Global Health Night at the Phillies!
On Tuesday night, September 20, over 650 CHOP staff and their friends and families attended Global Health Night at the Phillies. Even though the Phillies lost to the Washington Nationals, it was a fun game for all!
Former Global Health Fellow, Dr. Henry Welch, throws the first pitch at the game!
Las Promotoras de Salud
Promotoras de salud or “health promoters”, are an important part of the NPS (Niños Primeros en Salud) program in Consuelo. Promotoras de salud are women that are identified by Ramona, our nurse, as natural leaders in their barrios. They act as a resource for health information in their community and provide support for children in the NPS program as well as breastfeeding mothers.
Here are some pictures of NPS health workers learning more about the importance of breastfeeding and practicing their skills!
The Work Begins in Consuelo
The weather in Consuelo this week couldn’t be any different from last week, when we were inundated with rain and the roads turned into puddles of mud. This week it is hot, and life in the barrios is back to normal. Below are some pictures from the hard work the CHOP team did last week.
Below, NPS coordinator Abel Gonzalez, and our new Global Health Fellow, Dr. Marc Callender measure the height of a four year old girl new to the NPS program.
Siblings and neighbors look on as Dr. Marc Callender measures the height of a new member of the program.
Dr. Deb Voulalas, Dr. Marc Callender and Abel Gonzalez all help to measure the head circumference of a toddler new to the program.
Above, mothers from the recently enrolled barrio, Cachipero, meet for their first educational charla, or talk, given by the Robert Reid Cabral residents about cholera. Dr. Ingrid Japa and the CHOP team look on.
8-25-11 DR Encuesta Trip
Animo is a Spanish word for a positive outlook when circumstances are tough. This is the perfect word to sum up our little working group here in the DR. We flew from Phila to Miami to have the flight cancelled because of Tropical Storm come Hurricane 3 Irene. We stayed overnight in Miami with no luggage trying to collect information from the DR and peers to decide whether or not to attempt the trip the next day. The next morning there was no new info but the decision was- if the plane leaves-so do we.
Under the leadership of Maura Murphy (a woman who has been working with Global Health for only 8 months but seems to have been doing with for ten years she is so knowledgeable), with an incredible sense of humor and a desire to get to work we got on the plane to Santo Domingo in our clothes we had been wearing for 24 hours and flew to the DR. Upon arrival, the bags of course, had been lost and the storm was beginning full force in the DR very shortly after arrival. With promises of our luggage later that night and Martina’s famous cooking we travelled the 45 minutes to Consuelo with our invaluable friend and collegue Abel.
The following day we got up, had some coffee, still with no luggage or running water headed to the Centro de Salud. Work in the Barrios was impossible with the still raging storm locals were scared and stressed, many not home because they were forced to head for friend’s homes or sturdier buildings. In Consuelo, schools were closed, the Centro de Salud closed at noon and we were sent home, wondering if we going to be able to work at all this trip.
That night we collected ourselves, our luggage arrived in pouring rain (It had been three days since we last saw it leave on the belt in the Philadelphia airport) from a brave driver from Santo Domingo who was the only one willing to drive around in the flooding streets. We counted our blessings, ate more of Martina’s famous cooking and enjoyed each other’s company and Maura’s version of 20 questions.
Finally Wednesday came, the weather cooperated and we headed to the Barrio Chachipero where our work was to enroll children under age five in the preventative health program set up here. The neighborhood of Chachipero gets it s name from the ashes that used to rain down on it when the now defunct sugar cane plant was still operational. The small neighborhood of about 150 homes stands in the shadow of the skeletal buildings that processed sugar cane some 10 years ago. When the factory closed, so did the economy of Consuelo. There are now precious few jobs, the main economy now is pulling the metal and copper out of the plant and selling it on the black market. Abel told us stories of folks being shot with regularity by the plant guards, while stealing the metal. We met one man who had been shot in the foot while stealing metal who told us that even though he had been shot, the price of the metal was well worth it because there is no other way to make any money for food.
