10 minute read
TOGETHER IN HEALTH
In March 2014, the first cases of Ebola were reported in the West African country of Guinea. The disease quickly spread across borders to the neighboring countries of Sierra Leone and Liberia, and within months the World Health Organization declared the outbreak the largest and most complex since the virus was originally discovered in 1976. As he has many times before, responding physician Dr. Dziwe Ntaba drew on the power of community for solutions.
COVER STORY
Written by Lori L. Ferguson
An emergency medicine physician with significant experience in global health initiatives, Dziwe Ntaba was working as an assistant professor of emergency medicine at Columbia University when the Ebola crisis began to spiral out of control. He quickly decided to get involved. “It didn’t take long to realize that I just had to go,” Ntaba recalls. “I understood the community perspective. I spoke the CDC [Centers for Disease Control and Prevention] language, and I understood a little of the political dynamics and operational challenges of working in countries like Liberia.” The physician’s insights were borne of first-hand experience on the continent, first in Southeast Africa in his childhood home of Malawi and later in the East African country of Burundi, where he worked with his friend Deogratias “Deo” Niyizonkiza to co-found the nonprofit organization Village Health Works, which he continues to support as chief medical officer.
AN UNEXPECTED CALLING
Ntaba was born in upstate New York, the son of an American mother and a Malawian father. His parents met when his father, Hetherwick Ntaba, came to the U.S. to attend college and medical school. When Ntaba was still an infant, the family returned to Malawi where his father was eventually appointed the country’s minister of health. Ntaba remained in Africa until age 8, when he traveled back to the U.S. with his mother and enrolled at Blake.
Despite his father’s commitment to medicine—the senior Ntaba has enjoyed a long career in the public health sector—Dziwe originally felt no desire to follow in his footsteps. “My father worked so hard and his job was so all-consuming that I was pretty sure I didn’t want any part of medicine,” he recalls. But as Ntaba matured and the burgeoning HIV epidemic in sub-Saharan Africa grew, he began to feel the pull to help. At Macalester College, Ntaba began taking pre-med classes, discovered that he liked science, and before long he, too, was on track for a career in medicine. He earned his M.D. from Oregon Health and Science University, followed by an M.P.H. from the Harvard School of Public Health. It was there, on September 11, 2001—the first day of public health school orientation and also the fateful day of the terrorist attacks—that Ntaba first met fellow classmate Deo Niyizonkiza. A native of Burundi and survivor of the genocide that tore through that country and neighboring Rwanda in 1994, Niyizonkiza’s story is chronicled in Tracy Kidder’s 2009 book "Strength in What Remains." On 9-11, Niyizonkiza joined other Harvard classmates in sharing his pain and shock at the attacks and the traumatic personal memories they revived. He and Ntaba soon became close friends.
Niyizonkiza subsequently returned to Burundi and, in 2006, invited Ntaba and several others to see the work he had undertaken to help the community build a hospital in Kigutu. The timing was perfect. Ntaba had just completed his clinical training in emergency medicine, and the genocidal civil war in Burundi was finally drawing to a close. Once in-country, Ntaba quickly realized that here was an arena in which he could make a difference. “Burundi is one of the poorest countries in the world, and the health care system is very fragile,” he explains. “The need for better health care is something that everyone can agree on; it can be a unifying aspiration, especially in a war-torn country like Burundi.” Ntaba immediately signed on to help.
A VIRTUOUS CYCLE
The Kigutu clinic opened in 2007, and for the next three years Ntaba served as the medical director. He invested a great deal of time and energy in the clinic. Yet he underscores that it was members of the community, led by Niyizonkiza, who made their dreams a reality. “The community came together to build the clinic—residents got to know their former enemies and set aside their differences with the realization that everyone needed, and wanted, better health care.”
From the outset, community drove the creation of what is today known as the Sharon McKenna Community Health Center. Village volunteers were generous with their time and resources, demonstrating their commitment by donating the 25 acres of land where the clinic sits, making bricks, planting crops and building an access road all by hand. Niyizonkiza and his team responded in kind, structuring the clinic according to the villagers’ needs.
The community’s dedication so moved Niyizonkiza and his cohort of American volunteers that they decided to form a nonprofit, Village Health Works, to further support the community’s initiatives. They sought guidance from mentors including renowned anthropologist and physician Paul Farmer, founder of Partners in Health, a global organization that provides health care to communities in need. Village Health Works took root and continues to grow and flourish today.
“We witnessed the development of a virtuous cycle,” Ntaba observes. “When we began, the community essentially had no health care, and conditions were abysmal. Infant mortality was high. The risk of death during pregnancy was extreme, and diseases like HIV and TB were going untreated. Once basic health needs were met, however, we witnessed a profound paradigm shift. Residents moved from a fatalistic perspective focused on day-to-day survival to a desire to invest in their children and, by extension, their community.” People began the push to address issues such as malnutrition and food security, says Ntaba, which in turn led to a desire to address the issue of poverty through economic development initiatives.
