One of the best things about healthcare delivery in Guyana is that it is nationalized. Care is free and available to every citizen. It is financed and managed through the Ministry of Health working together with regional and local government. There is an independent private sector. However, despite a national health system, there are several gaps in the delivery of health care in Guyana.
Chronic diseases, such are hypertension, diabetes and heart disease, are becoming more prevalent in Guyana and currently there is not an infrastructure in place to help manage this growing problem. Patients are presenting to the emergency department at advanced stages at which time there may not be great treatment options available. Unfortunately the regional health center, which would ideally be the place for primary care, is not very equipped. There is usually just one physician available to staff a large local population and he/she may not be well trained to manage chronic disease. The availability of equipment such as blood pressure cuffs, glucometers, monofilaments, debridement tools for diabetic ulcers are often in limited supply. Lab testing and monitoring are usually not available. The idea of routine screening and preventative medicine is nonexistent. Ancillary staff, if available, is also not well trained.
While most patients living along the coast have access to some sort of health care, whether through regional health centers or the local emergency department, those who live in the interior have little to no access. This is largely because of the sparse population and difficult terrain. The population comprises mostly of indigenous people and miners - in emergency situations, they travel for days to the capital to receive care.
In Guyana, there is very little support for persons with mental health disorders or substance abuse. During my short time in Guyana, there were more than a handful of persons presenting with suicide attempt, often with paraquat, a freely available but deadly herbicide. At a public health level, there needs to be better regulation of who has access to these poisons as this is an easily preventable cause of morbidity and mortality. There is poor education about mental illness among the population as well as among providers. If a patient survives a suicide attempt, he/she is discharged from the hospital without any resources or treatment to address with underlying mental illness. Substance abuse, specifically alcohol, is never addressed. Training providers as well as the development of a psychiatric unit or treatment center will be a small step to help address this growing problem.
One of the largest challenges to health care delivery in Guyana is the lack of an integrated health information system. Medical records are completely on paper and patients’ charts do not go with them throughout their contact with the medical field. The medical record is not used to support decision making. For example, if a patient presents to the ED with hypertensive emergency, a new chart is made up for the admission. Even though the same patient presented a week prior with the same issue, the record is not automatically included and there is no way to use information about their previous treatment to guide treatment decisions now. In addition, the contents that make up the medical record are sometimes sporadic and often incomplete.
There are many areas that need to be built up for the health care system in Guyana to become what it needs to be. There needs to be programs in place for advance training of physicians and compensation and work plans that keep these well trained physicians interested in staying in Guyana. Local health centers need to become the first line for screening and management of chronic diseases. Also, within the public health sector education programs need to be developed that teaches local population about disease, mental illness and a healthy lifestyle.
In Guyana, there appears to be a commitment by the government to improve the overall healthcare delivery system. With the monetary support and partnership with many foreign agencies, Guyana is slowly on its way to delivering the care its people need.
With the current ebola crisis in West Africa, Senator-Doctor Bill Frist weighed in at The Costa Report on critical aspects of the outbreak.
Aug 11 2014
All I can say is, I don’t know how they do it. I have finished my time in A&E and have been on female medical ward for the last week and a half. The female medical ward is housed in a new facility that opened several months ago. There are approximately 8 patients per room. Patients have to bring their own sheets, clothes, toilet paper, water, and any other supplies that they might need. There are many nurses and even more nursing students around, but I have yet to figure out exactly what they do. Care by the nursing staff is haphazard at best.
It is so busy here! There are two interns who take care of 60-80 patients at any given time and every 3rd day they do a 36 hour shift. Rounds every morning are quite exhausting and interminable. We either help the interns pre-round (this may involve checking vitals, starting IVs, updating orders) or we round with the sole internal medicine consultant (in the country!) during bedside teaching rounds. There are about 20 medical students who attend these rounds and it is the only semi-structured teaching they receive during their internal medicine rotation. I spent some time going over a few cases with them and though they are eager and enthusiastic to learn medicine I worry about how they will develop the skill sets needed to identify and manage disease processes.
Unfortunately, because the wards are so busy and it is often only the interns around to manage patients, many things are missed or overlooked. Labs take a long time to return and once they do show up may be forgotten until the next day on rounds. A patient’s clinical status may deteriorate without anyone recognizing or alerting a physician of the change for hours. There is a lot of death and, unfortunately, sometimes it seems all but inevitable.