Working through the day we enrolled the entire Barrio in one day. Parents over and over again were amazed that two doctors, Deb Voulalas and Marc Callender, would travel out into their homes with unpaved streets to talk to them about their children’s care. Abel and Larissa Slavic (herself from the DR, not far from Consuelo) chatted with families, weighed children and interviewed families with such ease it did not seem at all the fledgling effort it really was. Ramona, the Nurse at the Centro and NPS shared her knowledge and experience with the team and it was clear to us all that this effort would have been almost impossible without her. Finally, two medical residents from Robert Recabral Children’s Hospital were with us and though they were there to learn they showed grace and skill beyond what was expected of them.
Tired, sunburnt and with much Animo, our little team returned home to La Casa Roja Wednesday night. We had come this far not knowing exactly what to expect, not expecting at all what actually had occurred and like the little engine that could, succeeding with the sheer will and positive attitude.
It is now Thursday morning and our energetic little group is headed out to Barrio 41 to work in the torrential rain and mud. While conditions are difficult we are all aware and appreciative, of each other and that families allow us to share their experiences and our knowledge. Viva La Republica Dominicana!
More guava jelly and coffee; less formula, please.
I’m passing a rainy afternoon on the porch of Casa Roja. Through the house, I can hear the roar of the downpour on the kitchen’s tin roof. Outside the wrought-iron enclosure of our front porch, water is dripping from the fern, the banana leaves, the birds-of-paradise, the mango tree across the way (oh, mangoes, how I wish you were ripe already!). The rain is much-needed – it’s been a dry April in Consuelo.
This is my third visit here, and this time it’s just me and Maura Murphy, CHOP Global Health Program Manager. We’ve come to meet, observe, brainstorm, and begin to develop ideas about how we can grow and shape the Global Health program here going forward. We’re looking for ways to do this that are sustainable, useful to the community, and valuable to our clinical partners. It’s an exciting project, and I feel lucky to be here not just because it’s, you know, the Dominican Republic (warm weather, warm people, amazing coffee, merengue and bachata, tropical paradise, etc).
We arrived on Monday. Without wasting a minute, we dropped our bags and headed back out to meet Lara and Ramona in Barrio Puerto Principe, where they and a breastfeeding expert from San Pedro’s chapter of La Leche League were leading a workshop for the pregnant women and new mothers of the barrio. Priscilla, the lactation expert, reviewed with the women the benefits to mom and baby of breastfeeding, dispelled myths, gave advice. A few babies sat quietly on their mothers’ laps throughout the meeting, gorgeously fat and bright-eyed little testimonials to the benefits of breastfeeding. This type of workshop is especially important here, in a place where there’s a popular sentiment, for some reason, that formula is best – even though clean water to prepare it with is often extraordinarily difficult or time-consuming to come by.
Afterwards, we made our way along the rocky dirt roads of Barrio Villa Verde for another workshop with that barrio’s new and expectant mothers. In both places, I noticed the mothers’ pride when we congratulated them on the considerable achievement of exclusive breastfeeding. Now, Priscilla will meet with the women of each barrio monthly, and the health promoters will lead monthly breastfeeding support groups. The NPS team has been tireless in its efforts to encourage breastfeeding in the barrios, and it’s exciting to see that their efforts (if those happy, pudgy little niños we saw at the breastfeeding meetings are any indication) are finally paying off.
Changing popular sentiment is no small undertaking, and we have a long way to go. Last night, Maura and I went to Zaglul, the local supermarket, to buy some essentials. I wanted to get some guava jelly, and, as it happens, the jelly shelf is in the infant formula aisle. That’s right. One (half empty) shelf for jellies and jams, and an entire half aisle for infant formula, stocked floor to ceiling with more varieties than I ever could have imagined existed (and I’m a pediatrician). We sighed, then moved on – I cleaned out the coffee shelf and we were on our way.
But it’s exciting to think that the NPS barrios, where breastfeeding as a practice seems to be gaining some real traction, could be leading the way for a change in how Consuelans feed their babies. It would give those mamas something big of which to be even prouder.
