First Aid Health Promoter Training

Today was the second day of our primeros auxilios (First Aid) course with the second year health promoters Domitila, Ingrid, Samuel, Mariela, Benita, Delma, Clara, Magali, and Veronica. We taught Evaluate, Call for Help, and Treat; Cuts, Injuries, and Fractures; Animal Bites; Hemorrhage; Burns; Choking; Drowning; and Shock. This is a relatively shy goup (compared with the two graduated classes) but they did a very good job getting involved in the scenarios this time. One of the fun challenges of this year -- and a really nice learning opportunity for me -- has been experimenting with how to teach to health promoters. There is a book published by the Hesperian Foundation entitled "Helping Health Workers Learn." It is full of great ideas for teaching including models for explaining complicated concepts in simpler ways (many people have not even had a health course before), adapting information so that it's appropriate for the setting, soliciting important contributions from the learners as the people who know the patients and the setting best, etc. Planning for the courses takes a few days between the two lead health promoters and three of us volunteers. We've learned some important lessons along the way. One being that the learning has to be active and breaks for games are a must. Something new I learned today is that magic tricks don't get quite the response they get in the States. They seem to be disturbing to people. I think I'll save those for kids! Dominga teaching about wound cleansing Shom with a great fracture face Veronica stabilizing the fracture with Clara's help Magali cleaning a dog bite Clara responding to a snake bite Taking a break for hot potato ("patada caliente") Shom suffers a bloody nose mid-lecture

Clara gives Shom a handDomitila saves Ingrid with the Heimlich maneuverDomitila gives back blows to a choking baby

Delma choses a donated watch for taking pulses and resp rates

Copan, Honduras

This weekend I traveled to the Mayan ruins of Copan (Honduras) with Elena, Shom, Dick, Jen, Jim, and J&J's two adorable girls Emma and Abby. It was such a nice trip. Before we headed out from Guate City, Elena, Shom, Dick and I ran a bunch of errands in the City (fluoride, supplies for making shampoo and anti-itch lotions, formula, etc). Running errands in Guate is nothing like running errands back home. The car exhaust turns your stomach (I try to time my breathing between belches of black smoke from the truck in front), you can’t park so our ride just had to circle, and it’s so dangerous you are constantly on edge (or at least I am). We spent that night at Jen and Jim’s and enjoyed some wine, the memory of which had to last me through the trip since I had to start another course of metronidazole that night. That makes for 5 bouts of amoebas in as many months. TMI.

We caught the bus for Honduras at 5am the next morning and had an easy trip. Copan is beautiful. Jen described it well as “Antigua but a little rough around the edges”. The streets are all cobblestoned and the houses/stores are white-washed with Spanish roof tiles. The hillsides are lush green and the views are spectacular and relatively undisturbed. We spent the first afternoon at a “waterpark” though it ended up being closer to a collection of pools with some questionable water. The girls were in heaven and, well, so were we!

The next day we toured the Copan ruins. We had a great guide who shared a little of his story with us. He had worked some 15 or so years excavating the sites (wow!). He got involved one day when a visiting archeologist from Harvard found him on the roadside and asked if he wanted some work for the week. There after he has studied quite extensively and was incredibly knowledgable. It seemed sad to me that such a well-educated and experienced man was only giving tours as his living. Anyway, compared with Tikal the ruin site was less extensive and most temples smaller but the carvings were more interesting. There were stelae (historical records that look something like stone totem poles), a stone staircase that was also a historical record of the prior 300 years, a ball field, a human sacrifice “altar”, and a series of tunnels that allowed you to view the temples that were covered over as the Maya built bigger temples atop earlier ones. The story of the ball field and sacrifice alter was interesting. The game involved keeping a ball from falling to the ground. It was played only by nobles. The captain of the winning team was sacrificed as an honor. He was first given a liquor drink then laid over a large stone with a groove for his head. A neck vessel was cut and he slowly bled to death. The loser had a worse fate: he became a slave.

