Global Pulse Blog

Access, Cost, Quality

In a country like Nicaragua that is the 2^nd poorest country in the western hemisphere, poverty impacts every aspect of life especially health care.  According to the U.S. Library of Congress,  Nicaragua has a three tiered health care system where; 1) The upper 1-2% of the population receive care in private clinics and private hospitals and often go abroad for specialized care. 2) About 8% of the population has government health insurance. This includes mostly government workers, military personnel, and part of middle class who receive the insurance through their employer. 3) The remaining 90% of the population relies on the free public hospitals, health centers, and health posts. Now, this doesn’t sound so bad until you realize that the 8% of the population that has government insurance receives 40-50% of the nation’s health care budget and the public system that serves 90% of Nicaraguans, though it does provide low-cost/free care, lacks quality and access.

For example, I have been working in Nicaragua where I have had the blessing of knowing a 16 year old young woman with Ewing’s Sarcoma. One day when going to visit her in the hospital, I encountered several realities of the Nicaraguan public hospitals. The following is a personal account embedded with the perceptions of the Nicaraguan people that I spoke with about the situation and realities faced at every public hospital/health center/health post in the country.

When I arrived at the hospital her mother told me that before giving this young woman her third dose of chemo for this cycle, she became very pale and was gasping for breath. They debated intubation but instead gave her some medicine and oxygen. She was now left with her mother in a sparse ill-equipped hospital room. The young woman still had a 103 degree fever, was vomiting and was very pale.

1. The room has six patients in metal beds some with sheets, run down equipment, blank faces, no pillows, no water, no utensils with which to eat, paint chipping off the walls, and a window open to the hot air outside.
2. One of the other women in her room had traveled 2 days to get to the hospital. Many people from the area of the country she is from never see a doctor in their whole lives because they do not have the financial means, physical strength, or time to travel.
3. There was one nurse for all 60 patients in the medical and orthopedic units.
4. The oxygen that they gave this young woman was not working…there was nothing flowing through the tube!
5. Her labeled IV was supposed to be changed 5+ hours ago and the IV site was now red, warm to the touch and blood was infiltrating the tube about 5 inches!
6. Her mother told us that she had not seen the oncologist in 15 days! Somehow in these 15 days of not seeing the patient, the oncologist decided that the patient was okay to have chemo.
7. They had not run any urine tests that her mother could remember despite the fact that the young woman, who is on chemotherapy, was initially admitted with a kidney infection.
8. The young woman looked the weakest I had seen her. She quietly told her mother that she needed to go to the bathroom and her mother got the bedpan from under the bed and moved it under her to urinate. The entire process was very painful for the young woman since her hip/tumor site had to move to have the bedpan under her.
9. There is no toilet paper in the hospital.
10. I asked the residents who were about to pass into the room to wait until after she was done urinating just a moment to give her a little privacy/dignity. They, without saying anything, turned away from the room and chatted in the hall for a moment. I told them when she was done and they could pass into the room, but instead they continued to chat and then LEFT without looking at her or any of the other women in her room.
11. I asked a Nicaraguan doctor I am working with why they would just leave like that and she said… “that is what it is like here. That was the patient’s only chance to see a doctor today and they don’t care if they skip a room or not.”
12. Then, the cleaning lady came to mop the floor of the young woman’s room/hall with chemicals that were making even me nauseated. Ammonia and apple. The young woman, like most patients on chemotherapy, immediately started vomiting at the smell.
13. I tried to tell the nurse that the IV needed to be changed and that the oxygen not working. She was in the middle of preparing the medicines for her 60 patients and she didn’t have time to care.
14. Then , when I went to the social work office to tell them of her IV and oxygen, they said it was not their problem and that we needed to speak with the Medical Director of the hospital.
15. There was a long line outside the Medical Director’s office and he was not there. Luckily, the doctor I was with knew one of the doctors working there and told him of the situation with the hope that he will look into it.
16. The young woman’s mother/primary caregiver was tired and crying more and more frequently
17. The family members/friends, if patients are lucky enough to have them, are really the ones that know what is going on with the patients. They are doing the positioning of the patient, feeding, advocating, and doing assessments (not clinical ones…but still asking questions to rate/evaluate how patient is doing.)
18. The doctors rarely talk to the patient, the patient’s family and the nurses…they work pretty independently and do not look at much more than the patient’s chart to see how the patient is doing….only the super busy nurse and doctor write in the chart, so it doesn’t reflect what’s really going with the patient only what treatment was received/ordered
19. If a family member is to ask for something or offer information to a doctor such as “my daughter has vomited 10 times in the past hour” the doctor often doesn’t listen and instead is annoyed. The family member and patient are then labeled as problematic and their care if affected.
20. The longer a patient stays in the hospital the worse the patient’s care becomes…this young woman had been in the hospital for 17 days.
21. Many patient’s in the hospital die of dehydration (from not changing IVs) and hospital born infections. So many patients do not trust the hospital to help them.
22. There is even less medical care at night and on the weekends.
23. There are also many medication error and neglect and no accountability.
24. I learned that they do not require teaching medical ethics in all the medical schools here and bedside manner is rarely a topic that is taught.

