Sunday, January 25, 2015

Look, Listen and Learn: The Clinic in Nejapa

We are in the last moments of preparing for the Mission of Healing 2015, and this year’s experience will be fine-tuned according to the learning and planning which took place during the visits Deb and I made to the Unidades de Salud of the northern micro-region.  The visits of October were made possible in large part through the efforts of Doctora Chiquillo, who works at the Unidad in Nejapa.  We spent one full week observing all aspects of work in the Nejapa clinic, learning from the staff, brainstorming ideas with Dra. Chiquillo, and walking through a wide range of climates and environments with the health promotors.  Dra. Chiquillo paved the way for us to meet with the coordinator of SIBASI Norte -- the governmental agency which oversees all of the Unidades and ECOS Familiares in the northern region.  We are extremely grateful for Dra. Chiquillo’s coordination and collaboration as we seek to support through the Mission of Healing the everyday work of healers who have dedicated their lives to caring for those most in need...

After a quick meet and greet in Nejapa, and a fruitful meeting at the SIBASI offices, what would two grandmas most love to do?  Hold babies, of course!  We finished off our first morning in Nejapa by hanging out with the maternal health nurses.  As we had observed elsewhere, the teaching and care offered to mothers was of excellent quality.  One of the primary focal points for the Unidad de Salud in Nejapa is the milk bank.  It is the first (and we believe only) collection site for breast milk.  Mothers change into gowns and carefully clean their breasts before donating their milk.  A mom can feed her baby from one breast while a technical nurse helps to collect milk from the other.  A mom can also manually express milk while a nurse or volunteer holds her baby nearby.  All of this is done in a clean room, designated exclusively for this purpose.  The milk is immediately stored and then taken to Benjamin Bloom children’s hospital where it is used to feed premature babies.  (Upon our return, we were able to gather more than 45 electric breast pumps, which are making their way to El Salvador a few at a time with delegations.  Short gowns (such as mammography capes) would make it a lot easier for the moms and the staff who wash the gowns.  Campaigns are held periodically to sign women up to be donors.  The clinic has also hosted two large collection days in the town.  We will be promoting participant registration in this program during this year's and future Missions of Healing.

Care for babies was followed by listening to a charla (educational talk) about how to prevent pregnancy and transmission  of Sexually Transmitted Illnesses. (Yes, somewhat ironic.) A health promoter from one of the local Lutheran congregations accompanied us to the clinic in order to provide the charla.  She teamed up with a technical nurse from the staff, who hauled out her prop:  a ginormous, carved, wooden penis.  This thought ran through our minds:  Wow, someone had to carve that thing.  Deb said, “Great contraception – any woman who sees that thing will run the other way!”  The audience was captive (waiting for their appointments) and interested.  They asked a good number of questions.

Once the giant penis was put away, our crew (Deb, me, the promoter and a pastor who was volunteering to organize files in the Archivos) walked across town for a late lunch.  It was delicious and gave us energy to walk partway back before the Salvadoran team members hailed a moto-taxi.  During the afternoon we took a complete tour of the clinic, including learning about some of the forms which Salvadoran medical providers use for various referrals and lab results.  The information we gained on the way that clinic personnel organize patients and conduct triage will definitely serve us well as we continue to fine-tune our own triage process.

Day #1 complete.  A night of rest and on to the next day's adventure...

Tuesday, January 6, 2015

Just Click: On the Road 2014

Taking a little break from the health clinic we traveled the highways one community to another, I kept my camera at the ready.  You never know what you might see out the car window...

Friday, December 26, 2014

Look, Listen and Learn: Back to Where it All Began

There are many times when we look back at moments shared or things accomplished with our sister church in El Salvador that we just shake our heads and marvel.  The connections made and friendships built during our very first little Mission of Healing in our sister church community is one of those moments.  We had never been to our sister church community before, we knew nothing about the neighboring community, Distrito, nor the little clinic there, but the wisdom of the locals to cultivate relationships between their neighbor nurses and their new US friends has born a lot of fruit over the past 15 years.

On Friday, after a couple of days out in the countryside dodging cows and learning about rural, door-to-door medicine, we traveled back to where it all began:  the little clinic in Distrito Italia.  We were pretty excited to go there - to see if maybe some of the original staff was still there, to see how the clinic has changed since our last visit there several years ago, and to connect with the medical staff who regularly interact with folks from our sister church community.