Two days ago I went out to the bateyes with a Dominican doctor, two nurses and a health promoter. We set up shop in an unused classroom in a school in the middle of the sugar cane fields and waited for people in the bateyes to line up to see a doctor. From 10am to 2pm, the mobile clinic team saw close to 50 patients of all ages, with varying degrees of sickness and aches and pains. This was the first time the team worked in this particular bateye, called Altagracia, named after the patron saint of the Dominican Republic, and they will return in one month’s time to follow up on the community.
When we were driving through the sugar cane fields to reach Altagracia, I reflected on how, for many people living in the bateyes and in many places in the developing world, accessing healthcare is an extraordinary task. To see a doctor, one must not only have the funds to pay for the consult, the tests and the medicines necessary to treat them, they must also find a way to get there. For people living literally in the midst of the sugar cane fields, transportation is one of the most difficult hurdles to get past. So, people live for months and in many cases years without treating medical illnesses. These illnesses seriously affect quality of life for children as well as adults. For children in developing countries, however, it is not only a lack of access to care that makes them vulnerable, but also an underlying presence of poor nutrition that makes them especially at risk for dying from a preventable illness.
In Altagracia, as in many other bateyes, malnutrition is a product of poor sanitation, an insufficient water supply and poverty. Children that grow up with chronic malnourishment will be affected by an increased burden of disease and the effects of stunted growth when they are older, which will in turn make them less able to work and provide a different life for their own children, a vicious cycle.
Luckily, only a few of the children that the team treated in Altagracia were below weight, and none of them were suffering from acute malnutrition. When the team returns, they will follow the children and ensure that they are still above weight, and if not, they will provide nutrition packets designed to improve nutrition for those individual children.
Nevertheless, as we were driving out of the bateye, into the picturesque sugar cane fields once again, I couldn’t help but think about what it would be like not to be able to afford the bus ride to my doctor, or be unable to find the funds to buy a prescription medicine I might need.
The truth is, I will probably never know. All I can do is try not to forget the people who do.
When you enter Barrio Puerto Principe, one of the new barrios where NPS is working, you get the feeling of walking into a shantytown of a big city…miles away from the bateyes and more expansive barrios to the north and south of town. Puerto Principe was named after Port-Au-Prince, the capital of neighboring Haiti, and is full of Haitian families who migrated to the D.R. to work in the sugar cane industry and stayed. In Puerto Principe, the houses of wood and corrugated iron are small and packed closely together, and as you walk through the winding pathways that have been etched into the grid of the neighborhood, you will often find yourself in makeshift plazas, where children play ball and laugh together when school gets out. Around every winding corner you might find women braiding each other’s hair, or playing card games while their babies play at their feet. The walk through Puerto Principe only lasts, at the most, 10 minutes, but the barrio is so densely populated that along the way you pass hundreds of people living in very close quarters.
Ramona knows everyone here by name, and as she took me on a tour through the barrio she stopped and introduced me to many of the mothers who have children in the NPS program. We spent at least 15 minutes at the home of a new mother talking about the difficulties and benefits of breastfeeding, and Ramona encouraged her to stop into the NPS clinic the next day for the next set of vaccinations for her baby. I can’t be sure, but I believe that young mother made it into town the next day and her baby got the shots he needed. We met another young mother whose 6 month old baby was born with a cleft palate. Luckily, he is a happy baby and has been gaining weight over the past few months. On Monday, he will be operated on in the capital and return home to the barrio soon after, a welcome homecoming for this small family. Ramona and the NPS team have been following his case closely since he was born and will follow up with him when he returns to Puerto Principe.
I am looking forward to hearing how his surgery went and wish I had a lot more time here to spend getting to know the families in the barrios.
After a couple of very productive days in Consuelo, I took my first trip into the barrios, or neighborhoods, where the Niños Primeros en Salud (NPS) program has been working since 2009. Ramona, our NPS nurse, walks through these barrios every day and into the evening after her work at the clinic ends. She tirelessly reminds mothers to take their children to the clinic for their shots, talks about the benefits of breastfeeding and dispenses words of advice whenever she needs to. She knows the names and homes and stories of every single patient enrolled in the program, a truly amazing feat.