There are many angles to look at the injustices of this young woman’s care, and the role of every person involved in creating an effective health delivery system. However, no matter what angle you look at or whether you are in the poorest or the richest country, the fundamental attribute of any health care system needs to be a balance between cost, access, and quality.

~Ayla Landry, BSN,RN

From the Author: Ayla Landry

My name is Ayla Landry. In May 2010, I graduated from Texas Christian University with a Bachelors of Science Degree in Nursing (BSN) and I am a Registered Nurse (RN). I have been involved in Nicaragua on a voluntary basis since 2008 originally assisting with a campaign against cervical and breast cancer, which are the #1 and #2 causes of death for Nicaraguan woman under 60 years old. The campaign is Nicaraguan-led and developed world-supported with several organizations from the US including NGOs, MD Anderson Houston, and MD Anderson Madrid supporting the efforts. I traveled to MD Anderson in Houston to learn as much as I could about the cancer care model and nursing role there. I helped set up a cancer registry, helped organized training conferences for physicians and nurses, helped in advocating the role of nurses in the pilot clinics created by the campaign, translated education materials (Spanish/English), and presented conferences in Spanish about the basics of oncology nursing care.

Most recently, for the past 5 months I have been living in Nicaragua to work/volunteer with a non-profit organization called Nicaraguan Resource Network (NRN). The organization has set-up churches in 26 different communities, 4 of which have schools, and 2 of those schools have special needs programs. In January 2011, NRN hired a wonderful Nicaraguan Pediatrician to provide primary healthcare to the nearly 1,800 children in their schools. I have been here in Nicaragua supporting and working alongside the physician in setting up a program to attend to these kids.

I dream to positively and significantly impact women’s and children’s health in the developing world and to promote global health education among nurses. While I was in Nicaragua, I was accepted into Johns Hopkins University for the MSN/MPH (Masters of Nursing/Masters of Public Health) program which will prepare me to accomplish those dreams, and I couldn’t be more excited to start the program at the end of this June.

This past week an excellent discussion of important global health challenges and developments, including those related to the Millennium Development Goals, took place at the TEDx Change Meeting, “The Future We Make”. TEDx is a new program enabling local communities and organizations to organize, design and host their own independent events to discuss innovative and important ideas.

Check out the webcast from the recent “The Future We Make” meeting on the Bill and Melinda Gates Foundation website for an engaging and insightful discussion of issues related to the Millennium Development Goals such as child mortality rates, birth rates, literacy, HIV/AIDS and more on a global level.

TEDxChange Webcast

The UN Summit on the Millennium Development Goals was held this past week in New York City. Occurring at a crucial time, with five years remaining until the 2015 deadline, world leaders met to discuss needed actions to reach the eight global development targets agreed to by the world’s countries and leading development institutions in September 2000 at the Millennium Summit when the United Nations Millennium Declaration was adopted, committing the UN nations to a new global partnership to reduce extreme poverty and setting out a series of time-bound targets – with a deadline of 2015 – known as the Millennium Development Goals. The Millennium Development Goals include:

• End Poverty and Hunger
• Universal Education
• Gender Equality
• Child Health
• Maternal Health
• Combat HIV/AIDS
• Environmental Sustainability
• Global Partnership

The Millennium Development Goals Report 2010 summarizes the progress which has been made thus far while striving to meet these goals as well as potential actions, strategies and policies which could be implemented to continue positive progress.

