Bill Totten's Weblog

Monday, March 22, 2010

Iran provides model ...

... to remedy rural health problems in the US

by Victoria Forlini (January 26 2010)

Three Mississippi physicians recently traveled to Iran to study its 17,000 "health houses" - rural medical outposts staffed by community health workers - in order to get ideas for improving healthcare in their own state. The World Health Organization ranks Iran's health houses program, where nurse-aides live and work in a rural community and can check in on patients, as one of the world's best, and with Mississippi at or near the bottom of most healthcare indexes (including an infant mortality rate fifty percent higher than the national average, and rising obesity, hypertension and diabetes) the doctors were looking for a better community health delivery system.

After the trip, which required approval from the US Treasury Department (to show they weren't violating sanctions) and the National Institutes of Health, the doctors now are creating a Mississippi version that calls for training nurses' aides in each community, and then sending them door to door to help with basic needs, such as taking blood pressure and improving sanitation. The health workers would refer patients to clinics or hospitals for more advanced care and follow up with home visits.

"The community health workers will know who has diabetes, who has high blood pressure, who is ten or twelve years old and pregnant", said Dr Aaron Shirley. "They will know it because they live in the neighborhood and see them at church or the corner store".

To learn more:

- See the Los Angeles Times article below
- See the NIH posting on the program below

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A remedy for Mississippi's health blues

The political hurdle could be high for a Delta doctor looking for low-cost rural healthcare solutions in an unlikely place: Iran.

by Bob Drogin

Reporting from Greenwood, Mississippi (January 25 2010)

Dr Aaron Shirley has devoted his career to serving the rural poor in the Mississippi Delta, but now the 77-year-old pediatrician believes the key to reducing the nation's highest infant mortality rates lies in a surprising place: the Islamic Republic of Iran.

Never mind that America and Iran broke diplomatic relations after militants seized the US Embassy in Tehran in 1979, or that the White House is seeking new United Nations sanctions to punish the regime for its nuclear development program.

In May, Shirley and two colleagues flew to Iran for ten days to study a low-cost rural healthcare delivery system that, according to the World Health Organization, has helped cut infant deaths by seventy percent over the last three decades.

In October, four top Iranian doctors, including an official from Iran's Ministry of Health, visited Mississippi for a week. They spoke at a conference in Jackson, the state capital, and toured the Delta.

"Sometimes communication was not easy", Dr Hossein Malekafzali, a professor in the School of Public Health at Tehran University, recalled in a phone interview. "But they can understand our system and translate it to Mississippi".

Iran and healthcare are politically toxic topics in Washington these days. But Shirley and a colleague are to go to Capitol Hill today to seek funding to open an Iranian-style "health house" in Baptist Town, an impoverished neighborhood on the edge of Greenwood, and in fourteen other Delta communities.

"We played black gospel and blues for those Iranians", said Sylvester Hoover, 52, owner of Baptist Town's only business, a one-room grocery, laundromat and barbecue grill. "They were just hugging us they were so excited. They loved it."

Tensions between the United States and Iran dominate daily headlines, but both governments have given quiet support to the little-known initiative in the Delta.

In Tehran, the Foreign and Health ministries approved a memorandum of agreement to authorize collaboration between Shiraz University of Medical Sciences and Shirley's team, which includes Jackson State University.

In Washington, the Treasury Department granted the Mississippians a license to ensure they were not violating sanctions on Iran. The National Institutes of Health also signaled its approval.

A posting on the NIH website notes that the "remarkable success of Iran's health house concept ... is providing hope and inspiration to officials in the Mississippi Delta".

Iran has 17,000 health houses, essentially rural medical outposts staffed by community health workers. The proposed Mississippi version calls for training nurses' aides in each community, and then sending them door to door to help with basic needs, such as taking blood pressure and improving sanitation. The health workers would refer patients to clinics or hospitals for more advanced care and follow up with home visits.

"The community health workers will know who has diabetes, who has high blood pressure, who is ten or twelve years old and pregnant", Shirley said. "They will know it because they live in the neighborhood and see them at church or the corner store".

Over the years, the federal government has poured tens of millions of dollars into primary healthcare research and delivery programs in the Delta, but the effect has been limited.

