1. Improving Health Outcomes in Rural Honduras by Working Outside the Medical Comfort Zone Douglas Stockman, MD Clinical Associate Professor Director, Global and Refugee Health Colleen Loo-Gross, MD, MPH PGY-2 Dept. Family Medicine, U. of Rochester

2. 2 Activity Disclaimer ACTIVITY DISCLAIMER It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. Douglas Stockman & Colleen Loo-Gross have indicated they have no relevant financial relationships to disclose.

3. Overview Learning objectives Questions for you Who we are and what we do Initial community assessment Identified health problems Focused interventions Closing points 3

4. Learning Objectives 1. Appreciate the significance of non-medical factors contributing to ill health in less developed countries. 2. Describe an approach to implementing non-clinical interventions in a global setting. 3. Learn a sustainable, generational approach to global medical work through a longitudinal community partnership. 4. Adapt and apply similar community-centered techniques in further global health interventions. 4

5. Why GH Work? Help the less fortunate –But how? –“Physician do no harm” Feel good about oneself Learn new things Experience exotic cultures Push on one’s comfort zone 5

6. Questions for You Why do you work with under-served populations? Do you help individuals or whole communities? Do your efforts improve outcomes long term or short term? What happens to your efforts once you leave? What is the right balance between curative and preventive interventions? 6

7. Our Answers to Above Questions 7 Initial QuestionsOur Answers Why do you work with under-served populations? Improve health in the most needy Do you help individuals or whole communities? Both Do your efforts improve outcomes long term or short term? Both What happens to your efforts once you leave?Many still persist What is the right balance between curative and preventive interventions? Preventive >>> Curative

8. Causes of Ill Health Multifactorial 8 Estimated Cause of Death 0-14 years Cause of deathTotal deaths (%) 1 Malaria18.1 2 Lower respiratory infections17.2 3 Diarrheal diseases12.7 4 Perinatal conditions12.4 5 HIV/AIDS8.5 6 Measles8.4 7 Pertussis3.3 8 Road traffic accidents2 9 Tetanus1.7 10 PE malnutrition1.6 11 All other causes14.2 Disease and Mortality in Sub-Saharan Africa. 2nd edition. Jamison DT, Feachem RG, Makgoba MW, et al., editors.Washington (DC): World Bank; 2006.World Bank

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10. GH Program Background FamMed residency training program Have GH track that residents join Partnered with Shoulder to Shoulder 2003 First trip to Southwest Honduras 2003 Partnered with one community, San Jose, 2005 Visit San Jose twice/yr, 2 wks per trip 10

11. Focused Community Assessment Obtain a history – use multiple sources Do a physical – walk about Perform testing – if indicated, hard data Create a differential – and rank order Implement treatments – start with low hanging fruit Reassess “patient’s” condition and efficacy of treatments – communities are dynamic 11

12. Example of Initial History Community meeting and questions –Who are they? –What are the 4 biggest issues for the community? –Describe health of community: common problems? –Available health & dental care? –Access to schools/education? –Access to food & water? –Past projects & outcomes? –Available local resources? 12

13. San Jose Problems Water and sanitation Limited education Nutrition/malnutrition Access to health care Poverty 13 As a clinician, what do you do now? Ignore the top 3 problems and do what you know, or dig in and see if you can help?

14. Thoughts on Interventions We are not the experts – they are The best we can hope for is collaborating partners This is their home, not ours. We go home to a cushy life. Any mistake, they live with Their time and effort is valuable Resources are VERY limited Think generationally, if you hope for sustainable community improvement Doug’s rule: 1 in 5 successes is good (PDSA) 14

15. Problem-focused Interventions Water –Piped water –Filters: SSF & PfP –Latrines –Pilas –Hand washing Education –Teacher training –Student training –School supplies –Scholarships Nutrition –Cook stoves –Piped water –Fish farms / Cash crops Health care –Trained 2 CHWs –Revolving drug fund –Fluoride program Poverty reduction –Microfinance –Handicrafts 15 Many others: train midwives, domestic violence, first aid kits schools, health education skits, improve fertilizer access, curative health care, and many more ……..

16. Focused Example: Water Walk-abouts & focused questions –Very challenging: not much water & poor quality –Identified local resources/prior work and built on that –Went for low hanging fruit –Realized could help some people, not all –Created solutions that have good chance for sustainability –Provided materials and training, locals did all the work 16

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18. Mis-steps Common Started with slow-sand filter –People prefer their own filter, not a central filter Introduced Potters-for-Peace filter –Small, low cost home-level filter Some are now requesting slow sand filter again –Higher output –More sustainable 18

19. Health Benefits: Improved Water Improve nutrition –Reduced calorie burn –Reduced diarrhea Improve health –Reduced diarrhea –Reduced scabies, trachoma Free up time for other activities –1-3 hrs/day more time 19

20. Focused Example: Poverty In absolute poverty there is no health Mis-steps –Handicrafts –Cash crops Microfinance –Area agency beyond reach of locals –Created our own microloan program (separate talk) Fish farms (TBD) 20

21. Focused Example: Poverty Personal Profile Maria Lopez is a 48 year old married woman with four children. Like most residents of Guanacaste, she is very poor and must survive on less than $2/day. We gave her a micro-loan to purchase materials to make tamales for sale at local gatherings. She reports back that she sells about 130 tamales per week and she can make a profit of up to $14/week. Through this increase in family income she has purchased chickens for eggs for the family to eat and has saved over $70 which represents the family's total savings for future needs. 21

22. Closing Points Community selection hard but important Do not promise anything Listen You are an outsider trying to learn the real problems of a community – politics will always be a hurdle Collaboration Minimize financial inputs (poverty is real and harder than you imagine) Think generational Have fun! 22

23. Questions / Discussion 23 www.sanjosepartners.org www.urmc.rochester.edu/family-medicine/global-health