Monday, April 27, 2015

Interns strike at MRRH, Mbarara, Uganda

April 27, 2015

Mondays on the wards here are always a little harried.  No one rounds over the weekend so come Monday morning you often find patients who were admitted over the weekend that little was done for, old patients whose care wasn’t progressed for two days, and beds that used to be filled with sick patients that are now empty.  Often no one knows what happened to these patients.  They either went home or passed away. 

This Monday (today) had the potential to be even more harried.  The interns went on strike at 5pm on Friday because the government has not paid their salary in months. Interestingly, at this government hospital, as with all government hospitals in Uganda, the interns are the only house officers who are paid.  Like in the United States, the interns are the workhorses at MRRH.  They admit patients in the emergency room, are on call overnight, and execute the orders that are written during ward rounds.  Without them, I was not sure how things would run given that even when they are there and working, patient care is often sub-par.

But, this Monday found the upper level residents and medical students rallying to take care of patients.  During post-take this morning, when we review patients admitted through the emergency room over the weekend, a single upper level resident presented the patients and discussed what she alone had done for them without the help of an intern.  She was calm, cool, collected and smiling after what had to have been a very busy weekend.  On the ward rounds, the medical students and nursing students stepped up to hang medications, consent patients for blood, and track down lab results – jobs usually completed by the interns.  Granted, things still fell through the cracks, orders still weren’t carried out over the weekend, and patients had still left the hospital without explanation.  But, this was no different than any other Monday here.  What was different was the pro-activity towards patient care.  Over the last few weeks I have felt that patient care often comes behind education, research, and the residents’ and attendings’ side jobs that they need to maintain to make ends meet.  But today the majority of residents and students seemed to be motivated self-starters and to be putting their patients first.

 It was refreshing to see.  Today speaks to the underlying devotion that these doctors have for their clinical work and their patients despite being pulled thin by a system that overworks them, doesn’t pay them well (or at all), and makes it difficult to deliver the quality of diagnostics and treatments that they know would be best for their patients.  Given these tremendous pressures, I have my fingers crossed that the clinical care system at MRRH can step up for what might be a months-long intern strike.  Perhaps more importantly, I hope that the attendings, residents, and students can maintain this Monday’s surge of motivation and accountability even when the interns return to work because this would have the potential to greatly improve patient care.  We’ll see what Tuesday holds…

Sunday, April 26, 2015

Promoting Best Anesthetic Practices in Ho Chi Minh City: Part 1

Hello readers!  I’m Jamie, one of the anesthesia residents at Massachusetts General Hospital in my final year of training.  I’m on a two week medical mission to Ho Chi Minh City, Vietnam, accompanied by attending pediatric anesthesiologist Dr. Denman.  We just finished the first week of our visit.  I have spent most of my time at Rang Ham Mat hospital, which specializes in oromaxillofacial surgery and dentistry.  We worked in a very busy two-room, three-bed surgical suite with a team of nurse anesthetists and one or two anesthesia attendings.  In contrast to many other medical missions, our goal for these two weeks was relatively unique: rather than bringing our own medical teams and performing a high volume of cases, we endeavored to make lasting and sustainable improvements to the existing anesthetic practices at Rang Ham Mat Hospital.  Our focus was therefore on educating anesthetists and anesthetists-in-training so that they may apply skills learned during the mission to their entire clinical practice.  We planned to work with the anesthesia teams on their regularly scheduled cases and help them find ways to improve their current processes.

Saturday, April 18, 2015

Sustainable echocardiography in Mbarara, Uganda

Good morning from Mbarara, Uganda!

I am just over halfway through my month at Mbarara Regional Referral Hospital (MRRH).  I have been having a hard time sitting down to write a first installment for this blog.  Despite having spent time here before, there is always so much to do, so much to think about, and so much to figure out how to express in words.

For this first post, I’ve decided to talk about brain drain as a way to express just some of intimately linked frustration and inspiration I feel acutely here.

Brain drain is a big topic and one that I want to address only on the scale of the echo lab at MRRH.  While the burden of disease here is swayed towards infectious disease, mainly HIV and TB, there is a remarkable amount of heart failure, too.  In the past, this was diagnosed clinically.  But a few years ago, MRRH received a Philips echo machine and in late 2012 and early 2013, a Ugandan doctor and a SEED volunteer used online courses and a textbook to teach themselves how to perform and interpret echocardiograms.  Using echo as a tool, they were able to elucidate the etiology of the heart failure burden amongst MRRH patients.  The majority of patients being referred for echo for “dyspnea” and “swelling” had normal echos.  But of those who truly had cardiac pathology the majority had evidence of diastolic dysfunction secondary to hypertensive heart disease, dilated cardiomyopathy of unclear etiology, and rheumatic heart disease leading to severe mitral regurgitation, mitral stenosis and aortic regurgitation.  What powerful data to have!  Not only did it allow providers to expand differentials of those with normal echo findings but it also allowed them to tailor heart failure treatment to the etiology of a patient’s pathophysiology.  What’s more, it provided information as to what conditions need to be addressed earlier in this community to prevent heart failure: namely hypertension and rheumatic fever.