Despite all the obstacles present, the best part about being here is the patients I get to work with. There is such a sense of gratitude and appreciation for the care that they receive and readily acceptance and trust even when things do not go quite right. There is such strength and resilience in the human spirit.
Yesterday was the last day of the rotation and I spent part of the day in medical records going over a couple charts of patients that I had heard about or taken care of. As I sat on the hard wooden bench, in the cloying sticky heat waiting for them to pull the records, I looked around and saw the tall shelves of recorded births and deaths at GPHC for the last 50 years. It was particularly striking to me at that moment that somewhere amidst all of that paper, the record of my birth could be found. Looking at GPHC currently, it is hard to imagine what it must have been like so many years ago. Nonetheless, I feel like I have come full circle and I never could have predicted it. I am grateful for the opportunity to be here and I look forward to creating opportunities to come back to teach, work and help build up the healthcare of Guyana.
Aug 08 2014
Senator William H. Frist, MD
As the CDC treats the nation’s first two Ebola cases there are a lot of questions and concerns about the disease in America—Could it become an epidemic here? How contagious is it? How is it caught?
Although my medical specialty is cardiothoracic surgery, I have spent a good deal of time working on global health issues in Africa and elsewhere, and I have been in close contact with the CDC over the past week. I thought it might be useful to highlight some of the features of Ebola that make it more—and less—dangerous.
As a viral disease, Ebola follows a fairly predictable timeline.
Incubation: the time between when a person is exposed to the virus, and when symptoms start. In Ebola, that incubation period can be between 2 and about 21 days. During that time, the patient does not feel sick and research suggests that they are not contagious. (see doi: 10.1016/j.phrp.2011.04.001) There’s been concern about infected travelers spreading Ebola to other parts of the world after traveling from West Africa. That is certainly possible with a long incubation period.
Onset of Symptoms: However, once an infected person starts to feel sick, they are quickly seriously ill. There is sudden onset of fever, intense weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhea, rash, impaired kidney and liver function.
Unlike a cold, when you could be spreading the virus and not really feel that unwell, Ebola patients know that they are sick. This is actually a good thing, because sick patients are easy to identify, isolate, and treat. Other diseases still need to be ruled out—malaria, typhoid fever, cholera—but it’s clear that the patient has a severe illness.
Transmission: Here is perhaps the scariest part. How do you get it? How did Dr. Brantly get it? How is the virus spreading between people?
Some diseases are infectious, but not contagious. Lyme Disease or Rocky Mountain Spotted Fever are transmitted from ticks to humans but cannot be spread from human to human.
Contagious diseases can be spread from person to person, but not all equally well. Chicken pox, small pox, and measles, for example, are airborne spread—meaning the virus spreads very well with each exhale. These diseases are highly contagious.
Ebola, on the other hand, is only spread through direct contact with the bodily fluids of infected patients—blood, semen, sweat, urine and other secretions. And then, that fluid needs an easy entry into the body: a shared needle, an open cut, an exposed mucous membrane. It could possibly be spread through a cough or a sneeze, but that would require a fairly large drop of mucous to be coughed into another person’s face and get into their mouth or nose or eye.
For healthcare workers in West Africa, this could be possible. With limited supplies, perhaps there is a tear in a glove, or there aren’t enough goggles to go around, or bedding is reused because there isn’t an adequate way to clean it.
If patients are being cared for at home—either because they are too far away from a medical facility, or there’s some cultural distrust of foreign aid workers—caregivers in close physical contact with sick loved ones would have no medical or cleaning supplies. There are also vast cultural issues that influence the virus’ spread, and I’ll touch on those soon.
But with supplies, knowledge, and fully-equipped medical centers, these circumstances would be much less likely to happen. For these reasons, the Centers for Disease Control (CDC) is not concerned about an outbreak in the United States.
The situation is certainly serious—and will continue to be very serious in West Africa. But although we don’t know everything about how this virus behaves and changes, we do have quite a bit of useful knowledge about how to keep it contained, and how to keep our healthcare workers at home and abroad safe.
It is good to be back in Guyana. It has been a week since my arrival and there is a feeling of returning home. Although I left this country when I was very young, the culture, the food, the sayings, even the hot humid climate and cooling ocean breeze are all so familiar and welcomed.
