Making Vicks With Vicente and Dominga

Today I learned from Vicente and Dominga how to make Vicks Vapor Rub ("beaks bay poor roob"). Our home made version (remedio casero) consists of eucalyptus leaves, cypress branches, the resin-laden heart of the white pine, and vaseline.

After removing the eucalyptus leaves and de-stemming the cypress, we boiled them together with vaseline for about 5 minutes. The actual recipe is three fistfulls of each plant plus two tubs of vaseline. Then you add one fistfull of pine. The concoction is then strained and poured into empty Norvasc bottles (I imagine that other empty bottles will do).

Vicks is a very popular remedy here for nasal congestion and colds. Our version is sold by the health promoters at 1Q each, about 10 cents. The store-bought version is about 75 cents. We made 42 bottles and spend 30Q so that's a $1.20 profit for the half day of work. Par for the course.

Ann Ming's Rotation

Ana and Sandra: Sandra in her new clothes for Feria.
Kate and Ana at Mass, feeeling very religious.

Ana and Shom teaching health promoters about WHO Essential Medications.
Ana, Marcos, and Alex at lunch after the "Order of the Quetzal" award.

Ana making home visits with the Health Promoters in San Gregorio.
Ana and Kate in San Gregorio.
Ana on a morning run with Angel.

Trip to Chichicastenango

Doggie Surgery

I haven’t sewn up a serious laceration since medical school and I’ve never done any veterinary medicine, well, until now.

Chiquita suffered a bad injury yesterday morning. She was out in the “campo” (farmland) with Angel and playing up ahead with Scrappy, when Angel heard her let out a squeal of pain. She came running down to him and he saw a large, gaping wound right across her back bleeding profusely.

Apparently, someone had taken a machete to her back…who knows why. Angel tried to find the person (and he mentioned later it was probably better for them that he couldn’t). He only found another man who told him it was a child who had done it. Unfortunately, they were a 40 minute walk from home. By the time Chiquita got back, she had lost a lot of blood and collapsed on the floor.

Angel came and got me from breakfast and asked if I could sew her up since there wasn’t a vet in town. The wound looked quite deep, even broke into a rib, but I figured I could do better than nothing so hurried up to the clinic to get supplies. It was a frantic (and dusty) hunt through the bodega and ER but I got most of what I needed.

By the time I got back, thankfully they’d actually found a young man who had some experience in caring for animals (I guess you could call him a lay vet). He didn’t have the supplies he needed but had more experience than I did so we made a good team and sewed her up. I think he was laughing inside at my attempt to maintain some semblance of sterile technique. He used his bare hands and the gauze I brought to pick out hair from the wound and didn’t mind when the needle and suture dropped on the dirty floor. But, he was also faster than I would have been given that I wanted to irrigate the wound and close some of the bleeding vessels. He talked me into just leaving those and closing the skin.

He gave her a penicillin shot and I brought her some expired TMP-SMX from the bodega (it wasn’t hard to find expired antibiotics or a no-longer sterile surgery set). Chiquita did great (most likely thanks to her blood loss that made her sleep through most of it). We started her on oral rehydration solution (cooked with chicken heads to her liking) and she was actually able to stand up later in the afternoon and this morning. The young man will bring her iron to take to help her recover from her anemia. Now I’m just hoping that we can keep the wound from getting infected. She is such a sweet pup and definitely a member of the family. I really hope she makes it through.

Update: Chiquita is doing great. She developed a big hematoma and some bleeding a week later from the wound, probably because she was totally non-compliant with bedrest orders. I was worried that the bleeding wouldn't stop since we didn't close any of the internal vessels but it did and the hematoma is starting to go down.

Volunteers: The Irony of Judgment

Depending on the time of year, San Lucas can be packed with volunteers. Right now is the “slow time” for volunteers so it’s just about 10 of us , those who will be here between 6 and 12 months. In December/January and June-August, the numbers might swell to around 150, most coming through for a week. I've included a number of pictures of my fellow volunteers and friends (as an excuse to share their wonderful faces)....they are great and this post is not referring to them.

There is much that can be commented on with regard to the role of volunteers in this town but one thing that has struck me right from the start is the relationship between the volunteers, themselves.

