GH2DP Outreach Trip to Rural Yoro, Honduras: June 2015

Students and residents preparing water
filters in Lomitas

Our upcoming outreach trip to rural Yoro, Honduras is fast approaching. Our team, in collaboration with the local Ministry of Health and many local, regional and international partners, helps provide care to approximately 1,200 people from 17 villages. We have been working collaboratively to provide care in this region for the past 10 years.

Our team is once again fairly large and includes attending
physicians (pediatricians and internists), medical and pediatric residents, an attending pharmacist, students from medicine, pharmacy and public health in addition to an undergraduate engineering student and numerous other individuals. We are once again collaborating with colleagues from Brock University and the National Autonomous University of Honduras on a project exploring the local prevalence of soil-transmitted helminth (worm) infection.

Engineers Without Borders students with a novel rain
water catchment device in La Hicaca 

We will also get to see first-hand numerous other projects we have been longitudinally collaborating on: an improved cookstove project we have been working on with a local nonprofit (the Pico Bonito Foundation) as well as the placement of numerous new latrines. We will also get to see the new chlorination systems that were installed this past year. Six of the villages we serve (and approximately 40% of the population we serve) have access to water directly in their homes via a network of pipes that gravity-feed water from five different cisterns which are themselves fed by a river deeper in the mountains. We collaborated with local partners to install chlorination systems that slowly leach chlorine into water at the level of the cistern. We have had a water filter project in the region since 2008 that provides clean drinking water to the entire region. We know from our prior work these locally-created filters are clinically and microbiologically effective. Since the new chlorination systems have replaced the filters for the villages where these were installed we have a project that will look at the microbiologic and clinical effectiveness of these new systems. Additionally, we will also be testing water (at the level of individual homes) for chlorine content.

With colleagues from the National Autonomous University
of Honduras and Brock University

We have once again partnered with VCU's Engineers Without Borders student chapter to trial several novel clean water devices.

We also have a study focused on knowledge, attitudes and risk factors for the mosquito-borne diseases dengue and chikungunya.

In terms of our direct clinical work we have modified our typical clinic schedule somewhat in an attempt to be more accessible to patients in outlying areas. The population we serve is spread across a wide geographic area and some people travel 6 to 7 hours one way by foot to see us; unfortunately the infrastructure only provides a few road access points to facilitate moving our group and supplies. We hope our new schedule will allow us to serve more people.

Testing water for microbiologic contamination 

This year we will also be trialing a new education project focused on our student and resident trainees. This focuses on core content highlighted during the trip (focusing on demography, tropical dermatology, tropical infectious diseases and chronic disease screening).

Clinic in Lomitas 

We have a fantastic group this year who have worked very hard to prepare for this trip. I am absolutely thrilled to work with and learn from this amazing group of students, residents and our many community, regional and international partners.

I will blog about our trip as cellular access allows; we also will be tweeting about the trip (#GH2DP).

3rd Annual VCU Global Health Showcase Recap

Dr. Kerkering speaking on the West Africa Ebola outbreak

Today was VCU's 3rd Annual Global Health Showcase, an opportunity for people around VCU and the greater Richmond community to share and discuss global health projects.

With Dr. Bearman and GH2DP residents and students

The day started with a keynote presentation from Dr. Thomas Kerkering on his work treating Ebola patients in West Africa. Dr. Kerkering is a VCU alumnus and his talk was both moving and compelling. He showed excerpts from a documentary on the early days of the current Ebola outbreak in West Africa (this documentary can be found here).

Subsequently there were several 'break-out'
sessions: one discussing getting involved in global health research, one focused on training opportunities for medical students and residents and one focused on providing healthcare in resource-limited settings.

Viewing posters

There was an excellent poster section exploring global-health related research from around VCU. VCU's Global Health & Health Disparities Program was well represented with our students and residents presenting seven different projects.

The day ended with an excellent session focused on some of the ethical challenges of getting involved in global health work.

