How public health is done in Barranquilla, Colombia
When I was a little kid, I’d go along with my grandmother as she walked miles and miles back in our ancestral hometown in northern Mexico. The heat was quite oppressive, but it was a dry heat. Still, we’d take breaks at people’s houses, drinking lots of cold water. See, my abuelita would buy entire bales of used clothes in El Paso and take them to the hometown to sell them to people who could afford to buy them only on credit. Then she’d make the rounds and collect a little bit of money here, a little bit there. She’d forgive some debt if most of it was paid.
Anyway, walking long distances in hot weather is something I’m familiar with. But it’s the dry heat of the Chihuahuan Desert. You sweat but it evaporates quickly, cooling you off quite effectively. You just have to stay hydrated and you’re good to go. Now, I know I keep bringing it up since I’ve been here, but, holy crap, it’s hot. It’s the kind of heat that is oppressive. It grabs you by the throat and doesn’t let go. You sweat, and it goes nowhere.
This is the reason why I am incredibly humbled today after spending the morning with the local health department’s “health walkers.” Surveillance for infectious diseases here is made up of different active and passive components. In passive surveillance, the people who collect the data send it to you passively, usually in the form of an electronic report of disease case counts. In active surveillance, the epidemiologist does the surveillance themselves. The epidemiologists in Barranquilla use the passive system to look at general case counts of people who make contact with the healthcare system (since it’s healthcare providers who do the reporting through the passive system). What about the people out in the community that don’t go to the doctor or don’t have access to healthcare? Well, let me tell you…
I didn’t get enough sleep last night since a restaurant behind the apartment building where I’m staying had an alarm going off all night. It started around midnight and didn’t let up even after I left at six. The guard to the apartment building said that the police had come around, but they couldn’t get a hold of anyone to go to the restaurant and stop the alarm. It was a very annoying sound. If I had broken in, I’d probably leave out of sheer annoyance.
By 6:30am, I was at the local health department. The sun was already up, but the heat was not very bad. It had just recently rained a little bit, so there was some coolness in the air. The chief of the group told me to be there by 7am, so I was there a little early. I got to see a lot of parents park around the department and take their children to a nearby school. This made me think of all the “differences” that we have between countries and cultures. We’re not that different, really. Here and in China, parents guard their kiddos and try to make sure said kiddos are alright. This would come around and slap me in the face in about two hours.
The chief and her group got there around 7:15am. We immediately piled into a pickup truck and headed out to the southwest part of Barranquilla, one of the poorest parts of town. Traffic was nuts, which isn’t a surprise. What seems to me like a very early hour of the day is not early at all here. People try to do as much in the morning before the sun really comes out. Once the sun is out in full force, things outdoors slow down a little bit. Most everyone travels by car or bus, with the A/C at full blast, I’m sure.
After about 20 minutes, we arrived at a health center where dozens of people were in line to receive different types of services. The center itself is closer to a hospital than a “center”, per se. (More on that later.) An old man in a plastic chair asked where the flu shots were being given. The chief pointed to a table under a tarp. “Okay, I’ll go and wait there,” he said. “I’m an old man. I need my vaccine,” he said.
If you’ve been reading this blog for a while, then you know of my fights with the anti-vaccine crowd. I really wish the very privileged, very sheltered anti-vaccine people came down here and talked to some of the people in line to get their vaccine. They will tell stories of recent outbreaks of measles or chickenpox or pneumonia that almost killed their children. They will tell you that sanitation has nothing to do with it. They have very clean water in Barranquilla. They will tell you that they can remember when vaccines were not plentiful, and diseases were rampant.
As the group settled into their different posts, the chief asked me to go with the psychologist in the group on her visits. You see, public health here includes mental health. The psychologist and I were taken by the driver to visit people who had recently attempted suicide. As you may or may not know, suicide is a very serious thing to me due to personal reasons. I didn’t hesitate in disclosing this to the psychologist. If I didn’t feel comfortable in listening to the stories I was about to hear, I wanted her to know why.
We drove a few blocks to a very poor part of the city. The homes were nothing more than four walls and some sort of a roof on top of them. We were looking for a woman who had recently attempted suicide. The psychologist was charged with following-up and making sure that the woman was getting the help she needed. As we jumped off the truck, the driver told us to leave all valuables in the truck. He didn’t want us walking around with our bags, wallets, and cellphones. Still, I took my cellphone with me. Don’t ask why. I’m dumb like that.
After a few people told us which way to go, we found the woman’s home. The woman’s daughter was there, but not the woman. The daughter told us that her mom lived with a boyfriend. The psychologist then asked what happened. I’m not going to give you the details, of course. But, basically, there had been a death in the family of one of the children. It unraveled the family and everyone went their own way. The daughter said her mom had not been the same since, hence her issues and her now multiple attempts at suicide. The psychologist gathered all the information she could and got the mother’s phone number to follow-up in person. We then headed to the second place.
