Monday, March 23, 2015

Rural Primary Care in Chiapas, Mexico

It is my second week working with the local pasante in Soledad.  One of the most striking challenges in this rural community is the care of patients with mental health issues.  Depression, especially amongst women, is rampant in the community, and driven in large part by the social structures un which they live.  Machismo reigns strong and many women start having children between 14 and 16 years of age, becoming financially dependent on their husbands.  While by no means the rule, in many relationships, women are treated as second class citizens and ruled by their husbands.  Domestic violence is prominent.  I have met several young women this week whose husbands do not let them leave the house without them, depriving them of what we know to be a fundamental human necessity for happiness – to socialize and form bonds and friendships with family and peers.  I met one women who we tried urgently to get to go to a nearby for an abdominal ultrasound who would not go because her husband was not home.  I met another woman who we treated for sexually transmitted infections who was trying to extricate herself from an abusive husband who also maintained two other families.  Many of these women certainly meet the DSM-5 criteria for major depression however their depression is so intimately tied with their social factors, their sometimes abusive relationships, their role as mother and keeper of the home, and their social isolation.  Individual psychotherapy is not available.  But through the clinic and through the support of the local physician and PIH, the community tries to combat this epidemic.  Community health workers visit these women weekly.  Support groups and women’s basketball teams try to combat social isolation.  The physician supports them with medication and monthly medical appointments.  

Rural Primary Care in Chiapas, Mexico

For the past week and a half, I have been in the community of Soledad, a small rural community in the mountains of the Sierra Madre in Chiapas.  The road up to Soledad is windy and unpaved and takes about 4 hours to navigate from the closest city.  Driving into Soledad, you are greeted by the expansive view of rolling mountains and deep red earth of the Soledad roads.  Here, I have been spending my days in the community’s health clinic, accompanying the Mexican pasante, or Mexican doctor recently graduated from medical school and completing a year of social service work as the community’s only physician.  The breadth of patients we see here is incredible from pregnant women to adults with chronic medical issues to neonatal sepsis to patients with schizophrenia.  The treacherous roads to the community preclude the entrance of ambulances and other emergency personnel and thus it is also the pasante’s job to be the first responder to local emergencies such as the fatal motorcycle accident this week that killed one young man and seriously wounded two others. 

Supporting Community Health Promoters in San Lucas Tolimán, Guatemala

Week 2

You can count the number of doctors in the town of San Lucas Tolimán on one hand, serving a population of approximately 35,000 people. At the Hospital Parrochia, there is one dedicated Dr. Tun, who remains on call 24 hours a day, 7 days a week, attending to emergency cases during evenings and weekends in his “down time.” Two nursing assistants remain in the hospital at all times, calling in Dr. Tun when cases become complicated. The nursing assistants are trained in many tasks, including placing IVs, cleaning and suturing wounds, and performing uncomplicated deliveries, including repairing lacerations as needed. 

The community health promoter program was established at least 10 years ago, with the assistance of a nurse Sue from the United States who lived in Guatemala for many years and designed the program based on an existing program run by a non-profit organization in the Petén region of the country. There are currently at least 24 promoters from at least 16 communities around San Lucas Tolimán. A few head promoters are paid through the Parrochia, receiving the equivalent of a little over US$300 a month. The remainder of the promoters are only paid if they participate in a nutrition and weighing project run by Dr. Paul Wise from Stanford. For each nutrition and weighing activity that a promoter takes part in, she receives about US$8. The large majority of promoters are women, with about 5 male promoters, including the head promoter Vicente, who was trained as a nurse.


There is only so much that one can do in a week, so our activities were guided by the hope of validating the work already being done, providing constructive feedback, and offering some additional training for the current health promoters.

Our first two days were spent observing and learning about the work being done in the communities, with each promoter coordinating and leading a weighing session for all the children in each community at least once every two months, plotting weight and height on growth charts, and providing additional support to children who fall off the curve. These children will receive incaparina (a nutritious supplement) as well as periodic visits from the health promoters in their home to see if the supplement is being used and if the child is gaining weight. Unfortunately, for many of the children who fall off the curve, their malnutrition is indicative of larger problems of extreme poverty, and many times the supplement is split among other family members who are hungry, thus making it difficult for the child to get the nutrition that he or she needs.

Other activities of the health promoters include periodic charlas, or educational talks, to community members, as well as the informal education that occurs in and around homes, among friends, among family members, and with others who may be curious or misinformed. During our time, we observed the health promoters working with community members to make shampoo out of natural ingredients, including a plant called escobilla and another called sabila (aka Aloe), with the key ingredient being an emulsifier called texapón that comes from the capital, as well as salt and a perfume. Shampoo is a public health intervention here because otherwise community members will resort to using an irritating detergent soap for their hair, causing seborrheic dermatitis and other problems.

