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Center for Global Health | Colorado School of Public Health
 

Notes from the Field

Guatemala


Marco Celada, MD is the Director of the newly opened clinic, part of the Center for Human Development - the University of Colorado's first ever international medical facility.  Rebekah Gaensbauer, MD, MPH and Kimberly Insel, MD, MPH are both Global Health Fellows with the Center for Global Health who will be making regular working visits to the clinic. 

They have all agreed to share with us updates of their work and experiences in Guatemala in their own words.  See their bios in the left hand column.

November 2014 - Kimberly Insel, MD, MPH

In September, I traveled with Pamela Hill, CNM and Annie Dominguez, MD to the Center for Human Development in the Trifinio. We introduced a group care model for prenatal care to our Community Health Workers (CHWs). This model brings community groups of pregnant women together to discuss health topics and help create support systems throughout a pregnancy. This model was piloted on our Comadronas (traditional birth attendants) who showed support for the new programming. Over our second week, the CHWs and I brought our group prenatal care model into neighboring communities of pregnant women. Our hope is to continue training on the delivery of prenatal care in a group model throughout December.

While I worked with our CHWs, Marco Celada, MD and Kelly McConnell, MD saw many pregnant women, children and adults in our clinic. As compared to clinics in the U.S., they saw a wide range of disease presentations. Dr. McConnell commented on frequent presentations of children with acute diarrheal and upper respiratory infections. She did multiple procedures and made use of the ultrasound during one particularly complex abscess drainage. Phil Miller, MD followed up on Dr. McConnell’s work, spending the month of October treating the same patients. He noted a heartbreaking case of malnutrition in a 28-day old child who was below her birth weight. These and many similar patients remind us all of the constant need for our community outreach and clinic programs.

Also in October the clinic’s intrepid nurse Zucely Lopez flew to Denver to participate in obstetrical ultrasound training. At the end of her visit she expressed that she learned a lot and that if she ever were to get pregnant “she would want to have her child in America.” However, Zucely will be able to bring this high standard of care back to Guatemala by providing obstetrical ultrasounds for patients in the Trifinio. She noted that over the past two months she has diagnosed women with diverse presentations including twins and a molar pregnancy.

I will be returning to Guatemala in December; I will focus on evaluating our CHW’s retention of content taught in September. In addition, I will be teaching basic concepts behind prenatal care and introducing how to incorporate use of our “Carnet” (patient’s personal health record) into the prenatal visit. Having now worked on projects in the Trifinio over the past six months, I have been humbled by the daunting task before us. Within the context of poor access to clean water, minimal access to education and endemic vector-borne diseases like Dengue, the communities within these regions have shown great resilience. In partnership with the Banasa Corporation, I believe our work to improve health and prosperity for individuals, communities and families in this region is just beginning.

September 2014 - Rebekah Gaensbauer, MD, MPH

It had been 18 years since I last visited Guatemala. During the four and a half hour trip from Guatemala City to the clinic site in the southwest Trifinio region, I wondered how much had changed. As a graduate student I had visited Guatemala for a field study course on health promotion/disease prevention efforts conducted by the government, as well as private organizations. Now, returning as a pediatrician and global health fellow, my task was to get a better understanding of the nutritional status of children in Guatemala, especially in the Trifinio region. I was eager to see how the health of Guatemala’s children had evolved.

Since April 2014, the Center for Human Development, a clinic created from the partnership of the Bolanos Foundation and the Center for Global Health, has been providing a range of healthcare services to the community including prenatal care, pediatric and adult services, vaccinations, dental services, research activities, as well as health outreach programs.

My days typically started on the back of a motorcycle, weaving around potholes, trucks and various animals. I was working with Millie, one of the community health workers or “tecnicas.” Millie’s work is part of a community-based surveillance and integrated health and development program. The program “Creciendo Sanos” has two main segments: a maternal-neonatal segment and an early childhood health and development segment. On a typical day we would navigate the maze of dirt roads weaving throughout the banana plantation and arrive at the home of a family with an infant. The homes were modest, generally four walls made of rough cut wood boards with a tin roof and dirt floor. Water was from the local well and meals were prepared over open wood ovens. After introductions, Millie would ask about the child’s recent health including fevers or diarrhea. We would locate a nearby tree or roof beam and hang the scale to weigh the child. Head circumference, mid-upper arm circumferences and length were also obtained and recorded. All of the health screening and anthropometric information Millie obtained was entered into an electronic data collection registry system and analyzed at the Center for Global Health in Colorado allowing for continued program evaluation and rapid cycle feedback. My visit was a direct result of both direct observations and early data analysis concerning for high rates of malnutrition in the Trifinio region.

