Ya Vengo!

Hola! As we wrapped up our last week in the FIMRC Alajuelita site in Costa Rica, we wanted to give you all an update on what we’ve been doing here!

Over the last week, we've been working on a “proyecto” (project) that we created to help improve the management of four major chronic illnesses that is commonly seen in the clinic such as diabetes, hypertension, obesity and asthma. Our group was asked to develop a plan during which we would produce a volunteer handbook that would help guide future volunteers in managing these illnesses when they come through the door.

For each of the chronic illnesses, we provided basic disease pathophysiology and specific socio-cultural-economic factors that are unique to the patient population here in Alajuelita that further complicates chronic disease management that goes beyond access to resources and medical attention. Next, we created step-by-step instructions on how patients with know history of chronic disease or demonstrate risk factors that would indicate screening and identify scenarios in which the physician or clinical staff should be notified emergently i.e. a child struggling to talk in full sentences during an acute asthma exacerbation or an adult having a blood pressure above 180/110. Our goals for these step-by-step instructions is to help streamline patient check in, provide appropriate medical care (urgent in certain cases) and allow time for health promotion and education. This leads us to the other component of our project, and arguably the most important component: health education and disease prevention. Through health education and empowering patients to take ownership of their own medical care, we hope that this would translate into creating long lasting change in people’s lifestyle habits, behaviors that would ultimately lead to better physical and mental well being.


Our completed binder!

Our focus for health education was primarily based upon providing basic medical knowledge that would be comprehensible at the population's general level of education (often is limited to grade school), discuss about risk factors for developing these chronic illnesses (tailoring these to the environmental/social/cultural practices that may contribute as a risk). We also wanted to focus on the importance of disease prevention and provide patients with tangible ways to prevent or control their chronic illnesses.

This portion actually required a lot of thought and insight into the living circumstances of the patients that we see in clinic. Having lived and worked in this community for an extended period of time, we gained an understanding of the limitations of treatment of these diseases necessary to give realistic advice and guidance. While we can argue that hypertension is shown to be most effective controlled by at least 2 anti-hypertensives, the reality is within our clinic that is situated in the slums of Alajuelita is that this treatment method is close to impossible to sustain over time due to limited resources. Instead, we tried tailored our treatment through non-pharmacological methods such as encouraging a low sodium high fruits and vegetable diet, 20-30 min of exercise on most days of the week, weight control etc. As this is our last week in Costa Rica, we also started brainstorming ideas for how to best disseminate health education, through activities that would cater to the local community. We discussed about hosting cooking classes during which patients can swap recipes and learn about healthy eating, exercise classes with yoga or simple exercise that patients can replicate at home or going into the schools to talk about asthma and incorporate the use of games and interactive workbooks. Our hope is that future volunteers can use this binder to identify patients with chronic diseases and use the educational materials that we made to educate patients on their disease, prevention, and treatment that is catered to unique challenges this population faces. We hope that the program is sustainable and will eventually help patients better control their chronic diseases in ways that make sense to them. We are planning to work with FIMRC to send some of this information to volunteers before they arrive in Costa Rica so they can jump right in and educate patients on day 1 and perhaps even use our posters and other educational materials to hold a charla (lecture) or a support group meeting!


Our patient learning about diabetes complications from Diego, diabetes man!


Serena giving a diabetes charla with brochures she made for future volunteers to distribute!


Too cute not to share! These kids were so interested in learning about how to use my stethoscope... he even asked me to turn around and breath so he could hear my lungs like I did to him!

For our last weekend, we were able to enjoy the beautiful coastal city of Montezuma and Santa Teresa with our adopted group member Luke and captured some of the most beautiful sunsets over the Pacific Ocean! We also visited Montezuma Falls, which consists of three sets of waterfalls emptying into freshwater swimming holes, one of which even had a rope swing!


Montezuma Falls


Playa del Carmen


Beautiful sunrise!

It has been such a pleasure to have had the opportunity to work with the clinic staff and the patients here FIMRC Alajuelita. We are grateful for the help and guidance that we received from Tatiana, Dayon and Dr. Natalia during our time here. It has truly been a once in a lifetime experience and we have all learned so much about the practice of medicine in Costa Rica, international medicine, public health, and the beautiful language, culture and people of Costa Rica. Thank you so much for all your support and for following our blog!! Muchas Gracias y Ciao from Costa Rica Team 2015 “Las Chicas”!! Ya Vengo, which means be back soon!

Let's Utsia Ingo!

It’s hard to believe that we’ve reached our last day in Uganda! In honor of our departure, we have one last quick blog update!

