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Vital Signs

Dartmouth fosters birth and rebirth in Kosovo

By Roger P. Smith, Ph.D.

Since 1999, DMS and DHMC have had a presence in the battle-scarred Balkans. The warring has stopped now, but it left the Kosovar health-care infrastructure in ruins. Kosovo's political system is still in transition, but its medical system is now in much better shape thanks to Dartmouth's involvement.

Rate: That involvement has ranged from educational exchanges to library partnerships to clinical initiatives. The most recent initiative was the third DMS-Kosovo project funded by the U.S. Agency for International Development (USAID). Aimed at improving Kosovo's infant mortality rate, it has three subcomponents: the extension of an earlier prenatal project in the Gjakova region to six other regions; a new project focused on perinatology (the care of babies just before and after birth); and a sustainability component, aimed at securing ongoing funding. Dr. James Strickler, emeritus dean of DMS, and Dr. Donald Kollisch, an associate professor of community and family medicine, are heading up the project.

Strickler is especially committed to the sustainability aspect. Many programs built with foreign aid begin with the best of intentions but disappear as soon as funding runs out. The sustainability component of this project is funded under a USAID mechanism known as a Global Development Alliance (GDA). The intent of GDAs is to forge public- private alliances to stimulate economic growth in underdeveloped parts of the world. DMS is the first medical school ever awarded a GDA. Joining Dartmouth in the effort are a nonprofit called AmeriCares and Webber and Company of Norwich, Vt., a private firm focused on emerging global markets. The three partners will seek immediate financial support and also explore such possibilities as creating a not-for-profit to raise funds within Kosovo—a novel idea in a formerly communist region.

The reason for the project's focus on babies is that Kosovo has the highest infant mortality rate in Europe—35 deaths per 1,000 babies born, compared to 5 per 1,000 for Europe as a whole. About 10,000 babies a year are born at the University Hospital in Pristina, the capital, and 25,000 more in other Kosovar

George Little, left—pictured here sharing his expertise with a resident in the DHMC Neonatal Intensive Care Unit—has also been sharing his expertise with Kosovo.

hospitals. That means if Kosovo's rate were at the European average, over 1,000 additional babies would live past infancy.

Roadblock: The prenatal component of the project hit a roadblock right away, with Kollisch's discovery that pregnant Kosovar women had no medical records. They received no blood pressure checks, diabetes tests, or counseling about smoking and diet. Often, they didn't even see an obstetrician until going into labor. He has now set up a records system and training for doctors and nurses in its use. It will take years to assess the program's effect on mortality, but women are already seeking prenatal care in greater numbers.

To head the perinatal part of the project, Strickler tapped Dr. George Little, a DMS neonatologist with decades of experience in regional perinatal outreach. After a visit to Kosovo, Little was excited about the opportunity for improvement. He found many babies born eight to 10 weeks early whom he felt could be helped immediately. A number were dying because of a lack of fairly simple care, such as the use of surfactant to aid the function of their undeveloped lungs. Little set as the first objective to care for babies who could survive with a medium level of neonatal care; he plans to address more complex cases later.

Little found the Kosovar staff to be well

trained and dedicated, but lacking organization and resources. Equipment is a particular problem—its availability and its maintenance once it's in place. "You can't just use the new devices and drugs after delivery and expect much improvement," says Little. "You need to set up an entire system involving community hospitals, education programs, [and] a transportation system for pregnant mothers. . . . It's extremely important to start with a comprehensive improvement in perinatal care."

Return: That brought Dr. William Young, a DMS ob-gyn with 30 years of experience, into the picture. His precept is: "The best investment of health dollars is in mothers and babies. It is there that the greatest return can be achieved." He hopes to develop a system of integrated maternal and child care in Kosovo. He has a head start because he's hosted many Kosovar exchange students in his home while they're on rotations at Dartmouth. It now gives him great satisfaction to see them in Kosovo as residents in ob-gyn.

It's this kind of understanding that has helped the Dartmouth players in the Kosovar projects appreciate what they're doing— not just improving birthing practices but also participating in the rebirth of a health-care system, an economic system, a society.

If you'd like to offer feedback about this article, we'd welcome getting your comments at DartMed@Dartmouth.edu.

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