Tuesday, July 21, 2009

Life Cycle of Our Medical Mission

So anyone who knows me well enough knows that I have been going on a medical mission to Nigeria every summer for the past 4 years. What I realized is that I've never sat down to really explain what this entails. I know some people think we just go and magically provide some medical care and there you go. I also know that even some of the people we work with who've come on a medical mission think that Mercy and I just jump into a mission and hope for the best. What a lot of people don't realize is how Mercy and I have worked on this process for the past 4 years with the goal of constantly improving the ways things work, from both a public health and a clinical perspective, and that the process is highly routinized, even if it looks like chaos when it is going on. This is how we can say we are ecstatic about how a mission turned out, while some people who volunteered and some community members can have their doubts about how effective the mission was. I think if I can get people to understand the bigger picture, then they may be able to look at the mission more objectively. So I thought that the first step is to walk you through the clinic process station by station so you can understand how things ideally work from our viewpoint.

Before I launch into the clinic process I should say that over the past 4 years we've evolved our goal of the mission from general healthcare to screening and treatment of cardiac risk factors. In particular we are targeting hypertension and diabetes. Why the switch you ask? The simple and short explanation is two-fold. First, it is very expensive to treat every condition that comes up, we can't always fix everything (lots of rare diseases show up when they hear Americans are giving away free medical care), and the local community of physicians were becoming upset because we were impacting their practices, particularly economically. Yes, that is a strange complaint, but the reality is, it is true and it is not something we wanted to continue doing. Whether we like it or not, the healthcare workers in the area have to make a living. It isn't like here where they can work at a large hospital system and they'll still make their salary. Bottom line, the less patients they see, the less money they make. And physicians in Nigeria don't make money like physicians in the US do. They are barely making it as it is, so if we destroy their livelihood it is a serious issue. If they leave their practices then who will be there to care for patients the 51 weeks a year we aren't there? So we had to address that issue. We decided that the best use of our money (we have a very limited budget, we are a completely volunteer non-profit) and the best care for patients would be to target health conditions that don't not get treated and managed well. When you think of Africa you likely think of HIV, maybe Malaria, and maybe TB. No one thinks of hypertension and diabetes. And yet, these two conditions can kill you almost as quickly if left untreated. But they aren't "sexy" diseases. No one gets up in arms about them. But they are very prevalent and vastly under treated. Even if they are identified most people do not have the access to medicines that can save their lives. So we decided that screening for these conditions and treating them year-round would be the best use of our funds and make the most impact on lives. This is why Mercy and I work so well together. She can focus on the clinical aspects and I can work on the public health & planning side. Together I think we make a great team.

Early each morning our crowd control workers arrive at the clinic site. We've used different sites over the years but the past 2 years we've used the town hall in Uromi for the main site. It has worked very well, and we like that it is a community site that is not under control of any shady characters that would try and extort things from us. It belongs to the community and we have support to use it. When the crowd control workers get there (between 6 and 7 am) there is usually a crowd already. They distribute numbers that will be used to enter the patients into the clinic. I don't have any pictures because I don't like getting up that early. So just imagine it.

After a patient receives their number they can either go inside and sit in the "waiting area" that has been set up. If they have a higher number they can go about their business and come back in a few hours. This rarely happens. Most people just hang out all day until they are called.

Once their number has been called they come up to the registration desk. Here they are asked basic demographic questions such as their name, their phone number (we switched from addresses because we realized more people had a phone number than an actual address we could find them at), their occupation, and their age or date of birth (not everyone knows either, sometimes they just guess). These are filled out in triplicate using carbon paper. Very old school, but it works. They are then given two copies of their form and enter the "clinic" area. The original copy stays in a bound book so we have proof of their attendance and can keep track of how many patients we've seen. We merge their info later.

When they enter the clinic they first have their height measured. This is important for figuring out their BMI, which is an indicator for cardiac risk (hypertension & diabetes) which is our main goal of this medical mission.

Next, the patient is weighed. Like height, weight is need for BMI.

Another measurement we take is abdominal circumference. This is a very effective, but somewhat under-utilized measure that can tell you a lot about a person's risk for diabetes and hypertension. We are not able to do cholesterol screenings or hemoglobin A1C levels (both are very expensive lab tests--not only do we not have the money for them, but no labs around are able to do the tests) so we want to get as many markers as possible during the screening.