That night we watched some of the primaries action on cable TV (what fun!) and played cards at a cute rooftop café. The next day we holed-up at the same café and planned out our course for the health promoters on hypertension. We returned to the City on Sunday and savored our last moments of sheer comfort and luxury with Jen and Jim over sushi.

Carnival

Today is Carnival (Latin: carne vale or “farewell meat”). It is a Roman Catholic tradition, marking the beginning of Lent (Cuaresma), that has developed its own character in various parts of the world. In most places, from what I have heard, big processions fill the streets; the people dressed in skimpy or over-the-top outfits, often with folklore masks. Wikipedia says that the loud music and often risque outfits that typify carnival represent the “last hurrah” before the 40 days of Lent, during which all bodily pleasures are to be abandoned. Here in San Lucas Toliman it may not be all bodily pleasures that are left behind but Luquenos do hold to the tradition of not eating meat and avoid having celebrations, including weddings (in fact, I was told that Lent was the reason Gela had to get married so quickly - 5 weeks after getting engaged - because otherwise she’d have to wait until after Lent).

For the last several days, the kids have been emptying the eggs from their shells (preserving the shell as much as possible), painting them in bright colors and filling them with confetti. At school this morning, they held the Miss Carnival competition, which I went to because I’m sick and didn’t feel up to applying fluoride in the schools (somehow, I was up for a Carnival experience). There were 8 Mayan girls competing. I haven’t stopped being astonished by how little they wear when they participate in parades or contests like this. Several were wearing the equivalent of bikini’s in front of their entire student body, teachers, and the town mayor. Even back home, most parents wouldn’t go for this. It’s hard to understand how such outfits became the tradition in a culture where girls who don’t even wear shorts - ever - or wear their hair down. Each girl had to give a short speech and perform a dance - the dances were straight out of the discotec. One had something of a belly dancing routine. Angel told me he thought she should win.

In the afternoon the kids gathered in the town square and went crazy cracking eggs on heads. Traditionally, these eggs are supposed to hold only confetti but over time, and as older kids corrupted the tradition, real eggs or eggshells filled with flour have come into vogue. I hear foreigners are a popular target. I decided I was too sick to have to take a second shower so I missed this. I got confetti'd last week at clinic anyway, so I know how much fun it is!

Trust

Dick (volunteer family practitioner) and I were talking this evening about what it is like to take care of patients here. He said he noticed that I talk a lot about the issue of not being trusted by my patients and he hasn’t felt that way in other sites or heard other docs who work internationally complain of such an experience. In fact, he said when he worked in India for 2 years, because care by a gringo was so esteemed, the charge for his visits was set higher than the charge for the local physician who had been practicing some 40 years.

It’s hard for me to decide what the most frustrating thing is about practicing medicine here but certainly vying for the distinction is that patients/families don’t trust that what I am saying is true. Yes, that happens in the States but here it’s part of every visit, to some extent. And it beats me down.

Here’s a recent example. Three days ago Francisco, Angel’s 7-month-old nephew, developed a cough. The next morning his mom asked me to examine him. She’d already tried a "small amount" of Bactrim that morning to see if it’d help but she said it didn’t. As I checked him out, his 3-year-old brother was coughing in the background (as are most of us here in the house). Francisco had a normal exam; just a clear, runny nose. He had developed a fever earlier in the day and Ana had treated him with Tylenol. I reassured her that he just had a cold, like his brother, and I’d keep checking on him. I did give her some cough medicine with the caveat that most parents feel like it doesn’t make a big difference but she could give it a try. [For the pediatricians gasping here (mostly residents), I have to break to explain a line of reasoning that has kept me sane in this setting. Parents here absolutely will not accept “reassurance” alone with no prescribed medicine. If one refuses to give relatively benign things like cough medicine, as I tried for a few weeks when I first arrived, the parents will definitely seek out a nurse or a pharmacist and will 80% of the time get an antibiotic like Bactrim and 100% of the time get a multi-component cough medicine. I have decided that keeping that from happening is important enough to justify my giving a cough medicine].

