EP39 OneWorld Health Internship in Uganda with Dr. Elizabeth Discolo, Sarah Bender and Felicity Duran

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I AM GPH EP39 OneWorld Health Internship in Uganda with Dr. Elizabeth Discolo, Sarah Bender and Felicity Duran

EP39 OneWorld Health Internship in Uganda with Dr. Elizabeth Discolo, Sarah Bender and Felicity Duran

Alexandra Arriaga: Hi and welcome to I AM GPH. My name is Alexandra Arriaga, and today we will be joined by Felicity Duran, Sarah Bender and Dr. Elizabeth Discolo. Dr. Liz is a medical advisor for the OneWorld Health organization. Felicity and Sarah are MPH students from the Global Health concentration who were recruited by OneWorld Health for a summer internship. Today, they will tell us more about their experience working with this nonprofit, as well as the biggest challenges they faced trying to provide high quality, sustainable health care in Uganda. Hi guys, how are you doing today?

Sarah Bender: Great, how are you?

Alexandra Arriaga: Could you please introduce yourselves?

Sarah Bender: Sure. I'll go first. My name is Sarah Bender. I am a dual degree MPH/MSN student, so I study both global public health and I'm getting my master's in nursing. I'm currently an emergency room nurse right now, and this is my last year at NYU.

Felicity Duran: Hi, my name is Felicity Duran. I'm a second year MPH student with a concentration in global public health and I'm currently a clinical research coordinator for NYU.

Elizabeth Discolo: Hi, I'm Liz Discolo and I am the medical advisor at OneWorld Health in Charleston, South Carolina and I am a physician and also have my master's degree in public health.

Alexandra Arriaga: Liz, could you tell us what is OneWorld Health and what is its mission?

Felicity Duran: Sure. OneWorld Health is a nonprofit organization based here in Charleston, and our goal is really to provide sustainable quality permanent health care to underserved nations around the world.

Alexandra Arriaga: Great. That's very cool. And Sarah, Felicity, why did you guys decide to join?

Sarah Bender: I first heard about OneWorld Health actually at NYU at a meeting they were having with one of its founders, Ed. He came to NYU to speak about OneWorld Health's mission and kind of what sets them apart from other non profit organizations that do similar things. I was really intrigued by their focus on sustainability because in my experience with global public health, I think that that's not focused on enough. So after Ed gave his talk, I came up to him and expressed interest in getting involved with OneWorld Health and it came about that as a last year MPH student that we have to do an applied practice experience and we figured out a way that worked for both OneWorld Health and myself as an NYU MPH student to make experience at OneWorld health my applied practice experience by traveling to Uganda.

Felicity Duran: I heard about this through NYU. I actually heard it because Sarah went to the conference and they actually shot out an email to the students and I was looking for an applied practice experience and this really interested me because it was very global health related and I have an interest in chronic illness and disease, so doing a study on hypertension in Uganda was very interesting to me.

Alexandra Arriaga: So what countries does OneWorld Health work in?

Elizabeth Discolo: Currently we're in Uganda and Nicaragua and we have four medical centers in Uganda. And then currently we have seven health centers in Nicaragua. And then we also have a mobile medical unit there. And right now we've been really happy with our presence in both of those countries. One place that we are expanding a little bit, given some of the civil unrest in Nicaragua right now, a lot of the Nicaraguan citizens have fled to Costa Rica. And so although we're currently still operating our facilities in Nicaragua, we're also considering expanding a little bit to Costa Rica to help serve that population as well.

Alexandra Arriaga: That's amazing. And approximately how many clinics would you say that you guys have?

Felicity Duran: We have in Uganda there are four full medical centers those all provide a full spectrum of care, primary care as well as OB and women's health services, pediatric services, inpatient surgery, the full gamut. And then in Nicaragua, we have seven facilities as well as our mobile unit. And those are more outpatient facilities that are focused more on primary care and family medicine.

Alexandra Arriaga: Wow, that sounds amazing. Sounds like you guys do a lot of good work. And so going back to Uganda, you guys made a trip there, correct?

Sarah Bender: Yeah, we went there in August of 2018.

Alexandra Arriaga: Oh, awesome. And what was the main burden that you guys focused on?

