UNC in Nicaragua: a forward-looking program that will “hold us accountable”

By Kim Gazella

The Nicaraguan mother was frantic, her baby gasping for breath. They had been at the clinic the day before, but the antibiotics didn’t seem to be working. The clinic, staffed by UNC second-year medical student Andrew Chen and a UNC pediatric medical resident, was short on medication. A last-ditch option was to give the baby epinephrine through a nebulizer, but the electricity was out, the battery hadn’t been charged and a search for diesel fuel for the generator had been futile.“We remembered a radio station in the community, and I’d become friends with the disc jockey there,” Chen recalls. “So we asked if we could bring a patient into this radio station, because we needed electricity.” The station was nothing more than a tiny room with an old computer and a small couch – the size of a large closet in the United States.

“We plugged in the nebulizer and got 10-15 minutes of medication to the baby,” Chen says. Then the fuse on the nebulizer broke.

One hospital was five hours away and across a large river, the other, a three- to four-hour bus ride on a rocky road. The bus had already left. “We tried to get [the mother] a ride and couldn’t, so we told her to catch the next morning bus. There was nothing else we could do,” he says.

Opening students’ eyes

CSHI participants, summer 2008

Adequate medical care is a constant struggle for millions of Nicaraguans, especially those in rural areas. UNC medical students are learning about the challenges first hand through a unique exchange program between UNC and the University of Nicaragua – Léon (UNAN). Chen was one of seven UNC medical students in the program in summer 2008, and he says the experience solidified his desire to work in international public health and, particularly, in community health (Chen recently returned from the summer 2009 program).

Learning more about other countries’ health needs is an important aspect of the program, says Douglas Morgan, MD, MPH, director of the UNC Center for Latino Health. He says the program benefits students in several ways, including teaching them about diseases they would not see in the U.S. and augmenting their medical Spanish skills. More importantly, he said, it expands their knowledge of and approach to health systems.

“It helps to open their eyes to global health care needs, and exposes them to a different health system and different way of doing health care in the clinical setting,” says Morgan, who also serves as director of the UNC program in Nicaragua.

UNC joined forces with UNAN in 1999 after Hurricane Mitch demolished much of Nicaragua’s Atlantic Coast side. The collaboration began with service and teaching initiatives, followed by research initiatives in 2002 that focused on gastrointestinal disease, renal disease and women’s health.

Last year, the UNC students teamed up with their Nicaraguan counterparts to begin a health survey project in the country’s Sahsa region, an area of 50 villages located in northern Nicaragua. In addition to the students, the team includes professors from both UNC and UNAN, along with health promoters in the communities. UNC sent three professors, two medical residents and seven second-year medical students. This relationship – having faculty and students from both countries – makes the project both unique and sustainable, Morgan says.

“You have faculty from both sides, and students from both sides, and the research is ongoing throughout the year,” he says. “So it’s all integrated and sustained, and we’re not just parachuting in for a short time and then leaving without having done meaningful and lasting work.”

While the collaborative relationship between the universities began in 1999, the Sahsa project was born more recently. After Hurricane Felix ripped through the country in September 2007, the University of Nicaragua was a first responder for disaster relief, concentrating inland rather than at the coast.

“The hurricane did not cause loss of life so much as it underscored the chronic health care needs of that area, so UNAN decided to establish a permanent presence there, rotating faculty and students,” Morgan says. “We fit into the research service and teaching piece, and when I was talking with them about what we could do, that’s how Sahsa was born.” Morgan is referring to the Collaborative Sahsa Health Initiative (CSHI), the formal partnership between UNC and UNAN which seeks to advance health in that region through combined service, teaching, and research missions.

Learning firsthand about health care needs

Students administer the health survey outside a woman’s home

Last summer, the students from both universities formed teams with local health promoters in the region and fanned out to survey women in their homes about their health histories and health care needs. The students work in the clinics part of the time, which gives them direct medical care experience, but the project’s practical side was the field epidemiology initiative: the health needs assessment.

UNAN uses GIS technology (geographic information system) to track the basic health needs survey and the diarrheal disease assessment. By integrating the collected household data into a map, researchers can pinpoint disease and health patterns, and better stage interventions or target solutions.

UNC medical student Kamal Menghrajani said she felt privileged to be welcomed into the people’s homes. In Nicaragua, about 80% of people live on $2 per day; in rural areas, the majority live on a dollar a day. Their homes are essentially wooden shacks with almost no furniture, dirt floors and livestock running in and out. Some homes have small benches or hammocks for bedding, but sometimes, as Menghrajani learned, four children in one house sleep on cardboard.

“We knocked on doors and asked the women how they were doing, how many kids they’d had and how many had died, and about the burdens of having maternal and child health care needs met,” she says. “It was really interesting to be in this privileged position and learning intimate details of their lives.”