But a big question remained, were the echo reads produced by these two doctors who did not have formal echocardiography training accurate enough? Could we extrapolate data on prevalence of heart failure etiologies from them? Could we base primary prevention programs on them?  If the answer was Yes, then maybe we could establish a solid echo lab at MRRH and prevent the already limited number of providers from leaving Mbarara for further echo training in far flung cities, many of whom do not return.  If the answer was No, then we had to go back to the drawing board to figure out how to make echo a sustainable tool in this community.

To answer this question, the two doctors who were doing echos here last year, a generous echocardiography attending at MGH, and myself designed a study to compare the echo reads between the two providers at MRRH and a board-certified echocardiographer at MGH.  While we await final results, the prelim data is encouraging.  Maybe all you need to make the majority of diagnoses is access to online courses, a textbook, and, of course, time and motivation!  Could this prevent the need to brain drain providers away from their community for more more formal echo training?

But, when I arrived back in Mbarara this year, the echo machine was mostly gathering dust.  The SEED volunteer had left after his tenure at MRRH and was back in San Francisco.  The Ugandan doctor who was doing echos last year had recognized the importance of echo and had gotten funding for further training in Kampala.  She is supposed to take a 5hr bus ride every Friday morning to MRRH to perform and interpret echos during echo clinic.  This does not happen consistently.  Last week she arrived at 12p for a 9a clinic and was only able to perform 10 echos before having to catch to bus back.  Rumor has it she likely won’t bring her skills back to MRRH when she is done with training.  It’s a shame and frustrating from the perspective of this privileged, and still sometimes idealistic, western resident.  But I also understand it from her perspective: she now has this powerful and profitable skillset that she can market anywhere, particularly in places where she is guaranteed a salary, which isn’t always the case in this government-funded hospital.  What’s more, I want her to be professionally fulfilled, challenged, to advance to the highest level of her ability, and to be compensated for it.  We all want that.

So how do we remedy that desire with the need for consistency and accuracy in the echo lab here? The answer to this question is where my initial frustration over the brain drain issue begets inspiration, creativity, and the resolve to ask more questions, find more answers, and work to implement sustainable solutions. Could mid-level providers who are more likely to stay at MRRH perform and interpret echos?  What is the best way to teach someone how do a good echo and interpret it accurately?  Based on the cardiac pathology in this community, is a more limited echo sufficient to make most diagnoses?  Would having a telemedicine link to board-certified echocardiographers as backup for difficult cases help at all?  Can we make staying at MRRH appealing to providers with a higher level of training?  These are the questions that get me excited, that make me realize that the frustrations and set backs eventually lead to renewed creativity and professional motivation.  These are the challenges that drew me to medicine in the first place and that get me jazzed about pursuing a career in global cardiology.  I am thankful that my very brief visits to MRRH give me the opportunity to get frustrated, get inspired, get creative, and reconfirm my career goals.

Sunday, April 12, 2015

Compañeros en Salud – a model for rural primary care in Chiapas, Mexico

Weeks 4-5

Laguna del Cofre

Today I arrived in Laguna del Cofre, a community in the mountains about an hour and a half from Jaltenango, named for a nearby rock in the shape of a chest surrounded by water. Approximately 2,500 people live in Laguna, all recent migrants over of the past 60 years, looking for land that could be cultivated. The primary crop is coffee, with a yearly harvest of corn that families store for their own use throughout the year. The town boasts of little crime, with a local legal system, whereby a nominated committee carries out sentences and issues jail time in the local jail, depending on the severity of the crime. A volunteer neighborhood watch program also patrols the community at night to ensure order. For example, if anyone is found walking around drunk on the streets, they are put in the jail for a day or two. Notably absent from the local law enforcement is any sanction around domestic violence, which remains common.

