Sunday, February 12, 2012

Notes from the Field: Chiapas Round 2





I am fortunate to be back at the Hospital San Carlos, in Chiapas, Mexico for two weeks. I am again welcomed by the dedicated staff doctors, the St. Vincent de Paul nuns who run the hospital, and other volunteers from around the globe. During my two weeks here, I help staff the outpatient clinic “consulta externa” while helping with complicated inpatient cases, or giving impromptu brief lectures or case reports.

After my first week, I am again reminded of the complexity of providing care in a low-resource and culturally diverse setting. Not surprisingly, there are some parallels to American healthcare, and to my work at Over60, a federally qualified health center, where I must balance current treatment recommendations and diagnostic algorithms with a scarcity of resources, an unequal distribution of wealth, and a cultural milieu which may have different understanding of health and life.

The breadth of illnesses seen is extensive ranging from tropical diseases like Chagas, to foodborne illnesses such as Typhoid fever. With total fertility rates remaining high, it is also not uncommon to see married fourteen year olds coming for their first prenatal visit. As a Geriatrician, I am obligated to either remember something from my Ob-Gyn rotation in medical school ten years ago, or hope that there will be an octogenarian in the waiting room, so that I can graciously forgo this consult, and allow my more knowledgeable colleagues to conduct the prenatal visit!

Ultimately and not surprisingly, the burden of chronic disease is spreading and quickly surpassing infectious diseases as an important public health concern. It is not uncommon to see patients in their 5th or 6th decade of life, presenting to the doctor for the first time with undiagnosed hypertension and diabetes. In some ways, this fact is reminiscent of some of the new patients I see at Over60, in Berkeley, CA. While management guidelines for these illnesses do not differ, there are many more complex sociocultural issues to consider.

Firstly, though I am a native Spanish speaker, I must often use an interpreter as the majority of patients are monolingual Tzeltal, Tzotzil, or Tojolabal speakers. Secondly, the long-term management of these illnesses will be dependent on medication availability and other individual patient factors. Thankfully, due to donations and purchases, the hospital does stock a fair number of medications to treat these chronic conditions. In this way, at the end of each patient consult the patient is able to pick up the prescribed medications from the hospital pharmacy with quantities ranging from a few days to up to 3 months. Yet, because many patients live several hours away, it is not easy for many of them to return for scheduled follow-up or for prescriptions. Many must resort to local pharmacies to purchase prescribed medications, hope they can find the same one, and attempt to gather enough money to make the purchase. Given this context, it is also not uncommon for patients to turn to pharmacy staff (usually doctors employed by the pharmacy) for medication recommendations—presumably creating a conflict of interest—or to curanderos from their own community for more traditional remedies. These facts alone make the management of chronic illnesses all the more difficult. Lastly, it is increasingly difficult to explain the role of long-term medications for chronic disease in the context of a population who is largely of limited-literacy, and is primarily used to the treatment and “cure” of symptomatic infectious illnesses. How do we then, as Geriatricians, explain that many of the afflictions of Aging, are chronic, not curable, and rather solely manegeable?

On this trip, this question has been quite prevalent in my daily patient consultations. I have already seen quite a few older patients and have been contemplating whether the standard Geriatric approach I use with my patients in the US is applicable to the patients who live in rural communities where cultural norms and the role of elders in the community may be different. I’ve wondered whether assistive devices will be as helpful to my patients who live in remote communities with unpaved roads, or in small towns like Altamirano where the streets are cobblestoned and full of potholes, or sidewalks a foot high off the street.


Despite these trepidations, I did decide to give a donated walker to one of my first patients, who claimed to be 100 (but did not know the current year or the year of his birth). I am hoping it will help prevent more falls, given his worsening gait which I presume is due to severe peripheral neuropathy of unknown cause—as I cannot test for B12 deficiency or other etiologies. Yet, I am also wondering if I am being na├»ve or culturally insensitive not knowing what will actually help this gentleman in his own community. Similarly, as in my prior visit in 2010, I found it interesting that this gentleman not only did not know his birthdate or the current year, but a few other patients where in a similar situation and where not oriented to time. This observation led me to ask a few more patients if they knew the year and their birthdate, and has made me question the validity of applicability of many of the dementia screening tests we are currently using. Given the high rates of low-literacy and illiteracy, I do not think that I could even use the Mini-Cog as an initial pass because of the clock draw component. I have become so accustomed and reliant on the MOCA, but am realizing that this test will not be applicable here.

