Thank you to so many of you who called or emailed me after reading my most recent entry, “horrible.” I have been meaning to write a follow-up and now that I’m home -- in Montana -- for the holidays I have a little time to reflect and even more time to post an update.
After Roman passed away, I cried for a much of the next two days. Angel couldn’t have been a better support, coming in to check on me, telling me how hard it can be working with “mi gente”, and telling me that it’s just not healthy to be too sad. Friday night I skipped dinner and he hurried into my room right at 6pm (dinner time), relieved that he caught me in time to warm me that there are lots of things I shouldn’t eat while being so sad. All I can remember is avocado. It turns out nursing women aren’t supposed to eat avocado either, according to local wisdom. Maybe that’s why there are so many avocados laying around on the ground. Anyway, he really was kind. On Tuesday, just three days after Roman passed away, Roman’s mother and a friend brought Jose in for a swollen penis. I was working upstairs with the health promoters and they asked to see me. I was thankful for the chance to see them again and check in. They were being strong and doing ok but Grandmother was really suffering, they said. I put Jose on antibiotics and asked if it would be ok if I visited them at home the next day to check on him. I told them I recognized it might be hard for Grandmother to see me but they said it would be really nice if I came by.
I mentioned to Angel I’d like to visit them and he very kindly offered to accompany me. It was really great to have his company, not to mention his skills in finding their house. Home visits in Guatemala are one of my favorite things for many reasons. First, it is really interesting to see where people live; it gives so much more context. Second, it feels like “the way medicine should be”, a doctor being as supportive as possible to the patient rather than making sick people always travel and wait in long lines to be seen. Three, the communication seems so much more horizontal and less vertical. They invite you in and you are thankful to them while you answer questions and they are thankful to you.
Anyway, back on track. As usual, the best we could do in finding their house was get to the house of the best known person in their neighborhood, Professor Thul. The tuk-tuk took us right there. Kids playing in the streets pointed us this way and that until finally, “that’s my grandmother.”. It nearly always goes like that. We knocked on the door and they warmly invited us in. Jose was sleeping peacefully under a mosquito net. They brought out plastic chairs and cokes. I checked on Jose, who was looking better. It was very strange to see him by himself and so oblivious. I asked how Grandmother was doing. She was out checking on a cousin who’d just suffered an abortion and, they told me, couldn’t come back for a day because one who has been around abortions, deliveries, or menstruating women can bring sickness to babies. They said she’d not been eating, had been very tearful, and her diabetes had gone out of control…she even passed out over the weekend and it took a bit to get her back. As I changed Jose, I could hear Angel talking to them behind me. He told them how upset I’d been and how much I’d been worrying about them. They told him how much they’d appreciated all the times I’d cared for the boys and were thankful that they’d always gotten better. They said they knew God had chosen to take him because neither Rafael nor the doctora (me) could find anything wrong with him (that’s not entirely true). It was helpful to hear them talk and to learn that, as devastated as they were, they didn’t blame me. I know it’s selfish to care about that but it was important to me. I also didn’t want them to live their lives feeling like he could have been saved if only a different doctor were there. That may be true (though I pray it’s not) but I think it would be torture for them to think that.
As I joined them in conversation and we finished our cokes, they told us stories from their year, a very difficult one for the whole family. There had been several deaths, some financial troubles, and unsuccessful relationships. They pulled out the one-and-only picture they had taken of the babies. It was taken just three days before Roman died. That is amazing to me. Thank God they had one picture at least. It reminded me that so many families don’t have that. In the picture, Roman and Jose are laying side-by-side. Roman is the bigger one of the two, though both are chubby and look the picture of health, kicking their legs up in the air. They are resting their heads on Guatemalan textiles and have a bible between them. It’s a very beautiful photograph.
We finally said our goodbyes and I told them they had my cellphone and could call me with any concerns, knowing anxieties would be running especially high. As we walked down the path towards the main streets, we saw a woman arriving in a tuk-tuk. I recognized it as the grandmother. My heart was racing but I just had to say hi to her. She collapsed in tears and gave me a big, strong hug saying “my angel is gone. I don’t understand why he had to go. I tried so hard.” I felt she was saying just what I felt. We cried together. Kids gathered around so I took the eggs she was carrying and we went up to the house. We sat and talked some more. She looked really tired and much older in just the week that had passed. But she was very kind to me and it helped so much to process with her and to feel sure that she would make it through, somehow.