I have been working in A&E at Georgetown Public Hospital, the country’s tertiary care center, for the last 5 days. I am amazed at the broad spectrum of pathology that we see in any given day - some of these have included cerebral malaria, snake bites, herbicide poisoning, tetanus, advanced HIV, acute myocardial infarction, infected diabetic foot ulcers, and strokes. What is most impressive to me is how many complications I have seen from poorly controlled chronic medical conditions, many of the same disease processes that we deal with in the US. As an internal medicine resident, I think about my own panel of patients back home and how aggressively we are taught
to manage diseases such as hypertension, diabetes, and coronary disease. Unfortunately, this is not possible in Guyana in large part due to lack of a trained physicians to take care of these people and poor medical records (surprisingly, many of the first line drugs that we use to manage chronic illness are available here). Guyana, like so many developing countries, continues to struggle with “brain drain” as more and more trained professionals migrate in search of a more economically secure way of life. In the medical profession, those who are left behind do the best they can, but are often overworked and undertrained.
Working in a developing country with so limited resources certainly requires that I adjust the way I think about and approach a disease process; this is easier said than done. The emergency medicine residents do the best that they
can to be aggressive in the resuscitation of very sick patients - unfortunately, often with so few ICU beds, ventilators, equipment for monitoring, it is difficult to sustain a high level of care for the critically ill and many do not survive.
There is just so much that we take for granted in the U.S. I met a 17 year old girl who was brought in to A&E by her parents with 6 months of a progressive motor weakness and spasms that left her wheelchair bound and in sign
ificant pain. She had been in and out of the hospital, with essentially negative work up including lumbar puncture, plain films and CT head. She had seen a private neurologist and needed a MRI. Due to the cost she has not yet gotten the test and even with her consultant advocating her case to the ministry of health, the outcome is still pending. Getting such a simple test that is so easily accessible to us in the U.S. seems an almost insurmountable hurdle to overcome in the work up of her disease.
It is humbling experience to be here and is a great reminder of what a privilege it is to be able to practice medicine and to serve those who need the most help. I am constantly being reminded to how much I don’t know and how much I can learn from my patients.
Aug 04 2014
Kate Etue, Director of Communications
Aug 04 2014
During the time that has passed since my last report I have been focusing my attention on the Tennessee Radon project. As I mentioned before I really have become interested in this particular project. Through my contacts I have been able to acquire short term radon tests to distribute throughout the community. Thus far I have received scores on 15 of the 20 test kits I have sent out. A safe radon rating for your home under is 4 pCi/L, so far ever test I have gotten back has scored under “1” pCi/L which is great! It has been rewarding to be able to go into the community and pass out the short term radon test not only because I can get data to record, but also because I can talk with the participants and help them to understand the major affects radon can have on their health. I feel like I am truly making a difference in some of these peoples’ lives and helping them understand what could be happening in their home is an eye opening experience for most.
Now that we are more than halfway through with the field experience semester the projects I have been working on are nearing completion. The only projects left are wrapping up of the data collected with TN radon, TV lobby, and Smokeout Day (which is Nov. 15). Looking back and seeing how far I have come since day one of my internship is really unbelievable. At the start of my internship I thought it would drag on forever and that I would get nothing accomplished. Now I can say that I was completely wrong, I have worked on numerous projects that not only helped me to complete my curriculum but also helped the community in one way or another and I feel like time has flown by and that I need more.
The date of our final presentation, when we show all that we have worked on, is approaching fast, and I can not be more excited and nervous all at the same time. I can not wait to show my fellow classmates and mentors all that has been done during my internship, but also to show them what a need there is in rural healthcare and communities.
Aug 01 2014
Senator William H. Frist, MD
As I hope you’ve heard, there is an outbreak of the Ebola virus in Western Africa right now, particularly in Liberia. Two American aid workers, Dr. Kent Brantly with Samaritan’s Purse and Nancy Writebol, a volunteer working with the faith group Service in Mission, were recently infected.
I’ve been discussing the situation with the Centers for Disease Control, and I wanted to write a little bit about the transmission and natural history of the virus.
Ebola is a type of viral hemorrhagic fever (VHF). Four families of viruses cause VHFs, and Ebola is from the family Filoviredae. Dengue fever, Yellow fever, Crimean Congo fever, Hantavirus and Lassa fever are other types of VHFs you may have heard of.
Humans are not a natural vector for the Ebola virus, so outbreaks occur after a human comes in contact with an infected animal such as a monkey, pigs or especially bats. Human-to-human spread then occurs through contact with bodily fluids such as urine, secretions, blood, stool or contaminated medical equipment.