"The system is broken", Shirley said in frustration. "It's time to try something new".

Mississippi ranks at or near the bottom of most healthcare indexes. Obesity is rife among children, and teenage pregnancies, hypertension and diabetes are all too common. The state suffers the nation's worst infant mortality rate - about fifty percent higher than the national average - and the lowest life expectancy.

The uninsured mostly go to hospital emergency rooms for basic care, from colds to toothaches. Better preventive care could ease that traffic and lower costs, so local hospital administrators are receptive to a new system.

"People will be skeptical at first because of Iran", said Paula Lang, chief nursing officer at the 34-bed Patients' Choice Medical Center of Humphreys County in Belzoni, which is slated to get a health house. "But I think they will embrace the concept when they see how it works".

Jennifer Tate Hibbler, payroll administrator at the Greenwood Leflore Hospital, the largest in the area, said health workers could help with problems such as identifying children about to quit school because their families couldn't afford glasses.

"I was a senior in high school before I saw a dentist", she said. "Our community definitely needs this".

Shirley's group is seeking $30 million in federal funds for a three-year pilot project and has lined up support from Representative Bennie Thompson (Democrat, Mississippi), who represents the area. But Thompson said colleagues facing reelection could balk at backing anything tied to Iran.

"It's fine with me", Thompson said. "To be honest, anything that can improve deplorable health conditions in the Delta, I'm going to support. Even ideas that are foreign to a lot of people."

The proposal to emulate Iran came from James Miller, a medical services consultant in Oxford, Mississippi. He first heard of the Iranian health houses several years ago at a conference in Germany.

"I realized this was a model that worked", Miller said. "Plus the Iranian model seemed most transferable to the Delta situation".

He took the concept to Shirley, who has a much-deserved reputation for challenging the status quo in Mississippi.

Raised in poverty, Shirley became the state's first black pediatrician in 1965. He endured police brutality as a civil rights activist, helped create the state's largest community health center and won a MacArthur "genius" award in 1993. He now heads a nonprofit group that turned a former shopping mall into a medical center for Jackson's poor.

Going to Tehran didn't faze him. "I felt safer in Iran than I felt in Mississippi in the 1960s", he said with a laugh.

An Iranian American professor at Jackson State University, Dr Mohammad Shahbazi, reached out to Shiraz University of Medical Sciences in southwest Iran. The university agreed to sponsor a visit, and Iranian authorities approved visas for the three Americans.

"When we went, all we received were open arms and 'How can we help you?'" Miller said. "They were just amazed that Americans would come and ask for their help".

The Iranians who were brought to Mississippi got a shocking view of rural American poverty when they arrived in Baptist Town.

The blighted warren of muddy streets, weed-filled lots and about 500 shotgun shacks - each has three rooms in a line so a shotgun fired through the front door supposedly would exit the back door - is isolated between two railroads and a bayou.

The all-black community boasts a proud history as a front line in the civil rights struggle and a cradle of the Delta blues. The local cemetery is one of three that claims to be a final resting place for Robert Johnson, the blues legend who died in 1938.

But unemployment is widespread. There is no school, medical clinic nor community center, and many occupied houses look as decrepit as those that are abandoned.

In one, retired cotton worker Erleen Smith, eighty, huddled on a folding chair by a space heater as a frigid draft blew through her ill-fitting door on a recent afternoon. She had lit all four burners on the kitchen stove to help fight the cold.

She grabbed a pill for her blood pressure, swigging it down with water from a jelly jar. Old vinyl records hung on the wall as the only decoration. She can't afford a TV, but friends stop by to check in and chat.

Told about the proposed health house, she shrugged.

"I ain't never heard of Iran", she said. "But we could sure use somebody's help".

Copyright (c) 2010, The Los Angeles Times,0,3381542,full.story

Iran’s health houses provide model for Mississippi Delta

by Ann Puderbaugh

Global Health Matters (Volume 8, Issue 6) (November - December 2009)

A rocky, remote region of southern Iran may not seem the most likely place to look for a health care delivery model that would work in the US. But the remarkable success of Iran's health house concept - in which small primary care centers are located in each community - is providing hope and inspiration to officials in the Mississippi Delta.

