By Mohammad Shahbazi
Jackson State University
Human beings are members of a whole,
In creation of one essence and soul.
If one member is afflicted with pain,
Other members uneasy will remain.
If you have no sympathy for human pain,
The name of human you cannot retain.
—Sa’adi Shirazi, a 12th Century Persian Poet
One of the most pressing issues in public discourse, nowadays, is how to deal with ever increasing health care costs at a time when the United States, and indeed the world, economy is weak. Individuals and governments around the world are facing debts and budget deficits. Cutting health services and medical expenses has been a target by some and there are others who view such an act as evil, arguing that this will leave people less healthy in the short term and that the preventive approaches will be jeopardized in the long term.
Less known is what will happen if the current medical model-based health services are cut to the existing underserved populations in a state like Mississippi, where the health ranking has been at the bottom of the USA’s fifty states since the 1990s. What will be the outcome of cutting health services to the people of such a state where close to 30% of its rural population live below the poverty-line? What will happen to its underserved black population among which is found high rates of obesity, diabetes, infant mortality, stroke, poor nutrition—chronic diseases—and reduced life expectancy? What will happen here, as Cossman et al. (2003) put it, where people living in the Mississippi Delta are 24% more likely to die each year than the average U.S. citizen—i.e., 20% of all deaths or 18,000 deaths per year?
It is well documented that the Delta region of Mississippi is faced with challenges across the spectrum, including: health, education and economic challenges. These disparities are interconnected, as poor health status contributes to lower educational achievement, which inhibits regional economic growth, and both limited education and impoverished conditions perpetuate poor health outcomes. The America’s Health Rankings, 2010 reports the following facts on Mississippi:
- a high prevalence of obesity at 35.3 % of the population;
- a high % of children in poverty at 31.9 % of persons under age 18;
- a low high school graduation rate with 63.6 % incoming ninth graders graduating within four years;
- a few primary care physicians with 81.9 primary care physicians per 100,000 population;
- a high rate of preventable hospitalizations with 97.8 discharges per 1,000 Medicare enrollees;
- a high infant mortality rate at 10.3 deaths per 1,000 live births, and;
- a high rate of deaths from cardiovascular disease at 373.7 deaths per 100,000 population.
Despite such significant disparities, the present barriers to health improvement include a common focus on short term, fragmented, and incremental changes that often reflect the interests of specific stakeholders rather than the long-term needs of the entire community which compounds the lack of coordination of efforts by institutions and public/ private agencies. Combined with such short-sighted vision, the history and culture of the region are characterized by persistent racism that leads to discrimination against individuals in areas like the Delta with high proportions of black people. What should public health professionals do facing such public health challenges?
Search for a Model
In 2008, after years of empirical data regarding dismal health outcomes and pervasive health disparities in the Mississippi Delta, and despite millions of dollars spent on health related initiatives and academic research, existing strategies clearly had not achieved the desired results. New ideas were urgently needed.
I decided it was time to take action to find solutions to the health issues in the Delta, so I started an intensive research program by bringing together Jackson Medical Mall Foundation (JMMF), Jackson State University (JSU), and the Oxford International Development Group (OIDG), a group that I will refer to as the “Team” from here forward. They represented the community, the academic and the business sectors respectively. Together we have worked intensively to research proven, common-sense solutions to the Delta’s rural health challenges. The Team examined a wide range of cost-effective approaches to primary healthcare delivery for similar population groups around the world, which could be integrated into the existing U.S. system of private practices, regional health clinics and community hospitals. The Team also met individuals, community groups and rural hospitals throughout the Delta for input regarding their views of the current situation and perceived needs for a new direction to increase health access and develop health-related programs based upon community defined objectives—and not from the institutions that were perceived as part of the problem.
Criteria for the Model
The Team’s research criteria included a review of proven models that would:
- Provide a mechanism for reducing costs to the overall system due to inappropriate use of hospital emergency rooms;
- Focus on primary care that shifts the burden of costly curative interventions to cost effective preventive strategies;
- Encourage community participation and individual responsibility for public and personal health to ensure long-term effectiveness;
- Reduce health disparities in a cost-effective way through increased access to basic healthcare services in areas un-served or underserved by the current system;
- Increase coordination between all levels of providers to improve outcomes and reduce hospital re-admittance after patient discharge;
- Utilize and train community health workers to address the current acute health professional shortage and provide people on government assistance programs and others a career track for employment, further education and community service;
- Promote and facilitate community-based applied research for determining and influencing the “causes of the causes” of poor health (e.g., the social determinants of health), an area of increasing interest among international public health institutions, and
- Provide a vertically integrated information system to track outcomes to determine effectiveness of both programs and implementation practices
Model from an Unlikely Country and a Memorandum of Understanding (MOU)
Based upon this investigation and with the above criteria and regional healthcare challenges, I suggested that a health services delivery model tailored along the lines of one established by the government of Iran might fit in Mississippi.
Iran’s primary health care system has been recognized by the World Health Organization as a successful model, one that uses the “health house” as the primary point of contact for its rural population. The post-Shah era Iranians put in place an integrated system that eliminated health disparities that existed for the rural population prior to the 1980s, and provided a network of services to the urban inhabitants which had not existed before. With a national policy in place to deal with health disparities, the Iranians accomplished their goals despite numerous challenges, including an eight-year-long war with Iraq, economic sanctions, and consequent political isolation. Given such accomplishments and the recognition by the World Health Organization, my colleagues were interested in learning more about the Iranian Primary Health Care system.