Another day, we visited the health promoter Cesia as she and Vicente were giving talks about preventing accidents for kids at the local public school. Both Vicente and Cesia had a wonderful style with the students and quickly incorporated feedback that we offered into their work. For example, they incorporated teaching techniques of asking students to draw from personal experiences in order to understand and remember the material better, and they utilized visual demonstrations about how to carry scissors and other sharp objects. At the end of the lesson, we were invited to the front of the class to offer a lesson in proper hand washing and technique, with demonstrations and lots of singing of “Happy Birthday.”

Before our arrival, Vicente had suggested that the promoters would benefit from additional training in diabetes, so I had prepared a presentation with the basics of diabetes education – what diabetes means, how to recognize and test for diabetes, who to test for diabetes, and fundamentals of treatment for diabetes, which here primarily consists of metformin and glibenclamida (glyburide), in addition to lifestyle changes. 

It was interesting to give this presentation to two different groups of promoters – initially to the more experienced promoters (those who had been around since the start of the program and generally were older), then to the new group of promoters, who were recruited into the program over the last year. There was a marked difference between the two groups of promoters, which seemed to be related to the higher educational attainment of the younger group of promoters. While many of the older promoters struggled to read and write, literacy was a requirement for the younger group, and many had completed secondary school and were hoping to attain higher education. Consequently, the younger group seemed more engaged, participated more actively, took notes, understood the process of a role play, and gave feedback. The highlights of the training sessions were practicing with glucometers and engaging the promoters in role play activities, including modeling how to interview a patient. What was more difficult but valuable was teaching the promoters how to measure BMI and subsequently diagnosing several obese patients and many overweight patients, as well as finding a couple cases of uncontrolled diabetes among the promoters.

Friday was our day of consultas in a community more removed from San Lucas Tolimán, with very limited access to any reliable medical resources. Here we worked with the new group of promoters to see patients of all ages, with common complaints of chronic cough (?TB, ?inflammatory changes from chronic exposure to indoor fires, ?PNA), diarrhea and abdominal pain (?giardia, ?gastritis, ?worms), malnutrition, cataracts, poor dentition with cavities and infections, rashes, lacerations, and skin and soft tissue infections. We had basic antibiotic treatments, antiparasitics, some simple topical medications, vitamins, analgesics, and a few inhalers. We carried a few pregnancy tests, which were well used, as well as glucometers and point of care hemoglobin test strips. We could have used additional materials for basic wound care and probing, spacers for use with inhalers, additional topical corticosteriods, as well as antibiotic formulations that were more age appropriate (ie: tablets for adults, suspensions for kids). We purposely left behind medications for chronic medical problems, as the follow up and future access to these medications for these patients would be very limited. Consultas (aka medical missions) are often unsatisfying, as they are only touching the surface of the needs of a community. Nevertheless, doing the consultas with the promoters was a great way to make a training experience out of what otherwise may sometimes feel futile.

Saturday we observed and assisted in the diabetes clinic at the Hospital Parrochia, run entirely by the head promoter Vicente. The diabetes clinic is only open on Saturday mornings, with each patient visiting the clinic once a month, for a blood pressure check, weight, and fasting blood glucose check. The only medications available are metformin and glyburide, which are given in a one month supply at a cost of Q15 and Q10 for the visit. Vicente is fairly well trained in diabetes education, so provides a valuable service to the patients, although his grasp of medication management remains limited. Luckily, Dr. Tun is always only a phone call away, and usually within 10 minutes of the hospital.


What I have learned about successful community health worker programs is fairly simple and intuitive, but nonetheless often difficult to achieve and the tendency to cut corners when working with limited funds and pressing community needs is great. Nevertheless, with foresight, careful planning, and defining a realistic scope of work appropriate for the funds available, these programs can both empower and improve the lives of individuals in extremely resource limited settings.

Lesson #1 – Recruit for attitude, train to skill; however, a basic initial skill set is very valuable.
During our time in San Lucas Tolimán, we met with several amazing promoters whose dynamic nature and optimistic attitude would be difficult, if not impossible, to teach. These women asked the right questions, took their work seriously, displayed great compassion, and established immediate rapport with patients. They were hard working and not motivated primarily by external incentives of monetary reward or privileged status. These campeonas are crucial for any program to move forward, to overcome challenges, and to set the tone for the work of the group. Nevertheless, a good education cannot be underestimated. The stark difference between the young group of promoters (less experienced but better educated) and the older promoters speaks to the process of learning how to learn, how to process information, how to ask questions, how to record information learned for future review. These subtle skills make all the difference. Literacy at the very least is a reasonable pre-requisite for recruiting promoters.

Lesson #2 – Planned (and scheduled) follow up of patients is key.
The key advantage of community health promoters is that they are located in the communities where outreach is needed, that they come from these communities and thus are in a prime position to provide close follow up and compassionate, culturally appropriate seguimiento. However, follow up needs to be planned and expected within the scope of the project and the responsibilities of the promoters. Follow up should be scheduled.