I can’t even put into words how much it meant to me to get to see the family again, to visit them in their home and to show how much I was grieving for them. I can’t imagine having been more fortunate in having to go through such an experience to have the family react in the understanding way they did. It could have been so different. And then to have so many of my friends back home share their similarly trying times in medicine … and parenting and other parts of life … it just reminded me of how many wonderful people I have around me.
Wednesday, December 26, 2007
Saturday, December 1, 2007
Horrible
For the first time in my life, my career, a patient of mine, a patient for whom I was solely responsible, died. There are so many emotions swirling around inside me now that I can’t even think straight. It feels odd writing about it publicly but I feel like I have to process it and I also feel like I want to share. I can’t just write the good of this year without the bad.
I have seen several times two twin boys, Roman and Jose, who are now 4 months. They first came to the clinic (and saw Rafael) at 8 days of age when one had a seizure that had been going on all night. He was found to have a glucose of 8. After being stabilized, they were sent to Solola, where the other had several seizures as well, and then to the City where a work-up included a CT showing a head bleed in one but no abnormalities in the other but that’s all I ever could learn about the work-up from the grandmother (who was taking the role of mother). Since then, they have been seizure-free on their phenobarbital and have only come in with several minor illnesses. Two days ago, they came in with one day of fever, vomiting, and diarrhea. Their stool was positive for amoebas. Their urine was negative. I started them on metro and the vomiting stopped but fever continued and was very high (up to 40.8) and persistent. They were fussy but their physical exams were normal and vitals unremarkable otherwise. A CBC yesterday (third day of illness) was fairly unimpressive with a WBC on Roman of 13.5 62%N, 34%L, ESR 6 (they always run an ESR) and a WBC of 11.5 on Jose with a similar diff. I decided they just needed time to turn around but hospitalized them yesterday for observation because of the very high fever. Rafael apparently saw them last night before leaving and didn’t make any changes. According to the nursing notes, Roman’s fevers spiked to over 40 two or three times within 5 hours despite Tylenol and ibuprofen. He was also given neo-melubrina IM twice (not ordered). At 8pm, he began grunting and immediately developed cyanosis. He was given 3L O2 (I assume by blow-by because that’s the way they most often do it) and then immediately developed fixed and dilated pupils. Jose had no further fevers and his diarrhea became minimal and he looked good this morning.
What happened? I don’t know.
I picked up charts this morning, as each day, to review the vital signs. I asked the nurse how the boys were doing and she said, as I looked at Jose’s chart, “Oh, the brother died.” Literally, that was how she told me. She told me she heard he’d had a seizure and then cyanosis but the notes didn’t say that and the mom told me he didn’t seize. There were no heart rates or resp rates or BPs or O2 sats beyond the last Q6 vitals (they don’t do them more frequently even with an order). It’s so hard, with so little reliable information, to know what happened and I really want to know. Could he have had systemic amebiasis (and what is systemic amebiasis like)? Did he seize and obstruct? Was he septic (I don’t think so)?
Going to that bedside to see Jose and talk with the mom was really hard. She was tearful and sad but kind. She asked if she could take Jose home for Roman’s funeral at 3pm. She said Jose had been sighing out of suffering for his brother. It was really, really hard to see Jose by himself without his twin. Their whole life the family will have a constant reminder of that absence.
Do they hate me? Do they think that I mistreated their son and that is why he died? What could I do that would be helpful to them? Should I visit them?
It didn’t help at all that Rafael didn’t come to work today. He didn’t tell me yesterday when we were working together that he wouldn’t be here. That is how things go here. Apparently, he doesn’t tell people he’s not coming because then much of the other staff doesn’t come. I wish he would know that I would appreciate being told if he’s not going to come. There were several adult inpatients. I asked what would happen with them. The nursing assistants (no nurse today) said maybe I could see them (a woman with persistent nausea, vomiting, and vertigo; a man with advanced heart failure; a man with ETOH intoxication).
I went to see the other pediatric inpatients (three others). All had diarrhea. Emotions on the ward were high. All the parents were clearly feeling very stressed, I can only imagine because of having witnessed this terrible loss last night. They were respectful to me but tough. I felt like they really didn’t want me caring for their children and didn’t trust what I had to say. They all wanted to know why we weren’t doing more, faster. The nursing assistants were pretty slow and had missed several of the scheduled meds and needed reminders to give them. I tried hard to push on but really felt the unspoken hostility. And I was feeling my own hostility with the nursing assistants, Rafael, the parents.