Last week, one of the Ugandan volunteers at the clinic, Bosco, specially requested that we come out to his school to give a menstrual health talk and sex education to the girls (mainly because his school doesn’t have any female teachers). Because Bosco had been such a huge help to us as a translator, we eagerly accepted. So last Wednesday, eight of us left the guesthouse just before 6:00am and made the two-hour trek to Bosco’s school in Bufuma. We were greeted with much anticipation given that “muzungus” don’t often hike all the way out to this particular sub-county. Instead of just giving lessons to the older girls, we managed to create age-appropriate curriculum for all of the grades. For Primary 1-5, Irene, Jenny, and Sara F. gave brief lessons on heart health and wound care. For the P6 and P7 boys, Quoc, Ben and Marsel gave a sexual health talk that focused on the importance of condom use and sexually transmitted diseases. While they worked with the boys, Stephanie and I gave the girls a similar sexual education talk and gave a lesson on menstrual health. Normally, as part of the menstrual health lesson, we have the girls make washable menstrual pads. However, Bosco’s school is quite large and the P6 and P7 classes alone had about 100 girls! We didn’t have nearly enough needles or time for them all to make their own during our talk. So instead, all of the FIMRC volunteers (yes, boys included!) worked like crazy the week before and made all the pads we needed so we could hand them out! Overall, all the lessons were well received and we were thrilled that the students had so many questions to ask!

Beautiful views on the hike to Bufuma Primary School

Photo from our two-hour hike to Bufuma 

Finally arriving at Bufuma Primary School!

The P6 and P7 girls from Bufuma Primary School received washable menstrual pads during a menstrual health education session. All the pads were hand sewn by FIMRC volunteers.  

As part of the heart health talk, students used stethoscopes to hear their own heartbeat. 

Jenny, Sara F, and Irene show off their health lesson supplies including Ester, the paper doll we used for wound care. Ester is laminated so that students can practice cleaning her cut, putting on topical antibiotics, and covering her wound with a Band-Aid. 

Photo with students from Bufuma Primary School

            In addition to our educational outreach, we continued our regular clinic work. Quoc presented another CME seminar to the staff, this time covering the management of epilepsy. Ben and I finished the school profile for the Bushika Junior Education Centre and presented the school director, Richard, with a copy. He was thrilled by the end result and said that the document would be very helpful to him in the future. We also helped Jenny do an inventory check of the entire dispensary before a new shipment of medications arrived. Once the shipment came in, we helped to log and organize all the new items. 

Marsel and Ben help clinic staff member, Irene, see pediatric patients in Station 3 Annex

Group photo with FIMRC clinic staff 

On Friday, we returned to the Bushika Junior Education Centre, where we had been holding weekly health lessons, for the last time. For most of us, we had gone there every week and established relationships with the students and staff. To show their appreciation, the entire school put on an assembly just for us! Each of the primary grades presented small songs, poems, or skits. The moment that really tugged at our heartstrings was when two boys from P3 got up to perform a skit about wound care. It was wonderful to see the students use our lessons and watch them repeat the wound care steps that we had taught them.

As a result of a national polio vaccine campaign, our small clinic was closed for the weekend and Monday. Since we had a long weekend at our disposal, we decided to end our Ugandan adventure the best way we knew how – with a safari! Please enjoy the pictures we’ve included. We have had a fantastic time and couldn’t have asked for a better send off.

Rainbow over Murchison Falls 

Group photo from our safari van

Thank you so much for following our blog! We have learned so much while working in Africa and so appreciate all the support we’ve gotten from our friends and family. We are excited to share our pictures and stories with everyone in person!

Return from Mulembe

In celebration of our last week abroad, here's a poem attempting to capture our trials and tribulations in Uganda.

To mulembe, we were sent,
Bushika Junior empowerment.
Mona mona, coffee roasting,

Downhill all the bodas coasting.

Childhood rashes, Post Test Club,
Pepto-Bismol, pink with love.
Richard, outreach, miles, who’s countin?
Kids with babies, up a mountain.

Hey muzungu, how are you?!
Morning nausea, diarrhea x2.
Bufuma in the morn with Bosco,
Rafting down the Nile, also.

Homebrew or mosquito nets,
Cetamol 1gram TDS.
Matoke on a plate like Nuusu,
Passion fruit I could get used to.

Excess matatu, rising sun,
Going to get Bududa lung.
Mai the cat, such a pest,
Fan-taa, Stoney or a Krest.

Popcorn and a movie screen,
GO GO Bushika soccer team!
Puzzle pieces missing still,
DEET latrine. All bugs. Must kill.

