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2015 Recap: La Romana, Dominican Republic

Accompanied by Dr. Norma Hannigan, six undergraduate students spent 3 weeks in January 2015 at the Clínica de Familia La Romana in La Romana, Dominican Republic. The clinic serves primarily HIV/AIDS patients and their families but also provides primary care services to people without HIV. Global Health Nursing is a service-learning course during which the students work on projects necessary for improving the care provided to patients. A primary focus of the course is the connection between social justice and nursing.

Students were selected based on their GPA, essays, and language ability. The students who attended—Mariel A., Felix D., Maria P., Karen T., May C., and Leonela C.—all worked closely with their Dominican supervisors on a variety of projects:

• Felix worked on a project aimed to help clinic staff cope with the stress of working with HIV patients;
• Mariel created materials educating patients on preventing HIV reinfection;
• Maria and Leonela worked on methods for enhancing medication adherence that nurses and health promoters can use;
• May and Karen worked on behavior change theory and methods for adherence counselors to use.

The course also included cultural exploration with trips to a local artist colony, local caves, and to a School of Nursing so the students could meet their counterparts in the Dominican Republic.

Student Reflections: Week 1

"My parents were both born in the Dominican Republic and since we landed, I have felt a very strong connection to the country, one I thought I had lost since I was last here. Being here only 5 days has taught me a lot about myself, my classmates, instructors and also the Dominican culture. I have learned something new every day since embarking on this journey, and hope that remains the trend throughout my time here in the country and in Clinica de Familia La Romana. Having spent 6 years away, I come back with a new knowledge, a different mindset and a clearer vision for my career moving forward. The staff in Clinica de Familia has been very welcoming and helpful during our first two days and clinic does an excellent job of integration and working efficiently as a team, which are essential in an efficient healthcare system. I’ve been inspired by the work being done here in Clinica de Familia and hope to return as a volunteer in the future."

"It has been three days since we have arrived in La Romana, and I am beginning to question if coming here was the right decision for me. This is the longest I have been away from my partner and daughter. Being homesick, along with feeling lost because of my lack of Spanish comprehension has made it hard for me here. However, it was my visits today to one of the government-run hospitals that almost brought me to tears. I went to visit a patient of one of the health promoters from the clinic, who had HIV and was being treated for tuberculosis. The lack of staff, care, medicine, and equipment really surprised me. The patient room was dirty, his bed was unmade and stained, and I did not see a single nurse on the floor. There were no proper masks, gloves, or gowns that we could use like we do in the United States. I did not see any medical equipment or nursing staff on the floor. This hospital was a huge difference from the second hospital that we visited. The other was a private hospital that received a lot of foreign funding and volunteer help. The quality of the physical building, equipment, staff, and care seemed remarkably different.

Seeing the great difference in healthcare within La Romana really made me appreciate the healthcare system in the United States. It’s one thing to hear about conditions in other countries, it’s another to be there to experience and see it. Also seeing the disparity in healthcare even within one city really makes me question many things about foreign aid. How is it that there could be such a low-quality hospital just minutes away from a modern, clean, well-equipped hospital? Why is it that volunteers focus on the one that only provides for those with insurance and charges a relatively large amount for the residents of the city? It made me think about a discussion we had with the Mina Halpern, the executive director of La Clinica de Familia La Romana about international funding of healthcare clinics. One thing that really surprised me was learning how governments use health funding as a way to shape foreign policy. When a clinic receives funds, there are often many rules and restrictions tied with the money. The priorities of the clinic do not always match that of what they are required to do with the foreign aid. These two experiences renewed my interest in politics and validated my interest in healthcare policy."

"My first day of rotations at the Clinica de Familia La Romana was definitely an eye opener. The staff at CFLR made sure that all the students felt welcomed and felt a part of the team. In fact, the patients themselves treated the students with kindness and great acceptance. I felt very confident to ask questions about things that I didn't understand and that I observed while I shadowed one of the physicians of the team... I sincerely learned more than I have ever learned throughout my whole college experience. However, the most interesting part of the rotations of the CFLR was interacting with the patients of the HIV/TB affected population. It was very unfortunate to see that some of these patients were not able to fully access the proper treatment for their conditions because of their limited resources and financial situations... I find it very interesting that the issues of health care seem to be very universal in the sense that the gap of resources and access has a great affect in the quality of care for patients regardless of the country."