One 6-month-old had just arrived with grossly bloody stool and vomiting. His dad wondered why we were waiting for the stool study and wasting time not getting an x-ray or an ultrasound or something. Then they insisted on leaving. They were upset with the IV in his arm which was on TKO (the nurses don’t run maintenance fluids ever; just boluses and TKO) and “solo por el gusto” (just because). The one-year-old who’d come in two days ago with 5 days of fever, cough, and diarrhea being treated with ceftriaxone and metronidazole was much better (initial sats were 70’s) so they wanted to leave, though her diarrhea was still pretty bad. I’ve seen these kids who leave so quickly (nearly all want to leave as soon as there is some improvement) come back near death. I tried to talk them into one more day but couldn’t.
A couple a patients had traveled all the way from an outlying community for the results of stool samples they sent in with Ritu yesterday but the stool had been thrown away because the lab guy didn’t come to work yesterday and the only other lab in town that processes stool also was closed. Only the parents came today without their kids so we couldn’t repeat the sample. So they just wanted treatment with metronidazole for having come so far.
It was a terrible, terrible morning. My hardest yet, by far. I couldn’t go into work this afternoon. Mary and Ritu took a walk. They came upon the family of Roman and Jose leading the funeral procession for Roman, carrying his little, white casket. His mom was being held up by relatives.
I feel like I should go home….home, home. I’m not sure what good I’m doing here in a place where western medicine is so unaccepted by so many people. And where the nursing care is so poor and the ability to evaluate and monitor patients so bad. Could Rafael do a better job on his own? Quite probably. At least as good of a job. I could move to working only in the communities with the health promoters. But I now have clinic patients I follow more consistently and I also value my relationship with Rafael. What do I do about those patients? About the commitment I made to them, to Rafael, to the community, to myself? Given that running away wouldn’t change the awful realities here, is there some better thing I could do to actually make an impact? How will I be able to go back to the hospital?
I have seen several times two twin boys, Roman and Jose, who are now 4 months. They first came to the clinic (and saw Rafael) at 8 days of age when one had a seizure that had been going on all night. He was found to have a glucose of 8. After being stabilized, they were sent to Solola, where the other had several seizures as well, and then to the City where a work-up included a CT showing a head bleed in one but no abnormalities in the other but that’s all I ever could learn about the work-up from the grandmother (who was taking the role of mother). Since then, they have been seizure-free on their phenobarbital and have only come in with several minor illnesses. Two days ago, they came in with one day of fever, vomiting, and diarrhea. Their stool was positive for amoebas. Their urine was negative. I started them on metro and the vomiting stopped but fever continued and was very high (up to 40.8) and persistent. They were fussy but their physical exams were normal and vitals unremarkable otherwise. A CBC yesterday (third day of illness) was fairly unimpressive with a WBC on Roman of 13.5 62%N, 34%L, ESR 6 (they always run an ESR) and a WBC of 11.5 on Jose with a similar diff. I decided they just needed time to turn around but hospitalized them yesterday for observation because of the very high fever. Rafael apparently saw them last night before leaving and didn’t make any changes. According to the nursing notes, Roman’s fevers spiked to over 40 two or three times within 5 hours despite Tylenol and ibuprofen. He was also given neo-melubrina IM twice (not ordered). At 8pm, he began grunting and immediately developed cyanosis. He was given 3L O2 (I assume by blow-by because that’s the way they most often do it) and then immediately developed fixed and dilated pupils. Jose had no further fevers and his diarrhea became minimal and he looked good this morning.
What happened? I don’t know.
I picked up charts this morning, as each day, to review the vital signs. I asked the nurse how the boys were doing and she said, as I looked at Jose’s chart, “Oh, the brother died.” Literally, that was how she told me. She told me she heard he’d had a seizure and then cyanosis but the notes didn’t say that and the mom told me he didn’t seize. There were no heart rates or resp rates or BPs or O2 sats beyond the last Q6 vitals (they don’t do them more frequently even with an order). It’s so hard, with so little reliable information, to know what happened and I really want to know. Could he have had systemic amebiasis (and what is systemic amebiasis like)? Did he seize and obstruct? Was he septic (I don’t think so)?
