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Colorado School of Public Health


Notes from the Field


Saskia Bunge-Montes and Roberto Delgado-Zapata are Celgene fellows at the Center for Global Health, and will be making regular working visits to the clinic. Saskia is from Guatemala City, and Roberto is from Lima, Peru. Kelly McConnell is the Global Health Fellow, and is focusing primarily on curriculum development and education for the Trifinio site. Lyndsay Krisher is the Guatemala Project Specialist, responsible for coordinating the resident rotations, and activities on the ground at the Trifinio site. Though they have different backgrounds and skills, they are all passionate about making change in how healthcare is delivered in Guatemala and throughout the world.


February 2016 - Saskia Bunge-Montes, MD

I’d like to think that after so many trips down to the El Trifinio region I have a good sense of what I can expect. However, every single trip has had its challenges, lessons and adventures – but such is life in global health.

This last trip included a combination of activities (mapping, translating, supervising, etc.), throughout which the message I took away was “increased capacity.” I left this last Guatemala trip reflecting on how much growth the clinic and projects have been through and the amount of time and resources spent on building the capacity of people at the site. Nurses, administrative staff, lab technicians, even cleaning staff have undergone training in some aspect of their work. They’ve learned new skills or how to do old skills more efficiently. While it is an ongoing process, capacity building is definitely one of the developments that is most exciting about this site. It not only assures the quality of the services provided but it also the sustainability of having locals in charge.

While capacity building methods like workshops, lessons and experiential learning are direct, I think that exposure to other people and ways of thinking is an important motivator to learn more.

As an example, pharmacists in Guatemala aren’t trained as they are in other nations, so they are mainly just in charge of sales. Knowledge of dosing, interactions, pharmacokinetics and pharmacodynamics are definitely subjects not addressed in their training. However, when I was there this month, a University of Colorado pharmacology student was rotating through the clinic pharmacy and spent a month exposing Carolina, our pharmacist, to subjects such as antibiotic use and resistance, dosing and interactions. It was gratifying to see Carolina’s interest and the pride she took in her new knowledge. Even better was seeing how this exposure then inspired her to want to learn more. Weeks and even months after the pharmacy student left, Carolina still emails asking for books and websites where she can find specific information. She’s been instrumental in having people who come asking for antibiotics - which you don’t need prescription for in Guatemala - come to the clinic instead to make sure their use is warranted. People come to the pharmacy asking for an antibiotic because it’s a cultural practice to take them for almost any ailment, however, more often than not it’s not something they really need. With her new knowledge on antibiotic use and resistance, Carolina asks people what they want it for and then suggests that they come into the clinic to see the doctor instead. So, even short exposures to people that have a different skill set can have endless positive spillovers on the people in the clinic and in this community as a whole.

Just as with Carolina, there are many examples of people whose growth I’ve enjoyed watching for the last two years. From specific skills like doing an ultrasound to learning how to drive and getting a tuk-tuk license, to those developed though experience like leadership and public speaking skills. I can safely say that everyone that’s worked at this site has learned or been incited to learn through exposure to different people, obligations and experiences. Continuing to watch and be a part of this growth is something I definitely look forward to.


January 2016 - Lyndsay Krisher, MPH

When I first started working at the Center as the Guatemala Project Specialist, I could not have imagined how quickly the project would grow. We now have community outreach programs in maternal and child health and development (growing all the time), research projects in infectious disease, a busy clinic and soon-to-be birthing center of local physicians, nurses, and medicine residents and students from Colorado, and so much more. One aspect of my job is to help support our team of Guatemalan community health nurses who implement the maternal and child health programs in the communities of the Trifinio. The nurses work tirelessly to implement our programs, and in doing so have gained the trust of the communities – without which we could not be truly effective in our work. In January, I had the opportunity to go with them out in the communities and attend some of the child development care groups and maternal health prenatal and postpartum home visits, to see the nurses in action. It was so much fun and enlightening for me to spend time with them and learn more about the important work and challenges they face each day.