I have started searching the literature for other screening tools which may be more applicable to this population and which are less educationally biased. The Sweet-16 is probably a screening tool which would be appropriate, but unfortunately, because of its closed-access, I will not be able to use it. I am hoping that other GeriPal readers from our international community may have more experience with dementia screening in rural communities with low literacy rates. Please send in your comments and suggestions!

In the meantime, despite these challenges, the rewards of providing care here are immense, and I can only hope that I am making a tiny dent in the lives of a few patients. By educating one patient, I hope that in turn that new information will be transmitted to another family member, a friend, and ultimately an entire community.


by: Carla Perissinotto MD MHS


To learn more about San Carlos or to make a donation visit: www.hospitalsancarlos.org

5 comments:

Anonymous said...

This is not an impartial comment, as Dr Carla Perissinotto is my daughter. Several years before she was born I was also in Southern Mexico doing work for the indigenous peoples of Oaxaca, where the concentration of diverse ethnic groups and cultures presented similar yet also different challenges. Though my work with the Ministry of Education did not have a specific medical component and was directed toward the social integration of the disposessed population, the same medical issues that confront Hospital San Carlos were of much concern. The main focus of our work was the social integration via educational mechanisms to introduce Spanish as a communicative tool while maintaning and enhancing the native languages that are vital to and inseparable from an individual´s identity. The barriers were as formidable as the ones facing the dedicated staff at San Carlos and the patients trying to receive even a modicum of medical care. Enormous distances over forbidding terrain with no roads as we undesrtand the word. Many isolated villages could only be reached by small planes landing in makeshift airstrips. Like Carla having to depend on interpreters to obtain dependable data, we also had to surmount the difficulties of at times even identifying the Indial language we were dealing with. And, much to the point, we were also comfronted with powerful local traditions, regulations and "laws" that made our intentions difficult to explain and be accepted. Mistrust was common. Measurement of time and distance--so common to us--were often alien to them. As in the case in Chiapas, age was difficult to determine. Kilometers, miles or leagues were meaningless and "one hat or two hats" (the time it takes to weave a hat from fibers) made more sense to them.

Yet the personal rewards were gratifying, even if we improved their lot just a little bit. The beaming face of a child being given the first "book" he/she had ever handled, the joy of sharpenng a pencil or tracing the outline of an animal or flower on paper were justification enough for me to have spent a year in Oaxaca.

San Carlos is clearly doing much more and I trust it can find enough support to keep it going for many more years.

Stay safe and healthy,

Giorgio Perissinotto
Your father, also

Professor Emeritus
University of California,
Santa Barbara

Anonymous said...

Beautifully said, Giorgio. And clear that the apple does not fall far from the tree...

Thanks for sharing, papa y hija.

Dzovag

Alex Smith said...

I'm enjoying reading about the good work you and your father have done in the area! Keep up the international reporting!

I wonder what either of you think about this sort of age old bioethics question: how far does one's obligation extend to worst of members of your own family? how far to one's neighbors? how far to one's community? how far to one's country? and how far to worst off groups internationally? Should the standard of care for rural Mexicans be the same as the standard of care in the US? This question gets at the Paul Farmer concept (we owe the same to all, the standard of care should be the same everywhere) vs. the traditional public health approach (do the best you can in the community given scarcity of resources).

I just bring it up because in my experience working in other countries it always seems to be at the core of the tension - should I be doing more? how much is enough? what is my obligation?

Carla Perissinotto, MD said...

Great question Alex. These questions on international health are always challenging when I work abroad. I often think of this when I am doing primary care in low resource settings because I try to apply the principle of what would I do if this patient were seeing me in my clinic in Berkeley. ie. what are the health maintenance recommendations for this 65 yo patient, and do I still make the same recommendations when I know that these recommendations will put tremendous econonomic budrens on the patient? Or do I explain my thoughts and allow the patient to decide how to proceed.

It is also hard to come back to the US, and realize that my own patients here, in my community need me just as much. Therefore making me question if I should continue to work abroad or focus my efforts here where there is also great need. Very difficult questions. Ultimately, I hope my experiences in both places will help to educate more physicians, and physicians to be, and allow me to better care for my patients.

David Robinson said...

That's one thing about medical ethics that I seem to rarely see put into practice these days (at least on a large scale). Most doctors seem to be adding up to the prices by making a lot of prescriptions, even if the patient can't handle the bills (that applies elsewhere of course).