Mental Health Inequality in Chiapas, Mexico

This is the room where a man has been incarcerated for five years, without ever leaving.  I don't call him a patient because I didn't meet him personally, but his story churns my stomach.  He is somewhere around 60 years old, and developed schizophrenia when he was 18.  He was odd but functional for many years, but in later years grew increasingly aggressive and threatening both to his family and to people in the community.  He had one psychiatric hospitalization, where they used injection medications that aren't available in the community.  Once he was discharged back home, he refused to take oral medications.  After he attacked his family, they decided he needed to be locked up, for the safety of everyone.  It took eight men to restrain him and secure him in the above room and he hadn't left this room in five years.  

Note the rope that is tied to the metal door... That is to keep it locked.  There is a hole where they pass him food and he uses the floor to go to the bathroom.  No shower, no grooming in five years.  As we walked near the house, it smelled of filth.  He yelled for his mother repeatedly and said that he wanted us to go away, whoever we were.  I don't know if he meant us or voices he was hearing, although we're the most likely culprits.

We were there to try and convince the family to let Compañeros en Salud try and get an injectable antipsychotic in the community that lasts for a month, in the hopes that it will make him calm enough to be able to come out of his locked room.  The proposal was that we get the police and lots of back up, open the door, sedate him, clean him and bathe him, give him the medication and return him to the room after it has been cleaned.  The hope is that he may be able to be calmed enough that he won't have to stay a prisoner for the rest of his life. 

His family was hesitant; they'd had lots of doctors try to fix him, and all of them had demanded large sums of money.  They also didn't want to be hurt.  Another big concern...  We would need to destroy the metal door, which had been solderd shut and they didn't have money for a new door.  But the seed has been planted, and hopefully they will make it happen.

The situation makes me feel physically ill. There is nothing humane about what is being done to him, which I say even as I understand why his family is doing it.  There simply are not places for people like this man to go in the long term in rural Mexico.   With only one psychiatric hospital, there are long wait times for a place in the hospital, and there are no discharge locations where patients who need interim care can go. While his family was trying to mitigate the harm he could cause, I can't imagine a more terrifying situation for a paranoid patient than to be locked in solitary confinement, essentially forever.  People of sound mind go crazy under those circumstances, let alone people with his degree of illness.  

I say this with deep respect for each of the individual players, who are doing their best in a terrible situation.  And yet the horrific inequality of how impotent we were in the face of this awfulness shows how large the problem looms.  And it is a hard measure of how well they are able to take care of the mentally ill, some of society's most vulnerable.

-Sarah Kimball, PGY-3

Internal Medicine, Brigham and Women's Hospital

Thoughts on two weeks of rural primary care in Mexico

Update: I go to Jaltenango today enroute to Refoma, the second community that I am working in.  From what I understand, it is both more rural and yet closer to Jaltenango.  It is apparently also a community of many Jehovah's Witnesses.  

My last night in Laguna was marked by an after-dark walk to the pantheon/cemetary to try and get phone reception in order to talk to the main office about a case.  All the lights are gone, which is unsurprising after the three days of gloomy cold rain.  It also means that I haven't showered in two days because it is too cold to envision an icy bucket bath.

I've learned a tremendous amount about how I have (mostly subconsciously) learned to practice medicine by being here.  Today, we had a female patient who has a history of gallstones and who clinically seems to have progressed to pancreatitis.  As usual, the question arises of whether she is safe to stay here in the community until Monday, when her family can take her to the local hospital with surgical capabilities.  And the answer as to whether she is safe, as with so many things here, is that I haven't a clue.  I know how to risk-stratify pancreatitis in a hospital, where I can get labs and imaging.  I can fearlessly quote mortality statistics.  Here, I'm fairly certain of our diagnosis, but without the laboratory confirmation that I've learned to rely on, I feel paralyzed with doubt on how to treat people.  My pasante is so much more fearless, having gotten used to trusting her instinct without needing multiple (or any) forms of confirmation of her clinical instinct.  Somewhere in the middle is probably best for patients.

