Promoting Community Health in Honduras

Promoting Community Health in Honduras (link to .pdf)
by Douglas Stockman M.D. Director and Barbara Gawinski , Assistant Director Global and Refugee Health

The Department of Family Medicine at the University of Rochester continues to operate a year round Global Health Program which offers didactic training throughout the year and travels twice a year for two weeks at a time to rural Honduras. The Department has partnered with an NGO called Shoulder to Shoulder and a rural community called San Jose San Marcos de la Sierra in the Southwestern state of Intibucá, Honduras. The needs of the target community are great and go beyond curative medicine. By listening to the concerns of the local community members and performing qualitative community assessment, we are creating interventions designed to address the common problems. Below are highlights of our May 2008 trip.

The largest concerns of the village people continue to be water projects and latrines. The irst two ferro-cement water tanks we built are doing well. A third tank was started while we were there. This tank will provide water for the volunteer, Matthew Malek – a UR med student, who will start living in San Jose in July. Villagers from La Calera and Portillon, who were bene iting from piped water projects, were required to help with this tank’s construction. In addition to helping the project move forward faster, Portillon members learned about the speci ics of ferro-cement tank construction. The Portillon people will be building a ferro-cement tank as part of their piped water project.

During our November 2007 trip we helped La Calera begin a piped water project. They had completed the irst half of the project and had installed pipe from the water source to a distribution tank. During this trip we helped them purchase the additional 2+ miles of tubing needed to install a faucet at every household. When we arrived they had already hand-dug all the trenches required for the project. Within 12 hours of the pipes being delivered to San Jose Centro where the road ends, the pipe was being carried on villagers’ shoulders for the 2+ hour walk down the treacherous mountain-side to La Calera. Given each person was carrying 27 pipes that were 20 feet long and each bundle weighed over 60 lbs, it was quite a feat of human endurance.

We built our irst Ventilated Improved Pit (VIP) latrine this trip in San Jose. The VIP latrine has a chimney which helps remove some of the foul smells from inside the latrine. The initial latrine was made for the volunteer house. We were able to train a local person, Apolinar, on construction techniques. He will run this project with DFM providing the materials that must be obtained outside the area such as cement and PVC pipe for the chimney and each home must providing all the labor and local materials. Six months ago, teachers from the school asked for some assistance in creating teaching kits in science and math. Representing the First Unitarian Church’s Honduras Project Committee – Teacher Resource Committee, Moritz Wagner and Barbara Gawinski, along with the team members from the Department of Family Medicine, personally delivered over 50 pounds of school supplies to the classrooms, three teacher science/math curriculum kits, and 250 books and resource books to four of the ive schools in the San Jose region: San Jose Centro, Portillon, Potreros, Guanacaste. Scholarship programs are also being started in the area.

We are always impressed by how much we can accomplish in two weeks when dedicated hard working people pool their collective energies and skills. There was a great synergy between this group and the many hard- working Hondurans. We are building a very strong relationship with the Hondurans that is already yielding many fruits. Our Global Health Program is maturing nicely and expanding to include The First Unitarian Church has provided new resources to the Hondurans through teacher education and potential for student scholarships. Thanks to everyone who has made this program a success.

National Primary Care Week

National Primary Care Week: Lunch & Lecture Series
The Center for Primary Care, Department of Family Medicine, AMSA and the Robert Wood Johnson Foundation present:

"Primary Care in the Developing World"
with
Dr. Doug Stockman
Clinical Associate Professor & Director of Global and Refugee Health

Case Method Room
Oct. 13, 2008
noon-1p.m.

Helping in Honduras

University of Rochester Currents (link)

By Susan Hagen
susan.hagen@rochester.edu

In 1992, when Stephen Schultz was selecting his family medicine residency site, Rochester was at the top of the list. The School of Medicine and Dentistry’s program, established in 1968, was one of the oldest and most respected in the country.

Schultz, a Boston native who has worked for four months in a clinic in Kenya during medical school, was deeply committed to global heath care. He felt Rochester’s family medicine program could benefit from a global health track to help prepare future physician to practice in underdeveloped areas around the world.

A decade later, the University recruited Schultz to direct the family medicine program, giving him the opportunity to develop that focus: “I made having a global health track a condition to accepting the job.”

Under Schultz’s leadership, the University’s global health/family medicine residency program has become nationally recognized for its ongoing partnerships with several villages in the remote mountains of southwestern Honduras. At a time when competition for family medicine residents has tightened sharply, the global health track is credited with increasing applications to Rochester’s program by 25 percent. Today, 60 percent of the University’s incoming family medicine residents specialize in global and refugee health, a program directed by Doug Stockman, a clinical associate professor of family medicine.

At the center of the University’s program is its project in San José, Honduras. Home to seven small villages and some 2,000 indigenous residents, the San José area has no running water, no electricity, and no medical facilities. The area is impoverished; most households live on less than $1 a day. Twenty percent of children are malnourished.

“San José is the second poorest county, in the second poorest state, in the second poorest country in the Western Hemisphere,” says Stockman.

Yet, it was the community’s wealth in human resources and its commitment to improve living conditions that convinced Schultz and Stockman to select the isolated region as their global health site in 2003. As part of the ongoing partnership, village residents have pledged to work side-by-side with the Rochester team to improve health care access and maintain numerous outreach projects. Rochester, in turn, contributes medical personnel, resources, and, perhaps most importantly, knowledge.

For two weeks each fall and spring, a brigade of about 15 residents, faculty members, nurses, dentists, medical students, and volunteers converge on the area. Using a converted storage shed and plastic sheeting to divide “examining rooms,” the team sees more than 100 patients each day, treating everything from congestive heart failure to parasites.

