Anconcito, Ecuador

Bienvenidos a Ecudaor!  The time has flown by, and my wife Lauren and I have had our share of hard work, new experiences, and excitement!

Anconcito, Ecuador

We are working with the Foundation for International Medical Relief of Children (FIMRC) on a project to assess childhood malnutrition and anemia in the rural fishing town of Anconcito.  There is a great deal of need in the community, with widespread poverty, overcrowding, and limited access to healthcare being among its chief problems.  Some statistics: the majority of families in Anconcito survive on $200 or less per month, and while the cost of living is substantially less here than in the U.S., it is still hard to make ends meet. For reference, the minimum wage here in Ecuador is $366 per month, but since so much of Anconcito depends on the fishing industry, and some times/seasons are profitable while others are not, families here are often making far less than minimum wage.  Indeed, less than 6% of families make more than $400 per month!

Additionally, while diseases such as parasites and diarrhea are common, often owing to contaminated tap water, there is little in the way of medical care for the community.  The Ecuadorian Ministry of Health (MoH) runs a small clinic here in town where people can receive free health care, but there are only three doctors for a town of nearly 20,000 people, and, while private clinics do exist, the poverty of the residents here makes cost a daunting obstacle to using these services.  The MoH clinic is understandably overwhelmed with its impossible task of trying to provide care to the town, so patients often must wait weeks or months to be seen.  And even when they do get in for a visit, the MoH clinic has so few resources at their disposal that the level of care provided often falls well below what we would expect in the U.S.  Cases of even low complexity must be referred to a hospital in the nearby town of Salinas (I once saw a child with an earache referred to a pediatrician in Salinas because the MoH clinic didn’t have an otoscope to perform a proper ear exam).  I do not blame the doctors at the MoH clinic; they are good people doing the very best that they can.  The task before them is simply far, far greater than the manpower and resources they have available to them.

It is in this context that my wife and I are conducting our research.  To our knowledge, there is very little data about malnutrition in this community, so we are hoping to help fill that void of knowledge.  Our study involves collecting height and weight measurements of children aged 0-59 months, as well as collecting hemoglobin samples from kids aged 6-59 months.  From these data, we will estimate the prevalence of manifestations of malnutrition such as underweight or stunting, as well as estimate the prevalence of anemia in the community.

We are nearly done with data collection at this point, and while we have yet to sit down and analyze the data, we can already see that malnutrition and anemia are both very significant problems in children here.  Stunting is very common, and even the children that check out as “normal” on the growth charts are nearly all below average for height-for-age.  Additionally, mild-to-moderate anemia seems to be almost the rule rather than the exception, and our screening has even detected a handful of cases of severe anemia that required urgent medical attention.

We hope that our work here will be much more than an academic exercise.  We are collaborating with the MoH clinic to conduct the study (they are very kindly lending us their hemoglobin analyzer to perform our tests), and we will share the information we collect with the doctors there so that they can hopefully follow up with the children most in need of medical intervention.  We also hope that our results will be useful to FIMRC as they continue to work to develop interventions to promote health and nutrition here in Anconcito.

But it hasn’t been all work and no play for Lauren and me.  We have taken advantage of our weekends to do a little sight-seeing in this beautiful country.  One of our trips took us hiking and snorkeling at Isla de la Plata (Sliver Island), also known as the “Poor Man’s Galapagos,” where we saw blue-footed boobies, a whale, a shark, sea turtles, and a huge variety of fish.  This past weekend, we visited the city of Cuenca, a sprawling historical city surrounded by beautiful mountains.  And this weekend, we hope to journey to Riobamba and see the famous volcano, Chimborazo.  Ecuador truly is a land of immense natural beauty, and I wish we had more time to see it all!

 

Chris and Lauren in Cuenca, Ecuador

Private Practice in Flint

As Ji-sun mentioned below we both have been working at a private clinic in Flint that provides care specialized in internal medicine and pediatrics. The clinic functions as a safety net health center serving some of the most vulnerable individuals of the Flint community. Most patients fortunately have been able to obtain health insurance following the Affordable Care Act, however the clinic still offers care to those uninsured/ underinsured struggling to find care. Being able to work alongside a variety of providers in both the primary care and urgent care setting has allowed for immense learning opportunities. I have become more familiar with the management of chronic conditions such as hypertension and diabetes as well as learned how to manage acute presentations ranging from upper respiratory infections to ankle sprains.