How can I tell how likely it is that our patient's chest pain is angina without ever getting an EKG, or lipids?  What is the pretest probability in a rural Mexican farmer who has never smoked but who probably inhaled tons of smoke in an indoor kitchen?  How do I treat him without access to a stress test?  How applicable is the Framingham Risk Score (or pick your favorite) to him?

I've learned that, in the absence of the screening tests that the majority of my patients get, I tend to suspect cancer at every turn.  I blame this in part on three years at BWH, with all our Dana Farber patients.  But in every abdominal pain in an older man, I see colon cancer and I fret about every woman with pelvic pain having cervical cancer.  I hadn't realized how much comfort I personally take in having an easily accessible screening panel.

In addition, so much of my practice at home is based on not missing anything.  We will get chest x-rays and labs for the lowest probability events.  So often, we use the language of 'ruling something out.'  Here, as testing is so hard to come by, you have to be pretty darn sure that you need something before you make someone travel.  

In my last day, we had two children who clinically looked like they had hepatitis A (one of whom's mom actually said, "his urine looks like coca-cola and his eyes are yellow."). How many kids in the past two weeks with diarrhea and abdominal pain actually had hepatitis?  Are we sitting on an outbreak?  Do you need the serological confirmation?  All these questions are new ground for me.

On an unrelated note, here's my pasante, myself, our neighbor's daughter and one of a thousand local dogs.

-Sarah Kimball, MD

Primary Care in Chiapas, Mexico

Some of these posts are backdated, due to poor internet access in Chiapas.  But in short, thanks to funding from the Partners Center of Excellence, I'll be spending the next month in rural primary care clinics in Chiapas, Mexico with Compañeros en Salud, the Mexican arm of Partners in Health.  While I work on my Spanish (starting from a place of fumbling with many years out of practice), I'm hoping to get a sense of how primary care is practiced in a place where routine health exams are not the norm, and where people come without good access to the health care system.

My role here is as a medical consultant to the Mexican pas antes who are stationed here for a year.  They do six years of schooling, including a year of hospital training.  As a payback to their community (because medical school is paid for by the government), all pasantes do a year of community service.  My first post is in Laguna de Cofre, high up in the mountains of Chiapas, and about two hours from Jaltenango.  We have a small house next to the clinic where my pasante and her nurse live along with anyone else who comes along and needs a place to crash, like me.

On our first day, we left Jaltenango at 7am and headed straight for clinic, as the line was already getting long by the time we arrived at 9:30  From what I understood from my broken, aching Spanish, today's clinic included (in semi-medical speak)

Pts 1-4: pregnant mother and there kids, there for HIV testing.  Kids negative, mother positive.  Presumably from father, who travels back and forth to Tiajuana for work, as HIV rates are quite low here. 

Pt 5: well pregnancy check

Pt 6:  woman with pain in multiple parts of body, likely from stress.  IUD placed. 

Pt 7: woman with RA, who was getting dexamethasone injections and developed Cushings Syndrome and diabetes.  Now off steroids, but in lots of pain.  No clear other medication options available.

Pt 8: 60 yo man with exertional chest pain. No EKG or stress test easily available.  No clear idea of protest probabilities without lipid testing. Opted for nitrate trial diagnostically.  

Pt 9: 70 y.o. man with hypertension and vision changes.  As a side note, he was as tall standing as I am sitting.  

Pt 10: 70 y.o M with hemorrhoids and hearing issues.  Clearly no colonoscopy, but they have hydrocortisone suppositories with lidocaine in them.  Brilliant!

Pt 11: hypertension and sore throat

Pt 12:  well pregnancy check.  23 year old with three other children

Pt 13: sick kid (eeek! I don't know what to do with kids!) with diarrhea.  Fortunately, the wonderful

Pasante that I am working with knows kids may better.

