Public Health in the time of Cholera

The first pandemic of cholera occurred in the 1810s and was believed to have originated in the India/Bangladesh area where pools of still rice water facilitated its spread (5). Cholera itself can range in severity in its host, from a mild diarrhea to a level of fluid loss bordering on hemorrhage. Patients with cholera can lose up to 1L of water in their stool per hour and develop a hypovolemic shock within 24 hours of infection (6). When you think about it that’s an insane amount of diarrhea that you would have to pass in order to develop shock within hours of feeling ill but it can happen. In fact about 10% of patients who acquire cholera develop this severe form of disease (2). There are estimated to be around 2.8 million cases of cholera and 91,000 deaths every year world wide (1). That number of deaths used to be much higher, in fact it was close to 10% (consistent with the percentage of people who develop severe disease). Now that percentage is closer to 0.5-1%. What changed? Primarily the advent of fluid resuscitation. Since introduction of oral rehydration therapy (water sugar and salt) the mortality rate from cholera has dropped off dramatically. The process for treating a cholera patient frequently involves putting a bucket for stool under their cot, and a bucket for vomit, then measuring their output and giving them the same amount to drink. This saved lives, essentially giving hopped up Gatorade to people prevented them from dying. Now we can shorten the course of illness with the use of antibiotics (2) but the most important part of cholera treatment remains fluid resuscitation.

Part of Vibrio Cholera’s strategy for spread is that there is a high percentage of infectious organisms in a patient’s stool and these organisms are even more infectious than those found in the natural environment, frequently referred to as “hyperinfectious” in the early stages of infection (6). So if you can imagine someone just vomiting and pooping liters upon liters of infectious fluid everywhere in a place with limited sanitation and struggling healthcare facilities then you can imagine what happened in Haiti, when UN peacekeepers accidentally introduced cholera there when they arrived, and be concerned about what is happening in Yemen in the wake of their humanitarian crisis.

The UN peacekeepers first arrived in Haiti in 2004 after Aristide was ousted from his presidency. Their time in Haiti has been plagued with scandal including sex abuse and infamously in 2010 when peacekeepers arriving from Nepal brought cholera with them and spurred an ongoing epidemic which has killed at least 9,500 people and infected hundreds of thousands of Haitians (8). The devastation is made worse by the fact that it took until last year for the UN to acknowledge its role in this epidemic and pledge funding to help correct the problem (8). To date only a small portion of that funding has actually been raised.

In a statement on May 9th Doctors Without Borders (MSF) warned of a growing outbreak of cholera over the last few weeks in a war-torn Yemen. The MSF have treated 780 patients since the end of March with a sharp increase in the last two weeks (3).  Open conflict has been ongoing for the last two years between the Houthi rebels and the Saudi Backed government (though he origins of the conflict and initial uprising go back even further). Currently there are 14 million people in Yemen living without access to sanitation or safe drinking water (4). Part of the underlying problem is a combination of destruction of existing health infrastructure (via airstrikes) with inadequate access to food as well as restrictions on fuel imports (4). Only 45% of the 3,500 health facilities surveyed by the UN in November 2016 were fully functioning (4). Some global health organizations are calling the devastation caused by the breakdown of Yemen’s government the “largest humanitarian crisis in the world” (9). This is a perfect storm and without any large public health intervention it will likely brew for years causing death and devastation in its path.

 

  1. “The global burden of cholera” Ali, M et al, Bull World Health Organ. 2012, Mar
  2. CBC website general information on cholera
  3. http://www.doctorswithoutborders.org/article/yemen-increased-response-needed-cholera-spreads
  4. Yemen crisis: Who is fighting whom?, 28 March 2017 http://www.bbc.com/news/world-middle-east-29319423
  5. “turning the tide against cholera” Donald McNeil Jr. New York times 2/6/2017
  6. Cholera transmission: the host, pathogen and bacteriophage dynamic. Eric J. Nelson Nat Rev Microbiol Oct 2009
  7. After Bringing Cholera to Haiti, U.N. Can’t Raise Money to Fight It. Rick Gladstone for the NY times 3/19/201
  8. UN. Votes Unanimously to End Peacekeeping Mission in Haiti. BySOMINI SENGUPTAAPRIL 13, 2017
  9. Cholera Compounds Suffering in a Yemen Torn by War, Rick Gladstone for the NY Times 5/9/2017
Posted in BMC

