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.