Gaden Relief Projects Helping Tibetans preserve their unique culture. Planning Report

Zadoh Health Project – August 2001
Submitted June 29, 2001

By Dr. Robbie Chase

Contents

I. Community Health Assessment
II. Health Clinic and treatment
III. Materials required: Medications and Equipment
IV. Timeline; Contacts; organizational

I. Community Health Assessment

The purpose is to get a general picture of the major health problems for the local people of Zadoh around the site of the Jamseng Health Cetnre, particularly those conditions treatable by Western medicine, and treatment delivery is feasible. A local Chinese doctor will be on salary but local siupply of medications and diagnositics is lacking.

A survey requires knowing how many people there are as well as how many of them are sick, so basing it on a representative selection of households is often the better way, instead of opening up a clinic and inviting everyone to come who wants to. Because this is a planning trip, the community health assessment should take priority to providing treatments (which can be done to some extent).

Information about the common health problems comes from Rinpoche's trip in August 2000:

Zadoh town (30,000 a lot of ex-herders who lost herds in the 1996 and 1997 famine- lots of social and health problems, open sewage, no public services. Health problems: digestive (gall bladder, appendicitis, stomach upset/indiestion, cold and flu, rheumatisim/arthritis, foot and leg swelling, high blood pressure, heart disease, dental problems, kidney and bladder stones, a lot of skin problems scabies, lice, women's bleeding problems, depression child malnutrition and diarrhea. Poverty is a big problem. Jamseng Health Centre, 1 hrs drive away, is a rural area with 7000 people, a lot of them herders and away in the summertime. Water quality and sanitation is better, many live in tents.

Plans are to do a household survey using a participatory approach to gather information combined with medical examination as required. Assuming 4 days or parts of days for the survey, we could assess 8 -20 households and extended families (not closely related, chosen randomly or scattered geographically- one way might be to select 10-20 children, not related to each over up to the level of their great grandparents). Sessions might take 2-3 hours each, depending on the family size, the numbers present, and how elaborate we get. With information gathered about close relatives and their households, each with 50 or more people, we would have a sample of 400-1,000 people.

At each selected household, the family gathers and provides information on every one's health. A genogram, a visual diagram of the extended family is constructed, on a large 5x8 ft sheet on the floor with different coloured cards representing family members, on top of which markers or notes are placed to record specific information about the individuals and their health. It would have to be done indoors; the cards would blow around too much outside. With the genogram outlining the family like a 'mandala' and Rinpoche as lama and translator both, the session will be very interactive and informative. A digital camera, and note cards on individuals can record much of the information.

First, the current household is mapped out, and those of close relatives. To this are added those who have died, miscarried, moved away. In a group interview process a series of questions inquire into different health problems; those who are ill are marked. If the person is present, he or she can be examined and assessed (e.g. for TB, hypertension, anemia, or worms), given an index marker and the information recorded. The person is given a numbered card with which he/she is to attend the clinic for treatment and advice.

The following is a list of health problems known to be common in Zadoh that will be investigated. Most are fairly easily diagnosed and reasonably treatable by the clinic and followed by Jamseng Health Centre.

pulmonary tuberculosis,
asthma, respiratory infections (ear, nose, throat, lung)
hypertension,
diabetes,
anemia,
vitamin deficiencies (Vit D- rickets),
intestinal worms,
diarrhea,
gastritis,
ulcer malnutrition,
orthopedic conditions and disabilities
history of specific sicknesses (hepatitis,
vaccinations
mental health and disability
assessment of general living conditions, hygiene, poverty, nutrition

1. re. Tuberculosis- discussion with Earl Herschfield MD Director of TB program HSC, Winnipeg

People have likely been vaccinated with BCG, so tuberculin skin testing is not useful. Best approach is to treat active tuberculosis cases that are sputum-positive for TB bacilli. Children don't cough up as much and may not be diagnosed by microscopy, easy to do. X-rays, bacterial cultures, are not necessary. The TB cases take 6 months of medication, and are re-tested; 90% become sputum-negative.

For this to work you need a microscope, and a good supply of TB drugs, there should at least 3 months worth on site before you start, because undertreating or stopping early leads to failures and increased drug resistance.

WHO and World Bank fund TB programming in agreement with China. WHO reports that TB programming will commence in Chinghai province in the next few years. A local Zadoh program must have a stable supply of TB medications and a way to ensure full compliance with a long course of treatment.

I will learn how to prepare sputum samples on microscope slides and to fixed them. Slides on as amny as 30-35 people suspected of pulmonary TB will be prepared and brought back to HEAlth Sciecne cetnrte TB Lab for staining and microscopy. Records will be kept and postive individuals tracked for futrue tretment and household prevention measures. We will also try to meet or contact local health authorities in Yushu and Chinghai to find out about TB programming in the province.

2. re. specific local health conditions.

There is a echinococcus tapeworm transmitted from yaks, to dogs who eat raw viscera via fecal contamination to people, particularly children. It is a slow process but the tumor-like cysts in liver, lung and brain can get as large as 10 cm. Worm medicine can stop or prevent it, but it can be hard to diagnose early without chest xray and ultrasound. Isaac recalled many women describing heart problems and 'zinging in the arms and legs' to be very similar to our notion of depression, and other local cultural idioms for psychological problems.

