My job, pt. I: Moldova’s Health Profile

I’ve been getting more questions recently about what the work side of my life actually entails.  It’s a huge topic, so I’m tackling it in three parts.  The series will move from the broad to the specific.  This is Part I, a general introduction to the public health situation in Moldova.  This article is by far the lengthiest, and if the background is boring, I won’t begrudge you for skipping it.  But it also contains the roots of the problems I struggle with daily, so it’s an important part of my work here.  Part II will look at my specific projects, and Part III will focus on what I do on a daily basis.

Moldova has what’s known as a “dual health profile,” meaning that it has elements of a health care system of a fully developed nation, but simultaneously struggles with problems typically associated with less developed countries. As an example, while Moldova has high vaccination rates and one of the highest doctor and nurse to patient ratios in the world, it also faces a high prevalence of TB, and access to safe drinking water and sanitation standards remain a pressing problem in rural areas.

Moldova is often summed up as “Europe’s poorest country.”  Obviously, this depends on a lot of definitions, but based on GDP per capita and given the broadest possible conception of Europe, only Kyrgyzstan and Tajikistan are poorer, so the general point is well taken.  Despite this fact, however, at Moldova has a higher life expectancy (by 2 to 5 years) than other significantly richer post-Soviet states.

• Life Expectancy: 68.5 years (WHO, 2007), 70.8 years (CIA World Fact Book, 2010)

On other key indicators of health such as infant and maternal mortality, Moldova is also outperforming the rest of the Eastern European WHO region (WHO 2005).

• Infant Mortality: 13.13 deaths/1000 live births (CIA World Fact Book, 2010)

Arguably, then, Moldova is doing pretty well given the context – it’s significantly below the global economic average, but nevertheless can boast health outcomes somewhat above the global average.  This fact is impressive, because wealth is a key predictor of health outcomes – though not by any stretch the only important indicator, remember the U.S. has a lower life expectancy than Bosnia and Herzegovina.  The point is, clearly systems and public policy matter too.  And “doing well given the context” isn’t much consolation to those people dying at young ages from preventable causes.

Looking at key challenges, demographics are a big picture concern: mortality rates are higher than regional averages, pointing to an underlying trend of an aging population resulting from very low fertility rates and net outward migration.  This explains the overall shrinking population.

• Fertility rate: 1.28 children born/woman (rank 213 of 225 countries; CIA World Fact Book)
• Population growth: -.079% (CIA World Fact Book)

Epidemiologically, rates of many major communicable and non-communicable diseases are on the rise (this is called a “double epidemiological burden”).  Key causes of mortality include: liver disease (primarily linked to alcohol consumption), cardiovascular disease, cancer (particularly pulmonary and digestive/colorectal), HIV/AIDS, and TB.

Water and sanitation are another key concern.  The primary source of water in rural areas is wells, less than 25% of which were found to meet sanitary standards in 1999.  While things have improved since then, this is an area where Moldova still lags its more developed neighbors, Ukraine and Romania.  This issue has wide ranging effects, and is linked to some of the communicable and non-communicable diseases above.  Contaminated drinking water is a huge potential carrier of diseases; the presence of minerals and other impurities in the water could also be part of the cause of the high rates digestive/colorectal cancer.  And then there are the very basic problems: when indoor plumbing is rare, so is hand washing.

And then there’s the communist legacy…

State communism was an all encompassing political, economic, and socio-cultural system, so as with all things in this region, it’s necessary to consider the legacy, because it has profound effects for public health.  Most importantly, healthcare was free and of high standards.  Preventative health education was absent from this system.  This fueled a perception that “my health is somebody else’s responsibility.”  Now, this is a problem we suffer from in the U.S. as well, but the difference in degrees is palpable.

It remains common in Moldova to go to the doctor only when sick, a fact which is readily on display at any medical center, where virtually all the patients are elderly.  School age children have their school nurse and annual exams from the doctor, but essentially, the entire working population is absent from the health system until a problem develops, at which point solutions are much more costly and much less successful.

Add to this a post-Soviet economic crisis, during which the economy lost up to 80% of its value.  In a time of such crisis, the country struggled simply to try to maintain its existing health and sanitation infrastructure as the health of the population – as measured by every major indicator – plummeted.  People cut corners, that’s how one gets by.  But that corner cutting led to that decline in health, and a crisis is a hard time to embark on a new project like building an effective health education system.

Putting it all together, or, what any of this means for me

In short, there is only the most limited conception of preventative healthcare.  Public health education, itself, is a very new concept.  Coming from the States, it has been shocking to realize just how much public health messaging has become a normal and accepted part of our lives.  Take hand washing: parents teach this lesson to their kids from an early age.  The message is then reinforced with practice everywhere they go, from school to the doctors office.  Every flu season, signs will crop up reminding us lest we forget, as well as giving very specific instructions on how to wash our hands properly.  Later in school, we learn about viruses and bacteria in science classes – the depth of information tracks our neurological capacity to absorb it, and our need for more sophisticated explanations.  And then we become parents, and a whole host of pediatricians, classes, and parenting books tell us how to teach our kids the same lesson, starting the process all over again.

Taking a step back, it’s really a pretty sophisticated operation.  The intervention has been effective too, dramatically so.  And while we might not consider this odd today, none of it existed 100 years ago.

Putting this all together, many of the health problems facing Moldova are at least partially preventable.  These problems are also in areas where public health interventions have shown high levels of success.  As a result of this history, however, the concept of preventative health is still taking root.  The Ministry of Health recognizes this, and has made the promotion of healthy lifestyles a major priority of late.  Prevention requires many things, but more than anything else, what it requires most is public health educators.  The government can coordinate curricula and run big campaigns, but effective interventions require local health providers to also become teachers and leaders, because these messages have to be taught by trusted authorities, and reinforced constantly.

The good news is, given the high ratio of doctors and nurses, there is already a large and local workforce being directed to implement health education campaigns, but this is a new job for them, and it’s a big one.  And that, in a nutshell, is why I am here: to facilitate the development and implementation of effective health education at the local level.