Last Week at Santa Rosa!

Reflections, Stories, and Things I've Learned

This is last week volunteering at the Santa Rosa Health Center and I am sad! I have had an amazing experience and will definitely miss spending time with all of the wonderful people I have gotten to know. As I think back and reflect on the last eight weeks, I am amazed when I think about how much I have learned. 

For example...

My Spanish vocabulary has grown immensely. I have become comfortable giving commands formally and informally to the patients as they come in and have learned a handful of new words and phrases, such as... 

Perímetro cefálico – Cephalic perimeter (head circumference)

Presión arterial – blood pressure

Bien pegado – “stand up straight”

Archivar – to file 

Odontología - dentistry

 Quítese la casaca, por favor - Please take off your jacket

Tome el asiento - Take the seat

Voy a tomar su presión - I'm going to take your blood pressure

Espere afuera - Wait outside

¿Para quién es la atención? - Who is the attention for?

Sácale de su ropa – Take off his/her clothes

...and so much more!

 I feel like my ability to converse naturally and quickly with the patients who come in has improved significantly. I am able to answer questions that the patients may have instead of just referring them to a more fluent Spanish speaker. 

In addition to improving my Spanish vocabulary and speaking ability, I also have developed and honed a variety of new skills that pertain to working in a health center. 

*I know how to weigh and measure patients when they are called to the triage area and recently I have learned how to take blood pressure as well. 

*I have also learned how to correctly weigh and measure the babies in the healthy child control area. Measuring the babies accurately is quite the chore as it is very difficult to get them to be perfectly straight and flat but I feel like I have definitely improved. 

*I also know how to do a psychomotor evaluation for babies of various ages. 

*On a handful of occasions, I have performed a curación del ombligo, or cleaning of the navel and umbilical cord, that is required for all the newborns who come into the clinic. (The very first time I had to clean the bellybutton of a baby, it was comical! That day, there was a mountain of babies who needed to be seen by the doctors and we were all incredibly busy. A mother brought in her newborn baby and I sent her to buy the sterilized gloves that were necessary for the doctor to clean the bellybutton. When the mother returned, I asked the doctor, who was busy with her head buried in the piles and piles of paperwork that must be completed for each patient, if she would clean the bellybutton. Without looking up from her work, she asked me "Do you know how to do it?" At that point I had only watched a few times while she cleaned a bellybutton and so I appropriately replied "No, I do not." She looked up from her work for just a moment, looked me in the eye, and sternly said "Learn."  She put her head back down and proceeded to fill out forms.  I found this comical because she never bothered to teach me how to do it; she only told me to "learn." Of course, I pulled on the gloves and used the tiny gauze squares with a squirt of alcohol to remove the crusties and goobers and clean out the navel. Since that day, I have cleaned several other bellybuttons, each time with more confidence that I know what I am doing.) 

*I have become acquainted with the somewhat confusing filing system and can pull a long list of files in no time at all. 

*I also can fill out new files and paperwork when new patients or newborn babies come into the clinic. 

I'm sure that this list does not even include all of the simple tasks that I have become accustomed to doing at the health center on a regular basis. Even though I have loved learning how to do these things and doing them, there are other lessons of deeper importance that I have learned during my time at the health center.

There are people who come to the health center seeking help despite incredibly difficult circumstances. While there is free (or nearly free) insurance for most patients, the simple task of arriving at the health center can be a great feat for some of the patients. There are some people who have to walk great distances up and down  incredibly steep hills on rugged dirt roads in the beating sun or in pouring rain. In order to get confirm an "appointment" with the doctor (although, I would never use the word appointment to describe what happens in the health center), it is necessary to arrive at the clinic very early in the morning. The first patients who receive attention often have waited outside the doors of the health center since 5am in the morning. The patients have to wait in a very long line in order to place their name on the list to receive medical attention. After placing their names on the list, they have to wait until they are called by the nurses in traige and then wait more for the doctors to call them back to the treatment rooms. They often wait for hours and hours in the waiting area, which consists of a few rows of benches lined up on a mound of dirt and gravel underneath a patchy tin roof in front of the health center. There are people waiting outside in the down pouring rain or in the dry heat of the sun from early in the morning until the center closes for the day.

This has made me realize how much I take for granted at home in the United States. When I need to go to the doctor, I call, make an appointment, and show up at that specific time. I have often complained as I've sat comfortably in the padded chairs in the quiet, air-conditioned waiting room if I've had to wait for even just a few minutes for the doctor or nurse to call my name. I can't imagine that I would ever go to the doctor if I had to arrive at 5am and then sit and wait for five hours or more, possibly in the pouring rain, just to be seen by a medic for a few minutes. The people here make a much bigger sacrifice in order to receive medical attention. They are much more patient and typically everyone waits courteously outside for their name to be called. 

In addition to this, it is very clear that the Santa Rosa district of Cusco is a very poor part of town. I have seen traditionally dressed women come in wearing the typical sandal-type shoes with extremely dirty feet. When they remove their sandals, mud and dirt often have formed an outline where the straps had been. Sometimes the people have a distinct body odor scent, as if they haven't bathed in several days. I have noticed some patients wearing the same clothes on multiple different days when they have come in. When I explored the Santa Rosa district with the obstetricians for a few days a while ago, we wandered up and down many, many streets of mud brick adobe homes. The streets were dirt and mud, bumpy and jagged with holes, bumps, and channels where the water would run. The dwellings were constructed entirely from the adobe bricks composed of mud and straw. Dogs, cats, chickens, and sheep lived right alongside these people around their humble homes. I'm sure some of them had electricity of some sort, but I would be very surprised if these people have televisions, computers, or internet in their homes. 

Something as simple as personal hygiene is definitely something I have taken for granted as well. It is so easy to be accustomed to having luxuries such as a warm shower and clean clothes on a regular basis that I forget to be thankful for even these simple things. In the United States, we are overwhelmed and bombarded with the desire to always buy new things, new clothes, and new toys to the point that we feel a sense of entitlement to these things. I don't believe it is a bad thing to buy new clothes or to take a shower everyday, but I do think that is it very important to maintain a humble attitude of appreciation for the luxurious lifestyles that we have been blessed with. I'm sure that there are many people around the world who live in much worse conditions that even those that I have seen during my time here. 

