By JULIE MINDA
When two U.S. medical residents traveled in the spring to Santo Tomas in Guatemala, as trailblazers for the new Providence Health & Services Educational Exchange, they learned just how difficult it can be to reach rural populations with health care services.
A medical student from Universidad Rafael Landívar of Guatemala City, second from left, conducts a home visit with a community member in Fraijanes, Guatemala.
To get to their base in the small mountain-top town in southwestern Guatemala, the residents flew into Guatemala City, drove three hours on the highway then three hours on mountain roads. Guatemala is an impoverished country with poor health indicators for infant, child and maternal mortality; nutrition; and literacy, according to the Central Intelligence Agency's World Factbook, which notes that Guatemala's large indigenous population is disproportionately affected by the health concerns.
Santo Tomas, a rural town with a large indigenous population, has limited health care staff, supplies and equipment, according to information from Providence. A small primary health care clinic in Santo Tomas staffed by a medical student and a community health worker provides care for community members.
During most days of their monthlong stay, the American doctors joined a medical student from the Universidad Rafael Landívar in walking or driving about an hour from Santo Tomas across rough terrain to villages where they went door to door to assess the health of villagers and provide limited treatments. The residents spoke Spanish, and the medical students translated for the villagers, who speak an indigenous language. The medical teams provided pictorial and verbal information on health. Their focus was on children, pregnant women and sick adults.
Back at the health clinic, the teams posted information about the health status of household members on health maps. The health mapping is a project of Guatemala's institute of integrated medicine, its ministry of health and the Universidad Rafael Landívar. The American medical residents also treated clinic patients.
Dr. Mark Rosenberg, director of the internal medicine residency program at Portland, Ore.'s Providence Portland Medical Center, said the residents returned to Providence ready to do the work of identifying people with unmet health needs and tackle the question: "How do we create true efforts toward community health?"
As Catholic Health World went to press, Providence Health & Services Educational Exchange was preparing to send the second pair of medical residents to Guatemala. In the exchange, Providence welcomes two medical students at a time from Guatemala City's Universidad Rafael Landívar to train in Providence facilities alongside clinicians focused on family and internal medicine. Guatemala does not have a family medicine infrastructure, and this exchange is helping the university to learn best practices for potentially starting up its own family practice training, according to Aimee Khuu, who directs Providence Health International, a program of Providence Health & Services, Renton, Wash. Six Guatemalan medical students have trained in the Providence system to date.
A child stands at a well in San Miguelito, Guatemala. Participants in the Providence Health & Services Educational Exchange have taken part in projects in the village to improve community health, including vaccinating dogs against rabies.
Khuu said the Providence medical residents in Guatemala "learn a different approach to care ... There's a lot to learn from (the Guatemalan) model of care, from a population health perspective. ... And the Guatemalan students learn a lot about our integrated teams" in family practice. Some emerging U.S. population health models have health care providers assessing the health needs of specific populations of people and targeting the people with the greatest needs with interventions. The exposure to health mapping in Guatemala grounds the U.S. medical residents in a tool useful in a proactive approach to population health, said Rosenberg.
Khuu and Rosenberg were part of the team of Providence Health & Services leaders who developed the Guatemalan exchange program to build upon existing Providence international outreach efforts. Individual Providence facilities participate in educational exchanges in Kenya and Uganda. But, Providence wanted to create an exchange program that potentially could recruit residents practicing at facilities throughout Providence's five-state service area. And, they knew they wanted to partner with an educational institution in the host country.
Planners honed in on Guatemala because Providence knows the country and its infrastructure — it sends clinician volunteers on missions there to provide medical and surgical aid. Providence volunteers also already support community health programs in Guatemala through other mission projects, including clean water and safe breathing initiatives. Most of those initiatives are in Guatemala's Chicamán region, which is about 150 miles northwest of Guatemala's capital and largest city, Guatemala City.
Providence selected Universidad Rafael Landívar as its academic partner in large part because of its population health programs. Medical students at the Jesuit university complete their required rural health care internship around Santo Tomas, aiding in rural clinics and contributing to the health mapping of the community.
During initial meetings between Providence and the university to plan their collaboration, "the university told us how they wanted us to support them," said Khuu. Like all Providence Health International efforts, this one "is directed and owned by the locals, and they suggested from the start that this be an exchange."
Gaps to fill
Providence and the university developed the exchange to address gaps in the Guatemalan and U.S. health care systems.
Rosenberg said when U.S. medical residents go into villagers' homes and work in a remote, thinly resourced clinic, they learn how to identify population health needs and see the potential benefit of directing scarce resources systematically to achieve health and wellness goals for a broad population. He explained, "In the U.S., we're so hospital and acute care focused. We're trying to become more community focused, more focused on prevention and healing. This transition is not easy; and this exchange lets people see how it could work."
A medical student from the Guatemalan university explains a map in the San Miguelito clinic that plots the health status of village families.
Amanda Rosen, one of the first two U.S. medical residents in the exchange program said the experience taught her "more about public health and (the) impact of community on individual health." She said she also learned that a patient's declaration of "good health" may be relative. She said Guatemalan villagers with multiple chronic conditions may define themselves as healthy if their neighbors suffer greater disability or infirmity.