Felicity Duran: When we went to Uganda, we were focused on collecting baseline data for hypertension for OneWorld Health to create a protocol for them. And it's only the beginning of creating a protocol. It's going to take a while. But as of now, and even before then, there wasn't a lot of information that we could work on specifically for Uganda or Sub-Saharan Africa on hypertension. And it is a big burden on the country. It's one of the top contributing factors to loss of life. So we were told to collect information from the patients at mobile clinics based on their age, male/female, demographics and if they have access to health care and medication.

Sarah Bender: And I can speak to kind of for people that don't know hypertension is when your blood pressure is high. So medically, it's defined as a blood pressure greater than 140 over 90 and when you have high blood pressure, you might not feel it, but it can lead to chronic diseases like heart disease. It can lead to stroke, problems with your kidneys and premature death. So although hypertension isn't something that you might have symptoms of initially, it's very important to have a blood pressure that's less than 140 over 90 to prevent these chronic diseases.

Alexandra Arriaga: So was this your first time in Uganda for both of you?

Sarah Bender: Yeah, it was.

Alexandra Arriaga: Oh wow. And did you find any cultural differences that shocked you or any cultural differences that maybe just affected your work?

Sarah Bender: Yeah, it was definitely different. The culture is very different there, the people are very welcoming and friendly. We found out quickly that religion is very important to the people in Uganda. And we connected with them through establishing a relationship with the leading members of the churches. And we held most of our mobile clinics in churches. There's also just some subtle cultural differences such as nonverbal communication. Ugandans when they kind of want to say yes or they agree with something, they just give you a little bit of a head nod and it kind of seems like they don't understand you or you're not really sure what that means. So we had to get used to the fact that the little head nod that they give us meant that they are following and they understand and they agree with what we're saying. Versus in the U.S. they might say "yes" or "I understand" or something like that. And yeah. Let's see. I don't know if you want to talk about, you know, some of the wording that we used to talk to patients that we kind of had to change because it didn't translate well.

Felicity Duran: Right, so when we were collecting data, we did qualitative surveys, which means that we went up to patients, we had it written down and we asked them specifically the questions that we had, but we also needed to use interpreters because in Uganda there's many different languages and it could range from a few to more than 40 just in one region. So we used interpreters, but there was some wording that we had to change on the surveys so that the interpreters could translate it correctly. For example, we were told that patients wouldn't know hypertension or high blood pressure as those terms. They would know it specifically as pressure. So when we asked the questions to the interpreter to ask to the patient, we had to say pressure instead of hypertension or high blood pressure. And we also couldn't use the word clinic because there was no full understanding on what that was. We had to use medical center instead, because that was more of the equivalent in the region.

Sarah Bender: Another word I can think of, I functioned as a provider in the clinics, and the word hurt, like "where is it hurting you?" doesn't translate. So you have to say "where is it paining you?" Because when you say hurt to the translator, they literally have no idea what you mean, so you have to ask "what's paining you today" which was something that as a provider I had to get used to as well.

Alexandra Arriaga: Oh wow. But I think you guys, obviously you adapted quite well. You come back and you have all these little nuances down and you know exactly what you're talking about. That's great.

Sarah Bender: Yeah. When you see hundreds of patients a day, you quickly learn to adapt to make the encounters productive and making sure the patient can understand you well.

Alexandra Arriaga: Of course. And so now that we've talked about the cultural part, what would you say was one of the biggest challenges that you guys encountered there and how did you tackle them?

Sarah Bender: So just to give you an idea of what the day to day was while we were there, we did mobile clinic for five days and we went to three different locations. So we were in two different locations for two days in one location for one day. So we would wake up really early at around 5:30 in the morning and we would have our breakfast and we would leave on the road usually by about 7 in the morning and it was about an hour to two hour drive depending on the location, usually down some dirt roads. And we would have 6 to 10 vans with all of the clinic staff as well as all of our materials. And then we would set up and start the clinic and we would usually be there until right before dark. So around 5:00 or 6:00 and then we would head home. So you know, it's a really long day. It's very exhausting. We had to keep a positive attitude and also making sure that we kind of kept in mind our goals about collecting data as well as treating the patients because the patients weren't there to take surveys, they were there to get medical care. So we had to incorporate both. I think another challenge also is just all the emotional things that come with serving in a country like Uganda where there is a lot of poverty. Usually when we arrived at the clinics there would be over 200 to 400 patients in line at 8:00 a.m., meaning they camped out there overnight. They were waiting so long to get this medical care. It's their only chance to get medical care really for some of these patients. So just acknowledging that and acknowledging that we couldn't see all the patients who needed to be seen and there was such a great need was definitely challenging for us as a provider. And also just making sure that we saw all the patients that needed to be seen and treated them appropriately.