The volunteers as a whole, one has to imagine, are a group of warm-hearted, concerned people who want to make the world a better, more equitable place. Everyone is working towards the common goal of improving the lives of people here in SLT. You would think that would mean that when you walked into the Parrochia for each of your meals, you would be greeted with hugs and enthusiastic moral support. That can be found amongst close friends but more evident, ironically, is judgment. This judgment is palpable and uncomfortable. It especially comes out whenever one begins to talk about the work s/he doing "in the field".

I can see where it comes from: people coming through with a huge amount of enthusiasm for starting new projects and infusing new ideas but not being able to stay long enough to respond to the enthusiasm and ideas of the locals (long enough meaning a life time, or just short of that). The great ideas go through a predictable pattern: incredible enthusiasm on arrival and lots of talk over mealtime about the plans, a few days of trying to get things off the runway usually met with locals saying “thanks” and “sounds like a great idea, this would really help us” but pointing out that money and supplies and logistical support will be needed (and this can only come from Parrochia or international benefactors), a few days of trying to conjur up Parrochial interest in the project usually met with very little interest because of the arguably correct assertion of the Parrochia that all projects need to be driven by and sustained by the local people, and a few days of disillusionment and upset just in time to get on the plane…hoping that back home the ideas might catch someone’s interest and generate some money that can be sent down (I’ve heard some locals point out that it might just be simpler to send the money at the start and save the plane fare). But, as I hear from volunteers (long and short-term, alike), once back home, the rat race begins again and the urgency to solve problems here just isn’t there like it once was. And then, new volunteers come. (Oh, and long-termers seem to go through this same cycle, though the phases might be prolonged and the disillusionment phase seems to be followed by acquiescence, during which one just decides to "go with the flow" and follow the lead of those you are working with, maybe putting a little idea and inovation here and there. I haven't gotten passed that phase but think that there might be several more phases to follow, hopefully one of insight and the ability to truly move things "forward" a little bit without pushing agendas or creating dependency....though my even suggesting that volunteers might be able to "move things forward" sounds like the next phase may be a repeat of the aforementioned cycle).

The sad thing is that this cycle, and getting caught in it, doesn’t say anything bad about the person who is trying so hard to change the world, yet they often pay the price of a rather cold reception by other volunteers, especially longer-term volunteers. I think this depressing cycle is just the reality of a very, very hard problem (poverty and systematic, deliberate inequities) lacking easy solutions.

Even amongst the long-term volunteers, I feel like the judgment is palpable. Many people want to make sure that you are in your place and don’t fall victim to some illusion that you are actually helping very much. But rather realize that you, too, are in the cycle and when you leave if you are lucky you will have not caused any harm here. It seems like people feel their own legitimacy as a "do-gooder" is threatened and they must battle for the best “do-gooder” status. In a way, I understand that this judgment might serve a purpose. Maybe it’s not good for us all to feel we are doing something great here when we really could do better by going home and advocating for social change or sending money to support locally-driven programs (scholarships, teaching of skilled trade, elderly food programs, etc). But, because I myself wish the Parrocial volunteer circle could be a warmer, more supportive place, I have to believe that this ritual of judgment just isn’t necessary. I’m going to try to avoid being part of it, as best I can.

Coffee: It's That Time of Year

It's coffee harvest time. School is out and Nov, Dec, and Jan are the peak months for collection and processing.

The hills are covered with "mata" or coffee plants. When the coffee is ripe, it turns red from its green, unripe color. It is then dried and peeled. The peeled bean is white and is dried further and then roasted. Finally, the roasted bean is ground. Historically, this was done on stones like the Native Americans ground corn. Now it's mill-ground, primarily. The traditional belief is that plants have souls and to grind the beans in a machine hurts its soul and the bean cries out. The flavor isn't as good for having induced this trauma on the soul of the bean. But, hand grinders can't compete financially so almost all marketed coffee it mill-ground.

The Parish has much of its own land and also purchases beans from local growers at Fair Trade prices. I'm still learning what is meant by Fair Trade but it was explained to me that the price is kept steady so that farmers aren't as affected by temporary market fluctuations. Also, rules are placed on how the plants and beans are harvested. For example, a Fair Trade purchasers might insist that the beans it buys have not been exposed to fertilizers or environmentally toxic pesticides and that children under 12 not be involved in the harvest.

