How I decided on Puerto Escondido

Just a few thoughts for those thinking of participating in a program such as this. First, you need to decide what you want to do (study a language, work on a service project with other Americans, learn in another country, volunteer in a clinic) and where you would like to go to. Ask people you know, check with local colleges and churches for projects and programs. Word of mouth is quite helpful and the web is amazing.

I decided I wanted to spend 4-6 weeks to visit a Central American country, study Spanish, immerse myself in the community by living with a family and work in or observe in local primary care clinics.

A doctor in my hometown has a connection to a hospital project near Lake Atitlan, Guatemala. I talked with her and read the web page information and decided that, although an excellent project, they really wanted long term volunteers and going for just a month would require me to do a lot of leg work (arrange housing and food, etc.) and perhaps not leave much energy for the volunteering. Many of the patients at their hospitalito speak indigenous languages and so the local staff have to translate into Spanish for the foreign volunteers. I wasn't willing to add another language being translated into the mix. My Spanish just isn't that good.

A nurse practitioner friend goes to Nicaragua once or twice a year and volunteers for a week with work camps providing direct medical care. I wanted to go and live with people in a Spanish country, not travel with a group of Americans, so that choice wasn't for me.

I have connections to another group in Nicaragua and they suggested that I contact Mama Licha's Clinic. This clinic provides much needed reproductive health care to young women. I looked at Nicaragua, thought about traveling alone, the need to arrange housing, language tutoring and all. I haven't traveled on my own much didn't feel comfortable with that plan. This may be perfect for someone else.

On the web, I found three programs that provided homestays, Spanish instruction and clinic visits: Costa Rica, Honduras and Mexico.

I settled on the Child Family Health International program in Puerto Escondido for the following reasons: The program had a US office and when I contacted them my questions were answered quickly. They were quite clear about the program they had set up, number of hours of Spanish instruction, time in clinic, how families were chosen as homestay providers and what the homestay families did and did not provide. They gave me a budget for expenses beyond the program fee that was accurate. The program described to me is the program I found in Puerto Escondido. They were quite concerned about participant safety and had lots of advice and support worked into their program. They provided health insurance and a cell phone, details that impressed me. I received reading material and watched orientation powerpoints via web prior to going.

I liked the program in Puerto Escondido because it is a small town (30,000 to 50,000) and the program focused on public health primary care clinics, with the type of patients that I see here in the United States. The drawbacks of the program in Puerto Escondido is that it is designed for students (and thus I would not be seen as a professional but rather a student) and the clinic time focused on observation (rather than providing direct care.) Puerto Escondido also has a fairly large foreign population due to the great surfing in the area and parts of town dedicated to serving tourists. This was nice in that I could get a break from the 'real' Mexico, but eventually, I wanted to be only around Spanish speakers. When deciding, I felt the advantages outweighed the disadvantages. And I was right.

If you are looking for a immersion language program here are questions to ask:

• What size are the classes? How many students does the school usually have?
  
• How many levels of classes does the school offer weekly?
• What is the nationality and educational preparation of the teachers?
• Do the teachers use any English in class (my preference is no English)?
• Will you have the same teacher all day?
• Will the teachers change weekly?(Sometimes 4-6 hours a day of one teacher gets old.)
• Does the school provide other services (cultural, cooking, tours)?
  
• If you want to learn Medical Spanish, does the teacher have a medical background?How are they qualified to teach Medical Spanish?
  
• What countries do the students come from? If you have classmates who don't speak English, you will not be tempted to speak English. I see this as an advantage.
• How are the homestay families chosen?
• What does the homestay provide (number of meals per day, shared or private bedroom, shared or private bath)?
  
• Will there be other students in the homestay?
• What is the expectation of the homestay families: do they just provide a bed and meals or do they include the students in their day to day activities?
• And then of course, cost.
  

I will mention two other programs that are great for facilitating foreign volunteering:

• The work camps sponsored by Volunteers for Peace. Most of the camps are for those under 35, but this is a great way to extend a trip to another country as the camps themselves are quite reasonable in price. My son did Spanish intensives for a month in Spain and then spent several weeks at a work camp in Spain where he had true Spanish immersion.
• International Cultural Youth Exchange. I went to Sweden with this organization in 1974 and since then their program has changed from a secondary school foreign student exchange into a youth voluntary service organization, with longer term volunteer opportunities. The unique aspect of ICYE is that students it is not a to the US or from the US exchange, but an international exchange.

