Building mental health capacity in rural communities

Katherine Schiavoni, MD, MPP

Resident in Medicine and Pediatrics

PGY-4

May 11, 2019. 

I am nearing the end of my one-month rotation with Compañeros en Salud / Partners in Health in Chiapas, Mexico. As mentioned in my last post, I am working a resident mentor in several rural community clinics in the Sierra Madre region of Chiapas state.

During my month in Chiapas, I have had the opportunity to learn more about the mental health program developed here by Compañeros en Salud (CES). Mental illness, particularly depression, is increasingly recognized as an equal concern in poorer areas as it is in well-resourced settings. The World Health Organization estimates that depression will be the leading cause of disability worldwide by 2030. CES trains its social service year physicians (pasantes) to deliver mental health care in the rural primary care setting. The pasantes receive training by the mental health team, including a psychiatrist and psychologist, to deliver brief structured interventions in the clinic using motivational interviewing and cognitive behavioral therapy techniques. They also receive training in pharmacotherapy and are able to initiate medications when needed.

This month, I witnessed several beautifully conducted visits for depression. In one consult, a woman in her mid-30s presented for headaches and pain in her neck and arms. The pasante, Alex, asked thorough questions about her physical symptoms and listened to the ways in which the pain impacted her. After about 10 minutes, he gently asked, "and how is your mood? Is there anything difficult going on in your life right now?". She began to cry and discuss how her husband's alcohol use is impacting her children, and how she feels guilty about what they have experienced and hopeless about the future. Alex provided psychoeducation about depression, and about the effects that trauma can have on children's behavior. They engaged in brief motivational interviewing about problem solving strategies and agreed to meet again, including with her children, next week. He also prescribed an NSAID for the headaches. Upon leaving, the patient looked visibly relieved.

Letrero Community

In collaboration with the mental health team, pasantes also treat patients with schizophrenia. Before CES began working in Chiapas, many patients with psychosis were confined to small rooms, or chained in their homes because families had no other options. The clinicians on the mental health team can now visit these patients in their homes and pasantes can provide oral and injectable antipsychotics. In one of our consults, woman in her late 20s with schizophrenia presented with her mother for a follow up visit. The patient wore dark sunglasses and spoke at length about her concern that there was a microchip implanted in her brain. Despite her delusions, she has been functioning at home and able to sell foods with her mother as part of their business. Her mother displayed a high level of understanding about the nature of her daughter's disease. The patient was moderately controlled on risperidone, and we made plans to coordinate with the mental health team’s psychiatrist for further titration of her medication. Many challenges remain, but the quality of life for patients with psychosis is generally improving.

Compañeros en Salud is now in the process of training mental health community health workers, called acompañantes, similar to their existing programs in chronic disease and maternal health. The acompañantes will receive a training course in recognizing mental health conditions, providing psychoeducation and talk therapy. They will also follow patients longitudinally who are being treated with pharmacotherapy by other members of the team. A large part of their role will be to help reduce stigma and increase education about mental illness in the community.

The process of building mental health capacity is ongoing, but there have been tremendous gains already. It has been a privilege to see the amazing work happening and to be part of the care of patients at the community clinics.

Doctor as teacher in rural Mexico

Katherine Schiavoni, MD, MPP

Resident in Medicine and Pediatrics

PGY-4

May 2, 2019

¡Saludos! I am about half-way through a one-month rotation with Compañeros en Salud / Partners in Health in the rural Sierra Madre region of Chiapas, Mexico. I am fortunate to return to Chiapas after rotating with Compañeros en Salud (CES) as a resident mentor last year. During my rotation this year, I am visiting 3 different clinics in the communities of Reforma, Capitán, and Letrero.

I am in my final year of medicine and pediatrics residency, and next year will be staying in Boston to practice primary care at a community health center and do a fellowship in population health. I am interested in social determinants of health and caring for adults and children across the life span, particularly in Latino communities. My away rotations in Chiapas have been a tremendous opportunity to learn about the people and culture of this region, understand the health care system in rural Mexico, and develop skills in delivering care in a low resource setting. At its core, rotating with CES also provides great learning in broad spectrum primary care.