With Dr. Bearman and current GH2DP Pathway Residents

3rd Annual VCU Global Health Showcase: Making it Work, Getting it Right

The 3rd annual Virginia Commonwealth University Global Health Showcase is coming up on April 20, 2015. This is an all day event featuring an exciting keynote from Dr. Tom Kerkering discussing his experience with the Ebola outbreak in West Africa, several breakout sessions and a poster session featuring global-health related work from trainees across the university. This year's meeting is called "Making it Work, Getting it Right." The theme of the meeting is giving students and faculty key tools to engage in global health work.

VCU EWB students trailing a novel water catchment device
in Yoro, Honduras, June 2014

Prior showcases have been a wonderful opportunity to network, share ideas and build new relationships. The first showcase led to our program's (the Global Health & Health Disparities Program, GH2DP) current partnership with VCU's Engineers Without Borders (EWB) student chapter. This relationship has led to the development of several novel clean water technologies for use in rural Latin America as well as helped support or ongoing clean water campaign in Yoro, Honduras.

VCU EWB students trailing a new biased filter,
Richmond, VA, 2015

It is not too late to register and come out for the showcase on April 20th! Details about the showcase (including the agenda) can be found here.

Global Health Resources Guidebook for Students, Residents and Fellows

In preparation for a 'breakout' session at the upcoming 3rd Annual Virginia Commonwealth University Global Health Showcase I put together a resource guidebook for students, residents and fellows interested in global health; this can be found here.

This 'book' contains a number of links to great online resources: from lists of post-graduate training programs in global health to international and domestic volunteer opportunities to lists of great global-health related books and journals. Additionally, it links to a number of free (!!) online training resources for global health.

Special Guest Blog Post from Nadia Masroor: February GH2DP Outreach Trip to Yoro, Honduras

This is a special guest blog post by Nadia Masroor, who has joined us on the last few health outreach trips to Yoro, Honduras, and who recently returned from Honduras: 

Our February trip to Olanchito and La Hicaca provided some excellent feedback on several ongoing projects. On Thursday February 12^th, Dr. Bearman and I had the wonderful opportunity to meet with Padre Pedro and the rest of the Catholic priests in Olanchito for lunch.

Afterwards, Dr. Bearman, Padre Pedro, and I met with the Pico Bonito Foundation to discuss their progress on current projects. Pico Bonito has successfully installed chlorination systems in La Hicaca, Chorro Viento, and Puerto Rico. Those living in these three villages are encouraged to use the chlorinated water cisterns for their water supply. In order to determine the efficacy of chlorination, the 2015 brigade team will plate and incubate chlorinated water to assess microbiological growth. As for those who do not have access to the cisterns, an estimated 90-100 filters will need to be distributed in June 2015.

Hike to Chorro Viento

The Pico Bonito Foundation has recently installed new cook stoves in many of the homes in LaHicaca. According to the foundation, each cook stove costs about $100. We plan to continue this project by funding Pico Bonito to install another 15-20 cook stoves this year. Padre Pedro and Rosa, who is the nurse providing care to the people of La Hicaca and surrounding villages, will determine which impoverished homes are most in need of cook stoves. In conjunction with the cook stoves, the Pico Bonito foundation has also agreed to install new latrines for the people in Sector La Hicaca. Approximately 15-20 latrines, which cost $100 each, are projected to be built throughout the village this year. Lastly, in order to replace the deteriorated school latrines, we have requested 4 new latrines to be constructed as well, which have been estimated to cost $800-$1000. To say the least, our meeting with the Pico Bonito Foundation has enlightened us on the plethora of projects we can initiate in order to improve living conditions in La Hicaca and surrounding villages.

Later that day we met with Dr. Alma Nunez from the Ministry of Health to discuss the June 2015 brigade. Historically, La Hicaca has been the clinic site for 3 days and Lomitas has been the clinic site for 2 days. This year, however, Padre has advised spending 2.5 days in La Hicaca and 2.5 days in Lomitas. By increasing clinic time in Lomitas, Dr. Nunez and Padre hope that the brigade will be able to extend its care to more people. The total number of brigade clinic sessions will remain the same. In addition, Padre Pedro will work with the Ministry of Health to provide dental services for 3 days, covering both La Hicaca and Lomitas.