Both of theses organizations started up in Europe after World War ll with a goal to preserve world peace and intercultural understanding by encouraging youth to work and live together.

Agua Fresca

Agua Frescas are drinks made with fresh fruit and water. They aren't thick like smoothies but the main ingredient is fruit. The picture shows a guava agua fresca I enjoyed in a Oaxaca restaurant. It is easy to make: take the fruit, preferably without any seeds or coarse skins and place it in the blender with at least half water and puree. Then pour it into a pitcher and add more water, ice, lime juice or sugar as needed.
I made some yesterday for friends who came over. I used cucumber (peeled and seeded), lime juice, a small amount of sugar and a sprig of parsely in one. It was pale green and really quite refreshing. One friend suggested that it needed salt and pepper to suit American tastes. In Mexico, cucumber is often treated as a fruit. The other was of watermelon. That was easy, seed the watermelon, blend with water and add more water. It is red and tasty.
This is a form of refreshing drink that I can quickly make at home and not need to worry about disposing a juice bottle later. I am happy to have learned this.
I also enjoyed drinking jamaica tea (hibiscus), horchata, atole, and mexican hot chocolate.

Thoughts on my adventure

This past month, I observed the services provided in Clinics sponsored by the Oaxaca Department of Health in and around Puerto Escondido. The services provided meet many, but not all the needs of its citizens. I believe that health and well being would be improved as a result of implementation of two programs, Opportunidades and Seguro Popular which provide health care more readily to Mexico’s poor.

In 1983, the people of Mexico amended it’s constitution to state that its citizens have a "right to the protection of health". Here in the US, we have yet to determine that protection of one’s health is a right. This summer, President Obama and the US Congress, with input from many sectors, is in a debate to determine just how much the government should be involved in health care. Meanwhile, it is estimated that 50 million Americans live every day without any form of health security. I applaud Mexico for creating a safety net that protects the poorest of its citizens from some of the ailments which plague mankind.

Seeing the styles of assessing patients, diagnosing illness, prescribing medications and charting at the three clinics I visited was interesting and informative. I saw providers with little more than their own interview and assessment skills providing quality care and improving the health status of their patients. Truly, high tech testing and imaging are useful in diagnosis and treatment, but not necessarily a prerequisite.

Surrounding myself with Spanish speakers all day long greatly helped revive and improve my Spanish. I am thankful that so many were patient with me and willing to have serious conversations despite my basic difficulties with speaking. I have come away with a realization that I can speak Spanish, but I have a lot of room for improvement.

Many people ask if I will return to Puerto Escondido or do something like this again. I am sure I will do something like this again. Bill (my husband) and I are always talking about what we would like to do next. I would like to find a similar opportunity, but one which afforded Bill and I the opportunity to settle into a community and continue to provide a needed service for that community. This could be in the United States or elsewhere. We will just have to wait and see what way opens. I would love to visit Puerto Escondido and Oaxaca again. I don’t have a plan right now, we will just see what the future brings.

Photos!

I have created a web album with a lot of my photos from my recent trip to Mexico.You can go directly to my Picasa Album Once there, you may select a slide show (upper left hand side) or scroll through them. Enjoy!

Getting Around

I am home in Fulton safe and sound. I plan to do several posts to review the experience over the next few weeks. This post will focus on getting around in Oaxaca state.

In Puerto Escondido, I traveled mostly by walking. I quickly learned that I had to be very attentive of the pavement as steps of any size may occur anywhere. I marvel that I had so many close calls and came away without a bad strained ankle or something. When the distance was too great (about one mile is my limit) I would avail myself of the wide variety of choices for public transport. There were 'private' taxis and one could get anywhere in Puerto for less than five dollars. I only did that when I had luggage. Usually, I would take a camioneta (small pick up truck) which has been converted to public transport by adding benches and a canvas roof over the back. There were also collectivos (collective taxis) and buses. All were licensed, agreed on fees and ran on established routes like spokes -to neighborhoods and to nearby villages- from the main market downtown. They all cost 4 or5 pesos per ride (less than 50 cents.) The routes were not obvious. My host family and staff at clinics were quite helpful in helping me understand the ins and out of public transport here.