I asked her tonight how he was doing. “Oh, he’s better than before. I had to take him to the doctor because he still didn’t sleep well last night” (cures are expected to be immediate even when it’s explained they won’t be and seeing several practitioners - of all types - for one illness if it doesn’t resolve right away is not uncommon). “It turns out that he has an allergy in his throat so they had to inject him.” “I think they injected him with the same medicine you gave, since it started with dex-something, and now he’s doing better”. Given that I gave him dextromethorphan and it’s not an IM med, I’m thinking they gave him a dexamethasone injection. Steroid injections are common. He’s just 7-months-old and has a cold!

So, 1) This poor baby got harmful and unnecessary treatment and even more frustrating is that this type of treatment is ABSOLUTELY the rule rather than the exception 2) His mother is convinced that I missed the allergy in his throat because the assumption is always that more treatment, especially injections, are better 3) This baby will improve quite soon as his cold runs its course but the improvement will be attributed to the shot and the same cycle of bad and harmful care will continue.

I try to not let these things get to me. But they do get to me because some manifestation of this happens nearly every day and often many times a day. It is not uncommon that a few days after I make a diagnosis and start a treatment, a patient’s parent tells me they found out what the illness actually was and got a different treatment and the child is now better. As if they just want me to know that I missed the diagnosis (usually something like “empacho” or “mollera caida” or non-entities like strep throats in 3-month-olds). Though I know I am practicing the best medicine I know how to practice and whatever goes on around me was happening before I came and will keep happening after I leave, I just have to ask myself, why am I fighting this one-man battle? Until there are high standards for the training of practioners here plus checks and balances on the medicine practiced, bad care will continue to dominate and patients will have trouble distinguishing good from bad.

But the abundance of practioners of questionable quality (at best) doesn't explain why patients and parents don't seem to trust me. Is it that I'm not from their culture?, Is it that I'm young?, That I'm female?, That I don't speak Kaqchikel?, Is it an issue with conventional medicine in a place where traditional healers and traditional Mayan health beliefs dominate? I think it's a mixture of my being white and my representing conventional medicine where Mayan health beliefs dominate (haven't perceived any issues with my gender or my age).

White people are associated with Ladinos. Ladinos have a long history of severely oppressing the Maya. Until the last 20 years or so, Mayan people almost never entered professional fields such as medicine. Even now, it's rare for a physician to be Mayan. Ladino physicians rarely choose to practice in the poverty-stricken regions where Mayan people live and, even if they do, charge too much for the vast majority of Mayans to be able to consult with them. So, most Mayans have limited exposure to conventional medicine and much more -- lifelong -- exposure to traditional healers. Those who have seen physicians have undoubtedly been exposed to inadequate treatment with substandard work-ups, in part because of resource scarcity but in part because of physician prejudice against patient. On the other hand, I'm sure Ladinos do command some respect that Mayan physicians don't simply because even the oppressed may internalize the message that the oppressor is superior.

The biggest issue, I think, is the one of not accepting conventional medicine. Part of the reason for this gets back to what I just mentioned: it's new and unfamiliar. Part is because practitioners are generally not of good quality (I'm being frank). "Pharmacists" (very limited training - months) and "nurses" (also, very limited training) act as conventional healers but without the education to do so well. They err on the side of dramatic overtreatment with harmful medicines like gentamicin and, while they are pretty consistent in their diagnoses (sore throat and bronchitis are very common), they are quite inconsistent in their selection of medicines (Bactrim, cefadroxil, steroids). So, the experience with conventional medicine must often be disappointing. Also conventional medicine struggles to gain favor in the face of traditional beliefs that do seem to work because nearly all illnesses improve over time (especially in kids) and because unseen phenomena like viruses and antibiotic resistance and subclinical medication toxicities are hard for people with no formal education the grasp.