Based on Brock University’s findings from the June 2014 brigade, the majority of the population suffers from Trichura, which cannot be effectively treated with albendazole alone. Thus during this year’s brigade we will be distributing oxantal pamoate in addition to the albendazole to provide enhanced Trichura coverage. Padre Pedro has taken on the task to inquire and purchase both the albendazole and the oxantal pamoate.

Cistern in Chorro Viento

Dr. Nunez has proposed aggressively promoting the brigade via Radio Catolica broadcast in order to increase awareness and participation. Therefore, Padre Pedro will collaborate with Radio Catolica in order to provide the brigade dates and details about the services offered. We hope to see an increase in the number of people who attend the brigade in June.

On Friday February 13^th, we traveled to La Hicaca so that could meet with Rosa in el Centro de Salud. Rosa graciously agreed to continue sanitation education and to take on the latrine and cook stove projects with Pico Bonito. She has also requested an additional 300 speculums for cytology exams.

In the afternoon, we had the opportunity to examine the water cisterns with the new chlorination systems in La Hicaca and Chorro Viento. We drove to La Culatta and climbed up to Chorro Viento. The 45-minute hike was definitely not an easy one and made me appreciate the 5-6 hour journeys many people endure to come to the brigade. Below are some pictures of the cisterns and the chlorination system installed.

New chlorination system in Chorro Viento

We attended Mass on Friday evening, traveled back to San Pedro Sula Saturday morning, and flew back to the US on Sunday. Although a short trip, we have gained a substantial amount of knowledge on current programs implemented in La Hicaca and surrounding villages.

I cannot wait to return in June- to see the progress and of course, to see my friends.

VCU GH2DP Outreach Trip to Yoro: Pictures Published

Outreach group in La Hicaca 

An overview of our recent outreach trip to Yoro, Honduras has been published on the GH2DP website and can be found here. A slideshow of pictures from the trip can be found here.

Distributing water filters, Lomitas

Dental clinic, La Hicaca

Engineers Without Borders students with water test plates

Medicine clinic, La Hicaca

Medicine clinic, La Hicaca

Medicine clinic, Lomitas

June 2014 GH2DP Outreach Trip to Yoro: Preview

Our group leaves for the mountains of the Yoro province of Honduras this coming Sunday, where we will spend over a week seeing patients and participating in a number of public health projects.

Testing for bacterial water contamination (presence of
color = growth of bacteria) 

This marks our 9th large-scale medical mission to Honduras since 2005. Initially our efforts were primarily focused on providing acute medical care. Since that time our work has expanded to include numerous public health projects including a large-scale, filter-based clean water initiative that has led to supplying approximately 1,500 people with clean water. Additional efforts have included regular mass de-worming, an indoor air pollution assessment and subsequent education initiative, several mass anemia screenings, improved access to cervical cancer screening and a large Chagas disease knowledge and attitudes assessment. Our group has been blessed to have wonderful community partnerships which help to direct and facilitate our efforts. In the nearly one decade since we have been active in Honduras we have come along way... but there is much, much more to do. 

Our program (the Global Health & Health Disparities Program, GH2DP) has a tripartite mission: improve the health of people with poor access to healthcare, expose US-based learners to medicine in resource-poor settings and to systematically study our efforts to learn what works and what doesn't. This work has involved the efforts of myriad individuals, non-profit organizations and academic departments here at VCU. 

Medicine clinic, La Hicaca 

Since 2005 we have seen over 10,000 patients. Beyond providing acute medical care we now regularly screen and treat patients for chronic diseases such as diabetes and hypertension. We also screen patients for vision issues and provide eye glasses, help facilitate dental extractions and help support cervical cancer screening, as well. Every person in the 17 villages we serve receives anti-worm medication at least twice yearly; since 2008 we have distributed nearly 20,000 doses of anti-worm medication. 

