Ethiopia is one of the most rural countries in the world. 85 percent of the population live in dispersed small communities. Even the capital, Addis Ababa, which has 4 million people, represents only 5 percent of the population. To get health care to the rural population the government has developed one of the most innovative programs on the continent: the Health Extension Worker program. Health Extension Workers are Ethiopia’s version of the barefoot doctor program. The government trained 32,000 young women in basic health and then put 2 in each of the country’s 15,000 health posts, which are one or two room facilities that serve approximately 5,000 people.
One of the health extension workers’ most important functions is related to malaria. They are supposed to work with the community on malaria prevention--teaching people how to use malaria nets, to accept indoor residual spraying, to come to the health post if they have a fever, to take all the medications they are given, etc. In fact, the only diagnosis and treatment health extension workers can give relates to malaria.
In Gombore, I met Etaferahu Minase, a 23-year-old who had been a health extension worker for five years, and Yirgalem Tadese who, at 24, had already been one for six years. I wanted to see what they did, so I asked them what they would do if I came in with a fever. I was told they would give me a rapid diagnostic test. So I held out my finger. They looked at me confused. Then they understood and were embarrassed. There was a room full of people from the U.S. and Ethiopian health ministry watching--along with at TV camera from Ethiopian TV. Eventually, Etaferahu set up the rapid diagnostic test, and jammed the lancet into my finger. After 10 minutes or so it was clear, I did not have malaria.
I then asked what she would do with me. Since the main alternative diagnosis for a fever is pneumonia, I thought she might examine me for crackles in my lungs when I inhaled. There was this funny looking device on the table. It was a cylindrical cone with an opening at the top--almost like a modern version of the wooden tubes doctors used to use in the 19th century to listen to the heart and lungs. So I pulled up my shirt, turned my back on Etaferahu. She looked puzzled. I grabbed the auscultation thingamabobber and handed it to her. She became all shy and turned away with a smile on her face. After the buzzing from the onlookers quieted, I was told this funny trumpet like thing was in fact an auscultation device, but for listening to the fetal heart beat in pregnant women not for diagnosing pneumonia in clueless American visitors.
One of the most impressive things of this health center is that the walls are filled with charts and graphs of data on how well they are doing. (And these charts were not just put up for my benefit. A surprise visit to another health center not expecting my visit showed identical charts on their walls.)
Ezekiel J. Emanuel is special advisor for health policy to the Office of Management and Budget and the head of the bioethics department of the National Institutes of Health.