Respect for all
Maria Mercedes Cabrera Cifuentes is a Guatemalan medical student who rotated through three Providence health centers in the spring. She said she was surprised that clinicians welcomed her fully as part of their team — she'd expected to just follow and watch. Instead, she examined patients, discussed their cases with the team and made treatment recommendations.
Cabrera Cifuentes said she was surprised to learn that many of the conditions that are prevalent in Guatemala are also common in the U.S., such as diabetes and hypertension.
She said she was impressed to see clinicians of varying socioeconomic and ethnic backgrounds treating a diverse patient population. "Wealthy or indigent — everyone received the same quality of care. I wish people in my country could see the commitment of caregivers for all patients, regardless of their station in life. These Americans working there (at Providence) treated patients as if they were family."
Providence presents skills workshop for Guatemalan 'mother counselors'
Providence Health International of Renton, Wash., bolstered the skills of hundreds of female community health workers in Guatemala through a free, two-day workshop Aug. 20 and 21 in Cobán, Guatemala.
A speaker addresses the crowd during the workshop.
Presented in part by four community health workers from Providence Health & Services' Southern California region, the workshop aimed to boost attendees' self-confidence and to help them improve their leadership skills and public speaking, to teach them to lead health trainings and give instruction on health-related topics and advocate for domestic violence victims and other women in need. The training also assisted them in balancing the needs of their own families with the needs of the communities they serve. Workshop presenters also shared tips on efficient time management.
Two hundred and fifteen "madres consejeras," or mother counselors, participated in the conference, which Providence cohosted with an international aid organization called Medical Teams International. Mother counselors are volunteer community health workers who have received basic training to provide "case management" to families in rural communities. Each counselor monitors the health of about seven to 10 households in her community. The counselors provide health and prevention education on pneumonia, diarrhea and other diseases that are leading causes of death among children.
Mother counselors take part in the conference, which Providence cohosted with the international aid organization Medical Teams International.
According to information from Providence, in the Chicamán region that many Providence International programs target, 91 percent of babies are delivered at home. The infant mortality rate is 63 deaths per 1,000 live births. The rate in the U.S. is 6 per 1,000 live births, according to data from the World Bank. Mother counselors from Chicamán were among the workshop attendees.
Aimee Khuu, director of Providence Health International, said the risks for pregnant women and their babies is high in rural areas of Guatemala. The Chicamán region is more than 30 miles from Cobán, which is the nearest large city. The gravel mountain roads in the area frequently wash out. While Chicamán has a health center and three rural clinics, those facilities have limited staff, supplies and equipment. Also, it is difficult for rural villagers to reach the few Chicamán clinics, much less the more advanced medical facilities in Cobán, said Khuu. She explained that most rural women do not have the money to travel outside their village. They also do not have the time, since many have other children to care for. Most will not travel alone; and their husbands normally must work, and so they cannot accompany their wives outside the villages.
Additionally, there are cultural barriers to accessing advanced care in Guatemala's large cities — the mountain villagers who live around Chicamán wear traditional dress and speak indigenous languages. They often are looked down upon by people in the large cities, said Khuu, explaining the rural villagers may be less inclined to seek care at medically advanced facilities in the cities for fear of how they might be perceived due to cultural differences.
“Mother counselors” gather during a free, two-day workshop in August. The event was sponsored in part by Providence Health & Services' Southern California region.
Khuu said mother counselors provide a basic level of care to people who cannot seek care elsewhere. Medical Teams International and Providence aid teams provide some medical training to the counselors. But, the two organizations identified a need to build up some of the softer skills of these volunteer counselors.
Khuu said most of the counselors have between five and 10 children of their own; and most are illiterate and have no formal education. She said the workshop enabled the counselors to learn ways to take care of themselves and their families as they serve others. The workshop also showed them how they could enhance the work they're doing in their communities.
At the conference, the counselors also met health care providers in their regions. And, they described their work and experiences during a forum involving Providence, Medical Teams International, two charity organizations — Food for the Hungry and Mercy Corps — and the Guatemalan Ministry of Health.
Aurelia Ma is a manager with Medical Teams International in Cobán and an event participant. She said that during the gathering, conference organizers gave the counselors a round of applause in appreciation for their volunteer work. "We realized it was the first time they had been truly honored in this way. It was very emotional for all of us."
Khuu said, "The madres believe theirs is a unique vocation from God. They believe they are called to their work. (Working with them) is an opportunity but also a challenge. They need training."
International programs must balance short- and long-term needs
A key challenge in developing any international aid program, the Providence Health & Services Educational Exchange included, is to balance the short-term needs and goals of the program with the long-term perspective.
That is according to Dr. Mark Rosenberg, director of the internal medicine residency at Providence Portland Medical Center of Portland, Ore.
He said that in Guatemala, as in most other developing countries, medical aid volunteers are doing work that wouldn't get done without their presence. The surgeries they perform and treatments they administer would not happen in the short-term if they were not there.
But, there is a danger, he said, in delivering international aid in a way that does nothing to help the recipient country develop its own solutions to its health care challenges. "In an ideal world," Rosenberg said, "Guatemalan surgeons would have the capacity to" do the surgeries that medical aid surgeons are now doing.
Rosenberg said that's one reason the exchange is so valuable — it not only provides immediate aid in Guatemala, it also provides the practitioners of the future with new skills.
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