Improving Quality of Life in Underserved Communities: A Case from Humanity Initiative's Student-Led Clinics

Abstract

Using the case study of a 12-year-old girl diagnosed with complex congenital heart disease at a student-led clinic (SLC) organized by Humanity Initiative (HI) in Karachi, the paper highlights the effectiveness of SLCs in providing accessible and comprehensive healthcare services. The article contributes to existing literature by demonstrating the practical benefits of SLCs in a real-world setting, particularly in resource-limited environments. It underscores the potential of SLCs not only to improve community health but also to enhance medical education by providing students with hands-on experience and fostering a sense of social responsibility. Collaborative efforts between medical students, professionals, and the community are essential to ensure the continuity and effectiveness of healthcare interventions. For the success of such initiatives, there is a need for sustainable funding, effective follow-up protocols, and reliable communication channels with patients, offering solutions like peer mentoring and technology integration to overcome these barriers.

Introduction

In Karachi, as in many other metropolitan cities worldwide, the issue of healthcare disparities in underserved communities remains a pressing concern. ¹ These communities encounter numerous obstacles, including limited access to healthcare services, inadequate infrastructure, and socioeconomic barriers that impede their ability to access equitable healthcare. ² The concentration of underserved populations in rural areas exacerbates these challenges, resulting in discrepancies in healthcare delivery and health outcomes. Moreover, factors such as poverty, lack of education, and unequal distribution of healthcare resources further contribute to these disparities. ³ Consequently, individuals in underserved communities often face hindrances such as lack of knowledge, financial constraints, and transportation issues, leading to delayed presentation of illnesses and increased financial burden. The urgent need for innovative solutions in healthcare delivery to address these disparities cannot be overstated.

One such innovative approach is the concept of student-led clinics (SLCs), which actively engage medical students in collaboration with physicians to provide healthcare services to underserved populations. ⁴ SLCs serve as a cost-effective solution to combat the health workforce crisis while addressing the healthcare needs of the community. By focusing on primary interventions and disease prevention, SLCs not only treat patients but also educate them on healthy lifestyle choices. ⁵ The implementation of SLCs represents an effective strategy for promoting community-oriented healthcare, advocating for equitable access to healthcare services, and cultivating a sense of social responsibility among future medical professionals. ⁴

In Karachi, Humanity Initiative (HI), a student-led not-for-profit organization, has spearheaded efforts to address healthcare disparities through initiatives such as SLCs. Founded in 2013 following a crisis that devastated minority ethnic groups in the city, HI is committed to promoting healthcare and awareness accessibility to underserved communities with the assistance of medical students and health professionals. HI from time to time does take help from people from allied fields to carry out activities like carnivals and leisure activities for therapeutical purposes. HI's SLCs take place in impoverished areas every 2–3 weeks in the same locality to provide continuous care and monitor follow-up. In places like orphanages and old-age homes, SLCs are recurrent and take place every 6 months to conduct a screening camp and monitor residents’ health. SLCs are funded through donations and fundraising through bake sales, etc Having worked for more than a decade HI has developed good relationships with people as well as corporations who are happy to trust us with donation issues and we recurrently go to them for donations. Other than that, HI also organizes bake sales from time to time where all profits go toward SLCs, and a general call for donations results in a reasonable amount being raised.

These SLCs aim to decrease health inequity by providing free-of-charge healthcare services. While the medical camps are fully free and patients do not have to pay for the checkup or the medications, anything outside of the medical camp, eg, laboratory investigations and procedures do not come under the domain of medical camp and hence have to be pursued by the patient on their own. However, we still try to provide relief thereby also providing free referrals to tertiary care hospitals and sponsoring any procedures taking place by crowdfunding (as the cost is very high of those). Thus, these SLCs make healthcare more accessible and equitable for those in need. Through its proactive involvement in crisis management and humanitarian efforts, HI exemplifies the transformative impact that student-led initiatives can have in addressing healthcare disparities and promoting health equity in underserved communities.