In addition to the time I spent with the nurses, I also worked with a MPH student from the Environmental and Occupational Health concentration as well as an Occupational and Environmental Medicine fellow from Denver Health to pilot a health risk assessment survey that we created in collaboration with the Center for Health, Work, and Environment at Colorado School of Public Health. The survey will be taken by workers at the AgroAmerica palm oil and banana plantations that are near the Trifinio clinic. While we have implemented several programs for the communities of the Trifinio, we have not yet initiated services to directly benefit the workers themselves at the Agro America work sites, outside of the clinic. To pilot the survey instrument, we collected and reported basic health and safety information from about 50 workers from each site - just over 100 in total. Each day we tweaked the survey a bit more, removing and reworking questions to make them better understood by the workers, until by the end of 6 days of surveying, we came away with a succinct and thorough tool that captures the information needed to understand the health status and needs of the population. Questions include the number and type of injuries suffered at work, chronic disease history, water and soda consumption, stress factors, how many hours of sleep they get per night, and so on. Having this tool completed will allow us to obtain a baseline of the health conditions of this vast and diverse workforce so that we can tailor programs that directly serve their needs and ultimately improve health and safety conditions at work, home, and in the community.


December 2015 - Roberto Delgado-Zapata, MD

As soon as I started as a Celgene Fellow at the Center for Global Health, all I heard about were the projects currently developing down in Guatemala. The first month, I had the opportunity to meet with some of the project managers to get to know what each one was doing and how could I get involved. First, I decided to focus my research interest in child health and development and so along with my mentors, Stephen Berman, MD, and Maureen Cunningham, MD, MPH, we planned a trip to El Trifinio so I could check the real nutritional status, and find out what nutrient deficiencies the children from our communities are most risk. Our goal is to design and develop a nutritional intervention that takes into account the limited resources in the communities.


Before the trip, what I knew about El Trifinio region is that it is a geographically, cultural and socioeconomic diverse area, surrounded by many crops for export. Also, not so different from many rural areas in Latin American countries, most of the population struggles with poverty and lack of access to health, education, and sanitation. Overall, it looked very familiar, in terms of necessities, to the communities I had worked with in Peru, but this time I was not working in the dry and cold highlands, but rather in the very hot and tropical lowlands.


From the very beginning of our way from Guatemala City to El Trifinio, we could see breathtaking scenery: volcanoes and mountains surrounded by a thick mist; and as time passed, the landscape quickly turned to green rolling hills with some houses along the road. But it is incredible how this natural wonder contrasts with the high rates of chronic malnutrition exacerbated by the political, economic and food insecurity crisis the country is facing.


About half of Guatemala’s children are malnourished, and they will face physical and developmental challenges in a very complex scenario that offers few opportunities to their families. I got the opportunity to interview the nurses from our clinic, nurses from the health posts in “Los Encuentros” and “Chiquirines” communities, mothers from “Carrisales” and merchants also from “Chiquirines” local market. It is surprising that even though these communities are surrounded by crop plantations and most of the population works for them, they have very limited access to fresh vegetables and fruits, which are available only from a local market that opens twice a week. They also have limited access to meat and chicken, and they cannot buy much because of lack of refrigeration. It very difficult to stand there and observe that despite being surrounded by an incredible valley, very little of those crops actually make it into local market and homes.


More surprising yet is that in contrast to the poor diversity of fruit, vegetables, and grains sold in the local markets, the number of infant formula from different brands and size is much higher. Through my conversations with the mothers and health post nurses, I realized how contradictory it was that some people say they don’t have money to buy fruit or vegetables but they do for buying expensive infant formula, rather than breastfeeding. So the problem is not just necessarily economics or poverty, is combination of lack of education and opportunities that make this paradox.


