David Flood

Implementation and Outcomes of a Comprehensive Type 2 Diabetes Program in Rural Guatemala

Background The burden of chronic, non-communicable diseases such as diabetes is growing rapidly in low- and middle-income countries. Implementing management programs for diabetes and other chronic diseases for underserved populations is thus a critical global health priority. However, there is a notable dearth of shared programmatic and outcomes data from diabetes treatment programs in these settings. Program Description We describe our experiences as a non-governmental organization designing and implementing a type 2 diabetes program serving Maya indigenous people in rural Guatemala. We detail the practical challenges and solutions we have developed to build and sustain diabetes programming in this setting. Methods We conduct a retrospective chart review from our electronic medical record to evaluate our program’s performance. We generate a cohort profile, assess cross-sectional indicators using a framework adapted from the literature, and report on clinical longitudinal outcomes. Results A total of 142 patients were identified for the chart review. The cohort showed a decrease in hemoglobin A1C from a mean of 9.2% to 8.1% over an average of 2.1 years of follow-up (p <0.001). The proportions of patients meeting glycemic targets were 53% for hemoglobin A1C < 8% and 32% for the stricter target of hemoglobin A1C < 7%. Conclusion We first offer programmatic experiences to address a gap in resources relating to the practical issues of designing and implementing global diabetes management interventions. We then present clinical data suggesting that favorable diabetes outcomes can be attained in poor areas of rural Guatemala.

Perceptions and utilization of generic medicines in Guatemala: a mixed-methods study with physicians and pharmacy staff

BackgroundAccess to low-cost essential generic medicines is a critical health policy goal in low-and-middle income countries (LMICs). Guatemala is an LMIC where there is both limited availability and affordability of these medications. However, attitudes of physicians and pharmacy staff regarding low-cost generics, especially generics for non-communicable diseases (NCDs), have not been fully explored in Guatemala.MethodsSemi-structured interviews with 30 pharmacy staff and 12 physicians in several highland towns in Guatemala were conducted. Interview questions related to perceptions of low-cost generic medicines, prescription and dispensing practices of generics in the treatment of two NCDs, diabetes and hypertension, and opinions about the roles of pharmacy staff and physicians in selecting medicines for patients. Pharmacy staff were recruited from a random sample of pharmacies and physicians were recruited from a convenience sample. Interview data were analyzed using a thematic approach for qualitative data as well as basic quantitative statistics.ResultsPharmacy staff and physicians expressed doubt as to the safety and efficacy of low-cost generic medicines in Guatemala. The low cost of generic medicines was often perceived as proof of their inferior quality. In the case of diabetes and hypertension, the decision to utilize a generic medicine was based on multiple factors including the patient’s financial situation, consumer preference, and, to a large extent, physician recommendations.ConclusionsInterventions to improve generic medication utilization in Guatemala must address the negative perceptions of physicians and pharmacy staff toward low-cost generics. Strengthening state capacity and transparency in the regulation and monitoring of the drug supply is a key goal of access-to-medicines advocacy in Guatemala.

Exploring mechanisms of food insecurity in indigenous agricultural communities in Guatemala: a mixed methods study

BackgroundThe country of Guatemala has one of the highest rates of chronic child malnutrition in the world, which primarily affects the rural, indigenous Maya population. In this study we explore the apparent paradox of endemic food insecurity and child malnutrition coexisting in Maya communities alongside a predominance of agricultural land holdings and food production.MethodsA mixed methods design explored food availability and access in a rural indigenous agricultural community, as compared to a nearby urban indigenous community. Structured surveys in both open-air markets and corner stores examined price, quality, and availability of foods. Structured household surveys examined land ownership, crop production, perceptions of food security, and the diversity of children’s diets. Key informant interviews with local farmers clarified findings related to land holdings and farming patterns.ResultsChildren’s diets demonstrated a lack of diversity, and were especially deficient in dairy, flesh foods, eggs, and vitamin A-rich foods. Food insecurity was highly prevalent, with limited availability of, and access to, nutritionally diverse foods. In particular, the expansion of nontraditional agricultural exports (NTAEs) reduced food availability by displacing subsistence crops. Poor returns on investment for NTAEs limited the available cash for food purchasing, further exacerbating poor diets. Food availability was further reduced by infrequent access to open-air markets in the rural setting as compared to the urban setting, with high risk of food spoilage. As a result much food purchasing was of low-cost, low-quality processed food which, unlike higher-quality fresh foods, were equally affordable and available in both the rural and the urban environment.ConclusionsThe proliferation of NTAEs and commoditized foods reduce dietary diversity and displace the production and consumption of fresh, nutritious foods, even in rural communities devoted primarily to food production. Rural agricultural communities in Guatemala therefore bear many resemblances to the urban “food deserts” of higher-income countries.