Chen concurred, saying he found the people to be very open and forthcoming. Sometimes, the 15-20 minute survey would become an hour or more, just listening to people’s stories.

“It really struck me because if you think about being here in the states, if somebody knocked on your door and asked to sit down and ask personal questions about how many pregnancies you’d had, or whether you’ve had abortions or miscarriages, or how prevalent is diarrhea in your family, it would be very unlikely for anybody to allow you into their households,” he said. “But not once did we get denied to speak to someone in the household.”

For Mayra Alicia Overstreet Galeano, the visits were even more personal because she grew up in Nicaragua. The UNC medical student spent the first 10 years of her life on an island off the country’s Atlantic Coast; her family moved to the U.S. in 1985 to escape the political unrest after the revolution.

“For me it was great, because I always knew there’s an historically underserved region of the country, and it was nice to see the medical school there putting some resources in areas other than on the western coast,” she says, noting that has always been an issue in Nicaragua. “Getting to go into the homes and talk to people was really the best part.”

The lack of resources and access to health care made a deep impression on all of the students, as Chen pointed out with the story about the baby and the nebulizer. For Menghrajani, it was the case of a woman who had a large mass on her face, which she kept covered with a towel. It was difficult to know whether this was a case of domestic abuse or a medical concern. When Menghrajani’s team visited the woman, a UNC doctor instructed them to ask if her teeth bothered her.

As it turns out, she had tooth pain and had noticed a lump in her jaw. She went to the clinic, and staff referred her to a hospital that was 19 hours away by bus.

“They said it was perhaps lymphoma, and so they ran tests and said they would treat her if the tests were positive,” Menghrajani recalls. But while the woman could afford the bus far, she could not afford to stay near the hospital for the week it would take to get the test results. “She said she would go home and come back [for the results],” Menghrajani says.

Unfortunately, the hurricane struck, devastating the infrastructure and leaving the roads in shambles. The woman never found out the diagnosis, and she didn’t get treated. “She was so poor that even though health care in that country is free, she couldn’t get the care she needed,” Menghrajani says.

So the home visits, Menghrajani says, add depth and a human side to the research, and she believes that this aspect will lend credibility to the project.

“Seeing the health conditions there first hand, and then having the data to back that up, will allow us to actually do something about it,” she says. “It will give us a baseline to use in the future, so we can tell if we are making progress.”

Ultimately, she says, “this program is very forward looking and will let us hold ourselves accountable.”

A new way to think about medical careers

A typical dwelling in the Sahsa region of Nicaragua

Living in the United States and spending time in Nicaragua can profoundly change a person’s outlook, mainly because Nicaraguan poverty is somehow rawer, more searing, more in-your-face than American poverty. Just ask the UNC medical students.

“Their poverty is different than in the U.S.,” says Menghrajani. “I now know how lucky I am and do not want to waste the opportunity to be a doctor. There, they are lucky to get a 3rd grade education. Here, the public is effectively paying for me to become a doctor (because UNC is a public university). So it is very humbling to see these situations and not waste what has been given to me.”

She says that often when medical students begin exploring specialties, the “mentality is to make the most money.” But after her work in Nicaragua, she says she is looking into fields where she can be of most use.

“When I think about it now, I am asking myself if this is a field where I can spend holidays or extra time going abroad and applying those skills to helping others,” she says. “It is definitely a shift for me.”

Chen says he not only solidified his career interest in public and community health, but realized that projects and relationships are the keys to success. For instance, he says that teaching people to build latrines would have an immediate and lasting impact on their health. (In Nicaragua, many deaths are caused by malnutrition, diarrhea and pneumonia; at least 50% of Nicaraguan school children suffer from intestinal parasites.)

“I have done a little work abroad before, but not as rural as this,” Chen says. “I always knew I was interested in public health, and this reassured me that I want to pursue international health, public health and community medicine. But I also now understand the importance of the sustainability of projects from a community health aspect, and the importance of building and sustaining relationships.”

As for Overstreet Galeano, the native Nicaraguan, she says she always hoped she would be able to return there to work one day.

“I do go back and spend summers and holidays there, but this is the first time I have been able to work there,” she says. “I am hoping to work on community and family medical issues, ideally along the Atlantic Coast area.”

All three students returned to the Sahsa again this summer, and CSHI expanded to include nursing and public health students, in addition to the medical students.

Morgan, whose passion for global public health started during his days as an engineer in the Peace Corps in Honduras, admires the energy of the students and understands the key role that they play in these efforts.

“Much of this project was driven by students” he says. “Their enthusiasm and energy were the motor of this project, and important to help jump-start a permanent assessment system there. Our students were key.”