Mariana is the pasante I am working with, who started in the recent CES cycle in February. She is from the Distrito Federal de México (DF), and wanted to be in a rural site for her service obligation. However, the majority of rural sites have very little support and often also suffer from violence and crime surrounding narco-trafficking. At most of these sites, it is common to run out of necessary medications for your patients’ chronic conditions, thus limiting your ability to ask patients to adhere. Something as simple as a pregnancy test can be hard to come by. Some months, the Secretaría de salud will give you what you need, other months no. CES corrects this problem by supplementing the supplies that the Secretaría gives with supplies that the pasantes ask for, using a large portion of the CES budget to buy these medications and tests locally. Furthermore, CES provides a community of pasantes and supervisors, and access to the larger world of medicine and global health, making the experience much less isolated and demoralizing than it otherwise might be. CES also offers a degree of prestige to its pasantes and all pasantes graduate with a certificate in global health at the end of the year.

Mariana explained that there are many options for the servicio social (service obligation). Most sites are in urban areas, some are rural, and the focus varies from hospital medicine, to primary care, to research, to administration, to medical education. The concentrations and sites vary in popularity, in reimbursement by the government, and in hours and duties. While Mariana is effectively on call for emergencies at all times (and patients know where she lives), others at urban sites may only be required to attend 6-hour shifts during the week. These lighter options often appeal to those seeking to enter a residency program after their service year, as it provides time to study for the required entrance exam. Mariana, on the other hand, is not sure what she wants to do within medicine, and thus felt that this experience would be valuable. Most posts are paid to variable degrees and the rural posts may have slightly better compensation, to serve as a mild incentive. Certain posts are not compensated at all, with the incentive of being fewer hours, ability to stay in the city, etc.

Thinking about these options and the sacrifices that they require from pasantes, I appreciate the work that CES is doing, as it is attracting highly qualified and motivated individuals to difficult posts and making them positive experiences. There is something so fundamental about allowing a physician to do one’s work, to practice medicine to one’s full potential, to have the basic resources to serve one’s patients, all of which we generally take for granted in the U.S.

The work of the clinic

Our day starts at 7:30AM, with breakfast cooked by a woman who has been cooking meals for the pasantes in Laguna for the past few years. She receives about $3.50 a day for the meals that she provides, paid by the pasantes and other visitors who eat with her. Her husband has been away in the United States for the past 8 years, with intermittent communication by phone, and has not met their youngest son. He works in construction and sends money home, allowing the family to build improvements and additions to their home. Notably, despite the distance, she must ask for permission from her husband (or in his absence, from her in-laws) if she wishes to travel outside of the community or do anything other than the routine. He has recently been talking about coming home for a time, and she wants to know what sort of contraception she can use discretely, such that she won’t be left pregnant again with an absent husband and father.

At 8AM the clinic opens for the day, with some previously scheduled visits and many patients arriving in the morning to place their names on the schedule for the day. Mariana has created her own schedule template, giving herself 30 minutes for each appointment, with an hour designated for lunch, with the goal to end the clinic day at 4PM. However, inevitably we were seeing up to 25 or more patients each day, with many double bookings and additional patients showing up after hours. The clinic is open 6 days a week, from Monday through Saturday, with Sunday as a day of rest for the pasante, although Mariana uses the time to make home visits and attend to medical referrals for her patients.

The day to day medicine that we saw in the clinic was not unlike what you might see in Boston or any other primary care clinic: many children presenting with diarrhea and cough, with likely viral illnesses; otitis media, although with more cases of perforated tympanic membrane than I have seen in my time thus far as a clinician; many women with depression, with some very severe cases, exacerbated by “sad life syndrome,” a term coined by our former primary care chief at the Brigham, women who are struggling to make ends meet, who have seen children die, who are abused by their husbands, who have conflict with their in-laws (who are inevitably their neighbors), or who have developed post-traumatic stress from motor vehicle accidents or other calamity. CES has really done a wonderful job in improving the care around mental health for patients at the clinics it serves, with capacitation courses for the pasantes, who regularly use the PHQ-9 and GAD-7, as well as offer advice to patients on cognitive behavioral therapy strategies. Furthermore, the acompañantes (community health promoter) program that I will talk about later has a strong focus on mental health, in particular depression, and all patients in communities with acompañantes are given the option of being paired with a health promoter who will visit them on a weekly basis to check in and see how they are doing.

We saw a lot of chronic pain and headaches, much of it likely exacerbated by depression and stressful life situations, not unlike the patients that I see in my clinic in Boston. A lot of NSAIDs and Tylenol are prescribed. Opiates, thankfully, are not widely available. Mariana has the option of requesting amitriptyline and other neuropathic agents from CES, which I encouraged her to do for her patients with severe chronic migraines, likely fibromyalgia, and other chronic pain syndromes.