Local growers I spoke with weren't jumping up and down about the Fair Trade system but seemed to think that in some cases it was good.

Feeling Helpless in the Face of Malnutrition

Today I went with Vicente and Dominga to Xejuyu to follow up on patients with asthma, hypertension, diabetes, malnutrition and acute complaints. I feel a little out of my element with hypertension and type 2 diabetes but I have to say that trying to treat the malnutrition is my greatest challenge by far. It may be the complaint I most dread of all the complaints here.

Two months ago, when I was questioned first by a mom in clinic about her child’s weight and what she could do to make her eat more and gain more, I winged it. I hadn’t had time, and still haven’t had time, to look up all the conditions that are new to me here and figure out how to tailor my approach to the setting, so I often struggle the first several times I see something. I start explaining things as I would in the States and usually realize that I’m being anything but helpful. I laugh disappointedly at myself now as I remember what I actually said when faced with this first case of an underweight child: normal kids won’t starve themselves as long as you provide them with plenty of nutritious food. Well, of course, there isn’t plenty of food in 99% of the homes here. If you actually ask, many will admit that there truly isn’t enough money. What do say? There’s no way to explain that away. Even trying to tell parents to limit sweets and save the money for nutritious foods seems like I’m just trying to make myself feel better and deny that the solution comes from providing resources not counseling.

Then they usually explain that they do try to give as much food as they can but the child doesn’t like to eat. They will only eat a half a tortilla and say they are full. When they are 23 pounds at 6 years of age, it’s hard to say, well, you can’t force a kid to eat, you just have to make good choices about what you provide. They want ideas. Once again, I’m at a loss for words, literally. You can’t say try things coated in high fat, tasty foods like peanut butter or cheese or full-fat milk, because they don’t have PB here and don’t have refrigeration for milk or cheese.

Most would like a vitamin to make the child hungry. I haven’t been taught that vitamins make a child hungry but that is the conventional medical wisdom here (confirmed by Rafael) and I don’t want to start a unilateral debunking campaign. So I try to explain that vitamins are best absorbed directly from food. I try to promote the concept of ensuring the child eat a fistful of food from each food group daily. I realize, though, that I’m not even sure what I’m teaching is right for the context. Maybe sheer quantity is more important than eating from each food group. If there isn’t enough money, that money might best be spent on more beans and tortillas; forgetting fruit and eggs that are more expensive.

After finding myself feeling helpless in the face of malnutrition over these past 2 months, I decided to read as much as I could about it this weekend, so I could do a better job of counseling. I read a great guide for nutritional counseling of children under 2 years in the developing world that provided a lot of data about quantities and types of food that are needed and timing for introducing the foods. I was really excited about the idea of having some true knowledge behind my counseling.

But today I felt as helpless as ever. The elephant in the room is that there just isn’t enough money for food for all the kids in the family and that numerous other social factors are playing into the malnutrition that can’t be solved by a doctor in a clinic visit. I know I will continue to be faced by this challenge all year and will continue to search for a more satisfactory approach. For now, I think it’s the things that don’t require my medical expertise that are probably making the biggest impact; things like deparasiting and the nutrition program of the health promoters, though the potential for such programs to make a positive impact has been debated. The health promoters are out of money for nutrition programs for the rest of the year anyway. They need $20/month to keep it going. I said I could fund the rest of the year (seeing as will cost about half the price of a haircut back home) but what do they do when they are on their own for funds. It’s a never ending problem.

Feria Week

Today is the last day of Feria week. Feria is the second biggest celebration of the year, just behind Semana Santa. We had Tues through Friday off and it was really nice, actually. It´s amazing how quickly time fills up, just like back home.

Ann Ming and I spend most of the Feria week mornings doing some work for her rotation or going over tropical medicine topics with Dick (he is a GREAT teacher). There were a few lunches hosted at various homes and the afternoons and evenings we dragged ourselves out in the rain to get in a little Feria action. Angel even got us out on the dance floor and it was great to see him having such a good time.

