Skip to main content

One of my main projects this summer has been working in the Case de Sante, a health clinic nestled right between lush, green fields of corn and sorghum less than a mile from my homestead. With walls made of cement rather than mud and painted a bright yellow, the building stands out. But the cheery color and photos of old Duke students lining the walls don’t mask the center’s difficulties.

Former Duke Engage students established a health insurance system for the CDS almost 10 years ago, but since a drought caused many members of the community to lose ability to pay the 1800 CFA (approximately $3.10) cost of insurance for their family for the year, enrollment in the system plummeted from 50 families to just 8 by the time we arrived.

For the first few weeks, I and the two other students working at the CDS spent time talking with the two clinicians who have worked there since the center opened in 1998, Basile and Odile. We examined their financial records, scouring the books for some shred of proof that the system was still working and didn’t need to be gutted entirely, and conducting interviews with families who had stopped paying for insurance. Our initial calculations led us to believe that the clinic had lost over 30,000 CFA during the last year, a far cry from the 8,000 CFA deficit the Duke Engage team found last year. However, after presenting our findings to Professor Piot and Basile, we learned that we had been misinterpreting the records.

When we corrected the calculations, new problems emerged. Only a few families actually saved money on the system over the last year because the discounts they received on medication rarely added up to the 1800 CFA buy-in. The clear solution was to reduce the price of the insurance system, but we struggled to determine how much lower the price could go without depleting the clinic’s reserves.

After hours spent tapping in numbers on an iPhone calculator, we had our answer. Based on some VERY rudimentary projections based on the average price per visit to the CDS and the average number of visits per family, we determined that the CDS could sustain a insurance system with a 1000 CFA buy-in.

After we cleared the price cut with Basile and Odile, we set to work making posters to advertise the new insurance system and designing a notebook to track per-visit savings for insured families. We also organized a free check-up day to promote the system and disseminate important information about high blood pressure and malaria prevention.

Throughout this trip, the divisions between males and females in Kabye society have been clear. Men work in the fields, while women stay home cooking and tending to the animals. Although the village is divided into male and female clans containing individuals of both genders, men and women generally keep to separate spheres. But, unlike in Western society, it seems to me that these divisions are based more on convenience and practicality rather than malicious or misogynistic internet. Regardless, before our check-ups, I never would have believed that these dynamics could even be seen when looking at individuals’ health. We took almost 20 people’s blood pressure, and 5 of them had hypertension, all of them women. These findings mirrored those found in a larger study at the regional medical center in Farende. Due to social norms promoting women being sedentary and cooking, local women are more likely to suffer from high blood pressure than their male counterparts.

In my global health classes at Duke, we talked extensively about the social determinants of health, about how factors like race and income often deter people from seeking medical care. What I was unprepared for, however, was the realization that, even in a community with universal economic barriers, there could unequal disease burdens on men and women.

My time at the Case de Sante provided me with valuable insights that I can take back with me to Duke, that I can use to inform the classes I take and the career I choose to pursue after graduation. It reminded me that health is not a given, nor is it equally accessible to everyone. Not in the United States and certainly not 5000 miles away in Togo.