A Patient Navigation System to Minimize Barriers for Peritoneal Dialysis in Rural, Low-Resource Settings: Case Study From Guatemala

BACKGROUND: CHRONIC KIDNEY DISEASE IN GUATEMALA Guatemala is a lowerto middle-income, Latin American nation with a population of 16 million people and a growing need for rural dialysis services due to a confluence of factors. First, although the epidemiology and risk factors for chronic kidney disease (CKD) in Guatemala are not well understood, there is evidence that CKD mortality is among the highest in the Americas. The emerging entity “chronic kidney disease of nontraditional causes” may be a CKD risk factor in rural Guatemala, and regional data show that diabetic renal disease is a significant driver of population mortality. Second, approximately 40% of the population are rural indigenous Maya, a group that faces significant socioeconomic, geographic, and language barriers in accessing specialty nephrology care that is available only in urban tertiary centers. Finally, Guatemala’s population is growing and aging rapidly, greatly increasing the absolute number of people at risk for CKD.

Case reportAccompanying indigenous Maya patients with complex medical needs: A patient navigation system in rural Guatemala

a Wuqu’ Kawoq | Maya Health Alliance, Guatemala b Department of Emergency Medicine, Massachusetts General Hospital, United States c Departments of Internal Medicine and Pediatrics, University of Minnesota, United States d Division of Women’s Health, Department of Medicine, Brigham and Women’s Hospital, United States e University of California, San Francisco, United States f Burrell College of Osteopathic Medicine, United States g Division of Global Health Equity, Brigham and Women’s Hospital, United States

Insights into Global Health Practice from the Agile Software Development Movement

Global health practitioners may feel frustration that current models of global health research, delivery, and implementation are overly focused on specific interventions, slow to provide health services in the field, and relatively ill-equipped to adapt to local contexts. Adapting design principles from the agile software development movement, we propose an analogous approach to designing global health programs that emphasizes tight integration between research and implementation, early involvement of ground-level health workers and program beneficiaries, and rapid cycles of iterative program improvement. Using examples from our own fieldwork, we illustrate the potential of ‘agile global health’ and reflect on the limitations, trade-offs, and implications of this approach.

Screening for chronic kidney disease in a community-based diabetes cohort in rural Guatemala: a cross-sectional study

Objective Screening is a key strategy to address the rising burden of chronic kidney disease (CKD) in low-income and middle-income countries. However, there are few reports regarding the implementation of screening programmes in resource-limited settings. The objectives of this study are to (1) to share programmatic experiences implementing CKD screening in a rural, resource-limited setting and (2) to assess the burden of renal disease in a community-based diabetes programme in rural Guatemala. Design Cross-sectional assessment of glomerular filtration rate (GFR) and urine albumin. Setting Central Highlands of Guatemala. Participants We enrolled 144 adults with type 2 diabetes in a community-based CKD screening activity carried out by the sponsoring institution. Outcome measures Prevalence of renal disease and risk of CKD progression using Kidney Disease: Improving Global Outcomes definitions and classifications. Results We found that 57% of the sample met GFR and/or albuminuria criteria suggestive of CKD. Over half of the sample had moderate or greater increased risk for CKD progression, including nearly 20% who were classified as high or very high risk. Hypertension was common in the sample (42%), and glycaemic control was suboptimal (mean haemoglobin A1c 9.4%±2.5% at programme enrolment and 8.6%±2.3% at time of CKD screening). Conclusions The high burden of renal disease in our patient sample suggests an imperative to better understand the burden and risk factors of CKD in Guatemala. The implementation details we share reveal the tension between evidence-based CKD screening versus screening that can feasibly be delivered in resource-limited global settings.

Patient Navigation and Access to Cancer Care in Guatemala

Cancer epidemiology in Guatemala is an emerging field. Although one hospital-based cancer registry has existed for years, recent efforts to develop a population-based cancer registry in Guatemala City for pediatric and adult cancers would make population data available for the first time.2 Despite these limitations, in 2013 it was estimated that there were approximately 13,000 incident cases of cancer each year, the most common of which were cancers of the stomach, prostate, and cervix.3 For the majority of the adult population without private insurance or social security, the primary cancer referral centers in Guatemala are two large public referral hospitals (Roosevelt and San Juan de Dios) and the private, not-for-profit Instituto de Cancerología (National Cancer Institute [INCAN]), all in Guatemala City. Most elements of care at Roosevelt and San Juan de Dios are free of charge, and the Guatemalan government partially subsidizes cancer care for public-sector patients at INCAN. However, standard medications are sometimes unavailable, radiation therapy infrastructure is insufficient, and direct costs incurred by patients still can be significant.4

Treatment of end-stage renal disease with continuous ambulatory peritoneal dialysis in rural Guatemala

A 42-year-old indigenous Maya man presented to a non-profit clinic in rural Guatemala with signs, symptoms and laboratory values consistent with uncontrolled diabetes. Despite appropriate treatment, approximately 18 months after presentation, he was found to have irreversible end-stage renal disease (ESRD) of uncertain aetiology. He was referred to the national public nephrology clinic and subsequently initiated home-based continuous ambulatory peritoneal dialysis. With primary care provided by the non-profit clinic, his clinical status improved on dialysis, but socioeconomic and psychological challenges persisted for the patient and his family. This case shows how care for people with ESRD in low- and middle-income countries requires scaling up renal replacement therapy and ensuring access to primary care, mental healthcare and social work services.