Despite seeing many sad situations, my time at the public health center has been filled with positive memories. There is one young mother who I have seen in the center multiple times. Her baby had been born shortly before I arrived. He was very small and very malnourished. I remember watching the young mom wipe tears from her eyes as the doctor lectured her about the state of her newborn baby during his first or second checkup. Just yesterday I saw the same mother bring her two-month-old baby into the clinic; he now is a chubby young little guy with thick legs and round cheeks. His weight and height were right where they needed to be for a baby of his age. 

It is so wonderful to reflect on such a positive outcome to this story. If the young mother (who is 15 years old, by the way... I checked her file) had not chosen to bring her baby boy in for his regular controls, she may have not known that he was severely malnourished. In the worse possible outcome, the baby could have died from malnutrition if he did not receive more attention. Fortunately, the mother had access to care and chose to put forth the effort to bring her child into the clinic once a week or sometimes even more frequently than that. 

I have been incredibly blessed to have had such a wonderful experience at the Santa Rosa Centro de Salud and am very sad that my time there has come to an end. Tomorrow, Thursday, the 13th of March, will be my last official day. Although it would be easy to go to the health center with a heavy heart tomorrow, sad that it will be the last few hours I will spend there, I would rather go with a positive spirit, thankful for the wonderful experiences I have had and the relationships I have formed with such amazing people. It will be hard to say goodbye, no doubt, but I can be joyful knowing that I have been able to make a difference at the health center I love so much.

The Latino Patient – The Clinical Encounter

GREET: Characterizing the Latino Patient

After covering relevant cultural values and the belief systems of the Latino population and addressing variations in the beliefs due to generational differences, The Latino Patient moves on to present a culturally competent care model for Latinos. It begins by offering the acronym “GREET” as a way to characterize Latino patients. By gathering relevant background information about each individual, healthcare providers can increase their understanding of the personal and cultural history of each patient. Expressing an interest in the patient’s personal background can also increase the amount of respect that is perceived by the patient. The GREET acronym is as follows:

G = Generation

R = Reason for Immigrating to the US

E = Extended or Nuclear Family

E = Ethnic Behavior

T = Time Living in the US

Generation

It is important to determine whether the patient is an immigrant or a second-, third-, or fourth-generation Latino. The degree of acculturation varies with each generation and each brings to the table its own set of unique characteristics. The later generations are much more similar to the mainstream culture than recent immigrants

Reason for Immigrating to the US

Knowing a patient’s individual reason for immigrating to the United States can give the healthcare provider insight into the social, political, and economic stressors that may affect the mental and physical health of the patient.

*This category does not apply to second-, third-, or fourth-generation Latinos.

Extended or Nuclear Family

By gathering information about the living circumstances of the patient, the healthcare provider can have an increased understanding of the social support network that the patient may or may not have. Typically, in the Latino culture extended or nuclear family members live in close proximity to each other. This can present problems for immigrants if they are unaccustomed to living far from family.

Ethnic Behavior

It is useful to gather information about the patient’s personal preferences in regard to food, music, holidays, and recreational activities. This is important because habits such as consumption of alcohol at parties or celebrations can have significant health implications.

Time Living in the US

As variation in acculturation is seen from generation to generation, similar variation is seen as the time spent living in the United States increases. Patients who have recently immigrated will cling more tightly to traditional Latino cultural values, while second-generation Latinos who have lived their entire lives in the US will be more similar to the mainstream culture.

The Clinical Encounter

There are a few important points to keep in mind during the initial part of the clinical encounter with a Latino patient. While the healthcare provider may be accustomed to interacting with a diverse clientele, it may be a new, and sometimes scary, experience for the Latino patient. Cultural and language barriers can be equally, if not more, intimidating for the patient, who is making an effort to seek medical attention in a health system that may be entirely different from the system in the country of origin. With this in mind, there are a number of crucially important factors that should be taken into consideration during the initial interaction with the patient.

Eye Contact

As a sign of respect, making eye contact with the patient is critical; however, it is important to be careful with gender differences. Maintaining eye contact for an extended period of time with a person of the opposite gender may be perceived as an attraction towards that individual.

Facial Expression

A simple smile and friendly facial expression can work wonders in setting the tone for the entire clinical encounter. The combination of a smile and eye contact can make the patient feel accepted and welcome in the office. A stern face can send the message that the health care provider is unhappy with the language or cultural barrier.

Gestures and Touch

Gestures such as standing up when the patient enters the room and gesturing towards a chair while greeting a patient can send a welcoming message. It also shows respect for the patient. A warm, firm handshake upon greeting the patient can also contribute to the feelings of respect perceived by the patient.

Voice Intonation

Healthcare providers will be best-received if they talk in a friendly voice that is neither too loud nor too quiet. A loud, abrupt voice may give the impression that the healthcare provider is ill-tempered, impolite, or upset with the patient. A quiet voice may imply a lack of personality.

Titles

The use of titles is very important in the eyes of Latinos and conveys respect for the patient. By using titles such as Señor (Mr.), Señora (Mrs.), and Señorita (Miss) before the last name of the patient, the healthcare provider can show respect for the patient and gain respect in his or her eyes.

The Latino Patient – Effective Communication

Delivering Health Messages Successfully

While conveying health messages to Latinos can be difficult at times, by taking the cultural values into account, a health professional can increase the effectiveness of the communication. In order to initiate change in a behavior of a Latino patient and to help maintain the change, it is important to consider four different factors: familism, friends, faith, and fatalism.

Familism

While the Latino culture is not individualistic, telling a patient to change a habit in order to improve personal health may not be a sufficient reason to invoke change. As the culture is more family oriented, implying that changing a habit may be beneficial for the family is much more likely to result in a change in the behavior.

For example, to encourage a smoker to quit smoking, one might say that changing the habit will allow the patient to…

• ×          Live a longer life and have the pleasure of knowing his or her grandchildren
• ×          Set a good example for children
• ×          Protect family members from suffering or harm caused by secondhand smoke
• ×          Save money for a family vacation

Friends

Similar to the idea of familism, Latinos highly value their social relationships and connections. The opinions and advice given by close friends are held in high regard and have strong influence over the actions of many Latinos. Again, encouraging a habit change in order to achieve a personal goal is not likely to produce a change. On the other hand, referencing issues related to friends and relationships may have a greater impact on the patient.

