January 7, 2015

Health pamphlet in Creole
Photo Credit: Crystal Croom

Health promotion posters at DIGPRES
Photo Credit: Crystal Croom

Crystal: Today we had the pleasure of learning about the members of DIGPRES and its role in the Dominican community. DIGPRES is an acronym for Spanish words, but is basically the general directory of health promotion and education in the Dominican Republic. If translated correctly, their mission is to create a healthy lifestyle and environment in the population through the regulation and conduction of actions that involve health promotion and education to the public. DIGPRES created various pamphlets and educational posters to educate the public about various health issues, such as dengue, cholera, chikungunya, or malaria. These posters included the symptoms of the many diseases and prevention measures. They were also displayed in a basic manner that required minimal education to understand, giving them the ability to reach numerous people in the Dominican population. DIGPRES also had handouts and posters on health promotional activities and practices for the public to enjoy. They also know that there are many Haitian immigrants so they also make promotional booklets in Creole so their message can reach everyone. Various committees were established within DIGPRES to focus on certain health topics of concern in the Dominican Republic. We were given the opportunity to meet with some of the members of the breastfeeding committee, and they shared some of the information they give to the public. The members of each committee work hard to educate the public about various health issues and health promotional practices. They enter many communities and neighborhoods to reach as many Dominicans as possible. Unfortunately, DIGPRES is a government-run organization, and minimal government funding is given to healthcare in the D.R., making it hard for DIGPRES to fulfill their mission and vision.

Breastfeeding Committee
Photo Credit: Kirstie Geier 

Kirstie: DIGPRES had many resources to help educate and promote the practice of breastfeeding in the Dominican Republic. Their breastfeeding committee worked diligently to reach as many individuals in various hospitals and communities. They would speak with expecting or new mothers about the multiple benefits of breastfeeding for the mother and the child. They also handed out pamphlets for the mothers to keep to or to help reinforce their education. Their teaching may include how to help the newborn to “latch on,” proper diet when breastfeeding, proper positions to hold the baby during breastfeeding, and how often to breastfeed their child. We were informed that recently the presence of breastfeeding has decreased in the Dominican Republic due to the heavy amounts of baby formula advertisements and the stigmas surrounding breastfeeding, such as the women appearing less attractive to their husbands. The commission has worked hard to have laws mandating formula companies to clearly display what is in the formula and in the Spanish language. The labels also must be simple and not overly attractive to the consumer.

The students and leaders of DIGPRES in front of DIGPRES
Photo Credit: Xavier

Lastly, their commercials have to say that breastfeeding is the best choice for the mother and child and formula is the alternative method when one is not able to breastfeed. The establishment of a breastfeeding committee portrays a positive aspect of the healthcare system in the D.R. Their understanding of the importance of breastfeeding reflects positively upon their education regarding healthcare. If their committee is successful, the widespread practice of breastfeeding will have a positive health outcome in regards to maternal child health amongst the D.R.

The students with the Dominican doctor
Photo Credit: Xavier 

Rose: Today we got the chance to meet a Dominican doctor who gave a presentation that included an overview to the health systems in the D.R. We learned how the system has similar objectives to the U.S., but with different implementation techniques. He also explained some of the challenges that the D.R.’s healthcare system faces and some possible solutions. The challenges included: infectious diseases, the Haitian-Dominican border, the prevention system, lack of incentives for healthcare providers, unsafe punishment to healthcare providers (extra work hours), and inadequate health conditions. The possible solutions he presented included: border control, promotion of cardiovascular screenings, cancer prevention, salary improvement, fewer work hours, and the abolition of absurd punishments. These all seem to be serious problems with feasible solutions, but because of a corrupt government, it is even more difficult to instill political change. Unfortunately, one theme that we continued to see is the blaming of Haitians for many of the D.R.’s issues. This theme was present at DIGPRES and also in the doctor's presentation. Almost all of the prevalent infectious diseases that were presented to us were explained as brought over by Haitian immigrants. It was interesting to hear this interpretation of how the diseases have been spread when such an explanation was almost illogical for some. It seemed that perhaps culturally it was more accepted that the Haitian immigrant population was responsible for carrying the prevalent diseases and bringing them from Haiti to the D.R., than to accept that some of these diseases may have come from within the Dominican Republic’s borders.