Student Reflections: Week 2

"Our first “real” work day in La Romana, was on January 7^th. On the 7^th and the 8^th, we had the opportunity to tour and learn about different healthcare facilities, such as Seguro Social, Hospital El Buen Samaritano, MAMI and Hospital Francisco Gonzalvo “Salud Publica.” I along with two other nursing students accompanied a promotora de salud (health promoter) to the hospital Seguro Social. We visited a Haitian, male patient that has both HIV and tuberculosis. The health promoter explained to us that she had brought the patient from home because during a visita domiciliaria(home visit) she noted the patient was very ill. The patient had not been adhering to his medications, causing his status to worsen. It was truly devastating to see the condition of the patient and the hospital itself. The sheets on the patient’s bed were filthy and there were no pillows. Needless to say, something as simple as a pillow can be a luxury in communities with such limited resources. Moreover, the patient was taking multiple pills and had difficulty swallowing; it was extremely heart breaking to see him in pain while taking the medications.

On the other hand, I was extremely impressed by the Hospital El Buen Samaritano. There were beautiful decorations and the walls were painted in different colors. I loved how their system works in terms of assigning sections. For example, each floor is divided into sections, and one nurse, doctor and housekeeper is assigned to each section. I think this is a great way to figure out the “go to” person in case something goes wrong. The Hospital El Buen Samaritano is in the process of building an intensive care unit and an isolation room. Also, I really liked that this hospital has an operating room inside the emergency room. This must be really helpful and probably saves a ton of time whenever an emergency surgery is needed.

The next day (on January 8^th), we visited El Módulo Anexo Materno Infantil (MAMI), which is the unit of comprehensive care for adolescents (up until 19 years old). MAMI works in collaboration with Hospital Francisco Gonzalvo “Salud Publica” and the Clínica de Familia La Romana. The services provided in the MAMI include family planning, rapid HIV testing and with pre- and post-counseling, pregnancy tests, prenatal care, psychological consultations, gynecology, pediatrics, a clinic for men, and sexual and reproductive health education. What I liked best about MAMI is that staff does a charla (teaching) about sexual and reproductive health. This charla is done in one week at a local school. Day one consists of a pretest to see what the students know about topics such as HIV and family planning. The staff also does a teaching about the reproductive system and how pregnancy occurs. Day two focuses on family planning methods. On the third day of the charla, the students are taught about sexually transmitted infections and diseases. On this day, the class is separated by gender to allow the students to be more comfortable. The fourth day is specifically based on HIV teaching and what it is like to live with HIV. On the last day of the charla, students are given a post-test to see how much they learned and are also taught about general prevention and proper condom use. At the end of the charla, students are given a certificate as proof that they attended the charla. Interested students can be trained to give charlas to other children and are referred to as “el grupo joven de MAMI” or peer groups.

I am really glad I had the opportunity to visit every one of these healthcare facilities and learn about the differences that exist in the healthcare system within the same community."

"It is the start of our second week here in La Romana. We have had the opportunity to tour many healthcare facilities and speak to many important individuals of the healthcare system here in the clinic and the community. The more I learn about health care system, the more I realize how much politics plays a role. Despite this being true everywhere, I feel like it's not something that I thought about back in the United States because I've never really seen the things in this perspective. I've always been fortunate to have access to healthcare, and as a nursing student, I have always focused on the direct clinical care instead of a bigger picture. Before this trip, I fought tirelessly for as much clinical care experience as I could get. Not that clinical experience isn't important, but now I feel like I could have a bigger influence on health care if I approached it from a more holistic perspective.

I am surprised in so many ways everyday here. For one, the clinic staff is amazingly close. There are over 90 staff members but their relationship is more like that of a family. The way they interact and support each other is unlike any clinic staff I have ever met. They have been able to exert such a positive influence on the community and foster a positive environment with limited resources. Another thing I’ve noticed is that the community health promoters attend to their patient’s spiritual side. They recognize that a patient’s spirituality is strength and use it to motivate their patients. During a home visit, I was able to see how a person’s religion can pull them through the worse of the worst. It was a learning experience to see how much religion meant to someone, especially when they have almost nothing else.

As our presentation date gets closer, I hope that I am able to provide some useable information to the clinic. My goal for the week is to finish my project and put together a presentation. I also am looking forward to more home visits and the visit to the bateyes. It’s a very different experience physically and emotionally when you visit a patient in their home. Aside from learning more about their lives, I think it shows the level of trust that exists between the patient, his family, and the healthcare provider. I hope to be able to bring back this type of relationship to the states in a receptive way."

Global Health Nurses burning the midnight oil at Clínica de Familia La Romana in the Dominican Republic:

The Global Health Nursing Group arriving at at the Clínica de Familia La Romana in the Dominican Republic (from left to right: Leonela, May, Karen, Dr Hannigan, Maria, Mariel, & Felix):