In this paper, we present a case of a 12-year-old child who was identified in the clinic to be cyanotic and having reduced oxygen saturation. The CARE guidelines were adhered to while presenting this case. This case was categorized as a high-risk case and to be referred to a specialist. The case is presented here to exemplify the real-life crucial role of SLCs in providing critical healthcare services to underserved populations, helping the patients in their whole medical journey from diagnosis to treatment. This case highlights the transformative impact of SLCs by showcasing how a severe condition affecting quality of life was identified and managed through coordinated efforts at the HI-SLC. By focusing on this case, the perspective underscores the effectiveness of SLCs in bridging healthcare gaps, offering hands-on learning opportunities for students, and fostering a sense of social responsibility. It demonstrates that SLCs can navigate significant challenges to deliver life-saving care, reinforcing the argument that these clinics are a vital component of healthcare systems in resource-limited settings and should be continued and expanded.

The Camp at Orphanage

On May 6, 2023, a general health camp was organized for 115 children at the orphanage by HI. The camp included anthropometric measurements and a basic medical history for each child, followed by rotations through the following stations: general physical exam, cardiovascular exam, abdominal exam, respiratory exam, CNS exam, and motor exams.

The camp operated three separate circuits simultaneously, each supervised by an MBBS-certified medical doctor. Medical student volunteers were assigned to stations for conducting all examinations, once they completed it they presented their findings to the doctor who reviewed all findings and repeated tests if required. At the end of the camp, children received prescriptions if necessary and obtained medications from the on-site pharmacy.

Before the camp, we asked the medical students about their expertise and which rotations they had undergone and used it to assign them a particular station. For example, if they had an interest in neurology and they had already rotated in neurology they were assigned to the CNS and motor examination station. The medical students were given a brief teaching regarding their station precamp. During the camp, doctors and senior camp leaders were constantly rotating and supervising the medical students working. Wherever required, the doctors and leads taught the students regarding clinical skills and knowledge.

While SLCs are ideally multidisciplinary, involving collaboration between medical students and allied health professionals such as physiotherapists, occupational therapists, and pharmacists, the SLC in this case was solely operated by medical students supervised by licensed doctors, focusing on screening and management.

Case Presentation

A 12-year-old female of 30 kg weight presented with complaints of shortness of breath on exertion, palpitations, and cyanosis. On examination, she was found to have Grade-4 clubbing, and bluish discoloration was observed on her nails. Cardiovascular examination revealed a displaced apex beat, with a split of second heart sounds as well as a pan systolic murmur, there was good peripheral perfusion despite the peripheral cyanosis. Respiratory examination revealed clear bilateral lung fields with equal air entry. She had an oxygen saturation of 66%; however, she was clinically active and maintained a Glasgow Coma Scale of 15/15. No significant abnormalities were found upon gastrointestinal examination, with the absence of tenderness or visceromegaly.

The medical students and doctors together identified this case as high-risk and highlighted it to be referred to a specialist.

Humanity Initiative's (HI) Role in the Patient's Care

The camp lead from HI spoke to a pediatric cardiology consultant at a quaternary care university hospital regarding the patient's case. The consultant agreed to waive the patient's fee as per HI's request. Subsequently, the consultant conveyed the need for an Echocardiogram followed by a right heart catheterization for further exploration if necessary. The patient in question is a child currently residing on the premises of an orphanage. HI contacted the orphanage caretaker and then organized for the patient's family based in a village on the outskirts of Karachi to visit the city and meet the Doctor for further counseling. The family arrived a few days later and was communicated the need for an in-patient stay including an ECHO and subsequent relevant interventions necessary. The HI lead spoke to and answered any questions the family had. Furthermore, as the hospital was a private institute, it requested some funds to cover the administration, technical, and pharmaceutical fees. We had to arrange for these funds from our end as the patient's family could barely make their ends meet let alone pay for hospital bills. HI, with the help of the orphanage's authorities undertook the responsibility of fundraising to pay for the patient's care. A request was generated for the hospital's welfare department for waiver of chargers, the hospital's welfare department agreed to waive off roughly half the amount via Zakat (A source of Islamic funding analogous to donations made in the name of Islam) while the other half was raised via crowdfunding.