The director of the Unidad de Salud (health clinic) was eager to meet with us, but was busy conducting an autopsy when we arrived, so we waited for a bit.  Curiously, a motorcycle was parked next to a set of stairs-to-nowhere in the middle of this strange little waiting area.  Modern art?  Physical therapy zone?  We couldn't decide.  Pretty soon the autopsy was complete and the director led us into a very nice, large, air-conditioned conference room.  We talked about the retirements of some of our friends, and others who were working in different clinics.  We were super happy to see the head nurse, an old friend.  We made good plans for working together.

Despite the fancy meeting room, it was pretty clear that this Unidad has some pretty big challenges.  They have no phone lines (apparently local thieves made off with the cable - more than once) so the doctor and head nurse give out their own cell numbers to manage emergencies.  Most communication, setting up appointments, etc. must be done in person.  As local gang boundaries shift from one community to another, the staff is flexible with accepting patients who technically should be visiting another nearby clinic for their care.  Because this area has been designated as "urban" there is no ECO or team of health promoters to travel to the homes to provide care.  This is a very big challenge, because although the communities surrounding Distrito are only a bus ride away from the city of Apopa, the families live on tiny plots and survive by living in large family groups and pooling together resources from farming rented land, working as day laborers, raising a few chickens and selling items in the market.  Poor sanitary conditions, low water quality and insufficient control of mosquito habitat greatly impact the quality of health in these poor communities.

We toured the facility.  The pharmacy was small, but seemed to have the basics.  The exam rooms were clean and most had been remodeled.  We were surprised to find a large physical therapy room with a few pieces of old yet functional equipment.  We were very surprised to meet the psychologist and two members of the art therapy team.  In a region where poverty and violence touch every family, this art therapy team is a true blessing!  We were absolutely impressed with the enthusiasm and creativity of this team, and with their availability to go out and do workshops in different communities.  We know from our years of work with the Mission of Healing that this type of healing resource in a community can do much more to heal the spirits of the people than a little zipper bag of ibuprofen.

We spent quite a long time talking with the director and all of the staff members and imagining ways in which we could work together in the future.  As the church works to develop its team of health promoters, there will surely be opportunities for the church and the Unidad to complement one another.
Physical therapy room
Gasoline for the mosquito fumigation machines

Fumigating for mosquitoes

Exam room
Art Therapy

Clinic director in the dental treatment area

Sunday, December 14, 2014

Look, Listen and Learn: Super Doctora

A calm bit of road which allowed for a photo
Another early morning and another long ride out to San Pedro Puxtla.  Upon our arrival we were excited to learn that this day was a truck day!  On truck day, the team has access to the government pick-up truck in order to deliver heavy boxes of medications and supplies to remote sites where once per month the team runs a medical clinic.  The ride to this month's remote site was "in the opposite direction of the ECO base, in an area that scares us because the gangs have come there and sometimes threaten the health workers."  It was sad for us to hear that gang activity had come to this remote location and hard to understand what possible economic value gang members could find in terrorizing these incredibly poor farmers.  We bumped along the road without incident, bracing ourselves so that our heads would not hit the ceiling of the cab.  We could not stop laughing because the bumps were incredible!  We asked if the truck had a name, and since it did not, we all agreed to name it Caballo (horse).

Delivery accomplished, we traveled down the same dirt and rock road we had walked the preceding day and arrived at the ECO clinic.  We spent the morning observing all of the operations of the clinic, noting that most of the patients where women who were expecting babies, had recently delivered babies or are raising babies.  Nutrition is a huge issue among these rural families who survive on what they can grow and store.  Many mothers receive powdered milk from a government program.

Dog vaccines are free - provided
by nurses.  The sign below says
"Don't threaten your kids with
Family Planning Information
The clinic itself does not have electricity, so the refrigerator which the government sent for vaccine storage is still in its box.  The team (doctor, 2 nurses, 3 health promoters and a utility guy who cleans and runs the pharmacy) has to run some fund-raising activities in the town in order to pay for an electrical hook-up.  La Doctora has a great educational style, and the makeshift walls between treatment areas are covered in educational posters.  The government actually requires information to be posted about nutrition, dengue/chik, HIV/STD's, and a variety of vaccines.  There was a very helpful bulletin board about family planning, however, at this clinic like so many others, the medications or devices are not available.  It seemed to us that the government simply cannot keep up with the demand nor the expense, and it reinforced our efforts to at least bring a suitcase full of condoms for the Mission of Healing.

The team treated us to a delicious lunch which was made in the community and brought to the clinic:  carne asada (stewed beef), chirmol (fresh tomato, onion & cilantro), rice and avacado.  We shared a lot of laughter around that table.  Re-energized for the afternoon, we loaded up on water and hopped into the truck for a ride out to a patient who lives quite a distance from the ECO clinic.  The story of our Super Health Promoters on that afternoon is recorded in another Blog Post.

