Chaguite, Cuje, Clinic

We have worried about the value of our annual clinic since we first opened the doors in 2007.  We intended NOT to be a duffle-bag medicine project—arriving with U.S.-based notions about what our patients might need and dropping off short-dated medicines in small quantities.  Eight years later, we’re still trying to find ways to make our clinical efforts smarter, better founded, more integrated with local medical and health efforts, truer to the needs of our partners.  We are encouraged by this year’s meeting with Dr. Blanco.  We hope that our evolving relationship with the Totogalpa clinic will allow us to be more strategic and more attuned to needs defined by those who have responsibility for providing health care on a continuing basis.

Our community-based approach inclines us to learn as much as possible from those who live in the communities we intend to serve with health care efforts. Our work in Chaguite has provided us with systematic information and increasing understanding of the health and health care needs of residents of that community.  We know better than to generalize these understandings to residents of the remaining communities that comprise Cuje—the micro-region served by our annual clinic.  We envisioned a Cuje-level Comite de Salud (CdS; Health Committee) that would comprise representatives of residents of each of the communities.  We imagined collecting information from brigadistas in each of the communities and we hoped that we might, through snowball sampling and sociometric techniques, identify such a group as a start for consulting with residents about ways to make our clinic more responsive.

In pursuit of that goal, we reprised our satellite-sites approach to the annual clinic this year.  The objective was to take each day’s clinic as close as possible to the geographic center of the remote communities of Cuje.  Working from those locations, we would dispatch team researchers to conduct interviews with the communities’ brigadistas and with members of randomly selected households to identify community residents who might be (1) interested in participating in discussions about improving the clinic services; (2) trusted to represent residents’ beliefs and needs.  After the first day’s efforts, student researchers reported that there is something wrong with the questions we’re asking or with the respondent-selection process.  Respondents usually were able to identify their community’s brigadistas or other leaders, but they routinely reported that these people did not represent their interests, did not understand their needs, and did not work with them or on their behalf.  We tweaked the questions and the general strategy and tried again the next day.  The results were unchanged.

None of the students on the current MANOS team participated in the first round of interviews in Chaguite.  We were asking very similar questions then—and we got answers very similar to what we are hearing this year in other communities.  That seems nearly impossible to believe now and, seen from our now customary view of collaboration in Chaguite, these other communities seem desperately (1) unfamiliar (because they are) and (2) lacking in social infrastructure (which they may be).  I have the benefit of historical perspective.  I recall residents of Chaguite who were able to identify two or three key leaders (some of whom were brigadistas) — and I remember the same residents saying that they do not work with these leaders and that these leaders do not represent their interests.  I remember the leaders saying that they try to hold community meetings but that residents will not attend and will not collaborate in projects with potential value for the whole community.

This year’s effort to “sample” our way into some rough understanding of the other communities and their social infrastructures was a well-intended effort to find a short-cut for gaining information from residents throughout Cuje.  We want to hear their voices as we think about how our clinic can be more than duffle-bag medicine.  At this moment, it does not appear that there is a short-cut, no substitute for the years of work in the community, on the ground, in the homes, working with good social science methods to learn, using the resulting information and knowledge to build relationships.

Dr. John Showalter (M.D., Knoxville, TN) played a significant role in our follow-up conversation with Dr. Blanco (Totogalpa Clinic Director).  His understanding of our approach and shared frustration with the apparent limited value of our annual clinical efforts were crucial to the discussion.  Speaking medical professional to medical professional, Dr. Showalter was able to convince Dr. Blanco of our determination to be more than another itinerant bunch with good intentions.  We will do all we can to build on this step forward.

Dr. Showalter joined us at the end of the week in two additional meetings, one at a medical school in Managua and the second at the American Nicaraguan Foundation (more on that in a later post).  Through inquiries by Kristina Ripley, we have been in contact with a professor of medicine at this university.  We toured the medical school, talked briefly about our projects in Cuje, and learned about our host’s interests in extending health services to the under-served in Managua.  Dr. Showalter inquired about good strategies for short-term, annual clinical projects and about sources of medicines that would be appropriate for the Cuje population.  His participation in the discussions clearly elevated the seriousness with which are efforts are regarded by this local medical professional.

Baby steps—but they seem to be in a good direction.  We don’t know yet how to make our clinic more responsive and more responsible.  We’ll add more research on brigade and short-term, international clinical approaches to our work for the remainder of the semester and it will top the list of topics for next fall’s seminar.