Intrahospital Stay

Based on the relevant history and clinical exam findings, the patient was admitted to a tertiary care hospital in Karachi with a principal diagnosis of complex congenital heart disease. Upon admission, the IV line was maintained and a series of investigations including Hb, creatinine, and PT/ APTT were ordered that returned unremarkable.

The patient was planned for an ECHO that showed situs ambiguous solitus type with dextrocardia, small ASD with bidirectional flow, mild hypoplastic LV and mitral valve annulus, severely dilated right ventricle with large VSD (16 mm), severe pulmonary stenosis, EF 66%.

Furthermore, a CT angiogram was ordered. The report suggested an overall appearance of Polysplenia syndrome with findings: Midline liver suggestive of situs ambiguous with dextrocardia, bilateral hyparterial bronchi, bilateral bilobed lungs, bilateral left atria, interrupted IVC with the continuation of the azygous vein, double SVC, ASD, and VSD, double outlet right ventricle, pulmonary artery stenosis with post stenotic dilatation, no significant stenosis seen in the branch pulmonary arteries, common origin of right and left coronary artery and pectus carinatum.

The patient was then planned for right heart catheterization that showed: situs solitus, interrupted IVC with azygous continuation, severe pulmonary stenosis with PA pressure of 26 mm Hg, systemic 110, Qp:Qs = 0.4:1. The patient was not suitable for completion of Fontan procedure or Gleen shunt, BT shunt will be considered later.

Role of Student-Led Clinics in the Care of the Child

The involvement of HI's SLC was pivotal in the diagnosis and management of the 12-year-old girl with complex congenital heart disease. Due to the financial constraints and the living situation, this child never had a chance to visit a hospital for any checkup despite having the symptoms and physical findings. The SLC conducted in the orphanage resulted in the child finally getting some overdue medical attention. The students and doctors were able to correctly identify the signs and symptoms and recognize that further referral was required. After this, the SLC team worked efficiently to make sure the patient's family was consulted on the need for further treatment. The team also contacted a pediatric cardiologist and brought them on board, while arranging for the funds required for the consultation, testing, and treatment.

The SLC facilitated the patient's care pathway, from initial diagnosis to specialized interventions, ensuring continuous support and follow-up. The SLC model allowed medical students to gain hands-on experience in identifying and managing a rare and complex condition, this provided an educational platform for students to develop clinical skills, develop organizational skills, foster social responsibility, and contribute meaningfully to community health. SLC played a critical role in bridging the healthcare gap for the patient, offering a community-oriented healthcare delivery that extended beyond immediate treatment to include holistic patient management and support.

Discussion

This journey from a mere health screening led by students to the identification and management of a highly sophisticated and rare disease in a resident child of an orphanage reflects the huge success of SLCs in boosting community health. People who struggle to meet their ends enough to afford a meal twice a day are hardly concerned about the optimization of their health. This child representing thousands of such children around the country, was living with a complex illness that limited her potential as well as posed a huge risk for a complication, yet she had never visited a doctor, nor did she or the caretakers think of this as concerning.

SLCs effectively address common complaints such as hyperlipidemia, depression, and diabetes.^6–8 Additionally, case reports like this demonstrate their capability in identifying rare conditions. The HIHI SLCs, which operate entirely free of cost and are staffed by volunteer medical students and doctors, exemplify a successful social entrepreneurship model for addressing community health needs, particularly in underserved areas.

SLCs offer multiple benefits, firstly they provide healthcare to those who otherwise do not have access to high-quality healthcare, who are our primary beneficiaries. Secondarily they provide donors with a meaningful impact, offer healthcare workers the opportunity to volunteer their time and knowledge, give students the chance to learn autonomously with firsthand patient exposure, and uphold high standards in community health management. This model is a win-win for all involved.