In addition to our clinical responsibilities Ji-sun and I chose to focus our community project on health education. In many outpatient clinics, like this one, providers have large patient loads leaving very limited time for educating patients about their health. Understanding the impact that education can have in helping patients manage their health we chose to provide diabetes health education at the clinic. With the high patient loads of the clinic many patients find themselves waiting 1-2 hours to be seen, which for us was a perfect time to focus on providing health education. This thought to serve 2 things: opportunities to provide health education and patients would not be so focused on their waiting time. The waiting room provided a perfect avenue to implement education on a diversity of health related topics. We provided patients with simple yet important handouts covering topics such as what diabetes is, common symptoms, medication use, nutrition and physical activity information. We also spent time working individually with patients that desired more information about managing their chronic condition. Patients shared how being better informed about their diabetes made them feel more confident in being able to work with their provider to better manage their health. 

Empowering patients to take on a more active role in their health is essential and the health outcomes are by far better, thus we hope that our efforts in promoting health education are continued!

Hurley Children's Center and Nutrition for Flint Children

Hurley Children’s Center is a one-of-a-kind clinic in a one-of-a-kind city. After all that Flint has faced, this clinic truly does the best it can to provide its patients with the many resources they can use to improve their lives. This clinic is home to many wonderful residents, attendings, PAs, health psychologists, WIC staff, dietitians, nurses, and many more members.

One of the biggest changes the clinic has undergone in the past two years is its move to the current location. In September of 2015, the clinic moved from its old location next to Hurley to the new location next to the Farmers’ Market. The thought was that maybe families would be more likely to purchase healthy food options if they had to travel next door for their clinic appointments anyway. Since the move, other programs with a similar goal have been implemented. The Double Up Food Bucks program has been expanded to Flint, which allows people who buy fruit, veggies or milk with a Bridge Card at a participating site to get a matched amount of Double Up Food Bucks to spend on fresh fruits or vegetables. The Hurley Children’s Clinic also participates in the Fruit and Vegetable Prescription program, which gives “prescriptions” for produce at the Farmers’ Market. These are $10 vouchers given on days when the market is open, and bags of fresh produce on days that the market is closed.

After being in the clinic as a medical student for a few weeks, I have seen firsthand how much this population could benefit from these programs. Many staple diets include chicken nuggets, hot dogs, chips and pop. It is difficult to advocate for healthier choices when produce is more expensive and less convenient, so hopefully these programs can have some positive impact.

The project I am involved with is a qualitative study which aims to address how these programs, as well as the move of the clinic, have impacted the patient population at Hurley Children’s Center. We are interviewing parents and caregivers of patients who are willing to discuss their experiences with the programs. We hope to find out how the programs have been beneficial, as well as what barriers patients still face in accessing healthy food. Hopefully, we will receive answers to these questions that we are not able to predict. For instance, many people viewed the move of the clinic’s location as an obvious positive, but many parents do not like traveling to the new location because parking is more difficult. If we are able to find out more information like this, hopefully these programs can be improved to provide a greater benefit to the Flint population!

Hamilton North Pointe Clinic and Breast Cancer and the Environment

I've been working at the North Pointe Hamilton Clinic on the North side of Flint since early January.  I see patients with the Med/Peds residents and then present the cases to the attending physicians.  The clinic has been very busy lately!  I've been able to interact with a multitude of patients from different backgrounds.  The clinic serves a population that is mostly Medicare, Medicaid, or uninsured.  Most of the patients have multiple chronic medical conditions that have not been addressed in many years.  I get to work with the residents in creating a plan of attack on which issues to address first, and which ones can wait until later.  I am getting more comfortable with management of diabetes, hypertension, obesity, and COPD.   I also get to help with a lot of well child visits, which are my favorite!  I love seeing kids and counseling parents on nutrition, anticipatory guidance, safety, and behavior.

I've also been working with the MSU Extension office here in Flint on a research project showing a connection between the consumption of high amounts of animal fat, exposure to phthalates, and BPA exposure during adolescence and the later development of breast cancer.  I will be going around to various schools in Flint this month presenting the research results after nutrition classes.  My goal is to make the public aware of the importance of a healthy diet and the dangers of certain chemicals (phthalates and BPA) and what kinds of products contain those chemicals.  Hopefully I can make an impact.