Assembling and cleaning water filters 

Our clean water program provides water filters that are created in-country and provide clean drinking water to entire families for up to 2 years. Since the inception of the program we have distributed 401 filters and now provide clean water to approximately 1,500 people (roughly 75% of the region we serve). This year we are partnering with a local non-profit organization to provide entire villages with clean drinking water via a chlorination project involving cisterns. It is estimated that 6 of the 17 villages we serve will have access to clean drinking water via this project-without the need for water filters. 

In terms of educational efforts, to date we have provided global health experiences to approximately 80 students and residents. Of these learners, 32 have been afforded advanced mentorship on public health research projects that have led to 10 publications and 15 presentations at national and international conferences. More importantly, their work has advanced our medical and public health missions. Additionally, we have an active GH2DP residency pathway which involves over 150 hours of advanced training in global health as well as a Student Scholars program. 

Our June trip may be our most ambitious ever. We have assembled a fantastic team of students who have been working hard the past 9 months raising money to help procure medicines and supplies. We also have a terrific group of residents and other staff.

We have 4 survey projects planned: one focused on worm infections, one on women's health issues, one on barriers to water filter use and one on access to clean water. Additionally, we are partnering with researchers from Brock University who will be doing fecal testing to evaluate the regional worm burden and the effectiveness of our mass-deworming program. As well, a group of engineering students from VCU will be traveling with us to trial novel water catchment technology. We anticipate seeing approximately 1,000 patients, or roughly half of the population of the region we serve. 

Stay tuned for updates on the trip. 

VCU GH2DP Honduras Group's Work Featured by VCU's Division of Community Engagement

Earlier this month our group traveled to the Yoro area of northern Honduras to meet with our community partners and ministry of health officials and to lay the groundwork for our June 2014 trip. The VCU Division of Community Engagement is now featuring our work on their site (this can be found here).

Also, the VCU undergraduate chapter of Engineers Without Borders was awarded a Quest Innovation Fund grant to support their development of novel rain catchment technology for use in Yoro. Congratulations to all of the students involved in this project!!!

VCU GH2DP Honduras Trip: Final Post

17 villages we serve in Yoro; the villages appearing in color
are those that may benefit from the new water chlorination
system (see text) 

This will be my final post prior to coming home tomorrow; this has been a whirlwind trip filled with productive meetings and some great new potential projects.

One of the projects we are most excited about is a new water chlorination project; piggybacking on older technology that is currently in place, new chlorination systems may, once installed, provide clean drinking water to 6 of the 17 villages we are currently supplying with water filters. We hope the chlorinated water will provide more consistent access to clean water in a more sustainable, community-driven way.

The map above unfortunately is not high resolution but provides a sense of the potential impact of the chlorination systems. The villages that appear in color are those that would be supplied clean drinking water via the new systems; the villages in gray are those in which clean drinking water will continue to be supplied by our current water filter project.

VCU GH2DP Honduras Trip: A Day in the Mountains

Hiking to Chorro Viento

Yesterday we got up early and left Olanchito to drive out to the rural, mountainous area where the people we serve live. This is a large area that consists of 17 villages and roughly 2,000 people. Because of logistical issues we have only visited 2 of these villages in the past (La Hicaca and Lomitas) and have coordinated with our community partners to have people from the outlying villages come see us in these places. Practically speaking, this means that some people have to walk 6 hours (each way) over mountains in the hot sun (it's typically in June and we are near the equator = hot, hot, hot) just to see us in clinic.

We were excited yesterday to have the opportunity to visits a few additional villages we have never

En route to Chorro Viento

been to: La Culatta and Chorro Viento. Our primary goal was to assess older water catchment infrastructure and to see if a new chlorination project is feasible and acceptable to people living in areas that would be served by the new technology.