Ebola is not technically contracted by respiratory contact with an infected individual, but aresolization of secretions—for example, a coughing patient—can cause spread of the virus. Therefore, barrier precautions like gloves and gowns as well as airborne precautions like masks and goggles (to prevent absorption through the cornea of respiratory droplets) are necessary to prevent transmission. For healthcare workers, infection is almost exclusively the result of a tear or other weakness in their protective barriers.
VHF viruses are dangerous because they are highly contagious, have a high rate of infectivity with low doses of exposure and high rates of complications and death. Therefore, it is important to recognize the signs and symptoms to quickly isolate potentially infected individuals. First, the individual’s travel history is important if not already in an endemic area. Second the timing is helpful to raise suspicion. The incubation period is a few days to weeks. The illness begins with fever and muscle soreness, low blood pressure, red eyes and a rash (specifically, petechial hemorrhages). The constellation of these symptoms with potential exposure is enough to warrant immediate quarantine.
The virus then attacks blood vessels all over the body and increases vessel permeability resulting in fluid loss and bleeding. The fluid and blood loss causes shock and disorders of the clotting system resulting in hemorrhage from mucous membranes as well as in internal organs such as the gastrointestinal tract and lungs. While there are experimental drugs under research and being used in Liberia today, the only known available treatment at this time is supportive care. Supportive care includes fluids, blood products, blood pressure and respiratory support and possibly comfort measures.
The key to survival of Ebola is immediate and sufficient isolation of infected individuals and treatment with aggressive supportive care in an intensive care setting. Once patients have stabilized they are no longer infectious and can be taken out of quarantine. The virus is so rapidly fatal that naturally occurring outbreaks can be contained if patients are quickly isolated and effective barrier and airborne precautions implemented.
There are some experimental drugs for Ebola, but none have completed clinical trials and some have only been tested in lab animals. Many are arguing that the most advanced of these treatments be made available to the sick, even though they haven’t been fully tested yet. One such serum was administered to Ms. Writebol. Dr. Brantly has had a blood transfusion from a boy who survived the virus, in hopes that some antibodies to the virus may be transferred.
Much of the outbreak problem in West Africa can be attributed to lack of knowledge about the virus to recognize and immediately quarantine the sick, as well as the cramped facilities where the healthcare workers were operating. West Africa has never seen Ebola before, and most healthcare facilities are not properly equipped to handling the kind of quarantine needed.
The Centers for Disease Control is currently working to send in personnel and supply support to help contain the virus. Dr. Friedan, the director of the CDC, has little fear of spread to the U.S. due to quarantine posts at all points of entry. He also predicts it may take up to six months to completely contain the virus in Liberia, but he’s confident of eventual success.
Join me in praying for all of the infected individuals and the healthcare workers on the ground and abroad that are making efforts to help contain the outbreak.
Aug 01 2014
Numerous projects and learning experiences have arisen during my time at Roan Mountain Medical Center. I've learned you always have to be flexible. Originally I planned on working more with the patients and the administrative side of health care here at the Medical Center, but after a few weeks I learned there are more areas that I can reach out into.
One of the first projects that I worked on is an Internet survey. During this project I not only developed the survey using skills I have learned, but I also got to administer it. After going out into the community and recording results from the survey the data showed some people use the Internet for health information, but not a large amount. A surprising discovery from the data was an assortment of people young and elderly in this rural area still use home remedies regularly. After receiving this information I now plan to research home remedies and become better educated on home remedies and the out come when using them.
Also during my internship I have developed a health observation bulletin board. On this board I put up monthly health events that are going on with information about the topic and contact information. I know this seems like I very ineffective way to spend some of my time but I feel that it is providing awareness about current health issues. I have also made multiply contacts with different organizations that help to provide information packets on the topics that I can give out to our patients
The most recent project that I have been working on is Tennessee Radon. Earlier when I mentioned being flexible this is what I was referring to. I never thought that my time at Roan Mountain Medical Center would be spent working on an environmental issue. It turns out this project has become my favorite and I have been able to make numerous contacts from local to state level concerning Radon in the Roan Mountain area. I am very excited about this project because I feel like it will be the one to impact the community most.
As to update you about my interaction with the staff, it is still limited but I have made progress. I am now familiar with each employee and their day to day tasks, and I think my relationship with them will only grow as my projects start to develop more.
I would like to keep acknowledging and thanking all the people that are making this opportunity possible for me. Thank you Big Kenny and the LoveEverybody Foundation, Dean Wykoff, and Mr. Baylor.