For example, to encourage an alcoholic to attend AA meetings, one might say that joining AA will allow the patient to…

• ×          Help friends who struggle with the same problem
• ×          Be accepted by friends
• ×          Influence and be influenced by others in the social group

Faith

Religious faith and faith in the health care provider are both very important. Many Latinos believe strongly in the power of God to heal and direct the outcome of all circumstances. When an illness is experienced, Latinos may visit shrines and offer prayers, candles, or other offerings to God or saints with hopes that they will cure the illness. Faith can also be placed in a trustworthy health care provider with whom the patient has had past experience and successful outcomes. This faith can help encourage a patient to begin or maintain a healthy lifestyle change.  As a health care provider, alluding to a patient’s faith in God can be beneficial in encouraging the change.

Fatalism

Fatalism is the concept that all events are predestined and that all humans are subject to an unavoidable fate over which we have no control. This can present a real challenge for health care providers, especially if the patient believes that there is nothing that he or she can do to change the situation.

To encourage a patient to make efforts to overcome an illness, one might say…

• ×          “God may be testing your faith and want to see you make efforts to improve”
• ×          “There may be other missions in life that God has planned for you and overcoming this obstacle might be important in achieving the others”
• ×          “God or the saints may be impressed with your perseverance and unwillingness to give up."

The Latino Patient – Health Attitudes, Beliefs, and Practices

¡Abrígate Bien!

One of the many historical attitudes towards health that is held by many Latinos is known as the Hot and Cold Theory. This theory claims that the body has four different fluids of different textures and temperatures:

Blood- hot and wet

Yellow Bile- hot and dry

Phlegm- cold and wet

Black Bile- cold and dry

In this pattern of thinking, a balance in the body among the four types is seen when a person is healthy. A sick person experiences an imbalance among the fluids. According to this theory, temperature plays a big role in the health state of individuals. For example, to lower the temperature of the body, a person may be offered a cool drink. On the other hand, drinking warm liquids and consuming warm foods such as tea or soup is thought to help an individual with a cold.

 I have seen practices similar to this in the belief patterns of nearly every Peruvian person I have met. They all seem to 100% believe the wives' tale that if you are cold, you will catch a cold. It is almost humorous how frequently I am told to “Abrígate Bien,” or “Dress warm.” The temperature here is not exceptionally cold on most days. Usually the temperature ranges somewhere from 55 to 75 degrees, but the people here usually dress as if they were living in the arctic! In the clinic, many of the nurses and ladies wear multiple layers of clothing, including warm jackets and scarves, for the entire day. On multiple different occasions, I have been working in the health center in just my short sleeved shirt and constantly am asked if I am cold. I usually proceed to explain that it is much, much colder where I am from and so I don’t feel so cold here. In addition to this, a few people have sternly told me that I need to dress warm or I am going to get sick and then the whole clinic will be sick. Since then, I have worn at least a long sleeved shirt on most occasions.

The need to dress warm especially applies to the babies who are brought into the health center. When they come in, I always tell the mothers to undress the baby so that we can properly record the weight and height. The undressing process usually is quite lengthy as the babies are typically wrapped in two or three blankets and clothed in several layers of jackets, sweaters, and shirts, complete with socks, gloves, and hats. Sometimes the babies are actually damp with what I presume to be sweat by the time all the layers are removed.

I find it really interesting that even the educated professionals working in the public health center find it so important to dress warm all the time. One time the head nurse working with the babies got mad at a mom for leaving her baby undressed and exposed to the cold for too long. She lectured the mother about how her baby was going to get sick. The same nurse has lectured me about the same thing on a few occasions as well. 

The Latino Patient – Cultural Values

Cultural Values of Latinos

Acculturation increases as individuals remain in a country for a longer period of time and as the generations proceed. The initial immigrants that come to a country will retain many of their core values and traditions from their home country but their children and the children of their children will become more and more representative of the mainstream society. For Latinos in the United States, there are a few basic values that seem to be retained regardless of the amount of time spent in the country or the generation level. While the culture in the United States tends to be very individualistic, the Latino culture is group- and family-oriented. American culture is often focused on personal achievement; Latinos strive for harmonious relationships and cooperation. In the US, respect is often awarded to those who have achieved success, but for Latinos, respect is given due to age, gender, or hierarchy.

In addition to these three values that are constant across generation and acculturation levels, there are several other general values shared by all in the Latino culture that do vary slightly as individuals acclimate to the mainstream culture.

The values listed below are the most relevant to a clinical encounter in a health care setting.

Collectivism

Latinos tend to enjoy spending time with others as opposed to being alone for personal satisfaction and self-assurance. Workplace or social relationships strengthen all and give the individuals a sense of belonging. Situations are viewed from the perspective of the group instead of that of the individual.

Familism

Latinos highly value family relationships and often maintain close relationships with family members, close and distant alike. Due to the fact that many Latinos consider the family to be “sacred,” many health issues can be addressed most effectively by including some or all family members.

I have witnessed this with my host family. We spend time very regularly with various family members, including the brother of my host mom and her father. Much of the distant family, including various distant cousins, aunts, and uncles, has also come to visit on multiple occasions.

Personalismo

Personalismo refers to the ability to relate to other human beings on a personal level, without regard to the social level or economic class.

My host mom is a prime example of this. My host family is well-off compared to much of the population in Peru but when visitors come to our home, she treats everyone the same, always offering food, tea, or anything else we may have to offer. We have had visitors from the “campos” (fields or country, generally people of a lower economic standing) come to our home, and they are always treated with respect and courtesy.

Respect & Power Distance

People in positions of power deserve respect and obedience. In a health care setting, a doctor is rightfully perceived as being more knowledgeable about health and disease than the patient and thus is respected and obeyed. Additionally, respect and admiration are awarded due to valued qualities a person may possess, such as honesty, integrity, and courage.

Simpatía

The ability to develop a harmonious relationship that expresses a warm and caring attitude is known as simpatía. It is important for a health care provider who is working with Latinos to have a “people-oriented” disposition.