Dermatologic concerns were also common, many likely resulting from chronic unprotected exposure to sun, smoke, and other elements, with much pityriasis alba in children, military heat rash, melasma, post-inflammatory hypo- and hyper-pigmentation, verruca plana, and a few cases of likely scabies. Pterygium and cataracts were very common, as well as other eye complaints including possible cases of scleritis and glaucoma, with a major challenge being the difficulty in obtaining a medical referral, ie: to ophthalmology, and the difficulty pasantes have in performing a good fundoscopic exam with only the simplest ophthalmoscope, very brightly lit exam rooms, and little dedicated training to the exam.

CES on the whole has a reasonably well working system of referrals, with several recent pasantes who currently serve as the referral coordinators and advisors, accompanying patients to visits in Villa Flores or Tuxtla or San Cristobal, as needed. Nevertheless, the process is clunky, with patients often coming back to the clinic two or three times to bring necessary paperwork, ensuring their seguro popular (public health insurance) is active, getting their photo taken, etc. Furthermore, notes from the referral specialists are generally not available, and the pasantes must often rely on the patients themselves to discover what the specialist recommended. If they are lucky, the referral coordinators may have been present during the referral visit and can give a more comprehensive synopsis. Nevertheless, there is no place in the medical record or elsewhere for this information to be stored, so information gathered from referrals from prior years are often lost when new pasantes arrive. Moreover, there is some degree of unnecessary referrals that occurs due to the lack of diagnostic testing. For example, working up secondary amenorrhea and infertility can often be started by a primary care physician with a lab test for TSH, prolactin, timed FSH and perhaps progesterone and/or testosterone. However, these labs are so difficult to obtain that the best way to get this information is to refer the patient to a specialist in the city.

The clinic has done a reasonable job in promoting family planning, with the primary method being the one or two-month progesterone injection. Many women have also requested the implant, although Mariana is still waiting for the implants to come in. IUDs are occasionally used, although the only available IUDs are the typically less-desirable copper IUDs. Nevertheless, pregnancy tests are constantly on short supply, with no tests provided by the Secretaría de salud for many months. During my week in Laguna, we had several newly positive pregnancy tests, with one notable undesired pregnancy in a young woman currently studying for a professional degree without contact with the father, who was certain about her decision to seek abortion for the pregnancy. Not only would a pregnancy stigmatize her within her conservative Catholic community and family, but it would likely also make it difficult for her to complete her degree. Abortion, however, is a tricky topic as it remains illegal in Chiapas. In México, abortion is only legal in certain clinics within Mexico City, bringing many young women to the city for this purpose, if they are lucky to afford the trip. Others may turn to other methods to terminate the pregnancy. While we could not legally prescribe or refer our patient for the abortion that she felt was necessary, we did the best that we could to offer emotional support and guidance as she decided what her next steps would be.

We did see one case of suspected tuberculosis, with the unfortunate situation of lacking access to N95 masks or any sort of negative pressure or particularly well-ventilated room. As we learned during the CES course a couple weeks ago, the tuberculous bacterium thrives in cold dark places, and the warm sunny environment of the clinic was at least one thing in our favor. Pasantes apparently can request N95 masks from CES, but need to make the specific request. This patient had several bouts over the past year of “a severe cold,” with the past week of coughing with some sputum tinged with blood, as well as a 9 lb weight loss and night sweats. He had a notable lung exam with not only crackles and wheezing in the lower right lung field, but also striking bronchial breath sounds. The CES protocol for suspected TB is to obtain three induced sputum samples for AFB smear testing in Jaltenango (although the sensitivity is poor), and only if these are negative, then to refer the patient to obtain a culture, which is a more complicated process.

Other conditions that we saw: GERD, gastritis, hypertension, diabetes, MODY, BPH, osteoarthritis, pneumonia, likely bacterial gastroenteritis, pyelonephritis, vaginitis, abscesses, burns and falls, allergy, chronic urticaria, hematochezia, cirrhosis and more.

Home visits

During the course of the week in Laguna, we conducted several home visits to patients who had difficulty leaving their home due to age or disability, or who had missed follow up visits in the clinic for some other reason. The small size of the community makes such visits possible, but I also found striking the dedication of Mariana to make these visits happen, conducting them during off hours from the clinic, such as on Easter Sunday, her one day of rest. 

We visited a woman with severe rheumatoid arthritis who had been inadequately managed for years, who had been basically bed bound just months before. The day we visited her, she was up and walking around with only mild pain in a few joints. She had been started on methotrexate and prednisone a couple months ago, which Mariana now carefully titrates, filling a pill box for the patient every two weeks with the new regimen. With Mariana’s access to Up-to-date on her tablet (available through CES to all pasantes) she assesses treatment response at each visit with the validated Simplified Disease Activity Score. Her score continues to improve.

