zondag 28 april 2013

Advanced Health Decision Making in a prison

After she passed the usable checkpoints within the prison, Randa met Ahmed in the meeting room.
He had been in jail since he was 16 as a consequence of being part of a militia.
His family escaped to abroad and now he was 26 and had almost completed his punishment.

In prison, he had exposed himself as being very interested in medical care, whatever that word means in the apocalyptic world he was living in.
He had developed an expertise in withdrawing blood for laboratory investigation and teeth extraction.
Because of that he was noticed by the people of a Beirut University that had developed here a program for basic health care.
This had began seven years ago, one month after the end of the 2006 Israeli attack on Lebanon that severely hit the vast majority of South Lebanon’s villages. Immediately after the end of the war, the president of the university had launched a civic engagement project with an action plan to help the population, each institution in its area of expertise.
After 18 successful healthcare missions in all the destroyed villages in South Lebanon, a group of volunteers wanted to continue serving the community by working with the most vulnerable population segment, namely the inmates in Lebanese prisons. The hospital and the university administration were very reluctant to this project; putting students in direct contact with convicted persons in an unfamiliar environment was sensed as taking a high risk.
But the enthusiasm of volunteers and the positive feedback of the prison’s authority encouraged the hospital administration to engage in this project.

Ahmed was meeting Randa, a nurse with 19 years of experience in healthcare.

Before her current position as senior consultant for a Health Consulting Group, she was involved in the prison project.
At first a comprehensive assessment of prisoners’ health was developed.
This included a general check-up as well as activities of screening and prevention of cardiovascular, dermatological, psychiatric diseases and some cancers mainly breast and cervical cancers in women.
Missions were performed on a Saturday every 6 to 8 weeks and 100 volunteers on average were involved in each mission.
They were aware that they could not assess the health of all 5500 prisoners in a three year period especially that the missions were performed, as mentioned before, one Saturday every 6 to 8 weeks.
So they decided to give priority to the 300 women inmates and the 170 minors because they were the most vulnerable and controllable given their limited number. The second priority went to 4 medium size men prisons not exceeding 200 inmates each.
Secondly the aim was to create a healthcare system in Lebanese prisons that covered primary, secondary and tertiary healthcare, emergency services, as well as care documentation through an electronic health record.
In order to create a sustainable system, an insurance system was set up, sponsored by NGO money for those who couldn’t afford the yearly 300$ fee.

Randa had just returned from an international conference concerning Advanced Health Decision-Making.
This initiative was set up 2 years ago by ABIS( the Academy of Business in Society), Rutgers University in New Brunswick and the Corporate Citizenship Trust of the pharmaceutical company Johnson and Johnson.

In May 2011, they had a first meeting in New Brunswick bringing together healthcare managers, policymakers, industrial people, academics, human ecologists and other species that more or less had something to do with healthcare.

The meeting was not set up to obtain predestinated outcomes and didn't follow a strict roadmap.
The aim was to emerge thoughts and concepts about possible evolutions in healthcare, opportunities and innovation in a spirit of openness, trust and collaboration.
Focus moved from traditional health care strategies and interventions to questions as : "What is health?" or "Who owns health in a community?"

During a second meeting in October 2011 in Fontainebleau with the cooperation of Insead, emphasis was put on conditions and leverages of better healthcare decision making as management information, technology, systems innovation, policymaking and knowledge brokers.

In Glasgow in March 2012, a visit was set up in an occupational day center for psychiatric patients and socially isolated people who found there a meeting point and working together in a more or less sheltered environment.
Health of the population was significantly decreased after the closing of much of the ship industry with a huge unemployment as a consequence.
A mission statement was worked out with emphasis on health decision-making based upon patient and community empowerment, and a comprehensive model of health including education, prevention and social involvement.
Unlikely alliances and partnerships could challenge traditional concepts of health care and facilitate innovation in order to achieve better quality health outcomes for individuals and communities.
Key issue was the extent of responsibility of a person for his own health which could be conceptualized as an invitation more than an obligation not to be captived within the dictatorship of health control as described in the book “Corpus Delicti” of Juli Zeh.

The journey was oriented to the Arabic Spring but the meeting in Cairo in December 2012 had to be canceled because of the unstable situation.

From 23 to 24 April, an international bunch of academics, hospital managers, policymakers, consultants, industrial people, entrepreneurs and communication experts had gathered in Sharjah, the little sister of Abu Dhabi and Dubai.

The territory of the state is very fragmented due to the historical alliances between tribes and the ruling family in the city of Sharjah.
The state has about 600,000 inhabitants with more than 80% expats and foreigners mainly from India, the Philippines and other Asian countries.
The luxury hotel could easily compete with a five-star Hilton in the United States with one critical difference : alcohol was not available as the consequence of the gratitude of the emir of Sharjah towards Saudi Arabia who had helped them financially in bad times during the eighties.

But could we deny that there was a small change in our perception when we were told it was only a three-star hotel priced at USD55 a night, breakfast included.
Could it have been an anticipating metaphor for our the congress :
“high-quality low-cost by adv
anced decision-making

“The venue was the most beautiful university campus in the world”, Frank said.

