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.

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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.

When one thinks about global health, there are certain images that come to mind: developing nations with insufficient medical resources to meet their residents’ needs, high rates of infection and parasitic diseases due to the lack of potable water and lack of necessary infrastructure, and disease that we in the United States consider exotic or unusual.

There is a certain amount of truth to these images, especially for global health work that takes place in isolated communities.  However, it is becoming ever more evident that any efforts toward improving global health must begin to shift their focus away from acute disease and infectious illness and start to pay attention to chronic, non-communicable disease like diabetes high blood pressure (hypertension), heart disease, chronic lung disease, cancer, etc.  Last month, the World Health Organization (WHO) held its First Global Ministerial Conference on Healthy Lifestyles and Non-communicable Diseases Control to discuss issues surrounding non-communicable diseases (NCD) in further detail.  The WHO notes that nearly 80% of the 36 million global deaths that occur annually occur in low- and middle-income nations, with more than 9 million people dying prematurely before their 60th birthday.  As great as this burden is, it expected that by 2030 NCD-related deaths will increase by 50% in South-East Asia, the Middle East, and Africa.  Already, NCDs account for 63% of global deaths (36 million of a total of 57 million deaths annually) and are placing enormous burdens on already-stressed health care systems and national budgets.

In her opening statement for this meeting, WHO Director-General Dr. Margaret Chan noted much of the increasing burden of NCDs is related to a combination of factors that are familiar to any of us who work in primary care in the United States: obesity, tobacco and alcohol use, lack of nutritious foods, lack of exercise, etc.  At the large-scale level, Dr. Chan calls on governments to begin to make changes that can benefit populations: restricting tobacco use and advertising; lowering sodium contents of foods; implementing urban design plans that emphasize walking, cycling and safe places for children to play; and reducing excessive alcohol use.  These are important goals, and will be the focus of further discussion at the higher levels of governments across the globe.

At the very local level, such as in the communities of Paraiso where we work, the importance of NCDs is evident.  We have already noted many of our adult patients who are being treated for hypertension, diabetes, etc.  Our organization  has moved to focus on bringing sufficient numbers of medications for chronic diseases in order to complement the treatments for infections and acute illnesses that we previously expected.  We have also continued to make new diagnoses of hypertension and diabetes every trip to the community.

Our new focus on NCDs has complicated our work significantly.  Working on short-term medical trips, it is very easy to focus on acute illness: typically, the medications we can provide can effectively address the problem.  However, working to care for patients with NCDs means bringing enough medicine to last for longer-term treatments, looking to establish ongoing relationships with patients, and attempting to record (and save) a medical history that includes prior medical problems, and document a plan of care that would be available for follow-up care in the future.  All of this is a challenge in a community in which people move around with some frequency, literacy and educational levels are often low, and contact with the local health care system (and supplies of affordable medicines) are limited.

In order to address these challenges, we are trying something new.  Soon-to-be Dr. Matt Imm, who was an undergrad working with our organization in the DR in 2006 and 2007 and who helped establish the Partnership for Ongoing Developmental, Educational, and Medical Outreach Solutions (PODEMOS) at the Ohio State University School of Medicine, presented us with a great opportunity.  PODEMUS had developed a health passport to facilitate their short-term medical work in which multiple teams would spend time in a community in Honduras over the course of a year but the individuals making up the team might differ each time.  The health passport allows documentation of a patient’s history; provides a space to document each patient’s vital signs and physical exam; and permits documentation of a treatment plan.  In the interest of privacy, this health passport stays with the patient (not with the international team), and patients are encouraged to present the passport any time they access medical care either locally or through other international teams.  Each time the patient sees a healthcare provider, the passport can be reviewed and updated as appropriate and can then be made available to the patient’s next health care provider.

In January of this year, we distributed nearly 300 passports.  In June, we will see how many patients return with passports for us to review and we will find out how many of these passports and been reviewed and updated by other providers.  We also plan on distributing more passports in order to do our part to try and address this issue of NCDs.

Health Passport cover

Introductory information for the Health Passport

Background information about the Health Passport

Documentation of past medical, family, and social histories

Visit page, allowing documentation of relevent history and physical exam findings, and the treatment plan

In another post, Jess Lucia notes the difficulty in obtaining a crucial resource when lives in poverty in a marginalized community.  Water is a fundamental necessity, but safe drinking water is all too often unavailable leading to preventable illness and costs.

In Santo Domingo, our housecalls and community work take place primarily in the community of Esfuerzo de Paraiso.  This is the most marginalized of the barrio’s communities, is physically isolated, and is the least developed area of Paraiso.

Jess Lucia, who joined us on January’s trip to document the project, has noted her thoughts about Esfuerzo on her blog.  Thoughtful as always, with photos that illustrate the community’s challenges.

At the bottom, Jess invites questions.  Jump in!

In case you are visiting the site to learn more about working in global health settings, I’ve uploaded a slide show I put together for a presentation regarding international medical service.  I hope this is helpful, and I am happy to provide more detail if needed.

The next medical service trip to the Dominican Republic will be May 31 to June 11, and will be in collaboration with medical and pharmacy students as part of HOMBRE.

If interested, let me know!  We are particularly looking for providers to be part of the team: physicians, NPs/PAs, etc.

