10 May 2011

Sustainable - Ecstatic.

Everyone talks about 'sustainability.' 'Sustainable development.' (which, by definiton, should be sustainable - otherwise - it's patchwork construction and shantytowns, metaphorical or literal). The environment.
Etc, etc, etc. It's as much of a generalized buzzword as "global health" is becoming in medicine.

If there's one thing I learned in Cameroon, it's that I can't take on things much larger than a village. A small part of a health district, perhaps. A health district (rural). A larger health district (someday). Part of a small NGO (someday). One project, perhaps two. Other things are less sustainable.

In medical school, the largest thing possible was a small, student-run clinic in a homeless shelter, operating for a few hours two nights a week and a morning every other weekend. That, in itself, was enormous. And there were several of us. (Alone? Possible? One person is not sustainable).

The Mall, Washington, DC, February 2003
In college, I was actively anti-war (can't even be apolitical in writing). (and I've learned that the strict position of 'anti' isn't useful anyway.) Peace marches, protests, demonstrations, a dizzying 'march on Washington' (to be done once in a life, at least, if politically inclined) gave a sense of community and something greater when the state of the world was terrifying. In this state, there are rallies at the state house for single payer healthcare. I haven't gone. It’s the global and local thing. Someday, maybe, WHO-type work. Someday, definitively, public health education/behavior change communication and program design. Local to larger to local.

If I hadn't gotten into medical school the first time, I would not have applied again. It would have been, I think, a year of something then two years of MPH. There are so many paths to the same thing – these are not Frost’s diverging roads.

Hopital de District de Mvangan

I digress.

Different ways to get at the same thing.

Sustainability, ecstatic. Things I worked on – sustainable/sustaining. Me – ecstatic.

When I – when we – took over the homeless clinic, almost two years ago, it was not, in my viewpoint, functional. My basic stance was either we turn this into a real clinic or we shut it down. The clinic operates within the largest homeless shelter in this city. (But this is not a story about the clinic). It was tied to the Department of Public Health (DPH) – sortof.  We took supplies from their supply closet (ah, the delectable power of having that key on my key chains… the thrill of wandering and finding new things for the clinic, new ideas for how to expand and what we could do with them. This is a story about that). We had the same patients in the same clinic space as two health care providers from the DPH. We had files, sortof. They had files. We gave them copies of our notes, the billing parts that were not ever filled out correctly. The “billing sheets” went to the DPH for their statistics, which help determine state funding. And every year, the clinic leadership turned over to a new group of medical students. Medical school is short and fast. Four months into starting first year, three months – or less – into starting clinical volunteering, students have to decide if and who is going to lead next.

African Development Bank's unbelievably costly hospital, Amvom, which has nothing but expensive walls and nothing to sustain it

This is not sustainable unless there is a standardization of clinical practice.

This is not sustainable unless this clinic is a direct part of the DPH.

This is not sustainable if there is no public health group incorporated as part of clinic leadership, running monitoring and evaluation.

This is not sustainable if there is no cohesive clinic structure, cohesive and streamlined clinical practice, standard of care and operating protocol – because – the clinic coordinator is not the same, every night (though, in the end, it rotated between about 4 people, every week, who were there at one or both of the clinic nights).

Without the above, this is not a clinic.

This is not a story about what I did, or about what we did – it’s a story about how we made something function.

At the end of a year, less, the clinic was a clinic. Maybe a shaky one – we weren’t sure. It was part of the DPH. We were continuing all the relationships we had cultivated. The way to create sustainability, or the illusion of a functioning structure, is to present it as if it has always been that way, and that this is just the further iteration of institutional memory. So we conned them – the new group of students – into thinking this was a longstanding procedure, a longstanding part of the DPH, that their job was to continue and continue to improve. We wanted it to be an illusion – or was it, or did it need to be? – that these were time-honored and strong foundations, that they weren’t brand new. We inculcated our new recruits with new procedures.

Prior clinic in Amvom, which functioned for a long time

A checklist.

I just finished reading Atul Gawande’s The Checklist Manifesto. And I just returned to clinic for the first time in a little over a year. It’s functioning exactly as we hoped –moreso. The same structures are in place, the relationships are stronger, and the foundation we left was firm enough to be built and improved upon. Many things we’d wanted to do, but had not had the time to do – have been are being done. And then I realized how we’d done it.