Compañeros en Salud (CES) works collaboratively with the Mexican Ministry of Health to support 10 rural clinics in the Sierra Madre region of Chiapas. The clinics are staffed by a social service year physician (pasante), nurses, and community health workers (acompañantes). The primary role of a resident is to see patients with the pasante and to provide mentorship and teaching. CES provides additional teaching, supervision, and clinic supplies/medications beyond what would typically be offered in the social service year. The organization also offers an ever-growing network of mental health, maternal health, and chronic disease services for patients, as well as access to secondary and tertiary care through its referral program.

Sunset on the square in Reforma community 

I have been particularly impressed by the ability of pasantes to serve as teachers to their patients and clinic communities. During our clinic consultations, we spend a significant amount of time talking with the patient about our assessment of their condition and proposed treatment plan. There is significant emphasis on explaining a diagnosis in understandable terms, and relating treatments to familiar touch points, such as taking vitamins. The pharmacy is also located in the clinic space, and therefore pasantes can teach patients about their medications with the actual pills they will take. Particularly for patients who cannot read, it is very helpful to show them the pills, explain the purpose of each, and how to take it. The visual learning seems to improve understanding and adherence. Patients also bring back the physical boxes of medication for follow up visits and medication reconciliation.

The pasantes also lead group visits (consultas compartidas) for chronic conditions, including diabetes. I was able to participate in several diabetes group visits with the pasante Irving at the Reforma clinic. One of the groups had been meeting monthly for a year. During the groups, Irving taught about 1 topic per session such as healthy diet, medical complications of diabetes, or myths about medications. The patients also supported each other with suggestions about dietary changes they had made, or reframing misconceptions. For example, it is often believed that using Insulin will cause blindness and therefore patients are reluctant to use it. Two of the patients in this group had been on insulin for several months and are now doing well, which has changed the perception of other group members and made them more amenable to using insulin if needed. It was inspiring to watch the mutual respect and encouragement in the group.

Doctors in CES have developed a direct role in teaching patients about chronic disease management in a way that is appropriate to the cultural context and health literacy. I look forward to using more of these techniques in my own clinic in Boston!

Capacity Building in Rwanda.

Jessica Crothers, MD

Fellow, Medical Microbiology, Brigham and Women’s Hospital

PGY7

May 22, 2019. 

Working in the lab in Kigali, Rwanda

I went into medicine with all sorts of ideas about what my career would look like, not many of them very usual. Global health, anthropology, art therapy, women’s advocacy, integrative care, and innumerable other things that seemed to pop up by the month. I’ve always been like that, interested in most things that come my way.  But then I started the long road of medical training and I began to meet the neigh-sayers. Your career can’t look like that because of reimbursement. That sounds nice, but you don’t get that much time with patients. Academic careers won’t allow you to take that much time for international work. I began to feel trapped by the confines of real-life medical practice, but I always found ways to keep my secret career dreams alive.  My path rambled, as they all do, and I eventually found my way into a fellowship at BWH where I was introduced to the COE. I began going to dinners, symposiums and even applied for a travel grant. Through the Center I have met physicians with careers that look even more diverse and interesting than the dreams I had been quietly keeping alive. And, more importantly, I began to see how to make my dreams become reality.  The COE serves a powerful role as connector, facilitator and dream builder. I am incredibly grateful for the opportunities it’s afforded me, and the people it’s brought into my world. The career I once dreamed of is finally taking shape.

Global Health Symposium

Catherine A. Colaianni, M.D. 

Resident in Otolaryngology 

PGY 4

May 14, 2019

As an otolaryngology resident with an interest in global surgery and ethics, I am always on the lookout for thoughtful programming related to these topics. To that end, I was thrilled to hear about and apply for admission to the Global Health Symposium this October, sponsored by the Partners Center of Expertise in Global and Humanitarian Health. I came with an intention to learn more not only about the practicalities of designing a career serving abroad, but also to identify specific mentors who have had success pursuing careers and research in this arena. Therefore, in particular, the panel discussion held during the symposium was especially useful for me. The panels were broken out by specialty, and so I joined a group of surgeons and anesthesiologists to discuss how they had found – or, put more accurately, designed – their career paths in global and humanitarian health. The outcome of this discussion has changed the way that I’m thinking about my next academic and career steps. I’m in the midst of applying for fellowship in head and neck surgical oncology, and as a result of the panel discussion during the Symposium, I am specifically targeting institutions that have a history of global and humanitarian health work, as well as longstanding teaching relationships with institutions abroad. I feel that this will best position me to be able to contribute in meaningful ways, and to continue to identify surgical mentors whose interests align with my own. 

