几年前，我在坦桑尼亚与一群医生和科学家会面，讨论是什么阻碍了让更多人接受艾滋病治疗。通过帮助全球更多艾滋病患者获得治疗药物，我们在与艾滋病的斗争中取得了巨大进展。然而，在3700万艾滋病毒携带者当中，仅有半数正在接受治疗。
正当我们讨论这一问题的解决方案时，来自无国界医生组织的汤姆·埃尔曼站了出来，与我们分享他所在机构学到的一个艾滋病治疗新方法。他讲得很简短，只有5分钟而已，但当他结束分享的那一刻我就在想：应该有更多人采用这种做法。
汤姆描述的创新并非一项新技术。它是一种简化艾滋病治疗的方法，使之更加有效，同时对患者的需求做出更好的反应（需要说明的是，在汤姆向我讲述的创新方法中，视频里主要介绍的小组模式只是一个例子而已）。
上个月，我邀请汤姆参加我们在纽约举办的“目标守卫者”大会，分享他所在机构的故事。大会不仅庆祝我们在全球健康和发展领域取得的成就，而且聚焦那些依旧存在的挑战，包括抗击艾滋病的工作。
汤姆向观众介绍了莫桑比克的情况。从2003年开始，无国界医生便开始在莫桑比克政府的支持下开展与艾滋病有关的工作。在艾滋病治疗刚刚推出的时候，政府采取的是一个传统的方式，即由医生在诊所集中掌控艾滋病患者的护理和治疗过程。在一个每十个成年人中就有一人携带艾滋病毒的国家里，诊所医护人员超负荷地工作，他们往往只能在每个病人身上花几分钟的时间，而病人却需要定期地花好几个小时前往诊所，然后排长队接受治疗。
虽然这种方法首次成功地让数千病人接受到了艾滋病治疗，但并没有像它本应做到的那样服务患者的需要。因此，许多病人（30%左右）中途退出治疗也就不足为奇了。
2007年，在莫桑比克太特省的村庄里，一些艾滋病患者组成的小组决定挑战这种集中治疗的模式。他们不再每月步行数小时去领取抗逆转录病毒（ARV）药物，而是以轮流的方式，派小组里的一个人为所有人代领药物。一种新型医护模式就是这样开始的，它被称作社区ART小组，英文简称CAG。
由于等候时间缩短、前往诊所的频率降低，艾滋病治疗变得更加简单，于是更多病人得以持续接受治疗并且活得更加健康。这也缓解了莫桑比克医疗系统不堪重负的状况，使得医护工作者能够有更多时间关注那些最需要帮助的病人。
鉴于这种新型医护模式被证明具有重要作用，无国界医生与莫桑比克卫生部展开合作，在全国范围内推广这种互助小组。社区ART小组只是“差异化医护模式”中的一个例子，这种模式正在通过不同方式、在非洲不同的环境中进行应用。在其他国家，社区通过自己经营的药店分发艾滋病药物，或者调整相应的方法来满足病人个人及群体的具体需求。
汤姆说：“这些模式的本质非常简单。你倾听病人的需要，你信任他们，调整你的服务去满足他们的需要。你将一些事化繁为简，不再将其当成医疗问题来处理。”听到一名医生谈论要弱化医生在治疗中的角色，这令我颇为惊讶。然而结果本身足以说明问题。
对于我们的基金会来说，这个方法也成为了一股真实的推动力量。虽然我们没有资助无国界医生，但它激励我们在向其他国家推广差异化模式方面发挥更大的作用。
汤姆总是寻求在已经取得成绩的基础上进一步开拓，这是他给我留下的深刻印象。他曾说道：“如果我们的目标是向每一位有需要的病人提供治疗，我们就需要走得更远一些。我们需要调整医护模式，使之适合于流动人口与难民，以及亿万被迫留在冲突地区和脆弱国家中的人们。”
接下来，无国界医生期待看到这些以患者为中心的新型医护模式能如何被用于改善其他疾病（如结核病）的治疗方法，或者将医护覆盖范围扩大到更多弱势和边缘化的群体，包括性工作者、流动人口和那些被困在冲突地区的人们。此外，这些模式还能被改造后应用于与计划生育或非传染性疾病有关的工作。
汤姆的愿景是建立起基于医护人员与社群之间互信、平等伙伴关系的卫生保健系统。通过赋予社群权利，他期待看到一个新的世界，在那里“不让任何一个人掉队”将不再只是一句口号。在汤姆和他同事以及与他们合作的病人的共同努力下，这个愿景正在逐渐变为现实。
Leaving No One Behind
A few years ago, I met with a group of doctors and scientists in Tanzania to discuss the challenge of getting more people on HIV treatment. Huge progress has been made in the fight against HIV through increased access to lifesaving AIDS drugs for millions of people around the world. And yet, only half of the 37 million people living with HIV are receiving treatment.