Going to that bedside to see Jose and talk with the mom was really hard. She was tearful and sad but kind. She asked if she could take Jose home for Roman’s funeral at 3pm. She said Jose had been sighing out of suffering for his brother. It was really, really hard to see Jose by himself without his twin. Their whole life the family will have a constant reminder of that absence.
Do they hate me? Do they think that I mistreated their son and that is why he died? What could I do that would be helpful to them? Should I visit them?
It didn’t help at all that Rafael didn’t come to work today. He didn’t tell me yesterday when we were working together that he wouldn’t be here. That is how things go here. Apparently, he doesn’t tell people he’s not coming because then much of the other staff doesn’t come. I wish he would know that I would appreciate being told if he’s not going to come. There were several adult inpatients. I asked what would happen with them. The nursing assistants (no nurse today) said maybe I could see them (a woman with persistent nausea, vomiting, and vertigo; a man with advanced heart failure; a man with ETOH intoxication).
I went to see the other pediatric inpatients (three others). All had diarrhea. Emotions on the ward were high. All the parents were clearly feeling very stressed, I can only imagine because of having witnessed this terrible loss last night. They were respectful to me but tough. I felt like they really didn’t want me caring for their children and didn’t trust what I had to say. They all wanted to know why we weren’t doing more, faster. The nursing assistants were pretty slow and had missed several of the scheduled meds and needed reminders to give them. I tried hard to push on but really felt the unspoken hostility. And I was feeling my own hostility with the nursing assistants, Rafael, the parents.
One 6-month-old had just arrived with grossly bloody stool and vomiting. His dad wondered why we were waiting for the stool study and wasting time not getting an x-ray or an ultrasound or something. Then they insisted on leaving. They were upset with the IV in his arm which was on TKO (the nurses don’t run maintenance fluids ever; just boluses and TKO) and “solo por el gusto” (just because). The one-year-old who’d come in two days ago with 5 days of fever, cough, and diarrhea being treated with ceftriaxone and metronidazole was much better (initial sats were 70’s) so they wanted to leave, though her diarrhea was still pretty bad. I’ve seen these kids who leave so quickly (nearly all want to leave as soon as there is some improvement) come back near death. I tried to talk them into one more day but couldn’t.
A couple a patients had traveled all the way from an outlying community for the results of stool samples they sent in with Ritu yesterday but the stool had been thrown away because the lab guy didn’t come to work yesterday and the only other lab in town that processes stool also was closed. Only the parents came today without their kids so we couldn’t repeat the sample. So they just wanted treatment with metronidazole for having come so far.
It was a terrible, terrible morning. My hardest yet, by far. I couldn’t go into work this afternoon. Mary and Ritu took a walk. They came upon the family of Roman and Jose leading the funeral procession for Roman, carrying his little, white casket. His mom was being held up by relatives.
I feel like I should go home….home, home. I’m not sure what good I’m doing here in a place where western medicine is so unaccepted by so many people. And where the nursing care is so poor and the ability to evaluate and monitor patients so bad. Could Rafael do a better job on his own? Quite probably. At least as good of a job. I could move to working only in the communities with the health promoters. But I now have clinic patients I follow more consistently and I also value my relationship with Rafael. What do I do about those patients? About the commitment I made to them, to Rafael, to the community, to myself? Given that running away wouldn’t change the awful realities here, is there some better thing I could do to actually make an impact? How will I be able to go back to the hospital?
Thursday, November 29, 2007
Trip to Tikal
The third-year health promoters will graduate from their training program on December 15th. To celebrate, we all took a trip to Tikal. A nurse practitioner, visiting phyisican, and the Parrochia all pitched in to fund the 12-hour road trip and all the meals. This was the first time many of the health promoters had traveled past Guatemala City. In all, there were 9 health promoters, 6 of their children, 3 gringos, and the driver…19 in a minivan made for 15 (only two of whom got seatbelts), so that meant kids on laps, on the floor, and balancing on half butt-cheeks. But we made it in one piece and without much drama.We did get stopped by the police for what remains an unclear and undeclared reason. The driver had to tuck a good sum of money in his registration papers so that we could continue on (this is “just the way it works” here).
