The European Chiropractic Union held its annual convention in conjunction with the Hungarian Chiropractic Association at the Budapest Congress Centre from 25 to 27 May 2018.
Dr. Nadine Harrison, previous supervisor of the World Spine Care clinic in Shoshong, Botswana, was invited to give a presentation on the final day of the conference. Her talk, Adaptability in Pursuit of Optimal Patient Care: Lessons Learned in Under-served Communities, describes Dr. Harrison’s experience treating patients with spine pain in an underserved area. Due to the numerous challenges of patient care in a new environment with patients of varying culture who spoke a different language, she found herself needing to adapt in myriad ways. She also outlines the foundation of the World Spine Care model, which rests on the triad of an integrated, evidence-based, sustainable approach to spinal disabilities.
View the entire talk below, or on YouTube.
Transcript from Dr. Nadine Harrison’s presentation
I’d like to share with you today a presentation about the skill of adaptability in pursuing optimal patient care and some of the lessons that I have learned whilst serving in underserved communities with the global organization, World Spine Care. We all know that spine pain is a huge problem with 1 billion people suffering worldwide from spinal pain. And that low back pain is the leading cause of disability worldwide. Shockingly, together, low back pain and neck pain have a greater burden than HIV and AIDS, depression, malaria, breast and lung cancer combined, stroke, diabetes, and Alzheimer’s disease.
What we know is that since 1999 the prevalence of low back pain has increased by 54% and we know that this has disproportionately affected low and middle-income countries such as Africa and Asia. We also have been able to learn that it’s the working populations that are most often affected and in low-income countries. These are people that have little or no movement for modification within their workplace. We can understand that people in these communities are unable to perform traditional social activities because of their pain and disability. They become withdrawn they lose their sense of Independence and they lose their identity. Populations are booming and the aging members of these populations are continuing to increase, so we can expect that the prevalence of low back pain and the costs to assist in tackling it are only going to rise.
This presents World Spine Care – a nonprofit organization that is on a mission to improve lives and underserved communities by creating access to the highest quality spine care possible. It was set up by. Dr. Scott Haldeman, who is an amazing clinician within our field, I’m sure many of you know him. And we currently have seven clinics that are in Botswana, Ghana, the Dominican Republic, and India. And although they all run slightly differently, they are built on three foundations. That is that they are integrated, evidence-based, and sustainable. I’m going to focus on Botswana and where I have spent the most time so we’ll talk through how the triad of these three foundations interplay together.
First of all, the clinics are set up in collaboration with the local government in a country and they help to financially back the projects, and we set up clinics within existing healthcare infrastructure. This is the Shoshong clinic in a rural village, and we also have a department within Mahalapye District Hospital and one more in the main referral Hospital in Gaborone. Volunteers provide evidence-based care when the cit- clinics have been set up and at the same time World Spine Care facilitates nationals from the hosting country in completing relevant qualifications. This is Hilda Molate and she has just qualified as a DC from Palmer. She has now returned to Botswana where she is taking on the role of the clinician in the main departments there and she’ll be paid by the Ministry of Health allowing for an exit of the volunteers and the sustainable program.
I spent one year in Botswana as a clinic supervisor and my job was to oversee the logistical running of the program, to provide patient care, and to also facilitate the research and volunteer programs that we have. And when I arrived in the country, I was very hungry to create a lot of positive change. What I realized very quickly that this pioneering program in a developing country was really vastly different to the well-established and smooth-running practice that I had been working in in the UK.
As I have reflected on my journey in a year in Botswana, I realized that I went through a hugely adaptive process in order to provide care. I had to adapt my skills to make sure that they were appropriate for the environment and the individuals that were in front of me. And this adaptability is what helped me to navigate a new healthcare infrastructure a new culture and a new unique and challenging clinical environment. I had to work in a global team. We have local health care assistance that aid us with translation and the running of the clinic and then a turnover of volunteers that come for up to three months to provide clinical care. So, you have a melting pot of different lifestyles, backgrounds, different work ethics, and different social values and you have to adapt to working amongst your differences, respecting the differences between you and really sharing a very strong common motivator. We also had to adapt to treating each individual in really some quite extreme circumstances.