Time Orientation

Managing time appropriately is not of high priority for Latinos. In most Latin America countries, the pace of life is a little slower and more relaxed, with less bureaucratic health care systems. Consequently, when Latinos immigrate to a country like the United States, they may often arrive late for appointments, not out of respect for the doctors, but rather because their culture never taught them to value timeliness.

I have fully experienced the lack of concern for time and timeliness during my time here. On more than one occasion I have had to wait at least 30 minutes for a friend to show up to hang out or have coffee. Coming from a culture where time management is crucial, I absolutely hate to be late and hate to have others waiting on me. It is different to experience an entire culture that doesn’t care so much about being on time or not.

Out of the Ordinary Events of the Week

Eat Well. Stay Healthy.

Something a little out of the ordinary happened on Tuesday this week. When I finished working in triage, I made my way back to the CRED ("Crecimiento y Desarrollo del Niño" aka Child Growth and Development) area to help with weighing, measuring, and evaluating the babies. There was an exceptionally large hoard of ladies crowding the tiny space and I wondered why the nurses weren't telling them to wait outside for their turn, like they usually do. It turned out that there was a "charla," or chat/presentation, for the mothers in the clinic and many of them were told specifically to come in on that day to participate in the chat. 

The first segment of the presentation was a very brief talk about how to prevent stomach cancer. One of the doctors in the clinic gave the presentation and talked about various factors that can increase the likelihood of getting cancer, including things like genetics and lifestyle. She stressed that while we have no control over the genes we inherit, we can choose to live in a healthy way and take control of the factors that we can. 

The doctor covered basic healthy habits that can prevent stomach cancer among various other health problems. She recommended that everyone eat five fruits everyday in addition to vegetables like lettuce and broccoli. She also said that exercise is important in preventing cancer and that everyone should get 30 minutes of exercise daily. While it is not likely that many of the ladies in the health center have time to go for a run or hit the gym every morning, the doctor did say that even just walking a total of 30 minutes everyday can be beneficial and they don't have to be 30 consecutive minutes. I don't doubt that many of the mothers walk at least 30 minutes everyday, if not more, just getting around town and such. The doctor also suggested not drinking alcohol in excess or smoking. Most of the advice given seemed pretty basic and nothing was all that novel for me, but it could have been the first time some of the ladies heard some of these things.

The second part of the presentation was much more hands-on and much more interesting. It was about how to properly feed babies and young children and how to eat as a nursing mother. The nurses brought in food and showed examples of various different types of foods in different forms and quantities to give to babies of varying ages. I helped by making a mashed potato puree mixture with other vegetables and meat. It pretty much was homemade baby food made by mashing all the components of a meal into puree. 

There were all sorts of different types of food: rice, quinoa, lentils, potatoes, carrots, squash, chicken, and chicken liver. I found it really interesting that the nurse stressed multiple times how important it is that the babies and nursing mothers eat liver at least 2 or 3 times a week. She said that anemia is a big problem and liver is high in iron. I personally am not a huge fan of the idea but do admit that I have eaten liver a time or two while I've been here. I don't particularly care for it, but it's not horrible either. 

I think the talks were very beneficial and it definitely added some spice to my day. I think that preventative and educational talks are really important as I've mentioned before that I think the majority of the problems experienced by infants and children come from a lack of knowledge. I'll be interested to see if this is a  somewhat regular occurrence or a one time deal. 

Strike!

Today and yesterday in the health center, the doctors were on strike. There still were a few doctors who accepted patients with emergencies or who needed immediate care but there were significantly fewer patients than normal. They only accepted a total of 15 patients yesterday when normally there are double or triple that seen by the medics alone. Today no patients were seen by the medics, but a few patients were still seen by the obstetricians and in the child grow and development area. 

The posters on the door to the health clinic said:

Paro Medico - Por la Reforma de Salud

Más insumos para pacientes

Mejor infraestructura

Más medicamentos por tu SIS

No a la privatización de Salud

 Which translates to:

Medical Strike - For Health Reform

More resources for patients

Better infrastructure

More medicine for your SIS (Integral Health Insurance)

No Privatization of Health

 Today I found out that the strike was not limited to the Santa Rosa health center but was nation wide. I believe unfair pay and salaries were part of the issue that the doctors were protesting, but I am not 100% sure about the exact reasons behind the strike. It made for a slow couple of days in the clinic because of the significant reduction in patients. I hope that Monday of next week isn't too crazy with all the overflow of people who would have been seen today. 

The Latino Patient - Defining the Latino Patient

Who are "Latino Patients" in the United States?

In 2002, when this book was written, there were 35.3 million Latinos living in the United States. In order to provide healthcare appropriately to this population, there are three main challenges that providers must overcome: language, diversity, and culture. Adequately overcoming the barriers in communication involves having some proficiency in the Spanish language in addition to understanding the diversity in the Latino group and its culture. 

Here are a few of the many facts mentioned in The Latino Patient about the Latinos living in the United States:

• The terms Latino and Hispanic can be used interchangeably, both referring to people of Spanish decent (from Spain) and people whose native language is Spanish.
• People from different Spanish-speaking countries in Latin America have distinctive accents and speech patterns. 
• For example, Mexicans use many idioms, Central Americans tend to speak very quickly, and South Americans have melodic intonations and an more educated vocabulary.
• There are 22 different countries to which Latinos can trace their origins.
• The majority of Latinos are Catholics, which can influence their attitude towards health and disease.
• For example, some may believe that an illness or ailment is a consequence of disfavor in the eyes of God.
• U.S. Latinos are a young population, which a median age of 25.9 compared to 35 years as the median age of the general population
• The life expectancy is 79 years for the Latino population while that of the general population is 75 years.
• The major health problems of Latinos in the United States are similar to those of the general population, including diabetes, tuberculosis, and HIV infection, among others.

There are a few interesting theories that may explain the low mortality rates seen in the Latino population. One of these is known as the healthy migrant effect, which suggests that the people who immigrate are those who are physically able to go and healthier than those who remain behind. Additionally, the salmon bias effect states that many Latinos return to their home countries after a temporary stay in the United States, wishing to return home when they grow old or become seriously ill. 

