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What the Global South could teach rich countries about health care — if they'd listen

Dr. Matthew Harris visits the primary health-care center where he worked in Brazil 20 years ago. The author of <em>Decolonizing Healthcare Innovation: Low-Cost Solutions from Low-Income Countries</em> says: "I really think that if people had been more receptive to learning from Brazil 20 years ago, we could have had an army of community health workers in [the U.K.] by now."
Courtesy Dr. Matthew Harris
Dr. Matthew Harris visits the primary health-care center where he worked in Brazil 20 years ago. The author of Decolonizing Healthcare Innovation: Low-Cost Solutions from Low-Income Countries says: "I really think that if people had been more receptive to learning from Brazil 20 years ago, we could have had an army of community health workers in [the U.K.] by now."

When Dr. Matthew Harris returned to the United Kingdom in 2003 after a four-year stint in Brazil, he remembers being fired up with ideas—only to encounter what he describes as a "wall of prejudice."

He had moved to Brazil in 1999 after finishing medical school in London and working in the U.K.'s National Health Service (NHS) for a year. There he had to start over and re-train to be certified as a doctor in Brazil, passing proficiency exams in Portuguese through the University of Sao Paolo.

On his return to the U.K., he was convinced his home country could learn so much from the Brazilian health system, if only they were prepared to listen.

They were not. So, he came to understand how researchers and clinicians from the Global South must feel when they go unheard because of the many prejudices that still grip global health.

Harris's new book, Decolonizing Healthcare Innovation: Low-Cost Solutions from Low-Income Countries, delves into what these biases mean for the future of medicine. Harris, now a public health researcher at Imperial College London, spoke to NPR about his book via video call. The interview has been edited for clarity and length.

When you returned to the UK after working as a family doctor in Brazil, you mentioned having a revelation?

When I returned to the U.K., I found myself in this interesting position of being both an insider and an outsider. I'm a U.K. born and trained clinician and public health doctor. I was also a Brazilian doctor at the same time. That gave me a real sense of sort of an injustice that was happening. I could see what the opportunities were to learn from the Brazilian system, at the same time I could see that some sort of arrogance was preventing people from fully considering it.

What did you urge the National Health Service to consider at that time? What has changed since then?

It's taken 20 years to get to this point, but yes, we've brought across the community health worker role that underpins the Brazilian primary-care system into the U.K. And it is now, I'm very glad to say, scaling very successfully throughout the country.

It wasn't a role that we had in this country prior to this effort.

We began piloting at the tail end of 2021 We recruited four community health workers in the council estate in London (low-income housing) and based on that experience, it expanded to ... a dozen other localities.

Local health workers cover small geographies, have a way of winning trust and perform a comprehensive array of activities that integrate people into primary care. Other countries like Brazil, Ethiopia and India have shown how a coordinated community workforce could provide long-term health and social care support at scale.

So, it's very exciting that we've been able to get this far. It's just sad that it took 20 years. I really think that if people had been more receptive to learning from Brazil 20 years ago, we could have had an army of community health workers in place by now.

What were the objections about at first?

Those objections were never rooted in fact. There were just unsupported beliefs that it would lead to problems. For instance, a community health worker role of this nature is proactive. It's about knocking on doors and getting to know families even before they've had problems. People said it wouldn't work (in the U.K.) because people don't like others knocking on their door.

Some said it was far too expensive to have this sort of initiative because it's only going to be effective at scale (in large numbers), missing the point that actually, if it's at scale like it is in Brazil or in India, you start to see significant population health outcomes across the board, so cost should not be a limiting factor.

Some even explicitly said, 'it's [from] Brazil, you know, it's too different. We prefer to pay attention to countries we think are more similar, like France or Germany.' But actually, when you really think about it, France and Germany are as different to the U.K. as Brazil is.

In the book, you discuss how structural and resource disadvantages lead a dearth of research from the Global South, and that leads to a "hidden curriculum." What are you referring to?

We have a "hidden curriculum" in all of our global health institutions in the West — that West is best — because we generally teach from those sources. So even though there might be excellent research being conducted in Brazil and Argentina and Rwanda and Ethiopia, we don't really draw on it very much. So, what are we teaching our students? We're perpetuating that worldview over and over and over again, which is that that kind of research (from other geographical regions) doesn't matter.

In your book, you say that there's a lot that high-income countries can learn from low-income countries, what you call frugal innovation. Low-income countries don't have unlimited resources and tend to do the best they can with what they have. On the other hand, you say that spending more on health care for high-income countries wouldn't guarantee better outcomes. Could you explain that?

