Global Health is Also Local Health

It was another long hot summer in the Dominican Republic, but for Columbia Nursing students at the Clinica de Familia in the city of La Romana, the intensity of the heat was overshadowed by the intensity of their experience working among the poor and sick at the eastern end of the island.

"I wanted to put myself outside my comfort zone," says Melanie Swan, '14 , who is in the Family Nurse Practitioner Program. "This was my first exposure to global health, and my first week there I was in shock – the weather, the language, the culture, the healthcare issues. But the four weeks I spent in La Romana were a wonderful experience, truly unforgettable."

Swan, who will graduate in December and plans to pursue a DNP degree at Columbia Nursing, is not alone in her praise of the program, which annually hosts more than 60 Columbia medical, public health, nursing, and dental students, as well as residents and post-graduate fellows. Swan is one of eight nurse practitioner students who attended this year’s four-week summer program.

Another is Zoe Andrada, '14. "Clinica de Familia offers a tremendous service to that community,” says Andrada who is also in the Family Nurse Practitioner Program. "In fact, the experience gave me a new point of view regarding how to work with immigrant populations in this country, especially the Dominican community here in Washington Heights.”

Derrick Luis Lewis, Student and Volunteer Coordinator at Clinica de Familia, has seen this change of perspective many times since joining the staff in 2011. "When they first get here, some students have the tourist vision – sky, sun and sand," he notes. "We’re on the coast, some 80 miles east of the capital. It’s beautiful, but behind these world-class beach resorts is a large, impoverished society built on agriculture and manual labor. Many women here work in the sex trade industry, which is legal in the DR. Some students who come here have never seen anything like it before."

It was the HIV epidemic that led to the founding of International Family AIDS Program (IFAP) in 1999 by CUMC Professor Stephen Nicholas, MD, who serves as Dean for Admissions at the College of Physicians and Surgeons. IFAP is a collaborative project within CUMC that supports Clinica de Familia La Romana, as well as other interventions elsewhere in the world. IFAP’s primary historic focus has been on countering the vertical transmission of HIV from mothers to babies in poorly resourced areas. IFAP’s first service site was in La Romana and has become the Clinica de Familia La Romana (CFLR).

Currently, Clinica de Familia is the largest HIV clinic in the eastern Dominican Republic, offering care and antiretroviral treatment to 1,600 children and adults with HIV each year. During its 15 years of operation, the clinic has grown and now also oversees MAMI, the Maternal-Infant Health Annex, working as a public/private collaboration with a large Ministry of Health provincial hospital across the street. MAMI offers adolescents sexual and reproductive health services and education, including a large prenatal care program and family planning services. In addition, Clinica de Familia also offers two week-long summer camps in the countryside for children and adolescents with HIV.

"It’s important to remember that global health is also local health," says Ana Jimenez-Bautista, who was born in the Dominican Republic and is the current director of programs at IFAP. "You really see the truth of this in urban areas like New York, where there are so many immigrants. That’s one reason we provide opportunities for students and others to participate in these programs. Ultimately, education and health go hand in hand.”

Students are integrated into the staff and work a full work week, usually rotating through the clinic, MAMI and the hospital. Students also take on projects that increase the quality of care or support the overall ongoing work. Recent projects have included creating products such as patient educational modules, patient satisfaction surveys and needs assessment research.

Some students join projects already underway at the clinic. Not surprisingly, since sex workers are a large percentage of CFLR clients, one such project involves an ongoing, active outreach to the 60 or so sex-related establishments in the area via the Community Health Promotion Team.

"I had never dealt with sex workers before, so I joined that project," Andrada says. "I visited brothels with a worker from the clinic who teaches them about disease, birth control and other issues. This was my first trip abroad as a clinician, so I could assess what steps we could take to help people in these situations. Now that I am back in New York, I’m trying to organize some kind of fund-raising event to support the clinic."

The program at Clinica de Familia is geared toward integrating patients, students and staff as "part of a family, where comprehensive care, education and research are entwined to improve patient health," according to Lewis. "We are going in a great direction."