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The minutes of the May Medical Symposium are provided here in their entirety. If you have any comments please post them on the appropriate blog.
If you have difficulty posting you comments please contact info@laroman.org Use the following links General Forum - open to all comments http://groups.google.com/group/laromana-general-forum?lnk=srg Batey Clinic Formulary http://groups.google.com/group/la-romana-batey-clinic-formulary?hl=en Batey Medical Records http://groups.google.com/group/la-romana-batey-medical-records?hl=en Promotors Health Care http://groups.google.com/group/la-romana-promotoras-health-care?hl=en Promotors Training http://groups.google.com/group/la-romana-promotoras-training?hl=en
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La Romana Medical Team Symposium
May 28-30, 2007
This symposium is the dream of many, put into formation by three women from Kansas City, lovingly known as the “Three Amigas” – Bev Timmons, Ginny Beall and Pam Logan. They have enlisted the leadership of facilitator, Carol Cowden to help work our way through an incredible agenda. There is representation from many of the US teams, plus representations from Good Sam Hospital, the Haitian Missionary Baptist Church, doctors, promotoras, volunteers, interpreters, and friends from Haiti. Kristy Engel, our ABC missionary is also part of the leadership. We are blessed to have all been called to this ministry. May God Bless the next three days. The following are day to day, speaker by speaker, minutes of the happenings. If you were there, I hope that it serves as a reminder. I am sure I have missed parts – what I have noted are the highlights – not word for word. IF you were not there, and reading this for the first time, I hope you can get the essence of our time together. This was historic – please ask questions and see where you can hop on board!
Monday, May 28
Kristy Engel opened the seminar with prayer asking for God’s leading and wisdom – that God would be the one directing our words and conversations and that He and He alone would get the glory. Bev Timmons discussed the vision for our time together. - Need for coordination between teams and DR, bateyes, renew the spirit of co-operation. Thanks to J. McKibbon for underwriting the conference. Carol Cowden then began the conference!
Goal for the conference is to start the dialogue between teams and medical personnel in LaRomana. We shared together around the whole room – our names and the best thing about the community we live in. These were a sample of the comments: Friendly People; proximity to health care; relationships; people smile; things going on; unconditional love; support in the community; warmth; it’s rural – you can know everyone in the community; closeness to family; good food; feeling at home; diversity
Some of the needs we saw as basic- Need for water, education, safety, health
It was clear that whether you were from the States or the Dominican, the need for love and fellowship was important. Things we take for granted in the States like water, education, safety and health care are what we need to understand as needs as we minister to people on the bateys.
Speakers were in groups – and we had a question and answer period after each group.
Speakers were as follows:
Rod Henrikson- Good Samaritan Hospital Board Chair The State of the Good Samaritan Hospital First time that this gathering has happened – many here today became involved after the Hospital was built – The first 10 –12 years were spent in preparation for the ministry to come. Feb 1986 - first group came to help build new church – met with Central Romana to ask for land for a clinic. Need for health care for those that had no care available. Three years later, footings were poured starting in Feb.,1990. Other groups started coming in 1993. Elsa started going to school in Santo Domingo – started Promotora program.
Hospital has constitution, Board of Directors – 4 members from the church, 4 local people and 4 North American’s. They meet every other month – has oversight of everyday running of hospital. He expressed the caution that the Good Sam not grow so fast that it cannot financially keep up.
Elza Phanord: Opening Remarks We were honored to hear the “First Lady of LaRomana” speak of her history with her husband, Jean Luc Phanord and their ministry to the poor in LaRomana and in the bateyes in the sugar cane fields surrounding LaRomana. They came in 1980 and we have all been part of the history since then. Her wise words are reflected in this statement – “In God – there is no coincidence, only purpose.” And this became the hallmark of the week’s conference.
Bob Beck – Good Sam Mission Council The Role of the Mission Council This was formed in 2000 as a conduit for charitable giving. Becoming a 501c3 organization allows the council to receive contributions in kind from businesses or employers who match contributions. It is also responsible for support in the US for the continuing work that needs to be done – acts as a primary resource and funnel for new people to learn about the mission. www.LaRomana.org website has introductory information. He told us about the initiative: Sugar Cane Kids to help educate kids in the Bateyes. Bob encouraged us all to send stories and information to be shared on the website.
