Puerto Rico in December

Just about two months ago, I joined a medical team which traveled to Puerto Rico to help with recovery from Hurricane Maria.

The conditions were very challenging: infrastructure including water and power was very hard hit, and medical care was not wholly accessible. Clinics and hospitals–if open–are running on generators, and often for shorter hours and at reduced capacity with reduced staffing.

On December 16, I will be traveling back to Puerto Rico as a member of a volunteer medical team composed of one MD, one clinical PharmD, a clinical Psychologist, two medical students, and a pharmacy student. We will be volunteering at the Clínica Bantiox–a volunteer-run free clinic in Toa Baja which has provided care for over 3,000 patients since the hurricane damaged and shut down local health systems.

The need for medical care is still significant. Care for chronic conditions and assessment for new or acute problems is needed, especially as many patients have been displaced from their usual source of care, and/or their usual medical office is closed or inaccessible.

Given the need for care and the short turn-around time, the Board of this organization has agreed to allow donations specified for Puerto Rico to be accepted via PayPal–please use the link on this page. Please consider donating to support this work–all donated funds will be used to purchase medications and necessary medical supplies.

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Many hands make light work

Since I’m re-posting Jess’s post here, I figured I would use the same title.

Jess describes the nature of the team exactly: everyone does whatever work is needed, whenever that work is needed.  We all chip in–regardless of title, position, or experience.  Strong teams are created by a unified sense of purpose and mission, and this is best communicated when the team’s leadership focuses on meeting the goals needed to make the project successful.  If this means seeing patients–then so be it.  If this means counting pills–then that is what we will do.

This has been the approach from the very beginning, with 5 undergrad students in 2005.  No job is too small, and no person is too big.

And that is why we are still here, working with this community, in partnership.

A Wonderful Review of This Year’s DASV/SOMOS Team

Jess Lucia has documented this year’s DASV medical service team in this blog post, and her thoughts on returning to the DR for the second time here.

Jess writes about these experiences better than I can, and her photos are lovely.  Please take a moment to read these posts.

Tumblr!

As a way to provide more timely updates regarding our work in the Dominican Republic, we have set up a Tumblr account.  This will allow us to post more pictures, and will be easier to update while we are in the DR.

You can see what we are doing here.

Pasaportes de Salud

Yesterday, I had the opportunity to present at the American Academy of Family Physicians 8th Annual Family Medicine Global Health Workshop.  I presented on the issue of chronic diseases in developing nations and the challenge of providing appropriate continuity of care, and some of the challenges we have faced in doing so.

Here are slides from the presentation for review/comments:

 

Five in Five to Survive: Global Health, and Non-communicable Diseases

(The following post was written by Irène Mathieu, a second-year medical student at Vanderbilt. Irène was a member of the SOMOS undergraduate medical team that worked in Paraíso, and she spent a year in the DR on a Fulbright scholarship.  Her blog can be read here.)

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The Occupy Wall Street movement has spread like crazy to cities across the country, including my own (now even more) beloved Nashville. Last month the United Nations held its second ever high-level meeting on a health issue – noncommunicable, chronic diseases (diabetes, cancer, cardiovascular disease, and smoking-related illnesses; referred to from now on as NCDs). And this past weekend was the sixth annual conference of National Physicians Alliance (NPA), a small but growing national organization for doctors inclined toward activism, that unspoken part of the Hippocratic Oath.

The people camped out on Wall Street listening to Cornell West want pretty much the same thing as NPA doctors – for our national and international leaders, like the UN, to cease their unhealthy relationships with Industry. Unhealthy political relationships directly correlate to an unhealthy citizenry. Sadly, the UN meeting in September was notably devoid of the grand-scale commitments made the last time it held a high-level meeting on a health issue, which was HIV/AIDS.

This year, there were a lot of mumbles and hand-waving and broad framing of nebulous ideals. The heavy hand of industry in the fight against NCDs was predicted to be a stalling point at the New York meeting. Unfortunately, in many modern-day democracies – most obviously in our own – corporations are afforded more rights and privileges than people. We, the people, may not wield the financial power that corporations use to gain these privileges – but we do have a voice. And if HIV/AIDS was the major health justice movement of the ‘90s, then NCDs are our task.

The NCD Alliance shares this belief as its premise. Even Ban Ki-Moon observed that NCDs represent “a public health emergency in slow motion.” (Then he proceeded to lead the UN in an equally slow-motion response to the crisis.) NCDs are food issues, housing issues, environmental issues, urban planning issues, and educational issues. Every sector of society could play a role in decreasing the burden of these diseases. The only way to make sure such a complex movement makes an impact is to align our interests by setting goals we can all agree on.

Attendees of the UN meeting last month would have done well to set a series of goals like the Millennium Development Goals (unfortunately those will be largely unmet, however). World leaders could create a set of targets or indicators – say, 15 concrete items, like a target average blood pressure for a subset of the population or a percentage of people with high cholesterol on statins or hours of media time devoted to public health campaigns – and participating countries could select, for example, five indicators to work on in the next five years. Let’s call it the Five in Five to Survive: five things we, as a global community, can do in five years to increase survival of the people in our population who are most vulnerable to NCDs. And let’s hold our leaders accountable to them.

It’s clear that we cannot wait on those who attend UN high level meetings to make the commitments we need to decrease the global burden of NCDs. So what if health care workers and others who work with communities heavily affected by NCDs make up their own Five in Five? What if we create a national or global network to share best practices?

When our leaders fail on their commitments to the people, the people should bring their commitment to the leaders. Let’s bring it.

Wrapping up

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.

The last few days

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.

Rain, dominoes, yucca and bananas, and water

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.

Challenges in Paraiso

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.