We stayed at a Parish in the town of San Benito in the region of Peten. There is a thriv
ing health-promoter program there and we briefly met their promoters but, through a little miscommunication in planning, didn’t spend an evening sharing traditions and performances with them as had been done during the trip two years ago when the current graduated class celebrated their graduation.The first night we met with Sue Hammerton who started the health promoter program in San Lucas and is ADORED by them all. She was delightful though I only got to speak with her for a few minutes. That night the health promoters treated us all (in honor of Sue) to a great ceremony of traditional dancing, songs about illness
and health, mock patient visits, games, and jokes. We fought off heat and mosquitos to get a little sleep that night.The next day we visited the small, peaceful island town of Flores where we met, Janette, the expatriate nurse who orders medications for health promoters across Guatemala via Concern America. Then we took a boat to a tropical island animal reserve called Petencito.
On Sunday we visited Tikal, which the “Rough Guide to Guatemala” says is “possibly the most magnificent of all Maya sites”. Tikal was a Maya metropolis first constructed around 900 BC and inhabited until about 900 AD. It was “discovered” in 1695 and excavated beginning in 1956, though only 15% has been fully uncovered. The temples are enormous and the stairs up them are remarkably steep and of questionable stability. In fact, the stairs up one of the temples were closed in January due to two serious falls, one of which was fatal. The views from their tops over the jungle are incredible. When we started out in the morning we saw a couple of different monkey troups and later in the day saw a red fox, a pisote (something that looks like an anteater), and several toucans.
We returned home and slept for 4 hours before embarking on the long return drive marked by a brief stop at Rio Dulce, a large river and lake in Southern Peten.
Petrona and Rosa getting ready to dance
Shom and Socorro hugging to pop a balloon
Rosa and her daughter waiting for boat to Petencito
Group on boat to Petencito from Flores
Socorro and little Helen on boat to Petencito
Outside of Petencito
Petrona and Rosa in Petencito
Vicente and Abelino with a wild pig in Petencito
Leopard in Petencito
Toucan
Kate and Abelino hiking the trails of Petencito
Dominga and Rosa hiking in Petencito
Petrona Castro trying out gringo shades
Kate and Vicente on dock to return from Petencito to Flores
Health promoter group entering Tikal
Jungle canopy in Tikal
Shom and Rosa on top of pyramid
Helping Vicente capture our feet AND the top of the pyramid
Resting at the top of the pyramid
Un-excavated pyramid
Rio Dulce
Sunday, November 18, 2007
Baptism of Estefany Merleny
I had the great pleasure of being asked to be the godmother (madrina) of a baby I have taken care of a few times over the last 3 months at the hospital. I was really flattered to be as
ked by her parents, Ana and Byron, but wasn't sure I should accept since I'm not Catholic and I will only be here for a year. But they were sure they wanted to go ahead with it and I got the blessing of Father Greg, so I accepted.
They had explained to Father Rich, whom they had asked to be the godfather, that they felt the baby had been so sick so much of her life that the
y should bring health and God together with a doctor as the madrina and a priest as the padrino. Estefany is now healthy and so hopefully their worries are behind them.
Today was the ceremony and it was a nice experience. It will take some creativity for me to figure out how to support and impact Estefany over the years from a distance but I'm determined to do as good a job as I can. Ana is only 21-years-old and Byron is 24. They have three children, 3 years, 1.5 years, and 4 month
s (Estefany). They all share one room with two beds in a home of 18 people. Ana's mom (Estefany's grandmother) has 11 children, the youngest being just 1-year-old. Ana and Byron are hoping to not have any more kids for the time being but they aren't comfortable with birth control, for religious and social reasons. I can see a struggle ahead of them.
ked by her parents, Ana and Byron, but wasn't sure I should accept since I'm not Catholic and I will only be here for a year. But they were sure they wanted to go ahead with it and I got the blessing of Father Greg, so I accepted.They had explained to Father Rich, whom they had asked to be the godfather, that they felt the baby had been so sick so much of her life that the
y should bring health and God together with a doctor as the madrina and a priest as the padrino. Estefany is now healthy and so hopefully their worries are behind them.Today was the ceremony and it was a nice experience. It will take some creativity for me to figure out how to support and impact Estefany over the years from a distance but I'm determined to do as good a job as I can. Ana is only 21-years-old and Byron is 24. They have three children, 3 years, 1.5 years, and 4 month
s (Estefany). They all share one room with two beds in a home of 18 people. Ana's mom (Estefany's grandmother) has 11 children, the youngest being just 1-year-old. Ana and Byron are hoping to not have any more kids for the time being but they aren't comfortable with birth control, for religious and social reasons. I can see a struggle ahead of them.