Moises Sifren –Good Sam Hospital Administrator Hope for the Future From the Perspective of the Hospital Leadership We learned that it was the death of Moises’ mother, due to lack of access to obstetrical care, that became the impetus for the beginnings of the talks about a need for a hospital for Haitian people. Moises is the director of the Good Samaritan Hospital – he proudly announced that we have 50 DR doctors of many specialties, has one of two dialysis units in Eastern DR, >50,000 patients per year: 15,000 have been seen by US teams. Youngest hospital in LaRomana – feel proud about this Active social work of the hospital not a priority in other hospitals – no other hospitals support the work in the bateyes Moises work is with the American groups – Dominican doctors are the backbone of the hospital and Dra. Adriana has control over the hiring of doctors and nurses. Moises felt strongly about lifting up the Dominican doctors and their good work for the hospital and the teams.
Dr. Adriana Nunez – Medical Director of the hospital. She stressed the importance of working together - that it is not “our” hospital or “yours”. We all work together to do the work. She sees the need to maintain the programs and work and continue moving forward. Excellent opportunities for DR doctors to train in the US, both here with visiting teams and in the States. She is very active with the Promotora program and looks forward to much more in the future.
Kristy Engel Our ABC missionary in the DR, Kristy was commissioned in 2000. She worked originally in Haiti with Dr. James (whom we are blessed to have with us for the conference as well). Main job is organizing medical teams. Started with about 20 bateys – now in >150 by expanding the work into bateys that need care. Work began with 20 teams per year, now grown to 46 teams in 2007. Talked about need in this first meeting for honest communication going forward. No one has the same function –that we all need to realize that work is going forward – that we not get upset with things that might not be what you want or see but that everyone keeps an open mind in realizing that God is in control and that it is He whom we serve.
Leslie de la Rosa Finance and accounting – has been there for ten years, beginning when Moises began. As the hospital and ministry have grown, the leadership has changed within the hospital. Continued growth and leadership development is vital. The correct management depends on the strength of the institution and the hospital is strong. The Institution is greater than the leaders, with the leaders going away but the institution remaining, and the work continuing.
When questioned about who is using the hospital? High use 85% Dominican, 15% Haitian; (mostly from the bateyes) Transportation is an issue, ability to pay for testing, or treatment. Surgeries by teams are provided free to patients in the batey. Patients from town pay 350P to help cover costs of food and transportation for batey patients. 91% of Batey folks use local clinics.
Hope for the Future From the Perspective of an Interpreter, Physicians, and Encargardo de Operativos
Margarita Brito, MD A physician who has worked now for 4 years in the hospital and bateyes, Dr. Brito sees the need to work on HIV program, pap smears, work of the Promotoras but they need more equipment, education, and facilities for medical care. Need for treatment program for hypertension, and follow-up to prevent mortality
Junior Belisea Nelson Head of the interpreters – need to expand the Promoter Program and adequate supplies to other bateyes that do not have it. Sees a growing role for the interpreters.
Miguel Santelis In charge of tickets to be sold for people to be seen in the bateys - Importance of visiting teams to care for people in the bateyes for those that cannot get to care. We have expanded to the San Pedro area where there are many bateys formerly owned by the government where the men are now unemployed. Sees the need for more teams.
Cecilia de la Rosa –In charge of Surgical department Physician at Good Sam – General surgeon – has worked with Doctors in the US especially in Kansas City and Massachusetts. His appreciation was shown by the statement “You have taught us to love our own people more and that helps us to work better.” “Teaching has been very important. In our country they are starting a Social Security program. As a hospital we cannot be left behind and we need to move forward. We will need more technology and knowledge to enter into this phase. In this new system we will need to be working with insurance companies and will need to staff appropriately. The building needs to continue to grow, the programs now started need to grow.
Q & A Why do people not come to batey clinics/Good Sam Hospital? Multifactoral – economic reasons (fees, transportation), cultural reasons (seek local help to treat disease outside the hospital setting), unable to leave children to come for treatment. Often the promoters will contact Kristy or MD to make specific visits – many critical cases have come to the hospital because of this
Social Security Program – may still leave many without health care because of not having proper ID cards – majority of people are not eligible nor can they afford the costs of obtaining legal status. The Haitian immigrants need money and a legal strategy – but this is a political process that will take a long time. They may have access to public hospitals, but those may not be as clean or care may be not as good. Public hospital in LaRomana has made major improvements but was built in 1974 for 75,000 and now LaRomana is >300,000 people. This makes the mission of the hospital even more important. Only employees of Central Romana can get health care there – and then it is stratified dependent on their job. Family dependents cannot be treated there, often because of the informal status of marriages.
