Matthew Harris is a Clinical Senior Lecturer in Public Health Medicine, Honorary Consultant in Public Health Medicine, Director of Postgraduate Taught Courses in the School of Public Health, Imperial College London, and Theme Lead for Innovation and Evaluation in the NIHR Northwest London Applied Research Collaborative, UK.
Matthew has lived and worked in Brazil as a family doctor, in Ethiopia working for the WHO in immunization programmes, and in Mozambique as an HIV Technical Advisor, and served for two years as a Global Health Policy advisor to the UK government.
In 2014 he was awarded a Commonwealth Fund Harkness Fellowship to research Reverse Innovation in the US as a Visiting Research Assistant Professor at New York University, under the mentorship of Prof James Macinko (UCLA) and Dr Don Goldmann (Institute for Healthcare Improvement, Boston). In 2018 he was awarded an Imperial College London Presidents Excellence in Teaching and Learning grant to advance the Reverse Innovation agenda in higher education by ‘decolonizing’ the curriculum of the Masters in Public Health. In 2019 he was appointed co-Editor of the Reverse Innovation series in the BioMed Central journal Globalization and Health.
“But also that are our gaze, let’s call it intellectual gaze, is very much towards the West – it’s a Eurocentric or North American gaze- where we predominantly pay attention to those institutions in those countries… And it’s therefore a mindset approach where we have to understand that we’re missing opportunities to adopt or learn from countries that are doing far more with a lot less, simply because we’re not used to that.”
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Matthew’s primary healthcare team in Brazil
…You have extensive experience right around the world- tell us about your current role and how you got there…
Matthew Harris. I’m a Public Health Consultant in the NHS, here within the Imperial College Healthcare NHS Trust, and I’m a Clinical Senior Lecturer in Public Health Medicine. But I didn’t really set out to do any of those things, which is often the way isn’t it, in clinical careers. I qualified in medicine a long time ago now, in the late 90s and, for one reason or another which I won’t bore you with, I ended up moving to Brazil after my house jobs and re-qualifying Medicine there. I learned Portuguese from scratch and I had to pass their exams in the medical school at the University of Sao Paulo in order to become a Brazilian doctor. And then I went and worked as a GP in a rural area, super deprived, extreme poverty, in the northeast of Brazil. You could probably picture it; houses made of mud and there was no sanitation and no electricity. I had to get four buses to arrive at work and I was running a single-handed GP practice with 5,000 residents in my list, for about four years. I then moved into Public Health, returning to the UK, worked, did my Masters in Public Health at the London School of Hygiene and then worked in sub-Saharan Africa for a year or so with WHO and running an HIV hospital in central Mozambique. And that’s really what moved me more into the public health space, thinking about the big picture, thinking about population health, and thinking about policies rather than patients in terms of clinical care. I did my PhD in Oxford University shortly after that, and then into the training program to become a Consultant in Public Health and that’s what’s brought me to where I am now.
DMacA: Let me bring you back to Brazil because you paint a picture of poverty and a health service that was really very basic. But what struck me about Brazil is that there have been incredible steps forward in medicine, particularly in Primary Care, inspired by a previous government. Tell me a little bit about that.
MH: It’s a fascinating story actually, I have to say, and my experience as a GP in their system actually inspired the rest of my work, which I can go into later. We’ve done a lot of work over the last 20 years bringing elements of their Primary Care System into the NHS, particularly around the role of community health workers. They didn’t have Primary Care before the late 1980s. The primary care that they had was essentially walk-in clinics, if you could afford it, or you could show up at Accident and Emergency. There was structured Primary Care Service in play. But then, at the end of the military dictatorship in the late 80s, they underwent a radical social, political, and economic transformation into a liberal democracy that put health right at the centre of its Constitution. So they created, for the first time, a unified health system that they call the SUS system. (Sistema Único de Saúde). It’s a unified system a bit like our NHS in the sense that it was taxpayer funded and it was the government’s responsibility to provide health care, particularly Primary Health Care, for all citizens, free at point of use. And that was a radical transformation at that time, based on the lack of primary care that they had prior to that. It was really part of a big social movement to make sure that citizens and residents all have access to care and, it was actually inspired by British GP system to a large extent, because they really wanted to develop this idea of Family Medicine which they didn’t have previously and also a mix of the Cuban system as well, which was a big influence. But what they did really well, I think, was to leverage community assets in the form of community health workers in underpinning their Primary Health Care system so they deployed at pace. It was remarkable the speed at which they’ve created this system. They have essentially a primary care healthcare unit that’s composed of a single-handed GP, a practice nurse, and a nurse auxiliary, and between four and six community health workers all recruited from the local area. But, what’s really interesting is that those community health workers are resident in the areas that they then also serve. They’re recruited from that community and they are allocated to a micro area of about 120 to 150 households, with no overlap or gaps between those little micro areas, and they’re mandated to visit every month the households within those areas just to check in on people, to find out how they’re doing, to build those relationships and that trust, whilst at the same time working with the primary care team very very closely. So,essentially they are the ears and eyes of the GP and the practice nurse out in the community.
