Movements to reduce inequities in international health outcomes, rectify current healthcare infrastructure, and expand the supply of available medical resources are perpetually flashing on television screens, newspaper headlines, and Instagram posts. These campaigns typically characterize their mission as addressing or strengthening “global health.” The Global Fund to Fight AIDS, Tuberculosis, and Malaria is one such movement, working tirelessly to prevent and treat these diseases in low- and middle-income countries. Meanwhile, the World Health Organization’s Framework Convention on Tobacco Control is fighting to stub out smoking through measures like increased taxation, advertising restrictions, and smoking bans. The United Nations’ Sustainable Development Goals also play a crucial role in promoting good health and well-being by providing universal health coverage, vaccine access, and improved sanitation and hygiene. These dynamic and far-reaching global health movements are fundamental in tackling the many challenges that stand in the way of achieving equitable and accessible healthcare for all.
While attaining comprehensive global health is an optimistic and well-intentioned goal, there is still much work to be done to achieve global health for all. Securing healthcare for all requires addressing not only healthcare infrastructure but also the specific social, economic, and political factors that affect health outcomes. It demands ensuring access to essential medicines and vaccines, promoting health literacy and education, improving sanitation and hygiene, and strengthening healthcare systems — at the individual community level. No two villages, cities, states, or nations are alike. For this same reason, it is crucial that societal factors are considered from the ground up, rather than the top down approach currently overemphasized.
As a premedical college student, I am fascinated by the role of policy in shaping medical care delivery. Throughout high school, I slowly found myself disillusioned by how the mission of global health was addressed and consequently sought to consider alternative methods of providing healthcare to every human being.
As a result of the COVID-19 pandemic, my view on our ability to solve global health issues shifted from optimistic to negative. The virus rapidly spread across borders and continents, leading to widespread illness, hospitalizations, and deaths. This pandemic overwhelmed healthcare systems in many countries, leading to shortages of medical supplies and equipment and disruptions to routine healthcare services. According to UNICEF, disruptions to essential health services caused by the pandemic may have resulted in an estimated additional 239,000 child and maternal deaths in South Asia. Moreover, there was a profound impact on mental health and well-being, with increased rates of anxiety, depression, and stress reported worldwide. A study published in The Lancet Psychiatry Journal estimated that the global prevalence of depression increased by 27.6% during the pandemic, with rates highest in low- and middle-income countries.
The pandemic disproportionately affected vulnerable populations such as the elderly, low-income communities, and essential workers, highlighting the inequities in global health. According to the CDC, as of April 2023, individuals aged 60 years and above accounted for over 80% of COVID-19 deaths globally. Low- and middle-income countries represented 52% of excess deaths in individuals aged 60 and older. Furthermore, a public health student found that individuals living in lower-income counties experienced a mortality rate more than twice as high as those living in wealthier areas in the United States. Additionally, essential workers were at a higher risk of contracting the virus, with a study demonstrating that counties with the largest proportion of essential workers were correlated with the highest COVID death rates by March of 2021. There is an urgent need for targeted interventions to address the systemic inequities that have exacerbated the impact of the pandemic on vulnerable populations.
As my second year of college came around and I engaged more deeply with healthcare and climate policy groups on campus, it came time to consider how I envisioned incorporating international medicine advocacy in my future career. So, I decided to use my winter break to undertake an internship in Bangalore, India, where I sought to gain insight into more unconventional paths to achieving global health.
Through my internship with the Society for Community Health Awareness (SOCHARA), an organization that emphasizes community health over a top-down approach to healthcare delivery, I was able to interact directly with community stakeholders in low-income villages to better understand gaps in medical care. My field visits demonstrated how factors beyond one’s income could influence healthcare access. During my interviews with village residents, I learned to pay close attention to the existing infrastructure, demographics, leaders, culture, and many other social factors that influence the interactions between communities and medicine.
These avenues of more holistic community understanding will help us build healthcare resources and infrastructure for the specific populations served. Implementing a broad, Westernized approach and applying it across all developing countries does not cater to the individual needs of every community. We have been attempting to employ this method for decades, yet global health is not progressing as rapidly as it needs to. Our international leadership must consider a different approach: community health. By focusing on the health needs of specific communities and building from the ground up, interventions can be tailored to address the unique challenges and barriers to robust healthcare access within that community.
This framework begins by actively establishing partnerships with community organizations, leaders, and residents to ensure their voices are heard and their needs are addressed. Comprehensive assessments should be conducted to identify the health needs, resources, and existing disparities within the community. Once action is taken, emphasis is placed on health promotion, disease prevention, and early intervention strategies. Community health programs are developed with resident volunteers to educate the community about healthy behaviors, provide screenings, vaccinations, and preventive care, and encourage lifestyle changes that reduce health risks. Ultimately, when community members are involved in the planning and implementation of health programs, they are more likely to take ownership of the solutions and work to sustain them beyond the lifespan of the program.
According to the World Health Organization, community health approaches have been successful in reducing maternal and child mortality rates, improving the management of infectious diseases, and increasing access to healthcare services in underserved communities. For instance, a community-based intervention in Nigeria that focused on maternal health improved the probability that a woman undergoing pregnancy had a birth plan by 42% and the probability that she attended a newborn check-up within a month by 41%. Similarly, in Bolivia, a community health program that trained local volunteers to provide basic healthcare services resulted in a 52.1% reduction in mortality rates for children aged less than five years.
Furthermore, this bottom-up approach allows for a more targeted and efficient use of resources. Global health interventions can be unnecessarily costly. By focusing on community health, resources can be directed to areas where they are most needed, resulting in more effective use of limited resources. A community health initiative with health extension workers in Ethiopia lessened treatment costs per tuberculosis patient by 63% compared to costs associated with general health workers. In Uganda, another community health approach attenuated patient costs from $510 to $289 per patient, and saw the tuberculosis treatment success rate improve from 56% to 74%. Moreover, the average duration of patient hospital stays dropped from 60 days to 19 days, enabling a greater number of patients to receive timely care. Similarly, a community health program in rural Zambia that focused on minimizing malaria deaths was 36% more cost-effective than the traditional facility care, even though patients’ adherence to their treatment plans increased. Community health approaches can thus outperform traditional global health interventions in terms of both costs and efficacy.
My experience with community health approaches in India spurred me to think about the type of global health system I seek to champion. I am committed to this paradigm of community health and I aspire to tread ahead of health crises rather than “mopping the floor” after problems occur with devastating consequences. I envision a network of community health activists — whether they are patients, nurses, physicians, policymakers, lawyers, or otherwise — coming together to build robust healthcare systems that deliver to all those in need. By uniting, we can identify the unique health challenges faced by our communities and work toward solutions that address them. Our efforts at the community level can also create a ripple effect by inspiring other communities to take action and leading to broader changes in global health. Through prioritizing community health and working together from the ground up, we can make progress toward achieving the longstanding goal of global health for all.
Image by Nguyễn Hiệp is licensed under the Unsplash License.