January 8, 2015

A technician at the level three hospital cleaning the endoscopy equipment
Photo Credit: Kirstie Geier 

Kirstie: Today was an exciting day because I was able to have a first hand experience in a hospital outside of the United States. The sights at this level three hospital were intriguing. The hospital and healthcare differed greatly from that of the U.S. The U.S. has an unlimited amount of resources to provide healthcare, which allows them to administer an elite level of care. As a result, my expectations of healthcare were greatly heightened and skewed. My exposure to this level three hospital in the D.R. opened my eyes to the different scenes and practices that occur in healthcare facilities other than the U.S. This specific hospital was a regional hospital and the mainstay of healthcare for hundreds of thousands of individuals in the surrounding areas. It is classified as a level three hospital, which means it has almost everything to offer in regards to healthcare specialties such as emergency rooms, pediatrics, gynecology, surgery, diagnostics, a lab, labor and delivery and others. The hospital, like many places in the Dominican Republic, was very open and not enclosed like our hospitals in the U.S. Although the fresh air can be therapeutic and beneficial to patients, the open air and doors allows for entry of many insects. Mosquitoes are very popular in the Dominican Republic and can carry diseases like malaria and dengue, which are harmful if they spread them to humans when they bite; therefore, the open system may be detrimental to patient health as well. One method in particular that also caught my attention was their process of sterilization of equipment for colonoscopies and endoscopies. Their sterilization process differed greatly from ours in the U.S. and was not as strictly sterile. From my eyes, the sterilization processes they utilized in the D.R. were not as rigorous compared to the U.S.; however, they created functionality with the resources they had and provided care to their patients in need.

Entrance to the ICU at the level three hospital
Photo Credit: Crystal Croom

Crystal: In addition, while on our visit to the level three hospital, I noticed that the intensive care unit (ICU) had very strict rules. Overall having restrictive rules aren’t uncommon, but I had my own thoughts as to why some of the rules were in place. The ICU at the level three hospital had visitation from 3:00 p.m. to 3:30 p.m. I thought was very short compared to some of the visitations I have encountered in ICUs in the U.S. In addition, I thought we would all be able to go inside and get a look at how the ICU was set up. Sadly, only three students were able to go inside for no longer than a minute. These was upsetting because I really wanted to see for myself what it looked like and compare it to St. Joseph’s hospital. Even though I wasn’t able to witness the ICU for myself, my thoughts on why they had these rules in place meant that they were taking the highest precaution possible to avoid dangerous exposure to their patients, which was a positive aspect of the hospital’s healthcare practices. In opposition to the rules in place for the ICU, it was assumed that with inpatients on units other than the ICU, that family members of the patients were with them while admitted. When we further discussed this topic, I found out that because of the lack of nurses it was up to family members to aid their loved ones back to health. This meant helping the patient bathe, eat, go to the bathroom, and make sure they were taking their medicine. We were informed that family plays a crucial role in healthcare here in the D.R. and their presence has an important part in attaining a state of wellness.

People trying to enter the locked unit at the
level three hospital
Photo Credit: Rose Kalala 

Locked unit at the level three hospital
Photo Credit: Rose Kalala

Rose: One of the most overwhelming aspects of the hospital was the level of security present. We witnessed security guards (a lot of them armed) at almost every entrance. Barred gates, similar to those in a prison, controlled crowds. This sight was very shocking for us students. It was hard to understand why a place like a hospital, which to us is a symbol of care giving and helping one another, would also be home to symbols of violence and inequality. It was explained that families’ frustrations often times turn into aggression and that is why these precautions are necessary. I only began to somewhat understand this when I witnessed a woman arguing with a security guard at an open gate. She was trying to come into the unit, but they would not allow her for some unknown reason. She started to holler and that is when the security began to close the gate on her so that they could be sure she could not enter. This made me wonder how and why these measures of security even came about and since when did they become necessary. There are so many factors that contribute to the aspects of the health system that need improvement, it is hard to really judge one part of the system without taking the circumstances into consideration.