To be perfectly candid, I feel like I'm occupying a controversial space with this question. I just want to unpack it slightly. Because, of course, firstly, it's definitely a generalization to talk about low-income countries do[ing] more with less. I'm not trying anyway to glamorize those settings and I'm not trying to say that we shouldn't invest in health care, but I do feel that unfettered investment is clearly not sustainable.

We've seen this in the U.S. — one could argue that its spiraling health-care costs aren't always commensurate with the outcomes. The U.K. is going in the same direction. So, when we hear that the system needs more money, we need to ask if we can afford it. And that's why I wanted to draw attention to the frugal health-care innovations from around the world.

Because, when you look at these technologies side by side, the expensive ones against the frugal ones, they deliver the same outcomes oftentimes at a fraction of the cost.

Can you give me some examples that really caught your attention?

Robotic surgery is an interesting one. You know there will be impressive outcomes for individual patients by the use of robotics. It's an exciting invention and cutting-edge technology. But when you're looking at randomized controlled studies of the use of robotics compared to non-use of robotics, there isn't a huge difference in terms of length of hospital stay or clinical outcomes for patients. So one has to ask, well, why are we using such expensive technologies?

A good example of frugal innovation is hernia surgery. In India, instead of using commercial mesh to treat hernias in an operation, you can just cut a bit out of a mosquito net, sterilize it with ethylene oxide, and actually it's just as good if not better than the commercial mesh at a fraction of the cost.

Another example is postpartum hemorrhage in obstetrics. So when a mother delivers a baby and is bleeding and can't stop the bleeding, one of the devices that we use is called a balloon tamponade device, which you insert into the uterus. You fill it with saline, the balloon gets bigger and bigger, exerts a pressure inside the uterus and stops the bleeding. But you can have the exact same outcomes just by tying a condom onto the end of a urinary catheter. It does exactly the same thing at a fraction of the price. That's being used in Bangladesh and in sub-Saharan Africa as well.

There are many other examples. There's one from the Brazilian Amazon, where researchers have discovered that by using the skin of the tilapia fish, you can treat severe burns, second-or-third degree burns, just by placing the [fish] skin after it's been sterilized onto the burn and leaving it for 10 days. [Unlike topical creams, the fish skin sticks well to the surface of the wound, preventing secondary infections and reducing the need to change dressings as often.] It heals and leads to perfectly good outcomes without needing skin grafts or bandage changes which are painful and can lead to infections. The phase 3 trials that have been conducted in Brazil suggest that the outcomes are just as good and it only costs $11 for a course of treatment

We spend about 8 billion pounds per annum on burns treatments here in the U.K. for about 4 million patients each year.

You talk about de-colonizing global health. What's the best way to do this?

We can use two approaches—soft reform and radical reform.

Some of the ways in which universities in particular are addressing this is by paying more attention to the diversity of their sources of knowledge — the kind of journals that they use in their teaching, the regions from where they're teaching — and trying to be more inclusive. And medical schools are using different images of dermatological conditions, thinking about how these problems manifest or look on different skin types, so that we can be sure we're not inadvertently discriminating or leading to worse outcomes for people of color. These are really important initiatives to make everybody more conscious of this bias. However, all this is soft reform — it still is about bringing knowledge into a mainstream, which is still Western.

So radical reform asks questions that are deep and philosophical — reflecting about why we even have a mainstream in the first place. So it should go beyond trying to be more accepting of other people's and regions' knowledge to examining what has led us to this social construct in the first place. And how can we actually reinvent or how can we actually reorganize our global health knowledge economy, where there is no mainstream, where learning just happens organically and flows in any direction.

How can white people engage in global health without perpetuating these tropes or deepening the harm? As a white man writing this book, what has your own journey been like?

Yeah, I have mixed feelings about this. It's challenging, I'm not going to lie. I can't help that I'm white, male, middle-aged, that I've been educated in elite institutions in the West. But that doesn't mean we can't be, for want of a better word, allies and contributors for developing a more evolved and equitable knowledge ecosystem within global health.

I think we play a part in working in partnership, collaboratively, openly, understanding that we too have problems that other people can help solve. We don't hold all of the knowledge, we do not hold all of the wisdom by a long stretch.

Kamala Thiagarajan is a freelance journalist based in Madurai, Southern India. She reports on global health, science and development, and her work has been published in the New York Times, The British Medical Journal, BBC, The Guardian and other outlets. You can find her on X (formerly Twitter) @kamal_t

Copyright 2023 NPR. To see more, visit https://www.npr.org.

Kamala Thiagarajan
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