Alexandra Arriaga: So Liz, OneWorld Health creates 100% operational and self-sufficient centers. Can you tell us more about this model?

Elizabeth Discolo: Yeah, I'd love to. One of our founding principles was that we wanted to fill the gap between the government facilities, which everyone can go to, but often there's a very long wait time and sometimes there's lower quality of services there. And then between that and the private facilities that are usually too expensive for the majority of patients to utilize. And so we kind of wanted to fill that gap in the middle. The way that we do that through our clinics is by, we still charge a fee. It's not a free clinic or anything like that, but we charge a fee that's affordable to the majority of our patients. And within about 18 to 24 months, on average, we've been able to create 100% sustainability, which means that the fees that the patients are paying for their services cover 100% of our operational costs. And so that means paying the staff, running lab tests, getting x-rays, accounting for custodians and for clerks and everything that it requires to make a medical facility run. And so that's basically been the model and it's been really successful for us so far.

Sarah Bender: And going back to what you talked about, what you asked me earlier, why did we did decide to join OneWorld Health? It was really about that, what Liz just talked about, the operational and self-sufficient centers, because I've been on medical mission trips before and a lot of times it's kind of this parachute model where you come in and you provide really great care for a week and then you just leave with no followup. But one of the great things about OneWorld Health is that we are able to refer patients to the nearest medical center in Uganda that OneWorld Health has for follow up. So we would give them a month of medication for their high blood pressure and we would instruct them to go to the clinic within a month to see the doctor again, recheck their blood pressure and get more medications. So it wasn't just a temporary fix, you have sustainability in the country and the patient can continue to receive care after you leave.

Felicity Duran: Right. And then the mobile clinics can continue to fill in the gaps that haven't been filled in yet. So it's a really great model.

Elizabeth Discolo: And though the one thing that I would add to that, and those are both excellent points that Sarah and Felicity are bringing up. The other thing I would like to point out is that we have short term volunteers and that's what Sarah and Felicity were doing. But at our permanent facilities, we have all local staff, so they're all trained in country. They all live in Uganda or Nicaragua, whichever location we're in. And so we're also providing jobs to the community and helping train various medical staff and other people as well, cashiers, clerks, the people doing the construction of the facilities. We really try to create some community buy-in with that as well.

Alexandra Arriaga: Yeah, it seems like you guys are doing a great job at integrating everything and I think that, like you guys mentioned, the sustainability of the project itself is just what makes it so good. Because then it just means that it's going to be there for a long time and it's actually going to make a difference in the patient's health.

Elizabeth Discolo: Right. Thank you. That's exactly what we're trying to do.

Alexandra Arriaga: I'm very glad that you're doing it. To get things on a positive note, what was your favorite part of the trip?

Sarah Bender: I think my favorite part and one of the most rewarding things was just seeing how grateful the patients were to receive care. I was taking blood pressures on patients that didn't even know what a blood pressure cuff was that were well into their 50s, which you just wouldn't experience here in the United States. It was so rewarding for them to be so positive even if they waited in line all day just to be seen by a provider and have them be so grateful for the care and really feeling that you're making a difference, not only in the moment, but also being able to introduce them to what healthcare is and how to get more access to it through the OneWorld Health medical centers that are based around Uganda.

Felicity Duran: Yeah, and I had a few favorite things, so it's hard to choose but I was not in the provider's side. I was in the pharmacy side so I had a little bit of a different perspective. In those, I really liked the bonding experience that we had within our group and with the patients and that I got to learn how to calculate certain things in the pharmacy, like I know how to calculate suspensions, which are liquid medication for children, now. I never thought I would have to use chemistry again. And I also really liked the feel, like how happy the patients were. There was this one day that we came in to the church driving and the patients were singing and dancing and we have a whole video of that and it was very rewarding to see that and feel that. And I also really liked that one time where one of the patients tried to adopt me. She said "oh please come home with me, you'll be my daughter." And I was so touched.