Shoulders of Giants

I had the delightful experience during my present trip to Haiti of meeting the Haitian dermatologist who noticed an uptick in Kaposi’s sarcoma cases within his clinic in 1981, and thus located the first cluster of AIDS patients within Haiti. The story he told me was a testament to the luck that plays such a big role within global health; he had worked for several years in Algeria, and as such had seen Kaposi’s sarcoma in that context and was familiar with the (still rare) disease. Upon seeing cases in Haiti, he reached out to the limited number of pathologists and dermatologists within the country in 1981, only months after the initial MMWR reports from New York and San Francisco came out. As he prepared a report based upon the 11 patients he and his colleagues found, a friend of his working with the CDC came for a visit to seek out precisely Kaposi’s sarcoma and PJP patients, based on CDC data showing non-gay patients of Haitian origin in the US also suffering from the recently discovered immunodeficiency disorder.
Several other Haitian physicians and public health practitioners contributed to these discussions, first leading to publication of their case series in 1982, and shortly thereafter culminating in the foundation of GHESKIO, one of the premier HIV research institutes and the first, to my knowledge, within a LMIC. More than 30 years later, after period of government intimidation, their group published impressive results of their initial cohort to start ART back in the 90s.
In addition to giving me an appealing model of what my semi-retired life might look like (this gentleman continues to teaching residents at two teaching hospitals and is employed to help with employee education at GHESKIO), he stands as a great example of how we move forward medical science, with a combination of preparation, curiosity, felicity, and perseverance.  As well as a great reminder that our colleagues in LMIC are equally talented (just limited too often by the resources at hand and the demands that they face).
(I didn’t ask for his permission to write about him, ergo I’m not using his name)

When Plants Become Medicine: Biopiracy, Bioprospecting and Questions of Consent

PlantsMedicines

The problem may be that money does grow on trees. Globalization has allowed for cross-cultural interactions that can turn common knowledge from one group into discovery for another. In medicine this exchange has led outside practitioners and researchers (often from high resource countries) to explore other medical traditions for cures to diseases that have evaded their own methods. A lingering question attached to this global network is whether the rights of indigenous peoples are being protected as access to their knowledge systems is more easily penetrable, and whether intellectual property rights (IPR) have been used to exploit traditional knowledge based systems. These questions are particularly ingrained in today’s field of bioprospecting, or “exploring biological diversity for commercially valuable genetic and biochemical resources” (1). A term often synonymous with bioprospecting is “biopiracy”, which has been used by victims of bioprospecting who are not compensated by or protected from foreigners using their traditional knowledge of bioresources (2).

As more pharmaceutical companies and government-funded programs explore biodiversity-rich countries, such as India and Mexico, that also include culturally diverse indigenous populations, conflict arises. These issues are not limited to the specific qualities of plants and animals, but also of consent, environmental sustainability, and protection of the practitioners’ intellectual property.  We explore the developments and controversy of bioprospecting in India and Mexico to provide a framework for this ethical dilemma.

 

The relationship between India and bioprospecting is sensitive, as the country has seen itself as the victim of exploitation of its own biodiversity and traditional knowledge base. One example of these ‘exploitations’ includes the patenting of methods to extract specific chemicals from neem. These extractions were found to act as a pesticide and also hold bacteria-fighting qualities (3). Many indigenous communities in India felt it unfair to grant this patent, as they have been using neem to remedy such problems long beforehand. The patent was challenged, but because the “patent-holder had improved on existing knowledge,” the decision could not be overturned. The Indian government brought to light a similar controversy when the US patent office approved a patent in 1995 for the wound-healing qualities found in turmeric (2). The patent was once again challenged, as the plant has been traditionally used in Indian communities to heal wounds and rashes (4). This time the patent was indeed overturned, showing the complexity of intellectual property rights.