In addition to language differences, which is an obviously barrier, there are many factors that affect the decision of Latinos to seek healthcare and treatment. While nearly two thirds of the Latino population has health insurance coverage, a third still remains uncovered. This increases the difficulty in accessing healthcare for many Latinos. Many resort to seeking care in emergency rooms, which obviously can provide care for temporary problems but lack the ability to offer follow up or preventative services. Acculturation, the changes that must be made to adapt to a new culture, also presents Latinos with unique challenges. This includes learning to live in a culture that is loaded with rules and regulations. Practices such as taking a number, waiting in line, filling out forms, and so on, can be great hassles for Latinos who are unfamiliar with such habits.

The Latino Patient - Introduction

The Latino Patient

The next piece of literature I am working through is The Latino Patient: A Cultural Guide for Health Care Providers by Nilda Chong, MD, DrPH, MPH.

Chong begins her book with a personal vignette about her experience 35 years ago as a doctor in a rural part of a Latin American country. Along with a team of health professionals, she was part of a temporary clinic set up in a very rural area in the tropical rain forest. As the sun sank beneath the dense canopy of the forest and the team packed up their equipment after a long day of work, a woman approached her, barefoot and sweating with a child on her back, and asked if her child could be seen by the doctor. The woman proceeded to explain that she had left her village at 4am that morning to walk to the clinic but was delayed by a flooded river and had to wait 2 hours for the water to subside before she could swim across with the child in tow. The medical team was exhausted after providing medical and dental treatment to over 500 patients that day and Chong thought to her herself that if she said yes to this lady, she would have to say yes to every other person who sought attention at that point. However, the team leader pulled her aside and asked her to imagine what the lady had gone through just to arrive at the clinic. The team agreed to provide treatment to the lady and any other that might come along. The experience greatly impacted Chong as she had never thoroughly contemplated the issues that the people living in such a rural area face on a daily basis and could not relate to the woman's suffering. This experience, among others, inspired Chong to write The Latino Patient so that health professionals who work with patients from a Latin American background might be able to have a more thorough understanding of their culture. She addresses the unique aspects of the Latino culture, including relevant values, health status, beliefs, and practices as well as appropriate ways to interact with and treat Latino patients in order to most effectively and respectfully provide treatment.

The Latin American population in the United States has been growing significantly in the recent past and will continue to grow in the future. In 2002, 13.3% of the population was Latino and it is thought that by the year 2050 that number will have grown to 25%. With this in mind, it has become increasingly important for health care provides to know how to appropriate interact with the Latino population. For non-Latino health professionals, understanding the culture is essential to providing "culturally competent care." This includes establishing sensitive and effective communication with the patients during their time in the clinic and understanding the cultural differences. It is important to understand the critical cultural values and to know a handful of tactics that allow health care providers to interact in a culturally respectful way. As I am reading, I am excited to be able to compare what this book has to say about Latino patients living in the US with the patients I am in contact with in Latin America. I hope to be able to put into practice some of the advice that Chong offers, not only during my time in Peru but also when I become a health professional myself.

Chong, N. (2002). "Latino Patient: A Cultural Guide for Health Care Providers." Yarmouth,  ME: Intercultural Press.

Peru: Improving Health Care for the Poor - Summary Six

Conclusions and Recommendations

The final section of the report offers various recommendations about reforms that need to take place in order to improve health care for the poor. While Peru has seen marked improvements in many areas in the health care sector, a wide gap still remains between the outcomes of health care services for the poor and the non-poor. A continued emphasis must be placed on primary care in addition to caring for poor mothers and infants and controlling communicable diseases. 

There is a great need for expanded coverage and quality of maternal, prenatal, and perinatal services to improve the health status of mothers and infants. While these services need to be strengthened, it is also important to promote their importance to mothers and increase their use by the poor. Additionally, communicable diseases play a much deadlier role in the lives of the poor than in the rest of the population. In order to prevent many diseases and increase the quality of health among the poor, efforts must be put forth towards improving water and sanitation, education, and agriculture. 

It is also imperative that the poor have increased access to hospitals and health care clinics. There should be a certain percentage or amount of expenditures that must be allocated towards the treatment of the poor. This sort of reform would be difficult to achieve, however, because there is no clear way to define or identify the "poor."

The report also states several reforms that need to occur in the realm of Human Resource Policies, including the following, quoted directly from pages 62 and 63 in the report.

"Establish a human resources department in the ministry of health"

Currently (in 1999), MINSA does not have an administrative sector targeted towards addressing human resources issues. The main purpose of this sector would be to set a high and consistent standard for hiring and evaluating existing personnel. It also would be in charge of overseeing continuing education and training of all health professionals. 

"Introduce a public medical service examination"

This exam would be administered to all personnel seeking employment in the health field to clarify the high educational standards that must be met to work in the public sector. It would help raise the bar on the quality of professionals that are allowed to enter the field as well as provide a standard by which the medical universities and institutions can be held responsible. The ministry should be the main enforcer of educational standards and content in order to regulate the quality of education in all institutions.

"Introduce certification of university medical programs"

A certification process would exert direct pressure on universities to continually improve the content of physical training and educational standards.

These are just a few of the many improvements that are listed in Peru: Improving Health Care for the Poor. While I'm sure that much progress has been made in the health care system of Peru in the last 15 years, I am certain that there is still much room for improvement.  A great disparity still remains between the quality of care received by the poor and by the wealth, but that is a problem that even more developed countries face. Overall, I feel like MINSA and the health professionals are putting effort forth towards bettering the health of the entire country and while great progress has been made, there is still much to do.

Peru: Improving Health Care for the Poor - Summary Five

Human Resources for Health Care

According to this report, in Peru in the 1990s (and mostly likely today as well) the quality of health services for the poor was greatly impacted by the availability of trained professionals with an appropriate mix of skills around various parts of the country. In the late 1990s, there was actually an excess of health professionals most likely due to the presences of several new medical schools that allowed for a greater number of students to graduate. MINSA took advantage of the excess of health workers and hired many new workers on short term contracts. 

