Health-care team looks to sustainable solutions for an impoverished people
by Jack Chase, M07

Rural fires gave way to city street lamps below us as we descended through the dusk toward Managua International Airport. Our group of eight Tufts medical students was going to provide acute care for a month in the RAAN, the North Atlantic Autonomous Region of Nicaragua.

Members of the Tufts medical team walk down the main road in Coperna, a town in the North Atlantic Autonomous Region of Nicaragua where they provided care.

In the plane’s hold were eight plastic crates sealed with duct tape. Inside were medicines bought with donated funds, diagnostic equipment, educational handouts in Spanish and even tarps and rope to construct extra exam rooms. Into those crates had gone months of research, planning and late-night meetings. We hoped they contained the answers to all the illnesses we would encounter.

We worked with Bridges to Community, a New York-based NGO, and MINSA, the Nicaraguan Health Ministry. Joining us were attending physicians from Tufts School of Medicine, a Tufts engineering student, students and faculty from Tufts School of Dental Medicine and other volunteers.

Like most American medical students, we have been raised in communities of relative wealth. We have had the privilege of years of education. We have been instilled with the belief that we can find a treatment, and usually a cure, for any illness. What we hadn’t predicted was that the most pervasive illness in Nicaragua doesn’t respond to medication.

Each morning as we arrived at the clinic, our patients were waiting—usually 20 or more. They ranged in age from newborn to more than 100 years old. Some had walked from communities 12 hours away to get to our clinic. Babies were carried in arms, and the elderly walked with canes in temperatures that often exceeded 95 degrees. Yet despite distance, heat and illness, our patients were waiting each morning.

Over the course of a month in February, our team cared for more than 2,000 patients. We saw epidemics of back pain caused by long days of working the fields; waves of diarrhea and intestinal parasites caused by tainted water supplies; thousands of teeth rotted by decay and hundreds of children who had fallen off the growth curve as a result of malnutrition. We provided common remedies: ibuprofen for musculoskeletal pain, albendazole for parasites and vitamins and protein supplements for malnutrition. Tufts dental students and faculty performed extractions and distributed toothbrushes and toothpaste.

These treatments work in the moment. But it’s hard not to feel a sense of futility in giving 30 ibuprofen tablets to a patient who has walked 10 hours to seek treatment for back pain, only to arrive with leg pain as well. Even when we could treat a problem definitively—like giving antibiotics to kill pneumonia-causing bacteria—we knew these same illnesses would recur. And when they did, we would already be gone, the clinic might be empty and the community would be no better off.

Negar Aliabadi, M07, and Myriam Salazar, an interpreter with Bridges to Community, with a young patient in Mongallo, RAAN

Hard choice
Some of our patients had potentially curable diseases, such as colon cancer, Graves’ disease or congenital heart defects. Despite the opportunity to receive free care in the national health ministry hospital in Managua, our patients couldn’t afford the trip. The cost of a round-trip flight to Managua is about $127 U.S.—roughly four months’ income for a resident of the RAAN. Patients often have to choose between medical care and feeding their families.

It doesn’t take long to realize that the root of most illness in Nicaragua is poverty. It is the second poorest nation in the Western Hemisphere, behind Haiti. The yearly per-capita income is $900, and more than half of the people live on less than $1 a day—the World Bank’s definition of extreme poverty. More than half the population lacks adequate sanitation facilities. Ten percent of Nicaraguan children are moderately to severely malnourished, and 20 percent suffer from severe growth stunting.

Each patient we saw was a reminder of the human toll of systemic poverty. The staggering prevalence of patients with diarrhea and suspected intestinal parasitism results from a lack of potable water. Most women and girls live with severe neck and back pain because without plumbing, they need to haul water from local rivers. (Imagine if you had to lug all the water you use each day in a bucket for half a mile. Five gallons, the amount you’d need to flush your toilet once or take a short shower, weighs about 40 pounds.)

Chronic musculoskeletal pain is rampant among men and boys who spend 14-hour days chopping grass with a machete—a prerequisite for slash-and-burn subsistence farming. Malnutrition is widespread because people don’t have the money purchase or grow nutrient-rich foods. Many rural families cannot afford enough staples, such as rice and beans, to adequately feed their children.

The Nicaraguan government simply doesn’t have enough money to keep clinics open and supplied with doctors, nurses and medication. Two of the clinics in which we worked had been closed for years prior to our visit in February, leaving entire communities with no recourse.

A group of community health leaders (lideres de salud) and midwives (parteras) was given health-care supplies, including bandages, iodine and gloves, for use in caring for residents of remote areas of the RAAN.

The long haul
In places like the RAAN, acute-care clinics need to be supplanted by sustainable solutions. And so we looked for some longer-term solutions to improve community health. We piloted informal “porch talks,” an opportunity for residents to ask questions and to learn about illness prevention and symptom relief that might alleviate the need to walk six hours to a clinic. To begin to create a primary-care infrastructure for distant villages, we held workshops with community health leaders and midwives on topics ranging from prenatal care to water purification. With colleagues from Tufts’ Department of Civil and Environmental Engineering, we tested local water sources and surveyed residents about water access and water-borne illnesses.

Our work in Nicaragua would not have been possible without our Bridges to Community colleagues, many of whom were born and still live in the RAAN. They worked as administrators, translators and cultural brokers, facilitating our work in the clinic. In the evening, after our clinic day ended, the Tufts and Bridges colleagues ate dinner in local homes and discussed the challenges we faced.

We have not forgotten the lessons we learned in Nicaragua. We are developing a public health initiative for Tufts’ future work in the RAAN, focusing on community health leader training, radio-broadcast general health education, transportation for rural residents to health ministry hospitals, nutritional supplementation and access to urgent care services. The initiative will expand our collaboration with Bridges to Community, MINSA and other community-based organizations working in the RAAN year-round.

We have come away from this trip having taken a first step toward understanding the challenges that face Nicaragua, and other resource-poor nations, in the establishment of a comprehensive, universal health-care system—a goal that has eluded the United States, despite of all of its resources. Each next step will give us a clearer view of the problems that we face as health-care providers, both domestically and internationally, in the hope of providing all people worldwide with access to the basic human right of health care. These are the steps of a journey that will take a lifetime. We have taken that first step.

The author (holding the baby) and Dr. Brian Lisse, clinical assistant professor of public health and family medicine, celebrate with a new father in Campo Uno on Valentine’s Day, when his son was born.

Jack Chase received his M.D. from Tufts on May 20 and is now pursuing a residency in family and community medicine at the University of California at San Francisco. Next February, he and his classmate, Kristin Anderson, M.D./M.P.H. ’07, will return to the RAAN with the 2008 Tufts medical team. For more information on Tufts’ work in Nicaragua, or to support the project, contact Linda Smith in the medical school’s Office of Student Affairs at 617-636-6568 or e-mail Linda_J.Smith@tufts.edu. This story ran in the June 2007 Tufts Journal.