Our second home visit was slightly less satisfying, with greater push back from the patient regarding treatment for hypertension. She was an elderly woman with blood pressures in the 160/100 range, who is followed by an acompañante who had notified us that she had stopped taking her pills. She had been tried on both enalapril and amlodipine previously, taking only one pill before concluding that the medicine was caliente (hot), causing her stomach discomfort and diarrhea. At the same time, she accepted several medicines that her family bought for her over the counter in Jaltenango, including metronidazole and a natural herbal remedy. We tried mostly unsuccessfully to explain to her the nature of her disease and the risks of untreated hypertension. We encouraged her to try a new medication (chlorthalidone) that we assured her would be fría (cold), in attempts that she might accept it. The acompañante visited her later in the week to bring the new medicine, but she was away in Jaltenango with her family.

Our final home visit was perhaps the most productive, as it uncovered the fact the a young man with likely MODY (Maturity Onset Diabetes of the Young) had been injecting himself with insulin that was surely inactivated due to lack of access to a refrigerator or cooler. He had valiantly been keeping the insulin in a cup with water, in hopes to insulate it, but his consistently “hi” fingerstick glucose readings and severe symptoms of polyuria (urinating 10 times a night) and significant weight loss told a different story. He had previously been pegged as a patient who refused to take care of his health or accept his diagnosis, as he sent his wife to the clinic to pick up his meds on his behalf, and frequently missed follow up appointments. However, during the visit, it became clear that he didn’t really understand his disease or how his treatment worked. Over the next few days, we took extra care to visit him at home to check his fingerstick glucose throughout the day, as we administered active insulin to him from the clinic. The only insulin currently available is glargine, which is unlikely to control him adequately, as his post-prandial glucoses are consistently very high, despite now improving fasting values. However, we are making progress in a patient we had almost given up on.

Las acompañantes

There are ten acompañantes (community health promoters) in Laguna, women who were nominated by the community and selected by CES to provide additional support to patients struggling with chronic diseases, in particular depression, hypertension, and diabetes. Currently, only three or four CES communities have acompañantes, although the goal is to expand to all the CES communities. Each acompañante receives an incentive of a dispensa (box of groceries) at the end of the month. Although one might think this would cause less friction in the community than direct payment, the distribution is conspicuous and the acompañantes continue to meet friction from community members who have not yet received the benefits of the program.

Each acompañante follows about five to ten patients at a time, visiting patients in their homes on a weekly basis to see if they are taking their medications, assist with filling pill boxes, provide encouragement and education, and provide psychosocial support. The acompañantes fill out a short form every month indicating whether the patients are taking their medications as prescribed as well as reasons for non-adherence. The acompañantes meet with the pasante monthly to discuss difficult patients, problem solve, discuss changes to management or medication plan, and think creatively about how to provide the best tailored care to each patient.

All of the acompañantes complete a course designed by CES with a focus on depression with techniques in cognitive behavioral therapy and medication management. The course takes place over 10 or so sessions, lasting an hour or two each session. During the course, they are reminded what depression is, where it comes from, the importance of taking medications daily and having patience for the medications to take effect, and they learn techniques to improve self-esteem, to change negative automatic thoughts, to focus on positive thoughts and activities, to engage in medication and relaxation techniques. Many of the acompañantes themselves struggle with depression, and have started to use these techniques in their own lives, in addition to helping to counsel patients.

The course was initially designed to be directed at patients and has since been expanded to include the acompañantes. While informal evaluations have noted improvements in PHQ-9 scores and overall patient management, CES has not yet completed a formal evaluation of the project. The next step would be to design a sort of randomized controlled trial – pulling from a pool of patients with depression who wish to take part in the course, with half of these patients assigned to take the course this term and half of them assigned to take the course next term. The half that is not taking the course receives care as usual from the pasante in the clinic. PHQ-9 scores are already monitored for all patients during their monthly visits with the pasante in clinic. It would be a small step to gather this data in a more formal way.

The parteras

All of the communities where CES works have a system of parteras (local midwives) who attend to many home births. More recently, woman have started going to the hospital in Jaltenango for their delivery, and some woman have been opting for elective C-sections, as these are through private clinics that are thought to provide better care (although they cost a significant amount of money). The parteras have varying degrees of training and are paid for each birth attended. I have heard that the amount of money paid to a partera after birthing a baby boy is greater than that paid for a baby girl, presumably due to the value placed on the birth.