January 9, 2015

Kirstie in the exam room in the level two hospital
Photo Credit: Crystal Croom

Sign for the vaccination room at the
level two hospital
Photo Credit: Kirstie Geier 

Kirstie: Today we visited hospitals classified as level two hospitals, which means they do not have all the healthcare services and specialties to offer as a level three hospital. These specific hospitals did have an emergency room, a lab, pediatrics, simple surgeries, and other specialties; however, it was much smaller than the level three hospital we previously visited. The first hospital we visited was extremely crowded and busy. They had many beds per room and separated the men from the women, which is a cultural practice. This was also in place due to the limitations with the infrastructure in the healthcare system of a developing nation. They had consultation rooms for their certain specialties, like pediatrics. They also had a small area for children to receive their vaccinations. Unfortunately, one of the hospitals did not provide follow-up care or appointment dates for the children’s series of vaccinations or next vaccination. The responsibility of ensuring their children receive vaccinations falls into the hands of the parents. This can be an issue because the parents may not have the education or understanding of vaccination series or when the children need to get their next vaccination especially, with a lack of record for their child.

Sign at the level three hospital
Photo Credit: Rose Kalala

Rose: Today we also met Dr. Elisa Fernandez, a Dominican OBGYN who started her own private practice in Santo Domingo not too long ago. She spoke to us about many issues surrounding women’s health in the D.R. including, teen pregnancy, abortion, maternal mortality, and legislation on breastfeeding. She completed her residency and an internship in the Unites States and spoke English. Her presentation opened a lot of our eyes to the realities that Dominican women face everyday. Although this is changing, Dominican women see a lot less support through the above mentioned issues than women do in the U.S. Teen pregnancy rates are much higher and resuming education is not a right, but sometimes refused; women do not have the right to abortion, but are subject to severe punishment if they do abort a pregnancy; maternal mortality rates are very high (160 deaths for every 100,000 births) compared to the U.S. (<10 deaths for every 100,000 births); and reproductive rights, including breastfeeding and paid maternity leave, are all issues being pushed for improvement. All these topics are very heavy and hold a lot of important information that not only speaks on the healthcare system of this country, but also speaks on this country’s culture, which is very important for us, as foreigners, to learn about and understand as future healthcare professionals.

Filing system at the level three hospital
Photo Credit: Crystal Croom

Crystal: At both level two hospitals we visited today, we could clearly see that they lacked organization. What especially caught my attention was what I assumed was the patient filing system. The manila folders were stacked all over the offices. There was not any clear labeling or an organized structure compared to what we are used to have in the U.S., before computer filing. This could cause a lot of problems especially if papers are mixed up with different files. This could potentially cause misdiagnosis or the prescribing of the wrong medicine that could seriously harm the patient. It is shocking to believe that this is a functional system where they have every patient’s accurate paper work.

January 10, 2015

Fruit stand at Boca Chica
Photo Credit: Kirstie Geier

Kirstie: Today we were lucky enough to have a free day! Some of us elected to spend time taking in the sun on the beach! Nine students took a taxi to a beach called Boca Chica, which was about 30 minutes from our hotel. It was an interesting ride full of sights that further enriched our knowledge about the culture here in the D.R. The beach was breathtakingly beautiful. The crystal water met the white sand and the sun was high in the sky. Hotels lined the beach that attracted a crowd of people from many places all over the world. We even met people from Minnesota, which is not too far from home! There were also many local vendors on the beach selling a variety of items. We were constantly asked if we would like a massage, pedicure, Dominican music on tape, bracelets, sunglasses, or fruit. We also were finally able to drink coconut water out of the coconut! The vendors were very persistent with selling their goods, which is representative of their culture here and portrays their need to make a living. We were also informed by one of the locals on the beach to be careful and to not accept the first price we were given by the vendors, as they knew we were easy targets to rip off. The vendors were also giving full pedicures on the beach.

Boca Chica
Photo Credit: Kirstie Geier

Vendor at Boca Chica
Photo Credit: Kirstie Geier

As I watched them perform this service I could not help but think about how this related to health. The tools they were using to give the pedicures were not sanitized by any means. They also used the water from the ocean. As they moved from client to client, they did not leave the beach to clean their tools, they merely cleaned their tools in the ocean and refilled the same bowl for peoples feet with ocean water. This is a very unsanitary process, especially when dealing with peoples’ feet, which can carry bacteria, fungus, and other various items that can lead to infections. Pedicures involve the cutting of peoples’ nails and cuticles which allows for entry of these organisms into the clients, especially the entry of mass amounts because the tools were not cleaned as they moved from client to client. This practice could result in unfortunate health issues for each customer that received this service.

