Clinic Developments in Peralta

We have more exciting news from Peralta as the agreement between the Dominican Ministry of Health and the clinic as resulted in the hiring of a physician, nurse and community healthcare workers.  Medicine will be arriving shortly as well.

On our recent trip, we had the opportunity to work alongside the new physician, Dr. Amada, who originates from Peralta. The Ministry’s official recognition of the Peralta clinic allowed her to return and work in her community.  The health care workers are also members of the community, such as Onassis, who has worked with the volunteer teams for years.  It’s been wonderful for the clinic to be able to employ locally.

We saw approximately 500 patients during out trip. Now that Dr. Amada is full-time, we hope to set up a telemedicine system where we can communicate with her in real-time, year-round to answer any questions or consult on cases. Additionally, we began research to study the effects of HTN on hearts, through the use of echo and EKG.  By drawing comparisons of rates of high blood pressure in the US, Haiti and the Dominican Republic, we hope to determine the factors contributing to this risk

The water business is still running smoothly. Over 14,500 5-liter bottles are sold per month.  The sales support the 20 families that work as water distribution point agents.  Recently, when the water system for the community faltered, the families provided non-potable water at no charge until it was fixed.

With each step, the Peralta clinic has gotten closer to becoming a self-sustaining system in which we are no longer needed.  As we wind down our primary care work there, we’re working with our local partners to assess new, potential communities to serve.  Stay tuned for more updates.

Sincerely,

Dr. Babs Waldman

Interview with a Trip Leader

An Interview with Maria Keegan

Nurse Practitioner and Trip Leader
 

When did you go on your first trip with Rush Global Health and Community Empowerment (CE), and where did you go?  

I went on my first trip to Peralta, Dominican Republic, in November of 2014.  I’ve been on eight in total.

For those that have never been, what’s Peralta like?

Beautiful.  The physical beauty of Peralta is tough to describe, and if I try to wax poetic about the baby donkeys on the road or the fruit trees or the mountains, I won't do it justice.  However, one thing that has really stuck out to me is the strength of the family structure in the community.  It’s why, despite having very few resources, patients can return over and over, year after year.  Their family members are putting their health first.

In what way do you work with CE?  

I'm the Program Manager for Rush Global Health, which partners with CE. I'm the first one in this role so it’s a little bit of everything, a Jack-of-All-Trades situation, which I really enjoy.  I do quite a bit of the logistics and coordination: getting teams travel-ready and making sure local CE leadership has the information they need to make the trip successful.  Additionally, I teach in the Rush Summer Institute.  Currently, I’m in the pilot phase for the RISE (Rush Interdisciplinary Service-learning Experience) program this fall, which I'm super excited about. 

From a trip leader perspective, why is a global health experience important? 

I really believe that sustainable, programmatic global health work can help shape better healthcare providers, who are more flexible in uncomfortable situations, and who understand the needs of underserved populations in a real, tangible way and who care to stay engaged with the needs of those communities.

What makes you return with CE each year?

I love that CE puts an emphasis on autonomy.  Meaning, the goal is for the communities in which we work to eventually take over the clinics and projects, and manage them independently.  In this way, CE is not a charity, it’s a community partner that invests in mutually beneficial relationships.  We have the privilege of learning how to be better healthcare providers while working in our partner communities and in turn, we work to offer our partner communities healthcare and service that is deserving of that privilege.  For me, it’s also personal.  I love the communities we work in and have gotten to know the members quite well.

What work have you found the most impactful?  

I have a hard time choosing between the primary care and surgical work.  Because my background is medical, I tend to be drawn to that work, which largely treats chronic illnesses in the community.  However, recently I joined some surgical teams and it was pretty incredible to see patients who would have either lived very uncomfortably or nearly died from a treatable condition, come out the other side of surgery with a new lease on life. 

You’ve seen the work in Peralta and Jerusalem from the beginning – what moment(s) stick out the most? 

