these changes. Several leading NGOs, including the International Red Cross, Doctors Without Borders, and World Vision, are currently working from the programmatic end to develop a community preventive health curriculum that will include topics such as birth control and sanitation. Even education on smoking, which is quite rare in rural locales due to extreme poverty, will become a part of this program in anticipation of sky-rocketing cigarette use. Also, the Ministry and NGOs are combining forces on several new initiatives, such as a Community Health Volunteer program, which trains two laypersons in each village as health educators, primary caregivers, and liaisons to the medical system.
The Communication Division
Though political cooperation will continue to be essential, a much more difficult challenge to developing new community health programs has emerged: the communication barrier. Communication between the medical world and local communities has long been one of the most difficult aspects of effective healthcare^iii underdeveloped countries. For a healthcare transition to a preventive system heavily reliant on teaching, developing new communication strategies is of the utmost importance.
For example, after Hurricane Mitch, World Vision distributed many tons of chlorine to the people of heavily hit regions in Southern Honduras for water purification. When the staff returned in January, they were frustrated to find that nearly all of the chlorine had been used to wash laundry. Because clean clothes are a more tangible value than peculiar-tasting water, the residents had used chlorine for the former purpose. The advantages of the purified water had simply not been clearly understood. World Vision found the efforts to teach the value of potable water experientially were far more successful. When the local health officers pointed out the lower prevalence of illness (especially diarrhea and gastrointestinal diseases) in those households that use potable water, incidence of diarrhea decreased by 70 percent.
In order to maximize the effectiveness of communication, it is crucial to determine the most receptive and needy audience for a preventive care curriculum. Adolescents have proved a far better audience than adults. Thanks to proactive education reform in the 1980s, teenagers generally represent the most educated generation of rural villages. Furthermore, children are not only the future of Honduras, they are the majority 51 percent of the Honduran population is under 19.
Adolescents have been far more responsible in adhering to health education programs, according to recent case studies by NGO medical brigades. Physicians in these brigades make trips into rural Honduran villages to make diagnoses and prescribe medications. The average patient in the clinic receives two to three different types of medication, and many mothers who came to the clinic had two to four ill children, for a total of perhaps 15 medications. Because the adult population is almost completely illiterate, all communication is oral. But the process was confusing; although the directions for each medication were explained, the unlabeled medication would then get tossed in a sack with a dozen others. During house calls, doctors found that the medications were not reaching the patients. Several steps have since been developed to improve this interface, including the use of cartoon pictures to identify medicines, the most successful of which was working not with the mother but with an adolescent in the family. Adolescents were usually more educated, less occupied by household duties, and more receptive to input from a physician than their mothers.
This focus on implementing local communication will prove essential to creating a health system capable of sustaining health in Honduras. The severity of Hurricane Mitch both showed that a change in medicine is necessary and cleared the way for it, demonstrating that the best system for primary care and for disaster relief alike will be a system that is focused on long-term, sustainable health. Perhaps the biggest problem facing the new system is the relationship between NGOs and the Ministry of Health: both are integral components of an effective medical system, but they must coordinate strategies to maximize their efficiency. Now, the focus must shift toward developing tools and strategies to implement changes in a country with a literacy rate of only 70 percent. This is the only way for Honduras to create a health system aligned with future needs and strong enough to weather frequent disasters. When the next hurricane or flood strikes, the people of Honduras will then have the training and skills to respond.