Many indigenous communities in India argue that knowledge pertaining to specific herbal usage has been practiced by traditional healing practices including Ayurveda, but because it is so old a practice, it is not formally written down nor is it systematically used, and therefore cannot be legitimately be patented. This has left the bioprospecting field wide open for other companies and researchers to swoop in and use this knowledge base for scientific discoveries.

India has gone through great lengths since these cases by taking ownership of and calling for acknowledgement of traditional knowledge based-systems. India created domestic laws to help foreign bioprospectors determine the traditional knowledge of bioresources. For example, in 2000 the Biological Diversity Bill was passed, in which the use of traditional knowledge-based bioresources must in some way accredit the indigenous people holding that information via some form of a benefit-sharing model (2).  In an effort to avoid further patent controversies, India went even further and created its own Traditional Knowledge Digital Library. The goal of this database was to provide upfront information regarding traditional healthcare practice and medicinal uses, so as to avoid illegitimate patents in foreign countries (4). Yet even if it is deemed ethical and appropriate to compensate an indigenous people for their traditional knowledge resources, how can this be achieved?

Examples in India of benefit-sharing models and propositions include a monetary-based platform, in which a community is repaid for exporting and utilizing plants of medicinal value. In certain contexts, benefit sharing has shown to aid rural or disadvantaged communities in India, such as the ‘community-bioprospecting’ model in South India. Here, a community-based company acted as a mediator between bioprospectors and community needs to guide monetary benefit-sharing plans and utilize local ethnomedicine knowledge that promote both the spread of traditional and valued knowledge as well as improving the quality of life of disadvantaged communities (1).

While success in one cultural setting is a stepping stone forward in this murky river of conflict, constructing a viable bioprospecting revenue sharing model is extremely challenging to apply in different places. Multiple U.S. agencies including the National Institutes of Health (NIH), National Science Foundation (NSF) U.S. Department of Agriculture (USDA) and the Department of Energy (DOE) collaborated to create the International Cooperative Biodiversity Groups (ICBG) (5). The program’s mission was to:

“address the interdependence of biodiversity exploration for potential applications in health, with investments in research capacity that support sustainable use of these resources, the knowledge to conserve them, and equitable partnership frameworks among research organizations in the U.S. and low- and middle-income-countries (LMICs).”

In Mexico a joint project including the University of Georgia, El Colegio de la Frontera Sur (ECOSUR) in San Cristóbal de Las Casas Chiapas, Mexico, the Mexican Institute of Social Security and a private firm Molecular Nature Ltd of the U.K. won a grant from the ICBG to create a framework for the bioprospecting process while also protecting and compensating the intellectual property of traditional Mayan practitioners in the region of Chiapas. Advocacy for the Mayan communities was to come out of the Protection of Mayan Intellectual Property Rights (PROMAYA). One aspect of this was to create a trust fund for Mayan communities that would be funded by any royalties on drugs resulting from the ICBG project, as well as ensure increased infrastructure building for research. Despite the similar effort as in India to compensate locals and acknowledge their knowledge, this arrangement was immediately opposed by local groups as well as allied international NGO’s, calling into the question the process of consent (5). At the center of this controversy was PROMAYA and anthropologists Elois Ann Berlin and Brent Berlin of the University of Georgia. The Berlins brought extensive knowledge of the area and maintain that they had done significant work to ensure that communication with local communicates was adequate and appropriate. However, recent controversies in other bioprospecting projects and a lack of an easily determined representative voice for the communities led to rapid public outcry. Despite modifications to the grant, the project was ultimately terminated under the pressure from these protests when ECOSUR withdrew from the project. The Berlins’ full perspective on the rise and fall of the project was published in 2004 (7). It should be noted that not all ICBG projects had such a negative result. In a 2013 Current Anthropology piece Rosenthal compares the relative success of the ICBG in Peru to the tumultuous ending in Mexico (6). “The Peru and Maya ICBGs have struggled very publicly with the definition and implementation of prior informed consent in attempts to build equitable and ethical research collaborations. An analysis of the contrasting political, cultural, and governance environments and the differential outcomes of the two projects suggests that the governance of potentially collaborating indigenous societies is key.”