Entrance to the Toros stadium
Photo Credit: Crystal Croom

Students at the Toros baseball game
Photo Credit: Rose Kalala

Crystal: This evening we had the chance to attend a baseball game to cheer on Los Toros. We all knew that baseball is an important sport in the country so we all were pretty excited to attend the game. It was about a two-hour drive to La Romana, the hometown of the Toros. It took us a while to get our tickets, but we were finally able to make it inside. The stadium was medium sized, which I would describe as smaller than Orioles Stadium and bigger than Towson’s Baseball field. The stadium was clean and had nice fan artwork for the team. The game was not sold out or packed with people, but there was a good crowd of people supporting both teams. The Toros were not winning this game, but whenever they made a good play the crowd went wild. The Toros also had their own dance team who were very entertaining with their moves. To provide even more entertainment they had a marching band play to get the crowd even more excited. Towards the end of time at the game, a few adorable little boys came and sat with us for the remainder of our time. I think they just wanted to sit with us, but they were nice company. It was definitely a great experience to see how Dominicans act at their favorite pass time.

Rose: Today was a bit rough for me. I woke up feeling fine, but around noon I started to feel a bit nauseous and ended up starting a cycle of sleeping, then waking up to vomit, then going back to sleep, up until the time we were leaving for the baseball game. I knew the baseball game would be an experience I did not want to miss so I convinced myself that I was feeling well enough to go. Once on the bus, the nausea returned and I alerted my professors of my predicament and took some medication I had brought along with me to help relieve my symptoms. It was not until we were exiting the bus to enter the stadium that I started to feel better. Thankfully, by the time the game started, the medicine had kicked in and I was feeling much better. I was able to enjoy the baseball game with my class and witness some cultural differences between this event and American baseball games. It was A LOT of fun. One thing I noticed at the game that caught my eye health wise, was when my classmate came back with a hotdog from the concession stand and told us that the vendor had picked the hot dog with his visibly dirty bare hands, and slapped it in the bun that he held in his other, ungloved hand. It was almost comical how appalled we all were because we are so used to the sanitary precautions taken by people that handle food, especially at public events. My classmate decided to embrace the culture and eat the hotdog anyways and I was proud of her for that! :)

Panorama of the baseball game
Photo Credit: Rose Kalala

January 11, 2015

Pothole on the sidewalk in Santo Domingo
Photo Credit: Kirstie Geier 

Kirstie: Today was another free day in the Dominican Republic! It was a cloudy and rainy day; therefore, I did not venture to the beach. I enjoyed catching up on my sleep, as all the activities had left me completely exhausted! A few of us decided to try to Chinese restaurant in town for a late lunch. As we were walking there I noticed many things about culture and health. One element that I noticed is the way in which people drive in the D.R. The way the Dominicans drive is something us Americans would describe as pure chaos. They do not stay within the lines, people pull out in front of one another right and left and horns are constantly honking. Also, there are many cars on the roads of the D.R. As a driver here, you have to be constantly alert. In regards to health and safety, the driving here is not safe for pedestrians. Pedestrians do not have the right of way when crossing the street and have the potential to be struck by the many moving cars. Also, amongst the chaotic roads I have observed many of their drivers texting and on their phones while driving. This could lead to the death of pedestrians attempting to cross the streets or many drivers on the roads. In addition, having many cars on the road does not have a positive effect on the surrounding air. Cars pass on many fumes that can be harmful, especially to the people walking around the D.R. I have also observed that many of the cars that are utilized here are older models, which pass on even more harmful fumes, which could result in more negative health outcomes for the population. I also was informed that many children here suffer from asthma, which is due to the poor air quality and pollution, which the cars directly contribute to this issue. Lastly, on my way to lunch I noticed the many potholes and dangers that made up the sidewalk. There were many huge potholes on the sidewalk that easily could’ve been missed and resulted in my injury or Dominican people if they were not paying attention to the ground below them.