The second case was a teenage girl who also had a recent death of someone close in her family. She was acting up, so her mother grounded her. The girl then slit her wrists, deep, telling her mother that life was not worth living. The psychologist talked to the mom about the need to continue counseling. Apparently, the girl had stopped wanting to go to counseling, and that’s why we were there. The health department mental health staff take it seriously if you don’t go get help, and they will get on you about it. After a chat from the psychologist (who was a woman), the teenage girl agreed that she would try and get along with her psychiatrist.
We also looked for a couple of other cases, but they had moved or given wrong addresses. So the psychologist was going to clear that up and then try to follow-up with them again the next day. We then headed back to the health center. The chief was waiting for me along with a group of “health walkers.” The health walkers are people who work for or with the local health department in identifying and intervening in outbreaks. They walk along neighborhoods and ask people about different health-related things. Today, they were asking about Chikungunya.
“Chikungunya (pronunciation: \chik-en-gun-ye) virus is transmitted to people by mosquitoes. The most common symptoms of chikungunya virus infection are fever and joint pain. Other symptoms may include headache, muscle pain, joint swelling, or rash. Outbreaks have occurred in countries in Africa, Asia, Europe, and the Indian and Pacific Oceans. In late 2013, chikungunya virus was found for the first time in the Americas on islands in the Caribbean. There is a risk that the virus will be imported to new areas by infected travelers. There is no vaccine to prevent or medicine to treat chikungunya virus infection. Travelers can protect themselves by preventing mosquito bites. When traveling to countries with chikungunya virus, use insect repellent, wear long sleeves and pants, and stay in places with air conditioning or that use window and door screens.”
From what I learned from the people in San Joaquin ten days ago, Chikungunya can be quite debilitating. As we walked along, the walkers asked people if they had any kind of flu-like symptoms. They also asked if any children in the household were not up-to-date on their vaccines. If there were any children missing a vaccine, the parents were instructed to take the children over to the health center right then and there to get the children caught up. Some even offered to babysit the other kids while the parent went over. (The health center was about a block away, by the way.) We also went into the households and checked for potential mosquito breeding sites.
That is when we walked into a small house which was made up of a couple of rooms. One room was the living room, kitchen, and a bedroom all at once. The one woman there was the mother to three children, one of them special needs. He dragged himself along the floor, trying to interact with us but very much non-verbal. The other children ran to and fro, seemingly excited at all the attention they were getting. There was a small water plant in the middle of the living room. The health worker picked it up and we saw dozens of little mosquito larvae. In the back yard, there were plenty of other sites where water had built up, and they were also chock full of larvae.
She was told all about the mosquitoes and how they were responsible for the Chikungunya outbreak. The workers told her to cover all containers that have water, or to not keep water in containers, period. Anything with larvae in it had to be cleaned out and scrubbed thoroughly. When asked if her children were vaccinated, she said, “Yes, especially him,” as she pointed to the special needs child.
This is when it struck me that parents will do their darnedest to protect their children. The woman, with all of the hardships of her living conditions, still made it her responsibility to immunize all of her children. And she knew that her child with special needs would be at more risk of complications from vaccine-preventable diseases.
We continued to walk around some more, not finding any people with Chikungunya symptoms. There were a couple of children who did need to get caught up on their vaccines. The parents were told to bring them over to get caught up, and the parents did, just like that. The chief told me that they did this every day, throughout the years. She said that they do a more intense “health walking” when there are outbreaks. “If we find a child with measles, each of us splits up and takes on a block around the home of the child, looking for non-immunized children and other measles cases.”
We finally went for a tour of the “C.A.M.I.N.O” center. The waiting room was packed with people seeking care. The chief walked me around and showed me the different things that the center has to offer. There are full lab and x-ray services. (If the lab can’t be performed there, it can be sent to a reference lab.) I also got to meet the physicians working there. They were so young!
I really don’t know of any health department in the United States where the epidemiologists walk the streets and actively look for public health problems to fix. I’m sure they’re out there. Not everyone can be as complacent and, frankly, lazy as some of the public health people I’ve met in the States. Then again, maybe public health triumphs in the United States have cost us our strength, and victory over certain bugs has actually defeated us. And I’m not joking… There are threats on the horizon that American public health workers are very unprepared for.
While I thought I was coming down here to impart some of my knowledge on disease surveillance, I ended up being taught a great deal of lessons hanging out with the local health department staff. Sure, I may have overheated (again) and crawled back into the apartment feeling sick and exhausted, but it was worth it to gain some perspective. (I feel better now that I have some fluids in me. I forgot to bring water with me today.) I’ve heard that this is how it goes when you leave behind your comforts and go where the bugs are.
You become something else entirely.
Originally published at epidemiological.net on July 8, 2015. Edited for Medium on July 9, 2015.