After their measurements are taken they then go to get their blood pressure taken. This will tell us whether or not they have or are at risk for hypertension.

After their blood pressure they get their blood sugar checked by a glucometer. Without going very in-depth about fasting vs. random blood sugar tests, we look at the blood sugar test as a random test and therefore treat diabetes risk more carefully then we would in an actual clinical setting. We set the bar higher because we don't want to treat someone who is borderline when we aren't sure what their long-term sugar levels are.

After all of the screening procedures are completed the patient goes to the nurse triage station. The nurses will look at the patient's numbers and compare them to the cut off points we've determined and they will either discharge them or send them on to the physicians. The nurses have a very important job, because they often do a lot of education and counseling at this station. Patients want to be treated for everything and do not feel any consolation that they are not at risk for diabetes or hypertension. We give out vitamins to make them feel like they haven't completely wasted their day (which WE know, but it's harder to explain that to them). Medicine dependence is a big issue in Nigeria which we are trying to combat in Uromi, but we have a long road ahead of us. Bottom line, if they don't get any meds, they don't think they've been "treated" regardless if they need it or not.

If the patient is at risk for diabetes or hypertension then they need to see the doctors. But before that we want to take their picture, in case they don't show up later and we need to track them down. This also ensures that when they go for their monthly medicine dispersal we are treating the right person. Again, the importance of medicine comes into play. People will "sell" their information to people who just want to get meds. This has lead to some sticky situations and again why we are trying to explain you don't just take medicine. Taking hypertension or diabetes drugs when you don't need them can cause serious harm (passing out, etc.) and even death.

After their picture they then go to the physician. Like the nurse triage station, the doctors have to listen to a lot of complaints unrelated to diabetes and hypertension. They do a lot of education and then tell the patients that they have to go to a formal education station at a pre-determined time (we usually held education sessions at 9am, 1pm, and 4pm). Sometimes the patients would be irritated that they wouldn't be getting meds RIGHT THEN, and they'd give up, but most of the patients would go to the education session.

The patients would then go to St. Anthony's Church to one of the outside pavilions. This is where we held the education sessions. We used to do them at the hospital but we had some issues with the Chief Medical Director and decided to look for other venues. We have a good relationship with the Catholic Church in Uromi so we were given access to the pavilion for free and with community support. At the pavilion the patients sit through a 20 minute presentation about diabetes and hypertension which covers the basics, e.g. what is the disease & how it works in the body, what lifestyle changes you should make (diet & exercise), education about medicine and why you may or may not need it. They then have a question and answer period where they can ask lots of questions about the diseases. This typically last about 30 minutes and they have lots of good questions.

After the education session they are asked to select a primary health care clinic where they will go for their monthly check-ups and medicine dispersal. Again, some are irritated that they aren't getting their meds right then, but it is still part of our grand scheme. If we give them their meds there, they may not follow up with their health clinic, and if they don't, there was no reason we should have treated them for 30 days and not again til the next year. We are trying to educate as well as treat so this is an important part of the process.

At the end of the week we worked with the health clinics about how the process should go. It didn't go as smoothly as we'd like, but it was step in the right direction. This is the first time we've been able to accomplish this part, so we knew there would be some bumps and bruises but Mercy and I are used to that, and we can see when progress is made, no matter how little or insignificant it looks to outsiders. The patients showed up on Friday as instructed and waited patiently for us to work with the local workers to train them on the process.

After collecting the forms from the patients who showed up, Mercy would work with the healthcare staff (mostly nurses) to work out a management plan for each patient. For those on borderline we told them to do the things they learned in the education session (eat better, more cardio exercise), and to come back for a check up in 1-3 months. If they needed treatment (past borderline) Mercy and our other doctors would decide what prescriptions were appropriate and wrote it out on their management form.

After all the prescriptions were written, either the doctors or the pharmacists we had working with us would call the patients in, explain their management program and given instructions about their next steps (take meds, when to come for check ups, etc.). After that, they were all done with us.

So that is the long and the short of it. We hope that the process will stay in place and that next month we will get a report from our data collection agent that the clinics are all working and that they will continue to work until we come back next year! We're hopeful, but we also know that we may have more kinks that we may need to deal with in the interim.

Hopefully this gave you a better overview of the process. Leave a comment if you have any questions.

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