In an increasingly global world, one must question whether healing-practice knowledge can be in fact ‘owned’ by a community, and if so, how this may impede the spread of crucial and vital knowledge surrounding the use of bioresources as medicine. This area requires a multidisciplinary approach, as bioprospecting involves a complex interplay between governments, academic researchers, the pharmaceutical industry and the often disadvantaged communities that hold the precious knowledge of bioresources. Furthermore, each of these groups is comprised of multiple sub-groups with varied perspectives and motivations. Larger governing bodies such as the U.N., and its Convention on Biological Diversity, which strives to promote among other issues surrounding biodiversity, equal rights for indigenous peoples in respect to benefit-sharing also play a role in setting global standards for how the world should view ownership and protection of bioresources and indigenous peoples, respectively.8 “The Peru and Maya ICBGs have struggled very publicly with the definition and implementation of prior informed consent in attempts to build equitable and ethical research collaborations. An analysis of the contrasting political, cultural, and governance environments and the differential outcomes of the two projects suggests that the governance of potentially collaborating indigenous societies is key.”

Overall, the field of global health must look into how multiple facets in the global world, ranging from the international governments to community-based bioprospecting models, have responded to bioprospecting and biopiracy. We must question whether current perspectives of the topic are accurately dealing with a very real problem of infringing on a community’s bioresources and traditional knowledge. One of the problems bioprospecting faces today is the dilemma over how to protect indigenous peoples’ rights and who can speak as a reasonable representative of these populations. We now have the difficult task of treating bioprospecting both as a medium through which cultural practices are shared in light of the broadening global health field, while also regarding its detrimental qualities in further perpetuating social suffering of local communities whose traditional knowledge base may be exploited.

@eddiebriercheck co-authored this piece.

1.) Torri, Maria-Costanza. “Beyond Benefit-sharing Agreements: Bioprospecting for the Poor?” International Journal of Technology Management and Sustainable Development 8.2 (2009): 103-27. Academic Search Premier. Web. 1 May 2010.

2.) Kartal, Murat. “Intellectual Property Protection in the Natural Product Drug Discovery, Traditional Herbal Medicine and Herbal Medicinal Products.” John Wiley & Sons, Ltd. (2006): 113-19. PubMed. Web. 1 May 2010.

3.) Shimbo, Itsuki, Yoko Ito, and Koichi Sumikura. “Patent Protection and Access to Genetic Resources.” Nature Biotechnology 26.6 (2008): 645-47. Academic Search Premier. Web. 6 May 2010.

4.) India. Council of Scientific and Industrial Research. Department of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy. Traditional Knowledge Digital Library. Web. 05 May 2010.

5.) NIH Fogarty International Center. International Biodiversity Cooperative Groups https://www.fic.nih.gov/Programs/Pages/biodiversity.aspx

6.) Rosenthal J. Politics, Culture, and Governance in the Development of Prior Informed Consent in Indigenous Communities. Current Anthropology Feb 2006.

7.) Berlin, B and Berlin E.A. Community Autonomy and the Mayan ICBG Project in Chiapas, Mexico: How a Bioprospective Project that Should Have Succeeded Failed. Human Organization, Winter 2004.

8.) “Article 8(j): Traditional Knowledge, Innovations and Practices.” Convention on Biological Diversity. U.N., 05 May 2010. Web. 05 May 2010. <http://www.cbd.int/traditional/&gt;.