Sipi falls, a mighty wind,
Masala fries all day, a binge.
Setting goals with OVCs,
Tuesday meat not what it seems.

Eggs, toast and G.nut paste,
Bucket showers IN THEE FACE.
Lugisu, Musa’s time to train us,
Always, Quoc, ali kuena?

A B C, it's easy as 1 2 3

In Alajuelita we have spent the first few weeks getting to know the population. We have been exposed the living conditions, experienced the typical food, and chronicled the entire clinic population with a special emphasis on those with chronic diseases. Here, many people believe that their chronic illness can be cured with a simple medication. And many of the medications given for chronic diseases are shared amongst the entire family regardless of whether each individual actually suffers from the disease. This has led us to focus our project on ways to improve their understanding of chronic diseases. The project specifically targets some of the most common illnesses: asthma, diabetes, hypertension, and obesity. Because the majority of the population lacks insurance, the people have very minimal access to healthcare, particularly medications. Our free clinic serves to provide services to these individuals, however the amount of available medications is never sufficient. This makes treating diabetes and hypertension very challenging as some of the simple solutions in the United States such as insulin, or meds for hypertension impossible. Thus we have had to focus our efforts elsewhere and begin with education. 

Serena with Diego, diabetes man.

This is also true when it comes to treating asthma. During our pediatric rotation in the US, we grew very accustomed to treating asthma. When a child came in with pre-existing asthma, we assessed how well it was controlled by asking about certain symptoms, like waking up at night coughing, frequency of rescue inhaler use, and the amount that asthma is interfering with daily life. Once that was assessed, we made recommendations to either continue the same regime or add more medications. Medications almost always included a control medication that was to be taken everyday and a rescue inhaler for emergencies. Here, I have seen only a handful of patients with inhalers. The rest of the population cannot afford the inhaler or the medication for the inhaler. As a result, teaching parents and children about correct inhaler use is almost obsolete except for the few that have them. In addition, in the US, we use an asthma action plan. This plan outlines what to do if a child is having certain symptoms ranging from none to an asthma attack that requires immediate medical attention. However, our population neither has the medication nor the education necessary to follow such a protocol. Indeed, children come to the clinic for unnecessary visits due to this lack of education. Our goal is to use our brochures and posters to give this education and enact the plan to prevent unnecessary visits and time away from school. Finally, in the US, prevention is focused on making sure no one in the home smokes around the child, both in the home and car. Here, however, asthma triggers are everywhere. Since most children live in slums, floors are commonly dirt and cockroaches are abundant. Dist from dirt roads hangs in the air constantly. Therefore, we've had to think outside the box and recommend ways to keep dust down, such as wetting floors, hanging damp bedsheets around the child's bed at night, and sweeping floors multiple times a day. Even with education and interventions, controlling asthma in this environment is difficult.

Our asthma posters!

We have begun developing educational “charlas” (interactive lectures) to help patients understand these common illnesses. This hopefully will alleviate the minimal time the doctor has to run through basic guidelines for management while simultaneously focusing on patient understanding. Furthermore it is unrealistic to simply say “eat healthy” here. Much of the food includes heavy doses of vegetable oil and salt. So while a healthy diet is a component for hypertension, diabetes, and obesity we have again had to reframe our mindset and step into the patient’s perspective to develop reasonable guidelines. We had the opportunity to go to a local soup kitchen last week and give 2 charlas, 1 on brushing teeth and the other on hand washing. The kids were so interactive and excited! However, we learned that in order to give these charlas, repetition and participation is key. Instead of just holding up a poster and reading it, we played games and formed everything in a question to get the kids to participate and hear the information in various forms. Serena held her own workshop on using bead necklaces for natural family planning that went very well too! We are definitely keeping wgat we learned from these experiences in mind while we form our scripts for future volunteers!

One of our main goals is to make these efforts sustainable, so that future volunteers who are not as medically mindful can relay this message as well. Our interactive seminars all include a concise script easy to read for volunteers and in basic language for the patients. More importantly, our aim is to empower patients in the population who are willing to share their own experiences. We recognize that lecturing repetitively is rarely useful. Thus, we hope to identify certain patients in the population with personal experiences of these diseases, as well as ask them to lead certain workshops involving demonstrations of exercises because we know this will be a much more powerful motivator. 

We have been so lucky to work with Dr. Natalia who not only teaches us about the social and cultural context within which we are working, but also allows us autonomy to interview the patients and do physical exams. We've had so much fun working with her, and have learned a lot!

Physical exam!