Lesson #3 – The scope of the promoters’ responsibilities must be limited and defined, with clear referral mechanisms to a higher level of care as needed.
In order to provide adequate follow up and to offer high quality care, the scope of community health promoters must be limited to what they are adequately trained and equipped to manage. It is not reasonable to expect promoters to be a substitute for doctors, and a system should be set up whereby promoters can refer cases to the doctor when warning signs are noted or cases are unclear or complicated. The best run promoter programs seem to be the ones that focus on one particular health need and do it well. For example, the Paul Wise nutrition program has trained the promoters to recognize, diagnose, treat, and refer patients with severe malnutrition. Periodic weighings, feedings, and other educational activities are scheduled every month. Another program through the University of Virginia has focused on installing water filters in homes and providing public health education to the recipients of each filter, and seems also to be very successful. The scope of the project is very limited (providing safe and durable water filters), expectations of promoters and of clients have been set (every recipient of a filter must attend 20 one-hour educational sessions with the promoter about various health topics before they receive their filter), and close follow up has been scheduled (each filter recipient receives periodic home visits to see how the filter is working and troubleshoot any problems). After a few years in each community, the project moves on to another community, leaving behind the lasting effect of purified water and a population more educated about their health.

Lesson #4 – Incentives can make or break a program, but transparency is key.
Asking people to work without pay is not sustainable, not for individuals or for programs. Nevertheless, promoters are not immune from nepotism and corruption, so transparency of funds is important. If promoters are to be reliable, if they are to be “on call” and available at short notice, they should be compensated regularly, equal to the amount of work required of the job. Compensation should be fair, transparent, and consistent. Thus, a steady and reliable stream of funding is also key.

Sunday, March 15, 2015

Supporting Community Health Promoters in San Lucas Tolimán, Guatemala

Week 1

San Lucas Tolimán is a town on the side of Lake Atitlán with a population approximating 30,000-35,000 people. Over the past 15 years (after the signing of the Guatemalan peace accords of 1996), there has been decreasing violence and a slow increase in trust of government systems, which have helped to create paved roads, more reliable electricity, and internet in many towns. Children are vaccinated through government programs, with requirement of vaccination before official birth registration can be completed. Nevertheless, children suffer from severe malnutrition and are too frequently born with neural tube defects and cleft palate from folic acid deficiency in pregnancy. Domestic violence is common and few resources are available to women other than bringing a denunciation to the legal system. Obesity and diabetes are increasingly becoming a problem as the Tuk Tuks (local taxi system) have decreased individual physical activity, while a little extra disposable income has increased the consumption of sugary beverages like Coca Cola.

Upon my arrival to San Lucas, I found my way to the Hospital Parrochia, founded and run by the Catholic parish of Father Greg, who passed away several years ago, leaving the leadership and finances of the hospital in a bit of disarray. Nevertheless, Dr. Rafael Tun continues as the primary doctor for the hospital, on call 24 hours a day, 7 days a week, offering medical consults for children and adults, performing ultrasounds, delivering babies, and maintaining a small inpatient ward for simple emergency cases. As I learned on my arrival, he also welcomes four or five surgical missions each year, offering local patients operations in ophthalmology, podiatry, orthopedics, and gynecology.

The week that I arrived, a group of podiatrists and orthopedic surgeons had arrived, organized by Dr. Steve Miller, a podiatrist who has led many surgical missions around the world. To their credit, he investigates new partnerships carefully to ensure that follow up services will be available. At the Hospital Parrochia, a podiatrist from Seattle (Dr. Will) now lives full-time in San Lucas providing orthopedic and podiatry services, offering follow up care for post-op patients as well as assisting in case finding for upcoming missions.

I have never before learned so much about clubfoot, a relatively rare condition but neglected globally, with severe functional limitation of teens (pain, inability to walk) until corrected surgically (with a fairly substantial surgery often requiring multiple stages). But, if brought to care early (ie: first 6 months of life), clubfoot can be corrected without surgery, with simply a series of hard casts (the Ponseti method). However, getting infants to care is not easy, as there is significant stigma against any child born with birth defects, with claims of being possessed by evil spirits.

This week we will begin our work with the network of community health promoters in San Lucas. There are approximately 24 community health promoters, working in 16 rural communities surrounding San Lucas. The program has been set back by some corruption over the years (a few promoters were recently released from the program after having skimmed funds and donated goods for their personal benefit). Nevertheless, the majority of promoters, nominated for their leadership and integrity, are doing important work in communities with little access to basic medical resources and knowledge. The promoters were organized through Father Greg’s parish, with a head promoter named Vicente who works hard to keep the group going, despite lack of funds. Only promoters working with the vitamin project of Paul Wise of Stanford are currently compensated. More to come on our work in future posts.