Alexandra Arriaga: That's so sweet.

Felicity Duran: She's like "please, I'll feed you. Shower you with love."

Alexandra Arriaga: That's just too funny.

Felicity Duran: It was cute.

Alexandra Arriaga: After hearing this I've had a bunch of students now are wondering, "okay, how can I work with OneWorld Health?" So what can they do?

Sarah Bender: Yeah, I would definitely recommend for MPH students to be involved with OneWorld Health. They not only do these short term medical mission trips like Felicity and I were a part of, but in doing that we are also working towards delivering them data on hypertension. They do quality improvement and there is a huge area for public health within the organization. And what's great is that like Liz and other people that work there, a lot of them have their MPH, so they're great preceptors and mentors because they have the degree that you're trying to attain at NYU and they can kind of guide you in how to work on the project like we were working on with hypertension or whatever the need is for OneWorld Health. They can be a great mentor and guidance through your projects.

Elizabeth Discolo: Yeah. We're working on actively creating a long term partnership between OneWorld Health and NYU. And it's really exciting that they have a specific global health focus. And so, one of the other things that I think it was Sarah mentioned back in the beginning is that the research they were doing, it was kind of the first part of a multi-phase project. And so it's definitely something that's not, they did a fantastic job on starting, but it's something that's not finished yet because you honestly can't finish anything in a week or a summer or anything like that. And so it's something that we're going to continue and we're looking for interns from the NYU program to apply for next year to kind of do some of the next steps. And we have some other projects as well, but we're hoping to make it a long term relationship.

Alexandra Arriaga: Sign me up, I want to do it. And then finally, what motivates you guys to do this work and why is it so important to you?

Felicity Duran: I think that when I went to Uganda, I feel like I was more interested to be honest in doing the research thing. But I was also excited about seeing the patients. But I think that once I saw the true impact of it and what our research could lead to, that really motivated me. I knew that I was in the right place at the right time. I was at the right concentration. And this could really end up being part of my life's work. So I think that whole thing just motivates me. Knowing that I could make a difference by doing something that I like to do, to research, to ask patients questions, to interact with them, and to help coordinate studies that might benefit the public health.

Sarah Bender: Yeah, I think that I am primarily a nurse. That was my first degree and now I'm getting my master's in nursing to be a nurse practitioner and the masters in public health was something I wanted to add on because I am really passionate about public health and I think it's so important for healthcare in general, not only in the United States but abroad, especially. I'm just really motivated when I do these medical mission trips about, you know, how much you get, not only do the patients get, but you as a provider get. You kind of get this renewed sense of this is why I'm a nurse or this is why I'm a nurse practitioner. This is why I'm a doctor. It's really back to the basics and helping people who really have no basic medical care and just teaching them primary prevention and just small things they can do in their everyday lives to make their health better.

Felicity Duran: Right. And it adds to the holistic perspective that public health and especially global public health values.

Alexandra Arriaga: Yeah. And how about for you Dr. Liz? What motivates you?

Elizabeth Discolo: That's a great question. I'm trying to not repeat what anyone else said, either. Before I was working here, I was working in neurosurgery and you don't see patients when they're first starting to get sick. You see patients when they're already really sick and they've had a stroke or they have a tumor or they have terrible back problems. And I just started thinking about how things could have been different for them if they had had some basic health care earlier in their lives that could have prevented some of these more serious problems. And so just thinking of things from that perspective, I had always been really interested in public health and how could help more than just one patient at a time basically and help a whole population and I had done a few mission trips and the same thing that both Felicity and Sarah said. It's just an amazing experience and it reminds you of why you're doing things and it just kind of shows you that the great need that there is out in the world. I feel like if I have a certain skill set I should be able to put that to use and help as many people as possible.

Alexandra Arriaga: Yeah. Thank you for sharing that perspective. That's actually a very unique and I think everyone appreciates hearing it. It's been such a pleasure to have you here, guys. Thank you so much for sharing this time with us and giving us all this information, and we hope to hear more from you soon.

Sarah Bender: Definitely. Thank you for having us.

Felicity Duran: Thank you.

Elizabeth Discolo: Yeah, thank you so much for having us. We really appreciate it.