I was blown away by Devin Mehta and Bobby Bacci’s Electronic Medical Record (EMR) system in Jerusalem.  A few years ago, this seemed like an impossibility.  Jerusalem doesn’t have electricity, let alone internet.  But Devin, a physician who has stayed engaged with the Rush Global Health Program after he left to pursue a cardiology fellowship, and Bobby, who works in electronic medical records, thought outside the box to create an innovative solution.  To see it emerge and become successful was inspiring. It reminds us to think outside the box with ways to improve the care we offer patients.  They saw a problem, used the skills they had and came up with a patient care solution that radically changed clinic workflow for the better.  

How do you see CE evolving over the years?  

Like the Rush Global Health Program, I believe CE is going to continue to see tremendous growth in the coming years.  Even though we’ve added several more trips a year, we haven’t met participant demand.  Meanwhile, Peralta is nearly self-sufficient so we are beginning to source new communities.  It’s already proven to be a replicable model in Jerusalem so now there is simply the task of finding new partner communities. 

High Rewards in Surgery

Mr. Isidro Ramirez, accompanied by his daughter, is recovered thanks to Dr. Steve Charous (right) and the global health team.

It’s a warm sunny day in the mountains of Peralta, Dominican Republic.  Like most days, music permeates the colorful streets.  Residents pull out plastic chairs and sit in front of their homes, waving to one another as they pass by.  But today is no ordinary day for Mr. Isidro Ramirez, whose ability to breathe has become nearly impossible.  Something is blocking the airflow into his trachea.  Swallowing is nearly impossible, and he has lost 30 pounds.

Mr. Ramirez had massive nasal polyps and his frail body was a testament to how long he had been suffering. It was Dr. Steve Charous, an ENT surgeon, who performed the life-saving surgery at the Peralta Sub-centro de Salud.  Dr. Charous was on his first trip to Peralta with Community Empowerment through their partnership with Rush University. Now, not only can Mr. Ramirez live, he can do so in comfort.

Mr. Ramirez's experience is not unique.  Approximately 300 high-reward surgeries were performed last year in the fields ofOrthopedic, ENT, General Surgery, Urology, Pelvic Reconstruction and Gynecology. Most remarkably, all the patients are doing well. 

For many, we offer the only affordable surgical option.  The demand is high, most patient waiting months to years for basic surgeries. Some surgical specialties, such as ENT, are not available at all. Fortunately, several new surgeons have joined this past year.  Additionally, we continue to receive residents from multiple surgical specialties, who get to learn and serve in an inter-disciplinary and cross-cultural context.

As we begin to sunset our primary care program in Peralta, having achieved nearly complete self-sustainability through a partnership with the Ministry of Health, the surgical program continues to be a significant focus.  A third shipping container, provided by Project C.U.R.E. and filled with surgical equipment and dispensable supplies, will assist with capacity building at Taiwan Hospital in Azua.  This will enable our local surgical colleagues and CE volunteers to treat many more patients like Mr. Ramirez. 

- Stephanie Crane

A Reflection on Global Health

During the third year of my residency in internal medicine at Rush University, I had the opportunity to experience something that many young physicians cannot: a global health initiative. I am thankful for being in a program that allows residents to be able to travel to underserved areas around the world, while working to make a lasting impact on the health care system. Lasting impact on the health care system. This would have a completely different meaning to me by the time I completed my global health elective in Jerusalem, Haiti.

Prior to my trip, I was under an oversimplified impression that we would travel to an underserved area and treat patients with what we could, while patting ourselves on the back for helping others and enacting sizable change.  By the end of our week, I realized that a “lasting impact” meant so much more.

I was surprised and impressed to find that Community Empowerment has a continued interest in improving the health care facilities, despite having successfully built a stand-alone clinic months prior. For example, while I was there, the team was implementing an electronic medical record (EMR) system, which would improve continuity of care. As a result, I could use notes and data from prior clinic visits to treat patients. Instead of solely dealing with acute chief complaints, I could manage chronic disease maintenance as well. This was a new revelation for me. Being able to provide care longitudinally, by coming back every few months, is truly what it means to have a lasting impact.

Furthermore, I learned the value of testing and physical exams. Given the limited resources, it was often hard to tell whether the diagnosis was accurate or confirmed, so I learned to rely on history and the physical exam. Having to obtain our own vitals and urine dipsticks really emphasized how much we rely on other professionals, such as MAs, PAs and RNs, to make our own system run smoothly.