Saturday, November 17, 2007
Photos: Patients
6-year-old girl in Nueva Providencia with severe malnutrition and FTT
2.5-year-old boy in Nueva Providencia with macrocephaly
"Save me brother!" 
6-year-old boy with growth failure with his mom and sister
Rodman
Impetiginized tinea corporis
24-year-old with snake bite on his little finger. He sliced the bite with his machete and placed a tourniquet
Another snake bite...8-year-old boy
Pityriasis alba
Scabies
Morquio?
Still undiagnosed. His older brother looked similar and died suddenly at 12-years-of-age. His mom wants to know what the future holds for her son.
Madelung deformity?Going Upstream
There is a parable that is often told in public health circles to illustrate why it is so important when trying to remedy a problem to look for the root of the problem and fix it rather than focusing all effort on the numerous results of the problem. The parable goes like this:
You come upon a fast-flowing stream and you see a toddler struggling to stay afloat. You jump in and save the toddler. But no sooner do you get ashore than another baby comes floating down the stream on the verge of drowning. Each time you get to shore the same thing happens and you aren’t able to save some of the babies because it’s just you. So you start calling for help and townspeople come and start helping as well. Some have good ideas about how to save more of the babies, like placing a net across the river or making a chain of people to pass the babies back to shore. Meanwhile, one person thinks to walk upstream to find out why so many babies are coming down the river. It turns out that 50 yards upstream, the fence guarding the shores has fallen and the toddlers are wandering into the stream unknowingly. The townsperson fixes the fence and you all get together to celebrate over a Gallo (the local beer).
I’ve been thinking a lot about where I am in this stream lately. I’m treating a lot of scabies, URIs, LRIs, fungal skin infections, GI parasites, and malnutrition. On any given day, I meet at least one person whose story really compels me and I think “I’m going to sponsor this person. I have the money and they really need _____.” In the blank might be school fees (one mom told me in confidence that she’s been crying a lot lately because her husband says the four girls they have, oldest being 12 years, can’t go to school anymore because there’s no sense in wasting money educating girls), money for a continuing education class (the head health promoter wants to take a social work class for $150/mo to improve his ability as a lead health promoter; another health promoter was orphaned at 4 years of age to his 80-year-old grandfather when his mom, dad, and two other siblings were killed by the army but has since showed himself to be a very bright and dedicated health promoter with a great deal of understanding about natural remedies and a desire to take some classes on the subject), money for asthma medicine (a 2-year-old girl with bad asthma has been being treated with very frequent two or three day courses of IM gent and ampicillin by local pharmacists for her resp exacerbations because her family doesn’t have the money to bring her to clinic when she gets sick or buy her inhalers). Anyway, literally every time that I have my mind set on where I’m going to put my money, I find myself stopped in my tracks by the reminder that the money I have could make a much bigger difference if I could get further upstream.
The Parrochia makes is 100% clear that their belief is that as upstream as you can get is buying people land. People will never escape the problems associated with poverty if they don’t own land. In addition, by giving them something they can use for a variety of things: build a house, cultivate coffee, open a corner store, you have given them dignity and self-determination. I buy into this notion and found myself more recently thinking that when I leave here in June, I will donate towards purchasing more plantation land to be allotted to those still living under a system of indentured servitude. The idea of land purchase is really appealing when you see the beautiful new communities of Totolya, Tierra Santa, Por Venir, and Nuevo San Andres. All are peaceful communities supplied with electricity and water in with each family has its own home as well as a front and back yard.
But this week, when we visited Vicente in Quixaya, I started to doubt that this was the ultimate solution either. Vicente’s own father had been given land by the Parrochia many years back as part of a similar resettlement. Now that parcel of land is split between Vicente and his 4 or 5 siblings and their spouses and children. Each lives in a tiny house, kids and parents sharing beds, no free land for growing fruit or vegetables (they have a couple of potted vegetables). As the numerous grandchildren grow and get married, the property will be even smaller and I have to wonder if some will return to living on a plantation, renting land they can’t afford and ultimately return to the same destitute state they came from generations before. Of course, the land grant was important and valuable and makes them so much better off than they were before but now I’m thinking that further upstream is the issue of family planning.