During our walk through Barrio Filliu, the largest of the four target barrios, Ramona told me about the changes she has seen since she started doing community outreach for the program almost two years ago. Nearly 100% of the children in the barrios are immunized, all of the children take their de-parasite medicine every 6 months, and many of the come on a regular basis to the clinic to be seen by our pediatricians. The number of children in our nutrition program because of malnourishment has decreased dramatically, and those that haven’t graduated from the program are followed closely by our medical team. The women I spoke to in the barrios echoed what I heard from Ramona…that little by little the children in the community are getting healthier.
Although we have a long way to go, we are well on our way to getting there.
After a quick layover in Miami and a drive through an afternoon rainstorm, Rodney Finalle and I arrived in Consuelo, Dominican Republic for my first ever night on the island. We were met at the Casa Roja by our Pincus Fellow Lara, her husband Toby and their beautiful 1 year old daughter Lucia Rose. It is refreshing to be in warm weather after the long, cold Philadelphia winter!
Over the next few days we will be meeting with many of our partners here in the Dominican Republic. I look forward to putting faces to names and building on relationships that were started many years ago by our CHOP Allies (and of course having some more of Martina's cooking!)
More to come in the days ahead.
Maura Murphy, the new program manager for CHOP Global Health, will be blogging about her first trip to Consuelo, Dominican Republic over the next couple of weeks.
And when you learn to walk, wear shoes to avoid those nasty hookworms.
Yesterday was a day of first steps.
In the morning, the CHOP and NPS teams in their entirety met up at the clinic for our first-ever joint academic conference. The electricity in the clinic was out, so we were a little delayed waiting for someone to go buy gasoline for the back-up generator, so we could power our projector. But once the generator roared to life, doctors, nurses, pharmacists, and interpreters crowded into white metal chairs in the conference room and we were on our way! First, the two current rotating RRC residents gave a well-timed presentation about cholera. There has never been, to date, a cholera outbreak in the Dominican Republic, according to the NPS doctors. But with the worsening epidemic in neighboring Haiti showing no signs of abating, here it's on everyone's mind. Then it was our turn. Barbara Picard, nurse practitioner from CHOP's Market Street clinic, and Eden and I gave a case presentation. Our talk was on a bread-and-butter general pediatrics topic -- a child presenting with a neck mass. Nothing fancy, but we wanted to discuss how we approach a common complaint, with a broad list of diagnostic possibilities that we then narrow down based on the particulars of the case. More importantly, we wanted to learn how our Dominican counterparts would approach the same kind of patient.
Because of our late start, we ran over the allotted time, but the NPS, RRC, and CHOP pediatricians clustered around a table exchanging ideas and stories well into the lunch hour, in a rapid mix of Spanish and English that seemed to get everyone's point across. After a quick stop back at Casa Roja for a lunch of the clean-out-the-fridge, day-before-departure variety, it was time for the second half of the health promoter workshop, the first having passed successfully on Thursday afternoon.
The health promoters are a group of barrio residents (usually women, as it turns out), one from each neighborhood, who've been identified by the community as particularly capable. Neighbors come to them for advice, and they serve as a link to Ramona and NPS. The health promoter model is not unique to Consuelo or to the bateyes or barrios -- but it's hugely important here. Though these women have no formal medical training, sometimes they're the closest a barrio child will ever come to seeing a pediatrician. On Thursday, we met five of them in a breezy, covered outdoor meeting room at the Asilo, a residence for elderly men without families, run by the same nuns who founded the Centro de Salud. Alicia Genisca, CHOP second-year resident, delivered a charla on breastfeeding myths and truths, leading to a spirited discussion about community beliefs about breastfeeding. Barb then gave a talk about the contents of the supplemental food packets received by the families of children in the clinic's malnutrition program, and she passed along some recipes from Martina for the nutrient-dense foods in the packets (oatmeal, rice, beans, sardines, cornmeal, peanut butter, powdered milk, and calcium granules).
