Day Five: Orientation to Pequenos Pasitos

It is hard to know where to begin with this post. We went today to visit Pequenos Pasitos, a small clinic and community center located in the hills near Santiago. For 6 years, Brown has had a close connection to this clinic, supplying both a supply of medical personnel and students interested in sustainable development to the area.

Prior to arriving, we were told that this clinic would be a key way to see how Internal Medicine was practiced in developing country. Among the learning objectives in particular was observing how chronic diseases such as diabetes and high blood pressure were treated in remote areas with no access to medical care. I had wondered how this would work. Prior to this, the only experience with chronic disease I had had was in the U.S., where patients were told to come in for check-ups every 3-6 months to see how things were going. Admittedly, I had a hard time seeing how treating chronic diseases would work without this framework.

Turns out things weren't as put together as I had initially thought.

So we set out around 7:30a.m. in the morning on a GuaGua bus, ready for 40 minute drive up a foot of a mountain. Our team, which at that point was comprised of 8 people, quickly filled up a vehicle. But just as I thought the bus was considered full, the driver would stop and 4 more people would enter. Partway through the ride, I ended up sitting next to an ice cream vendor from Haiti. Not having enough room to place his enormous cooler, he ended up placing it on top of his lap and part of mine as well. We had an interesting conversation, though I dared not bring up the topic of the recent earthquake given our brief time together and my difficulty in understanding his Spanish. Adam, who was my travel buddy from our first day together in Logan Airport, sat on my other side, dozing fifully. To my amusement, the ice cream vendor ended up asking if he and I were brother and sister! This is particularly funny when considering that I am full-blooded Taiwanese and Adam is Italian by descent...:-)


When we reached the main Pequeno Pasitos clinic and community center, it was mid-morning. The facilities there are absolutely incredible, especially considering that the people who started it literally had to build from scratch using materials that they had brought over from the U.S. They also built a school in the past year, on evidence that that higher rates of preschool education contributes to better maternal and childhood health outcomes.


Diego, the visionary founder of Pequeno Pasitos, then took us up the mountain for several homecare visits. The first was to a mother who had preeclampsia and who had given birth 12 days ago to a preemature infant by cesarian section. We trekked up the mountain, each carrying several bags of food, for quite some time, stopping briefly to catch our breath and to grab something to drink. When we finally arrived, we were greeted by an angry dog and a naked two-and-a-half year old boy playing outside a fairly disheveled-looking hut. His mother was inside, keeping house and watching over her new child. We greeted her, gave her the foods, and proceeded to check up on how she was doing. Michael, one of the other students, took out his stethoscope and took her blood pressure. It was still elevated, but the mother seemed otherwise well. Dr. Gould, our attending, wrote a script for atenolol to control the blood pressure and reassured the mother that everything would likely return to normal in a few weeks.

The baby, too, was doing fine and sleeping soundly. After checking up on the incision, Linda, one of the two med students interested in OBGYN, took the sutures out. We all took turns counseling the mother on nutrition and baby care before leaving her home and hiking to the next home.



At the next home, which was much further up the mountain, we stopped at the house of an elderly woman who had been newly diagnosed with high blood pressure and diabetes a year ago during the last round of homecare visits. Her blood pressure was still fairly elevated when we checked it. When we asked if she was taking her medication, she responded yes, but that she had just run out of pills a week ago. Dr. Gould then asked the group if we should increased the dose of her current medication, or if we were at the point of actually needing to prescribe another medication.

Throughout this whole discussion, Diego had been fairly silent. It seemed he could not contain himself any longer though. Right in front of the patients, we were told that because of severe financial constraints, the Paqueno Pasitos clinic was not able to provide any more medicine for adults. For the past several years, Diego had fought to support various groups of Internal Medicine doctors and medical students as they organized electives and missions to provide primary care for the remote villages. His efforts had helped many, but ended up being a drain on his initial mission: to improve the health and wellbeing of mother and their children.

The tension in our group was quite evident as we stood there in front of this woman's hut. On the one hand, we all knew that she was "unhealthy" by U.S. standards. After all, she had uncontrolled high blood pressure, diabetes, and was feeling occasionally short of breath doing everyday tasks. In the U.S., it would be considered sacriligeous to diagnose a patient with those diseases and not treat them. But on the other hand, it seemed wrong to start someone on a course of treatment--only to discontinue it suddenly when resources went dry. If that was the case, it surely seemed we were doing more harm than good.

Heading down the mountain, it seemed that everyone's momentum had been deflated. We came in thinking in our hearts that we would be "knights in shining armor." But it soon became clear that we walked into a situation far beyond our control.

We spent the rest of that afternoon back in our apartment, talking to one another over "El Presidentes" (the national beer of the Dominican Republic) about how best to help Pequeno Pasitos. It was apparent that going from house to house with prescriptions for high blood pressure pills was not an effective approach to help that community. While there, we saw so many other issues that seemed more relevant than knowing one's A1C or blood pressure numbers: for instance, access to nutritious foods, poor health literacy, hygiene.

Ana and I volunteered to be the first 2 students to participate in the Pequeno Pasitos home stay program with a family in the community. We start tomorrow morning. Although we do part time work in the clinic, it seems that our afternoons are free to do whatever projects we wish. I'm planning to bring camera and journal with me, with the goal being to listen and to collect stories from the people living there. Too often, their needs get caught up between organizational agendas, and I'm hoping to be able to get some good informal interviews (perhaps a casual community needs assessment) so we can break through that barrier.

Hopefully this will be the case. This story will undoubtedly continue next week...