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It is always difficult to assess the final results from trips like this. How does one determine whether it was worth it?
–We provided direct care to about 400 patients, and distributed parasite medicines and vitamins to the community of Esfuerzo.
–We identified patients with chronic illnesses whose health might be improved (and for whom complications might be reduced or avoided) by addressing these illnesses.
–We strenghtened community ties, made new friends, and renewed our commitment to doing the best we can for our patients and for economicslly-marginalized communities.
–We taught students principles of team-based and patient-focused care, and demonstrated how to work in resource-poor areas without sacrificing proper care.
–We demonstrated principles of humanism, medical professionalism, and compassionate care.
–We bonded as a team, as friends and as current and future colleauges.
I don’t know how to judge which outcomes are the most valuable…but I don’t really care.
It was worth it, for all the reasons above and for many other reasons not mentioned and maybe difficult to explain
It was worth it.
As we approach the end of our last full day in the DR, it seems proper to discuss the last few days’ activities.
On Wednesday we switched our work site to the Fundacion Sol Naciente. The Fundacion has been a long-standing partner and we have been working closely with its director, Dr. Ramon Lopez, since 2006. The Fundacion runs an outreach clinic in the eastern part of Santo Domingo, in a barrio called Los Mina. We worked in this clinic Wednesday and Thursday, and provided care to a very different type of patient community. As opposed to in Parsiso, patients in Los Mina tended to be older, have more chronic illnesses, and have more contact with the Dominican health care system. As a result it is more like working in a free clinic back home: we helped manage chronic illnesses, but we still made new diagnoses of hypertension and other chronic illnesses during the clinic session. We only worked two days there, but we were able to provide further opportunies for our students to enhance their patient care skills and clinical judgement while also (successfully) partnering with local Dominican physicians.
Today, we visited some of the barrios in Los Mina to meet the members of Physicians for Peace‘s Resource Mother program (madres tutelares). This program matches pregnant teens with older women who help ensure that the teens make it to prenatal visits and pospartum and well-child check-ups, seeks to improve prenatal care and reduce risks of poor outcomes for newborns, and encourages teens to separate pregnancies at least one year apart. The Resource Mothers also act as lay health promoters, teaching residents of their communities about contraception, sexually-transmitted infections, etc. Currently, there are 20 Resource Mothers caring for nearly 200 teens. It will be interesting to see how the rates of childhood vaccinations, perinatal complications, and spacing-out of pregnancies could be affected by this program.
The barrios we visited are alongside the Ozama River, and have been badly affected by the recent rains and resultant floods. Infrastructure is limited: running water available only three days a week, the need to climb up the adjacent hills alongside the river hill to buy drinking water, and the 30-60 minute walk women must make to reach the local maternity hospital: a trip that must be made on foot as women get closer to term and are unable to ride the local motorcycle taxis–unless they can afford to hire a taxi.
Although our commitment is not as strong to working in the barrios of Los Mina (yet?), it is eye-opening to see the conditions in the barrios and inspiring to work with those seeking to make a difference.
In January, I figured out a new mantra while in the DR: nothing is linear. Why does the bus arrive between 30 minutes before to one hour after the expected time? Why did lunch take 2 hours? Why do I get pulled from clinic to deal with the press? Why do 3 cars try to fit into 2 lanes? Because nothing is linear. Things get done here, but it never seems to follow the path we might expect in the US: a certain amount of chaos and uncertainty is par for the course, and I am always reminded that I need to be flexible and adaptable.
Yesterday I left the school with two students at 8:30 in the morning, as clinic was getting started, to run a couple of housecalls. It has been rainy these past few days, but it wasn’t raining as we left and we figured we would be quick and be back in an hour or so. The rain picked up as we got into the community and we sheltered in a home for about 30 minutes. In this house, we were offered cups of hot chocloate as the family ate breakfast, even as we intruded.
We moved on to our first patient, Dona Teya. While at her house, the rain resumed. The road outside flooded, and the water rose to within a few inches of her threshold. The rain continued for nearly four hours, pouring down and easing up, and the water levels rose and fell. We were advised by a passerby that the drainage ditch that separates the community of Esfuerzo from the rest of Paraiso had flooded out of it’s banks, and we would need to wait until the level dropped before crossing back.
