13.3 - Health: Family Medicine. New Approaches Through Partnerships

Autumn 2005 (13.3)
Pages 78-79

Family Medicine
New Approaches Through Partnerships
by Meg Hayes

Meg Hayes They say: "Before any journey begins, you own it. But once you take that first step, the journey owns you." This certainly has been true in the partnership between the Oregon Health & Science University (OHSU) Department of Family Medicine in Portland, where I am a faculty member, and the Narimanov Health District of Baku, Azerbaijan.

Photo: Meg Hayes.

For me, the journey started in Portland in December 2000. It was a cold Saturday morning and I had hoped for the rare chance to sleep in late. But, on short notice, I had suddenly been asked to give a lecture about Family Medicine to a group of Azerbaijani physicians visiting our university. I agreed, never dreaming that a month later I would find myself in Baku.

The invitation to travel to Azerbaijan's capital was a delightful surprise. I imagined gazing out over the Caspian Sea, eating caviar, shopping for carpets, learning about a new culture, and then returning home with fascinating stories. Little did I imagine that five years later I would be spending my free time looking for financial resources to continue what has become an important collaboration that has captured the hearts and minds of medical professionals on opposite ends of the earth.

Narimanov Partnership
This partnership, funded through the U.S. Agency for International Development (USAID) and administrated through American International Health Alliance (AIHA), was charged with the development of a comprehensive, community-based, primary care system designed to meet the basic health care needs and improve the health status of Internally Displaced Persons (IDPs) and refugees in the Narimanov Health District. The Narimanov District, one of 11 health districts in Baku, is home to 12 percent of Azerbaijan's refugee and IDP population, estimated to be 26,000 in the district. This is the highest concentration of IDPs and refugees among the eleven districts. The majority of refugees remain concentrated in temporary housing, many lacking adequate nutrition, reliable supplies of electricity and water, and sanitary facilities.

The goal of developing such a health-care system was a tall order. Indeed, it was impossible to fulfill, but everyone approached each problem and issue optimistically, committed to move forward, refusing to allow our vision or enthusiasm be realization that the funding was limited to only three years. We set our sites high, which enabled us to succeed to a greater degree than might otherwise have been possible.

The first challenge we faced as partners was to develop a knowledge and working trust of each other against the back drop of substantial differences in cultural, social, language as well as medical practices. But we were all bound by our common love for our patients and profession, intellectual curiosity, and a strong desire to improve the health among the people we served.

Family Medicine
The partnership consisted of a series of exchange visits between medical professionals in Baku and Portland. When the Baku partners visited us in Portland, they had an opportunity to experience first hand what the concept of Family Medicine could mean. It was a new concept for them. We defined it as the ability of physicians to provide outstanding health care to a population of patients: men, women and children, from birth to death, in a therapeutic relationship, based on continuity of care and within the framework of an understanding of the social and family dynamics affecting that patient. This was a powerful concept for our Baku partners in terms of the ramifications for their health system, skills enhancement, and teamwork with nursing personnel and community educators.

The results of our three-year Partnership have strengthened the health care system in Azerbaijan. At the end of our Partnership, in May 2004, the Azerbaijani Partners opened the doors to the Primary Health Care Center (PHC) located in a remodeled wing of the Narimanov Health District Polyclinic No. 4. Today, the PHC has a professional staff of five Family Physicians and five nurses; all of them are well equipped to provide high-quality care to patients of all ages.

The Partnership work has not been limited to the facilities infrastructure, but includes significant attention to clinical issues such as: maintaining medical records, organizing patient flow, enhancing physician-nurse team relationships and community out-reach. The PHC includes space for clinical examinations and the Community Health Education and Resource Center, a patient education facility with books, audiovisual equipment and other learning aids.

Wendy Warren, Medical Project in Azerbaijan Women's Wellness Center
PHC Director, Dr. Saida Nasibova initiated a program for the early recognition of breast cancer. Since then, the Center has examined and trained 40,000 women in breast self-examination.

Left: Dr. Wendy Warren, of Klamath Falls, Oregon, giving training on colposcopy and Pap smears.

The Partnership provided ultrasound equipment, which is utilized for diagnostic examination. Through this clinical work, breast abnormalities have been detected in 895 patients, who were then referred to the National Oncology Center for treatment. These are now receiving follow-up care and psychological support at the PHC. Since 2004, about 300 women have been screened for cervical cancer. Dr. Elza Bayramova provides gynecological services including Pap Smear and Colposcopy diagnosis. In the past year, five percent of women who were screened were diagnosed with cervical intraepithelial neoplasia and have undergone appropriate treatment.

Mental Health Services
Nearly 90 percent of the refugee and IDP population treated at the clinic have been diagnosed with psychological disorders including post traumatic stress disorder and depression. Through the Partnership, physicians have been trained in pharmaceutical and behavioral interventions to assist patients.

The Partnership has attracted the involvement of a neurologist and psychiatrist, both of whom have traveled to Portland to meet with physicians of the Intercultural Psychiatric Clinic at OHSU and develop treatment guidelines for their patients. The Partnership also trained physicians in the physiology of stress and methods that can be used to educate patients in self-regulation of escalating stress and anxiety. The ability to decrease physiological stress impacts a number of disease processes including cardiovascular disease and diabetes, which are prevalent in the population.

Adolescent Health Program
Dr. Tarana Ahmadova's passion for adolescent health care was sparked during her visit to Portland where she learned about health clinics that provide information, education, peer counseling, hot lines and medical care in the areas of substance abuse, risky sexual practices, contraception, violence, and mental health issues. The establishment of the Adolescent Health Care Service has been carried out in cooperation with the United Methodist Committee Relief (UMCOR).