A Remote Context: Reflections on Practicing Medicine in the Navajo Nation

I recently completed four weeks of clinical work at the Northern Navajo Medical Center, a hospital and clinic owned by the Indian Health Services. The center is located the small town of Shiprock and surrounded by the Four Corners region, a both vast and beautiful part of the country. My time there was highly enriching, personally and professionally. I had the privilege of working with a wonderful and gracious patient population whose history is both sad and interesting, and I was challenged by their medical complexity. I also encountered some of the unique struggles associated with practicing medicine in a rural, under-resourced setting.

Being in such a remote location constantly challenged me to think about the implications of my medical decisions. One of the things that has continued to resonate with me was how often geography played into the nuances of our medical management. One of the more vivid interactions I had occurred in hepatology clinic with a patient who at first glance seemed very disconnected with his care. He had missed numerous visits prior to this appointment, and this time he arrived twenty minutes late. As we were talking, he told me that he had walked two hours to get to this appointment. Two hours for a fifteen minute visit, and that’s one way. I’ve seen some shocking things during residency. But there was something about his statement that was almost more jolting than those things. It wasn’t at all what I had expected to hear. I felt guilty about my slight annoyance when he was late. I also realized that with every patient at Shiprock, it was crucial to understand physically where they were coming from and where they would go after I sent them away. From deciding whether or not to admit them to making sure they got their mammogram in the appropriate location, it was always important to consider the geographic context.

The Navajo reservation is a sizeable amount of land. It’s the largest reservation in the United States and encompasses over 27,000 square miles. There are about 300,000 members of the Navajo Nation, and half of them live on the reservation. According to the 2010 census, the median income of the Navajo Nation is $20,000, and 43% of members live below the poverty line.

NN_LARGE_MAP2-682x426

Although the Navajo reservation is unique in that much of it lies on ancestral Navajo land, there is a sad and bloody history behind how it officially was deemed Navajo territory. The Navajos first encountered the Spanish in the late 1500s. For the roughly 300 years of coexistence of the two groups, there was hardly a peaceful period. In 1821, New Mexico gained its independence from the Spanish. Despite this change in leadership, skirmishes and raids between the Navajo and other settlers continued. By 1846, the United States had gained nominal control of New Mexico, and the Bear Springs Treaty was an attempt to make peace. Despite adherence of the most prominent Navajo leaders to this treaty, younger Navajo raiders continued to attack New Mexican settlements. Three years later, one of the most respected Navajo leaders, Chief Nabona, met with an American Colonel to attempt another peace treaty. Instead of a settlement, the encounter ended with American soldiers shooting and scalping Chief Nabona. Anger over this incident prompted the more war-oriented leaders of the Navajo to continue escalating violence.

In 1862, General James Carleton became head of the American troops in New Mexico. He thought (wrongfully) that all Navajo were violent and warlike and felt that the best solution was to confine them at Fort Sumner, an area on the Pecos River that the Navajo people called “Hweeldi.” The Navajo, however, refused to give up their land in order to move to this unfamiliar area. So General Carleton resorted to brutal methods in hopes of forcing compliance. He and his men burned towns, killed livestock, and destroyed fields.

In the dead of winter, these ruthless tactics worked. Many of the Navajo felt they had to surrender in hopes of staving off starvation and freezing temperatures. The subsequent 300-mile herding of the Navajo to Fort Sumner is called the “Long Walk.” It was completely inhumane. Many Navajo died of starvation and fatigue, and others were shot and killed if they couldn’t keep pace. At the end of it, over 8000 Navajo were crowded onto an internment camp of a meager 40 square miles. Conditions were decrepit, and both food and water were insufficient. Eventually, the Treaty of 1868 was signed.  It allowed the Navajo to reclaim some of their ancestral lands, and they were finally able to make the “Long Walk” home.