During the week Millie began taking me on targeted home visits for infants she was concerned about. We saw a child with Cerebral Palsy with recurrent aspiration and pneumonia, children with various rashes, and several children whose growth had either stalled or fallen off the growth curve. Some of the children could be successfully treated at home but other required referral to the clinic.

Guatemala has the third highest rate of stunting in the world with almost half of Guatemalan children under five years chronically malnourished (World Bank, 2010). Malnutrition has been associated with negative neurocognitive outcomes, maternal reproductive outcomes, and increased morbidity and mortality. The causes of malnutrition are multifaceted and complex. Multiple interventions have been attempted with various degrees of success to try to improve the nutritional status of Guatemalan children. However, much more work needs to be done. The Center for Global Health and Center for Human Development are working to tackle child malnutrition in the surrounding community. The challenge is to create a sustainable program which will not only identify children with severe acute malnutrition but also to try and improve the overall nutritional status of Guatemalan children.

World Bank. Nutrition at a Glance: Guatemala 2010. Available at http://siteresources.worldbank.org/INTLACREGTOPNUT/Resources/Guatemala4-20-10.pdf​


August 2014 - Kimberly Insel, MD, MPH

The Center for Human Development, the clinic in the Trifinio region of Guatemala witnessed record growth in July. The month began with the completion of the annual teaching conference at the Coatepeque Hospital, about 45 minutes away from the Center for Human Development. Providers from the University of Colorado including Amy Nacht, CNM, Gretchen Heinrichs, MD, DTMH, Edwin Asturias, MD, Marco Celada, MD, Ana Williams and Rachel Seay, MD, joined guest speakers from Quezaltenango and Guatemala City. The conference targeted residents, attending doctors, nurses, and nursing students at Coatepeque Hospital. Immediately following the conference, we witnessed a dramatic increase in the number of patients arriving to our clinic.

Lead by our clinic nurses Zucely and Jahana, we saw many sick children, adults, and pregnant women. Common diagnoses included gastroenteritis, parasitic infections, pneumonia, and dengue fever. In total we went form seeing approximately ten patients a week at the advent of the clinic to 30 patients a day in July. With the power of three visiting doctors staffing our clinic throughout the month, Rachel Seay, MD, Maya Bunik, MD, MSPH, FABM, FAAP, and myself were able to expand our work beyond the clinic walls.

In addition to spending six weeks seeing obstetric patients in clinic, Dr. Rachel Seay engaged in hands on training with the obstetrics residents in the Coatepeque Hospital. She taught 2-3 weekly didactic sessions, guided residents through complex fetal monitoring cases, proctored c-sections and supervised pelvic ultrasounds.  In order to better meet resident needs at the teaching conference for July 2015, she asked residents to complete a skills self-assessment evaluation for future curricular planning.

Meanwhile, Dr. Bunik worked with our tecnicas (community outreach workers) and comadronas (local birth attendants) teaching breastfeeding techniques through role-play and one-on-one discussions. In addition, Dr. Bunik was able to make rounds with the nurses and nutritionists and deliver a total of 25 pump kits in the Coatepeque Hospital.

Our work as providers was complemented by our ongoing community outreach projects. Our vibrant tecnicas, Millie and Sairy, spent the month of July continuing their diligent community outreach work for pregnant women and children living in the communities surrounding our clinic. Also out in the community in July was our fearless student, Ian Eisenhauer, who is entering his second year at the University of Colorado School of Medicine. Ian completed a two-month pilot study on water quality in households throughout the communities of Los Encuentros and Chicarines. In doing so Ian not only was able show levels of E.coli in public and private wells in these communities, but he also developed the first detailed map of its kind for this region.

What was most impressive in this month of growth is how necessary an individual and community approach is to improving the health of our populations. We are not just treating acute illness. We are treating the consequences of a population’s lack of access to care, lack of access to routine vaccination, and lack of access to clean water. Although I write from our clinic, our approach will extend beyond it to include soccer camps in the schools (thanks Marko and Larissa Babiak, Maya Bunik’s children), initiation of pre-natal group visits in households, and introduction of new training opportunities for residents from within and outside of Guatemala. Under the leadership of Marco Celada, our continued growth at the Center for Human Development will provide greater access to care for workers and families in this region.