Last month, a baby arrived to Mariana just moments before it died, several days after it was born. The partera had told the parents at the birth that the baby did not look well, but did not instruct the parents to seek additional care or go to the hospital. Officially, the parteras are supposed to report all births to the pasante at the local Centro de Salud, such that the information can be reported to the Secretaría de Salud every month. However, very few parteras have any interaction with the community doctors. It seems there is some friction between the midwives and the doctors, perhaps because the midwives are competing with the hospital for business.

In order to improve communication, Mariana had the idea to call together all the parteras to talk about potential collaboration, including sharing of supplies, sharing of information (ie: videos about newborn danger signs, reminders about maneuvers to stop post-partum hemorrhage and to assist with difficult deliveries), establishing new protocols (ie: group B strep prophylaxis for all women with risk factors – ie: fever, prolonged membrane rupture, previous neonatal death, preterm birth), and encouraging parteras to refer their patients to the clinic for newborn and post-partum checks and to the hospital in cases of emergency.

Through an overhead speaker system in the community, we issued an announcement for all the parteras to come to the clinic in the evening for a meeting. One partera arrived, mostly because she was seeking supplies for her deliveries, such as gloves, sterile cord ties, and gauze. She assured us that it would be difficult to get the other parteras to come to the clinic. Nevertheless, with the names of the other parteras, it should not be difficult to reach out to each one individually over the coming weeks.

The auxiliares

Theoretically every Centro de Salud (rural health clinic funded by the state) should have a pasante and a nurse assigned to the clinic for one year as they fulfill their social service obligation. However, nurses are in short supply, particularly in this district, and nurses here are not obliged to fill the rural service positions that have great demand. Thus, many clinics such as Laguna run with only a pasante, and if they are lucky, they may have a community assistant called an auxiliar. The auxiliares are lay people from the community who are hired by the government to perform various tasks, including monitoring the fulfillment of Prospera (welfare) requirements, helping in the schools, and helping in the clinics. The current auxiliar in Laguna mostly serves the Prospera program, ensuring that patients show up to medical visits, community cleaning days, and other required activities. If patients miss an activity, their welfare check technically gets reduced.

Fortunately for Mariana, a young woman named Melanie has become a friend of CES, and is currently studying nursing one day a week in Jaltenango (a four year program). With the incentive of furthering her experience in medicine and perhaps obtaining a paying job in the future, Melanie has been an incredible help to Mariana in the clinic, registering patients, taking vital signs, and administering injections and point of care testing.

This week, we began a new system designed to improve the clinic flow while helping Melanie learn about medical management and increase her interaction with patients. We put together four intake forms, one for diabetes, one for hypertension, one for prenatal visits, and one for malnutrition. Melanie uses the forms to gather important information from patients during intake. For example, the form includes reminders to calculate BMI, to measure fingerstick glucose, to ask about medication adherence and check whether patients are taking certain key medications. At the end of the form is space for Melanie to work with the patient on developing patient-directed goals, for example to improve diet, increase exercise, lose weight, or take one’s medication.

Ideas moving forward

There is much to do within CES, much to help capacitate the pasantes, much to improve the flow of the clinics, and to improve access to medicines and supplies. In particular, the lack of access to point of care testing, or really any testing at all, has been a struggle for me, as we rely so much on labs and radiology in the U.S. This week, access to a few key point of care tests (hemoglobin, rapid HIV, pregnancy dipstick, urine dipstick, glucose fingerstick) was crucial to the care that we provided. A few additional resources could make a big difference, including heme-occult guaiac testing and a microscope to review urine sediments, stool samples, peripheral blood smears, and pelvic smears. Also, access to an EKG machine and debrillator would allow pasantes to better respond to emergencies. Additionally, as ophthalmology referrals are difficult to come by, helping the pasantes become more facile in the fundoscopic exam would be very useful. In particular, access to PanOptic ophtalmoscopes and dedicated training could combat some of the current challenges. Other hands-on training such as skin biopsies, joint injections, musculoskeletal exam, and techniques for improved pelvic exams could all be very useful additions.