Geographical Inequality

There is a significant amount of geographical inequality in the health care sector in Peru. The attraction of professional careers and advanced medical equipment pulls many physicians to large metropolitan areas, namely Lima. For this reason, the rural parts of Peru in the Sierra and Amazon areas suffer from an extreme deficit in quality health professionals. "In 1964, the availability of physicians was 5 times higher in Lima than in the rest of the country." While this has been improving, due in part to increased growth of urban areas apart from Lima, there still is a significant shortage.

In an attempt to overcome this problem, in 1982 MINSA created the SERUM program, which mandates that all medical students serve one year in a rural or urban low-income neighborhood health establishment as "a condition for graduation." Although it is technically not a graduation requirement, it is a necessary prerequisite for employment in the public health center and for acceptance to state-sponsored internship programs for increased specialization. In the Centro de Salud Santa Rosa, I met a young dentist named Santi who is serving in the health center this year. I am not sure if the SERUM program itself is still active but if it is not, there is definitely another program that requires similar forms of service. Santi told me that he has to serve for a year if he wants to work for any government health center in the future. He said that some of the positions are paid but most are not. I got the feeling that he wasn't crazy about the time he has to spend in the health center but it is a necessary hoop to jump through before his career can progress. 

Additionally, the Salud Básica Program has offered incentives for health professionals who work in rural and urban low-income areas, often including large salaries and financial bonuses. However, increased salaries often do not overcome the desire of advanced professional careers associated with the city-based specialization and private clinics, especially when combined with the inconvenience of living in extreme rural areas. It is likely that the inequality of the distribution of health professionals will remain a problem that Peru will have to face for many, many years.

Quality of Training

According to MINSA officials and leaders in health professions, the standards in medical education have been falling. There were a handful of new medical schools and universities that opened in the 1990s, many of which lacked the resources to meet the teaching requirements of a modern medical education. Licenses required to operate have been granted liberally, with little regulation or monitoring of the schools prior to their acceptance. 

The quality of training giving to nurses has also changed. The report states that "teaching has become more bookish and less practice-based, while the strong 'warmth and service' orientation of nursing schools - commonly run by religious groups - gave way to a more career (professional quality) orientation." I have heard my host family mention that many nurses nowadays are rather cold and lack the warm mentioned in the quote. They have said that some nurses say things like "don't cry, it doesn't hurt,"and address the patients in an impersonal way instead of with care and compassion. Regardless of this, many people still consider nurses to be better equipped than physicians for primary care, especially in rural and community health clinics.

Many physicians are not equipped to face the challenges presented by providing health care in rural areas. The medical schools have not made appropriate changes to the curricula as the national priorities have shifted towards primary and preventative health or rural health delivery models.

While talking with some of the nurses in the health center, I was surprised to find out that the length of time it takes to become a doctor in Peru in not much different from any other career path. From my understanding, most students spend 5 years studying in college for the majority of the majors. I believe med students are required to attend one additional year and possibly more training for further specialization. The nurses I talked to were surprised that it takes 7 years to become a physical therapist and up to 12 years to become a physician. I feel like the doctors and nurses are able to appropriately equipped to handle the cases they seen in the health center, but I would be interested to know how their training and quality of work compares to the education received by health professionals in the United States. 

The Search for Missing Pregnant Women

Today when I arrived at the health center, I began my day as I usually do by helping pull files for the patients that need to be seen. After working through a few lengthy lists of "historias" (histories or files) the head office lady asked me if I would be interested in shadowing the obstetricians today. Of course I happily replied yes and followed her to the obstetricians' room.

I sat down and waited for a bit while the doctors/nurses (like I have mentioned before, I rarely know if the people I'm working with are doctors or nurses or something else) sorted through a bit of paperwork. One lady, Carmen, was searching through a database on the computer to find addresses of the "gestantes" (pregnant women) who had not been coming in to their regular checkups and control appointments. When the list was completed with a total of about 8 names and addresses, another lady named Milana and I took off to track down the missing pregnant ladies. 

While we were walking in the direction of the first address, Milana told me that the Centro de Salud Santa Rosa is the health care clinic for the region within Cusco called Santa Rosa. Only residents of this region are allowed to come to the clinic and receive the insurance called SIS that is offered there. As far as I have understood, SIS, which stands for Seguro Integral de Salud (Integral Health Insurance), is free or close to free for people who make less than a certain amount of money. I don't fully understand how the whole process works but I know it must be a good deal because Milana told me that some people make up addresses in the Santa Rosa region in order to get the free insurance. 

Milana also talked to me about how many of the pregnant women don't come in for their regular checkups, which is a big problem especially if something goes wrong with the pregnancy. Currently there are 510 pregnant women in the Santa Rosa region and under the care and supervision of the Centro de Salud Santa Rosa. If any of these women experience complications during their pregnancy and do not receive treatment, the Centro de Salud Santa Rosa is responsible. For this reason, the nurses and doctors are very adamant about making sure that the women come in for regular checkups. Often the ladies don't know exactly how to take care of themselves during pregnancy, which can be detrimental for the mother and the child. 

The first lady we met with told us that she had been going to her controls regularly and proved it to us by showing us her control card completed with up to date information. Milana took note and mentioned that the computer system may not have been updated correctly. She gave the lady some advice about different warning signs and various things to watch out for during her pregnancy. She said that if she experiences things like headaches, swelling of the arms or legs, or blood or other fluids coming out of the body that she should go to the hospital for care right away. It was also interesting because at various times while we were walking, we encountered pregnant ladies walking in the street and Milana would always stop to talk to them and ask where they were living, which health center they were going to, and if they were regularly going to their controls. 

While we were actually able to contact a few of the women, others were never found. Milana talked to a couple of ladies on the phone and left a note with the family of another. Every time we talked to someone (whether a family member or the pregnant ladies themselves) Milana filled out a form about the contact that was made. I believe the purpose of this form was to report that the health center made an effort to track down and contact the various pregnant ladies and relieve their responsibility if something were to go wrong during the pregnancy. 

While we only had visit about 8 addresses, this proved to be quite the challenge for various reasons. First of all, the address system in Cusco is far from organized and many of the doors and homes are unmarked. The various sector and blocks are organized by letters and then each of the homes has a number, C-10 for example. There was no clear way to know which direction to walk in to find a certain house number so often we just picked randomly and hoped we were headed in the right direction. More often than not, we walked many circles and up and down incredibly steep hills searching for elusive addresses. The lack of organization was exacerbated by the fact that some of the addresses we were searching for DID NOT EXIST. They were phony addresses that seemed real but were made up by the patients, like I mentioned before. Other times, the address did in fact exist, but the people living in the house did not even know the person who claimed to live there. It proved to be quite an adventure searching for all the missing pregnant women. 