Jen training our new secretary.

Serena interviewing a clinic patient.

On another note, we've been very fortunate to be able to enjoy the beautiful landscape of Costa Rica. A couple of weekends ago we went to Volcan Arenal with another volunteer, Luke. Last weekend, we went to Monteverde, a city in the mountains, and hiked through a cloud forest. Here are some photos!

Beautiful waterfall at volcan arenal.

Crossing a stream in the cloud forest!

Fashion forward boots for the muddy cloud forest

Her majesty volcan arenal

The sun is setting on our trip here, but we've all learned so much. We are excited to wrap up our project in the coming days and hopefully make understanding, preventing, and treating chronic illnesses a little easier both for the clinic and its patients. Until then, Pura Vida!

"Don't Go Chasing Waterfalls"

Hello everyone,

Thank you for keeping up with our blog posts. We are nearing the end of our time here in Uganda. Nine new volunteers from other medical schools decided to join us on our mission to help out at Project Bumwalukani. It has been the typical week at the clinic. Some of us tagged along with the clinical officers seeing patients. Besides seeing our share of skin diseases, hypertension, and viral respiratory illnesses, we had a few patients that needed special attention. Of note, a child living nearby had been seen at the clinic twice this week for an abscess near his left eye. Because the abscess was worsening, we thought the best plan was to send him to Bududa Hospital. Stephanie and Irene had the opportunity to escort him to the hospital for treatment. He was discharged a few days later and decided to pay our clinic a visit. It was great to see that he is recovering well.

            Besides working at the clinic, we received a presentation from Richard, the Health Outreach Coordinator, on Vitamin A supplementation. In the 2-hour session, we learned how to counsel parents about the benefits and the side effects of Vitamin A, as well as learned how to administer it to children. 

            We spent a lot of time at Richard’s Bushika Junior Education Centre. Last Friday, we visited the school to give the students presentations on health-related topics. Sarah and Stephanie had a discussion with a group of teenage girls about sexual health, including discussions about the birds and the bees, how to say no to sex, and family planning. We also talked to the students about nutrition, on what and what not to eat. This past Friday, our group came back to Richard’s school to educate them about heart health and first-aid basics. This involved teaching the kids how to measure their pulse, having them listen to their own heart through a stethoscope, and educating them about heart healthy foods.

            Sarah, Ben, and I were also involved with the task of creating a profile for Richard’s school. The profile would be their official document about the functions of the school. In theory, Richard is hoping to use the profile to register his school with the Ugandan government in the future, for grant applications, and for general informational purposes to sponsors and donors.

            Throughout this past week, we also went on multiple outreaches. We made home visits and performed individual home safety/health assessments, gave deworming medication, and provided vitamin A supplements. We also went on immunization outreach, providing vaccinations until very late in the day. A few of us tagged along with Musa to visit an OVC (Orphan and Vulnerable Children) patient at her home. Their home visit assessment consisted of determining her living conditions, addressing drug adherence issues, and answering the OVC’s concerns. We also held a CME session where Marsel gave a short but comprehensive topic covering the management of hypertension.

            Last weekend, we traveled to Sipi Falls for leisure. It was a nice Matatu ride through the best paved road in Uganda to reach our destination at Crow’s Nest Lodging. From there, we hiked up the steep terrain to view the first and second waterfalls. For the third and final waterfall, a few brave souls dared to go down the ‘wall of death’ to view the waterfall from the bottom. For the rest of the group, viewing the waterfall from the top was enough.

           

Thank you so much for reading our blog!

Drama Group performs a new act one Wednesday a month. The acts are suppose to be educational for the patients waiting at the clinic.

Ben and Richard during our Vitamin A workshop. Ben is pretending to give the balloon baby a "blue" capsule of Vitamin A. Vitamin A is administered to children starting at 6 months and is given every 6 months after until age 5. Blue capsules contain 100,000 IUs of Vitamin A and are given to children between 6-11 months. Red capsules are 200,000 IUs and are given to children between 12-60 months.

Stephanie and Irene walking with Arlington students home from school

Our amazing friends came by to the clinic to visit us after seeing patients. They are always looking for somebody to carry them.

The peds ward at Bududa Hospital

Irene educating Richard's students on nutrition

We made cut-outs of the different food commonly found in Uganda. The kids were really excited about getting the photo taken

CME on hypertension management

Immunization outreach with Kaliste

Setting up shop for immunization outreach

Sipi Falls

Sipi Falls

Paying close attention to our guide, Moses, at Sipi Falls

A picture of some our members at the bottom of the last waterfall; Sipi Falls