We could drive to La Culatta but had to hike out to Chorro Viento; this was a 30 minute "walk," at least for people living in the area. For us it was more like 60 minutes and was as strenuous as any serious hike I have ever been on in the United States. Keep in mind this was the easiest village to reach and it's January-far cooler than June. I have always respected the mental and physical toughness of people living in the area but this has given me profound new respect. It is not uncommon to see a woman in her 70s walk 3-6 hours to come see us wearing what amounts to plastic shower sandals; I am confidant I could not keep pace with these women.

When we reached Chorro Viento we also got to see a project that was created in partnership with a group from the European Union: a working turbine that supplied power to this village. This is the only village in the region with power and was made possible by their proximity to a local river/ waterfall. The project was incredible and people in the village had enormous pride in the

Cistern in La Culatta; there are 4 of these
in the region supplying water to 5 of the
17 villages we serve; the water is not
safe to drink but a new chlorination
project may be able to provide clean water 

technology. What was truly amazing is the power poles-every bit as large as those found in the US-were carried up the mountain by people from the village. No heavy equipment could reach the village so the poles were planted by hand. The work must have been unbelievably strenuous.

People do so much with so little in the area, and a little really
does go a long way. I left yesterday with a renewed sense of admiration for the people living in the area and with a strong desire to do more to help people in the region. We are hopeful we can continue the many productive partnerships we have established in the region to help improve the health of its people. It is a great privilege to be able to come here, to be welcomed into the communities, and to be given the opportunity to help.

The region has traditionally had a problem with poor indoor
air quality related to poor stove ventilation in homes. Many homes have
now had improved ventilation systems installed and are
effectively ventilating smoke from homes

We also brought enough anti-worm medication
to provide another dose to everyone living
in the region (this is part of a long-term longitudinal
regional project to decrease the intestinal
worm burden) 

VCU GH2DP Honduras Trip: A Day of Meetings in Olanchito

Meeting with the local Minister of health and his staff

Our first full day in Olanchito was a whirlwind but very productive.

We met with the local Minister of health and his staff and discussed our work to date and future collaboration.

Meeting with our local community partners

We then met with our local community partners and thereafter with staff from the Pico Bonita Foundation. We discussed collaboration on new water chlorination systems that can provide clean drinking water to 5 of the 17 villages we serve; we are very excited about this potential project.

Meeting with the Pico Bonita Foundation

Today we are traveling to the mountains and will be hiking out to several villages (Chorro Viento and La Culata) to meet with people and investigate old water procurement infrastructure. Will then meet with our community partners in La Hicaca.

More to come!

VCU's Global Health & Health Disparities Program Sets Off for Honduras (Again!)

Traveling to La Hicaca 

Our group leaves this Sunday to meet with our community partners and the local Ministry of Health in Yoro, Honduras. We have traditionally used our January trip to meet with our key partners, review information from the prior brigade and to help lay the groundwork for the subsequent large-scale, clinical brigade in June.

Since 2008 we have been serving a series of 17 villages with approximately 2,000 people in rural, mountainous northern Honduras. People in the region have little to no access to healthcare and suffer from fundamental environmental health pressures (such as lack of access to clean water and latrines). 

We have a large-scale water filter program in the region that has been active since 2008. To date we have distributed over 350 water filters, each of which can provide clean drinking water to an entire family for 2 years (or more). We estimate approximately 75% of the people in the region have access to clean drinking water as a direct result

Preparing water filters for distribution 

of this program. Anecdotally, less children are developing (and occasionally dying from) diarrheal illness. More objectively, the incidence of severe diarrheal illness reported to the Ministry of Health has halved since the inception of the program. 

One of our projects this past June, a Chagas disease knowledge and attitudes survey, was performed at the request of the local health ministry. Chagas disease is a parasitic disease that is common in Latin America and is associated with severe cardiac and gastrointestinal morbidity. We will be sharing the results of the project with our partners this upcoming week; we are excited to discuss study implications and next steps.

Working on the indoor air quality project

Two years ago the health ministry and local leaders asked us to investigate the problem of indoor air pollution. A now-third year VCU medical student, Audrey Le, formally assessed the issue and found certain home characteristics were associated with respiratory symptoms. Subsequently we discovered many stoves were in a state of disrepair and not effectively ventilating smoke. This upcoming week we will be meeting with a local non-profit organization who may be able to help repair these defective stoves; we are excited about this potential collaboration.