During their training, medical students acquire essential skills for diagnosing conditions. By learning to conduct thorough examinations and take detailed histories, students can generate differential diagnoses. Medical schools also teach laboratory workup interpretation, a critical skill for physicians. Throughout their education, students develop varying degrees of proficiency, with expectations to be adept at history taking and physical examination by mid-training. By their fourth year (in a five-year program, such as in Pakistan), students are expected to identify common conditions and understand further investigative steps. Final-year students are typically skilled in-patient history taking and examination, having gained sufficient exposure to diagnose and draft management plans.

Based on these competencies, the HI places senior medical students at history and examination stations under physician supervision. Junior medical students manage vitals, anthropometry stations, and counseling counters. Certified doctors serve as mentors and final evaluators, ensuring accurate diagnoses and refining management plans. Once approved by the doctors, senior students at the pharmacy station dispense medications according to prescriptions.

This collaborative approach synergistically enhances patient care and student learning while reducing the workload on doctors. It allows patients ample time to discuss their problems, as students take comprehensive histories. The involvement of doctors in confirming examination findings ensures no signs are missed. This method guarantees patients receive the best possible care in each aspect of their consultation—discussion, diagnosis, examination, counseling, and medication—handled by well-prepared students and doctors at designated stations.

When further investigations, such as blood tests or radiology, are required, the doctor drafts a prescription, and students explain it to the patients. The HI assists with the costs of these investigations. Patients can either communicate their results via phone to student representatives, who then discuss them with doctors and inform the patients of the next steps, or they can return to the next clinic, scheduled approximately 2-3 weeks later. If on review the team thinks the history warrants for a specialist review, the team gets a review from a specialist and requests them for a free checkup. Next, the patient's guardians are contacted and consulted to bring their child for a checkup. After the checkup, if any intervention is required then it is conducted after a mutual decision of the doctor and guardians. HI helps in fulfilling the logistical requirements of intervention. A detailed flowchart of this process is attached in Figure 1.

Figure 1.

Process of patient presentation to intervention.

Several challenges exist within this model. Patients often miss follow-up appointments due to scheduling conflicts with the HI-organized SLCs or lack of communication about upcoming clinic timings. When HI cannot cover the full costs of further workup, some patients forgo necessary tests and neglect their condition. Additionally, after initial screening at the SLC, patients may be advised to seek specialized check-ups at tertiary hospitals by senior consultants. However, the financial and time demands of these referrals can deter patients, and HI volunteers are not always successful in facilitating these visits.

In the case report above, the child's guardians, fortunately, agreed to a specialized clinic visit and the doctor waived off his charges while the rest of the charges were crowdfunded easily. This visit was crucial in identifying the need for an echocardiogram. The tertiary hospital provided financial assistance, enabling specialized testing and angiography. While the model effectively screens populations, significant uncertainties hinder the completion of the care continuum from diagnosis to management and follow-up.

Conclusion

The case of the 12-year-old girl with complex congenital heart disease identified through HI’s SLC underscores the profound impact of these clinics in addressing healthcare disparities in underserved communities. By providing free healthcare services, HI's SLCs effectively bridge gaps in access and facilitate early diagnosis of both common and rare conditions. This SLC model when combined with follow-up and referral provides not only a diagnosis but also a referral. The key factor in this is to establish connections with doctors and hospitals who can provide care at a subsidized cost. This way SLCs not only offer immediate medical assistance but also engage medical students in meaningful, hands-on learning, fostering a sense of social responsibility. However, there are many ongoing challenges in ensuring comprehensive follow-up care and the need for sustainable funding mechanisms. Future practice should focus on strengthening follow-up protocols, enhancing communication with patients, and securing consistent funding to cover further investigations and treatments. Additionally, research should explore the long-term outcomes of patients identified and treated through SLCs to better understand the full impact of these initiatives on community health.

Guidelines

This case report was prepared following the CARE guidelines, as recommended by the EQUATOR network, to ensure a comprehensive and transparent presentation of the clinical details and outcomes.