By Katherine Welch, M.D.
Recently I was discussing health care outreach to people who are prostituted, are street kids, or other similar population groups with someone who works with an organization that does outreach. She told me her organization had “tried” a health care outreach once but it didn’t seem go over very well. A group of foreigners, including some health care professionals, were visiting on a short term trip. They went out, walked the street and visited bars inviting them to a free clinic. They expected quite a few people – free health care from Americans! However, the only people who came were the 5 people that they already know and normally see. Why?
Sounds strange, doesn’t it? You’ve heard of short term trips that go into villages and they are inundated with patients who come from all over to take advantage of the opportunity to see a western doctor. Yeah, I’ve been there. I’m not a big fan of these kinds of clinics either, but that’s not what I’m discussing today.
Random and one-off clinics like that don’t work well in the “street” population unless there is a foundation of relationship – a bit of trust built up. Caring people doing outreach in the streets may not know each individual, but if a group has had a solid and consistent presence in an area, frequent visits, some relationship with the mama-sans or bosses, then the turn-out is usually better. If the health care professional has also been a consistent presence on the street then the success can be even greater.
I have been involved in larger clinics targeted to prostituted women with a team of foreigners providing care and I have seen them work OK. This is because the partner organization had already spent a significant amount of time in that community so the relational capital had already been developed. The partner organization also did quite a bit of work getting the women and their children to the location of the clinic. Teams also visit every six months, so there is some built in follow up of care, even if nothing happens in the meantime. Of course it is ideal to have a more regular and more local source of care, but this kind of thing can work in certain situations.
Hey, this doctor already knows where I come from… I don’t have to explain as much… I have less to fear… less shame to face.
There are, in many places, all kinds of health care options available in a city, even low-cost clinics. There are clinics specializing in STI treatment. Just because there are clinics available, even at low cost, street kids and prostituted women still don’t attend them. They typically don’t like going to doctors – they have had bad experiences due to discrimination (perceived or real). Clinics often open during times that don’t fit with their work hours or “lifestyle”.
Furthermore, many places doesn’t even come close to equaling most places, especially in Asia.
Many people on the street or in the bars don’t get straight answers that health care professionals don’t talk to them or explain to them or take any time with them. If it were only a matter of testing blood or urine, then it would be easy, but that doesn’t constitute good health care.
I find that many in this situation are actually afraid of the diagnosis – even if most don’t come right out and say so. This may be cultural. This may also be because they lack support from friends and families and there is nobody to lean on or help care for them should they get some difficult news. Generally, they have very low view of themselves. Why should they care about themselves when nobody else seems to?
They don’t want to pay. They are already strapped with debt or family obligations and expectations and are already sacrificing so much – to pay for their health care can seem too much. This point is also related to their low view of themselves – they are not really worth it.
Some people who are exploited or trafficked truly have limited access to health care. Their pimp or trafficker won’t let them see physicians, or charges extra for time off work, simply doesn’t care about their workers, or any other reason for preventing access to health care. However, access can be gained through careful identification and relationship building with these special patients.
The diseases and disabilities found in the bodies of exploited and trafficked people don’t account for the entirety of their health care problems. Many of their health care problems stem from the barriers to accessing health care, the discrimination, and the social injustice of the health care system. Health care is really much more than providing medicines to cure a disease, it is helping someone towards a more holistic well-being.
Katherine Welch, M.D., is an American pediatrician based in Thailand. She works as a consultant in serving the health needs of abused, exploited and trafficked people. You can learn more about her work at www.gorelentless.wordpress.com. She is also an Editorial Adviser for Cancer InCytes Magazine.