The symposium was also helpful in alerting me to the existence of travel grants for which residents are eligible. After learning about it from one of the panelists, I applied for and received the American Academy of Otolaryngology-Head and Neck Surgery Humanitarian Travel Award to partially fund a ten-day surgical mission trip to Conakry, Guinea with the Mercy Ships organization. Having this funding significantly lessened the trip’s personal financial impact that I had been preparing for, and as a result, I am now looking into returning in the next year or two to build on my experience. Having access to organized experiences such as the Global Health Symposium during residency training is crucial – it has helped me think about being creative when pursuing academic funding, making connections early, and identifying career mentors who share my enthusiasm for global surgery.

International Clinical Elective in Palliative Care in Kampala Uganda - Part 2

Kayla Wolofsky, M.B.B.S. 

Fellow in Hospice & Palliative Care at MGH 

PGY 4

May 10, 2019.  

Everyday at Massachusetts General Hospital we see people who are suffering and terminally ill. I was recently asked to reflect what made providing palliative care in Uganda different and at times more morally distressing. This question is best answered by reflecting on my last two weeks in Uganda.

During the second half of my elective I had the privilege of visiting patients in their home and providing palliative care. I worked with Hospice Africa Uganda (HAU) visiting patients in their homes in Kampala and the surrounding area. I later spent time in Naggalama, a small town in the central region of Uganda, working with nurses and nursing assistants at the St. Francis Naggalama Hospital visiting patients in their villages. It was such a privilege to be invited into the homes of these patients and their families.

Daily transport carrying our  medications and
supplies for the day 

At HAU our day would begin with prayer where “hymns were sung, drums were drummed” and daily announcements were made before we tended to some of the poorest of the poor with life limiting illnesses. The team would then meet and discuss the patients we planned to see that day. We would all then pile into a white van, alongside the much needed medications and supplies and begin our long commute in Kampala traffic to bring clinical care to patients in their homes. 

Beautiful drive between home
visits through the Countryside

In Naggalama this meant driving along long stretches of beautiful back roads in the Ugandan countryside.

During my visits we encountered complex ranges of psychosocial problems, diseases, cancers, and very poor living conditions. Many of the homes were made from homemade brick or mud covered with roofs made from thatched-grass or iron. Most homes had  plastic mats that covered the mud made floor or homemade rugs to protect the hand cut wood floors. Walls were lined with beautiful fabrics and the one large room that existed was separated by a curtain to make additional rooms.  The homes were frequently decorated with family heirlooms, biblical posters, and some even had a TV or radio. Unfortunately, some homes were often only large enough to provide shelter and home visits were had outside in the field on the ground or on wooden benches.  

Home with with the team from
St. Francis Naggalama Hospital 

There was no running water in many of these homes, and the nearest water well for many was at least half a mile away. Many of the patients we saw were so critically unwell they were unable to get water or food and  were very dehydrated and malnourished on our arrival.

What made this elective challenging, was being aware that if there was better access to health care and medications we could minimize their suffering. Despite the team's best efforts they were limited by lack of medications or resources. However, despite this very difficult path, where access to even the most basic medical care and treatments are a luxury,  patients, their families and communities continued to demonstrate their resourcefulness and continued to have a unwavering positive attitude. My past month in Uganda was such an amazing and unforgettable experience. I am grateful for the staff, volunteers and those that made this experience possible and to the patients who shared their story.

Diagnosis of Mycobacterial Infections in Rwanda

Jessica Crothers, MD

Fellow, Medical Microbiology, Brigham and Women’s Hospital

PGY 7

May 8, 2019

Entrance to Butaro Hospital in northern Rwanda

Tuberculosis is the leading cause of death from a single infectious agent worldwide. The WHO estimates that 10 million people developed active tuberculosis in 2017 and that 1.5 million of them died. Compounding these staggering statistics, Mycobacterium tuberculosis (MTB), the causative organism of tuberculosis, can be one of the most challenging diagnoses in clinical medicine. Notoriously difficult to culture, MTB often takes 4-6 weeks to grow in laboratory conditions and false negatives are common. Histologic visualization of the organism is similarly challenging, requiring special stains, time and experience as infections are often impressively pauci-bacillary and difficult to establish. Additional diagnostic strategies have been implemented to enhance timely diagnosis and therapeutic intervention, particularly in resource-limited settings in which patient follow-up can be difficult. These include AFB smear review and molecular (PCR) testing directly from patient specimens (GeneXpert, Cephied).  The multimodal and time-consuming approach needed for accurate diagnosis, often pushes physicians in high prevalence regions towards presumptive diagnosis and treatment as an important tact for both patient care and epidemiologic containment.