Now they’ve scaled the system throughout the whole country and that model of primary healthcare is now serving something like 75% of the population, and across 95% of the municipalities and has seen some extraordinary outcomes in terms of population health. So, over the last 15 to 20 years since it began to scale, municipalities that have a high penetrance of this model compared to those that don’t, all things being equal, have a 34% lower cardiovascular disease mortality rate. That’s pretty extraordinary but, when you understand what the community health workers do, you can begin to see the reason why. They spot diabetes and hypertension early on, they refer people in for testing early on, they talk about healthcare all the time, they help people stop smoking, reduce weight, physical activity, all of those interventions that we know promote health and well-being and have important outcomes downstream. They’re doing all the time with all their residents and, not just on cardiovascular disease, but also on mental health, depression, child health, immunization uptake, screening uptake, whatever it might be. They’re intervening, they’re giving advice, they’re signposting to all their residents all the time. So, those upstream interventions that are at a very low technical level and don’t require highly qualified individuals, have led to some important shifts downstream. So, you’re absolutely right, I think the Brazilian system has been phenomenal, not just because of the holistic comprehensive manner in which the community health workers work, but because of the extent to which, and the speed with which, it has scaled across the country.
“In Brazil… what’s really interesting is that those community health workers are resident in the areas that they then also serve. They’re recruited from that community and they are allocated to a micro area of about 120 to 150 households, with no overlap or gaps between those little micro areas… So, essentially they are the ears and eyes of the GP and the practice nurse out in the community.”
DMacA: Let’s change continents now and talk about Mozambique. Tell me about your experience there. I don’t think Primary Care is nearly as developed in Mozambique, I think you describe more of Public Health role.
MH: Yes, I’d say primary healthcare, at least in the days when I was working there and it has been a while, wasn’t like it was in Brazil or here in the UK. The clinics were much fewer and further between than here in the UK. They’re serving probably in the region of 10,000 to 20 000 people, maybe even more, and they would be staffed by, maybe, a junior nurse with a doctor visiting every now and again. So, a very different type of approach but things may have changed since then. I was running an HIV Day Hospital which was PEPFAR funded and was located within the regional centre of excellence, a big tertiary hospital.
It was quite an interesting time because, essentially, the HIV prevalence at the time was probably higher than diabetes is here in the UK but, of course, you manage Diabetes predominantly in Primary Care whereas HIV in Mozambique at the time was being managed in a vertical fashion. You could only get your HIV treatment or monitoring in the state hospital which was very distant from where most people were living. So one of the roles I had was to try and decentralize HIV detection and monitoring and adherence to HAART (Highly Active Antiretroviral Therapy) treatment out into the primary care clinics, which meant upskilling some of the more junior nurses that were staffing those clinics in how to support adherence, how to distribute the medicines out into the community etc, in order to alleviate the pressures on the Day Hospital.
DMacA: Lots of this work that you’ve done seems to fit in very nicely with your Harkness Fellowship. Tell me how that worked.
MH: The Harkness Fellowship which, by the way if anyone’s listening, is phenomenal and I highly recommend anybody to do it if they can. The Harkness Fellowship that I did was all about ‘reverse innovation’- very much speaking to the idea of what we can learn from low and middle income country contexts that can be adopted into high income country healthcare settings. In that Fellowship I was based at New York University, my mentor was Professor James Macinko who’s now at UCLA, and Dr Don Goldmann who’s the chief scientific officer at The Institute for Healthcare Improvement and we were starting to look into what some of the challenges and barriers are to adopting innovations from low-income countries. These aren’t settings that we typically pay a lot of attention to, the types of innovations that they produce don’t have the sort of bells and whistles and level of sophistication, technologically speaking, that some of the innovations that we often use here in the NHS might have. They innovate what we call frugally, doing more with less, probably out of necessity, possibly because it’s just a mindset, and then of course there are all these, what I would call ‘Colonial’ reasons as to why we’re not paying attention to those settings. The Harkness Fellowship started for me, at least it began my research interest, in this area.
We did a sort of pilot survey where we asked people in the U.S to rate abstracts online and we fictionalized their sources to either high income countries or low income countries, and we found that there was a strong signal to suggest that those people that were reading abstracts from the low-income country rated them far worse than when same abstracts were listed as being from a high income country, which sort of corroborated our sense that when things come from a low-income country there’s an additional challenge. There’s something else that you have to get over in order for those innovations to become palatable to clinicians in the UK and the US. And that really spawned a lot of other research that we’ve done since then.
DMacA: And that brings me to your recent book, because it includes a lot of those innovations. Tell us about the book and go through some of the titles of the chapters, which are really fascinating.
