Advice and Resources for Medical Teams Planning to Visit the UMC Senegal Mission

Contents Why Should We Organize Medical Missions to Senegal? Planning and Preparing Getting There How Big a Group? What to Bring Supplies Equipment Vitamins, Supplements and Medicines Our Recommended Pharmacy How We Run Our Clinics The number one concern - crowd control Clinic layout More tips

A one-room clinic in the village church

The Eglise Methodiste du Senegal (EMS, the United Methodist Church in Senegal), was launched in 1996 and has grown to a dozen congregations and hundreds of members. In addition to evangelism among the mostly Muslim population, the EMS started economic empowerment, social justice, and health programs. The "Wellness Program" focuses on dietary enrichment, children's feeding centers, local plant remedies, and education. They welcome small mission teams with a physician to help them provide basic health care to Senegalese people who otherwise would have little or no access to it. The greatest value to the Wellness Program is diagnostic screening for high blood pressure, diabetes, and anemia, which they can treat over time. Only very rarely can the Wellness Program address the needs of a seriously ill patient, because the cost for hospital-based care is far out of reach. Virtually all health care in Senegal is "fee-for-service" and since most of the people in the country live on the equivalent of less than $1 per day, little money is available for health care needs. Infant, childhood and maternal mortality are shockingly high and the average lifespan is under 50 years. Most people never see a dentist, an ophthalmologist, or any other specialist, and the results are visible. Any person who goes on a medical mission can be trained to contribute by weighing people, passing out pills with the pharmacy, checking blood pressures or taking temperatures. Senegal is a safe country both politically and from a health standpoint. If you partner with the EMS missionaries, you will be well cared for. The benefit a medical mission team can provide is staggering. If the team sees 60-80 people per day (a low estimate), it will give 400 persons more information about their health and the options they have. Ask the people of your church or other groups you belong to to donate money for vitamins, analgesics and antibiotics for you to bring with you. When you return, create a poster or other presentation and tell them what you saw and did. Witness is one of the most important parts of the mission. The Senegalese patients understand that a medical mission team has come from far away to care for them. They learn that the team is motivated by love through Christ. This understanding brings people together across religious and cultural boundaries - and the team members will feel this. The team will see Christ in every patient's face: the hungry, the suffering, the prisoner. He is there in every one you worked side-by-side with. He is everywhere, every day. This is why we go to Senegal. Salaam Alaikoum.

Mounting a mission trip is a complicated task. If you have no prior experience, then expect planning to take 10 to 12 months. You must identify the team, agree upon trip dates, coordinate with the missionaries, gather significant supplies, and you must be trained as a United Methodist VIM team.

To conduct a visit to the Senegal UMC mission, you should first contact the VIM Coordinator, Karen Ujereh, via e-mail. Karen will work with you to find an appropriate time for your group to come to Senegal and put you in touch with the Wellness Program staff. You will be working with, and under the direction of, the Wellness Program - they will help you explore and refine the purpose and extent of your medical work. Karen will be your main logistics contact before and during the trip.

The UM VIM training for the team is very important. A team leader must attend training, which is offered regularly through your jurisdiction's VIM coordinator. As part of this training, the team leader will receive a "United Methodist Volunteers in Mission Training Manual for Team Leaders". With what the team leader learns, and the manual, he or she can train the rest of the team. This training focuses upon the particular cultural customs and behaviors which the team must honor to be welcome and effective in their work - as well as sensitive to the United Methodist environment of the country. Also, there are a number of procedural forms which each member must complete. With process complete, the team leader should register the trip with your jurisdiction's VIM coordinator, after which you will be able to get special insurance for your group through the General Board of Global Ministries.

You must be immunized. A list is available on various Web sites, along with clinics and hospitals which provide these immunizations. Expect a cost of between $150 and $250 per person. You must have documentation of a current Yellow Fever immunization with you to re-enter the United States (although we have never had this checked). You must also take an anti-malarial drug as prescribed before, during, and after your trip - malaria is present in all portions of Senegal.

