Wednesday, February 16, 2011

Moving beyond doctors, and creative loan repayment programs: Alleviating medical and legal shortages in rural areas

Maybe doctors and other health professionals aren't necessary to solve health care deficiencies in rural communities. This is what Tina Rosenberg suggests in a recent New York Times opinion piece, "Villages Without Doctors," part of a series of columns focusing on global and local health care challenges and possible solutions. With certified nurses and doctors gravitating towards work in the cities, villages are embracing alternate ways to care for their communities.

The idea that local residents without formal medical training can substitute for doctors and nurses is gaining hold in the districts of Gadchiroli and Jamkhed in the state of Maharashtra, India. Here, a couple of programs, SEARCH and the Comprehensive Rural Health Project, are training community members to take care of their villages' health. Training seems to focus primarily on women's health -- delivering babies, conducting follow-up visits, educating new mothers about breast feeding and how to treat mild illnesses. The model has proven to be successful, with lower rates of infant mortality, higher birth weights and an overall improvement in health. A similar government-run program in Pakistan is training "lady health workers," as Pakistan calls them, to go into rural areas and care for women before, during and after birth. A recent study by the Aga Khan University in Karachi, shows that the health and education program is helping to save the lives of newborns.

Shifting focus to the United States, similar reasons lead to a shortage of doctors in rural communities, namely the movement of medical professional to urban settings. There is also the additional factor of a lack of health care for many Americans, which exacerbates the situation. While there doesn't seem to be a movement to veer from professionally trained doctors and nurses, there are programs focused on this problem. Some states in the U.S. are tackling the shortage of doctors by using loan repayment assistance to entice recent medical school graduates to work in rural communities. A Minnesota program, for example, offers up to $100,000 in loan forgiveness to students who work in a designated rural area.

Bringing the discussion to the legal field, I thought about loan repayment assistance programs (LRAPs) for attorneys. Many young attorneys have just as much, if not more debt than new doctors, and often face a job market with less likelihood of earning a substantial paycheck to help pay off that debt. This is especially true for public interest attorneys who often work for free throughout school and face fierce competition to secure a job before taking the Bar Exam. While there are school-specific LRAP programs, and federal government programs, I am not aware of programs like those in the medical field that target rural communities specifically. This said, perhaps a similar program be a good way to help alleviate the rural-lawyer shortage that some states face, while also providing law students with more options to climb out of debt. As far as training non-lawyers to handle legal disputes, I suppose that is another option as well.


vlshaw said...

I agree that more consideration should be given to loan repayment assistance for those looking to practice in rural and small communities. I myself would like to move back home and practice eventually, but my debt will probably prevent me form doing so for some time. The discrepancy in pay is sometimes enormous between two areas of the same state,

N.P. said...

I think in context, this concept works because it provides the fundamental minimum of health care that rural villages in India, Pakistan, and other developing nations need yet lack. However, I have a hesitancy with such programs because it is merely providing the bare minimum required. Yes, it is necessary to have such facilities, but aren't we forgetting the larger problem - that all of these peoples' medical needs are still not being met. Until you get qualified doctors to move into rural areas, a bare minimum will still not be enough.

Chez Marta said...

Perhaps there is another angle that we need to look at: how much the non-medical staff, nurses, nurse-practitioners, midwifes, or lady health-workers (a weird expression, innit?) contributed to the excellent results cited in the blog post?  Specifically, I'm talking about problems with the increased medicalization of normal biological processes, such as labor and delivery, pregnancy health care, menopause, and aging.

Anecdotal evidence shows that people age better, and cope longer on their own, in their own environment, with a nurse, nurse-practitioner, or other non-professional staff taking perfect care of their health needs (although this study disputes the wholesale applicability of this theory).  The advantage of midwife-conducted births is already demonstrated thoroughly, for example in producing only a tenth of the C-sections than doctor-conducted births. Hormone-replacement therapy, commonly used to treat the symptoms of menopause, has received bad press after it turned out that it may contribute to increased breast cancer rates, which most women would rather not trade for heat flashes.  Without sounding awfully New Age here, let's explore how to re-democratize health care, and make our population, both rural and urban, healthier by using a holistic approach.