Thanks to my academic network and supportive family/relatives in Iran, I was able to work with Shiraz University of Medical Sciences (SUMS) Officials. I arranged for the Team to visit the Islamic Republic of Iran in May 2009 to explore: a) if Iran’s recognized and award winning primary health care (PHC) system was a model that could be used in Mississippi, and b) whether the SUMS Officials would consider helping the Team to try the Iranian PHC model in Mississippi—for the rural population in particular.
Our visit to Iran assured us that the Iranians had indeed, despite many challenges, developed and implemented a comprehensive and inexpensive network system that has successfully eliminated geographical health disparities for the rural population in particular. The Team was most impressed with the Health Houses (khanihay-e bihdasht) and those that staffed them, the bihvarzha. Health Houses are at the heart of the Iranian PHC system. Given the keen interests of SUMS’ Officials, a memorandum of understanding (MOU) was signed. Accordingly, the Team and SUMS’ Officials formally agreed to collaborate in the following areas of mutual interest:
- to use the expertise of SUMS to develop public health programs based on the Iranian Republic of Islam (IRI) “health house” model for implementation in rural areas of the Mississippi Delta and other regions as may be appropriate;
- To jointly engage in research and other activities related to the social determinants of health and its impact on health outcomes;
- To jointly engage in research and other activities related to the HIV/AIDS Research Center of SUMS;
- To establish academic and other institutional exchange programs that may be used to provide mutually beneficial educational and cultural opportunities for students, faculty, researchers and the lay public; and,
- To develop other opportunities for collaboration that will help promote greater understanding and mutual respect among the Parties and between the people of the IRI and the United States of America.
The Team’s visit to Iran was followed by an Iranian team of health experts that came to Mississippi in October 2009. This indicated to us that the Iranians were committed to supporting our endeavor in addressing issues of health disparities in Mississippi. (It must be noted that these individuals came to our state as citizens’ of Iran and not as an official Iranian delegation.) Additionally, with the enthusiastic involvement of local, national and international organizations/institutions, including the National Institute of Health (NIH) and the Regional Offices of the World Health Organization (e.g., EMRO and PAHO), we soon realized that the work we had embarked on had the potential to have effects even beyond the State of Mississippi.
By the end of 2009 and early 2010 many local, national and international media (The Los Angeles Times The Associated Press, Al Jazeera, the American Association of Retired Persons, and many others) had written about and or broadcasted the fact that Iranians and Americans were working together to decrease health delivery costs and improve health indicators in Mississippi Delta—most titles read “From Iran to Mississippi…”. And most recently the New Your Time Magazine published a long story entitled, “What can Mississippi learn from Iran?”
This intensity of this publicity blitz has a two-fold explanation. One is obvious. Iran and the US ended their diplomatic and political relationships in the early 1980s, and have remained unfriendly and hostile toward one another ever since. Despite such non-cordial political relations, the Team was able to sign a major Memorandum of Understanding (MOU) with one of Iran’s high ranking educational institutions, and it is perhaps safe to state that after some three decades this was the first such MOU with a state institution to have been reached. The other explanation is the fact that our interest in introducing an integrated primary health care system for the Mississippians is timely coinciding with the WHO’s health-related agenda for the new millennium. Accordingly, WHO advocates a renewed commitment to strengthening health systems and moving toward the delivery of more comprehensive health services. This is based upon Article VII of the Alma-Ata Declaration on Primary Health Care (PHC): “Primary health care should be sustained by integrated, functional, and mutually supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need” (World Health Organization, 1978).
Subsequently, I believe that socio-culturally appropriate primary health care “now more than ever before…” is the only answer to addressing and ultimately eliminating the endemic health disparities in Mississippi. I am also a firm believer that anthropologists in general and those practicing applied anthropology in particular have much to offer when it comes to issues such as social determinants of health that is embedded in some cultures as norms.
Mohammad Shahbazi is Professor of Public Health and the Interim Executive Director, School of Health Sciences at Jackson State University at Jackson, Mississippi. He grew up in a sub-tribe of the Qashqa’i nomadic pastoralist tribespeople in southern Iran and attended a mobile ‘tent school’ – a literacy program designed for the Qashqa’i children—at age 9. At age 14 he started a difficult struggle for an education—a struggle that first took him to a small town in his sub-tribe’s winter quarter, then to a city (Shiraz), then to India and eventually to the Unites States of America in the early 1980s. Having earned degrees in mechanical engineering, computer/education and anthropology in the States (PhD in Cultural Anthropology from Washington University in St. Louis, MPH in Community Health/International Family from UCLA), he had learned that the main weapon needed to achieve improved health for low income peoples was simply the knowledge of public health and public health practices, but aided by the insights from applied anthropology. Trained as a medical anthropologist, he returned to Iran and visited his tribespeople and the region where they lived and found out that there had been infant/child deaths had been drastically reduced for over a decade – thanks to Iran’s Integrated Primary Health Care and its Health Houses program in rural areas. He joined Jackson State University in 1999, where he learned that despite much effort and expense in Mississippi (my his home), preventable suffering for his fellow-Americans in rural Mississippi could be relieved by attacking the social determinants of health which are the root causes of high morbidity and mortality for Mississippians and beyond.