Pt 14: teenaged boy with facial dermatitis

Pt 15: urosepsis in a 70 y.o. man with a permanent supracatheter.  Looked bad.  IV fluids, abx, monitored, no labs.  Will see tonight and tomorrow (he lives across the street) to make sure he doesn't need to be shipped to a local hospital (which he almost certainly does, but it is such an issue here to make happen)

Pt 16: told by a naturalist doc that he had bladder inflammation that he healed.  Wanted to talk to someone else, which is good because the story didn't make sense.

Pt 17: young girl with diarrhea

Pt 18: very depressed 15 y.o. girl who walked 2 hours to get to clinic.  Her problem is, in short, that she is a female in a a village in Chiapas without the ability to get out.  Not something sertaline will help, but that was what we had,

Pt 19: 19 y.o. lady with constipation

Pt 20: 15 y.o who was pregnant.  Wanted an abortion, but it is illegal in this state.  More about that later, which I find baffling and angering.

Off to this spot, which is my bed for the next ten days.

And our kitchen, which is barely functional but doesn't really need to be.

-Sarah Kimball, MD

The Spatial Epidemiology of Malaria - Part 2

In my previous post, I described the striking variation in the RDT positivity rate seen among different villages of the Bugoye sub-county. For example, from the village of Bugoye, we observed that 30% of RDTs were positive for malaria, while from the neighboring village of Izinga, the rate was more than twice as high. In fact, patients from Izinga accounted for nearly 20% of all positive RDTs at the health center. These differences suggest that local malaria transmission has a significant spatial component. In order to understand these trends, we must first understand the geography of the sub-county.

Cows crossing the Mubuku River near the Bugoye Power Station

For the last six months, my partners from the Mbarara University of Science and Technology (MUST) and I have been using GPS devices to construct a map of the sub-county. Guided by members of the local community, we record the locations of village health workers, community leaders, and health centers, in addition to outlining political boundaries. We have journeyed hundreds of miles up and down the hills and valleys of the sub-county. On the narrow paths, we have learned a lot about life in the villages in ways we had not been able to understand or appreciate before. In doing so, we have gained new insight into malaria risk factors, infrastructure challenges, and health-seeking behaviors.

Last week, we visited Izinga. At the bridge over the Mubuku River, we met the village health team that would lead us around the village. As we walked, we learned that Izinga was essentially a low-lying island situated between the Mubuku and Kitakena Rivers. In addition, a spillway for the hydroelectric plant supplying power to the nearby cobalt mines runs directly through the village. These features make the village particularly prone to seasonal flooding. The cold, fast-moving rivers are normally unsuitable for mosquitos, but when the water surges over its banks, it creates thousands of pools of warm, stagnant water that are ideal breeding sites.

Woman walking across damaged bridge over the Kitakena River

In May 2013, massive flooding devastated many areas of the Kasese District, which includes the Bugoye sub-county. Tons of mud and stone came crashing down through the valleys, destroying everything in its path. Thousands of residents from places like Kilembe, where the district referral hospital is located, were displaced. The sheer force of the floods cut new paths through the earth, changing the course of Mubuku River and washing away homes, livestock, and crops. As the water receded, once arable areas were turned to “swamps.” Unfortunately, the flooding has affected more than just agriculture. Compared to the previous two years, more patients from Izinga are being admitted to the health center for severe malaria. At this time last year, immediately before the flooding, patients from Izinga accounted for only 7% of inpatient admissions for malaria. This year, they account for 20%.

The town of Kilembe after massive flooding in May 2013

The case of Izinga is a classic example of how geography impacts human health. Geography, however, is not destiny. One need only to recall the devastation that Hurricane Katrina wreaked upon the city of New Orleans to know that Western Uganda is not unique in its experience with natural disasters. The difference is the resources. In New Orleans, Blackhawk helicopters, which cost about $6 million dollars each, quickly arrived on the scene to rescue victims from rooftops. Later, the Army Corps of Engineers rebuilt the levies, reportedly stronger than ever before, at a cost in the billions of dollars. In Izinga, there are no helicopters or engineers and certainly no billions of dollars.