Land of one thousand hills, Rwanda is lush and agrarian

Rwanda suffers high rates of tuberculosis, particularly in the context of HIV-infection. Diagnosis often includes clinical assessment, PCR testing with GeneXpert, histologic evaluation and less frequently culture, which is only available at the national reference laboratory. Not uncommonly, surgical pathology specimens are consistent with a tuberculosis infection, revealing granulomatous or suppurative inflammation, but are unexpected and thus no culture/PCR or AFB smear was performed. In illustration of this, a young woman presented to CHUK with primary infertility. An exploratory laparotomy was performed and she was found to have bilateral hydrosalpinx. Histology revealed diffuse granulomatous inflammation and while MTB was suspected, it could not be confirmed. She was initiated on 9+ months of antituberculousis therapy, no small task. In truth, she could have MTB. But she also may not. Her disease could be due to gonorrhea, chlamydia or immunologic dysfunction. But without the appropriate diagnostic tests, she must be treated statistically: granulomas in a high-burden region = tuberculosis.

As countries like Rwanda continue to build their medical infrastructure and capacity, scenarios like this can be focused. Without too much technical burden, special chemical stains (AFB/Kinyoun/Ziehl-Neelsen) can be performed on surgical specimens to enhance diagnostic precision. Visualization of acid-fast bacilli in the context of granulomatous inflammation is much more likely to represent true tuberculosis infection and warrant intensive therapy. To that end, we plan to help develop a protocol and procedure for AFB staining of paraffin-embedded histologic tissue sections in the CHUK laboratory while here in Rwanda. I brought supplies in my luggage (which luckily didn’t result in tie-dyed clothing!) and we began staining. It was challenging, not straightforward and of course, took ten times longer than expected. Working in new environments with language and cultural barriers can often be frustrating, and I felt it today, but these experiences also offer the promise of a special kind of success. When you overcome small differences, find common ground, and work towards a common goal, the collective success you feel is so much greater than if it had been easy.  The first day, it took us 2 hours to even start staining, just finding the proper glass wear and reagents was challenging.  But, by the end of the week, a new tool was added to the local armamentarium.

Of course, the disease encountered in this particular young woman could be MTB, it could be gonorrhea, but it could also represent a different type of mycobacterial infection; like M. abcessus or M. chelonea. Such diagnoses, however, require identification by culture or genetic sequencing. We discussed and taught about the molecular and culture differences that can be encountered in these infections, but test implementation may be a task for another day!

Capacity Building in Rwanda

Jessica Crothers, MD

Fellow, Medical Microbiology, Brigham and Women’s Hospital

PGY 7

May 8, 2019

Reviewing cases at the multiheaded microscope at CHUK in Kigali, Rwanda

The plane doors open and I step down the portable staircase onto the tarmac.  The warm, humid air surrounds me. It feels vaguely familiar, like a strange homecoming. I have never been to Rwanda, but after 11 years of medical school, residency, and fellowship, I have once again donned my red backpack and reentered the world. More than a decade ago, I wore this same backpack across Asia, South America and Europe. I had wanted to step away from the comforts, contacts, and safeties of home and see if the world would catch me; it did. As many fellow travelers can attest to, the world has a strange way of offering you just what you need if you are open to receiving it. It’s not always what you think you want, or the easiest road, but the universe, and the people in it, tend to provide to those with the faith to leap. I had leapt and was rewarded. New friends, new ways of seeing, new experiences, beautiful places, scary places, stories to tell. But, I had wanted to “help”, to participate, to add to the experience of humanity, and I quickly realized that desire was not enough. I needed something – a skill, knowledge, resources - in order to be useful. And so I ultimately returned home and began the long, arduous path of medical training. Now, 11 years later I return.