Dancing at the colonial zone
Photo Credit: Crystal Croom

Crystal: This evening the group went to the Colonial Zone to see how the community gets together to have a good time dancing. Tian told us that Sunday is a big day for families and friends to party and come together during the week. As we arrived the band was setting up and the people were flowing in. Also, as the band started playing, couples of people did not hesitate to get up to dance. Letting the music sweep them off their feet, moving with the beat, everyone was having a great time. A few of us got up to dance and immersed ourselves in the culture, moving with the crowd trying not to bump into anyone, as we were not as smooth as the Dominicans! I was asked to dance with an elderly gentleman, and it was fun just to be on the dance floor, plus I did not want to be rude and reject him. A dance group came out to show off their talents, and danced a fast-paced merengue, which is a traditional Dominican dance. They were dressed in vibrant green and red outfits. They were flowing around the dance floors, their dresses moving all around. Right before we left the community took the time to honor the flag and their country. I had a great time and learned how to merengue and bachata.

Trash on the side of the road
Photo Credit: Rose Kalala

Rose: One thing that I have continued to notice since we have been here is the excessive amounts of littered trash around the city. On our walk to lunch today, I noticed an emptied styrofoam carry-out dish less than a foot away from a trash can. This not only made me reflect on how this country’s amount of littering impacts the earth’s pollution, but it also made me wonder why there is a lack of enforcement of anti-littering laws. This was just another example of how there may be laws, but due to corruption or whatever the case may be, many of these laws are not respected. On our way to Caño Hondo earlier in the week, we passed by a huge landfill full of trash that was exposed to the air. This practice is detrimental to the health of the Domincan people for a multitude of reasons. Dr. Brace later brought up a good point that in the U.S. this would be illegal because by law, all landfills must be covered. The U.S. is not the best example of an eco-friendly country but we do have several initiatives that push for the protection of our planet, which is something the people of the D.R. could benefit from as well.

January 12, 2015

Location for women's organization
Photo Credit: Kirstie Geier

Kirstie: Today we took about a two-hour bus ride to learn about an organization of women who help other women in their community infected with HIV. This group of women provided ways for those infected to obtain skills to use in the workforce. They also helped them to sell various items that they made like jewelry, seat covers, candles, and bags to students who come to the D.R. to help them make a profit. We were also informed of the D.R.’s viewpoints towards those with HIV and how it is still considered a topic of taboo. The organization even went to great lengths to create a name that had no affiliation with the words HIV to not reveal that the members were infected. People also do not share or talk about their infection with HIV because of the country’s views towards individuals who are infected with this virus. Also, not all patients have to report to the ministry of health that they have HIV. In the public hospitals, the patients do not have a choice and it is reported, but in the private hospitals the patients are given the choice. We were also informed that many of the individuals who struggle with HIV are located in the poor rural areas, where they do not have close access to healthcare and have difficulty affording their healthcare. The mainstay of treatment for HIV is antiretroviral drugs, which are very costly. The cost of these drugs is covered for by donations from various organizations such as WHO (World Health Organization) for patients here in the D.R. Unfortunately, the leader of the program informed us that she was unsure what the next steps would be when the funds and donations came to an end, which was in the near future. Without proper treatment those individuals infected with HIV will have a shorter life-span and a life of poor quality. The lack of care for these patients could result in a vast spreading of this disease and detrimental health outcomes for the D.R.

Women of the HIV organization
Photo Credit: Rose Kalala

Rose: The women also explained that the closest healthcare facility was 4 km away, thus many of them utilize traditional medicines as their first line of healthcare, but if serious medical attention is required they must go to the next town over. They gave many examples of traditional medicinal remedies used in the community. Some examples included, olive oil and cilantro to relieve congestion or boiling bright orange tree leaves in water for parasite treatment in children. These remedies spread throughout the community by word of mouth and have been passed down from generation to generation for many years. They are so widely used in more rural areas because they are cheaper and more feasible to make since access to first level hospitals (or any other level) is extremely difficult. The president of the organization shared a personal example of this difficulty when her mother fell ill and had to be taken to the hospital. The only way her family could transport her was on the back of a motorbike. This made me realize just how fortunate we are as Americans to have the access to care that we do. Even though some have it easier than others, we all have the ability to reach a hospital or some form of healthcare provider whereas a lot of people in these rural towns of the D.R. do not.