Once you have settled upon the emphasis of your trip, and assembled your team, you can begin detailed planning of the medical work itself and the supplies you will need. Much of the balance of this Web site highlights these details.

Compared to other destinations in Africa, Senegal is easy to get to. On the western-most point of Africa, Dakar is a major stop for airlines and is only seven hours from New York.

You should coordinate your travel arrangements as a group, especially the last leg into Dakar and the return trip. The Dakar airport is a chaotic place and the fewer trips made there the better. You will have many flight options, with the final leg originating in New York, Washington, Atlanta, Paris, Lisbon, Madrid, or Milan (as of this writing in February 2006). You may want to spend the layover sightseeing in one of these cities. Keep in touch with Karen so that everyone knows your itinerary.

While the official national language is French, be aware that French is only spoken in urban centers and then most commonly by government workers, professional persons, and school children. Most patients you encounter will speak Wolof. A few will speak only Serer. Some patients from other African countries, such as Gambia, will speak English - so do not assume that conversations in English are private. The Wellness Program mission will provide translators to assist your work, but usually only a maximum of two. When speaking with government and church officials, it is very useful to have a member of your group be fluent in French.

Luggage

Dakar airport can be intimidating. After passing through passport control, get luggage carts, find your luggage and do not give control of it to anyone else! The mission support staff cannot enter the luggage area to assist you - you must gather your luggage and have it scanned to exit. There will be many men hovering around inside the baggage claim area who will offer to help - politely say "no." If they do help you, at best they will ask for a five to ten dollar tip - at worst you will lose a piece of luggage. When having the baggage scanned as you leave the claim area, be sure to have a member of your party stationed to identify and secure the luggage as it emerges from the scanner. With all of your luggage accounted for and on the carts again, move outside to the pick-up ramp where the mission staff will identify themselves and put your luggage into the correct transport. This process reverses itself when you arrive back at the airport to depart - do not take your luggage out of the transport until you have luggage carts and your group can move, together, into the departures portion of the terminal.

You must bring all medical equipment and laboratory supplies with you - there is no reliable source for items in Senegal.

All staff participating in the clinic will need hand cleaner (Purell or equivalent). As a matter of decorum, hands should be washed before seeing a patient - not after, which can be insulting.

The laboratory will need gloves, alcohol (or alcohol wipes), cotton pads, bandages, etc., associated with finger stick blood testing. Use disinfecting wipes (Lysol or Clorox) to clean work surfaces before and after the clinic.

You should bring patient encounter forms. The form we use is available as a two-up template that you can copy at Office Max or Office Depot on their heaviest white stock for about $70 per 1000 (cut and trimmed). Plan on seeing 100 patients at each clinic and print 10% more than you need.

You cannot have enough pens and pencils.

All equipment must be battery operated - as a rule the villages do not have electricity or usable water. Bring many extra batteries. Rapid test equipment for glucose and hemoglobin are very valuable for diagnosis. The only body fluids you can test are blood (finger stick) and saliva. Do not bring urine or fecal tests. Do not assume that you will have privacy for conducting examinations or tests - your clinic may be entirely out-of-doors.

All the equipment you bring should use metric measurements. You should also plan on donating most of your equipment to the Wellness Program rather than bringing it back home.