My patient’s trek to his appointment wasn’t three hundred miles, but it was still an impressive distance. The struggles he faced to transport himself to appointments and to the pharmacy inherently affected his medical care. Similarly, the struggles that the Navajo people underwent to reclaim their rightful land have helped mold their cultural identity. Medicine cares for individuals, and remembering each patient’s unique cultural identity is an integral part of their medical care. Whether it involves understanding their ethnic background or asking where they live, their story should influence both how we empathize with them and how we determine the most appropriate clinical management.

 

 

Posted in BMC

University of Pavia, Italy

by Christopher Gruenberg, EM PGY4 and Carol Shih, EM PGY3

We are very privileged and thankful to be have been invited by Professor Giovanni Ricevuti to the University of Pavia as visiting professors. From the moment we arrived and were greeted by Miss Edona Leka at our dormitories at the Collegio Universitario Santa Caterina Da Sienna, we knew that our visit would be filled with warmth, reward, and growth. Meeting with Professor Giovanni Ricevuti, we together planned and orchestrated a series of didactic lectures, small groups, case discussions, and simulations that would both review essential concepts of emergency medicine, but also introduce key differences in American health care practices and systems compared to Italy. We designed over 30 hours of content given to a multidisciplinary group of medical students, residents, and faculty members from specialties such as emergency medicine, cardiology, orthopedics, and traumatology. We presented provocative topics such as the American opioid epidemic, gun violence, and out of hospital cardiac arrest management to present new cases to medical students and residents that they may not see in Italy, while also engaging senior faculty in controversial issues of public health, policy, and community leadership.

Although a majority of the legwork of the elective was devoted to the conference halls, most of the rewards were realized outside of it. Professor Giovanni Ricevuti unexpectedly and graciously made sure that we had every opportunity to integrate into the culture and lifestyle of Pavia. We toured the University of Pavia where Nobel Prize winners Golgi, Scarpa, and Volta taught centuries ago. We traveled to Milan to take part in an international conference attempting to detect patterns of dementia by employing the resource of smart cities and phones. We broke bread and grape with medical leaders from England, Ireland, Spain, and of course Italy. Although branded as “non-academic,” it was this cumulative experience that gave us the insight into not only the cultural values of Italian and European people, but also an appreciation for how those values guide the structure and function of their healthcare system.

The last night of the elective could not have been a more proper summary of the give and take of our time with the students, residents, and faculty at the University of Pavia. Professor Giovanni Ricevuti rented out a small farmhouse in the countryside with tables 30 people long. Together we reminisced on our times together and made plans for the future. We debated the overutilization of resources for end of life care in America, and possibly the underutilization in Italy. We discussed the EKG curriculum and how it was taught in a way that really challenged clinical thinking instead of route memorization which they had been accustomed too. We of course talked about Trump. We delved into the drawbacks of government health care in Europe. And at the end of it we each learned something about each other and ourselves, and thanked each other in one of best Italian traditions of all, singing all together. We are excited about the prospect of sending residents to Pavia again in the future, and hopefully we can return the favor and accept visiting students from Pavia as well. Sharing our experiences, perspectives, strengths, and weaknesses as people and societies through these ventures is what has impacted me most as a person and will make this elective live on as one of our most rewarding memories of residency.

Posted in BMC

Kenyan EMS Curriculum Evaluation

by Ben Nicholson, MD, PGY-2, Emergency Medicine

Kenyan EMS started as a direct result of the 1998 US Embassy bombing in Nairobi. Since then, providers have worked to develop a national curriculum, training content, and expectations for EMTs. In the coming months and years, the senior leadership has plans to expand EMS to more cities in Kenya and increase the scope of practice. This August, I spent an elective rotation working in Nairobi Kenya to evaluate the current curriculum that the Kenya Council of Emergency Medical Technicians uses to instruct emergency medical technician (EMT) students. This was part of a broader evaluation of the state of prehospital education across Kenya as the country stands ready to greatly expand their prehospital resources.