The Rochester program ties medical training to community development and takes a long-term view of health. In many ways, the patient care delivered during the biannual site visits are its smallest contribution to health.

“We treat acute infections, yes, but we also focus on the determinants of health: clean water, sanitation, clean air, and education,” says Schultz.

Curative medicine is only helpful in certain situations, adds Stockman: “You can’t write a prescription for better water.”

An example of the program’s more comprehensive commitment is its ventilated stove project. Villagers were suffering from multiple respiratory illnesses: bronchitis, asthma, and pneumonia. An underlying cause, it turned out, was the use of open fire pits inside homes.

“The smoke was so thick,” remembers Schultz, “that I found myself involuntarily stooping to get out of the haze.”

In response, the global health team began working with villagers to install ventilated stoves. The program provides the chimney pipe and a metal plate at a cost of $25 per stove. To date, 140 stoves have been installed in the area, dramatically improving the indoor air quality for residents.

Water quality and access is another major focus. The program has provided support to complete a third 4,500 gallon holding tank, and has supplied a significant portion of the PVC pipe needed to bring water to 30 homes. The Rochester team is teaching local residents how to build ventilated improved pit latrines to protect the water supply, and providing low-tech solutions, like the inexpensive Potters for Peace clay water filters that reduce waterborne pathogens by 98 percent. Stockman says it’s a cost effective way “to save a child’s life.”

In an area where toothbrushes are about as rare as running water, the typical San José adult has lost nearly half of his or her teeth by age 25. To target young residents, Rochester’s program now provides local educators with a fluoride rinse that students use twice a week—a simple and inexpensive intervention that has reduced dental caries in children by 95 percent.

To make the effort self-sustaining, organizers have trained a community health worker to provide ongoing heath care services, and they have established a payment system to ensure medical supplies can be replenished.

“One of the things you learn when working in a very poor country,” explains Schultz, “is that, just like in the United States, there are different levels of poverty. There’s poor and then there is absolute poverty. We let the community decide who can afford to pay and who cannot.”

In this way, the program is able to replenish its supplies, without turning away the truly destitute—a better model, argues Schultz, than the free government clinics that operate closer to the cities. Those programs, says Schultz, “give away birth control and antibiotics, and then they run out. How helpful it that?”

The success of Rochester’s model of sustainability and community partnership has benefited from its collaboration with Shoulder to Shoulder, a national nonprofit that has helped build relationships between family medicine training programs and communities in resource-poor countries since 1990. Rochester was the third school to join the network, and remains one of the strongest participants, says Jeffrey Heck, Shoulder to Shoulder’s executive director.

“Rochester demonstrates best practices in terms of projects, meaningful relationships with the community, and long-term commitment,” says Heck, who notes that the program benefits both the Honduran communities as well as the U.S. participants by offering doctors a broader view of global health issues.

Elizabeth Brown, senior instructor of family medicine, agrees. “We are so accustomed to the wealth of this country. The trips encourage me to reevaluate what I think are necessities and to recommit to providing for underserved populations.”

University of Rochester Medical Center to provide help in Honduras

An article appearing in the Democrat and Chronicle
Justina Wang • Staff writer • September 29, 2008

Link to original article

Next month, about a dozen University of Rochester Medical Center doctors, nurses and students will travel to Honduras to repair water filters, build cook stoves, hand out school supplies and talk with impoverished families.

It's not pure medical work, but they believe their helping hands could do more for the health of people in developing countries than any stethoscope or needle.

"It's so easy to see there that if you don't have clean water and your child gets diarrhea three times a year, then the intervention is clean water, not medicines," said Dr. Douglas Stockman, director of the university's global and refugee health program. "Prevention is probably more important than curative care."

Since 2003, Stockman and residency program director Dr. Steven Schultz have taken a medical brigade down to the village of San Jose, where there's no running water, electricity, hospitals or clinics.

The project is part of the national Shoulder to Shoulder effort to help the poor in Honduras, and URMC has committed to helping the village for at least 10 years.

In the last two years, the First Unitarian Church of Rochester has also joined the project, raising more than $70,000 for the San Jose area and sending one or two parishioners with the URMC team.

During the twice-yearly, two-week trips, the group has installed 140 ventilated stoves, built 4,500 gallon water tanks, supplied 578 pieces of PVC pipe to bring water to 30 homes, put water filters in 20 homes, helped construct latrines, trained midwives, and handed out fluoride rinse for schoolchildren.

In between the community work, half the doctors and residents also see patients and write prescriptions in a makeshift warehouse clinic, where students learn that medical issues aren't isolated from daily problems.

Children who drink infected water come in with worm and parasite infections.

Poverty takes the form of malnutrition and stunted growth. Open fires in homes without stoves lead to serious burns, bronchitis and asthma.

Adults who have had no medical attention in their lives come in with advanced cancers, untreated diabetes and high blood pressure, schizophrenia and psychoses that have never been diagnosed.

"It's sometimes very difficult to see the causalities and linkages," said Schultz. "Violence is a huge concern in Rochester, but is it a medical problem?

"Maybe violence is having an issue on the health of many members of the community, and maybe as a physician I should be looking at that, and not just concentrating on what I'm doing in the exam room."

First-year resident Donald McLaren, a 26-year-old from New York City and a son of Haitian immigrants, said this is exactly why he went to medical school.

He wants to work with diverse populations and is preparing for his first trip to Honduras on Oct.18 — brushing up on his Spanish and picking out a tent and sleeping bag to keep out mosquitoes and scorpions when he sleeps on the floor of an open cinderblock school.

"This is going to be a very interesting experience," he said. "I expect to be shocked, and I expect to do a lot for the community in Honduras."

JUWANG@DemocratandChronicle.com