Episcopal Medical Missions Foundation
REPORT OF THE MEDICAL ACTIVITIES AND RESULTS OF INVESTIGATIONS CONDUCTED IN THE GLENDEVON COMMUNITY OF JAMAICA DURING THE PERIOD JULY 10-15, 1998
This report details the medical activities performed at St. Francis Episcopal Church in the community of Glendevon during the period July 10-15, 1998. A clinic was conducted by a staff of three nurses, a physician, an Episcopal priest, and five supporting (clerical) personnel from the St. Andrew's Episcopal Church of San Antonio, Texas following the invitation of The Very Reverend Justin A. Nembhard, Rector and Dean of the St. James Parish Church in Montego Bay and with the assistance of Dr. Linnette Jackson-Myers, St. James Public Health Department. The physician received temporary privileges from the Medical Council of Jamaica while the nurses received their temporary privileges from The Nursing Council of Jamaica.
The health needs of the people of Glendevon were first made known to medical members of the Episcopal Church in Texas during the summer of 1997. This prompted a site visit and needs assessment conducted by a physican and a public health nurse on July 26-27, 1998. Among the persons interviewed were Father Nembhard, Annette Mellish, lay minister at St. Francis Church, Glendevon, Barrington Fleming, newspaper editor and a member of St. Francis, and Benjamin Wauchope, a businessman from Hanover parish. Subsequent to the site visit a review of the medical literature regarding the health needs of Jamaica was made at the medical library of The University of Texas Health Science Center at San Antonio. Ninety-five abstracts covering the years 1993-1997 were collected and from these eighteen articles were analyzed covering the following areas; (1) sickle cell anemia, (2) diabetes mellitus, (3) hypertension, (4) nutrition, (5) violence, (6) care of the elderly and disabled, and (7) sex education, teen pregnancy, and family planning (see appendix A). A presentation of their findings was made by the site visit team to the parishioners of St. Andrew's Episcopal Church who accepted the invitation of Father Nembhard to conduct the clinic in Glendevon. It was decided that the needs that might best be addressed by the limited resources of St. Andrew's parish would be those identified in the areas of anemia, diabetes and hypertension.
RATIONALE FOR THE MEDICAL SERVICES OFFERED AT THE CLINIC
To assess the scope and impact of anemia on the population of Glendevon it was decided to offer the laboratory assessment of the microhaematocrit and instructions from a hematologist to anyone discovered to have anemia. Similarly random blood glucose determinations performed with a portable glucometer would be offered to the members of the community and if elevations were observed, a second, fasting blood level would be performed to confirm the clinical impression of diabetes mellitus. Those patients who either carried the diagnosis of diabetes or who were newly diagnosed at the clinic would be offered instructions in the personal and dietary management of diabetes by a diabetes nurse educator. Lastly clients who visited the clinic would be offered blood pressure evaluations by sphygmomanometer, and if hypertension was observed, they would be given instructions according to the recommendations of the World Health Organization (WHO Technical Report Series #862, Hypertension Control, Geneva, 1996) and seek follow-up or therapy as appropriate from their private physician, hospital clinic, or public health facility. This type of clinic, often referred to as a "health fair," is familiar to most.
OVERVIEW OF CLINIC PROCEDURES
Clinics were conducted from 9AM until all patients were seen (approximately 5PM) on July 10th and 11th and on July 13th, 14th, and 15th. Two rooms in the parish school were used. Clients were invited to give a brief medical history with particular emphasis on previous diagnoses of anemia, hypertension, and diabetes and on a family history of any of these conditions. They were offered a blood pressure check and given the opportunity to chose a random blood glucose determination, hematocrit, or both. After giving written consent, they were taken to the laboratory where they donated drops of blood for the glucometer readings and/or for the capillary microhematocrit tubes. The results of the blood glucose determinations were reviewed with the patient by the diabetes nurse educator. Patients with elevated blood glucose results were invited to return to the clinic after an overnight fast for a "fasting" blood glucose. Those patients who either were known to carry the diagnosis of diabetes mellitus or who were newly diagnosed at this clinic were invited to return for instructions in personal diabetes care and dietary changes by the diabetes nurse educator. Following the instruction period each patient was given printed materials to take home and review to underscore the lessons from the nurse. Patients were then seen by the physician who reviewed their medical histories, listened to their current chief complaints, and performed a limited physical examination as appropriate. Patients who were either known to be hypertensive or newly diagnosed at this clinic received their instructions from the physician (hematologist) who also counseled those with anemia. Patients with diagnoses established prior to their clinic visit and who had regularly scheduled appointments to their personal physicians, hospital clinic, or public health facility were encouraged to keep their appointments and were given a letter from the clinic physician giving the results of the limited physical examinations and laboratory studies performed at the clinic. Patients newly diagnosed were given similar letters with instructions to make an appointment with their personal physicians, hospital clinic, or public health facility to present the letter and receive follow-up care. No medications were dispensed in the clinic and no prescriptions were written. Therapeutic recommendations were limited to those medications that could be obtained without prescription (over-the-counter).