As we talked about possible solutions to this problem, Tom Ellman of Doctors Without Borders stepped forward to share what his organization had learned about a new approach to delivering HIV treatment. He spoke briefly—just 5 minutes—but as soon as he had finished, I thought: Far more people should be doing this.
The innovation Tom described wasn’t a new technology. It was a way of simplifying HIV treatment to make it more efficient and responsive to the needs of the patients. (And as I note below, the groups highlighted in this video are just one example of the approach Tom told me about.)
Last month, I asked Tom to share his organization’s story in New York City at Goalkeepers, an event to celebrate global health and development successes and focus on what challenges remain, including in the fight against HIV.
Tom told the audience about Mozambique, where Doctors Without Borders has been working in support of the government on HIV since 2003. When HIV treatment was first rolled out, the government followed a traditional approach. Doctors working in centralized clinics controlled the care and treatment for HIV patients. In a country where one in 10 adults was living with HIV, clinic staff were so overburdened that they often could spend just a few minutes with each patient. Patients regularly traveled hours to reach clinics and waited in long lines to receive care.
While the program was successful in putting thousands of patients on treatment for the first time, it wasn’t serving the needs of the patients as well as it could. Not surprisingly, many patients—about 30 percent—dropped off treatment.
In 2007, small groups of HIV patients from villages around Tete, Mozambique, decided to challenge this approach. Instead of walking for hours every month to pick up their antiretroviral (ARV) medication, they would send one of their group to pick up drugs for all the other group members on a rotating basis. And that’s how a new model of care, known as the Community antiretroviral therapy (ART) Groups (CAGs), got started.
Reduced wait times and less frequent visits to the clinic made getting HIV treatment easier, and more patients stayed on treatment and stayed healthier. It also eased the burden on the country’s overloaded health care system, giving staff more time to focus on patients who needed the most help.
With clear evidence that these new models of care were making a difference, Doctors Without Borders worked with Mozambique’s Ministry of Health to expand these groups across the country. The Community ART Groups are just one example of what’s known as “differentiated models of care,” which are now being applied in many different ways and settings across Africa. In other countries, communities operate their own pharmacies to distribute HIV medication or have adapted approaches to meet the specific needs of the patients and their communities.
“The essence of these models is very simple. You listen to patients, you trust them, and adapt your services to their needs. You simplify things, you de-medicalize things,” Tom says. It’s pretty striking to hear a doctor talk about reducing the role of doctors in treatment—but the results speak for themselves.
This approach also became a real catalyst for our foundation. Although we don’t fund Doctors Without Borders, it inspired us to take a bigger role in spreading differentiated models to other countries.
What impresses me about Tom is that he is always looking to build on the progress that’s been made. “If the goal is to provide treatment to everyone who needs it, the world needs to go further. We need to adapt models of care for the hundreds of millions left behind in conflict zones, in fragile states, for migrants and refugees,” he said.
Next, Doctors Without Borders is eager to see how these new models of patient-centered care could be used to improve treatment for other diseases like tuberculosis or to expand access to vulnerable and marginalized groups including sex workers, migrants and those caught in conflict areas. These models could also be adapted to family planning or non-communicable diseases.
Tom’s vision is to develop health care systems based on trust and equal partnership between health professionals and communities. By empowering communities, he imagines a world where “leaving no one behind” is not just a slogan. Thanks to the work of Tom, his colleagues, and the patients they’re partnering with, it is on the way to becoming a reality.
