House calls are not just a thing of the past. This is just one of the things I learned from my month in the Puerto Plata province of the Dominican Republic (DR) this spring during my global health clinical rotation.
It rained daily the first week as we walked in the muddy dirt streets on the way to the villages to see patients, and I vividly remember some of the sights that we passed.
  • A dead dog on the side of the road one morning.
  • Half-naked children playing in the mud.
  • A woman walking with a massive bowl of peanuts balanced precariously on her head.
  • And as always, children asking for pesos.
I remember thinking as I walked how very different it was practicing medicine in this rural country, as compared to what I had been doing in my other rotations in the US.
The home visits were conducted with patients in the Chronic Care Program of Health Horizons International (HHI), a US-based non-profit organization that works towards providing access to sustainable, quality health care in impoverished communities of the DR.
Two of my classmates and I were welcomed onto their mixed team of American and Dominican staff. They have developed a unique model that provides continuous health care to the communities that they serve with the combined approach of a community health workers program, regular US medical staffed service trips, and various public health research and development projects.
HHI is based in Montellano, a town on the northern coast of the island that was built up around a once thriving sugarcane refinery. The refinery’s closing has created a large unemployment rate that has led to poverty for many, most obviously seen in an area on the outskirts of the town, called Pancho Mateo.
Pancho Mateo was initially a barracks, or batey, that was constructed in the early 1900s to house the Haitian migrant workers and their families. It has now developed into an overcrowded community of an estimated 2,000 poverty stricken Dominicans and Haitians that suffer frequently from infectious diseases including dengue fever, intestinal parasites, and a recent cholera outbreak.
There is also a high prevalence of chronic conditions in this community, as well as in the three rural villages that HHI serves in the mountainous inland. Such conditions as diabetes, hypertension, hyperlipidemia, asthma, and epilepsy are difficult to treat in these areas with scarce access to medical care. HHI recognized the need for these conditions to be managed with a continuity of care that was not previously available.
Working towards this effort, HHI has trained more than thirty locals to be community health workers, or cooperadores, in their communities and provide basic primary care and patient education.
One of my roles was to assist the cooperadores with the home visits. I also participated in field screenings in these communities for unrecognized patients with hypertension and diabetes, so that they could be identified before the medical service trip (MST) the following week. HHI sponsors MSTs three times a year, each involving a week-long series of primary health care field clinics. At these clinics we examined and treated all of the current patients and over a hundred other people with acute or emergent issues.
Other tasks involved coordinating appointments with the specialists, accompanying patients to the appointments, following up with the patients after the MST, and communicating the results with the providers that had gone back to the US. We were kept busy, but I always felt that for as much as we were doing, I always wanted to be doing even more, for the need was great and it was ever more personal the more that I grew to understand it.
One of the most difficult parts of the experience was the provider and staff meeting at the beach at the end of the MST. For the patients that were found to have severe disease states that needed additional testing or imaging, or additional medication, surgery or other specialist care, we had to triage their cases and decide if HHI could provide them with further assistance. In the US, triaging means sorting out which patients need treatment now versus waiting.
In the DR, triaging meant sorting out which patients got treatment at all and that was a difficult process to be a part of. Besides the medical system of the DR, I learned about the people, culture, and way of life in this country. We grew accustomed to speaking Spanish daily, hand washing our clothes, traveling on motos up into the mountains and riding on the guaguas to the cities.
We grew close to the patients, the cooperadores, and especially to the HHI staff. Even the things that once seemed strange became commonplace to me by the end of the month, such as the cows grazing on the side of the road, the cockroaches in the buildings, sleeping under mosquito nets, falling asleep to the sounds of the dogs barking in the streets, and waking to the crows of the roosters.
The one thing that I couldn’t get used to was seeing firsthand the social and economic disparity for the undocumented Haitian immigrants that are without rights in the DR. For them there are even greater obstacles to employment, education, and healthcare. Nothing could have prepared me for the feelings that I had watching over a Haitian patient who had no one to care for her in the hospital or working alongside a Haitian cooperadore that I had grown close to and respected, knowing that he was not considered an equal among the Dominicans.
This global health rotation has expanded my perspective on health care in other countries and has given me a deeper understanding of the significant disparities that exist in many aspects of life for underserved populations around the world. Therefore, I believe that this experience will contribute to my cultural competency as a PA. It has also fueled my desire to work in primary care in an underserved area and to continue to travel, hopefully making it back to the DR again someday.
A common answer to almost any question in the DR is “Si Dios quiere”, which means “If God wants it to be”. While I still do not truly understand how people will not answer for themselves and can just leave it up to God as to what will happen, I do know that the future is uncertain for us all. And no matter where I end up, I hope to take this experience with me to help each of the patients that I encounter in my future career “si Dios quiere”.
This article was originally featured in the PAGH Nexus Newsletter June 2012.
A Student’s View: Puerto Plata Province, Dominican Republic
by: Kate O’Connor
Quinnipiac University PA Student Class of 2012
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