So, we passed the time with Teya and Clara. We played dominoes, and learned that if you are an American playing dominoes for the first time against a 70-year old Dominican woman, you probably will lose…badly. Sitting in Teya’s house, made of wood with a corrugated tin roof, we listened to the roar of the rain and watched the water as we played dominoes on a piece of cardboard perched on our laps. Clara made lunch, and made us plates of boiled yucca and bananas with fried sausage…even though she and Teya would be considered extremely poor by most measures. We were welcomed as friends, and in both houses the generosity and welcome was humbling.
The rain eventually slacked off, and we were able to walk out to the higher ground of the community. We went to look at the flood water, and the three of us were amazed: the entire valley separating Esfuerzo from the rest of Paraiso was flooded to the level of a man’s chest. (I will add pictures once I get back stateside)
It was clear we were not going anywhere anytime soon. I called up to the school to check-in and to let the team know what was happening. Radha and the group had things under control: they had continued the model of using student pairs to facilitate patient care, and were keeping up the pace.
By 5 pm, the water had started receding slowly but was still knee high. However, it was getting late and there was a chance of more rain later, and we began to make plans to walk out. Just then, two young men from the community offered to carry the students out across the water, and we were ready to go. The water reached to just above my knees at it’s deepest, nearly three hours after the rain had finally tapered off.
A one hour house all had turned into a nine hour experience. Nothing is linear. But we saw the hospitality and generosity of the community’s residents. Despite the unpredictability of life in the DR, many of the people we have worked with will go out of their way to help out and to make you welcome. It is an incredible, chaotic, unpredictable, but often friendly place, and the long-term relationships with the people and the community are incredibly rewarding.
This past Saturday we started our 3 days of clinic in the school in Paraiso. As usual, we had our students working in many areas: registration, vitals, shadowing in the consultorio (exam room) with the providers, and working in the pharmacy. In order to make sure we could see as many patients as possible, we also has 2 Dominican doctors working with us. One of the doctors spent much of the day engaged in political and publicity-related actions, while the other (Dr. N) actively saw patients.
Soon after we started seeing patients, we saw problems develop quickly with Dr. N. The student working with him came to me and asked if she could move to another role because she was very uncomfortable with how he approached patient care. He dismissed patients’ concerns, declined to address some (or many) of their symptoms, and was not responsive to our student’s questions. At one point, when a patient asked for a specific medicine, the doctor pushed the pen and medication slip towards the patient, telling them that if they were the doctor they should just write their own prescription. We switched another student to work with Dr. N, and received the same reports: Dr. N approached patient care in a paternalistic manner, did not listen to patients, did not ask many questions to explore symptoms, did not examine anyone, and tried to get out students to agree with him when he told patients that doctors know best and patients should follow directions.
I don’t think it is an exaggeration to say our students were astounded and offended by Dr. N’s approach to care. After returning to the hotel that afternoon, we held an important team meeting. We needed to decide how to address this situation and provide the kind of care we felt was appropriate and still see as many of patients as we could. Students’ concerns included potential harm to patients as a result of Dr. N’s approach, the possibility that the community might lose faith in us, and the fact that the students’ hard work preparing for this trip might be wasted if patients did not receive necessary care and appropriate medications.
We decided to change the way we set up the consultorios. We moved students around, took one from registration, and set up tables in the consulorio where Radha (our PharmD) and I were working together and have students take histories, perform physicals, and think about plans of care before presenting the patient to us. We could then confirm any part of the history or exam that we needed to and help finalize the recommended plan of care. We could teach patients about their medical conditions and their care, and review and educate patterns about their medications. We could provide patient-centered care in the way that we have been trained and in the way we feel is proper. We let Dr. N know that, given how busy he was with other obligations, we would be OK without him.
This shift worked extremely well. With the students working in pairs to see patients we saw over 100 patients the day after making the change. Students were more satisfied and patients seemed happier with their care. We even managed to get a few house calls done…something we couldn’t do with Dr. N because Radha and I needed to be onsite to address issues that arose from his work. We used the same system yesterday as we finished up in Paraiso.