This trip was informative for me, not only because I got the opportunity to meet each one of the team members at the Center for Human development, and get to know the great job they are doing to improve the health of the local population, but also because it reminded me why I decided to join the Center for Global Health team. It has been about 4 years since I last worked in rural communities, and seeing the day-to-day struggle these people experience is very moving. The problem about malnutrition is and will be challenging, but I look forward to future trips so we can start working together with our communities to tackle it.


November 2015 - Kelly McConnell, MD

As an educator with a focus on global health, I have been working on several projects to expand and organize the curriculum the Center for Global Health provides to our colleagues working at the Guatemala Trifinio site. This curriculum development relies on technology, and teamwork across disciplines.

The residents at Children’s Hospital Colorado have the opportunity to do an elective at our Guatemala site; I did the elective myself in September of last year. The month long rotation offers experiential learning with exposure to a multitude of clinical and psychosocial issues not routinely experienced here in the greater Denver area. We all enjoy the experience – the clinic, the colleagues at the site, and the challenges of working in this environment – as well as the travel experience, of course. However, the unique clinical situations we are faced with during the rotation requires strong preparation. It is vitally important for residents to have an understanding of the correct treatments for diseases they’ve never seen, and dosing for medications they have never used. Understanding the culture and the health care system in which they are working is another novel challenge. As a former participant and now fellow, I understand the importance of planning an effective curriculum to prepare our residents for success at the site. Furthermore, this educational opportunity will shape these physician’s careers – hopefully inspiring them to take their skills across borders again. I am working with education experts, and reading medical education texts to establish a comprehensive curriculum. We are doing exciting, collaborative work with global health track 2nd year residents. Along with faculty, we are creating outlines for practice in a resource limited settings, which can be reviewed prior to and during a clinical encounter. We indetified an app that will allow us to present our outlines in a video format to enhance learning and retention by providing multiple pathways of information input. I’m really excited about the potential of this part of the curriculum. We can develop a substantial set of information (in text and video formats) to be used to help residents navigate encounters in our clinic, but potentially in other settings as well. Additionally, we are developing further evaluation methods to ensure we are meeting the goals and objectives of our curriculum.

Another curriculum development project includes the community health nurses. We believe we have an obligation to their professional growth, which also ensures the highest level of service to our patients in the Trifinio. A group of educators at the Center for Global Health is developing this curriculum with another new technology. We are using a telehealth system – Vidyo, licensed by Children’s Hospital Colorado – to do weekly teaching. This system provides a platform for a core group of instructors to cover important material without the cost of regular travel to the site. We conduct teaching sessions on a near-weekly basis, which allows the community health nurses to engage through interactive questions and case discussions. This method is cost-effective while actually increasing our contact time with the team. We have piloted the system for several months with great success but are now developing a full curriculum with goals, structured teaching plans, and evaluations to create a robust program that can then be shared with other institutions as an effective, cost-saving educational model for community based health care. I look forward to continuing this work throughout my fellowship.


August 2015 - Saskia Bunge-Montes, MD

This summer I had the opportunity to travel back to the Center of Human Development in El Trifinio, Guatemala. This rural region in southwest Guatemala is about 5 hours away from Guatemala City and has more than 20 communities that are mostly reached by dirt roads. There are no real maps of the area and the last population census was done in 2002, so we don’t really know how many people live in the area or basic demographic characteristics of groups we want to serve. So, to provide better services in our community outreach programs and clinic it was decided that maps and a census of the area were needed.

I was part of the group that organized this project and was tasked with the job of training surveyors and local project coordinator in Guatemala. This was an exciting opportunity since I had been looking forward to working more closely with community members since I first visited the site a year ago. One of the goals of the the project is to incorporate community members and have them participate in the mapping. We hired four young surveyors aged 19-24 who lived in different local communities. One of them is a single mom, the second is a lawyer-in-training, the third just finished school, and the fourth is a secretary-in-training. These four young surveyors were happy with the offer of temporary employment and were very eager to learn about using the GPS and Palm Pilots we were using for the project.

