Pediatric Health in

Sarah Dickes Córdoba, Argentina February 2016 Outline

• Background information • Structure of the healthcare system • Most common pediatric diseases • Vaccination • Tobacco Use • Annual health controls • Conclusions • Significant personal experiences Background Information

• Population of Argentina: 43 million • Population of Córdoba: 1.6 million (2nd largest city) SOUTH AMERICA • 33.6% of population between 0-19 years old • High income level nation • Primary cultural influences:

Córdoba Italian, Spanish, German • 92% Catholic • 6 military coups from 1930-1976 • Representative democratic republic Clinical Site: Hospital Pediátrico del Niño Jesús

• Public, provincial hospital • Services offered: – Outpatient and inpatient care – Emergency services – Pediatric ICU – Dental clinic – Specialty services (pulmonology, cardiology, ophthalmology, gastroenterology, etc.) Entrance to Hospital Pediátrico del Niño Jesús Why Pediatric Health in Argentina?

• Relevant to my profession • Explore similarities and differences between Argentina and the U.S. • Introduce a variety of important pediatric topics rather than one specific topic Entrance to the Emergency Room Structure of the Healthcare System

• Public system Proportion of Argentinians – Government-funded utilizing each system

• Social security system 7% – Employer and employee- Public funded 44% Social • Private system 49% Security – Patients pay out of pocket Private or have private insurance

Types of Hospitals: Hospitals are either national, regional, or provincial hospitals. Most Common Pediatric Diseases

1. Nutrition, overweight/obesity 2. Gastroenteritis 3. Bronchospasm 4. Bronchiolitis 5. Vector-borne diseases 6. Domestic and sexual abuse

Aedes aegypti mosquito Reduviid bug Dengue Chagas disease Chikungunya Zika Most Common Causes of Death

Children <5 years: 1. Congenital malformations 2. Accidents/injuries 3. Infection Children 6-10 years: 1. Pathologies Adolescents (10-18): 1. Accidents/injuries 2. Suicide 3. Homicide Mortality Rate for Children <5 Years: Argentina compared to U.S.

13 per 1,000

6.5 per 1,000 Vaccination in Argentina

• Immunization schedule contains 19 vaccines • 2009 – immunization became required, free of charge • 2009-2012 – HPV, dengue fever, and pneumococcal vaccines added to schedule • 2015 – Rotavirus added • Very minimal anti-vaccination movement, if any • Comprehensive schedule, high vaccination rates (93-99%) Unicef (2013). “Immunization report.” Retrieved from http://www.unicef.org/immunization/files/EN-ImmSumm-2013.pdf. Tobacco Use

Gender Youth Youth cigarette Youth smokeless (2012)1 smoking (2015)2 tobacco use (2014)2 Male 17.4% 17.0% 4.4%

Female 21.4% 20.5% 3.0%

Both sexes 19.6% 18.8% 3.7%

• Global Youth Tobacco Survey: 25% of 13-15 year olds in Argentina smoke; 30% of Argentine 11-year-olds have tried smoking already.1 • Lung cancer is considered an endemic disease in Argentina.

1. “Tobacco Use Among Youths — Argentina, 2007 and 2012.” Morbidity and Mortality Weekly Report (MMWR). Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6327a3.htm. 2. World Health Organization (2015). “WHO Report on the Global Tobacco Epidemic, 2015.” Retrieved from http://www.who.int/tobacco/surveillance/policy/country_profile/arg.pdf. “Controles de Salud” (Annual Health Controls)

• Required annual health checks for clearance to attend school – General pediatrician (vaccines) – Cardiologist (EKG) – Ophthalmologist (vision screening) – Dentist (annual dental care)

A child receiving dental care in the dental clinic Potential Strategies and Interventions

• Individual-based – Improve nutrition – Reduce screen time and encourage physical activity –

• Community-based – Nutrition education – Community sports teams or physical activity events – Healthy cooking classes/events – Improve access to healthy foods in rural areas Potential Strategies and Interventions

• Systems-based – Increase physical education/activity in schools – Higher cigarette taxes – Increase physician salaries Conclusions

• Obesity and poor nutrition are global health problems • Although the U.S. healthcare system has its pitfalls, I have a greater appreciation for certain aspects of it • The U.S. could learn some lessons from Argentina to improve American pediatric health • Differences in patient care often have to do with a lack of resources in the public hospitals Profound Clinical Experiences

• Surgery: different anesthetic techniques • Hospital: adherence to isolation precautions • Medical education: student and resident roles

Me with the dermatology residents Profound Cultural Experiences

• Physician salaries compared to other sectors • Food (positive and negative aspects) – Pastries, wine, yerba mate – Awareness of nutritional value and cooking styles

Yerba mate Empanadas Alfajores The Hospital

Dental clinic

Child and baby scales Outpatient clinic (very old equipment)

Me and Dr. Hidalgo Family and Classmates

My fellow medical students and our program directors

My Spanish instructor, Sonia My host family Córdoba

Plaza San Martín

Avenida 9 de Julio

“Voting doesn’t change anything. Politicians come and go, but hunger remains. Organize and fight.” References

1. Average Salary Survey (2016). “Argentina.” Retrieved from http://www.averagesalarysurvey.com/argentina. 2. “Calendario Nacional de Vacunación 2016.” Ministerio de Salud: Presidencia de la Nación. Retrieved from http://www.msal.gob.ar/index.php/home/funciones/consultas-por-mail/184-calendario-nacional-de-vacunacion-2016. 3. “Global Adult Tobacco Survey: Argentina 2012.” Retrieved from http://www.who.int/tobacco/surveillance/survey/gats/argentina_fact_sheet_2012.pdf. 4. Hill, Anna (2011). “Expanding Waistlines: Obesity in Argentina.” The Argentina Independent. Retrieved from http://www.argentinaindependent.com/currentaffairs/newsfromargentina/expanding-waistlines-obesity-in-argentina/. 5. Index Mundi. “Argentina Demographics Profile 2014.” Retrieved from http://www.indexmundi.com/argentina/demographics_profile.html. 6. Keetch, Olivia (2008). “Smoking in Argentina: Youth Targeted?” The Argentina Independent. Retrieved from http://www.argentinaindependent.com/socialissues/urbanlife/smoking-in-argentina-youth-targetted/. 7. Pan American Health Organization (2012). “Argentina.” Health in the Americas. Retrieved from http://www.paho.org/saludenlasamericas/index.php?option=com_docman&task=doc_view&gid=111&Itemid=. 8. “Tobacco Use Among Youths — Argentina, 2007 and 2012.” Morbidity and Mortality Weekly Report (MMWR). Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6327a3.htm. 9. Unicef (2013). “Immunization report.” Retrieved from http://www.unicef.org/immunization/files/EN-ImmSumm-2013.pdf. 10. Wikipedia. “Politics of Argentina.” Retrieved from https://en.wikipedia.org/wiki/Politics_of_Argentina. 11. The World Bank 2016). “Argentina.” Retrieved from http://data.worldbank.org/country/argentina. 12. The World Bank (2016). “Mortality rate, under 5 (per 1,000). Retrieved from http://data.worldbank.org/indicator/SH.DYN.MORT/countries/AR-US?display=graph. 13. “World Development Indicators, November 2015.” Retrieved from http://knoema.com/WBWDIGDF2015Oct/world-development-indicators- wdi-november-2015?tsId=1310480. 14. World Health Organization (2015). “WHO Report on the Global Tobacco Epidemic, 2015.” Retrieved from http://www.who.int/tobacco/surveillance/policy/country_profile/arg.pdf.