DR government has “given up” many of the government owned bateys and as a result those bateyes are where the direst poverty exists. There is a government doctor that makes the rounds of bateys giving out meds – but they see only 20 – 25 patients at a time – not the ones who need to be seen. In some sites, the health promoter hands out the tickets. They will sometimes get meds for only one ailment- in short, it is less than satisfactory. So we must take a look at the current way we do health care visits and make them meet a multitude of needs.
Hope for the Future: From the Perspective of the Promotoras
Elizabeth Luisima – Head of the Promotora Program and Dr. Adriana Working with 52 promotoras –For the conference she divided in the bateyes in three groups and a Promotora was selected from each of the groups: One from the poor bateys, one from the poor barrios in the city, one from those that fall in the middle. Hope for the future is the training – more in depth education needed with follow up and knowledge about medicines – they know how to take care of hypertension and working with teams – but need more First Aid training and equipment to care for wounds and other problems that arise in the batey. No Patients have been turned away from the Good Sam. We had the privilege of hearing from three of the current promotoras Ylcia Salvant – barrio in LaRomana – La Lechoza-needy folks, much trash, without clean water. Memema Luis – Lima barrio –have family planning – parasite treatment – would like to work on the water treatment – Lucia Batista – Batey Benerito – has malnutrition program – family planning, q 6 month pap smear programs
Q&A Where are the promoters from, how are they trained, how are they chosen? Miguel recommends people but the community is responsible for picking the promoters from among their leaders. Some of the promoters do not read or write but have the desire (passion) to help – there is continuing education on a monthly to bimonthly schedule. The first step of training is establishing relationship in the community.
Understanding Cultural Differences and Beliefs Dr. Steve James – Missionary Doctor in Limbay, Haiti
This wonderful man has worked for greater than 20 years with the Haitian people. He and his wife and family of four children have been in Haiti home based in North Carolina and are committed to their work. They will be commissioned soon by ABC. Steve is a UMass trained Family Practice doc. Steve shared with us the main difference between Western and Haitian culture is the same as the difference between an “Idea Culture vs. Relationship culture” – neither is “one or the other” In Haiti – relationships are really important – not just friendly – it is how to relate in my world and everyone else –People that are living or dead – People do not want to be in conflict with either. In Western culture – we think more in ideas – concrete things to be done. This is reflected in health care in Haiti – even if people live close to a health clinic. In the idea culture – we think of “what” made me sick – in the relationship culture – it is the “who” that made them sick. Example of two brothers – one died of malaria – the other stayed well – and they slept in the same room – the medical reason (idea culture) is that he was bit by a mosquito – the “relationship” culture remembers that the brother that died had an argument with a neighbor and this is the revenge – This creates fear and destroys development of community.
As we all reflected on this, we realized how profound this statement was – and why we are having some of the difficulties we are having. We all need to step back and see the culture that we are working in and what we are coming from and how that affects who WE are and how we interact with those we are dealing with.
Afternoon sessions dealt with Remarks on the Survey, Results of the Survey and followed with small group discussions of survey findings.
The Survey (see attached) was constructed by the Amigas in KC and taken by volunteers on American mission teams, Good Sam staff and residents of the batey. Wilkin interviewed 80 people in the batey – four people from 20 different bateys It is not a scientific study and there may need to be many others listed.
