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.

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