Dziwe Ntaba ’90
“Then they said, ‘We need to educate our children,’” Ntaba recalls. “So we built a primary school right next to the clinic and began to develop after-school programs as well as early childhood development and Pre-K education initiatives. Throughout our journey, the community’s involvement has been integral—they are the constant driving force behind this success.”
A CHANGE FROM WITHIN
The power of community is a familiar leitmotif for Ntaba, and it came into play once again when he decided to travel to Liberia with the International Medical Corps (IMC) in November 2014 to join the fight against Ebola. Ntaba was charged with the implementation and strategic expansion of IMC’s training program as part of the Ebola emergency response, overseeing the training of national and international personnel.
“For the bulk of my time in Burundi, I felt like I was learning much more than I was teaching,” Ntaba observes, “and my time in Liberia made it even more apparent to me: community involvement is the lynchpin in effecting significant change in health care. Outsiders can offer training and assistance in the technical aspect of delivering care. But when it comes to realizing the behavioral changes that affect outcomes, community engagement is an absolutely essential, and oftentimes missing, ingredient."
The Ebola virus was something of a novelty in the region, and early public health information was not particularly helpful. “Early public health announcements mistakenly placed a heavy emphasis on avoiding bats,” Ntaba says, “advice that distracted from the dynamics of disease transmission and only confused an already skeptical population. Add to that the fact that many residents already harbored distrust of their own government and of outsiders, and things got complicated quickly.” Health care workers began arriving dressed in “space suits”—the gear that protected them from infection—spraying chemicals and collecting patients who would mostly never be seen or heard from again. According to local lore, people with supernatural powers such as witch doctors and traditional healers wore masks, so health care workers in protective gear were quickly identified as body snatchers. Fear and misinformation ran rampant, then evolved into anger and hysteria. In one instance, a team of local health care workers in Guinea was killed by villagers using machetes and clubs. The myth machine was fully engaged, Ntaba observes, and the best way to short circuit the destructive cycle was to engage the community.
Illustrations by Owen Davey
“We began training rapid response teams on professional community entry, which started with respectfully approaching village leaders to explain who we were, why we were there and how we could help,” Ntaba says.
“They, in turn, helped gain the consent of the larger community so that the response teams could do their jobs more effectively and efficiently. Responders started arriving in villages in their street clothes, accompanied by a social worker, and suited up in front of residents so they understood it was a human being inside the protective suit.” After this, health workers could leverage the newfound connections with the community to educate residents on protecting themselves during the outbreak. With these new measures implemented, the tide of the epidemic began to turn.
This approach also led local government to create community-led burial teams during the outbreak. It’s generally difficult for just anyone to contract Ebola, Ntaba explains. The deadly virus spreads only through direct contact with the bodily fluids of a sick patient, thus placing unprotected health workers and family caregivers of Ebola patients at the greatest risk. The issue is further complicated in Liberia, where venerated local traditions entail a process of cleansing the body before burial—ripe conditions for spreading the virus, as the infected individual is most contagious around the time of death. “It’s difficult to change people’s beliefs around generations-long burial practices,” Ntaba observes. “Rather than trying to dissuade family members from preparing their loved ones for burial, we trained them to do so safely, which finally helped break the chain of transmission.”
In December, Ntaba returned to his work as an emergency room physician in New York City, excited to see patients again and gratified to witness lessons learned in Africa motivating change in the U.S. He offers the growing trend of community health worker initiatives as a case in point.
Piloted in developing countries, these initiatives connect a marginalized patient—someone who lives in a remote location, perhaps, or has low health literacy—with a community health worker who interacts with the patient regularly to ensure that he or she understands the prescription regimen, takes medication regularly, follows up with appointments, etc. This “power of accompaniment” for patients with complex health problems in resource-limited environments has proved remarkably effective. And similar initiatives have been found to work equally well in resource-heavy settings like the U.S., Ntaba notes.
For example, in New York City a number of hospitals have instituted a patient navigator program in which disadvantaged or traditionally marginalized patients are identified in the E.R. and assigned a trained peer who assists them in navigating the complex health care system. “These health partners gain credibility with the patient and achieve greater compliance with treatment plans, thereby helping us realize better patient outcomes and cost savings,” Ntaba says. “It’s the essence of patient-centered medicine.”
“Everything I’ve learned over the last decade points to the transformative power of community-led interventions and initiatives,” Ntaba continues. “Priorities differ from one community to the next—one community is focused on health concerns while another may be primed to address educational issues—but no matter where you are, it’s easier to realize success if you work with priorities that have already been locally identified.
Looking forward, Ntaba sees tremendous opportunities for global health. “The number of people living in extreme poverty around the world has fallen by more than half in less than 25 years. At the same time, infant mortality rates have been reduced by more than half, which has been accompanied by a stunning drop in birth rates worldwide,” he says. “Our prospects for improving global health are great; the challenge lies in building upon what we’ve learned through effective implementation. In my experience, the key ingredient for success is meaningful community engagement. I’ve seen it work. I know what can happen when a community comes together, and I’m tremendously optimistic about the future.”
Lori L. Ferguson (writerloriferguson.com) is a freelance writer based in New Hampshire. She enjoys writing on lifestyle and human interest topics as well as all things artistic.