Histology slides processed at CHUK laboratory 

Armed with new knowledge, experience and an ever-increasing folder of power point presentations, I come to Rwanda to help train their next generation of pathologists. I come with my mentor, who began coming to Rwanda a decade ago (about the same time I left the road, he began to forge the one that I now join). At that time, the country was home to only two pathologists, both foreign-born. Many diagnoses went un-made, specimens un-grossed, slides un-reviewed. The push was for “tele-medicine” and international consultation, but the decision and motivation existed to increase local capacity and a local pathology residency training program was born. Now, 17 Rwandese pathologists practice in Rwanda! The residency program has more than a dozen trainees. They eagerly bring us interesting cases, hoping to confirm difficult diagnoses and proudly sharing exciting ones. They show us new developments: a new cryostat, grossing facility, histology capabilities. The day has come: Rwandese are providing high quality medical care for Rwandese.

New grossing bench at CHUK!

Rwandan has suffered more than most and its story is complicated, but the present reality is inspiring. Ravaged by a holocaust only 25 years ago, the country has made incredible progress in rebuilding and rebonding. The residents we teach are children of this holocaust, having lived through it as toddlers and small children. Each has their own story, but all are survivors. At first it seems abstract, but as I get to know each them, it becomes real, personal, and strangely inspiring. After so many years of slow, careful, difficult building, we are all in a place to finally create the future we believe in.

International Clinical Elective in Palliative Care in Kampala, Uganda Part 1

Kayla Wolofsky, MBBS

Fellow, Palliative Care at Massachusetts General Hospital 

PGY 4

Inequality of access to palliative care is one of the greatest disparities in global health care. In Uganda, the provision of palliative care services started in 1993 with the establishment of Hospice Africa Uganda by Dr. Anne Merriman, who I had the honour of meeting on my second day in Kampala.

A signed copy of Dr. Anne Merriman's novel "Audacity to Love: The Story of Hospice Africa: Bringing Hope and Peace for the Dying." 

Hospice Africa Uganda is licensed by the National Drug Authority to import morphine powder and reconstitute it into liquid form. This is done by Ugandan health workers who are trained to mix the powder with water to create oral morphine ( which is then poured into recycled, clean plastic bottles).  There are two different strengths of oral morphine available, 5mg/5ml and 50mg/5ml. 

Liquid oral morphine in two different strengths.
Green: 5mg/5ml and Red 50mg/5ml.

The International Narcotics Control Board determines how much opioid each country can receive per year. These estimates are based on a country's own prediction of its pain treatment needs for the projected year using data consumed in the previous year. Thus a country that consumed low amounts of opioids the previous year are allocated a low of opioids the following year.

I came to Kampala to learn about symptom management in a resource limited environment. I spent the first two weeks of my elective on the palliative care consult service at Mulago Hospital 

Coming to Uganda, I anticipated medications to manage patient symptoms would only be medications on the essential medication drug list. For pain management this would include: Tramadol, Codeine, Pethidine, and Morphine (oral and IV). I knew pain management would be challenging at times, but had hopes that with access to morphine, a medication we take for granted in North America, pain could be better controlled with the assistance of the palliative care team. However, despite being on the essential medication list, there have been very limited amounts of oral morphine available in the hospital and there is almost no IV/SC morphine.

Mulago National Specialised Hospital

Physicians will write a prescription for morphine and caregivers will have to go to the hospital pharmacy and fill the prescription. There have been times where the hospital has been out of stock and the caregiver will have to search for pharmacies that may carry morphine. Even if the patients are fortunate enough to be able to afford the materials necessary for  IV or subcutaneous morphine it is very unlikely they will be able to find a pharmacy that stocks this form of morphine. It has been very challenging to see patients in extreme pain and not be able to make them more comfortable.

In addition to lack of access to morphine many patients I have managed fear morphine and despite being prescribed may not fill the prescription. This is known as “opioidphobia”. Patients are aware of the opioid addiction crisis in the Western world and fear becoming addicted. They are aso very fearful of the side effects such as constipation. In addition to the patients fear of opioids, physicians and pharmacists are very cautious and also uncomfortable prescribing and distributing higher doses of morphine. Pharmacists despite having a written prescription for morphine by a physician will sometimes not administer what has been prescribed as they fear the dose is unsafe and patients do not get what they were prescribed.

It is clear that there are two significant barriers to access to morphine.  The international drug control system and the propaganda that promotes two myths about opioids: that they are always dangerous and instantly addictive.

Coming to Kampala, I knew there would be challenges with symptom management and access to non-essential medications, what I did not anticipate was the lack of access to medications on the essential medication list and the resistance to prescribing morphine. While enthusiasm for pain education and clinical training in developing countries has grown, restrictions by governments and health administrations have represented a significant barrier to practice changes.