Poverty, Genocide, and Superbugs: A Carbapenem-Resistant Wound Infection in Rural Guatemala

My last memory of Esteban haunts me, but I choose to remember most the day he showed up at a rural Guatemalan clinic in November 2013. A slender indigenous Maya man in his early forties who had remarkably severe type 2 diabetes, Esteban had been missing from the clinic for nearly 2 years. Observing the surprised faces of the clinic staff upon arrival, he explained that he had migrated to the United States from his village to look for work. However, he had recently decided to return to Guatemala because obtaining diabetes treatment in the United States was too difficult and expensive. He was back in the clinic to resume his free care. “I don’t know how peoplewith diabetesmake endsmeet in your country!” he told me as he flashed a mischievous grin. A few months earlier, I had begun working with a nongovernmental health organization serving indigenous communities in Guatemala. One of its flagship programs delivered medical care to about 150 adults with type 2 diabetes, most of whom were indigenous Mayas. Many patients, like Esteban, spoke one of Guatemala’s many Mayan languages, lived in isolated rural areas, and had relatively limited access to health services. The organization’s diabetes programming was compelling tome as it was of high quality, provided at no cost, and primarily managed by local Maya physicians and nurses. On his return to the organization’s clinic, Esteban reported persistent hyperglycemic symptoms, his hemoglobin A1C was greater than 13, and he had not been injecting insulin as he had been unable to afford it. The clinic staff re-prescribed him NPH insulin, dispensed lancets and glucose monitoring supplies, and titrated his insulin dose over numerous subsequent phone calls and visits. He did well. Over the next couple of years, Esteban’s glucose was well controlled with most of his hemoglobin A1C measurements below 7.5. It appeared as though he had avoided the debilitating complications that afflicted many other diabetes patients in the clinic such as amputations, renal failure, and blindness. I ran across Esteban a few times in the clinic during that period of time. He got a kick out of talking with me, always giving me that same mischievous grin as when we had first met. He seemed to think that we had a special transnational connection and that my presence as an American was hilarious—even absurd. He had chosen to return home to his rural Guatemala village from the United States, and who does he immediately find at the clinic? A gringo! In August 2015, one of the diabetes nurses informed me that Esteban had developed a severe foot infection requiring admission to a local hospital. A few weeks earlier, he had sustained a minor trauma to his foot, and, although he had thought nothing of it at the time, he soon developed an infected diabetic ulcer with pain, swelling, and purulent discharge. In the hospital, his infection was thought to be severe enough that he was at risk of needing an amputation. Fortunately, his ulcer improved with appropriate management, but, during the hospitalization, he also developed a pressure ulcer over his hip from a lack of repositioning. In addition, Esteban’s family spent down a large portion of their assets during the hospitalization, as they were required to purchase essential medicines and supplies that were unavailable at the public hospital. I saw Esteban for the last time on a sunny, warm day in December 2015. He came to the clinic alongside his wife, Magda, a petite woman dressed in a traditional Maya blouse and skirt. Because of his continued immobility and the lack of rehabilitation facilities or home nursing care in Guatemala, Esteban’s ulcer had worsened and had become infected. On examination, the clinic’s diabetes nurse and I observed a massive necrotizingwoundover Esteban’shipdraining a large quantity of pus. His wife showed us the results of a wound culture revealing the growth of aKlebsiella species resistant to all antimicrobials tested, including carbapenems. The diabetes nurse immediately contacted her clinical supervisor, and together they agreed that only immediate rehospitalization for debridement and intravenous antibiotics could possibly save Esteban’s life. Hearing this, Esteban snorted in disgust at the prospect of returning to the hospital, which he viewed as provoking this secondary complication, treating him poorly as an indigenous patient, and extracting scarce family resources. “I’m not going back to the hospital,” he declared. “Better that I die at home.” Approximately a month later, Esteban died at home. I was later informed that his family had made a last-ditch effort to treat his infection by purchasing various antibiotics at a local private clinic, including levofloxacin, although his infection was resistant to fluoroquinolones. His wife became a single mother to several young children. How did this happen? Where did he acquire such a highly resistant infection? Why did he die so young? I continue to reflect upon these questions now, years after Esteban’s death. Esteban was born into poverty and had the bad luck of developing diabetes at an early age. Because of his family’s geographic isolation and lack of resources, he was unable to control his diabetes early in its disease course. As a result, he was more susceptible to developing complications such as infected ulcers at an early age. He may have acquired the carbapenem-resistant organism during his hospitalization, as resistant Klebsiella is notorious for nosocomial transmission and has been reported widely in hospitals in Latin America. Or thebugmayhavedevelopedorhavebeentransmitted toEsteban *Address correspondence to David Flood, Medicine Pediatric Residency Program, University of Minnesota, 401 East River Parkway, VCRC 1st Floor, Suite 131, Minneapolis, MN 55455. E-mail: david@wuqukawoq.org