I interviewed EMT students, trainees on their clinical rotation, EMT instructors, and senior leadership. With players from many different stages of training, we worked through the current curriculum, how people view EMS and their role in EMS, the process for delivery of out of hospital care in Kenya, and the financial realities of providing this service. I met some wonderful people who taught me a great deal about Kenya and how the country has changed, particularly in the last decade.

As an educational assessment, I learned the processes involved in formally evaluating an educational product. Day to day, this meant interviewing people, typing up my notes, then summarizing these notes, and finally trying to extract themes from all of the interviews. Many days were spent Ubering around Nairobi or sitting in the garden at the guesthouse drinking Coke’s with cane sugar, pouring over my notes.

I spent time riding in the ambulance and seeing parts of Nairobi I otherwise would not have been able to safely travel. The EMTs drove me around Nairobi and gave me a personalized tour. Another interesting experience was meeting the senior EMT who oversees the training of the airport firefighters. He picked me up and drove me the 40+ minutes out to the airport for the meeting. The entire way we chatted about Kenya and EMS. This was a really great opportunity to meet someone from the country, across a shared interest, and understand more about the country and its people than would have otherwise been possible.

In the future, there is a great deal of opportunity for further collaboration and involvement. The EMS system has many areas of potential growth and refinement. One of the more exciting things was finding so many people who are passionate about EMS and have been working to develop it largely without any outside support or influence.

Overall, this was a great experience in terms of personal growth, learning how to conduct formalized research, and building relationships with folks in Kenya. It was certainly challenging, required a lot of self-motivation to stay on task, but I think it was well worth it.

Posted in BMC

A Pasante Life: following a first year Mexican physician during their social service year

It’s 8:45 PM in rural Chiapas, Mexico. A cool blanket wraps around the previously warm day in the small farming town of Honduras. With a syringe of medicine in his front pocket pasante Dr. Ivan Martinez does a steady jog up a steep hill to see about a patient’s chronic pain. Nestled into the Sierra Madre Mountains there are few flat places. As we’re nearing the top of the hill he gives me a summary of the patient’s history and how he’s approached the case so far. At the door he’s immediately and warmly greeted by four of the patient’s family members. They are each eager to provide Dr. Martinez with a different perspective on the patient’s illness. He hears from everyone as he does an extensive physical exam. Around twenty minutes later a decision is made and the medicine is administered. We quickly drink a sweet coffee the patient’s wife had placed at the patient’s bedside. Dr. Martinez has been thinking about dinner for a couple hours now, but he also needs to secure a projector from the local 7th Day Adventist pastor. He is planning to invite the community for a movie night. He’s hoping to show a film that might facilitate discussions on mental health, a major contributor to local morbidity. An hour later with projector secured and a couple “mini consults” completed he takes a breath, “Cenamos (dinner)?”

This is the day to day of a pasante who has reached the halfway point of his social service year. While responsible for the entire town’s healthcare, he has only been Dr. Martinez for about 6 months. As a safety-net in the Mexican healthcare system first year physicians are placed at rural locations without otherwise easy access to a doctor. For most patients pasantes are the entry point to all medical care. While, Dr. Martinez’s ultimate interest is in psychiatry this year he is managing everything from pregnancies to Parkinson’s disease. Referrals to specialists are possible but are also difficult and expensive. This means that patients are managed locally whenever he can. There is a single room in the clinic with three shelves of medicines to choose from. At least half of these are not the standard government supply but are supplemented by the Partners In Health (PIH) affiliate Compañeros En Salud (CES).  Despite the limitation in options the treatments are frequently adequate and simplify many visits. This can be helpful with so many patients to see and most decisions left only to Dr. Martinez. It is a stark contrast to first year physicians in the U.S. who have heavy supervision, with exhaustive options on treatment, laboratory testing, and consult teams. While at times it would be nice to have more help, there is an empowerment to the sole responsibility of a patient’s care. It is clear that Dr. Martinez is this community’s physician.

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Dr. Ivan Martinez walks back to the clinic with a father and daughter while discussing their recent illness. Impromptu consults are common.

