From the Village to the City: Speaking the Culture of Those We Serve
“Every city in the world has a village in its heart. You will never understand the city, until you first understand the village.”
- Gregory David Roberts, Shantaram
India has been called a country of villages — residing 40 kilometres from the main city can mean being a world away. Gaps in healthcare access between urban and rural populations are pronounced, with a staggering 67% of the population living in rural areas and most physicians concentrated in urban centres. Prior to starting my Global Health Corps fellowship, I was working in Karkala, India with Dr. Virupaksha Devaramane, a psychiatrist at a citywide hospital who recognized that transportation from villages to the nearest citywide hospital can present major obstacles to accessing mental healthcare in South India. To access the main citywide hospital, people might travel up to 40 kilometres, hop on three to four different buses, and spend a majority of their day in transit, inevitably missing out on an entire day of pay. He noticed a pattern of frequently missed appointments, a reluctance to take medicine correlated with a lack of literacy, and an inability to make out-of-pocket payments to the hospital — all of which lead to patients regularly getting lost in the system.
For some context, India spends approximately $75 per person annually on healthcare, whereas the United States spends $9,403. India faces a shortage of physicians, with a doctor-patient ratio of 0.7 doctors per 1,000 people. This is significantly lower than the global average of 1.4 doctors per 1,000 people, as well as that of other emerging economies like Brazil (1.9) and China (3.6). In 2010, Dr. Virupaksha opened a satellite psychiatry clinic 40 kilometres away from the main city in Karkala, which he visited and continues to visit every Wednesday. People still have to travel to reach his satellite clinic, but their travel time has dropped to less than one hour instead of four. Many of the patients he attends to consult alternative approaches to treat mental illness, including spiritual practices, Ayurveda treatment, yoga, or acupuncture. One of the first things I noticed was how important it was for Dr. Virupaksha to respect and encourage his patients to continue their alternative practices as complementary forms of treatment, as long as it was not harmful or exploitative. Despite the resource-constraints, I left South India feeling humbled and appreciative of people like Dr. Virupaksha who ensured that empowerment and listening to the community were at the root of care.
In my current role, I work within the Department of Health and Mental Hygiene in New York City — a city renowned for its innovative health programming, gold standard infrastructure, extensive funding, and large workforce. Living in a city with 472 subway stations means that transportation is not a significant barrier to accessing healthcare. Yet despite these advantages, a different set of disparities based on location exists: decades of racial residential segregation combined with inequalities have created startling health inequities between neighbourhoods in New York City. A 10-year difference in life expectancy exists between people living in the Bronx as compared to Manhattan, which is only eight short kilometres away.
While a variety of social determinants contribute to this alarming imbalance, I began to notice a trend: to reach that last mile in a city with abundant or constrained resources means finding inclusive methods of reaching neglected communities. In the U.S., a similar kind of reliance and comfort with alternative places of healing exists, as evidenced by the significant role faith-based organizations (FBOs) play in healthcare prevention and support. FBOs serve a multitude of classes, races, and age groups, often being a strong source of trust. By increasing their reach and effectively targeting the specific needs of affected individuals, FBOs are able to act as guides and communicators for hard-to-reach populations in the United States. Historically, many FBOs have played integral roles in delivering services for breast and cervical cancer, cardiovascular disease, and HIV/AIDS.
Neglected communities within a larger city aren’t only found in New York City - they appear all over the United States. In fact they are prevalent over the world. India and the United States are, in a sense, two sides of the same health equity coin. Two of the world’s largest democracies are at inflection points in the way they deliver and create programs to access healthcare. Both countries actively illustrate one of the World Health Organization’s core founding purposes: “where you live dramatically affects your access to essential health services.”
As we celebrate World Health Day today by shining a spotlight on Universal Health Coverage (UHC) for all, let’s focus on expanding our definition of what UHC is inclusive of by designing health services for and around the people who we serve. It is a reality that all countries, regardless of population size, will be differently equipped to address the healthcare needs within their borders.
“While we celebrate our strides, we must continue staying conscious that in every successful health initiative or strategy, there will be villages and neglected communities that still lack access to healthcare. To create a truly global response situated around person-centered care, we must collaborate and tap into all of the infrastructures already in place.”
However, to truly close the gaps in healthcare disparities, we must learn to speak the language of those we serve — whether that is through the inclusion of traditional health practices alongside mainstream medicine, the dissemination of educational material written in a local language, or the use of methods of communication that may be more accessible within certain communities. We must continue building partnerships with the communities we serve to develop trust and culturally competent interventions that are sustainable. While we celebrate our strides, we must continue staying conscious that in every successful health initiative or strategy, there will be villages and neglected communities that still lack access to healthcare. To create a truly global response situated around person-centered care, we must collaborate and tap into all of the infrastructures already in place.
Sharan Kuganesan is a 2017–2018 Global Health Corps fellow at the New York City Department of Health and Mental Hygiene.
Note from the author: On World Health Day, I want to applaud all of the community leaders, caretakers, providers, nurses, and analysts in small communities and big cities for seeing a need, for mobilizing, and for keeping us moving — you are the heart of all of this.