Going the Distance
Caring for 1,000 patients in three days among Nicaragua's remote mountains-long hours, organized chaos, and good conversations-taught students what it means to bring compassion into the clinic.
Global Health Brigades (GHB) at Jefferson was born out of a series of relationships.
Stephanie Kahn, the group’s founding vice president, had spent two years between undergrad and medical school working as an educational coordinator and research assistant with Jefferson Pediatrics/Nemours duPont Philadelphia.
“I got to know Stephanie pretty well,” recalls Esther K. Chung, MD, MPH, professor of Pediatrics and GHB faculty co-advisor. “So when she was accepted to Jefferson, I floated the idea of creating a student-led global health initiative.” Kahn’s response was a resounding “Definitely.”
Global Brigades, the parent organization of GHB at Jeff, was founded in 2007 and maintains a permanent presence in each country where it is active (Honduras, Panama, Ghana, and Nicaragua). It plays the role of connector, bringing together visiting medical volunteers and native caregivers to enable long-term engagement with the needs of host communities. Typically, trips to a given community occur every three months and last for about a week, encompassing aid areas like engineering, law, and microfinance, in addition to health.
It just so happened that one of Kahn’s fellow first-years, Emily Bollinger, had volunteered with the organization in college and relished the opportunity to continue serving, this time as president of Jefferson’s Brigade. Together, the two set about pulling together bylaws, talking to global health experts at Jefferson, and recruiting.
“Your big time to do research or to do something that’s not medical school is between your first and second year,” says Kahn. “You get about 10 to 11 weeks, but there aren’t a lot of abroad programs that offer a short-term option. GHB is a great opportunity for students who still want to travel but also want to do research.”
Bollinger and Kahn cast their net wide in an effort to attract an interprofessional group of medical, OT/PT, and pharmacy students, as well as a cohort from the Philadelphia College of Osteopathic Medicine. On the alumni side, Kahn’s mother, Michele Christie, MD ’84, and Frank Konzelman, PharmD ’13, also accompanied the group as clinical supervisors.
Among the experts whose advice they sought was Nick Leon, PharmD, associate professor of Pharmacy and co-chair of Jefferson’s Global Health Initiatives Committee, who had been a part of past Brigades, volunteering as a kind of free agent whenever his schedule permitted. As it turned out, he had time to serve as a faculty co-advisor with Dr. Chung for the Jefferson chapter.
“This is not helicopter medicine,” he says. “GHB will only go somewhere if they think they can offer continuity of service to the community.”
By the time spring 2017 rolled around, the group had done its homework and TJU officials gave their blessing to GHB. Planning began in earnest.
There were funds to raise—to cover airfare, living expenses, and buying medicines in-country—and a long list of supplies for care packages: 1,800 toothbrushes, toothpaste, soaps, shampoos, and other items. Brigade members solicited local businesses, friends, and family in order to meet their goals, receiving the full complement of essential supplies by the time GHB at Jeff was ready to go wheels up.
On June 4, the group flew into Managua, Nicaragua’s capital and only major city, and got oriented for their time in the country—organizing medicines, meeting their Nicaraguan counterparts, and acclimating to the heat. Work started early the next day.
Each clinic day began before dawn with a bus ride from their base in Estelí over the narrow roads leading to Puertas Azules and El Cebollal, the communities where the Brigade saw patients until well into the evening.
“The first day we went out into the country to Puertas Azules, there were hundreds of people waiting for us when we arrived,” says Bollinger. “Some had walked for hours just to be seen by our team.”
Business hours were a frenzy but provided ample opportunity for hands-on learning and meaningful patient interaction.
“I don’t speak any Spanish beyond some medical vocabulary,” Bollinger says, “but I was still able to build relationships with my patients through translators and by just taking time to be present.”
Every student managed a carefully delineated piece of the puzzle, from triage to dispensing medicines, rotating through each station to gain a wider perspective on their work.
“The whole thing is highly choreographed,” says Leon. “It’s set up so that after families have been seen and received their scripts, they go to a public health talk given by someone in the community, while our pharmacy team organizes the medications.”
This routine repeated every half hour and ultimately enabled the Jefferson Brigade to see 980 patients over three days. Evenings, after the dust settled and the Brigade was back at its base, were for reflection. Did you keep running into particular challenges? What kinds of illnesses were we seeing?
Among the most frequently heard complaints were respiratory illnesses and GI issues—caused by dirt floors and limited access to clean water. “Seeing all these cases and talking to the people, you quickly make a connection between health outcomes and social factors,” says Kahn.
Using Global Brigade’s in-house EMR system, students will be able to spot the signs of success such as a shift from acute-type illnesses to more chronic problems that can be effectively managed. As other volunteers work to provide better access to clean water and housing, Brigades like Jefferson’s bridge the gap between this wider context and the concrete behaviors—like dental hygiene and nutrition—that create a healthy community.
As Chung describes it, the disparities students are encountering in Central America are of a piece with what’s happening in Philadelphia’s underserved ZIP codes—the product of a complex mixture of poverty and a lack of resources. (See sidebar on the Philadelphia Collaborative for Health Equity on page 21.)
“They’re seeing how family and community matter to people who have very few material comforts,” says Chung. “And maybe more importantly, they’re learning ‘soft skills’ like humility and how to ask open-ended questions, which really prepare them to work in situations—the real world for instance—where patients are the best teachers.”
The week sped by, but the team’s experiences made the flight back home with them.
The people they met and the connections they made are shaping how Jefferson’s Brigade members think of themselves and their future as doctors. They are more attuned to the systems that empower—
and hamper—their work and are more sensitive to the impact a single person can have in delivering care or just brightening the day.
For now, Bollinger and Kahn are in the midst of prepping for Step 1 Board exams and will be handing over the reins of GHB at Jefferson, but not without helping to set the agenda for future Brigades.
“We want to have our members undertake a year-round engagement with these issues through speakers and other volunteer work,” Bollinger says, “It’s important to prepare, so we can hit the ground running.”
By Zach Nichols