The Belgian J&J director could be considered as the founding father of the AHDM initiative.
"Own child's beautiful child", one could have thought but anyway the campus resembled a kind of Arabic royal resort with mosque like buildings, green squares and lots of space which could only be available in the desert

The campus hosted about 600 students in medicine and another 600 in dentistry and pharmacy.
Less than 20% of the students were locals and most of them were sons and daughters of expats.
The Vice Chancellor of the Medical College was very proud of their interactive way of teaching especially the obliged reflective time that stimulated self knowledge and creativity.

It was in this mixed cultural desert environment that the participants would try to elicit the secrets of good healthcare decision only a couple of miles away of the highest tower in the world.

The second day of the congress, the group was supposed to design and build a vessel to prolong their journey not any longer roaming in the desert but the flag hoisted and the helm in the right direction on their way to a goal.

But the first day, the participants had to prepare calibrating their compass and study the maps and what could be more facilitating for this than sharing experiences.

Besides the Lebanon prison project, a Canadian M.D. talked about the added value of lab results for prevention, a German physician shared her experience working for the Aga Kahn Foundation in Kenia and a Belgian psychiatrist conceptualized opportunities for innovation in bridging between economic and relational dynamics and between developed and developing country strategies.
A British-Indian M.D. draw attention in a very convincing way on her attempts to create primary healthcare systems within the low class Indian population.

“I seek for what I want by torturing venture capitalists and governments”, she provoked, “they give in because they want to get rid of me”.
Furthermore there ware talks about a cancer survival program in Kenya, a system that allows consumers to instantly check whether their medicines are counterfeits and about European and international health policy planning on diabetes.
Key issue was the sustainability of the projects : while financing organisms seeked for measurable outcomes, the added value of such projects was highly influenced by the social and cultural context and oftenly shifting during the journey of the project itself.

“What was this congress all about?”, Ahmed asked Randa.
“Experts from all over the world were discussing strategies for a better healthcare decision-making”, she answered hesitating “and how you can use conceptualization, experimenting and bridging to find the right answers."
"I don't understand", was his predictable reply, “did you really tell these folks there about what is happening in our prison?"
"Well", Randa said " I was very proud to tell the story and regarding the enthusiastic reaction of the audience, it must have had something to do with decision making in health care."
“Did you tell them that buildings are in a very bad condition, cells are overcrowded and persons are detained in inhumane conditions and that ach prisoner has only 1.3 m2 of individual space on average.

Did you tell them that there are 1.3 showers/100 prisoners on average, with soap and toilet paper rarely provided by the administration and that at five o'clock, the guards are delegating control to the self defined hierarchical structure of the prison community.
Did you tell them that Christians and Muslims are hosted in the same buildings with continuous risk of an explosion of violence compatible with the outside civil war".

Randa’s thoughts went to the discussions of Wednesday where teams were selected to work upon themes as health credits, health values, access and impact of care.
The value of health was reflected in the eyes of Ahmed, access to health care was given through an opening in the iron gates, health credits were enhanced from zero to an acceptable level, be it for a limited part of the prison population and the impact could not only be conceived in a set of quality indicators but was totally visible in the regaining of dignity and hope of a population on the edge of civilization.

Didn't Pope Franciscus I make an appeal on moving with the church to the margins of the society realizing that all reconversion and innovation starts with caring for the forgotten ones.

Bright ideas were put forward in the afternoon sessions, new concepts defined and new strategies developed with the aim that this group in this place at this moment could create something new, the starting point of the creation of a better healthcare, a paradigm shift to your new model of health decision-making.
Freedom of interest, no defined outcomes, ownership of the group and international and multicultural focus where ingredients that would contribute to the successful creation of the magic drink.

But aren’t too many cooks spoiling the broth or how to steer a boat with 10 captains. 
Although statements were not always build up as a set of interventions logical following each other and although peoples talks were more like flashes in the audience moving in all directions, participants were enthusiastic about the discussions.
Not only the high intellectual level was appreciated but also the commitments and the good intentions of any participant combined with respect for each other's opinion.

In the "impact team", standpoints evolving from the discussion were synthesized and an agenda and roadmap was set up to start an experimenting project on the opinions of stakeholders in healthcare concerning the impact of their the decision-making.
A discussion framework would be prepared and every participant of the task force would set up a structured interview with a stakeholder as they were patients, providers, government, universities and companies.

This could be used as an input for the next meeting in Nairobi within about 200 days and eventually be prolonged in an action research project with cross fertilization of the thinkers (academics) and the workers (the others).

In the farewell session the core team was congratulated not only for their hard preparatory work but mainly for the respect they kept on showing towards the group and for the ownership of the process left to the participants as an intended consequence.

Could this be seen as a leverage for a renewed attitude of each of the participants dealing with sharing decisions and ownership with their patients and with the people they were responsible for.

Randa was not present at the farewell dinner in Dubai, at the bottom of the Burj Khalifa, with 828 m by far the highest tower of the world, reminding the tower of Babel in early history of mankind.

"What you're going to do with your life" she asked Ahmed, "when you have regained freedom?".
"I can work as a nurse" he said" I have developed an expertise on this experience here in prison.".
"But you're not allowed to", she answered friendly "you have no certification to do such things, they will put you back in jail.”
Ahmed returned to his cell and said to himself  "They still don't understand; they stayed in their ivory tower too long."