These two months of LMU are flying by!  I've learned a lot and have enjoyed the exposure to underserved populations.  I plan to take this knowledge and incorporate it in my future patient encounters no matter where I end up practicing.

Private Practice in Flint

Yvonne and I are working mainly at a private clinic in Flint, providing internal medicine and pediatric expertise to its patient population. The practice has 3 clinic sites, two on Flushing road and one on Saginaw road. One of these sites is an urgent care. This variety has been very exciting for Yvonne and I as we embark on the adventure of working with physicians and nurse practitioners - seeing different of practicing styles amongst all the health care providers.
In the urgent care setting, I am seeing patients with acute presentations, while at the other 2 clinic sites, I am seeing patients with chronic illnesses. At all the sites I also get to see pediatric patients. It has been a practice with a broad spectrum of patients, which has been great for educational and academic learning. I have also seeing a trend, of a lot of URI symptoms, given the current weather and its changes. Another aspect I've enjoyed, is that Dr. Arif and Dr. Ahmed take any opportunity they can get to add a teaching moment to every patient visit. Because of this, I have also learned about new medications that are either on trial or already in the market, and it's impact on patients' quality of lives.
Aside from clinical time, we have also been working on our community projects, which entail providing educational sessions on Diabetes and Hypertension with the patients waiting to be seen at the clinic, as well as providing Spanish classes at a local high school. It has been a slow start on these projects, but we are excited to share our results and impact with our other LMU students, as these programs further develop.

Genesee Free Clinic

        Latinos United came into existence during the Flint water crisis because all the materials regarding the crisis were in English, so the six major Latino organizations in Flint came together to distribute information to the Latino population. Myself, residents, and other medical students have been working with Latinos United for Flint since last September. Our original plan was the start health talks and health fairs for this population to raise awareness about diseases that Latinos are more susceptible to. We began this way but soon found out that there was a large subset of undocumented immigrants within this Latino population, meaning they had no access to health care. Through a team of highly committed and motivated individuals the Genesee Free Clinic wrote for and received a grant for a number free visits specifically for undocumented immigrants living within Genesee County. We have been going to events hosted by Latinos United and explaining that these undocumented individuals can receive care without fear of being exposed.  We started scheduling visits, but to our disappointment every single one ended up no showing.

            Now that I have been working at the free clinic we have actually had some of these visits used! I hope that the individuals that have been seen at the clinic will tell others that it is a safe program, simply there for their health care not for any ulterior motive. However, it is understandable this fear of being found out given the current environment in our country. Decisions for this group are often made out of fear of being exposed, which means that healthcare is often sacrificed. The programs in place to aid this population need to continue to reach out more than ever and assure them that there are resources, safe havens, and remind this group that they are not lesser than anyone else.

            I’m very proud of the work that Latinos United is doing, and I am honored to be a part of this group. While these office visits won’t solve the larger issue this country is currently experiencing, I do believe if utilized they could make an impact on the Flint population of undocumented immigrants. I hope that with a continued presence in Latinos United and repeated reminders of the grant that we can get more visits, which will hopefully equate to improved health outcomes for this group.     

Fighting Alcohol and Drug Addiction Together

The use and addiction of heroin, alcohol, opioids and other drugs are on a rise in the United States.  Specifically in Flint, Michigan there have been a large amount of addiction reported, as well as mortality from overdose.  Stopping any kind of addiction is no easy feat because the brain literally adjusts to the euphoria and makes your body crave the reward over and over again.  There are programs set in place for people who are ready to quit the majority of addictions that are known.  Programs such as Alcohol Anonymous for Alcoholics, long-term residential treatment, individualized drug counseling, 12 step programs and other self help groups.  These programs have all shown to be helpful with the aid of medical management for withdrawal symptoms, spiritual guidance and strong will from the individual.

In Flint, Michigan there is a unique approach to helping former and current addicts start and complete a road of recovery at the Genesee Community Health Center.  The Genesee Community Health Center is one of only two Federally Qualified Health Centers in Flint.  Their mission is to provide high quality healthcare services and programs in an integrated, patient-centered environment with a priority focus on homeless and public housing residents.  They offer a multitude of services from preventive health screenings, well-child visits and physicals to chronic disease management and mental health and substance abuse services.  They always leave room for walk-ins everyday and are right down the street from Hurley Hospital in case of emergencies.  They have a mobile clinic and do community outreach at a local mission every week.

