CERI – Cases and Camaraderie
Cindy here! This morning (Thursday, June 28th), Lauren, Briana and I traveled to the ASPAT offices together, where we admired some more of the jewelry that patients had made and that we’re bringing back to the US to sell.
After that, we split up – I went with Judy to Hospital Carrion, where the CERI meeting was taking place, while Lauren and Briana stayed with Melecio at the ASPAT office in order to discuss the MOU and next year’s project. I’ll leave those details to their own blog post, and in this one I’ll talk about CERI and what I learned there.
What is CERI?
CERI is a special committee of doctors who meet every so often (once every week or month, the frequency depends on the number of patients requiring their attention) to discuss the more complex TB cases from all of Callao and adjust their treatments if necessary. These more complex cases generally involve drug-resistance and/or patient non-compliance, and the team approach of CERI pools together the collective knowledge of the region’s pulmonary specialists and infection disease experts.
Thankfully, 2 of the doctors at CERI spoke English and were kind enough to explain the proceedings to me, so I didn’t flap around uselessly without Lauren and Briana.
Dr. Christian sitting next to Judy at the CERI meeting.
One of the two doctors who spoke English! I’ve forgotten his name and did not write it down, unfortunately. But he was awesome.
What does CERI do?
One of CERI’s main responsibilities is to prescribe new drugs or diagnostic tests to patients who might have drug-resistant strains. This is an interesting twist of Peruvian health care: all TB treatments and diagnostic tests are free-of-charge to the patient due to a recent initiative from the Ministry of Health. However, these materials obviously cost the government quite a bit of money, so to receive them, the more expensive diagnostics (i.e. the faster ones, and the tests for drug resistance) and treatments have to be approved by CERI and the Ministry of Health. Thus, even though the materials are free, they are not freely available to everyone*.
*This realization led to some interesting reflections on Jhosmel, the 3 year-old with MDR-TB in Hospital Carrion. His family had abandoned him, we thought because they couldn’t afford the treatment and hospital stay, but those bills are footed by the government automatically. Instead, they probably abandoned him because, even if he recovered, the resources (both financial and human) to help him develop into a productive member of society would be immense, as he can neither walk, talk, read nor write. Furthermore, they probably didn’t want to deal with the stigma surrounding a son with TB.
Everyone who deserves the more expensive tests and treatments seem to receive them, but often not in a timely manner. There are delays in transferring the paperwork from outlying health clinics to CERI. Lima’s hospital system has an electronic medical records program, but outlying health clinics do not have computers and thus their patient records and X-rays need to be shipped over to CERI by hand. It can be months before a case appears before CERI, whether due to nurse negligence or human resources being stretched too thin. For example, in the Centro de Salud Alberto Barton, there is one physician trained in TB care, but the physician-in-chief employs him to cover other procedures and he has little time to go through the TB cases and decide whether they’re severe enough to go to CERI.
Several cases that were reviewed today involved patients whose samples had undergone drug-susceptibility testing (i.e. drug resistance testing) and were shown to be resistant to one or more drugs. However, they had been kept on those drugs for weeks or months after the test results had come through, because CERI had not yet approved the change in treatment. Centralizing the decision-making is good, since it ensures that those making the decisions have the necessary knowledge, but bureaucratic inefficiencies can lower the effectiveness of centralization.
The review process stayed pretty similar for all 20 patients: look at their chart for compliance, check out their X-rays and test results for severity of the disease, adjust treatment if necessary due to drug resistance or presentation of side effects. I won’t go into details about individual patients. However, I did manage to discuss other problems facing TB prevention and treatment with the doctor acting as my translator, and he had some interesting insights.
1. One site of extreme TB contagion is jails throughout Lima and Callao. The health system cannot guarantee the safety of doctors and nurses who venture into the jail, so what usually happens is that the health workers train police personnel to go around the jail and carry out the National TB program, i.e.the collection of sputum samples for diagnosis and treatment monitoring. Despite the training, the police personnel do not have the same level of expertise as doctors and nurses and may not catch every new case of TB, so the health system is worried about the scope of TB infection and transmission in jails because they don’t really know how severe the problem is.
2. All health policy is made by the government, usually the regional governors, and these policies determine the treatment prices and programs offered in the area. Lima and Callao thankfully have free diagnostic tests and treatments, but there can be a lack of program continuation from governor to governor. The doctor stressed the importance of educating the government and getting them on board with what the health system needs, which is a niche that is filled excellently by ASPAT in Callao.
Despite these problems, the TB program in Peru has still improved immensely. Before 2000, the doctors had to send sputum samples to the Atlanta CDC to test for resistance, and this process could take up to 6-8 months! Now, the process is whittled down to a few weeks to 1-2 months, which is not perfect but at least a step down the right path.
At this point, Melecio appeared with Lauren and Briana, and all of us listened to a presentation on the effects of introducing the MODS (microscopic-observation drug susceptibility) assay to Callao. MODS uses a new liquid-culture technique to test for drug resistance. Apparently, the new test has not done much to diagnose more people, but it has halved the diagnostic time, so that they can be treated sooner.
After the presentation, the entire GROW team and ASPAT went out to lunch with a bunch of the doctors and nurses working in the TB unit of Hospital Carrion! We went to a cevicheria (Lauren and Briana did not eat much, as they do not enjoy seafood) and enjoyed the camaraderie and jokes of the hospital staff.
It was a fun lunch. =)
After getting food (by now it was 4 or 4:30), Melecio, Judy and the GROW team hopped into a taxi and drove to a government office to meet with a Coordinator from the Ministry of Health. She gave us a powerpoint presentation on the role of the government in the TB program, including the organization of the government diagnostic labs and the street festival the government had sponsored a few months ago to raise awareness and educate citizens about TB (it seemed similar to the children’s festival the GROW team had stumbled upon during our first weekend here). We were all tired by this point – we had spent over an hour in the waiting room, whiling away the time by teaching English to Melecio and Spanish to Cindy, and by the time the presentation was over, it was close to 8 in the evening. We probably didn’t process as much of the presentation as we could have, but it was gratifying to see the close relationship between ASPAT and the Ministry of Health official. Perhaps next summer’s GROW team will work more closely with the Peruvian government!