Dr. N is not a bad person. He is working in a public-sector position, and seems respected by his peers. But his approach to medicine is paternalistic and, to us, disrespectful of patients and how patients experience their illnesses. He had no interest in empowering or teaching patients. He was the center of the visit, not the patient. I suspect, based on my limited observations, is that this approach is common among many physicians here in the DR: the approach to care is fundamentally different from what we try to do in the US, and students are trained very differently here. Dr. N seemed taken aback when our medical students asked questions and tried to understand what he was doing…and he never answered any of their questions.
I am extremely proud that our students recognized this issue so quickly, and I am happy that they understood it to be a major issue. This tells me that we are training students who are looking at medical care from a patient-centered perspective, who partner with patients to provide care (instead of simply telling patients what to do), and who will work to humanize medica, care for patients they work with in the future. I am also proud that we came together as a team to discuss these concerns and that we settled on a solution as a team…and that the team pulled together to make things right.
Working to provide care overseas in marginalized communities means that you will need to overcome challenges of various kinds. In this case it was a community partner that was not living up to our expectations. When challenges arise, it is important to figure out how to overcome them without burning bridges you might need later and in such a way that it strengthens the team. I think we were able to do both.
Today, we planned an early start to complete the door-to-door assessment in the community. We thought we had about 60 houses to go, but that turned out not to be the case.
We completed the work in about 4 hours…accounting for 20-25 houses. This means we visited around 65 or so homes total…much less than the 100 we expected, and had counted on previous trips.
Luis, our local guide, feels this change results from the risk of flooding in the community. Coupled with the lack of infrastructue and the possible availability of more attractive lots above the flood plain, one could see why this change might occur. If so, though, it is a bit surpising that other marginalized individuals have not filled in those spaces.
It will also be interesting to see if the exodus continues, or if the causes become more evident. If the exodus does continue, how will this affect the community, its ability to develop a collaborative plan for improving health and living conditions, and the cohesiveness of Esfuerzo overall.
Today’s weather was less than ideal. After monsoon-quality rains last night, it rained all morning. Added to the usual humidity, the rain kept us damp nearly until lunch. Despite that, the team (2 pharmacy and 9 medical students, along with one PharmD and one MD) spent the whole day in the field.
We made it to close to 40 homes, despite the mud and the dampness. In each home, we checked adults’ blood pressures, provided dental flouride varnish treatments to all children under 18, and provided parasite medicines and vitamins to all household members.
We have never approached the community from this angle. So far, it seems well received: people are willing to let us into their homes and are willing to discuss the preventive care we are offering. Some go further: one family offered us habichuelas con dulce (a sweetened bean dish) to thanks us for our work.
So far, we have identified 11 patients who will need further care in the clinic Saturday, and we have close to 60 houses to go.
More of the same tomorrow…though I hope for less rain.
We have reached the end of our first day here in the DR, and we are getting ready for a full day tomorrow. We got in to the hotel late yesterday afternoon, after 16+ hours traveling. Despite that, we had enough energy to count pills out in preparation for tomorrow’s work in the community–over 22,000 vitamins in all.
Today we traveled to the community, to make sure that things were ready for tomorrow and to introduce the newcomers (most of the team) to the community of Esfuerzo and it’s residents–and to give a chance for them to see first hand something of the residents’ challenges.
Tomorrow, we will try out a new approach to providing care in the community. Give the increasing burden of non-communicable disease in developing nations (which I previously reviewed here), and given that soil-transmitted parasitic infections (which are part of the group known as “neglected tropical diseases”, or NTDs, becausenthey do not attract the attention of HIV/AIDS, malaria, or tuberculosis) are endemic in this part of the world, we will try to address these concerns more directly.
Our plan is to go house to house in Esfuerzo, provide parasite medications and vitamins to all residents, and check blood pressures for all the adults. This should allow us to detect high blood pressure and recommend treatment earlier than might have been the case, and should reduce the background rates of parasitic infections and so prevent more childhood illness.
There are around 100 homes in Esfuerzo. We will see how well we do and how far we get tomorrow. The continued rain won’t help us much: Esfuerzo floods easily, and this could impact our progress.
Hopefully I will be able to update again tomorrow and give a sense of things went.
Dominican Aid Society of Virginia 