Standing water in Izinga

How, then, do we respond to this epidemic? Minimizing the impact of future floods is the long-term solution, but this requires infrastructure investment that is not realistic given local resource constraints. In the meantime, malaria transmission will remain high as the mosquitos continue to flourish and the parasites infect more and more residents. Soon, we may see the RDT positivity rates in neighboring villages begin to climb. With relatively modest resources, such as bed-nets and insecticides, we can prevent the situation from getting worse. Even these interventions, however, are beyond the means of the community. But now that we understand the problem, we can begin to argue for the resources.

Ross M. Boyce MD, MSc
PGY-2, Internal Medicine
Global Primary Care Program
Massachusetts General Hospital

Understanding the spatial epidemiology of malaria in Western Uganda

The Bugoye Health Center (BHC) is located in the Kasese District of Western Uganda. This health center functions as the highest level of care for residents of the Bugoye sub-county, serving a rural population of approximately 50,000. The closest higher-level facility, Kilembe Mines Hospital, is located sixty minutes away when traveling by motorcycle. BHC is staffed by clinical officers and nurses from the Ugandan Ministry of Health and provides care at no charge. In addition to the outpatient clinic, there is an inpatient ward of twenty beds and a small laboratory with trained staff capable of performing basic diagnostic tests. As in many other resource-limited settings, the health center suffers from an irregular power and water supply and often faces shortages of key medications.

Entrance to Bugoye Health Center, Level III

Even with these limitations, BHC is always busy. Total reported outpatient attendance was 18,722 in 2013; a number that translates to more than seventy outpatient visits per day. While accurate population statistics are not available, malaria clearly represents the major burden of disease. Like most of Uganda, the climate in Bugoye permits stable, year-round transmission. According to health center reports, there were 7,753 cases of malaria at BHC in 2013. Rapid diagnostic tests (RDTs) have largely replaced light microscopy for the diagnosis of malaria, and are used preferentially given the ease of use and time constraints placed on laboratory staff.

Examining blood smears for malaria parasites in the laboratory

Since their introduction in 2011, nearly 7,000 RDTs have been performed at BHC, two-thirds of which were performed in the last year as the supply became more reliable. Accordingly, the number of parasitologically confirmed cases has increased to 42% in the last six months. While there is room for improvement, the introduction of RDTs has resulted in a marked change from the past, when all febrile patients were presumptively treated for malaria. This approach, while simple, contributed to the over-prescription of anti-malarial drugs and the under-recognition of serious bacterial infections.

Outpatient Clinic, Bugoye Health Center

The RDT positivity rate, which measures the percentage of all RDTs that were positive and is often used as a marker of malaria incidence, was 33% in 2013, with monthly rates as high as 51%. Yet even within this small community, there is significant variation between villages. For example, over the past three months, the RDT positivity rate among patients presenting from the villages of Bugoye, Ndughutu, and Bunyangoni was approximately 30%. Among those presenting from the villages of Muramba and Izinga, the positivity rate was 45% and 68%, respectively.

Looking down on Bugoye from the village of Muramba

Why is the positivity rate in these villages, many of which border each other, so different? Understanding this question is central to my work in Bugoye, and ultimately to developing sustainable malaria control interventions. Given that much of life varies little from village to village, I believe that the difference is best explained by geography. The local terrain ranges from mountain highlands in the west, often reaching altitudes of more than 2,000m near the borders of the Rwenzori National Park, to the densely vegetated wetland areas along the banks of the Sabo and Mubuku Rivers. Many of these “micro-environments” are ideal sites for mosquito breeding, and likely fuel the local variations in malaria incidence. Of course, identifying these high-risk areas, especially in a setting where there are no maps, can be challenging. In my next post, I will describe how we are tackling this issue, drawing on our recent experience in the village of Izinga.

Ross Boyce MD, MSc
PGY-2, Internal Medicine
Global Primary Care Program
Massachusetts General Hospital