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University of Colorado Denver


Notes from the Field


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.  Kim, Gabriela, and Saskia are fellows at the Center for Global Health, and 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.

June 2015 - Gabriela Samayoa-Reyes, BSc

As I am about to finish my one-year Celgene Fellowship at the Center for Global Health Anschutz Medical Campus, many experiences, adventures and lessons come to my mind. I will use this opportunity to revisit what I have been able to achieve as a fellow.

I have been involved in many different activities with the Center, at the beginning I thought that I was only going to be involved in actual laboratory work which is what I was trained to do. But I have done much more than that. I have challenged myself and my knowledge, which has allowed me to become a better and independent professional.

One of such activities was getting a surveillance project started. I’ve been involved from drafting all the laboratory procedures to actually troubleshooting the problems at the Trifinio Site. It has been a great challenge to do this from Colorado, trying to explain something technical using nothing more than a video call. You certainly get creative trying to solve problems. I had the opportunity to visit the site a couple of times, using my time so that every procedure was clear and understood and making sure that they will be able to continue without me physically being there.

I also did laboratory work as expected. I worked in an ongoing project with kids from Uganda, whose goal is to determine early parasite infection in new-born babies. I have worked in this all year long, setting up the assay, standardizing the procedure and actually running samples. My troubleshooting capacities where once again placed into action here, trying to get the assay to work as it is supposed to. This has also allow me to learn new techniques and to work with multidisciplinary groups collaborating together.

I am sure that there is great potential in all of the projects currently being done at the Center and at the Clinic Site in Trifinio. I am sure that we’ll see amazing results from everything that is being currently done. All of this is thanks to the effort and time that is put into each and every single project not only by the PIs but by every team member working here and down there.

What I can take from this year of fellowship are the experiences I gained and the lessons learned. Both of which opened a whole new set of opportunities; I got accepted into the Microbiology PhD program at the University of Colorado. I consider this fellowship just the beginning of many great thing to come and many new opportunities.

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.

March 2015 - Gabriela Samayoa-Reyes, BSc

For three weeks in March and April, I worked at the Center for Human Development at the Guatemala Trifinio site. My goal was to assist the laboratory set-up for the Dengue and Norovirus Surveillance projects. After finalizing some set-up details the Research Laboratory, I trained the lab technician that will be working on these projects. The final objective was to start collecting samples.

To start, this was a humbling experience. Realizing how people live here, and how they manage to make the most out of what they have made me re-think what I have, and how I dare to say it isn’t enough. What’s more amazing is their good heart; these people were willing to share their only meal with us, just because of our interest in helping them. My heart breaks just thinking about it.

This experience also reminded me what doing science in a third world country is like, even more in a rural area that is 6 hours away from Guatemala City. Things that we take for granted here in the United States are the biggest problems down there. Among these I can mention finding someone that knows the job, which is very unlikely to happen. The best option is finding someone qualified and interested in learning what the job entails. Getting the equipment needed was also a difficulty; we have been working in setting up this laboratory for at least six months, and there was always a delay because what we needed hadn’t arrived. Reagents and other lab supplies get imported, shipped and released from customs, which can take up to six months! Something else we don’t even think about in a developed country is energy supply; there is always electricity and we don’t need to worry about it. Down in rural Guatemala we have three back-up plans and it is very likely all of them could fail. Having several plans in place is extremely important, because we cannot jeopardize the study subjects’ samples. Samples that have been entrusted to the project are painstakingly collected from kids, and we are very serious about keeping them in safe conditions.

Tasks that wouldn’t have taken more than a week here in the U.S. took me 3 weeks at the Trifinio site. This was an enriching experience for me, not just because of what I learned about setting up a lab, but because of the people that I met and learned from. I can’t wait to be back and continue to help the project by visiting the people of the Trifinio, mentoring the lab technician, and making sure every sample is being handled in the best possible way.

February 2015 - Kim Insel, MD, MPH

At the start of this year, James Gaensbauer, M.D., M.Sc., and Dan Olson, M.D., began new research projects in the Trifinio region. The projects are actively underway this month. Also in February, our child development and maternal care directors both traveled with teams of faculty and residents to continue training and evaluation projects. These new and ongoing activities take place against the backdrop of daily care in the clinic and surrounding communities, which is provided by clinic director Marco Celada, M.D., and our local team of nurses and community health workers.

During my own recent clinic staffing experiences in the Trifinio, I was again humbled by the complexity of illnesses in this region. It is challenging to see one stunted child present with dehydration and it is harrowing to see several a day. There is an s. critical imperative to provide care for children who present daily with acute on chronic diarrheal illness and malnutrition.

The effects of unclean water, poor sanitation, and lack of fresh, nutrient dense foods plague many families in this region. These factors in combination with minimal opportunities for education create barriers to healthy livelihoods for many living in the Trifinio. Our community programming is directed toward safe motherhood and early childhood development, which allows us to begin addressing some of these barriers.

I am very grateful for the time I have had to work in the Trifinio. I continue to learn an incredible amount from our team of providers. With our physician Marco Celada and experienced nurses Zucely Lopez and Yajana Alonzo (amongst others) we have successfully delivered care to hundreds of residents living in the Trifinio. Along with the daily efforts of our talented community health workers—traveling in the heat to remote areas of the community—we have begun to foster new healthy opportunities for our communities to thrive.

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.

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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