A  new survey from the Centers for Disease Control and Prevention (CDC) suggests that  heterosexuals living in impoverished communities are as much as five times more likely to be HIV-positive than the general U.S. population, regardless of race or ethnicity. In the US, the overall HIV prevalence rate for African Americans is eight times the rate for whites, and the rate for Latinos is three times the rate for whites. Yet in very-low income areas this CDC study found that these disparities do not exist. The study examined 9,000 people in 23 cities, finding that 2.1% of heterosexuals living in high-poverty urban areas were infected with the HIV virus, including 2.4% of those living below the poverty line and 1.2% of those living above it. This is in comparison to the 0.45% rate of HIV infection in the general US population. The authors hypothesize that the findings could account for many of the ethnic and racial disparities in HIV infections in this country, since African Americans are 4.5 times as likely and Latinos four times as likely as whites to live in poverty.

A recent article in the Christian Science Monitor by the SEVEN Fund’s Michael Fairbanks explores a potential approach to addressing Haiti’s need for long-term economic support. While several different groups have contributed to relief efforts after the devastating January 12th earthquake, many are looking to develop a more long-term solution. A challenge to building private-sector support is the atmosphere in a country where the elite and wealthy have often supported business initiatives which favor big business and are not developed to lend support to those most in need.

In order to create prosperity for the average Haitian citizen, innovative solutions are needed to develop “attractive export market segments to serve with unique products, building new distribution systems, lowering energy costs, and providing skills to Haitian citizens who will be compensated for the high value they create” according to Pierre Marie Boisson, a Harvard-educated, Haitian international banker.

The Bill & Melinda Gates Foundation, the Health Institute of Carlos Slim Foundation and the government of Spain have each contributed $50 million to fund the Salud Mesoamerica 2015 Initiative.  The Inter-American Development Bank will coordinate and commission independent evaluations as well as manage the combined contributions of the donors. The project’s primary aim is to reduce health inequities by fighting dengue fever and malaria and improving nutrition and maternal health in Belize, Costa Rica, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, and Panama. The funding amount received by each country will be based on their poverty and health inequity status.  While each government will determine what programs to finance with the Initiative,  incentives will be placed for more equitable allocation of domestic funding and for policy that improves the health of the poor.   This project is expected to generate globally-relevant knowledge of how to scale up cost-effective health interventions in poor communities.

This is not the first time that Slim and Gates have partnered up.  They have been working together at Prodigy MSN, which has just celebrated its 10^th anniversary.

In an anti-drug conference held in Moscow recently, Russian President Dmitri Medvedev called for an a more globally unified effort to end the drug trafficking of opium from Afghanistan and the social problems that are a direct result from its trafficking. With over 90% of the world’s opium originating from Afghanistan, President Medvedev believes that that current efforts by international organizations such as the United Nations, NATO and Shanghai Cooperation Organization, are not enough. Opium poppies are the raw material used to make heroin.   According to the U.N. Office on Drugs and Crime, heroin has created a market worth $65 billion and caters to 15 million addicts world-wide.

The effects of Afghanistan’s 375 ton per year opium and heroin export are also felt at home through direct use and passive exposure such as  second-hand and third-hand exposure.  A new study that will be finalized this summer is expected to show that in Afghanistan 1.5 million people out of a total population of 30 million are addicts and that a quarter of those users are thought to be women and children.