We also hired a project coordinator, a young local pastor who is also studying business administration on the weekends. I wanted someone with a sense of leadership, who was able to speak easily with community leaders and was eager to learn, so he was the perfect person for the job. As a pastor he was an excellent and natural communicator and helped create a good environment amongst team with the surveyors and community leaders. A pastor in this area holds a position of distinction and is a trusted and respected person; having someone like him at the forefront helped when approaching community leaders. This was especially helpful since we were starting the project in the middle of a very controversial and heated election season in Guatemala, and tensions were high in these communities. For two weeks we approached community leaders and told them of our project and assured them that they would be getting the resulting maps and census data for their communities too. This was very good news to many of them because there have been projects in the past were people have gathered data from their communities but failed to communicate any findings back to them. We had community leaders appoint community members as guides or participate themselves with the survey. A community leader or an appointed guide accompanied each of our four surveyors in the communities, presenting the surveyor at the household and assuring that leaders knew about and approved this project. We’ve been successfully surveying for over eight weeks now and the team of surveyors and coordinator are doing an excellent job. I’ve loved being part of this process and seeing how motivated local leaders are and excited to be included. Through my conversations with leaders I’ve learned that maps and census data can empower these communities much more than I initially thought they could. I look forward to going back and being able to relate our findings back to the people that really want and need them most.

May 2015 - Saskia Bunge-Montes, MD

I’ve had the opportunity to visit the Center for Human Development in Guatemala three times over the past year. Every time I come here, I’m in awe of the families that live and work in this area. This dry, hot, secluded land is scattered with people living with little to no access to water. I am constantly struck by what they do here with so little, out of necessity. Every time I’m at the site I have the opportunity to spend the week tagging along with the nurses to maternal-infant care groups, individual house visits, and sometimes see patients at the clinic, too. I have enriching interactions with a variety of people in the area including nurses, engineers, plantation workers, mothers, infants, and traditional birth attendants – to name a few. Over the course of my visits, each person I’ve encountered has provided me with more insight into the community and surrounding area.

From an outsider’s perspective, this area seems geographically and culturally diverse, and therefore lacking one community identity. It’s a community is defined in part by the businesses that surround it. Within the same small area there are a mix of socioeconomic levels, a mix of ethnicities (indígenas, ladinos and mestizos) and a mix of cultural influences that make it hard to generalize the community as a whole.

This area derives some identity from its close proximity to the Mexican border. Additionally, there are three different Guatemalan states (San Marcos, Quetzaltenango and Retalhuleu) that converge in this area – giving it its name “El Trifinio.” It is an isolated area that is still heavily influenced by the surrounding cities and the active commerce that bustles through. Perhaps surprisingly, even the most remote homes have a radio, TV, or cellphone, so although they may be isolated, they are by no means disconnected.

One situation in particular made me realize how diverse even small groups within the community can be. At a recent maternal-infant care group, one of our community nurses asked a group of women what they would do if their child had a fever. The variability in answers surprised me. In my experience working in rural communities in Guatemala, I have observed some communities with “western” influenced responses, and other communities that reflect more traditional practices in their responses. This group had both. In response to the question of fever, one mother mentioned she would rub the child with alcohol and remove his clothes, or take him to the curandera. Another mother said she had seen on the Internet (on her phone) the correct dose of acetaminophen to give her child. Yet another woman said she’d probably take her child to a clinic first. So, in this small group of six women we had a range of answers that revealed the diversity of perspectives that are found in this area.

Community identity and diversity play an important role in health seeking behavior and health education. Both factors impact our clinic and our community outreach projects. The more we know about the community the better we’ll be able to serve the families that reside within it. I look forward to future visits and to better understanding the dynamics that shape their lives.

Center for Global Health

13199 East Montview Boulevard, Suite 310
Mail Stop A090
Aurora, CO 80045


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