Since returning to Chicago, I’ve implemented some of the lessons I learned. My next rotation was on the HIV service at Cook County/John Stroger Hospital. Interestingly, the socioeconomic demographic was similar to the residents of Jerusalem. I began to evaluate the need of testing even more. For example, I found myself asking, “is this really going to change my management of patient care?” We often ask these questions when obtaining more intensive or high cost exams, such as MRIs, but rarely do we ask about smaller tests like blood draws, which still are a cost and resource burden for many. Furthermore, I prioritized patient comfort by trying to do more “lab add on” tests instead of subjecting patients to more needle sticks. Similar to Jerusalem, I found myself managing patients with available medications as the medicines I generally administer were not available on formulary. I was more comfortable with this approach having rotated through the pharmacy station in the Jerusalem clinic.

Through my experience, I’ve learned that it is a slow and arduous process to create a sustainable program where local physicians can be self-sufficient.  During a trip, we can only work to help fill the gaps of health care accessibility, but impacting the system at large requires long-term commitment.  But it’s incredible to see how far we’ve come as a team.  The standalone clinic, with its separate exam rooms plus the EMR system are examples of this progress.  I hope to be able to continue the lessons learned in my future practice and more importantly, return to practice medicine in global health.

- Anuhya Gampa, MD 

Partnership in Peralta

In an unprecedented move, our NGO counterpart, La Fundacion Red Oasis (LFRO), in Peralta has successfully created a partnership with the Dominican Ministry of Health (MOH).  It’s the first time the MOH has partnered with a community-based organization to improve health conditions in rural areas.  

The partnership establishes the Peralta clinic as an official MOH clinic, which means the government is responsible for providing funding for personnel, including a physician, pharmacist, nurses and community health care works, as well as funds for medications and vaccines.  LFRO will oversee the staff selection. And clinic operations

Among the staff to be hired are several community members who have been participating with us in the clinic on a volunteer basis. Not only will this improve the quality of life in Peralta, but it allows people to continue living and working in their community.  For example, Dilcia Ramirez, a Peralta resident, moved to Santo Domingo to work as a maid while attending pharmacy school.  Now she will be returning as the pharmacist.  This is an opportunity that wouldn’t have been available previously.

It’s a bittersweet realization that the partnership with MOH marks the final phase of Community Empowerment’s role in the community.  While we will continue to provide support over the coming year, we will begin to phase out our primary care work.  This is because the combination of government support and proceeds from the water business, which directly supports staff and support clinic operations, allows the clinic to be self-sustainable.  Our directive has always been to reach a point where there is a self-sustainable and recognized medical presence, which would eliminate the need for our support.  It’s incredible to be so close to this goal.

Community Empowerment will continue to work with the MOH to implement our surgical program, which provides ENT, gynecological, urology and general surgery, along with three orthopedic teams, in the public regional and local hospitals.

As Peralta begins to shape their role in the greater healthcare system, Community Empowerment is working with LFRO to identify other communities in need where we may begin the process again.  Peralta will serve as a great example of achievable global health outcomes.

- Babs Waldman

News from Peralta

We're close to achieving our goal of integrating the Peralta Clinic into the Dominican Health system!

What made this possible was a unique, first-of-it's-kind public/private partnership between the Clinic and the Dominican government.  The partnership will allow the Clinic to hire a full-time physician, nurse and community health workers, who will provide on-going care to the community's patient base. In the meantime, we will continue to support the community through clinical care teams as long as needed, until Peralta is self-sustaining.   

The water business is thriving.  In addition to widely distributing clean water to remote communities, the business has been able to consistently support operational overhead of the clinic. 

Primary care teams from Rush continue to provide care on a quarterly basis. Our last trip was in June of 2017, and our next trip is scheduled for October.  The enthusiastic participation from Rush students, residents and staff and the strengthening of relationships with our friends and partners in Peralta continues to bring bidirectional vitality and integrity to this work. 

Stay tuned for more to come.

* Submitted by Dr. Stephanie Crane*

May in Jerusalem, Haiti

Update: On Friday, June 9th, Jerusalem Clinique received its official certification from the Haitian Ministry of Health, MSPP. This means access to Ministry of Health medications, vaccinations, and educational materials. It's an important step to building medical infrastructure in Jerusalem!