• Thermometer - A Temporal Artery Thermometer is best. We have been using the Exergen product, which can be set to read either Centigrade or Fahrenheit. Expect to pay $45.
• Scale - A bathroom scale with kilogram readings is adequate. Plan on $15. If your diagnostic process would be improved by computing Body Mass Index (BMI), then print out the BMI table we created based upon metric measurements.
• Metric measuring tape for heights - Use a seamstress cloth measuring tape at least two meters long with centimeter markings ($7). You may also want a shorter one for measuring infants ($4).
• Wrist blood pressure monitor - You want to take blood pressures quickly with a minimum of patient bother. You may want to buy a more advanced model, such as the Omron HEM-637 that can assist in positioning the arm correctly. Plan on $90. Also note that the physician(s) will likely need to take blood pressures themselves during some examinations, so you may need a second unit or more traditional BP tools for them.
• Glucometer - Reading glucose levels for many patients will be important - your physician should provide guidelines for tests based upon age and Body Mass Index. Consumer market, hand-held devices are good for this purpose. We have used the ONETOUCH® Ultra Meter ($70), which requires a smaller sample and reads in five seconds. The test strips run $80 per 100.
• Hemoglobinometer - Not as essential as a glucometer, this test for iron levels may be useful in diagnosing anemia and other conditions. We have been using a "Hemocue B" unit. Hemocue products are expensive to purchase ($800) and operate ($265 for 200 tests), so your lab technician or physician should evaluate the "STAT-Site® MHgb" from Stanbio Laboratory ($150 purchase and $180 for 200 tests).

You must bring all of the vitamins, dietary supplements, ibuprofen and acetaminophen you intend to dispense. These items are hard to find in Dakar and are much more expensive than in the United States and they will require a significant fraction of your luggage space and weight allowance.

The rules for bringing pharmaceutics into Senegal are those common to most countries:

• All items should be in their original, labeled containers
• Other than for personal use, prescription drugs cannot be brought into the country

In order to save space (not weight) you may elect to consolidate containers - filling empty space with pills from another container. The space savings can be as significant as 3-to-2, 2-to-1, or even 5-to-2. If challenged that the containers are not sealed, you will need to explain this process, but we have not been subjected to a search upon entering Senegal, as yet.

After arriving in Senegal, you must repackage your vitamins and drugs before conducting clinics. Do not attempt to fill patient needs from bulk stores at the clinic. We learned the hard way that the pharmacy cannot run efficiently if each dose is measured out individually. Let us repeat:

The Wellness Program has pharmacist pill-counters to use. You must bring plastic dose bags and fill them from your bulk stores. This is a good group activity in the early days after your arrival. Bring at least two sizes of dose bags: 3x3 (for smaller pills) and 3x5 (for vitamins and calcium). The dose bags must be reclosable. We also recommend that the bags have "white block" for easy labeling (we tried using mailing labels, but they don't stay on). Write the label on the bag first, then fill and seal it. We have purchased bags from ULINE and are very satisfied. Expect to pay about $20 for a carton of 1000 3x5, white block, reclosable. The 3x3 bags are more expensive ($31 per 1000) Because many patients will have multiple items ordered for them, you should also order 6x9 plastic bags ($29 per 1000) to collect and seal up these items for each patient. This is especially important if you visit a prison, because the drugs and vitamins you dispense must be kept by the prison nurse for each patient.

Prepackaging vitamins into dose bags

Useful additional resources

• Hydrocortisone cream - Between five and ten tubes
• Antacids
• Amoxicillin capsules (250mg) for adults and suspension (250mg/5ml) for children
• Bactrim
• A cephalosporin for skin infections
• Aciphex, Prevacid, or Zantac
• Iron supplement
• Toothbrushes - Team members should ask their dentists for donations
• Toothpaste - You can probably get toothpaste donated, but consider buying it in Dakar. The prices are only slightly higher and the weight of toothpaste will reduce your capacity for packing more essential items.

We don't expect that everyone will run a clinic the way that we do; however, we have learned a few things that we can pass on so that you will be more prepared. The locations for clinics are selected by the Wellness Program in advance and scheduled through a local "chairman" who takes certain responsibilities as will be seen. Clinics usually run from about 10:00am to 5:00pm with 30 to 45 minutes for lunch in the middle. Lunch is prepared and supervised by mission personnel and brought to the clinic location. Bring your own water for refreshment on either side of lunch - there is no clean water available.