So, why would I try to care for patients in this setting? Mostly because it's unavoidable since I'm here and people do seek me out (even if I were to withdraw from the clinic and just take a teaching role with the health promoters -- have considered this a lot) but also, I guess, because I hope that there is some good that comes to the people from practicing the best medicine I can in this setting and demonstrating to them that they do deserve it.

Coffee Picking

This weekend I picked coffee with Angel and David. Angel has three or four plots of land where he grows coffee. Since his wife died about 8 years ago, he hasn’t kept them up with fertilizer and weeding but the coffee plants actually still do pretty well. It takes about 2 full weeks to harvest all of his land.

The coffee harvest begins in the lower (warmer) towns around November and kids are out of school November through January for this reason. We are at the highest of the elevations around the lake so our beans were the slowest to “mature”. Many families here keep their kids out of school through this first month to help with the harvest because this is the income for the entire year. A well-maintained plot about 50 meters by 50 meters might yield $6000. But that’s the best of circumstances. Most don’t own land and so they harvest as day workers, where they make $3.50/day. And stealing of coffee is a high risk. One year Angel’s plot was stripped clean in one night by “ladrones”. The police don’t pursue the ladrones so the people are left to vigilante justice. Right now “the aunts”, as we call Angel’s 3 sisters that share our house, say they are having trouble finding “mozos”, or day-workers, to help them pick coffee because there is a social cleansing going on right now. If someone is found on land that isn’t theirs, there may be no questions asked before they are shot. People are afraid to help others pick but, ironically, most people support social cleansing probably because of the frustration that crimes here go absolutely unpunished (Elena found a statistic that 2% of crimes in Guatemala are brought to justice). So the aunts this year are carrying their own coffee out from the field on their backs, a task traditionally reserved for men.

We walked the 20 minutes to Angel’s plot, joining a couple other related families who have adjacent plots. They start with a series of whistles, each one a signature whistle for the family. Interestingly, here in the house each family member has his own whistle that functions as a name (very Sound of Music). The coffee plants, “mata”, were full of dark red “berries”. Angel would pull the small tree over and tie it down for me so I could reach the highest berries and then I’d just run my hand down each branch popping off the berries, trying to avoid stripping the branch of leaves or berries that weren’t yet ripe. It took about 20-25 minutes to clear one coffee plant and I guess there were about 600 berries per plant (his plants don’t produce particularly well). You’re hands get filthy and the sides of your fingers start to get a little raw. I can’t imagine doing it every day. Most people tie a collecting bag around their waist to drop the berries in but I just used a basket on the ground. In nearly 4 hours of work we collected 1.5 quintals of berries. Each quintal goes for about 150Q or $18. The Parrochia pays a “fair trade” price of 200Q but they insist that only the best beans be separated out and the remains are left to sell for much less to other buyers. Angel says they have not been willing to buy his beans.

When we were done, we visited a Mayan church, which was a cave with an altar. Angel told us that in the past, including when he was a child, everyone would go first to that cave and offer thanks to Don Diego Martin, a “saint” who oversees all the land. They would repeat the ceremony at noon and at the end of the day. They would ask permission to harvest. Sometimes you could hear the presence of Don Diego and his horse in the rustling of the leaves and you could hear the sound of his horse drinking water. Sometimes he would even speak to you. People no longer routinely give thanks for the crop or ask for permission to disrupt the land and he feels that’s why it doesn’t produce well. Before, his father recounts, there was a great abundance of coffee. If a passerby asked for some of yours for himself, you would be happy to give it to him because you had such excess. Other things can affect the crop as well, Angel told me. One year, he planted while he was drunk and the plants didn’t produce at all. He said that was because he had fire in his veins and it burned the plants. Others have told me that the decreased yield of the crops these days is due to the use of artificial fertilizers.