The community of Jerusalem, Haiti continues to grow. In fact, there are about a dozen wards within Jerusalem.  Homes have sprouted up on the hillside behind the clinic and local shops have emerged.  

Dr. Saint Paul, Fiquita, is doing an amazing job. She sees patients four days a week, which amounts to about 150 - 200 patients a month, and manages the team of community healthcare workers (CHW).  All data is kept by hand.  Being a constant presence in the community allows her to take a more holistic approach.  For example, she can have the CHWs follow up with patients who have borderline high blood pressure before starting them on medications.

From May 7-14th, Community Empowerment brought a team of medical residents and students, a nurse practitioner, a PA, a pharmacist and a veteran pediatrician to see returning and new patients.  Several of the volunteers were returnees.  They were joined by a team of eight interpreters, many of whom were returnees as well.  We saw 363 patients in total.

It was our second time using the Electronic Medical Record (EMR) system and it worked well.  We trained three of the CHWs to enter patient information and vitals.  Providers were able to use their own laptops, tablets or phones if they prefer.

The limits of our clinic were tested by three patients who needed hospital care.  One woman had acute jaundice, a newborn had a fever and jaundice and another newborn had asthma).  We took them to Bon Repos Hospital, but unfortunately, care there is a cost many cannot afford.  

Looking forward, we recognize the need for the following:

Pregnancy tests ($25 for 40)

HIV tests ($75 for 40)

U/A tests strips ($27 for 100)

“Watch” batteries

Good stethoscopes

BP cuffs

2 Exam tables

Additionally, we see the opportunity to educate patients who are waiting to be seen.  Basic information about illnesses and treatments would be valuable here.

Sincerely, 

Dr. Babs Waldman

Alfredo, Brian and Annie interview Wendys in the old clinic for our video coming soon.

A New Clinic, a New System

January 2017 trip to Haiti

It's hard to quantify or describe the impact of having an actual clinic.  Prior to development, our teams worked in an open-air church.  It was hot and dusty.  The wooden benches were our waiting area and the patients rooms merely consisted of chairs clustered together.  There was no privacy and concentrating was difficult.  Now, with the construction of our brand new clinic, our level of care has expanded.  Patients get the attention, care and privacy they deserve; providers can concentrate and focus.  Our January trip marked the first time a team was able to utilize the new clinic, which included new equipment donated by a Rotary Global Grant & ProjectCURE.   

Furthermore, this trip launched our Electronic Medical Record (EMR) system.  In an area where power is a luxury and internet is nonexistent, the ease and convenience of the EMR system, which lets doctors send orders to the pharmacy directly, is unparalleled.  Gone are the days when the pharmacists had to decode doctors' handwritten orders.  Now, we have a system that allows for better care, record keeping and tracking of outcomes.

The EMR system was developed by Global Health Coalition.  It's founders are Dr. David Mehta, a cardiology fellow in Milwaukee, former Rush resident and Haiti trip volunteer, and Bobby Bacci, owner of Prominence Advisors.  They, along with employee Selah Ben-Haim, joined our trip in order to ensure a fluid transition.  

With our new clinic and system in operation, the primary care  and dental team saw over 500 patients and held a focus group with female patients.  The focus group was aimed at determining the potential barriers of having male physicians and interpreters assist with their care.  In addition, we met with the local community healthcare providers and Jerusalem Clinic Board.  However, our biggest gain may have been the addition of Fiquita Saint-Paul, our new full-time physician, whom we've worked with extensively in the past.  We feel she is committed to improving Jerusalem's overall health.

Outside of the clinic, we were pleased to see the Water Committee expanding its capacity.  The demand for clean, fresh water has been so high that they installed two additional tanks on top of the water kiosk.  What's more, the Committee, along with the Clinic Board, is looking into the use of solar power in order to conserve energy and increase supply.

Overall, this trip was remarkable in that we were able to see tangible gains in our efforts to improve the healthcare system in Jerusalem.  It's a big win for the community.  Stay tuned for more trip updates, interview and travel stories from the trips to come.

Sincerely,

Dr. Babs Waldman