RESULTS OF MEDICAL ACTIV'ITIES AND INV'ESTIGATIONS CONDUCTED AT THE CLINIC
Two-hundred, forty-seven (247) patients were seen by the members of the medical team (see appendix B). One-hundred and seventy-three (173) were females and 74 were males. Their ages ranged from five months to 94 years as follows:
Age Range (in years)
Number of Patients
DIAGNOSES ENCOUNTERED IN THE CLINIC
Diagnosis observed in more than 30 Patients:
Hypertension was observed in 62 patients. Thirty-eight (38) patients had been informed that they were hypertensive prior to their clinic visit while 24 received the diagnosis for the first time. The youngest patient was 28 and the oldest 93 years. Among the 38 patients whose hypertensive condition was known 25 were receiving medications under the supervision of a physician or clinic. Six of these (24%) had WHO grade 3 (severe) hypertension. The WHO recommends that patients with grade 3 hypertension receive immediate evaluation and treatment. Seven of the 25 patients receiving medications for hypertension (28%) had WHO grade 2 (moderate) hypertension. In summary more than one-half of the patients with known hypertension receiving medication were not adequately controlled. There was no formal attempt to discern the reason for this although compliance, a general understanding of the medications, their names and the purpose for their administration appeared to be inadequate among these clients. For example in a small, informal survey, few patients could identify the relationship between hypertension and stroke or between hypertension and coronary vascular disease. (Sample question: "What could happen to you if your blood pressure remains too high?") Others complained that they had not refilled their prescriptions for hypertensive medications because of the expense.
Diagnoses observed in more than 20 patients.
Diabetes was observed in 28 patients. Twenty-five (25) patients had been informed that they were diabetic prior to their clinic visit while 3 received the diagnosis for the first time. The youngest patient was 12 and the oldest 93 years. Among the 25 patients whose diabetes was known 21 were receiving medications under the supervision of a physician or clinic. Thirteen (13) of these (52%) had random glucose determinations above 150 mg/dL. Four of the 25 patients receiving medications for diabetes (16%) had random glucose determinations above 300 mg/dL and only one had a random glucose determination above 500 mg/dL. In summary, the diabetes of only one-sixth of the patients receiving medication were not adequately controlled. There was no formal attempt to discern the reason for this although compliance, a general understanding of the medications, their names and the purpose for their administration appeared to be inadequate among these clients. For example in a small, informal survey, few patients could identify the relationship between diabetes and blood sugar levels or between diabetes and coronary vascular disease. (Sample question: "If you have diabetes, what happens to your blood sugar?") Others complained that they had not refilled their prescriptions for diabetic medications because of the expense.
Headaches were the chief medical complaints among 24 patients. Twenty-seven (27) well children were encountered in the clinic population.
Diagnoses observed in more than 10 Patients:
Anorexia (13 patients), arthritis (17 patients), and asthma (10 patients) were frequently encountered. No patients were receiving medications for anorexia while most patients were receiving medication for arthritis (ibuprofen and glucosamine preparations) and asthma (ventolin inhalers).
Diagnoses of particular note:
One hundred and forty-four (144) hematocrit determinations were performed and only 5 (3%) were anemic, suggesting that large screening programs to discover anemia would not be cost effective in similar patient populations in Jamaica It is of interest to note, however, that 3 (60%) of the anemic patients were not aware of their condition prior to the clinic visit. No cases of sickle cell anemia were enncountered and only two patients gave a history of sickle cell trait.
Cataracts were observed in six cases and two were diagnosed for the first time at the clinic. Cataracts were observed among only the 89 patients above 50 years or in 7% of the elderly. The case studies of patients with cataracts did however illustrate the delays encountered in obtaining surgery for these patients, delaysthat apparently are due to lack of medical personnel and cost which must usually be borne by the patient.
Varicosities were observed in seven cases and none were discovered for the first time at the clinic. In some instances the delay in seeking surgical remedies had resulted in gross disfigurement and stasis ulceration.
CONCLUSIONS AND RECOMMENDATIONS FOR FUTURE MEDICAL MISSIONS TO JAMAICA.
Future medical missions to the urban disadvantaged of Jamaica should continue to address the major health needs, namely hypertension and diabetes with its ocular complications. Provision should be made to provide anti-hypertensive medications which few patients can afford. In contrast insulin and oral hypoglycemics appear to be abundantly available and within the reach of most patients, while delays in addressing the ocular complications of diabetes such as cataracts are often seen. Opthalmologists with an interest in cataract surgery and the prevention/therapy of glaucoma would be a welcome addition to future medical teams. Although not discussed in detail in the literature of Jamaica, the findings of this team suggests that further study of the impact of arthritis and asthma on Jamaicans would be useful. ibuprofen is a prescription drug in Jamaica as is ventolin. Provision of these medications should be taken into consideration.
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