The Medical College of Wisconsin's Central American Connection

For people who believe in coincidence, there were plenty that led to the creation of a community health center coordinated by a group in Milwaukee and located in a remote region of Belize. Some take it for granted that there was a larger purpose in the events leading to a partnership between the government of Belize, a Chicago-based charitable foundation and the Medical College of Wisconsin's Department of Family and Community Medicine. Regardless of one's beliefs, the facts are pretty remarkable.

Belize, formerly British Honduras, lies along the Caribbean Sea between Guatemala and Mexico. It's existed as an independent Central American country only since 1981. The country remains challenged by high unemployment, urban crime and a growing involvement in the South American drug trade. The people of Belize come from several backgrounds, primarily Mestizo, Creole, Maya and Garifuna. The official local language is English, but Spanish, Mayan, Garifuna (Carib) and Creole are spoken as well. Tourism has become one of the mainstays of the economy.

In the early 1990s Dr. David Jaroszewski visited Punta Gorda, in the Toledo district of southern Belize, and was troubled by the area's lack of medical resources. When he returned to his work at the Medical College of Wisconsin he brought with him the seed of an idea for supplying the village with the staff and equipment needed to bring health care to its residents - and to give medical students an invaluable experience in international medicine. Through their regular trips, the founders and directors of the project - Dr. Jaroszewski, along with Drs. Clair Eliason and Jon Brodie - gradually established a rapport with local citizens and the few area health care providers. By 1994 the Belize International Health Program in Punta Gorda became one of the clinical rotations offered by the Medical College to students and medical residents.

Meanwhile, Anne Nohl had begun her career in medicine. Years earlier she'd put aside her medical school plans in order to raise her children; as they grew up and entered college themselves Anne became preoccupied by thoughts of the field she'd left behind. She entered the Physician's Assistant (PA) program at UW-Madison ("I would have chosen to be a doctor," she says, "but I didn't think I had the time") and graduated in 1994, then went to work with a busy surgical practice in Waukesha, where she also helped coordinated surgical rotations for medical students and residents.

By 1998 she was serving as Director of Clinical Education for Marquette University's PA program, volunteering at Milwaukee's Family House Clinic and serving on a Medical College of Wisconsin steering committee to develop a clinical rotation in Belize. She says this last experience, in particular, changed her ideas about the scope of her practice. At first, says Anne, the idea of a program in international medicine gave her pause. "We have so many hurting people in this country," she remembers thinking, "Why are we going anywhere else?" Then she was invited to go to Belize. "When you go abroad, you gain perspective on how much we have in the US, and what it's like not to have all those advantages. It makes you very aware, and it gives you much more of a commitment. That's what family practice is about - putting the soul back into medicine."

A Timely Meeting
Anne Nohl was asked to join the faculty of the Department of Family and Community Medicine, and soon became Dr. Brodie's successor as Director of the Belize International Program at the Medical College. By this time the Belize program was also receiving support from the Jericho Road Foundation International, based in Chicago. The way the pieces of the puzzle came together, Anne says, "was amazing." During one of his many trips on the "puddle jumper" plane to Punta Gorda, Dr. Brodie was seated next to two Americans. They began to talk and discovered they shared a mutual mission: the doctor's seatmates, from the Jericho Road Foundation, were seeking a way to invest their group's resources to help the citizens of Belize. The Foundation has since become an integral part of the Medical College program and the community health infrastructure of Belize. Jericho Road was responsible for building the Hillside clinic where the clinicians practice, and the Foundation's current Executive Director, Janet Hauter, is dedicated to maintaining the a commitment to the program.

Villagers a Fundamental Part of Planning Process

Local staff, students and medical residents worked hard to determine the health priorities of the local Belizean population. Together they established a community advisory committee and used a "Healthy Communities" model to address the needs of the people who lived in and around Eldridgeville, where the Health Center is located. The Healthy Communities initiative encompasses not just the physical factors that underlie health and illness, but also the social, spiritual, emotional, economic and other root causes. Sarah Beversdorf, MSW, MPH, directs this aspect of organization for the Belize clinic. "We really pay attention to what the community decides," she says. "It's all about mutual decision-making; if the community doesn't want it, we don't do it."

Together with Cherry-Mae Avilez, the on-site Director of Community Outreach, and Barbra Beck, PhD, Assistant Professor in Family & Community Medicine at the Medical College of Wisconsin, the September students and resident team conducted face-to-face interviews with 50 local households and held a series of focus groups to determine community members' key concerns regarding health and standards of living.

Expecting to hear about priorities of basic health care needs or services. Sarah and others we surprised when "community cooperation" was by far ranked above any other issue. Other priority issues included economic development, lack of schooling opportunities, alcohol and drug use, and sanitation. Through the focus groups, community members indicated this priority is highly related to the level of substance abuse in the community. As a result of this information, Cherry-Mae is coordinating substance abuse reduction interventions and involving the medical students in these plans. A peer education program has already been successfully launched.