“There are all of these adapted technologies, where clinicians have improvised using the resources available around them, but that turn out to be as effective as the technologies that we have overly engineered here in the NHS, and cost a lot more at the same level of effectiveness and safety.”
MH: Thank you. The book just came out last week so this is hot off the press, very exciting. It’s called:”Decolonizing Healthcare Innovation- Low-Cost solutions from Low-Income Countries” Its essentially in two sections, and I’ll start with the second section and then come back to the first. The second section invites the reader to explore six frugal healthcare innovations. There are many more than these, of course, but these are just ones we had space for, and where they’ve come from, and why they’re appropriate for the NHS.
I’ll give you some of the examples: I look at the use of mosquito net mesh for hernia repair. Now mosquito nets, as it happens, are made of exactly the same material as the commercial mesh that we use for repair of hernias here in the NHS, but cost something like 10 000 times less, so there’s a really significant cost imperative for us to use that mesh. And it’s being used at scale in India and throughout sub-Saharan Africa for hernia operations because, of course, the expensive commercial ones which are pre-cut and pre-sterilized, single use only and pre-packaged, are prohibitively expensive for those settings, so they’ve adapted. I also discuss in that case, the clinical effectiveness, and head-to-head clinical trials have demonstrated complete equipoise, and complete equivalence in terms of adverse events, infection rates, relapse rates, recurrence rates, between commercial mesh and mosquito net mesh. That’s just one example.
Another example is a device called Sayeba’s method which is for postpartum hemorrhage. Essentially it’s a condom tied to the end of the urinary catheter and you inflate the condom with saline, insert it into the uterus when there’s postpartum hemorrhage, inflate it with saline to exert pressure within the uterus to stop the bleeding. It was invented by Sayeba Akhter, a Bangladeshi obstetrician about 20 years ago and, essentially, it does exactly the same job as the balloon tamponade devices we pay for here in the NHS that cost about 300 pounds each. But, of course, tying a condom to the end of a catheter is cheap so it basically costs nothing and, the studies seem to show that the outcomes are identical if, in fact, slightly better using the condom and catheter device.
Another example, and I’ll stop here because there are many more to go through, is the use of Tilapia fish skin from Brazil. This is a fish that’s found throughout the Amazon, people eat it routinely, and it turns out that if you use the skin of the Tilapia fish which is very rich in collagen, two types of collagen I think, you can place it on second and third degree burns, the serious ones that otherwise you’d need to use skin grafts and it leads to a very rapid re-epithelialization in a short duration of time, less pain, less infections, less need for bandage changes, and only costs 11 dollars for a complete course of treatment.
There are technologies using fish skin available in the NHS but they’re acellular fish matrices that are bioengineered and cost about a thousand pounds for a segment about the size of your iPhone, so there’s a clear cost imperative again in that case in plastic surgery. And the list goes on and on and on.
There are all of these adapted technologies, where clinicians have improvised using the resources available around them, but that turn out to be as effective as the technologies that we have overly engineered here in the NHS, and cost a lot more at the same level of effectiveness and safety. So the business case is very very strong.
“But also that are our gaze, let’s call it intellectual gaze, is very much towards the West – it’s a Eurocentric or North American gaze- where we predominantly pay attention to those institutions in those countries… And it’s therefore a mindset approach where we have to understand that we’re missing opportunities to adopt or learn from countries that are doing far more with a lot less, simply because we’re not used to that.”
But then we come to the first half of the book which explores some of the colonial reasons why we’re not paying attention to those opportunities, and there are many, and it’s all to do with the fact that, in some senses, clinicians like sophisticated technologies. But also that are our gaze, let’s call it intellectual gaze, is very much towards the West – it’s a Eurocentric or North American gaze- where we predominantly pay attention to those institutions in those countries, somehow arguing that those contexts are more similar to ours here in the UK. But, these are very woolly reasons. All countries are equally different to each other for all sorts of reasons so, our preference to pay attention to the North American setting or European setting for inspiration is actually one that’s rooted in what we would call ‘White Eurocentrism’. That is itself very much rooted in coloniality because western medicine emerged at a time of colonial capitalist expansion in the Middle Ages, Enlightenment, and Renaissance periods. And it’s therefore a mindset approach where we have to understand that we’re missing opportunities to adopt or learn from countries that are doing far more with a lot less, simply because we’re not used to that. So the book is really about how to decolonize healthcare innovation, it’s about what can we do clinically, what can we do in higher education when we teach our Global Health students, and Public Health students, what can we do to address some of these imbalances in knowledge exchange in the way that we teach and the way that we understand how innovations really work, in order to find some of those opportunities, and leverage them.
DMacA: It’s been fascinating talking to you about this, let’s call it, ‘reverse coloniality’. I think it’s wonderful to hear your wide international vision of what we can do. It’s always a pleasure to talk to you. I can’t think of a greater contrast between your innovative mindset and your title as public health position. Matt thank you very much indeed. As always, it’s been a real pleasure.