At the end of our day, we made the long drive back to San Salvador, stopping for about an hour at La Doctora's house, where we were served delicious homemade pie and hot chocolate.  It was a huge honor for us to share in our friend's work, her friendships, her family, and her struggles.  We have often marveled at the stories she told about her work and the sacrifices she makes in order to have a job.  Now, having walked alongside her for a few days in her own work setting, we are even more convinced that she, like so many healthcare providers in El Salvador, is a Super Doctora!

Tuesday, November 25, 2014

Look, Listen and Learn: Trekking Out West

We couldn't possibly turn down an invitation to learn about the work of our young doctor friend.  After all, we have known her since she was in the university, and she has been helping us with the Missions of Healing for 6 or 7 years.  So, on Day #2 we loaded up our backpacks with water and set off bright and early for San Pedro Puxtla.  We had directions.  We had a map.  We still got lost.  We stopped many times for directions, and thanks to a really kind guy in the street who, in the rain, sketched out a map for us in his own notebook, we eventually found our destination.

Our friend (la Doctora) is the coordinator for an ECOS (Equipo Comunitario de Salud) Familiar:  a community-based family health team.  (Usually the Salvadorans just call it an ECO.)  The creation of ECOS throughout the rural areas of El Salvador has been a key strategy within the healthcare reforms that began in 2009.  Each ECO consists of a physician coordinator and support staff such as licensed nurses, technical nurses, health promoters and a driver/pharmacy person.  La Doctora's ECO is one of the first created in the country.  It is one of two ECOS based out of the Unidad de Salud or health department clinic in San Pedro Puxtla.  Each
ECO has it's remote clinic site and is responsible for the care in a large rural zone.

To get to La Doctora's little clinic, we had to walk about 3.1 miles on a rocky road - and it was HOT!  We walked off of the main road to "go see an awesome view" on our way to visit one of the doctor's patients - a little boy who was sick, and so very thin.  Malnutrition is a major issue for families in this rural area - one of the poorest zones in El Salvador.  Along the walk we saw beautiful flowers, latrines that were not beautiful, and as promised, an awesome view.  We could actually see ships on the ocean far, far in the distance.  We could also imagine that during a storm, the path would become a muddy, slippery mess.

When we got back to the main road we had only to walk for a few minutes when a pick-up came by.  We hopped in back and had an easy ride to the clinic.  The building was given to the ECO by the local mayor.  Before it had this building, the team used homes with large yards or porches.  On certain days of the month, the team still runs clinics out of homes in some of the more remote areas.  The ECO building has no electricity, so vaccines need to be picked up each day at the Unidad.  La Doctora and her team are in the midst of planning fund-raising events to raise money to put in the electrical hook-up.

The plan for the day was to go out and check homes for mosquito larvae.  A case of chikungunya had been suspected (only 1 in 10 suspected cases is actually tested due to lack of funding), so all the homes within 100 meters had to be checked.    We were with the nurse and la Doctora, while the promoters were out checking other homes.  One home was quite fancy, with a beautiful garden and a menagerie.  Most of the homes were very basic, made of adobe or stick-and-mud construction.

Before we knew it, it was lunch time.  We ate at a neighbor's home - the woman is a very good cook and the team often pays her to make their lunch.  After lunch we visited a few more homes, and then it was time to make the long walk back to town.  Luckily we got a ride!

The work day ends at 3:00 PM, when the ECO team reports back to the Unidad.  While the health promoters live within the communities where they work (and this is KEY to their effectiveness), the doctors and nurses typically travel long distances to get to their jobs.  The scarcity of jobs has created a very inefficient system in which none of the medical professionals seem to work near to their homes, and transfers take years to complete.  Despite the hardship of traveling five hours per day on the bus, la Doctora and others like her are extremely dedicated to their patients, and to their team members.

Thursday, November 20, 2014

Look, Listen and Learn: All in a Day's Work

Exterior of the Unidad de Salud
One full day.  What would we learn by spending just one full day at the Unidad de Salud in Guazapa?  It was our first observation day, so we did not know what to expect and we had no reference frame from which to make comparisons.  We were a little nervous - we did not want to be intrusive!