So there are two spectrums of patients clinically. On the one hand, we have our red flag patients. And I saw more pathology in one year than I will probably see in the remainder of my entire chiropractic career. One in four patients presenting to the clinic were HIV-positive. We saw spinal metastases, prostate disease, liver disease, severe neurological compromise, and learning how to act appropriately in a country where spine pain is largely poorly understood and there are low resources, requires adaptive skill.
At the other end of the spectrum were our classic neuromusculoskeletal patients, but each with a very unique reason for presenting, a unique clinical presentation, and a unique set of goals. How do you care for somebody that takes a 14-hour return bus ride to arrive at your clinic? How do you adapt to a young mother whose baby at 21 days old has just died? How do you respond to the man that tells you the exercises you gave him work, you are a prophet, and he wants three adjustments – one for the Father, one for the Son, and one for the Holy Spirit? And what about the man who has to walk 10 kilometers every day, despite his lumbar spinal stenosis, in order to tend to his cattle which are his livelihood? And how about the lady that lifts 100 liters of water in and then out of her house every day because she does not have any internal plumbing?
Only by adapting to each patient on an individual level can you provide care that is relevant, actually possible to perform, and in line with best practice. And if you stray from being truly patient-centered, you do not receive, er, achieve results in these communities.
Shared Patient Care
The next area of adaptation was actually one of shared patient care in the World Spine Care clinics patients represent and don’t always see the same clinician due to, by a variety of cultural factors in how they actually arrive for their appointment times and also the fact that there is inevitably a turnover of volunteers. And what I found was losing this ownership that we often have over our patients can be incredibly positive. We don’t have a blame culture or an ego that my treatment will work better than yours.
Instead, you have many minds that are contributing to one patient’s treatment plan. Clinicians are always learning, patients get great care, and the whole team can share in the joy of a patient’s Improvement. We had to be very careful to adapt and understand the local community customs where we were serving. In much of Botswana, the social hierarchy suggests that women of a certain age – elderly, middle-aged – should not do too much movement. Instead, household chores are left to the younger generations and you would often see at social gatherings and community events that the middle-aged women would sit for hours on end whilst the younger generations brought food, water, or carried out instructions. Now, we also know that the spine – spinal demographic effects elderly or middle-aged women from rural communities disproportionately to other demographics.
So only by understanding this and the community customs could we start to implement change by creating activity days and community days that were focused on movement and engage the people who were resisting this movement.
In April 2016, we started a yoga project which is a two-week long training program and to date, 819 local members of the Botswana Community have become qualified yoga instructors, and they now continue to teach classes on a regular basis in their local community.
And the success in this story has been using previous patients of the clinic that were from the rural backgrounds – women and elderly – to become the teachers.
We also had to adapt to local beliefs and there is a very strong undertone of religion in Botswana often. The metaphysical would be a talking point in consultations, and I frequently had patients asked if they had been cursed resulting in their pain. Patients would tell me that they felt that going to church was a relieving factor or asked if they should be praying to help improve their symptoms. And only by adapting to the way that you communicate and try to inform and educate patients, can you do so effectively while still respecting their local beliefs.
The last area of adaptation was working with an integrated approach. In the UK, I have often felt that I’m on the periphery of the healthcare system, but in Botswana, I had the opportunity to be a central integrated member of the health care system. We had to take time to get to know each other but we are working closely with radiography teams, orthopedic surgeons, rheumatologists, midwifes, and medical doctors to develop better care pathways for spinal pain patients.
I have gained confidence that I am an expert within my field and I equally have learned to build relationships so that I can turn to others for their advice in their area of expertise.
To conclude, Botswana forced me as a clinician to adapt if I was going to survive. If we can adapt to the unique patient story, presentation, and goals that are set in front of us, I believe we can pursue optimal patient care. If we can adapt to understanding the community’s beliefs and customs, we can seek to serve them better. If we can adapt to working in a team, we can become integrated advocates for our patients.
So my question is: should this be reserved for World Spine Care and working in low- and middle-income countries? Or what if we applied this level of adaptability to spine patients everywhere? If we adapt, we can put the patient first every single time, making them the center of all our decisions and all of our actions.
Now we’ve had some great quotes today from the other speakers and I would like to leave you with my favorite mantra at the moment. It is a photograph of a sign that is situated at the entrance of Kamothe Hospital in Navi Mumbai, which is the site of another World Spine Care clinic. And when I saw this sign it struck me as both simple and profound. It is there for every patient and every clinician to see:
“Patient First and Always.”
Thank you very much.