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.
January 2015 - Rebekah Gaensbauer, MD, MPH
The Center for Global Health works to improve health care in underserved regions of the world not only by improving and expanding the provision of health care services, such as in the Center for Human Development in Guatemala, but also through its research. The scope of research conducted by the Center for Global Health is diverse. One current study is trying to improve recovery from acute diarrheal episodes in children.
Diarrheal disease is responsible for approximately 800,000 childhood deaths per year globally, making it the second most common cause of pediatric mortality (Liu 2012). Diarrheal disease is also the fourth most common cause of global morbidity, causing an estimated 1.6 billion episodes per year in children less than 5 years (WHO 2014). Acute episodes of diarrhea are associated with weight loss, dehydration, electrolyte and micronutrient loss. Intestinal damage and the subsequent delayed return to normal bowel function can impair nutritional recovery in vulnerable children and contribute to both short term weight faltering, and potentially to long term malnutrition, growth failure, and increased mortality (Richard 2013, Black 2008).
Since its introduction, oral rehydration solution (ORS) has dramatically reduced death due to dehydration from diarrhea and is now the standard therapy for non-dysenteric diarrheal disease in low income populations (UNICEF/WHO 2004). However, while ORS improves electrolyte and water reabsorption, ORS does not directly promote healing of inflamed intestinal mucosa, nor provide nutritional rehabilitation. Multiple studies have demonstrated that the micronutrient zinc is important for GI mucosal integrity, and WHO currently recommends zinc supplementation for low-income children with diarrhea (UNICEF/WHO 2004). In addition to ORS and zinc supplementation continued breastfeeding is strongly recommended for children with diarrhea who can tolerate oral intake. Breast-milk contains factors including secretory immunoglobulins, fatty acids, lactoferrin, glycoconjugates and oligosacharrides, prebiotics, and immune modulators, that can prevent and ameliorate infectious diarrhea, provide nutrition, promote healing of the gut and restore healthy microbiota (Newburg 1998, Li 2014). However, the age when an infant or child is weaned varies, and many sick children are no longer breastfed.
Various studies have evaluated the effectiveness of using animal products enhanced with immunoglobulins against entropathogens as an attempt to duplicate the benefits of breast milk on infectious diarrhea. However, the results from these studies in terms of reducing diarrhea frequency and severity have been mixed (Huppertz 1999, Casswall 2001, Hilpert 1987, Sarker 1998, Ylitalo 1998, Xie 2013, Rahman 2012). The Center for Global Health is currently involved in a study assessing the impact of a combined colostrum/egg nutritional product on the acute and long term recovery from diarrheal disease in children. A clinical trial of this product is expected to start in January, 2015 and will recruit subjects in two sites in Guatemala. The study will emphasize not only recovery from the diarrheal illness itself, but also assess the impact of this product on weight gain in the weeks following recovery. If successful, this product may add another tool for the amelioration of the adverse effects of diarrhea on the world’s children.
December 2014 – Marco A. Celada, MD
As the saying goes “Time flies when you’re having fun,” and for me this past year has certainly flown by. In October, I finished my first year with the project, having spent almost 10 months at the site. Even though there were some tough times, and it was trying to be away from my wife, the enjoyment and gratification received from doing this type of work made time fly by. This entry will be the last one of the year and so I thought it would be fitting to summarize my experiences so far, but before I do that, I want to write about a recent case we had at the clinic.
On November 4th, around mid-morning, a mother brought in her three year old child who was convulsing. The mother ran from her home all the way to the clinic carrying her child, about a mile and a half. The mother stated her child had a fever the previous night. That morning he had been outside with a sibling when he started seizing. After about 10-15 minutes the seizing hadn’t stopped, so she decided to bring him to the clinic as she was fearful he was going to die. The first provider on scene was Anne-Marie Rick, MD, a Pediatric resident in at the School of Medicine, University of Colorado Anschutz Medical Campus and Children’s Hospital Colorado. Anne-Marie was rotating during November had just arrived at the clinic two days earlier. She did an excellent job securing the child’s airway, managing fluids to prevent aspiration, and doing the best with what was available in the clinic to stop the seizures and getting the child ready for transport. Due to the lack of an ambulance, we transported the child ourselves. Anne-Marie, along with our charge nurse Zucely provided the child with care during transport. This story has a happy ending since the child has fully recovered. However, if it wasn’t for the clinic, and if we hadn’t had Anne-Marie, a trained physician who knew exactly what to do, this child would have not likely survived. Even though we are set up as an outpatient clinic, being the only health facility within an hour’s drive of the nearest hospital, we know we are going to get all sorts of medical emergencies. In fact we have already had at least three or four other emergencies, mainly obstetric, which we have been able to transport or refer to the nearest reference hospital with positive outcomes.
To recap my first year, I will say the clinic reached many milestones. The clinic, which is the product of a partnership between the University of Colorado, Children’s Hospital Colorado and a private Guatemalan Banana Company, is a strong international presence for the University of Colorado. The clinic opened its doors to the public in April and also saw the first Pediatric resident from the University of Colorado and Children’s Hospital Colorado. We had our first University of Colorado School of Dental Medicine team visit in July. They visited two more times this year to provide dental services to the school’s children and also to adults. We had multiple visits from teams from different disciplines to provide training for our local staff and patient care at the clinic, these teams included pediatricians, obstetricians, nurses, midwives, water experts, medical students and public health professionals. We also hosted the first Physician Assistant student from the University of Colorado School of Medicine Child Health Associate/Physician Assistant program. We worked with Fred Thomas, MSSW, PHD, Director of Telemedicine at the University of Colorado School of Medicine and Children’s Hospital Colorado to establish telemedicine at the clinic (see the August newsletter of the Center for Global Health for an article on Dr. Thomas and Telemedicine). We even had one of the Pediatrics residents, Phillip Miller, MD present a case for morning report from our site via telemedicine technology. This was the first time the clinical case being presented was at a remote site and it just happened to be our international site in Guatemala.
For me it has been an interesting challenge working with the staff from the Guatemalan banana company and its ‘for profit’ business model, learning their way of doing things and also educating them in academia, public health, and our way of doing things. The needs of each partner is not always the same, and sometimes there are different pathways to one conclusion. Aside from clinical time and trying to make our patients the priority, I’ve kept myself busy and have enjoyed working with all the different teams of experts that have visited the clinic this year. I have also overseen our community health programs and supervised our community health workers. I have learned a lot from the administrative part of the clinic and programs, the setting up of the clinic, the lab, the pharmacy, the dental clinic, working with the Ministry of Health to meet all the necessary requirements to obtain our clinic, lab, pharmacy and birth center licenses.
We have made great progress and have had many milestones but there is still a lot of work to be done, and I’m looking forward to taking this project to the next level in 2015.
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.