In the morning, these chairs are filled
with waiting patients
The local Lutheran pastors had made the appropriate arrangements for our visit and the director of the Unidad greeted us warmly.  He is new in his position, but already seemed to be a little familiar with the work of the Lutheran Church pastors and health promoters within the church.  Deb, the nurse practitioner, and I introduced ourselves as representatives of the Salvadoran Lutheran Church and its accompanying sister churches from our synod of the ELCA. (Evangelical Lutheran Church in America).  We explained our purpose:  to look, listen and learn, with the hope that we can more fully align the protocols used during the annual Mission of Healing and multiply the positive impacts of the mission by identifying ways in which the church can support sustainable care plans throughout the year.

The conversation with the director was incredibly helpful.  We explained that one day of the mission in the coming year is designated for the communities around Guazapa.  The local pastors coordinate transportation for families to travel to the Mission of Healing site - a large open-air property which belongs to the church near Nejapa.  Right out of the box the director was eager to have staff members from the Guazapa Unidad accompany the people.  They could work alongside the US team and other Salvadoran volunteers.  They could see patients identified with chronic diseases and make the plans for follow-up care.  He offered a dentist, someone to do pap smears - it was incredible!

We talked a lot about medications.  We are strongly committed to purchasing as many medications as possible in El Salvador.  We certainly have had challenges bringing medications into the country (despite following all of the customs rules), and if we can support local production of quality medications, we want to do that.  With the implementation of healthcare reforms, medication prices have come down and availability has greatly increased.

At this point, one of the pastors in our meeting said, "But the medications from the US are so much better quality than those in El Salvador."  We hear this all the time - people do not trust the quality of their locally produced medications.  The director jumped right onto this point:  "You are a man of faith, right?  You know that people need to believe in their medications.  Faith plus medicine.  There is competition now, the medications are of a good quality and people need to believe that.  As leaders, we need to model that belief for the people."

We have struggled with finding the best way in which to provide care for chronically ill patients.  Initially we did not treat them (heart-breaking for patients with blood sugar and blood pressure levels off the charts).  Then, we tried leaving a year's worth of medication with the Lutheran Clinic, but follow-up and transportation were big issues.  We told the director that by developing stronger ties with the local Unidades, our hope is to incorporate local doctors into the Mission of Healing so that right on the spot they can make the follow-up plans.  Throughout the year, local pastors can provide encouragement and support to their people who need to follow a regimen of care.

We learned about dengue and chikungunya, and the protocols for treating these diseases for children, adults, pregnant women and the elderly.  The director provided us with a wealth of useful information.  In the midst of my notes about malnutrition and the Barcelona Study, I found this memorable quote from the director:  "People need to eat foods that are REAL."  We were feeling good synergy with the director.  With it's fifteen year history, the Mission of Healing provides a place of education and encouragement, a place where medicine and faith work together, a place where patients feel loved and listened to and cared for by their church and by doctors.  We hope to be moving forward in a good way that incorporates more local healers and encourages continued care and education throughout the year.

After the meeting, Deb and I were invited to observe one of the physicians.  The doctor introduced us to each patient, asking if it was OK for us to observe.  He was very attentive, from listening to the stories of an older woman with pain everywhere to carefully reassuring a new mom with her 5-day-old baby.  During his free moments between patients, he showed us all of the different paperwork he has and gave us bits of information about his practice:

  • He sees 6 patients per hour - that is what is allowed by the government
  • He has 20 active cases of tuberculosis - and his patients come 3 times a week for treatment
  • Upper respiratory illnesses and dermatitis are the most common diagnoses
  • Malnutrition is terrible and anemia is high
  • The number of patients with high cholesterol is increasing
  • The number of cases of renal insufficiency is increasing rapidly - especially in males age 22 to 25.  It is most frequent among men over age 50 who worked in the cane fields.
  • Diarrhea from roto-virus is common due to flies and lack of hand-washing
  • Violence is a big problem with the people because "they are violent inside"
Emergency Room
One ambulance - 3 patients
In the midst of an exam of a woman with a stomach issue, the doctor received word that there was an emergency.  He motioned for us to follow, and we wound our way to the front of the clinic where the emergency room is located.  There was a man who had suffered a stroke lying on a narrow exam table and receiving IV fluids.  The emergency was a 9-year-old boy who had fallen out of a tree and suffered a broken arm.  There was a little chaos because the boy only had his 17-year-old sister with him and she wanted to go back to school.  They moved the man to a wheelchair and took him out to the waiting ambulance.  There was already a woman seated inside:  she was in the beginning stages of labor.  The boy's mother arrived and they started to load him into the ambulance, but then his dad arrived too and said he could take the boy in a friend's pick-up.  That made space in the ambulance for the older woman with the body pain.  It is routine to wait until there are 2 or 3 patients ready to go to the hospital before the ambulance leaves.  There is only one Unidad ambulance for the entire area of Guazapa north to El Paisnal.  There is no EMT - just a driver - so usually a nurse rides along if possible.