Crowding is a problem at registration Patient intake - height and weight Local nurse prepares to take blood pressure Blood testing Physician consultation, with translator(right) An outdoor pharmacy

The number one concern - crowd control Let's get right to the factor that most directly determines the success of the clinic - crowd control. While it may be a suspect observation, there appears to be little cultural value in Senegal attached to "waiting for your turn." In an environment of scarcity, knowing that you are 30th in line is not necessarily reassuring. Therefore, it is vital to have clear processes and limits to set patient expectations. The places this is most important are at patient intake and at the pharmacy. Those arriving at the clinic must be made to understand: Whom to see to become registered as a patient, and that all registered patients will eventually be seen How the patient will be informed that his or her turn has arrived When the clinic will stop registering new patients The role of the "chairman" The chairman will be instructed to write people's names down on a list as they arrive for the clinic - perhaps two or three hours before the clinic is scheduled to open. This will be solved in different ways at each location, but the result should be the same. When you arrive, the list may already have 40 people on it. The first thing you do is give the overseer a supply of encounter forms and instruct him or her to: Call the patients in the order they were placed on the list For each patient: transcribe his or her name onto the encounter form determine the patient's age and write it onto the encounter form write the patient's number onto one upper corner of the encounter form give the patient his or her encounter form an tell him or her to sit down and wait until her number is called Once your clinic is ready to begin, your patient intake person should signal the chairman to send the first patient over. Thereafter, the chairman should send the next patient (by number) to your patient intake person only when asked to do so. In our experience, this is the smoothest way to run the registration and intake process. Deciding when to close the clinic The important corollary to this process is deciding when the clinic should close. There is no really good way to determine this unless the number of patients is constrained (such as in the prisons) - when you are committing to seeing all the patients regardless of the time required. In other instances, the forces at work are: The patients want you to stay open at least until they are each seen - regardless of how late they appear to register. This may be the only chance in years they have had to be counseled by a physician, so you can understand this motivation. The Wellness Program staff want to see as many patients as possible, especially when the clinic is held at one of the village churches, as an act of outreach and evangelism. The missionaries do not want to overtax you. They want your overall experience to be positive (and it will be), so they want to preserve your sanity. You may be personally torn. While the clinic will be tiring, perhaps even exhausting for some persons on their feet most of the time, there will always be another patient. You need to feel a sense of completion and accomplishment even as you are leaving some behind unseen. The decision process must involve the head of the Wellness Program, the chairman, and your entire team. Based upon our experience, we offer the following options: Village clinics. The village clinics tend to be very orderly and patient flow is predictable. The first patients are most often the elders (often there to check you out for others) and mothers with infants. As this group is seen, a steady stream of others will arrive until the local school lunch break - when a number of 8 to 13 year-old children will appear along with a few teenagers. Around 3pm, the group will thin out and by 4pm new patients will arrive only sporadically. Determine the time at which you must leave the village to return to your accommodations and accept new patients up until one hour before that time. Determine the time after which you will close if there are no patients waiting to be seen. Urban clinics. Clinics in urban settings will face virtually endless patient demand. Even if the clinic is not publicized outside of a "closed" community of interest, neighbors and friends will learn of the service and flock to it. Many patients will be waiting when you arrive and they will continue to stream in until you close. Set a number of patients that you will see and only register that number. During the first hour, measure how long it is taking patients to pass through the clinic (from intake through pharmacy) and extrapolate the capacity of the clinic through a projected closing time. Then limit the number of registered patients to that figure. Stop registering new patients at a given time, such as two or three hours before your planned departure from the site. This approach should be used carefully. If a large number of patients arrive before the cut-off time, your clinic may have to be open well after the planned departure time.

• Avoid putting the entire clinic into one space - such as in a village church building. The noise and lack of clearly-defined service spots will be confusing and frustrating. If you must use a single-room building, have the patients wait outside for intake and only wait inside for each service point.
• Ideally, the doctors should be far removed (50+ feet) from the rest of the clinic and from each other. This will be quieter for them and will also give you the possibility of an enlarged waiting area for the doctors.
• Ideally, the pharmacy should be an an enclosed space with controlled access. When the pharmacy is in the open, it attracts children and other idlers looking for what is being freely distributed (e.g. toothbrushes).
• If you are outside, be prepared to move as the shadows move.