Yesterday we went to the City so Ann Ming could stay over with some new friends of ours, Jen and Jim, before flying out today. I renewed my Visa and we made a quick trip through the Central Market and the Central Plaza. Jen and Jim are here for two years, Jim as a special education teacher and Jen as a family doc. They have come to love the City in the two months they´ve been here. I have to say, I haven´t found the beauty in the City, yet. It is incredibly crowded, polluted, and there is that constant, very real, threat of violence. But maybe over the course of the year with a few get-away visits to their home I will come to like it, too.
I got back to SLT last night and stayed out until 2am at the impromtu discoteca that was set up for Feria. It was an interesting experience. The strangest part was seeing the girls in their traditional traje (dress) dancing trance. For my part, I´m just hoping to get some salsa steps down before the year is up!

A Great Talk with Dick and Vicente

I have been feeling very inspired and invigorated this week. One of the reasons, besides having Ann Ming here doing a rotation (and, therefore giving me the opportunity to share this incredible experience), is that a Dick came into town and is already acting like a great mentor and support for me.

Dick is a family physician from Colorado who has come to SLT several times over the last few years, working for a week or two at a time with PA students. He has also worked in Africa and Asia in a medical capacity. He has seen an incredible number of things but has a calm, understated manner that is very refreshing.

Dick has recently retired and is thinking of moving to Central America permanently to do humanitarian work. He has spent the last two weeks gathering more information about the health systems here, the ideas and passions of the local community health workers, and finding out if his presence here would be appreciated on a long-term basis.

This morning, Dick, Shom, Elena, Ann Ming, and I met with Vicente (health promoter and health promoter coordinator) to find out what ideas Vicente had about how Dick might be able to help support the health promoter program. Dick has some money that he would be interested in using to support their efforts but wants to do it in a very thoughtful, intentional way. After a few hours of great discussion, we decided that Dick should talk to Paul Wise who will be able to share a lot of insight given his long-term relationship with SLT and the HPs. We're envisioning that there might be a way for Paul and Dick to set up some form of institute from which the HPs could request funding directed at specific prevention efforts (nutrition, diabetes screening and surviellance, asthma control, fluoride treatments). Further, we discussed the issue of whether HPs should be paid and what the up-sides and down-sides would be of providing them a salary or other compensation. The creative juices were really flowing. I am continually impressed by Vicente's insight and deliberate approach.

Dick has also been sharing with Ann Ming and me much of his public health and tropical medicine wisdom in the form of powerpoint slides and discussions. Once again, I can't believe how much I am learning and how much more I realize I want to read and learn. I feel very fortunate to have crossed paths with Dick.

Presidential Visit

Ann Ming and I decided not to travel this weekend and, instead, took part in the big festivities of Saturday which included a visit from the President of Guatemala to San Lucas to award Father Greg "The Order of the Quetzal". I'm told this award is on the order of the Congressional Medal of Honor. Father Greg received the award in recognition of his 35 years of service here. In the picture to the left the President is the man standing on Father´s left. Preparations were going on all week including bomb-searching dogs the day before. Each of the volunteers got a special pass to let us into the Parrochia to eat and we got a wonderful Thanksgiving-style dinner. I couldn't hear much of the service but had fun playing with the baby next to me. After the two-hour mass and then the one-hour award ceremony, Ann Ming and I went to Maria Jose's Confirmation and enjoyed a delicious turkey dinner that night.

Sunday was even more fun. Fifteen of the current volunteers rented a boat for the day (at $6 each) to take us around the Lake to the town of San Antonio Palopo, Santa Catarina, and San Marcos. We had sun all day, which is a first.

Today, it was back to work....a one-day work week. Clinic was hopping and we saw some interesting cases, including a 10-year-old girl who seemed to have glaucoma (eye pain, tearing, and corneal clouding). We sent her to the specialist in Solola but, unfortunately, the specialty clinic is only open of the weekend so it will be a week before she can be seen.

Tonight we will be enjoying the Feria some more with out family. Feria is a festival to celebrate San Lucas, the saint for which our town is named. And it's celebrated for over a week with rides, fair food, and games in the town square (el Parque). The kids are in Heaven. Hopefully the rain will let up some this week.

Highs and Lows

Days here are a mixture of emotional highs and lows. So many things can turn the tide. An improving patient and happy family -- a high. A sick patient and no way to get the evaluation or meds we need -- a low. Health promoters eagerly learning and advocating for their patients -- a high. Visiting doctors talking about locals as if they are stupid or conniving and acting as judge, jury, and executer (in the assassin sense of the word) of the current health care systems -- a low.