We concluded our observation time, ate lunch in little place down the street, and returned to take a tour of the pharmacy and the lab.  The pharmacy was small, but air-conditioned, which we discovered is the norm for the Unidades de Salud in the north.  This is really important for preserving the shelf life of medications in the heat and humidity.  Because the Guazapa Unidad does not have any specialty doctors, they cannot stock specialty medications (for example, their only gynecological medication was over-the-counter cream).  Still, we were pleased to see many common medications in stock, and we took note of things that are needed.  After we visited a variety of pharmacies, we were better able to evaluate the availability of medications at each location.  The lab deserves it's own special story...stay tuned for that one!

We looked.  We listened.  In just one day, we learned so much!  The eagerness and willingness of the staff to share their routines, their knowledge, their frustrations, their hopes and their enthusiasm for new connections was amazing.  

Monday, November 17, 2014

Look, Listen and Learn: Unidad de Salud

We came to look, to listen and to learn.  The two of us, a nurse practitioner and a church worker, did not come to see patients, did not come to bring medications, did not come to fix anything.  We came to look, to listen and to learn.

For nearly fifteen years our synod of the ELCA (Evangelical Lutheran Church in America) has accompanied the Salvadoran Lutheran Church in a ministry we call "Missions of Healing."  The Mission of Healing was born at a time in which the people in our sister church community and throughout poor communities in El Salvador did not have access to attentive check-ups or basic medications.  Public clinics hosted long lines of patients who would wait as long as 8 hours for a 1-minute consultation with a doctor and a visit to an empty pharmacy.  Education, especially about sexually transmitted diseases, was sorely needed.

The first mission of healing team had seven US members. We broke off from a synod delegation to spend four days in our sister church community.  Four team members worked with the teacher in the school and ran a Vacation Bible School event.  The medical check-ups took place in the tiny, ramshackle church.  The altar was the exam table.  The nurse practitioner examined hundreds of moms and babies and some men.  Her husband managed the few medicines we brought along.  A bilingual nurse from the US translated.  Nurses from a nearby town's Unidad de Salud  weighed and measured people and provided vaccinations.  The mission was grounded in a special worship service and the celebration of baptisms.

The Mission of Healing has grown and changed as the needs of the people have changed.  Fifteen years after its founding, the Holistic Mission of Healing (Misión de Sanación Integral) currently provides a healing experience for people in more than 30 Lutheran Church communities.  The people are bused to two different sites during two weeks of work. Spiritual healing through prayer and massage and educational charlas (chats or discussions) are a main focus.  Salvadoran doctors volunteer alongside US doctors.  Most medications are available and purchased in El Salvador.  The eclectic, healing team consists of about 60 healers (each week) from the US and from El Salvador, always with the accompaniment of the Unidad de Salud.  

What is the Unidad de Salud?  Healthcare in El Salvador is delivered via a tiered system.  Private hospitals and clinics are available for those who have plenty of financial resources.  Workers in the formal economy and their families have seguro or insurance which gives them access to a system of clinics and hospitals.  Medications (if available) are provided without additional cost.  The Unidad de Salud or Health Ministry provides free healthcare for everyone else - about 50% of the population. Anyone can go to the local Unidad clinic for care, and if the patient is insured, the Unidad is compensated.

Beginning in 2008, the national government in El Salvador began to implement a series of healthcare reforms to improve the accessibility and quality of healthcare for the uninsured population.  During recent Missions of Healing, caregivers have noticed the positive effects of the reforms.  As coordinators of the missions, the nurse practitioner and the church worker wanted to learn more.  The two of us received an invitation from the Unidad de Salud in Nejapa to come for an extended time to observe and participate in the daily work of the doctors, nurses and health promoters.  In October 2014, the two of us spent three weeks in the northern zone of El Salvador, with the amazing and caring staff of several Unidades de Salud.  In each location, we introduced ourselves and explained that we were there to look, to listen and to learn.  We were warmly welcomed by each Unidad director and given complete access to observe all aspects of care...and we have some amazing stories to share.

This is the introduction to a series of posts about our three weeks with the Unidad de Salud in the northern micro-region.  My friend and I want to express our deepest gratitude to SIBASI Norte and all of the staff members who shared their time and insights with us.  We believe that the strong connections between the church and the health ministry will be mutually beneficial to the patients and those who care for them.