Greatest needs: Health Care Education Food
Greatest Health Problem: Water contamination Family Planning Malnutrition
Ways Residents can address needs: Forums on health issues with promotoras Forums on community problems Parenting support groups
Way Others can address needs: Adult Literacy classes Skill training
Ways to obtain Health Care: Clinics located in nearby bateyes Mobile medical clinics Promotoras in bateyes
Ways to modify mobile medical clinics: Health education activities Collaboration with local providers with protocols Coordinate with Promotoras in clinics/treatment
We then were divided into groups to identify critical issues and create goal statements. (See final document)
Tuesday, May 29
Speakers today represented many different aspects of care in the DR
Dr. Martinez Peralta – Central Romana Representative El Seybo Clinic - coordinator of Epidemiology from Central Romana Primary problems related to the poor arise from lack of education and extreme poverty
There is frequently malaria – 54 cases in northern bateys. Causes: Haitian immigration and mobility (Broseros/migrant workers), heavy rainfall and mosquitoes that carry malaria. STD- AIDS: HIV rate is 2.8 cases per 100 people. Highest rate in the Caribbean is in DR and Haiti, with 85% of the cases here. 65% of that 85% is on the border between Haiti and the DR. Low educational levels is partly responsible for this. There is a rate of 5.6% in the bateyes who have/have had HIV. Hep B, STD, lack of protection and promiscuity in the bateyes. Poverty and poor education can lead to need for sale of bodies National programs for treatment of TB (DOTS program)that are well designed and have good results. HIV program – Hospital in El Seybo has program for HIV AIDS – testing, retrovirals,prevention of vertical transmission from mother to baby. They are working hard to prevent stigmatization and discrimination of those diagnosed. GI infections – secondary to non-potable water – skin problems, GI, Vaginal Vaccination program – mumps, measles, polio, meningitis, typhoid, tetanus, diptheria Rabies – started by infected mongoose that bite other animals. Workers are trained to a High Alert system to recognize symptoms of rabies in animals, as there is no treatment for victims of the bites.
Questions: Vaccinations: How can we help? 96% of the people are immunized thru access to 6 clinics and mobile vans. Where are the most malaria cases? Machena, Agua Blanca, 106 and Brabor Does Central Romana keep batey records? No. The hospital Central Romana is for mothers and children. The men on social security go to another hospital. The mobile medical vans visit the bateyes.
Program Highlights:
Mosquito Batey - John McKibbon John represents a group of people who have adopted the batey Mosquito Their motto - Ephesians’ 3:20 - “God is able to be infinitely more than we can even imagine”. They started seven years ago - Group decided to “meet” and be with the people. They wanted to KNOW the people - They have done a census – Mosquito has 130 people – 2 in 90’s, 20% >60, 35% school age – 1 teacher for whole batey – teaches 4 half days a week. They are hiring another teacher – mentorship program. They have become very involved with this batey and are trying to meet the needs of this set group of people.
Promotora Program – Bev/Dra. Adriana Elza – started – needed financial support for health promoter – monthly stipend of 1100 pesos – need more training of the 52 that we have. Malnutrition Program, Family Planning, Importance of follow up
Women’s Health Project– Ginny Beall Elza Phanord was in charge initially. Started in 1995 with Depo Provera. 1998 started a tubal ligation team. Family Planning stations dispensed oral contraception (13 cycles) and injectables. 2003 Women’s Health Project was begun, staffed by Elza’s sister, Dra. Pradeline, to provide batey women with year round family planning. Pro-Familia in Santo Domingo provided low cost OC. Now the Dept of Public Health provides free OCs and injectables – Over 1000 women have received tubals over the past ten years. More than 500 women are a part of this Project in all 52 bateyes. Mobile teams adapt family planning stations to the WHP, meeting with the women to do an oral history and dispensing only 1 pack of pills, with the local Promotora carrying on from that point on. Protocol for teams on request from gbeall@kc.rr.com
Malnutrition Program/EMR – Pam/Elizabeth Dr. Tony Diehl, Pediatric cardiologist, began the program. Worked out protocol in Haiti – Vitamins and De-worming medicine provided to children We are starting now to work with Batey Relief Alliance and Vitamin Angels – they will provide care for ages 1-6 (rather than thru 5). Teams should be aware of what bateyes are on MPP when dispensing deworming medicines.
Potable Water/Biosand Filters – Danny Perez Rotary International has been working with DR –Dr. Cecilio (surgeon at Good Sam ) received 25 filters – 15 were given to Good Sam and they were given to specific promotoras – Education of people who will use the filters is most important – Had a workshop at the hospital – 50% were not being used correctly. Need to identify appropriate people who need to filter
Pharmacy – Fausto In charge of the pharmacy at Good Sam – now open 24/7 He is anxious to work with American teams trying to standardize meds that are coming down so there is less waste. He supplies teams with meds when they run out. He would like to have a copy of each team’s formulary in advance of their coming so that he is able to meet their needs more quickly should they run out.