After decades of frustration and millions of dollars invested with dismal results, Mississippi health care pioneer Dr Aaron Shirley knew he needed a fresh approach. In some parts of his state, the infant death rate for nonwhites is on a par with Libya and Thailand. Mississippi's health consistently ranks dead last among states in annual tallies produced by the United Health Foundation. It has the highest rates of obesity, hypertension and teen pregnancy in the country, with about twenty percent of its population lacking health insurance.

"We've been attacking this problem over and over again with just heartbreaking results", said Shirley, chairman of the Jackson Medical Mall Foundation, a one-stop health care facility for Mississippi's underserved. "Instead of bragging about the number of buildings that get put up, I'd like to focus our efforts on improving health outcomes by providing primary care to people right in their communities".

Turning to Iran for advice

Together with James Miller of the Oxford International Development Group, Shirley reached out to Iranian health care experts for advice. He knew WHO and World Bank evaluations indicate positive outcomes from Iran's novel health house concept and thought it might provide the solution for his own population.

He discovered his Iranian counterparts are dealing with many of the same issues he faces: lack of funding and trained personnel. And yet they are having stunning successes, reducing child mortality rates by about seventy percent since 1980 and increasing contraception rates to ninety percent, even in rural areas.

Shirley and Miller began conversations with officials from the Shiraz University of Medical Sciences (SUMS), which manages more than a thousand urban and rural public health facilities in Iran's Fars province, in addition to training health care workers and conducting research projects. Over time, they built a relationship based on mutual respect and a desire to share information.

"There are many significant areas of collaboration open to us, both in areas of research, academic exchanges and healthcare delivery, all of which will increase understanding and friendship between our two nations and its peoples", according to Dr Hassan Joulaei, health deputy at SUMS.

Health house concept achieves results

Their ongoing dialogue led to an invitation to examine Iran's system in person. During a visit to Shiraz in May 2009, Shirley and his team discovered some fundamental differences between Iran's approach and the one used in the Delta.

In Iran, preventive care is a priority and special attention is paid to high-risk groups such as mothers and children. Health care workers are chosen and trained within each community. Preventive and curative programs are integrated seamlessly. The system is decentralized, which encourages regional facilities to become self-sufficient and empowers local communities.

In contrast, Mississippi has a fragmented ad-hoc system of hospitals, health clinics and individual medical practices, says Miller. "Our public health programs and services aren't integrated and are anything but user friendly. Our health research is often too narrowly focused on specific risk factors and, like the rest of the US, we place the emphasis on curing existing conditions rather than preventing them in the first place."

Introduced in Iran in 1980, health houses are the basic unit of the rural health care structure, with responsibility for family health and wellness, census taking, public education, disease monitoring and control, environmental health, and the collection and reporting of health data. The health house staff - usually local residents who've been specially trained - refer patients to the area's health center or district hospital if they need more sophisticated services.

Iran, US partnership forms

While in Shiraz, Shirley and his partners at Oxford International Development Group and Jackson State University signed a formal agreement with their SUMS counterparts to work together to adopt Iran's model to suit the Delta's unique needs, in addition to establishing educational exchange programs and joint research projects.

Last fall, in consultation with Fogarty's Middle East officer, Judy Levin, it was Mississippi's turn to host its Iranian partners for a conversation on how to reduce health disparities in both the US and Iran. Participants explored the possibility of jointly designing an information system to track health factors among rural populations in the two countries and developing "sister" research projects examining the social determinants of health - or the causes of illness and disease.

Mississippi develops health house plan

Shirley and his team have developed a pilot community health house plan and are looking for funding to implement it. So far, more than fifteen Delta communities have expressed interest in participating. "I believe this will provide a cost-effective way for us to provide quality primary care, engage local communities and empower individuals to take responsibility for improving their health", he said.

The project sites are intended to become permanent research nodes to generate health disparities data over time and the overall model is designed so that it is scalable and can be widely adapted.

"This is a wonderful example of how science can provide the basis for meaningful exchanges", according to Fogarty's Levin. "It also shows that great ideas can come from unexpected places and when we look outside our borders we discover how much we can learn from others."

Read more about Health Houses on the World Health Organization Web site:

Bill Totten


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