BY JENN DANKO // PHOTOS COURTESY OF GLOBAL HEALTHCARE PROJECT
Getting help for a medical emergency usually means dialing a three-digit number and waiting for an ambulance to rush in. But in the remote Guatemalan village of Pueblo Nuevo, where phone lines and vehicles are luxuries, those in need of an ambulance were forced to spend a month's salary in exchange for a ride to the nearest hospital. And that was when they could find a driver willing to make the three-hour trek down the rugged terrain of the northwest highlands.
“Most of the time, people died before they even made it to the hospital,” says Bridget Meyer, founder and executive director of Global Healthcare Project (GHP), Palo Alto, California, USA.
Having already forged a partnership with the community, GHP teamed up with residents to devise a rescue plan. Last August, Ms. Meyer and a team of 22 university students set out to provide an ambulance, set up an emergency call system and train some of the residents as basic emergency medical technicians (EMTs).
»We knew we only had a 30-day window going into the project. It all came down to pre-planning, implementation and compromise.
—Kevin Padrez, Global Healthcare Project, Palo Alto, California, USA
The team quickly found itself mired in local politics and stymied by the lack of infrastructure—while playing an intense game of beat the clock. Most of the project's volunteer participants couldn't commit to staying longer than four weeks.
“We knew we only had a 30-day window going into the project,” says Kevin Padrez, co-director of the project. “It all came down to pre-planning, implementation and compromise.”
GETTING IN GEAR
GHP's outreach in the area dates back to 2004, and Ms. Meyer says the project ideas come straight from the community. After local residents expressed a need for an emergency vehicle during a 2006 expedition, GHP set to work raising the resources to put the project into play.
The first step: securing a vehicle capable of making the drive up and down the treacherous mountain roads. To increase stakeholder buy-in, Ms. Meyer involved local residents in the purchase.
“I wanted to make sure community representatives came with me because I wanted to make them feel good about the car we were buying and make sure it worked for their area,” she explains.
A four-hour drive to the Mexican border yielded the purchase of a pick-up with a camper shell and mountain terrain tires.
The project stalled, though, when it came time to register the vehicle.
“We didn't want the car to be in the name of one person, but rather the town of Pueblo Nuevo itself,” says Nathan Kim, co-director of the project. The move was designed to have the community—rather than a single individual—be responsible for maintaining the vehicle. But the decision translated into more work for the project team.
“For that, we not only had to get an attorney involved but we also had to go to the federal Guatemalan government,” he explains.
Registration and notarization took nearly a month—almost the entire project timeline—necessitating a delegation of duties.
“This is where having multiple project leaders was helpful,” Mr. Kim says. Back in the United States, Mr. Padrez and Mr. Kim were compiling manuals to train the ambulance drivers (or “chauffeurs,” in GHP parlance).
“We spent most of our time before going to Guatemala creating a handbook of what we thought was most life-threatening and important to their village—like how to deal with bleeding or any type of trauma,” Mr. Kim says.
Certified EMTs, he and Mr. Padrez set to work boiling down 130 hours of classroom work into a one-week training session for villagers with limited education and medical background—as well as paltry resources.
“A lot of life-support techniques we use in the United States are not feasible based on equipment restrictions and accessibility,” Mr. Kim explains. “You also can't get to a facility fast enough when you are driving in the rural highlands. So there are a lot of things to consider.”
OPEN TO DEBATE
When the rest of the team joined Ms. Meyer on 1 August 2009, time management became one of the biggest project considerations. As the clock began ticking, team leaders gathered residents for a town hall-style meeting and began laying the legal groundwork for the project.
From the start, the community agreed that the best way to legitimize the ambulance program would be to create an amendment to the local government constitution.
“This is how you get the residents who volunteer to be more accountable,” Ms. Meyer explains.
The GHP team laid the basic foundation for the project, and let the residents decide what would work best for them within the established project constraints. Drafting a written policy that all community leaders signed off on ensured it would endure once GHP left.
Getting everyone to agree on those policies, though, proved to be a tedious process of give-and-take.
“Medical and social services have to be integrated into the culture and government of a community,” Mr. Kim says. “Ultimately, maintenance and running of this program falls into the hands of the native people.”
To ensure ongoing funding, GHP suggested adding a surtax to some of the items in the local pharmacy the not-forprofit had set up on a previous project.
TRAINING ON THE FLY
As the locals debated legal matters, Mr. Kim and Mr. Padrez were busy selecting and training the ambulance drivers.
“The first challenge is finding someone who is trained in driving a car,” Mr. Kim explains.
With official government driver's licenses hard to come by in rural Guatemala, the project leaders zeroed in on a limited applicant pool. The technical skill it takes to safely navigate the rugged terrain—especially in adverse weather—made finding the right candidates even more difficult.
And those weren't the only criteria.
“Another challenge was finding individuals who had time to give to the project outside of their work and had the literacy to complete the training,” Mr. Padrez adds.
By the third week of August, the team had selected three residents with the required skill sets, but then ran into a language barrier. Rather than presenting in a lecture format, the trainers had to demonstrate the different emergency-response scenarios.
It's okay to goof off every now and then. “A week into the project, some volunteers expressed a desire to have more bonding time, so they played games outside of the working environment,” says Nathan Kim, Global Healthcare Project.
We ultimately want someone to … be able to do this project in other countries so you can not only save lives, but also empower the community by having it be their program—not someone operating it from the outside.
—Bridget Meyer, Global Healthcare Project
Even with trained drivers, some of the basic equipment, such as an oxygen tank, simply wasn't available.
“There was no way to obtain or replenish a tank—even the hospital had difficulty getting one,” Mr. Kim says.
With much of the prepared material now unusable, the team was forced to adapt. “We had to change a lot of the material along the way,” he adds.
The team leaders focused the training on issues such as basic triage and profuse bleeding—leaving out, in the process, a lot of important material. It was a difficult but unavoidable decision.
“We really had to ignore a lot of the specifics,” says Mr. Padrez. “We basically had to adapt what we do.”
TAKING THE CALL
Once training ended, the project team shifted to equipping the ambulance with sirens, lights and medical supplies. But villagers still needed somewhere to call when they had an emergency, so GHP provided a satellite phone number and mandated that one of the ambulance drivers be available at all times.
During the final week of August, team leaders were able to see the project payoff themselves when a young girl required emergency transport to the hospital.
“We were packed to go for the morning, when one of the chauffeurs came down at about 10 or 11 at night and took a little girl down the mountain. I think at the time the power went out, which was really off about half of the time anyway,” Mr. Kim recalls. “The ambulance made a successful trip and returned that morning.”
Ms. Meyer is collecting metrics on the program and hopes to revisit Pueblo Nuevo to monitor results.
“I do have a monthly call with the people in Guatemala and check in to see how the program is working,” she says. “The idea is to save lives and I can definitely say we are doing that.”
One statistic she can share: No one has died in the vehicle since the project implementation.
In retrospect, GHP leaders agree there were a few things they probably would have done differently. Getting the vehicle registered prior to the team's trip would have saved some precious time, for example.
That's all part of the learning process, says Ms. Meyer, noting that such lessons learned were recorded in a guidebook that will serve as a model for future projects.
“We ultimately want someone to pick up this handbook and be able to do this project in other countries so you can not only save lives, but also empower the community by having it be their program—not someone operating it from the outside,” Ms. Meyer explains.
GHP now has set its eyes on Nigeria, Tanzania or South Africa, looking to help rescue another ailing healthcare system with a rural ambulance project in July or August. PM
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