"Our program goals are based on the health priorities of the local community in Belize," says Anne Nohl, "while at the same time helping our students develop the gifts that they have. There is just so much potential - we have a goldmine of opportunity here, we just need to help people realize how much help they could be to others."

The visiting staff from Medical College of Wisconsin, Marquette University, and the University of Wisconsin-Madison has learned to practice, like the local staff, in an environment with limited amenities. Only basic equipment, medical supplies and lab work is available, so staff must rely on each other and on their own skills to determining patients' medical histories and perform thorough physical examinations. One of the most productive aspects of the Belize program, says its participants, is that everyone - students, local providers, physicians, nurses and community health workers - must learn to live and work together in a situation that depends on cooperation.

Hope for the Future
Today, Anne Nohl is brimming with ideas for the future of the program. "One thing the community has asked us to do is to have our staff in Belize year-round. "We used to close during the summer months, and we still close during Christmas because the rest of the country pretty much closes down, too...and everyone has asked us to stay open all year." Thanks to a new third partner, the St. Louis-based Sisters of Mercy Health Care System, that is now possible. The clinic's role has become such an important part of the country's community health agenda that the Minister of Health has included it in the National Health Plan.

Thanks to an anonymous donor, Jericho Road Foundation was able to supply a Land Cruiser that serves as a mobile clinic, bringing much-needed medical care and supplies to remote Belizean villages. According to Anne Nohl, "some of the villages have small huts or rooms that we can use to provide health care," while some do not. "One of our dreams," says Anne, "is to get a real mobile medical clinic, something that actually has an examination room."

She continues to see parallels between the needs of the people of Belize and the underserved of our own country, and hopes to expand the Medical College's international track to include rotations at Milwaukee-area urban clinics. "What if we produced an international rural-urban track?" she asks.

Many of the issues faced by primary care health practitioners cross cultural boundaries: problems in Punta Gorda are also problems in Milwaukee and Racine and Green Bay. She also feels that the experience of both clients and staff would be enhanced if the International Program included health care practitioners from many disciplines. Multidisciplinary teams could include Physician's Assistants, nurses and Nurse Practitioners, dentists, physical and occupational therapists and junior medical students.

Anne Nohl insists that the people involved in the international program are simply ordinary people who've been called to a task that they can't refuse. In this close-knit situation people learn to work with clients from a range of backgrounds, often challenged by poverty and a lack of health services. They also learn how to work with each other. "We need to be able to train students to work together, and to work with people of all cultures," Anne Nohl maintains. "You don't get that staying in your own little cocoon."

In addition to the people already mentioned, many others have contributed their time and effort to the success of the Belize International Health Program, including Alan K. David, MD, Professor and Chairman of the Medical College of Wisconsin Department of Family & Community Medicine. Heather Lotz, Program Coordinator for Graduate Medical Education in the Department of Family & Community Medicine, not only maintains the Belize program website (www.family.mcw.edu\belize.htm), but organizes the volunteers and sorts out project logistics. "She's the one who's always there," says Anne Nohl. "She's vital to the program and goes way beyond the call of duty." Russell Robertson, MD, is Associate Dean for Volunteer Clinical Faculty and serves as Medical Director of the International Program, acting as an advisor and helping to put together the clinical part of student orientation. Sarah Beversdorf and Dr. Barbra Beck from the Center for Healthy Communities have given this project the education direction it needed. "Together, we've become a team that keeps on giving and keeps on getting stronger," Anne affirms with a smile.

Acknowledgement also needs to be given to Jericho Road Foundation International, UW-Madison, Marquette University and the Toledo health care workers for their collaborative efforts. The staff at Hillside Health Care Center and the surrounding community are the heartbeat of the services performed in Belize.

In 2001 Anne Nohl was named PA of the Year by the Wisconsin Academy of Physician Assistants. Her work with the Belize program contributed significantly to her receiving the award, said Jeff Nicholson, WAPA president. "Anne's career has been committed both to the education of a variety of health care professionals and to meeting the health care needs of the medically underserved in multiple settings, both locally and internationally. By bringing her two areas of interest together she has become a shining example and positive influence of the next generation of health care providers who will be serving the underserved of Wisconsin, our country and globally." Anne says she's humbled by the honor, but seems embarrassed by the attention. "It's not about me," she says. The success of this program is due to its staff. They're the ones that are really the heart and soul of this program."

Eileen Early, BA, BSN, RN
HealthLink Editor

This article includes information from the Medical College of Wisconsin Department of Family and Community Medicine.

For more information on the Department of Family and Community Medicine's Belize International Program, see our HealthLink article Expanding Horizons: Practicing Medicine in Belize.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.