Taking a Medical History in Las Terrenas
A NextGen Free-Standing Perspective Article
The Dominican Republic is located on the island of Hispaniola, which it shares with neighboring Haiti, 830 miles south of Miami. Las Terrenas, a town of 17,000 inhabitants, in the northern Samaná Province, became my home for 3 months last spring and summer. I went as part of an effort to learn more about cardiovascular health statistics in a rural, under-developed population. Aided by two local non-profit organizations, the Fundacíon Mahatma Gandhi and L'Asociacion Humanitaria Dominico-Europea, we conducted a cardiovascular health census in 1071 members of the adult population, thereby recording the first baseline health statistics for the area. Mostly data-gathering and hypothesis-generating in focus, our project evaluated the prevalence of specific markers of cardiovascular disease.
At the conclusion of the project, we had identified markers of cardiovascular disease (CVD), and they provided a hoped-for snapshot into the health of the population. Our results were as follows: the mean age of the patients surveyed was 41.2 years, with an age range of 18-90. The median systolic blood pressure was 128 mmHg (IQR 114.5-145), and diastolic blood pressure was 80 mmHg (IQR 74-90). Current smokers comprised 14.2% of the population while 14.6 % of patients reported past smoking. A family history of diabetes was reported in 30.6% of patients and 40.5% were aware of heart disease in their family. Known hypertension was present in 22.6% of patients while 4.9% reported being diabetic. We identified 464 cases of high blood pressure (43%), of which 277 (59.7%) were newly diagnosed. In the subset of patients for whom cholesterol and glucose levels were evaluated (n=189), the mean cholesterol was 182.7 mg/dl and the mean fasting glucose was 97.1 mg/dL. We found 29 patients (15.3%) with borderline cholesterol, 28 patients (14.8%) with elevated cholesterol, 43 patients (22.7%) with impaired fasting glucose, of which 29 (15.3%) were newly diagnosed, and 20 patients (10.6%) with diabetes mellitus, of which 13 (6.9%) were newly diagnosed. [1]
Data aside, the experience of working in a public hospital in the third world highlighted the limitations of our pre-fabricated research goals, which were not designed to address the genesis of risk factors and symptoms observed. The CVD signs and symptoms documented on our case report forms dictated immediate treatment plans, but they only addressed a superficial layer of understanding disease, while the origins of the growing CVD epidemic ran much deeper. Mounting evidence suggests that CVD is reaching epidemic status in the third world, where lifestyle factors coupled with lack of access to care may contribute to the trend of increased disease. These cause and effect relationships of the factors contributing to the observed symptoms implied solutions far more complex than the writing of a prescription for blood-pressure lowering medication. Over the three-month course of the project, the relationship between our patients, their symptoms, culture, and the tapestry of life in Las Terrenas, became clearer. Aware of work documenting cross-cultural similarities in the origins of CVD [2], I was struck by differences in environmental factors and wondered how significantly they related to disease development.
In my first year of medical school, I have learned about multi-factorial diseases: those with origins not simply in heritable traits assessed by comparative studies of mono- and dizygotic twins, but with an additional and somewhat mysterious, if not amorphous, environmental component. The Dominican Republic is a tropical paradise. Yet for all its unquestionable natural beauty, the poverty of the country and its link to disease is equally stunning.
What are the health consequences of poverty on this island and within this culture? Some of the neighborhoods we visited did not have running water, or a clean water source nearby. The solution for many is to bathe children, clothes, motorbikes and butchered meat in the same available stream. The price of gas for cooking stoves is higher than what many can afford. Unable to cook, people rely on street vendors' fried food for sustenance. For most of the poor, diet is further determined by what grows locally: coconut, rice, and plantains. While much other produce is grown locally (mango, papaya, pineapple), it is more expensive, thus many opt for less nutritious but higher energy foods that can be purchased for the same price. Perhaps faith should also be included in a consideration of environment. In Las Terrenas, faith is a central component of life: it is what enables people to overcome daily hardship. But in some cases it defines a certain fatalism that in turn can modify behavior (i.e., 'I'll stop smoking, God-willing') and makes me wonder if there are health consequences of faith in this population. In regards to physical activity, men are more likely to be employed in physically demanding jobs (construction, farm work), but women describe themselves as "sedentary" in their work in the home. While walking used to be the major form of exercise, the advent of the 'motoconcho' or motorbike has virtually eliminated physical activity from the daily life of many. The 'motoconcho' is an advance that has made life easier, accessible even to the poor, for better and worse.
Without clean water, the ability to buy and prepare food, and the assurance of a steady source of income, the attention given to health and role of healthcare is largely relegated to acute situations. In this respect, the Dominican Republic, with its free hospitals and clinics, addresses the urgent healthcare needs of its citizens. Nevertheless, while preventative care does not yet fit into the life and culture of Las Terrenas, we believe it could. For three months this past spring and summer, hospital staff began taking and recording blood pressures and resting heart rate, no matter the patient's chief complaint. Glucose and cholesterol tests were administered at a local pharmacy, with results and treatment options discussed with patients and house staff. Community-wide health fairs drew crowds of people who waited in line for hours to have their blood pressure taken and view a presentation about the four food groups and how smoking harms the body.
When the data indicates glaringly obvious health problems, it seems only natural to first imagine an equally straightforward solution. However, as we were assessing cardiovascular disease in a third world population, the range of causes of high blood pressure, cholesterol and diabetes seemed to be influenced not just by behavior and genetics, but also by the local environment and larger culture and society. Layers of cause and effect relationships are involved. In under-developed rural areas like Las Terrenas, solutions that initially seemed sufficient were proven to be superficial, and the history behind chief complaints and symptoms point also to an emerging complex combination of environmental and lifestyle factors. 
Rachel Anderson is a Brown alumna and a first year medical student at Albany Medical College.
References
- Grundy S et al. Diagnosis and Management of Metabollic Syndrome: An American Heart Association/National Heart, Lung and Blood Institute Scientific Statement. Circulation (2005) 112: 2735-2752.
- Yusuf S, Hawken S, et al., on behalf of the INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case control study. Lancet (2004) 364: 937-52.