 

July 2014 - Marco Celada, MD

After having a bit of a slow start at the new Center for Human Development, things have certainly picked up. Since our opening in April, we had a small turn out number of patients for the first three months. This has allowed us to fine-tune the operation of the clinic without being overwhelmed. 

 A short survey was passed around among patients, employees of the plantation in management positions, and community leaders. Based on the results of this survey, the following strategies were implemented:

  • Open up the doors to the entire community and not just the plantation workers and their families;
  • Shift from a voucher system to a cash up-front and discount system as a form of payment;
  • Lower the price of a visit even more, from the equivalent of $5 down to $2 for employees of the plantation and their families, and $3 for non-employees;
  • We increased our efforts to speed up the approval of the license to operate our clinical lab and were able to start operating as of July;
  • We obtained two desperately needed big donations of medications which has allowed us to provide free meds for a lot of our patients, and has brought us closer to opening our pharmacy (scheduled to open by the 1st week of September);
  • We scheduled several days of free obstetric ultrasounds for pregnant women, and our head nurse was trained by our team of ob-gyn faculty led by Gretchen Heinrichs, MD, DTMH.

The implementation of these strategies yielded great results; we went from seeing an average of 20 patients a week to an average of 20 patients a day. A couple of days we’ve had up to 30 or more patients. 

Fortunately when these changes happened we had a great team of providers at our facility, including faculty from Children’s Hospital Colorado and volunteers from Denver Health. As the number of patients increased and the number of services increased we rapidly created a good name for ourselves in the surrounding communities and among the plantation workers. 

This summer has certainly been a busy one here at Trifinio in southwest Guatemala, as we have had many visitors doing different types of work for the clinic and the community.  From volunteers working on a study to test private and public sources of water, soccer minicamps at the local school and  team of doctors and midwives participating at the 2nd Congreso Internacional of OB-GYN at the local Hospital of Coatepeque.  We have also had faculty of Children’s Hospital Colorado and our new fellows at the Center for Global Health, to the first trip of the University of Colorado Dental School team who treated the children from the local school. 

 These have been some of the exciting activities happening at our clinic over the last few months and only the beginning of many more to come.

 

May 2014 - Marco Celada, MD

The new clinic in Guatemala is beautiful. After years of planning and preparation, the new white walls now stand out from the surrounding banana and palm trees. It is impressive to see what the collaboration of the Center for Global Health at the Colorado School of Public Health and AgroAmérica have accomplished. There are six clinic rooms, two delivery rooms, one room for the new babies, and a dental clinic. Those together with a clinical and a research laboratory, pharmacy, central nurse station, new computers, and an electronic medical record make the facility look exactly like what everyone hoped it would look like. In this isolated and long abandoned rural area of Guatemala you’ll also find a modern electronic and communications system, with high speed wireless internet throughout the clinic and laboratory. There is also a server linking all computers to a home network, desktop computers and laptops for the use of the staff. It is designed to be a place for excellent patient care that meets the standards of United States medical practices in rural Guatemala.

The goal of the clinic is to impact the health of workers of AgroAmérica and their families. An initial rapid needs assessment of the community showed that some of the biggest challenges to health in the area relate to maternal and infant mortality and morbidity, which is why the clinic has a large focus on pediatrics and maternal health. The clinic was inaugurated March 2014 and opened for business April 2014. It has already impacted the community by decreasing the cost barrier to families, which is important to families that may make only enough to put food on the table and have little left over for anything else. A visit at the clinic is around $5 versus at least $25 at the closest hospital plus the cost of transportation and the loss of a day’s wages. We have seen a wide array of acute complaints ranging from a child whose neck and upper chest were covered with oozing blisters from bullous impetigo to a young man who hobbled in on a left leg likely broken in 2 places from a motorcycle accident.

April 2014 we had our first pediatric resident from the University of Colorado School of Medicine, Jake Mark, MD who arrived at the clinic to start his global health rotation. Jake has been a great asset and a much needed resource. His experience here has been truly global. Besides his clinical responsibilities Jake has helped fine tune some of the clinic’s operational procedures, helped to organize the area of pharmacy and meds, sort through hundreds of boxes of donated medical supplies, tested out our electronic records program, Clinical Fusion, just to name a few.

There are many challenges ahead. However, seeing what the collaboration between the Center for Global Health and AgroAmérica has already accomplished, it is exciting to think of the possibilities we have here to improve the health of not just our community but also to create an innovative health model that can be replicated around the world. ​​​​​​

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