Paraiso, the community we partner with in the Dominican Republic, is part of a larger barrio outside of Santo Domingo.  This barrio sprawls across a large expanse north and slightly west of the city center.  Paraiso itself is subdivided into smaller sub-barrios.  Some of these (like Altos, Veinte-Ocho and Carlos Alvarez) consist largely of cinder block homes and unpaved streets that at have curbs to control water runoff during heavy rains.  The most marginalized part of the community is Esfuerzo de Paraiso, which sits downhill from Altos and is separated from the rest of Paraiso but a drainage ditch that collects the runoff from Altos and the other sub-barrios.  Esfuerzo is bounded on its opposite side by a small river, meaning that the community floods easily–and rapidly–during heavy rains.  Esfuerzo does not have any paved roads or curbs, most houses are insubstantial structures made of wood and tin, electricity is in short supply, and there is no running water available.  Esfuerzo has existed for approximately 10 years, and yet has little economic development: most residents who work do so outside the community, or have small businesses selling food, candy, etc to their neighbors.  There are around 90 houses, and a total of about 500 residents in Esfuerzo.  We have seen over time that the residents of Paraiso have little contact with the local medical system, and there are no medical facilities in the community itself.

In 2009, the New England Journal of Medicine published an article addressing the impact urbanization has on health.  The authors note that most population growth in the developing world in the years to come will be in urban centers, and much of that growth will take place in marginalized communities such as Paraiso–Esfuerzo in particular.  Residents in these communities wield little power and have little chance to improve their lot: the authors note that “[t]hese residents are usually tolerated and their presence tacitly accepted, but the local government generally ignores them, accepting no responsibility for accounting for them in planning or the provision of services.”  The authors note that residents in these newly urbanized communities face “urban health hazards as comprising injuries, pollution, and chronic diseases, such as diabetes and hypertension” while “[i]ncreasing the population density in cities without proper water supplies and sanitation increases the risk of transmission of communicable diseases”.  Residents of communities such as Esfuerzo are faced with increased burdens of chronic disease, while still facing significant risks regarding infectious diseases.  In the context where residents will have little political impact or ability to change their communities’ resources, these residents will face enormous health risks heading forward.  Meanwhile, health care resources that could provide needed care for these communities is not easily available.

As the world’s population becomes increasingly urbanized, the combination of acute and infectious diseases and chronic illnesses will continue to cause great harm to newly urbanized communities such as Esfuerzo.  Those of us who work in developing nations must be aware of the ongoing shift in patterns of disease, and must develop approaches to care that address acute illnesses and tropical diseases (such as soil-transmitted worm infections) while also targeting ongoing care for chronic illnesses.  In the context of short-term medical trips, much can be accomplished–but only if a long-term partnership that includes the communities’ residents is established.  We are working to find effective (and affordable) ways to monitor and treat chronic illnesses in Paraiso and Esfuerzo, but we have also worked very hard to develop a trusting relationship with the community.

Through community-oriented primary care (PDF) approaches, the collaboration between health care providers and community residents can be strengthened.  This will lead to more effective and more cost-effective health care in communities such as Paraiso: newly-urbanized communities facing enormous health challenges in the context of few resources and disrupted social support systems.  For good or ill, urbanization is the way to the future–and health care providers and communities must find ways to minimize its harm.

Now that it has been two weeks since returning from the Dominican Republic, and I think that I have largely made it through the process of re-entering my normal day-to-day life.  What I consider “normal” here is so different from how the residents of Esfuerzo live that it is hard to explain and hard to conceive how the process impacts a person unless one has been through it before.

During the trip, the team grew close and accomplished a great deal.  Nearly 350 patients received care, and we launched a new initiative to provide patients with a personal health record (“pasaporte de salud”–health passport) that we hope will enhance chronic disease management and facilitate follow up care while empowering patients to be active in their own care decisions.  The new government of Santo Domingo Norte has taken an interest in the project (for better or for worse–time will tell), and we hope this interest will translate into more consistent government services provided to the community.  The new team members formed necessary connections with the community’s residents and leaders (official and unofficial) that will enhance our work over the next few years.

I suspect each member of the team has their own reactions to the return: the happiness of returning to families and friends, the pang of loss that results when 18 people who spent every waking moment together for a week of hard work are suddenly separated, the unease as the amount and variety of everything we have is contrasted with the facts of life facing each resident in Paraiso, and the anticipation of the next time we will meet as individuals and as a team to reflect on what has been accomplished and the very large amount of work still to be done.

A few links to other people’s thoughts:

David Aday’s letter to the team, which sums up how much respect we all have for the team members, and demonstrates the group’s closeness, friendship, and dedication.

Jess Lucia has been actively posting her thoughts about the trip: her first impressions upon return, an attempt to answer the most common question, “What was it like?“, and a description of the communities of Paraiso.

Finally, a link to Jess’s photographs of the trip.  She has a keen eye for catching emotion and context, and her work gives an in-depth sense of what it is like to be working in the communities of Paraiso and Esfuerzo.

Thanks to all the team members and to all those who supported the work.  I look forward to our continued work together.


Dominican Aid Society of Virginia

Contact us: DominicanAid@yahoo.com
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