Peru: Improving Health Care for the Poor - Summary Four

Reforms in Health Provision

This section of the report focuses on the reforms put into practice by MINSA in the 1990s in order to increase the availability of health care to the poor. MINSA is divided into a series of programs that are targeted towards different needs. Some of the programs are aimed at helping the poor with a significant portion of their budget while others are not so "pro-poor." MINSA's program for primary health clinics spends more money to provide assistance to the poorest 20% of the population than the richest 20%, unlike outpatient and inpatient hospitals where expenditures to help the poor are very minimal. 

The Dirección General de Salud de las Personas (DGSP) is the primary sector of MINSA targeted towards specific personal health services. This sector is also subdivided into 15 categorical programs and additional targeted programs. The major categorical programs include immunizations, malaria, tuberculosis, maternal-perinatal health, and HIV-AIDS/STD. An additional sector, Dirección General de Salud Ambiental (DIGESA), sponsors national programs directed towards improving environmental conditions of the poor, such as water, food and animal management. The targeted programs of MINSA include Salud Básica, which has been aimed at improving many health centers by offering higher wages for doctors and staff in rural and under-served areas, and Programa de Complementación Alimentaria para Grupos en Mayor Riesgo (PACFO), which supplies food and nutritional supplements to most of the poorest departments in Peru. Additionally, the Proyecto de Salud y Nutrición Básica and Proyecto 2000 focus on improving maternal and child health services in departments and provinces classified as poor.  

A lack of productivity in primary health clinics and under-utilization of hospitals are both big problems that challenge the health care. There are around 1,000 health centers that each employ between three and five doctors or health professionals. Each clinic produces on average 16 consultations per day, with each doctor seeing on average three patients or so per day. In comparison, a busy clinic in Lima might see 40 patients in just one afternoon. One explanation for these low productivity figures lies in the fact that there are weaknesses in the data available. The 1996 Infrastructure Census failed to include various activities performed by the clinics, such as preventive activities and extramural consultations. Hospitals in Peru are also severely under-utilized. The public hospitals play an important role and consume over 50% of the public health budget as well as produce around 50% of ambulatory consultations, most high-cost interventions, and nearly all inpatient services. A main problem with the hospitals lies in the fact that while they are the most available source of secondary and tertiary services, they only budget a small portion of resources to serve the poor. It is also interesting to note that on a national scale, only 52% of the hospital bed-days are utilized. This is a shocking low percentage, given the amount of unmet needs and congestion of some services. For comparison, in the United States, there is cause for concern if bed occupancy falls below 80%. 

While I personally don't have any experience working in a public hospital in Peru, I have seen many MINSA workers in the public health center. There are quite a few workers, including doctors, nurses, and office staff. From my experience, I have seen that they have a TON of paperwork to do for each patient that comes in. As I've mentioned before, I have been working with the child growth and development control unit for babies under one year of age. In this department, there are two ladies that sit and fill out form after form for each baby, in addition to three ladies who constantly enter information into a computer database. I typically weigh and measure the babies and then relay the information to the ladies who are doing the paperwork. I asked one nurse, Maria, about the paperwork, because it seemed like they were doing multiple copies of the same form for each baby. She told me that that specific form has one small box in which they write a four-digit code depending on the service provided or needed. For example, the basic checkup/control might be 0001, malnutrition might be 5554, and the administration of supplementary micro-nutrients might be 6767. For each service and each code, a separate form has to be filled out, which is absurd given that the form is exactly the same except for the one box. In my opinion, part of the problem with the low level of productivity is due to the fact that so many people have to be employed just to fill out the mountains of paperwork. I realize that the paperwork is important but I think it contributes to the low productivity figures. 

Peru: Improving Health Care for the Poor - Summary Three

Progress in Health Outcomes

In the 9 years after 1990, many improvements have been seen in the overall health status of the people of Peru. Child and infant mortality indicators increased by over 25% as a result of improved immunization efforts and control of diarrheal disease in children. Various educational campaigns promoted strong hygienic practices as well as Oral Rehydration Therapy. Additionally, there have been efforts concerted towards improving water and sanitation and malnutrition rates have decreased.

Even though progress has been made, the infant mortality rate was still very high in Peru in 1999. Many of the campaigns and efforts were directed towards the health of older infant and children so much less progress was made in the mortality of infants around the time of birth or maternal mortality. Hemorrhages, mishandled abortions, infections, and hypertension, are the primary causes are maternal death, all of which stem from inadequate birthing conditions both in the hospital and at home. In the population as a whole, about 50% of the births are overseen by skilled health professionals, while in rural areas as few as two out of nine mothers receive help and care during birth. In addition to the less-than-adequate conditions, there are other factors that also influence the health of the child and the mother, such as poor maternal medical and nutritional care during the pregnancy, which can result in low birth weight and prematurity.

The majority of infant and childhood deaths in Peru occur in the poorest 40% of the population where education is minimal and the living environment is worse. The biggest problem that I have noticed during my time working with the infants in the health center is a lack of education among the mothers, which is also addressed in this report.

"The extremely low levels of use of health services by mothers are partly a reflection of ethnic and cultural barriers, combined with low levels of female education and cost barriers... The cultural barrier in rural areas in heavily reinforced by staff that remain unprepared to deal with poor indigenous women, who especially object to unaccommodating birthing conditions and fear various other aspects of institutional care... Part of the problem was due to low quality of surgical care and part was due to the lack of capacity to communicate with mothers and especially indigenous mothers."

During the week and a half I've spent in the Santa Rosa Health Care Center, I have spent a lot of time weighing, measuring, and evaluation babies as they come in for their monthly check ups. I have seen a whole range of types of mothers and families come into the clinic. Some parents come in clean, well-dressed, and equipped with the latest toys and gadgets. There are other mothers who come in and look incredibly young, sometimes maybe 15 or 16 years old. More often than not, the young, poor mothers tend to have babies that are very small and malnourished. I often am often surprised that some of the older, "put-together" moms also have underdeveloped babies.