If people continue to have 10-12 kids, despite wanting only 2 or 3, poverty, overcrowding, and disease will continue. I’m sure, I will come to think even further upstream than this over time but right now I’m feeling like funding a program that disseminates information on family planning and makes the methods accessible is the most valuable thing I could do with my money.
You come upon a fast-flowing stream and you see a toddler struggling to stay afloat. You jump in and save the toddler. But no sooner do you get ashore than another baby comes floating down the stream on the verge of drowning. Each time you get to shore the same thing happens and you aren’t able to save some of the babies because it’s just you. So you start calling for help and townspeople come and start helping as well. Some have good ideas about how to save more of the babies, like placing a net across the river or making a chain of people to pass the babies back to shore. Meanwhile, one person thinks to walk upstream to find out why so many babies are coming down the river. It turns out that 50 yards upstream, the fence guarding the shores has fallen and the toddlers are wandering into the stream unknowingly. The townsperson fixes the fence and you all get together to celebrate over a Gallo (the local beer).
I’ve been thinking a lot about where I am in this stream lately. I’m treating a lot of scabies, URIs, LRIs, fungal skin infections, GI parasites, and malnutrition. On any given day, I meet at least one person whose story really compels me and I think “I’m going to sponsor this person. I have the money and they really need _____.” In the blank might be school fees (one mom told me in confidence that she’s been crying a lot lately because her husband says the four girls they have, oldest being 12 years, can’t go to school anymore because there’s no sense in wasting money educating girls), money for a continuing education class (the head health promoter wants to take a social work class for $150/mo to improve his ability as a lead health promoter; another health promoter was orphaned at 4 years of age to his 80-year-old grandfather when his mom, dad, and two other siblings were killed by the army but has since showed himself to be a very bright and dedicated health promoter with a great deal of understanding about natural remedies and a desire to take some classes on the subject), money for asthma medicine (a 2-year-old girl with bad asthma has been being treated with very frequent two or three day courses of IM gent and ampicillin by local pharmacists for her resp exacerbations because her family doesn’t have the money to bring her to clinic when she gets sick or buy her inhalers). Anyway, literally every time that I have my mind set on where I’m going to put my money, I find myself stopped in my tracks by the reminder that the money I have could make a much bigger difference if I could get further upstream.
The Parrochia makes is 100% clear that their belief is that as upstream as you can get is buying people land. People will never escape the problems associated with poverty if they don’t own land. In addition, by giving them something they can use for a variety of things: build a house, cultivate coffee, open a corner store, you have given them dignity and self-determination. I buy into this notion and found myself more recently thinking that when I leave here in June, I will donate towards purchasing more plantation land to be allotted to those still living under a system of indentured servitude. The idea of land purchase is really appealing when you see the beautiful new communities of Totolya, Tierra Santa, Por Venir, and Nuevo San Andres. All are peaceful communities supplied with electricity and water in with each family has its own home as well as a front and back yard.
But this week, when we visited Vicente in Quixaya, I started to doubt that this was the ultimate solution either. Vicente’s own father had been given land by the Parrochia many years back as part of a similar resettlement. Now that parcel of land is split between Vicente and his 4 or 5 siblings and their spouses and children. Each lives in a tiny house, kids and parents sharing beds, no free land for growing fruit or vegetables (they have a couple of potted vegetables). As the numerous grandchildren grow and get married, the property will be even smaller and I have to wonder if some will return to living on a plantation, renting land they can’t afford and ultimately return to the same destitute state they came from generations before. Of course, the land grant was important and valuable and makes them so much better off than they were before but now I’m thinking that further upstream is the issue of family planning.
If people continue to have 10-12 kids, despite wanting only 2 or 3, poverty, overcrowding, and disease will continue. I’m sure, I will come to think even further upstream than this over time but right now I’m feeling like funding a program that disseminates information on family planning and makes the methods accessible is the most valuable thing I could do with my money.
Photos: Rural Communities and People
Current school in Pampojila
New school in construction in Pampojila
6th grade classroom in Nueva San Andres
Young boy in traditional San Lucas dress
New houses being built in Nueva San Andres, where mudslide victims have been relocated
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