Friday, April 3, 2015

Compañeros en Salud – a model for rural primary care in Chiapas, Mexico

Week 3

Compañeros en Salud

The Mexican branch of Partners in Health, also known as CES or Compañeros en salud is based in Jaltenango, surrounded by a number of rural communities in the sierra of Chiapas, where new Mexican medical school graduates (pasantes) are placed to fulfill their one year obligatory service posts. Currently there are 10 pasantes in 10 communities, each about 1 to 3 hours from Jaltenango on rough rugged roads. CES maintains a relatively lean budget, using it to supplement the government support of the pasantes so that they do not need to rely on the goodwill of community members to host them free of charge (the government provides US$150/month and CES effectively doubles this stipend). The budget also supports several supervisors, all of whom recently completed the CES pasante program, who travel between communities to support, precept, and teach the current pasantes. Many of these supervisors will be living in Boston in the upcoming years to complete master’s degrees in global health and public health. Additionally, the budget allows CES to supplement the often inconsistent and meager medication supplies provided by the government, and to help ensure that the pasantes have the basic medical equipment they need to provide care. Several short and long-term volunteers also support CES, mostly from the U.S., with a medical director who recently graduated from Brigham and Women’s medicine residency program.

My role over the coming weeks is to offer support to several pasantes in two communities (Laguna and Monterrey), accompanying during visits and providing feedback and suggestions throughout the course of clinical visits. A major goal of the CES program is to improve the training of Mexican doctors, through direct clinical practice and observation, as well as through monthly didactics that take place in Jaltenango. During this month’s course, we discussed topics of biopoder (biopower), nutrition, diabetes, and tuberculosis. One pasante presented an M&M case (morbidity and mortality) of neuroleptic malignant syndrome in a man with schizophrenia and another presented a morning report style case of possible Scarlet Fever in a child. A humanistic curriculum session to discuss the emotional aspect of medicine was also included.

Overall, the program seems to emulate some educational aspects of a U.S. medical residency (although on a much smaller level), while providing extra support to pasantes who otherwise would have a very isolated and resource-restricted experience trying to care for the local community. Hearing pasantes talk about the various urgent cases that they have managed, you realize that with a few key resources and a good understanding of when to triage to a higher level of care, there is a lot that can be done in a very resource-limited setting. Some of those key resources include materials to start and maintain IVs, fluids, oxygen with nasal cannula, oral and nasal airways with ambu bag, suturing materials, local anesthetics, saline flushes, bandages, tourniquets, inhalers and nebulizers, steroids, antibiotics, anti-hypertensives, insulin, aspirin, and other key medications.

One thing that I will have to get used to in the coming weeks is the difficulty in obtaining laboratory work. In the U.S., when you start someone on anti-hypertensives, in particular on diuretics and ACE inhibitors, a basic chemistry panel is a must to ensure that our patients are not becoming hyper or hypokalemic. In the communities, however, the nearest lab may be over 2 hours away, a trip that many patients may not be able to afford or fit into their week. In the U.S., we order TSH screening tests like candy - if someone has constipation or fatigue or palpitations, failing to order a thyroid screening test would be neglect. However, in order to get a TSH in the communities, one not only has to travel to the hospital in Jaltenango, but one also has to pay an additional fee to the lab. For this reason, it is so important to be critical about what labs are actually likely to change management in a significant way. More on patient care in future posts, as I have yet to spend a significant amount of time in any one community.

Finally, one last observation that I have been struggling with is the fact that none of the pasantes are actually from Chiapas. The large majority of pasantes have graduated from one of the top Mexican medical universities, in particular from Instituto Tecnológico de Monterrey. On the one hand, CES is able to work with the best medical graduates to build their potential to function at a higher level and in that way bring up the overall quality of medical care in Mexico. These pasantes will go on to complete residency programs in various specialties, some will pursue degrees in public health and look forward to a career in research and program development, others will remain as general practitioners and work to educate the upcoming classes of pasantes after them. These individuals will be leaders within the Mexican medical system in the coming years. One day, CES can and should be run by Mexicans, who have a stake in improving their own health care system.

Nevertheless, Chiapas remains one of the poorest regions of Mexico, and the patients being seen in the community clinics are very different from the pasantes themselves. The difference in class and education and culture are marked. In some ways, the pasantes are almost as gringo as we are (of course, not really, but sort of). Some of them love camping and REI and American films as much as we do. Yet, the experience of serving these rural, impoverished communities must be striking and indeed quite impactful. In the U.S., programs like these (Teach for America, Americorps, National Health Service Corps) change the way individuals understand the inequalities in our society, and may help to change perspectives and policies down the road. Of course, what is ultimately needed is development of educational and employment opportunities and upward mobility for people in Chiapas. The goal is to have doctors from Chiapas who will stay in Chiapas and who understand better the needs of the community. What I have been told is that the universities in Chiapas are not good, and for this reason, CES has not had pasantes from Chiapas. However, how might the program change if these folks were sought out and recruited and mentored to their full potential? Certainly there would be challenges, but it would also bring a richness and perhaps greater accountability and responsiveness to community needs.