In addition to history and physical exam, where indicated, symptomatic individuals will have

Blood glucometer by pin prick (diabetes)
Hypertension (blood pressure)
Urine multitest dip sticks
Peak Flow spirometer device (asthma)
pin prick hemaglobinometer (anemia)
sputum microscopy (TB)

[a battery operated pulse oximeter to measure oxygen circulation would be useful Isaac says but expensive, unless we could borrow one from a hospital ]

Eye problems- significant problems found will be referred to the SEVA team coming in September.

II. Treatment

After the household assessment, a clinic will be held to follow up with sick individuals from the households and others. In Yushu they had difficulty limiting the crush of people. They had problems with people counterfeiting the referral cards, which should be numbered and given specific times to come. It may not be such a problem in the rural area around Jamseng, but it is important to organize well and avoid problems.

Below is a fairly specific list of medications to be available. Keeping the list fairly short and trying to standardize dosage is important to avoid confusion. The equipment will remain in Zadoh for use by the doctor and trainees. The plan is to take in one large suitcase of medications. The estimated amounts are likely 2-3 times more than the August clinic would use, but the SEVA group coming in September could bring in more supplies for ongoing treatments.

III. Materials Required

Assessment:

Genogram kit : coloured bristol board, cardboard, glue, markers (bring materials, plan on the trip and prepare once there)

Record keeping-

note pads, numbered referral cards Paper records of patients, sputum samples to ensure follow up. (with carbon copy for record?) digital camera (genogram layout, clinical photos, documentation) laptop (writing, photo download, spreadsheet

Medical diagnostics

Blood Pressure cuffs (2 mercury units donated by HSC)
Stethescope (donated)
Hemaglobinometer- NEED $450 to buy or donated [Evelyn: Starkman's?]
Blood Glucometer- COST?
Urine multi dipsticks- 500+
Peak flow meter (have)
Battery operated Otoscope / ophthalmascope

Treatment

Anemia:

Iron deficiency anemia
Multivitamin with iron (FeSO4 425 mg) 2-3/day x 3 mo= 300 , for 50? [=15,000 tabs] GI blood loss, peptic ulcer disease: Ranitidine 150 mg BID x 2 mo 250 tabs, for 50? [= 2,000 tabs]

Heavy periods, bleeding problems, oral contraceptives BCP 28 day packs, 12 mo supply x 10 [= 100 packs]

Hypertension

Hydrochlorothiazide diuretic 25, 50 mg tabs [2,000 tabs]
ACE inhibitor (with kidney disease, diabetes)- diltiazam [1,000 tabs]

Diabetes

glucose test strips; urine sticks
oral hypoglycemics- (requires checking fasting blood glucose
Metformin HCl 500 mg tabs (1-6 per day)

Anxiety

Diazepam- 5 mg tabs [500 tabs]

Intestinal parasites

Mebendazole 100mg tablets 1 tab BID x 3 days =6 x100 [1000 tabs]

Skin infestations (scabies, lice)

Lindane 15% sol'n diluted to 1% with water or vaseline [50 treatments]

Fungal infections

Nystatin, Miconazole, Triaderm, antifungal/ antibacterial/antiinflammatory

Pain control

Acetaminophen 325 mg [20,000 tabs]
Narcotic for severe cases / emergencies (hydrocodone, demerol) [500]

Antibiotics

Penicillin V 300mg TID x 7days = 21 tabs per course [1,000 tabs]
Amoxicillin 250 mg TID [1,000 tabs]
Septra- DS [1,000 tabs]
Ciprofloxacin 250 mg tabs- 500-1000/day [500 tabs]

Children's liquid antibiotics

Amoxicillin 50 courses
Septra 50 courses

Non sedating antihistamines [500 tabs]

Eye / Ear infections

Sofracort- antibiotic/corticosteroid for ear / eye infection 20 courses
Garazone- otic solution 20 courses
Gentamicin

Skin medications

Podophyllum resin, acid colloid for warts 50 courses
Hydrocortisone, betamethasone cr me tubes

IV. Timeline

July 1 Happy Birthday Rinpoche!

July 2-15 Solicit donations drugs from MDs, pharmacies, drug reps, CanMAP (generic meds at cost)

July 15 All donated drugs and supplies have been collected in:

Toronto: Conrad Richter tel #:905-640-6677 ext. 203 Winnipeg: Robbie Chase tel #: 204-229-6714 Vancouver Sharon Gretzinger tel #: 604-708-9081

July 15-30 Robbie buys remaining supplies, packs up one large suitcase; (surplus could be delivered with SEVA / Isaac in September)

July 31 depart Vancouver

August 1 Beijing

August 3 Xinang

August 6 Yushu: check local hospital and pharmacy re. TB program planning, medicine availability, Rokpa contacts

August 7 arrive Zadoh

Aug 8-11 assessment preparation

Aug 13-16 Household genogram survey-4 days

Aug 17,18 Clinics- 2-3 days?

Aug 23 Rob and Michelle leave Zadoh

Aug 26 return Vancouver

Aug 26-30 Rob in Vancouver before returning to WInnipeg