Handcrafted work by the Dominican women
Photo Credit: Crystal Croom

Crystal: Today as we were visiting the women who helped other women infected with HIV where we were offered to buy the crafts they had hand crafted. There was a wide selection of items to buy, such as candles, rugs, jewelry, vanilla extract, and a traditional remedy. They really only sell their goods to visitor like us, so it was nice to contribute to their cause. A lot of the products were made of recycled materials, which is good for the environment. As they were telling us about their products there were a few kids in the corner making noise. As I reflected on this, it was quite distracting, but the speaker did not seem distracted at all. It helped me realize a difference between our culture and Dominican culture. Many Dominicans are accustomed to background noise and can continue the task at hand, unlike Americans who are distracted by any form of background noise or interruption. Also, while they were discussing their support for those with HIV, many of us had questions about the people in the community that are actually infected with the disease. In the Dominican culture questions as such are considered taboo and are inappropriate to ask. It was encouraging to learn about the women coming together in the community to support each other and those infected with HIV.

January 13, 2015

Exam room in the level one hospital
Photo Credit: Kirstie Geier 

Kirstie: On this lovely Tuesday morning we had the pleasure or exploring the level one healthcare facility. We were supposed to visit two of these facilities, but we were unable to visit the first because the doctors and nurses were not present because they were making house calls. We were informed that this was a common occurrence in the healthcare system. This occurrence reiterated the theme of the D.R.’s healthcare system, which was a lack of resources. Unfortunately, doctors and nurses were not as plentiful in the D.R. as they are in the U.S. to provide care to patients in need, especially in the public setting. Also, during our visit to the level one hospital I noticed that the rooms were small and were not furnished with sufficient space. The building was also in close vicinity the road with open windows, which allowed for vast amounts of noise from the environment to pass through. This could affect the quality of healthcare given to the patient because it could hinder communication between the patient and the healthcare provider. It is also not an ideal environment to have and intimate or serious conversation regarding ones health struggles. My views of this visit could be skewed by my experiences in the U.S. due to our ample amount of resources present in healthcare. The D.R. shows its strength by maintaining functionality and providing care to patients with the limited resources available to them.

Doctor in front of level one hospital
Photo Credit: Rose Kalala

Rose: When we arrived to the level one hospital, there were about five patients present. The general doctor that gave us the tour had been with one of these patients upon our arrival, but stopped his consultation with the patient to give us a tour. Although, we were very thankful for his time, I could not help but to feel very guilty that we had taken the doctor away from his patient. I feel like this shows not only the level of privilege we have as Americans, but it also sheds light on yet another cultural difference between the two countries. If a group came to an American hospital for a tour, I believe the doctor would finish with his patient or not have a patient during the time of the tour, which then delves into the different views on the concept of time and planning between the D.R. and U.S. Although our treatment can be justified by cultural difference, it does not change the fact that his patient’s quality of care was affected by our visit. This leads me to wonder how other patients’ quality of care becomes equally affected by interruptions or the healthcare provider’s schedule.

Monument in honor of the Mirabal sisters
Photo Credit: Crystal Croom

Crystal: This evening we watched a movie called The Time of the Butterflies. This film tells the true story of the three Mirabal sisters, who in the 1960’s plotted to overtake the Dominican government. This revolutionary plot started with Minerva, the first women to attend and complete law school in the DR. Even through her struggle of getting in and completing law school her degree was withheld from her out of revenge from Rafael Leonidas Trujilo. He was a powerful dictator and his ruling over the country was harsh and demanding, harming anyone that disobeyed. Maria Teresa found her sister at law school after running away from home. She soon joins the revolution even though Minerva pleads her not to. Their forces and determination become stronger as they take more strikes at the government by trying to hide military weapons. At first their older sister Patria is hesitant to join her them, but decided she would rather be with them while they fought then to just watch. All three women were very strong as they were harassed, imprisoned, and killed. The ending of this movie was very sad as I did not want it to end the way it did but many believed in them and carried on their revolutionary plots to finally overthrow Trujilo. To honor their courage and strength a beautifully colored monument was built in their memory in Santo Domingo.