Written by Kara Palanuk, MD PGY2 at the Kaiser Permanente Oakland Pediatric Residency Program during…
Written by Preeti Dave, MD, Chief Resident at the Kaiser Permanente Oakland Pediatric Residency Program during a Global Health Rotation in March 2015 at the Hospital San Francisco de Asis, E.S.E., in Quibdo, Choco, Colombia.
This rotation was set up to be a needs assessment of pediatric-related health care needs, and an overview of the health care system in the department (region or state) of Chocó in Colombia with the goal of building a maternal child global health rotation there for Kaiser residents and attendings. We really appreciate the willingness of Kaiser Global Health to support and give us guidance on this endeavor, and were lucky enough to have Dr. Hernando Garzon, founder and program director of Kaiser Global Health come to Colombia during our rotation to help facilitate this and hopefully establish it as a Kaiser Global Health site.
We arrived in Bogota on a beautiful sunny Sunday morning after a red eye flight. During our layover to Quibdó, the capital of the department of Chocó, we decided to explore Bogota, the country’s capital. We got breakfast and spent some time exploring. On the way back to the airport, we saw that several lanes of the busy road between downtown and the airport were closed to automobiles for Ciclovia and had many casual bicyclists, as well as many people resting and picnicking along the side. Bogota was nothing like Quibdó from pictures that I had seen, so it was a good comparison and reminder that the department we were headed to has many health disparities compared other parts of the nation, and one of the main goals of our trip was to begin delving into presumed and known causes.
The department (or state) of Chocó borders the Pacific, the Caribbean, and Panama. It’s a tropical area, and most days were cloudy and very warm, with high humidity and at least a little precipitation. There are multiple rivers through the region, and in many parts, the only travel option is via the river. We stayed in Quibdó and only traveled a bit to the surrounding areas, in part due to logistics and apparent safety.
During our two weeks in Quibdó, we had a few different types of days. The day after our arrival, we toured two of the health centers in the surrounding towns, Certeguí and Yuto. The staff were all very welcoming, and we learned a lot about how their clinics function, and some of the needs, which varied at each site. The last full day of our trip, we also visited another clinic on the outskirts of Quibdó that regularly sees a high volume of patients and serves some of the many internally displaced people in Quibdó.
The sheer coordination for this trip was daunting. We again were lucky to have the nonprofit FUNBICHOCO as our liaisons, using many of their contacts to help coordinate each day for us. For example, the head of a local credit union / microlender loaned her minivan for several days, and recruited providers and collected supplies for a clinic day our second full day in Quibdó. The national police also escorted us for the first two days of the trip. There were two general practitioners, a dentist, and optometrist, and many nurses and other staff present. It turned out to be a very popular clinic, including for pap smears and other health screenings, and they had educational sessions as well. Many people brought their children to be seen by us pediatricians, and we were literally overwhelmed with the sheer number all trying to be seen at once in the morning. By afternoon, things were going more smoothly and efficiently because we each paired up with the local nurses. They were helping us in many ways, for example, by interpreting local phrases we didn’t know, plus they know many of the families well from the local clinics, so they were also able to help the parents give background history pertinent to each patient. I was happy to have only one patient that I admitted to a local hospital. We returned a few days later for follow ups, and mostly helped interpret lab results from screenings.
We toured the two main local public hospitals in Quibdó the next day after our busy clinic day, and by chance, we briefly saw the patient I sent for admission and his mother at the level 2 hospital, Hospital San Francisco de Asis. This is the referral center for most pediatric hospitalizations in the Chocó. It was a good reminder about resource availability. We saw a newborn on an adult ventilator in their NICU, because that was all that was available while they awaited bed availability to transfer the infant to a higher level hospital in Medellín. At the same time, their hand hygiene in the NICU was strict, and they had a great kangaroo care course being taught to parents by the nursing students. On the pediatric ward, there were about 4 patients in each room, with parents sleeping on the floor beside their crib. At the level 1 hospital, Hospital Local Ismael Rodán, the facility was newer, and had a different presence, in part based on their mission. The Level 1 hospitals in Colombia are tasked with the preventative care and public health needs of the area they serve as well. So the number of inpatients is smaller, but the hospital serves as a central point for its network of community health centers as well as auxiliary nurses. We spoke in depth with the head of the hospital, who was also a great resource through FUNBICHOCO to help arrange some of the other tours, meetings, and activities that were part of our two weeks.
We returned to Hospital Local Ismael Rodán the next two days to teach the auxiliary nurses that are part of two different networks. They gave us a great space with equipment, but most of all the nurses who attended were amazing. We went into the two days unsure of exactly what to teach and how we would be received, and we finished running out of time and taking group pictures with them. We definitely made the two days as interactive as we could with small groups and large group discussions. We learned a lot about the nurses and their jobs, which varied a lot. For many, their job title has changed from health promoter to auxiliary nurse. They have more training, but still deal with a lot of the same day to day issues. The ones in rural locations are often the only health provider for miles, and often get interrupted attempting to make dinner or awoken in the middle of the night to see a patient of any age. Some of the more local ones work in the clinics and have more set hours but have higher volumes of patients and have to deal with community perceptions that can vary. We discussed bronchiolitis, diarrhea, cough, rashes, and other topics the group wanted covered. These were also common illnesses we had seen during our tours and during our day in clinic. We didn’t cover mosquito-borne infections, of which there are multiple, including the time we were there, malaria and chikungunya had multiple cases.
The next week was a mix of appointments, such as the Minister of Health for the Department of Chocó and her sub-ministers, the operating officer for a company that handles the staffing for the auxiliary nurse in some of the rural municipalities of Chocó, the head of Ismael Rodán again and the person that coordinates the auxiliary nurses health campaigns and local data collection for the hospital, as well as seeing another local health clinic in the area that serves a large number of displaced individuals, and shadowing the pediatricians on rounds at Hospital San Francisco de Asis. We were able to get a good sense of the big picture, and that coordinating big public health projects requires multiple levels of coordination and that data collection can vary from site to site. For example, their vaccination rates seem relatively low on paper, but in reality, at all levels, people said that the vast majority of parents of any background want their children vaccinated, and vaccine nurses go home to home in many places to deliver them, suggesting the vaccine rate may actually be higher. When auxiliary nurses visit homes, they may interview families and fill out surveys, but the surveys vary depending on who they work for, so the data collected in each municipality varies. Also, basic public health measures, like providing reliable clean water, can be difficult with no specific water system in place. While it rains most days, one municipality was in the midst of a drought with no rain in months, and there was an outbreak of diarrhea involving at least 18 children’s deaths in a village whose only access was to river water without a way to clean or filter it. We only began to scratch the surface of what we had set out to do, yet at the same time, we were able to learn and accomplish quite a bit in our short time there.
We’re really excited about the possibilities of this rotation in the upcoming months and years. Hopefully it will include teaching days, days to observe the prescheduled monthly education, plus time in the local clinics and hospitals, as well as home visits with an auxiliary nurse, and public health related projects that would fit a resident’s interests and the local need. If anyone is interested in knowing more about the rotation, feel free to contact us.