For day two, Eden led off with an expanded version of the parasite charla we've been delivering in the barrios for the past two weeks, complete with new and disgusting close-up pictures of worms. Beth Resweber, CHOP PACU nurse, followed up with a companion piece on hand-washing, ending with her 20-second hand-washing song, which is always a crowd-pleaser (to the tune of La Bamba, "yo voy a lavar los manos...yo voy a lavar los manos con jabon, y un poco de agua..." ). Then Kelly and Carine and I gave our talk about vaccine-preventable illnesses, how immunizations work, and how to manage common side effects. Ramona delivered the part about the Dominican vaccine schedule, sharing a clever piece of Dominican wisdom that always impresses me: at birth, babies get the BCG vaccine in the left arm and the hepatitis B vaccine in the left leg; at 2, 4, and 6 months, they get a combined DTP/hep B/HiB shot in the right leg; and at a year they get MMR in the right arm. This way, even if a family has lost a child's vaccine card (which you can imagine might happen often given the crowded, cramped conditions many of them live in), by asking where the last shot was given, you can get a sense of how up-to-date a child's immunizations are. (But make no mistake, Ramona is strict on this: if a family can't provide an immunization record, the child starts the series from the beginning, no exceptions.)
At dinner, Kelly updated us on the data-gathering part of our anti-parasite barrio efforts: in two weeks, over one thousand barrio residents de-wormed and educated.
And to cap off the day, we found out that Lara's little daughter walked for the first time! We sat back and thought about it a little. It's a good feeling, learning to walk, watching the scenery change as you feel the momentum growing.
If CHOP were in Santo Domingo, it might look something like this.
Yesterday the nine of us, together with Lara (the Global Health fellow) and Dr. Jappa (from NPS) hopped on a guagua (mini-bus) bound for Santo Domingo, for a tour and conference at the Hospital Infantil Dr. Robert Reid Cabral. Named for a famous Dominican pediatrician, it's a 350-bed tertiary care children's hospital that serves as a referral center for the whole country. There are over a hundred pediatric residents, and as of several months ago, its fourth-year residents have started rotating through the Centro de Salud Divina Providencia in Consuelo.
When you walk into RRC, there's a vibe that I can only describe as "tertiary." I got teased a little for saying this, but it felt like home: the hum and buzz of a busy resident-run hospital, immaculate and brightly-lit, with signs everywhere encouraging hand-washing, and with white-jacketed young doctors and nurses peering curiously at the throng of visitors. The residents, mostly young women, were unfailingly polite and friendly, and clearly were proud to lead us through their pediatric wards, NICU, PICU, ER, and cardiology and renal transplant units. As we passed through the ER and stopped to chat with its medical chief, we noticed a resident attempting to draw blood from a young boy beside us. The boy was screaming and flailing, and the unlocked stretcher was rocking back and forth. Cool as ever, Kelly Vuong, CHOP ER nurse, walked over and set the stretcher's brake. The Dominican doctor then did her best to convince Kelly to move to Santo Domingo and take a job at RRC (but we're not giving her up).
After the tour, we took our seats in a conference room for a slide show and presentation. The first two RRC residents to rotate through Consuelo just completed their two-month stint here a couple of weeks ago, and they were eager to share their pictures and observations with their residency colleagues and with us.
As the first slide flashed up on a projector screen, our team exclaimed "Vero!" The snapshot showed the two residents posing in front of Casa Roja with Veronica, who is Ramona's cheeky, be-ribboned 9-year-old daughter and a frequent companion on our barrio treks. The residents went on to discuss their experiences seeing patients in the NPS clinic, doing batey and barrio outreach, and seeing patients in the Maternidad, Consuelo's own small hospital.
As Deb said, the pictures and the presentation could easily have been those of any CHOP resident returning from the D.R. But what we found incredibly moving was the emotion with which the residents described their surprise at seeing, for the first time, such deep poverty and disadvantage in their own country. "We often get upset when our patients arrive late for appointments," one said. "But now we understand the struggle they have to go through to get here," journeying from the countryside with no car, no phone, no extra money. They described the frustration of learning that patients couldn't afford to fill the prescriptions they wrote. It was an elegant summation of the challenges of rural poverty in the D.R., but it rang true to us, too, as applicable to the urban poverty with which we're too familiar back home in Philadelphia.