It’s called the Coordinator Checklist. It hasn’t changed; basic procedures really haven’t changed or obviated the need for change (the contact info is the same for the same four of us who were running it then, actually). We went through and tried to create a standard operating protocol; the things that needed to get done and how we did them. According to Gawande (and in truth), it’s too long, too complicated, with too many full sentences. It can serve more for troubleshooting, then, and the most motivated ones, early on, do read it. It references an entire binder of SOPs.

I went back to clinic last week. I was nervous and excited – how was it functioning, now, (and how much better would it be/how little had I worked), would I remember what and how to do things.
Clinic is there.
Clinic is better.
They’re more a part of the DPH. They’ve kept the same positions/core group structure that we created (ie, made up) and have built on it.
They’ve created more SOPs than we did – things we’d dreamed of, somewhat, and not had time to do. Better structure for patient education handouts – and using them more. Domestic violence screening practices. Etc.

And the coordinator for the night told me how the best thing we can do for patients is get them into primary care through the city programs.

He told me.

I started that. (Having a large/main focus of our clinic as getting our patients into primary care and training everyone else to know how to do it. And to track what we were doing.).

Things that feel tenuous when you “make them up”, when it was built on an idea and a few students in a windowless small group room … aren’t tenuous. What is real, then? (Anything).
This is not an NGO, this is not something that’s going to transform health or homeless health or a shelter. It’s not going to revolutionize anything. But it’s something. It is something. All it needs to be maintained are interested, motivated students (no short supply in any conceivable future). It’s incredibly lucky that we can count on that. We rely on free labor from people who are doing this because they’re passionate about it – and who, realistically, don’t forget that all this goes into residency applications (and for the pre-meds, into med school applications).

Closer to two years ago than I’d like to think about, I was on a bus from Yaoundé to Ebolowa, and we’d just arrived. The woman next to me asked me where I was going, and I told her I was going to Mvangan, that I had lived there for a few years as a Peace Corps Volunteer (did I even say PCV? Maybe I said American. Maybe none of the above). “Ah!” she exclaimed. “I know Peace Corps Volunteers in Mvangan and Ebolowa, they taught me about nutrition, it was a project with growing soy.”

She told me about the soy nutrition project, the teaching, the health and agriculture and business components.

I started that.

And now it’s infinitely better, and more, and makes more sense, and has done more than I would ever have imagined/could have done myself. I am unbelievably, incredibly lucky to have been able to (already) see not one but two of my most beloved projects grow and become sustainable. Take on a life of their own beyond me. Were these children, they’d be walking, and maybe talking, a little.

Fields in front of Hopital de District de Mvangan
Writing about the bits of public health that really excite me, the things that create programs that can sustain themselves (involving motivated people, obviously) – would not be, may not be so exciting. Monitoring and evaluation. Quality improvement. KAP studies (knowledge, attitudes, and perceptions). PACA – the Peace Corps one (Participatory Analysis for Community Action. or similar. I still use that). Behavior change communication.

Where There Is No Doctor. Helping Health Workers Learn. (Hesperian foundation). I still use those. Patient care, though, is only sustainable in out-patient, longitudinal practice – if that. Building they physician-patient relationship, working on stages of change. Etc.

With writing, I suppose this would include being quoted or included in someone’s personal anthology. Publishing has other attributes, unless the point is advocacy. Or something. But even that has a self-promotional aspect.
There are writers whose words are always in my head – and this includes some people I know personally, who are not published but are some of the most talented writers I’ve read. I used to be terrified of not writing again, that “it all” was gone. This was hardest when I was writing my undergrad thesis – if I went a week, almost two once, without anything writing itself – I was afraid there was nothing left. And then something would come, and for the time being, everything would be okay again. There’s a solution, actually – reading. Reading and going to readings. I was working on a book review, recently, for a book of Cameroonian poetry (The Oracle of Tears). It was difficult/impossible to get all the way through on an initial read – I kept putting it down to write. Anything that inspires others to write/think/read, then, is the sustainability bit. That more muses and Martians will be translated and expressed, that words will continue.

Lines that have been over my desk for many years –

“…open the notebook
and drunk with inspiration commence

                   ~Franz Wright “The Lemon Grove”

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