Additionally, we are excited to discuss several upcoming surveys we hope to administer in June: looking at knowledge, attitudes and risk factors for intestinal helminth (worm) infection and a survey on women's health issues. We also are partnering with a VCU undergraduate group, Engineers Without Borders, to explore a novel rain catchment technology (to help provide clean drinking water) and will be conducting a survey focused on barriers for optimal use of water filters. 

Clinic in Lomitas

During next week's trip we will also be supplying anti-helminthics to help bolster regional efforts for intestinal worm control. We will also be doing the groundwork for our upcoming clinical mission; figuring out key logistics such as clinic space, how to recruit patients, et cetera. 

I will post about our trip either during the trip or shortly thereafter; stay tuned. Dr. Gonzalo Bearman will also be posting about the experience, be sure to check out his blog. You can also follow our progress on twitter here. 

GH2DP Participants Present at ASTMH Conference in Washington, DC

Dr. Wang, Kate Pearson, Dr. Donovan, at the ASTMH
conference in Washington, DC

Congratulations to Dr. Jeff Wang, Dr. Summer Donovan and to Kate Pearson (a 4th year medical student at VCU) who presented their research at the annual conference of the American Society of Tropical Medicine and Hygiene in Washington, DC, yesterday. Jeff, Kate and Summer all worked on GH2DP-related projects in Honduras this past June.

Kate and Jeff looked at satisfaction with brigade care on our last medical outreach trip to Yoro, Honduras.

Town of La Hicaca; this is one of the sites where we see
patients in Honduras; Chagas disease is a major problem in the area

Our group provides medical and public health services to approximately 2,000 people living in 17 villages in the Yoro area of northern Honduras. Because of logistical issues (lack of road access) our primary clinical site is in the village of La Hicaca; people from the surrounding villages come see us there. Unfortunately, distance to the clinic is a significant barrier for many people, with some people having to walk upwards of 6 hours to come and see us.

Kate and Jeff found that satisfaction with brigade care differed on whether survey respondents were

Data from Jeff and Kate's survey

from La Hicaca or one of the surrounding villages (with the former group more satisfied with the services we provide, on the whole). Also, their work identified differences in the services requested, with mental health services being the second most commonly requested service in the surrounding villages (this was the 4th most requested service in La Hicaca).

Their work will significantly impact our future efforts to reach more individuals at remote village sites. It will also help us to tailor and expand the services we provide moving forward.

Dr. Donovan's work focused on knowledge and perceptions of Chagas disease in the communities we serve; we were asked to undertake this project by our local contacts in the health ministry.

Chagas disease is one of the neglected tropical diseases, and is an insect-borne parasitic infection that affects people in the Americas, especially parts of rural Latin America.

The insect vectors for the disease are known as "kissing bugs." They live in the walls and roofs of houses made of adobe, mud, straw and thatch, and emerge at night to feed on people's faces (I am not making this up). The insects thereafter defecate and the parasite (Trypanosoma cruzi), which is in the stool, gets inoculated through the skin when a person scratches.

It is estimated that 11 million people are currently living with this infection, and untreated these diseases persist for life. Chagas disease is associated with major morbidity: over time the infection can lead to heart failure and death from arrhythmias, as well as dilatation of the esophagus and colon with attendant gastrointestinal issues.

Dr. Donovan found that many people reported the presence of the vector in their homes (65% for people in La Hicaca, 76% for people in the surrounding villages) and that although general awareness about the disease was good (around 90% of survey respondents) understanding how the disease is transmitted was low (0%). This has implications for future control and educational efforts in the region. 

Chagas disease survey findings (LH: La Hicaca, SV:
surrounding villages) 

Again, congratulations to Jeff, Kate and Summer! They are phenomenal young researchers whose work will significantly impact the people we serve in Honduras. We look forward to more great things from them moving forward.