Next up was the hospital's director, who spoke warmly about the new partnership between RRC, the Children's Hospital of Philadelphia, and the Centro de Salud Divina Providencia -- about how much the three organizations can bring to each other as together we address the moral obligation to provide care to the neediest. We all know that this partnership is the result of long conversations and much effort on the part of leaders from all three institutions. And to me it feels like a major breakthrough. There are times when I find myself nearly overwhelmed by the enormous challenge of improving healthcare for children here (it's even overwhelming to think about the same task in Philadelphia!). But now, partnered with the institution that trains half this country's pediatricians, I feel like a huge piece of the puzzle has just clicked into place. The opportunity to share teaching and learning among the medical staff of the three institutions will be, I think, critical to really advancing the mission of all three.
There were hugs, photos, and even a few tears as the presentation ended and we talked some more with our hosts. The residents, who'd been clustered in the back rows like CHOP residents at noon conference, even lingered to chat for a few minutes before rushing off to their duties. The hospital buzzed on, and we headed off to do a little sightseeing, bolstered with a hefty dose of hope.
Guest blog entry! From trip leader Deb Voulalas, M.D.
Barrio Puerta Principe, where we've spent the last two days continuing the NPS de-worming and education campaign, is a sprawling neighborhood of nailed-together shacks. Led by Ramona, the NPS public health nurse, we wind further and further into the barrio along labyrinthine paths, often pausing to negotiate the best way across a puddle that stretches from the wall of one house to that of another. We notice that, by comparison, Monday's Barrio Filieu seems almost as spacious as a batey -- in Puerto Principe, the homes are smaller and built practically right on top of each other. But there's another important difference. Puerto Principe is in our own neighborhood. In fact, every day we walk down the street that bisects the barrio to get to our clinic or to downtown Consuelo. "We were in our backyard," says my teammate Carine Golfetto, RN, a nurse on CHOP's 4E/4S surgery unit. "We are so lucky here in this house -- it's gigantic. Yesterday we were less than two blocks away, and the difference...was huge."
We're getting a little more efficient with the charlas. Our Spanish is coming along. Myself, I'm getting a little more comfortable with, or at least used to, the idea that I'm entering people's homes and asking them to make huge lifestyle changes without the conveniences I constantly take for granted. We're actually ahead of schedule on the de-worming project, and it's a good thing, because Tomas (the storm, not, alas a new Dominican friend) has finally rolled into the area. As we were giving our last charla of the afternoon yesterday in a muddy clearing, the rain started pouring down. A few members of our audience (four women and a half dozen or so school-aged kids) gave a shout and scattered for shelter, but the rest stayed firmly planted. I'm not going, said one in Spanish, I'm listening! Her neighbor swatted her arm with the towel she'd been using to shield her hair, then used it to wave us into her house. Plastic chairs were wiped off with the same towel and we were invited to sit; a fuzzy old TV was turned off; and Olena Kucheruk, RN (research nurse in CHOP's Division of Endocrinology), and I finished off our talk for eight or ten women and kids in a space not much bigger than Eden's and my closet in Casa Roja.
The rain has continued to come down off and on since then, but our Dominican friends and partners braved a downpour last night to come to a reunion party at Casa Roja. The guest list included doctors and nurses from NPS and their families, Lara (the Global Health fellow) and her husband and adorable 10-month-old daughter, our ever-reliable interpreters, and even a few visitors from the Convent of the Divina Providencia, a group of Catholic nuns from Canada who founded the Centro de Salud that houses and oversees NPS. The food was provided by the inimitable Martina; the music was provided by our own Eden Kahle, MD and flutist extraordinaire, and by our friend Juan, a talented guitarist who is also a judge in San Pedro and the husband of NPS pediatrician Dr. Ingrid Jappa. (At least, they provided the music until the iPods were broken out and merengue beats sounded the start of Kitchen Dance Party #2, which lasted well into the evening -- because you can't very well leave a party in the middle of a tropical storm!)