Example: Outdoor village clinic The diagram at right shows the layout for a village clinic held outdoors. The space was constrained by buildings and lack of shade. The laboratory and pharmacy were moved every two hours to keep them in the shade of the trees (green). The doctors were separated and a waiting area established near them. We could not avoid the pharmacy being in the open, and it attracted its share of the curious. During the school lunch break, many children watched patient reaction to BP and blood testing at the laboratory. You have to accept that the clinic will be the most interesting thing in the village on the day of your visit. A separate, substantial, waiting area for the doctors is a very good approach for any clinic situation. It allows the intake and lab functions to operate a full capacity and also informs the doctors of how their service rate is comparing with the lab. This sort of feedback will help the lab, doctors and pharmacy pace themselves.
	Example: Two-Building Clinic A two-building set-up is a good one to separate the doctors and isolate the pharmacy behind a doorway. Even though there might look like there could be a lot of traffic through the one door, it is traffic controlled by the intake process and limited by the speed of the doctors. The only downside of this arrangement was a lack of waiting space for the pharmacy, but patients were content to wait outside until called.
Example: Best-Case One-Room Clinic If you have only one room to work with, you should consider having the doctors and pharmacy inside. Patient intake, vital signs and the laboratory can function well in an open environment. A separate doctor waiting area is very helpful, too. If inclement weather forces all activities into the one space, patient waiting for intake will have to remain outside and the doctor waiting area will be smaller.

More Tips Physicians should provide the laboratory with rules for blood tests. It is too costly to do blood tests on everyone, but the physicians can give guidelines based upon age, gender, body-mass-index, and blood pressure. Our guidelines can be a starting point. Avoid forcing people to stand while waiting in the clinic. If a patient will move from BP to the lab - and the lab is currently full - then there is no reason to have that patient step aside and make room for another BP. Similarly, there is no reason to weigh and measure a patient if he or she cannot be seen immediately at BP. The process simply slows down to the rate the lab can pass people to the doctors. This is the reason that a large doctor waiting area is an advantage - it provides a buffer to allow everything else in front of the doctors to operate at its own pace. Talk to the patients as you would talk to your patients at home. Even though these patients cannot understand you, your tone of voice and attempt to convey information will be warmly appreciated. From the Wellness Program team, try to learn a few words in Wolof so that you can direct the patient or thank him or her. A few patients will have a rudimentary understanding of English and will be proud to thank you. Expect that patients will return to the clinic with questions. After a patient receives his or her medicines from the pharmacy, he or she may need instructions repeated or some clarification from the doctor. This could be a few minutes or an hour later, so don't be surprised to see patients return and want to go directly to the doctors or pharmacy with their question - let them go ahead. Measuring and weighing young children can be very challenging. You will not see very many infants, but children up to three-years old may be frightened of the scale, the thermometer, or just you. Weight and age are the most important factors for the doctors to know. Have the mother hold the child and be weighed together and then weigh the mother separately to get the child's weight (this is often a good opportunity to get a photo of one of your group holding a small child or infant). Train the Wellness Program staff in what you are doing and let them participate. There is a very good chance that part of the team will include at least one nurse or nursing student, so rotate tasks and give yourself a rest and a chance to take photos. Craft activities are a good way to build goodwill with those persons waiting or to engage non-patient observers. Be sure that you can provide craft projects or materials for everyone (adults will also be interested). Most successful for us has been tearing sheets out of coloring books and passing out three or four crayons to each person. We have also made craftpaper flowers and small boxes out of greeting cards. Work surfaces may not be readily available, but the patients will improvise. Of course, the materials involved need to be inexpensive, compact, and light.

Craft activities are always welcome Remember to have fun and make friends