I have weighed countless babies throughout the past week and have taken note of the measurements I recorded. For example, I have weighed (at least) 5 babies who are one month of age. I saw a wide range of sizes from very small and thin to thick and chubby.
Here are the measurements I took:

Baby #1

weight: 3.300 kg

height: 51.9 cm

head circumference: 35.5 cm

Baby #2

weight: 4.100 kg

height: 54.8 cm

head circumference: 38.3 cm

Baby #3

weight: 4.300 kg

height: 55.6 cm

head circumference: 38.0 cm

Baby #4

weight: 5.000 kg

height: 57.3 cm

head circumference: 37.3 cm

Baby #5

weight: 5.200 kg

height: 58.9 cm

head circumference: 36.6 cm

According to the Weight-Age chart, the ideal weight for a baby boy is 4.500 kg, with a healthy weight ranging from 4 to 6 kg. The ideal weight is about 55 centimeters, ranging from 53 to 59 centimeters. Given this information, it is apparent that Baby #3, #4, and #5 all are within the health range of heights and weights. However, Baby #1 and Baby #2 are small in both the height and weight categories.

When Baby #1 came into the clinic for his checkup, I thought he was a new born baby coming in for his first control and was shocked to find out that he was one month old. His legs were very thin, instead of chubby health baby legs. His mother looked very, very young; I would say she was probably around 15 years old. When the doctor saw the measurements I had taken of the baby, she scolded the mother about the importance of adequate nutrition to promote health growth and development. She told her that her baby will sleep all day if she lets him, but she has to wake him up to nurse every two hours or so. The doctor showed the mother how to properly hold the baby while nursing in order allow the baby to nurse most easily. She also prescribed additional supplements and nutrients to give the baby every day to promote health grow and development. The mother was instructed to bring her child back to the clinic every three or four days for a few weeks so that the growth could be monitored more closely. I have seen Baby #1 and his mother twice since the initial one month checkup and am happy to report that he gained weight and grew a little each visit. His mother obviously took the advice of the doctor seriously and made the appropriate changes to her baby's eating habits. She was glowing when I told her that her baby had gained weight and looked much healthier.

I know that no mother would intentionally allow her child to become malnourished. The young mother of Baby #1 had tears in her eyes when the doctor was telling her about the condition of her baby. I honestly feel like the lack of education and knowledge about proper infant care is a huge issue that leads to cases like this. Many uneducated mothers might thing their babies are healthy without knowing about how they should be progressing in height and weight. Fortunately, the life of Baby #1 was probably spared because he mother chose to bring him in to the health clinic for the routine checkups. While a health care center with child control services was available to this young mother and her baby, I am sure that there are tons of other mothers who live in rural areas without access to routine checkups and care. Their babies may be malnourished and underdeveloped but they may have no idea that there is anything wrong, simply for lack of knowledge.

Peru: Improving Health Care for the Poor addresses the fact that the lack of education, especially in rural areas is a significant issue when it comes to infant mortality rates and maternal health. In rural areas, the report states that infant and child mortality rates are twice as high as in urban areas. While the main direct cause of death is infectious diseases, more often than not the effects of the diseases are exacerbated by malnutrition and a weakened immune system. The areas that experience the worse rates have both poor environmental conditions and low levels of education. Overall, in my opinion, improving the availability of education is essential in improving the health of people in both rural and urban areas in Peru. 

Peru: Improving Health Care for the Poor - Summary Two

Overview of Health Sector Financing and Delivery Systems

The health sector of Peru is composed of 5 primary sectors: the Ministry of Health (MINSA), the Peruvian Institute of Social Security (ESSALUD), several smaller public programs, a large private sector, and several NGOs. While all of these play an important role in various aspects of the Peruvian health sector, MINSA and ESSALUD are the largest government programs and supply the majority of the financing for the public in general. From 1988 to 1993, financing for health care services dropped significantly due to the decrease in personal income caused by the hyperinflation of the 1980s.  Even though rapid recovery took place from 1994 to 1997, the amount of money spent on health in Peru is very low compared to other countries in Latin America and around the world.

Taxes are a primary source of revenue for many of the health sectors. MINSA also receives monetary support from external loans as well as user fees. According to this report, "about half of the health financing is provided by households, mainly as out of pocket payments" in Peru.

MINSA has control of the majority of the assets and staff in the health care sector. It is in charge of most of the Primary Health Clinics as well as most of the large hospitals, employing the majority of Peruvian health care professionals. Additionally, the primary sector is exceptionally large, with other 200 small private clinics that employ 33% of the physicians.

Since 1992, there has been a substantial increase in the amount of health services available, especially in primary health clinics. MINSA and ESSALUD also have set into motion various reforms that encourage clinics to expand their hours of operation. Additionally, in the years since 1992, there has been a rapid increase in the amount of health professionals available.

MINSA plays many important primary roles, including supplying nearly all public health interventions. This includes coordinating the entire immunization program and all vector control operations. Vector control refers to the process of working to limit or eradicate vectors such as insects or animals that transmit disease pathogens. MINSA also shares responsibility in controlling food and water quality. MINSA is the primary and most essential provider of services for the poor. Its main role is played in rural areas in the highlands and in the jungle, although it is also crucial as the most important health care provider in urban areas as well.

"Most of the inequality in health care consumption results from the assignments of greater amounts of private expenditure to health care by the rich than by the poor... This is a common pattern as health care is a good whose consumption normal rises with income or faster." 

As a whole, the amount spent by MINSA on health care services somewhat reduces the inequality but it is not substantial enough or well directed towards the poor to completely equalize expenditures. MINSA is most important for people with the lowest income.

Although this report was written 15 years ago, I know that MINSA still is playing a significant role in the Peruvian health care sector today. I have seen many MINSA workers at the clinic at which I am volunteering. The infant development and growth charts that I have been working with (and mentioned in a previous post) are all approved and provided by MINSA. According to MINSA's website the current mission of MINSA is to protect personal dignity, promote health, prevent sickness, and guarantee integral health attention to all the inhabitants of the country... and so on (http://www.minsa.gob.pe, translation mine).