The CES Radio Show

Every Sunday morning, one of the CES supervising physicians Héctor invites a guest speaker to a local radio station in Jaltenango (broadcast to many of the rural communities where CES works) to discuss a topic relevant to public health. Previous topics have included nutrition, alcoholism, diabetes, depression, antibiotic overuse, UTIs and others. This Sunday we talked about hypertension, and I was the “expert.” Some common myths that we covered included the idea that hypertension could be caused by a susto (a scare), an idea that many people in Guatemala also have regarding diabetes. Other myths included the fact that medicines for hypertension are caliente (hot), meaning that they interact with various vitamins and herbal remedies and may cause gastritis or other problems. Many people buy these medicines over the counter, sometimes without the evaluation and prescription of a doctor, and we had a caller who asked if I could prescribe something for her over the radio for her headaches that she felt could be caused by hypertension. (Of course I said no). Other people are prescribed anti-hypertensives, then stop taking them because they are told the medications interact with alcohol and they do not wish to abstain from alcohol. Others stop taking their meds when they start to feel better, not understanding that hypertension is a chronic disease. Still others spend their money buying medications from pharmacies in town, believing that the free medications offered at the community clinics must be worse because they are free. We addressed these concerns, while also discussing the enormous burden of hypertension in the world (9 million 400,000 people die from complications of hypertension every year) and in Mexico (according to a 2012 survey, 1 in 3 people live with hypertension, yet only half of them are aware of their diagnosis, and only half of those are controlled). Finally, we spent a good amount of time discussing dietary, exercise and other lifestyle changes to prevent and treat hypertension at the most basic level. We ended the radio show with one of my favorite songs by Marc Anthony  :)

On Government Programs

Later in the day, Héctor took me on a jog through Jaltenango’s Ciudad Rural, a government program throughout Chiapas to build sustainable communities for low-income families. The community in Jaltenango was built after an earthquake destroyed the previous settlement, and is quite lovely. There are 600 brick homes with tile floors and enough space for a family, with a lawn in the front with space for a garden. There is a central garden where theoretically vegetables and fruits can be grown for local consumption (not sure whether this is currently in use, as it was too dark to see the gardens). There is a church. There is a central park/plaza for taking walks, sitting, jogging. There are streetlights powered by solar panels, which unfortunately cost too much to replace when they break (10,000 pesos), so at least half of the lights are out. Unfortunately, of the 600 homes, at least a third or more of the homes are currently unoccupied, as people have had to move out of the community to find work, as there are few job opportunities in the surrounding neighborhoods. Many of the residents work as mototaxistas, shuttling people around town in hybrid motocycle / taxis for 5 pesos (~33 cents) a ride. The homes were gifted to families, and thus are technically owned by the families that originally settled in the community. However, it seems there is some barrier to selling the homes if a family must move out, so the homes lie unused when a family can no longer support themselves on the meager job opportunities available in Jaltenango.

During our jog, Héctor explained to me a bit about the Mexican public health care system, explaining concepts that had been brought up during the CES course for pasantes about biopoder (biopower, or the systems and hierarchies that affect people’s health on a broad institutional level). For example, all Mexican citizens have access to universal health care through Seguro Popular (the health safety net insurance for those who don’t qualify for other insurance programs through employment and income levels), with a list of at least 250 preventive and other medical conditions that are covered fully by the insurance. These include things like vaccines, diabetes and hypertension care, prenatal and postpartum care, and many common urgent care conditions like parasites, respiratory infections, ulcers, dengue, etc. The difficulty becomes when the government and their body of experts must decide which conditions are covered and which are not. Theoretically, the most cost effective interventions for common conditions are covered, while less cost effective interventions for rarer conditions are not. Through decisions like these, the government is able to maintain lower overall health care costs, with approximately 6% of the GDP dedicated to health expenses (compared to 17% in the U.S.). Nevertheless, it is difficult to place a cost on the value of a life and decide when it is not cost effective to try to save a life. Also, which conditions are covered may be influenced not only by objective measures, but likely also by politics and who is making the decisions.

A third program that is quite interesting and again partially problematic is the program now called Prospera, previously called Oportunidades. Effectively a welfare program, the payments are however tied to requirements such as attending prenatal appointments, following up with chronic disease care, ensuring that your children attend school, etc. Payments vary depending on income and family size, on the order of US$60-$100 monthly. The program becomes problematic when you think about the power that it gives to those supervising visits, who determine whether or not an individual has completed the requirements and thus qualifies for payment, and when thinking about the barriers to an individual or a family in fulfilling the requirements, and the fact that the most vulnerable individuals will have the most difficulty completing the requirements.