The "club of love" seeks a new chapter

We are being called to design innovative health care programs," says Dean of Nursing Dyanne D. Affonso--and to rethink the way in which this country manages prenatal care. When a person of the energy, commitment, and vision of Dean Affonso becomes a standard-bearer, a long line of supporters is likely to form behind her.

And it has. The first queue formed in 1985 on the Island of Hawaii in the Hilo-Puna district, where Dean Affonso--prior to coming to Emory--began the Malama Na Wahine Hapai Project with funding from the National Institutes of Health. Awash in "mere ideas" at the time, Dean Affonso knew one thing for sure: the low birth weight rates on the Island of Hawaii were higher than elsewhere in the state. Exclusive of income and education, the women of the island were saying, If I am not sick while pregnant, why should I go to the doctor?

Indeed, most women would come for treatment either in the last trimester or appear irregularly throughout their pregnancies. Such indifference raised immediate questions in the dean's mind about the content of the care and the extent to which the treatment that women of Filipino, Japanese, and Hawaiian ethnicities received was relevant to their culture.

The Western model of prenatal care, according to the dean, "works best for sick pregnancies, since it goes to the beat of established medical outcomes and focuses primarily on the fetus." The Malama Project puts the focus back on women to make the point that the health care system cannot expect healthy children without healthy mothers. The current prenatal care system is designed to treat individuals--thus ignoring the context of women's lives--and features doctors assiduously hunting for disease. All this motion, the dean attests, overlooks the fact that "women gather in circles every day to support other women who are pregnant; that is the real health care." The staff of the Malama Project are integral members of this circle--offering free counseling and support in all aspects of pregnancy, childbirth, and post-childbirth.

In her efforts at reform, Dean Affonso says, "It was clear that I needed a partner in developing a more sensitive concept of well-being." So she turned to the health healers, whose influence is predominant in Hawaii. The healers long have understood the centrality of relationships in the emotional lives of women and are adept at rooting out discord and promoting harmony.

Western doctors--sometimes accused by their patients of being uncommunicative--might be mystified by the methods used in the Malama Project. Talking is considered paramount as a pathway to health, and the language of joy and pain these women speak is rich and filled with cultural relevance. Participants in the Malama Project speak frankly, for instance, about "what it is to grow another person in your body."

One of Malama's 1993 "graduates," Elizabeth Pacheco, was working through her grief over her mother's death in her first trimester. Speaking with nurses from the project on a regular basis brightened the road ahead considerably. She describes the experience by saying, "I have nothing but thanks and aloha to the staff of Malama. They became more than nurses to me. Each of them has become a good and dear friend. I call it my `Malama Club' because it is a club of love."

Customizing prenatal care to women also involves making adequate provision for their relationships with men and with their larger community. Men on the Island of Hawaii truly have become advocates for women's health care. For example, the Kiwanis Club has given its support to the Malama Project, and men from all different sectors of the business community are recruiting women to the program. In the words of Dean Affonso, "The people have claimed it; we do not own it."

An important source of financial support once the NIH grant ran out was the Queen Emma Foundation, which is a public trust devoted to promoting the health of Hawaiians. This year the foundation has made a gift to Emory to coordinate the expansion of the project, first to a site on the Island of Oahu. The larger plan, according to Dean Affonso, is "to improve the access, availability, and acceptability of preventative health care services, including prenatal care, for ethnically diverse and rural populations throughout the United States."

"It would be unethical for me," declares the dean, "to be at a place as privileged as Emory and not try to make resources available to lessen the low birth rates that are so high in the state of Georgia." Within two years, she hopes that the Malama Project will come to Georgia and that its establishment here will be a universitywide event. Soon, then, the Malama Project will be more than a compelling postcard from afar; it will arrive at our doorstep, seeking a new chapter and prepared to face an entirely new set of cultural challenges.--S.M.C.

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