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Four months after the earthquake in Haiti, it is being argued that the poor are receiving better healthcare than before the quake due to the influx of medical volunteers and donated medicines, working under the supervision of the Ministry of Public health and Population.  In an effort to address the question of what will happen after the foreign medical aid leaves, the Post- Disaster Needs Assessment estimates that the earthquake resulted in US $169 million in damages to health infrastructure alone and in addition to that, their three-year plan to improve the country’s health profile beyond pre-January 12th levels will cost US $546 million. Currently, “Outside medical organizations are now the backbone of Haitian medical care,” says Dana Van Alphen, regional adviser for disaster management at the Pan American Health Organization who has been involved in discussions with a Haitian presidential health commission. In an effort to make these improvements in access to healthcare permanent, the PDNA identified primary health (along with  adequate  follow-up) and the establishment mobile clinics and health centers as a means to provide universal access, quality services and essential medications. This would allow care to be available nationwide instead of concentrated in Port-au- Prince.

The PDNA also recommends a massive investment in training for Haitian medical professionals because it is believed that now that the need for urgent care has subsided and the consequences of the earthquake are no ;longer front page news, the influx of foreign health professionals is fading. This transition would include pairing Haitian medical personnel with foreign staff for training and transferring functional control of hospitals and clinics to locals.

To begin the process proposed by the PDNA, a company called Containers to Clinics will transport a ready-made clinic, which will be transported in two pieces to the grounds of Graces Children’s Hospital in Port-au-Prince . The clinic is set to leave Boston around May 15 in a truck, which will haul it to Brooklyn, New York, where it will be loaded on a freight ship and be set up by June.

Please follow this link to read an executive summary of the PDNA.

Many news articles have been written recently on the increase in the prevalence in chronic diseases across the globe.  Rapid economic development is seen as one possible cause of the swift spread of chronic diseases in the developing world.

Let’s take the increase in the prevalence of Diabetes Type II for example. China has nearly 250 million and India has about 50 million people with Diabetes and prediabetes.  It is estimated that by 2030, 366 million or 6% or the world’s population will have Diabetes. This condition has two different modes of contraction, one for the wealthy, mainly being obesity resulting from over-nutrition, and another for the poor via changes in the amount of exercise and diet that once consisted mainly of vegetables but now has switched to foods that are high in sugar, salt and fat.    The change of diet is a direct result of the increase in the numbers of people moving from villages to cities in search of work.  A study found that the influence of urbanization and change of living habits have a greater influence than genetic predisposition for  determining whether a person develops Diabetes Type II, these migrants were twice more likely to have hypertension and to have higher blood sugar than villagers.

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Join Commit in September @ commitinseptember.com

This is my first blog post on the Global Pulse Blog.  My name is Sam Vaghar and I manage the Millennium Campus Network (www.mcnpartners.org), a national non-profit network of university student organizations working to reduce extreme poverty and achieve the UN Millennium Development Goals.  The network spans 17 campuses across four cities and counts Dr. Paul Farmer, Dr. Jeffrey Sachs, and musician John Legend among its Board of Advisors.

I’ll save an explanation of my passion for student activism for another time.

Right now I want to invite you to add your name at www.commitinseptember.com, a new national petition to President Obama and Congress urging action on the UN Millennium Development Goals (MDGs).  We have put in specific asks on global education, global health, and long-term development in Haiti.  Our goal is to generate 25,000 signatures by the end of July and present them to White House and Congressional staff ahead of the UN MDGs Summit this September.

Why this matters: This generation is passionate about global health and development.  When you walk onto most college campuses, you will find a student organization (or five!) committed to raising awareness, fundraising, or engaging in service work overseas in solidarity with the world’s poorest communities.  But our leaders in Washington aren’t always aware of our generation’s passion.  Commit in September is one powerful way for all of us to show them what we stand for. We are calling on students to partner with us this year, signing the national petition, writing a letter to the editor, becoming a Campaign Ambassador (visit the site for info.), and joining with us, the United Nations Foundation, 1,000 peers and leading advocates at our conference this September at Columbia University on the eve of the UN MDGs Summit.

Together, our generation can build a grassroots movement for global development.  But we’ve got to get personal, reach out across our networks, and use all means available to create both social and political change.  I know many members of AMSA are leading the charge for global health equity, and I hope you will partner with us in this effort.  Please leave a comment so I can connect with you in the days and weeks ahead!

PS- It is a real pleasure to be joining this blog community.  I have been impressed by AMSA’s commitment, particularly in the advocacy arena, and the opportunity to connect with all of you means so much to me.  Hana, thanks for the invite!