Within just one year, the District's teen population has demonstrated a strong interest in these services. The program is now positioned to open its own Telephone Hot Line to be staffed by student volunteers, who are trained by the Adolescent Health Center, crisis management and peer counseling. The students will staff the hot line during the first two months, paired with experienced specialists. Afterwards, they will work independently as peer counselors.

Saida Nasibova, Saadat Mahmudova, Tarana Ahmadova Bronchial Asthma
Reactive Airway Disease and Asthma are leading causes of illness in the Narimanov District due to living conditions and exposure to situations that trigger and promote inflammation of the airway. A partnership initiative to provide patient education and peak flow meters to monitor status and provide early warning of exacerbation has allowed patients to manage their illnesses themselves to a large degree and act early to avoid an exacerbation. Programs to assist people to stop smoking is a critical component of this work.

Above, left to right: Dr. Saida Nasibova (Director, Primary Health Center) who initiated the program for early recognition of breast cancer; Dr. Saadat Mahmudova, promoted to National Coordinator for Development of Family Medicine; and Dr. Tarana Ahmadova, Adolescent Health Specialist. They were the major Azerbaijani coordinators for the Baku-Oregon Family Health Medical Program.

Home Visits
The visiting physician/nurse program is one of the unique features of the Narimanov program. The District is divided into 30 distinct areas, with a visiting physician-nurse team assigned to each area. Each team is responsible for approximately 3,680 people. The teams spend each morning working in their home clinic, and then visit patients in their homes in the afternoons.

Medical Bag Project Medical Bag Project
A key component of the Partnership was to enrich the home visit program through skills enhancement, physician-nurse team building and the use of a Mobile Clinic by providing medical bags equipped with all the essential diagnostic tools of a medical exam room.

Above: Graduation Ceremony for Medical Bag Training. Equipping medical bags with essential diagnostic tools of a medical exam room enabled the physicians and nurses to strengthen the Mobile Clinic. In the center are Stephen Kliewer and Saadat Mahmudova, program coordinators from Baku and Portland, Oregon. Through this initiative 92 percent of the refugees living in the Narimanov District in Baku were examined. Illness was diagnosed in 83 percent of the patients, many of whom were able to receive additional treatment at medical centers.

Skills enhancement sessions were held to train the District's physicians and nurses in the use of all the equipment, basic physical examination skills, and psychological counseling.

Through this initiative 92 percent of the Narimanov District IDP and refugee population were examined. Illness was diagnosed in some 83 percent of the patients and 46 percent were referred to a medical center for additional evaluation, while the remaining patients were able to be treated and receive medication and counseling via home visits. The Medical Bag Project gave the partnership physicians an impressive visibility in the community. Appearing on the streets with well-equipped, recognizable medical bags strengthened the confidence of physicians. Patients in need of care welcomed this extension of medical services.

Family Medicine - New Specialty
In 2002, the Minister of Health appointed Narimanov Health District Director, Dr. Saadat Mahmudova, as the National Coordinator for the Development of Family Medicine. A working group was established to begin training Family Physicians. Dr. Mahmudova is responsible for developing the strategy to introduce the concept of Family Medicine into the current health system in Azerbaijan. The working group assists the Minister of Health in fundraising to support the initiative, develop training and residency programs for clinicians and establish a network of Family Medicine clinics. In this short period of three years, they have succeeded in accomplishing the following projects.

1. Establishing a Chair of Family Medicine at the State Medical University (2003) for the continuation of training of medical personnel.
2. Offering a three-month course in Family Medicine at the Medical Advanced Training Institute (2004).
3. Certifying 10 physicians in Family Medicine.
4. Establishing a partnership between physicians in the city of Ganja with Family Medicine physicians from California.
5. Opening the first Family Medicine Clinic.
6. Developing consultant relationships between specialists from scientific research institutes and the Family Medicine Clinic.

The Baku Partners are a group of health care professionals with a proven track record, demonstrating that they know how to make a true difference in the health of a nation by virtue of their accomplishments in the Narimanov District. Azerbaijan deserves to have their collective skills recognized and continued in order to build a primary care system that will address the need for cost-effective, high quality health care.

The commitment to establish an academic presence will be important in training physicians capable of bringing this promise to reality throughout the country, not just in Baku. In the United States, the key factors in the training of family physicians have been the support of national and local governments, the development of organizations capable of providing oversight of the training requirements and certification, and professional specialty societies for continued medical education and representation of its members.

Azerbaijan Family Medicine physicians and their clinics need international support, a critical component for ensuring their success over time. Although the Portland-Baku Partnership has not received any funding since May 2005, the program is still supported - on a small scale - through individuals and organizations.

For example, the Rotary Club of Klamath Falls, Oregon, has raised money to support a Diabetes Initiative in the Primary Health Care Center. Diagnostic supplies, medications, patient education, and chronic disease management components will be implemented under the direction of Dr. Gulchin Gadimova who visited Klamath Falls during a partnership visit to Oregon. As I look back over this journey that unites people who live 8,000 miles distant from each other, I realize that my life has changed during these past four years because of my association with the Baku Partners. The experience has enriched my life immensely. I've become a better doctor, mentor and teacher because of this relationship. My deepest wish is to be able to bring this project and collaboration to the attention of others, who will, in turn, be inspired and join in the effort by contributing resources to help this seed grow and bear real fruit in strengthening the health of all the people of Azerbaijan.

Meg Hayes, MD, is Assistant Professor of Family Medicine at the Oregon Health & Sciences University (OHSU), and Medical Director at their Family Medicine Facility at Marquam Hill. Dr. Hayes has been involved with the Narimanov Partnership Project in Azerbaijan since late 2000. Because of the success of the three-year funded program in Azerbaijan, she is presently seeking ways to help extend and expand the program. Contact Dr. Meg Hayes: hayesm@ohsu.edu.