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In case you are visiting the site to learn more about working in global health settings, I’ve uploaded a slide show I put together for a presentation regarding international medical service. I hope this is helpful, and I am happy to provide more detail if needed.
The next medical service trip to the Dominican Republic will be May 31 to June 11, and will be in collaboration with medical and pharmacy students as part of HOMBRE.
If interested, let me know! We are particularly looking for providers to be part of the team: physicians, NPs/PAs, etc.
Paraiso, the community we partner with in the Dominican Republic, is part of a larger barrio outside of Santo Domingo. This barrio sprawls across a large expanse north and slightly west of the city center. Paraiso itself is subdivided into smaller sub-barrios. Some of these (like Altos, Veinte-Ocho and Carlos Alvarez) consist largely of cinder block homes and unpaved streets that at have curbs to control water runoff during heavy rains. The most marginalized part of the community is Esfuerzo de Paraiso, which sits downhill from Altos and is separated from the rest of Paraiso but a drainage ditch that collects the runoff from Altos and the other sub-barrios. Esfuerzo is bounded on its opposite side by a small river, meaning that the community floods easily–and rapidly–during heavy rains. Esfuerzo does not have any paved roads or curbs, most houses are insubstantial structures made of wood and tin, electricity is in short supply, and there is no running water available. Esfuerzo has existed for approximately 10 years, and yet has little economic development: most residents who work do so outside the community, or have small businesses selling food, candy, etc to their neighbors. There are around 90 houses, and a total of about 500 residents in Esfuerzo. We have seen over time that the residents of Paraiso have little contact with the local medical system, and there are no medical facilities in the community itself.
In 2009, the New England Journal of Medicine published an article addressing the impact urbanization has on health. The authors note that most population growth in the developing world in the years to come will be in urban centers, and much of that growth will take place in marginalized communities such as Paraiso–Esfuerzo in particular. Residents in these communities wield little power and have little chance to improve their lot: the authors note that “[t]hese residents are usually tolerated and their presence tacitly accepted, but the local government generally ignores them, accepting no responsibility for accounting for them in planning or the provision of services.” The authors note that residents in these newly urbanized communities face “urban health hazards as comprising injuries, pollution, and chronic diseases, such as diabetes and hypertension” while “[i]ncreasing the population density in cities without proper water supplies and sanitation increases the risk of transmission of communicable diseases”. Residents of communities such as Esfuerzo are faced with increased burdens of chronic disease, while still facing significant risks regarding infectious diseases. In the context where residents will have little political impact or ability to change their communities’ resources, these residents will face enormous health risks heading forward. Meanwhile, health care resources that could provide needed care for these communities is not easily available.
As the world’s population becomes increasingly urbanized, the combination of acute and infectious diseases and chronic illnesses will continue to cause great harm to newly urbanized communities such as Esfuerzo. Those of us who work in developing nations must be aware of the ongoing shift in patterns of disease, and must develop approaches to care that address acute illnesses and tropical diseases (such as soil-transmitted worm infections) while also targeting ongoing care for chronic illnesses. In the context of short-term medical trips, much can be accomplished–but only if a long-term partnership that includes the communities’ residents is established. We are working to find effective (and affordable) ways to monitor and treat chronic illnesses in Paraiso and Esfuerzo, but we have also worked very hard to develop a trusting relationship with the community.
Through community-oriented primary care (PDF) approaches, the collaboration between health care providers and community residents can be strengthened. This will lead to more effective and more cost-effective health care in communities such as Paraiso: newly-urbanized communities facing enormous health challenges in the context of few resources and disrupted social support systems. For good or ill, urbanization is the way to the future–and health care providers and communities must find ways to minimize its harm.