I have the pleasure of working with the Genesee Community Health Center and my mission is to learn as much as possible about the clinic, how it functions and of course see patients.  The GCHC has medical management such as suboxone and vivitrol and comfort medications as part of their substance abuse services.  Their approach to the counseling and psychosocial support that is necessary for a successful recovery program is what I have found to be one of the most unique I have encountered.  They have staff who are “Recovery Leaders” who have all at some time in their lives had an addiction to a drug or substance and have chosen to give back by helping others on their road to quitting their addiction. As a recovery leader you not only show support, but you offer a ride to a recovery meeting, give advice, take clients for coffee, support the family members of the person going through the addiction, whatever is necessary to really reach out and help that person get through this hard time and successfully start or continue recovery.  During an open conversation with some of the recovery leaders, I had the honor of hearing their background stories and I learned that they love what they do. They come to work everyday with a full heart, ready to help and also feel that this helps them continue their road to recovery because they can lean on each other when they’re having a bad day.  One recovery leader mentioned that she actively seeks patients and goes into “drug homes” and “sketchy neighborhoods” because she is so passionate about stopping the cycle of addiction and showing that help is there if you need it.

There are possibly other substance abuse programs with a similar approach or maybe the same approach that I have not encountered. I have encountered this approach and I feel I would be doing a disservice if I didn’t share what they are doing in Flint to make a difference in fighting addiction.

The Free Clinics

           If you look at the Detroit Metro area you will find a plethora of free health clinics. At first glance this seems incredible. In a place where the residents have lost so much, and lived in poverty for so long, it is inspiring to see so many clinics set up to provide at least basic healthcare for the residents of metro Detroit. However, the closer I looked the more I began to understand that an overabundance of free clinics might illustrate larger issues.

Firstly, if there are a large number of free clinics that means that we aren’t providing, or able to provide adequate healthcare (in the current system) to a large number of people that need it. There are a significant amount of social justice issues that explain this prevailing problem, which I will not delve into in this particular space. Secondly, I found another quite significant issue.  While it is beneficial if you have strategically placed free clinics to serve a population and thus eliminate the problem of a lack of transportation limiting access to healthcare, it can be counterproductive to have a random distribution of free clinics. I don’t doubt that the people who build free clinics do so with the best intentions, but I think that sometimes there is a lack of collaboration with already existing clinics. Those who start new clinics often do so, because of a perceived need that they hope to uniquely address. I argue that rather than continuously starting anew, we should invest in the already existing infrastructure. We should pool our resources and create phenomenal care in strategically placed locations.

The Gary Burnstein Clinic in Pontiac, MI exemplifies this idea. I was working there last week. It was 6 pm and we were beginning to see patients for the night. There was an excited buzz around the clinic that evening, because for the first time in a long time we were going to have a cardiologist seeing patients in the clinic. Not only that, but we also had a pulmonologist there, and we were beginning to do sleep studies on patients. It was especially thrilling because Gary Burnstein who started the clinic, in what was basically a closet, was a cardiologist himself. It is part of what led to this particular cardiologist to seek out the clinic and donate his time and expertise to care for those who needed it, but had no means to pay for it. This clinic is an example of how we should be using our resources. If we can create very strategically placed clinics where patients have access to every specialty then I believe we can improve patient care.

The clinic is an inspiring place, filled with altruistic volunteers that are trying to do a little extra good in this world. Yet, it must run to the best of its ability. This particular clinic fires on all cylinders in large part thanks to the executive director and his dedicated staff. They are constantly trying to pool resources so that people have the opportunity to come to the clinic for all of their healthcare needs. As the resources expand at Gary Burnstein I feel that the care the patients receive will continue to improve and hopefully their health will do so as well.

In closing, I think that the people who need care would better be served if free clinics spoke and collaborated a little bit more. It is similar to the problem that exists with electronic medical records in this country, where we as healthcare consumers would be better served if EMRs communicated with one another. We know the value of communication, but sometimes we falter, whether it is because we physically don’t have the means, we can’t find the time, or we are simply don’t know how to do it effectively.