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.”