As Dr. Martinez makes his way through Honduras some may wonder if he is also running for office. At over six feet (a foot taller than most patients) he stands out and rarely misses an opportunity to offer a broad smile and conversation to the many patients we pass going to and from the clinic. Frequently, he is securing medical and dinner appointments simultaneously. Like many pasantes Dr. Martinez lives with a local family, but gets his meals at various homes in the community. He says all of this interaction helps him to know the complete picture of the patient. With multiple generations living on the same street or under the same roof he often doesn’t need to take a family medical history. As one observes these interactions it is hard not to be reminded of the romanticized picture of the old country doctor. Yet his job has significant challenges. Aside from his lack of experience his patient population also confronts him with poverty, insecurity, and varying levels of education. More than 75% of the population earns under $5 a day. Most patients walk to appointments or have limited access to transportation. Some are close but others live miles away. He has to close the clinic at some point in the evening but it is difficult to tell some patients to come back another time.

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While Beautiful the Sierra Madre mountains offer serious challenges for patient transport and the delivery of emergency medical services.

In high resource settings physicians are now being trained to be more cost conscious. This means more thought in regards to the tests and procedures they order. They are trained to ask themselves why they are ordering a test or procedure and how the result would change management.  For pasantes this thinking extends far beyond making sure tests are clinically relevant. At times the questions and answers are sobering. A young mother’s symptoms suggest a potential aneurysm in the brain, a condition that can be rapidly fatal. The diagnostic approach is an emergent head CT scan. Yet several steps lay ahead. The closest CT scanner is five hours away. Perhaps if he can get the patient to the closest centro de salud (a slightly bigger clinic) he can transport the patient in their ambulance. Someone from the community secures a car and after making it the centro de salud the question becomes if the family will be able to pay for the CT scan. It is pointless for the one ambulance in the community to be used if they ultimately can’t pay for the scan. As family members are on the phone with friends and relatives scraping together these funds the pasante starts to think what if we do find an aneurysm? Will there be a neurosurgeon and funds to repair it? If not why are we asking this family to pay for a scan? All the while uncertainty of the patient’s diagnosis remains.

Dr. Martinez does have some resources others pasantes do not. As a member of Compañeros En Salud he has more medication options, access to electronic clinical resources like Uptodate, and can provide logistical resources for those who need to travel for more complicated treatments such as continued cancer care. Additionally, he has educational sessions and occasionally in person help from fellows and residents visiting from institutions in the U.S. This extra opinion can help with revision of tough cases and offer a break from solo decision making. He said it took about three months to get comfortable in his role, which is interestingly about the time many U.S. first year physicians start growing into their role as interns. Perhaps his most valuable resource are the acompañantes. Largely members of the local community these individuals follow-up with patients in their homes, review medications, and often identify barriers to the patient’s care. They also help patients navigate the referral process.

The following day as the sun leaks through the cracked doorway of the town meeting hall a handful of patients begin gathering. They have come for Curso de Triángulos, a group therapy session that is part of the care for patients suffering from depression. In addition to pharmacologic treatment given in clinic the courses are designed to provide both therapy and a confidential community support group for mental health. Some are more vocal than others but Dr. Martinez manages to get everyone involved. Today he has placed four pieces of paper on the ground with the words situación (situation), pensamiento (thought), emoción (emotion), and acción (action). Patients physically walk through these aspects of an experience they’ve encountered. They process how their happiness is influenced by not only the event but their own reaction.

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At Curso de Triángulos patients complement pharmacologic therapy with group based support and exercises.

Through this process of slowly walking through a problem together they gain a deeper understanding of themselves and form a greater level of support for each other. This exercise mirrors the relationship of the pasante and the community. While imperfect at times the relationship is a close one built on many steady visits together both inside and outside the clinic. The pasantes guide the health care of the community and the patients guide the pasante’s learning. In a few months Dr. Martinez will move on and these same patients will walk again with another newly minted physician. Their health and the physician’s growth a partnership.