Emergency - Dr. Bido In charge of the ER of Good Sam – provides a Dominican doctor to go with each medical team and provide continuity of care. ER now open 24 hours/day. Very happy to be working with teams. They are really wanting more opportunity for trainings.
Olga Valdman - Medical student from UMASS Pap smear clinics – Brought a tent to the batey and erected it, supplied with mattresses. In the morning – did education regarding the need for PAPs, technique, and STDs and in the afternoon did the procedures. Slides are read by pathologist – work still needs to be done in follow up.
Creating medical records that the patient will keep – better than central location because batey residents are ever moving. Brought examples of medical records that could be used by all teams, kept by the patients so that all providers, whether local or US teams, could have access to information on the patient’s major health issues.
Daniel Barett – In charge of purchasing at Good Sam – Buys all of the meds that are used by the hospital – and fill in the gaps for American teams.
Nabeeha Kazi - Works with Healthy Mothers, Healthy Babies - started a birthing home in Haiti. Need to establish birthing homes in clinics in the rural areas. Clinic staffed by Haitian women with a relationship with the people- includes emergency referral places, Maison de Naissance, that will take urgent issues (C-section, complications). In Haiti, they have established GPS locations of every house with who is living in it, ages and medical record of all inhabitants. They are investigating bringing this program to La Romana.
Development of Action Steps
The five issues that came out of the discussions were very global –
Split into 4 different groups:
Education of Health Promoters
Standardized Formulary
Presentation on MIRS HIV Program in La Romana
HIV Program Stephen Nicholas, M.D. (We were blessed to have with us this passionate pediatrician who has worked since 1983 on treatment of Children with AIDS) Professor of Pediatrics at Columbia 46 million people are infected with HIV world wide. 85% of HIV in the Caribbean is in DR; Hispanola has the highest rate outside of sub-Saharan Africa. Children are now living longer with HIV with treatment Before treatments were developed, children born with HIV would be dead by age 3. Now they are living to an average of 15 years, 28 the oldest. We now have the ability to prevent mother to child transmission by treating infected mothers and doing C Section and then treating the child with appropriate anti-viral drugs Drugs are provided free of charge through the World Bank and Global AIDs project MIRS Foundation is now the second largest provider of AIDS medication – DR government has 50 different sites to provide AIDS treatment, surveillance and detection. In LaRomana province 3% of pregnant women are HIV+– now in the bateys – up to 8% of pregnant women between ages15-24 are HIV positive in the bateyes. They are hot spots of prevalence. Govt. now uses MIRS protocol for treatment. The Eastern region has the highest rate of HIV in the D.R. We are at a crossroad for being an International model for treatment co-operation for HIV +. We are redefining the standard of care of women that are child-bearing – it will redefine many aspects of care. Aspects of confidentiality are the most difficult. There may be an “opt-out” testing but every child is tested. OB docs need as much information – not just pediatricians, and internists. Where we can overcome hopelessness, we give hope. Educate providers as much as communities. By finding HIV + patients and treating them earlier, you are making things safer for everyone.
Interest groups met as needed.
Wednesday, May 30
What’s NEXT?
Bob Beck – Availability of technical “chat rooms” using My Space (or variant)
SKYPE – can do everything up to video conferencing. The program is downloaded from www.skype.com Gives you capability of long distance conference – free with broadband capability – inexpensive if you do not have broadband. These are high tech tools that are easy to use Bob will set up on-line groups and will be the conduit for information technology. Could use www.laromana.org Bev Timmons will take on the responsibility to keep groups on task.
What is the timeline?
Group felt that each subgroup needed to set a plan that will work and set reasonable timelines that can be reasonably implemented with appropriate funding.
Health Education in the Bateys – overall Moderator – Cyndi McNamara and Devica First goal
Education of the Promotoras - Sarah
Unifying the health care efforts in the bateyes by establishing:
A. Overall goal - Development of Medical Team guideline book. Danny Perez and Nancy Cooley will oversee process
Routine review of guidelines/formulary Regular contact with and between team members – use of existing web sites and further information from Bob Beck
Thus ended the first conference of Medical Teams --- there is much work to be done and God willing, we will continue to meet and talk and work together - May God be praised – and may He have the glory – as we work together for the good of His kingdom.
If you would like more information, please contact one of the people who were present and see where you can fit in – there is more than enough work to be done!!!
Sincerely,
Shirley Shuster First Baptist Church Braintree, MA 02184
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