Today was a real high for both of the above reasons and finished up as a low for the last reason. I am so frustrated with much of what I see medical volunteers doing when they come through here. Maybe because I’m in medicine and am paying more attention to what medical volunteers do, I find them to be the biggest troublemakers of all the volunteers. (And it does strike me as ironic and sad that the very people who are trying so hard to help are the ones causing some of the biggest damage).

Just to give a bit of background, the health promoters are community volunteers, typically overworked (farming, caring for 10+ kids) and impoverished but willing to give of themselves for others. They undergo three years of training to be able to provide basic, safe, essential care and medications to patients in their communities who can’t access a physician (due to distance and cost). They purchase their own medications and sell them at cost, allowing the purchase of more medications to keep their supply going. On very rare occasions, there have been reports of some health promoters selling medications at a mark-up to earn some money. The vast majority of the health promoters do not do this and, despite their utter poverty, work for free performing and honest and selfless service.

One of the visiting doctors who has made many trips to SLT over the last 15 years brought up the concern tonight that health promoters have access to medications at all given the risk of them selling them for a profit. As evidence to support his concern, he sites that patients are receiving vitamin shots and gentamicin injections and also reports the story of one program of health promoters in Guatemala City in the 70’s that, after 20 years fell apart because of medications being sold for profit (he reluctantly admits that the program later came back together with some modifications that have allowed it to function well). My objections to his concerns, and implicit desire to take away from health promoters their privilege to provide medications to outlying communities and therefore deprive destitute patients much-needed medical care, are multiple. One, in all his years volunteering in SLT, he’s never once worked with the health promoters who manage these medications (much less introduced himself to them and learned about their program) yet he stands in judgment of them and their program. Two, he hasn’t educated himself as to their role well enough to recognize that they don’t actually have access to vitamin shots or gentamicin and that these meds are instead being supplied to patients by pharmacists who have even less training than health promoters. That health promoters likely protect patients from seeking care from pharmacists by providing them with informed assessments and reasonable treatments. Three, he aims to dismantle a working system without regard to the consequences for patients in the interest of heading off and theoretical future abuses. Four, as a foreign physician he acts as if he believes he has the right to decide for a community what their needs are and police systems they, themselves, have put into place.

I have worked closely with the health promoters and I believe they absolutely must continue to have the ability to distribute medications to the communities that don’t have physicians. And it infuriates me that this visiting doctor would act with such arrogance, paternalism, and callousness. I believe that despite is good intentions and high quality medical training, the patients here would be better off without his “help”.

Trabajando Con Los Promotores

Health promoters brainstorming "How to Use a Pediatrician for the Year"

Clinic visits with patients in Nueva Providencia
Fluoride applications in Totolya

A few weeks ago, I started spending less time in the Parrochia clinic and more time with the health promoters. My Stanford mentor, Paul Wise, had told me that he felt my greatest contribution this year would be in supporting the efforts of the health promoters and helping to strengthen their three-year training program that was established 4 years ago. I was excited at that prospect but also excited about working in the clinic seeing ambulatory patients and caring for hospitalized patients. I spent the first month mainly in the clinic learning what conditions are most commonly seen here, how they are typically approached by other local physicians, especially Rafael Tun, what the local beliefs are about health and illness, and what medications are available. This experience was very valuable. It gave me a solid base of understanding and I think helped me make sure that my approach, when I'm out in the community, would harmonize with the approach of local providers and patients.


But I also started to realize that my daily work in the clinic was probably not making the impact I had hoped. While I think it unloaded Rafael's incredibly challenging schedule and may have positively impacted some individual patients, most of these patients would be seen even if I weren't there and I found myself very frustrated by the limits on workups we could do in clinic and the hospital, nursing care that wasn't as thorough or informed as I'd hope for, and medications that really didn't let me treat things as well as I felt they should be treated.
So, happily, I've started working just two days per week in the clinic and hospital and three days per week with the health promoters on program from nutrition to fluoride treatments to family planning to care of chronic patients with diabetes, asthma, hypertension, and epilepsy. It is wonderfully rewarding work.