One collectivo driver told me that he paid 400 pesos for a tank of gas, and used 240 pesos worth of gasoline in a day. This makes the cost of gasoline higher than in the US. He was driving a sub compact car and collecting 4 pesos from each rider. At best, he would have five passengers, and he often would, but not consistently. He needed to have sixty riders before he had paid for the day's gasoline. He must have other expenses (rental/depreciation of the vehicle.) I wonder how many days he makes a profit/income. The Mexican government has a monopoly on gasoline, all sold by their company, PEMEX.

When I went down to the main road near my house, I would not have to wait more than 5 minutes before a collectivo and a camioneta came a long to take me on my way. It really worked quite well. The drivers and other passengers were polite, helpful and clean. I didn't see anyone arguing or upset with anything that happened. If someone needed help with a heavy load or due to infirmity, there was usually more than one person offering assistance. Sometimes the driver would determine that he couldn't take any more passengers, but the passengers would encourage the driver to stop. Everyone seemed so generous and helpful.

When leaving Puerto Escondido for weekend adventures, I took first class or second class buses or suburbans (vans that seat about 15 people with air conditioning.) In every form of bus, once we were in rural areas, the vehicle would stop if there was room in the vehicle. These short term riders paid the driver directly, and the driver came up with the fee, apparently off the top of his head at the end of their trip. The riders never argued and paid the requested amount, usually between two and six dollars. I noticed that most of the windshields on these buses or vans had cracks running through them. One first class bus had a speedometer and one other dial that didn't work. They all got me to where I wanted to go. I usually paid about ten dollars for these trips.

In populated areas, along highways there were frequent speed bumps causing most to slow down to less than 5 MPH for a moment. The drivers seemed uncannily aware of pot holes and slowing down when entering an area with more pedestrians. This would be the advantage of driving the same route multiple times everyday. There were also the occasional Mexican Army checkpoints on the coastal north-south road. One had to stop, but I never saw the military checking a vehicle. It occured to me that it would be less expensive to have five soldiers at one check point than to have them cruising the highways, as they would not need vehicles.

Safety awareness is on a whole different level. Will those windshields with cracks just break? None did. Even when rarely available, no one used seat belts. I only saw several helmets on scooter and motorcycle riders. The Federal Dept of Health has identified the three main reasons for death in Mexico as: diabetes, high blood pressure and heart disease. They are proud to have gotten infectious disease off of the top three list, and rightly so. I wonder where accidental death and disability ranks? Construction workers didn't use hard hats and usually had sandals on their feet. Many house holds had a water tank in their patio. They were often open to air, made of concrete and about the size of two or three bathtubs. Don't children crawl into these? I was told no, but I don't understand why this doesn't happen.

Flying in and out of Oaxaca City, including going through customs was no trouble at all. On my return, I changed planes in Houston. I arrived in Houston on July 7 around noon. Houston airport had just been closed down for several hours due to a thunder storm. My plane landed in Corpus Christi, TX waiting for the weather to clear. Everyone was hurried and worried and trying to make up time they lost. Wait lines were long. Waiting rooms were full, but there were seats for everyone. On the train between terminals, there were six US Army men. They were all speaking Spanish to each other, and good Spanish, much better than mine. I could easily hear what they were saying; they were just talking about their lives and friends. I thought, this is why I need to learn better Spanish: even the US Military relaxes in Spanish. Four of them had on uniforms with names and they were Hispanic surnames. I thought what appropriate welcome to back to the USA: People upset and inpatient because nature had caused a delay of up to twelve hours in their lives and a strong sign that Spanish will continue to be a part of US life.

Elections in Mexico, 2009

I arrived in Oaxaca on Sat July 4 and have really enjoyed my two days here thus far. I just want to take a moment to talk about the nationwide elections, which happened on Sunday, July 5, 2009.

Sunday, I was set to go on a guided tour of some sites in Oaxaca Valley. Tule, Teotitlan del Valle, Mitla, and the Sunday Market in Tlacolula. The tour started from a downtown hotel and the entrance to the hotel was a polling place. I had already seen one other in Central Oaxaca. They are open air and the election workers were of all ages, serious and working quickly to give people their ballots. There were other polling places near the tree with the largest girth in the world in Santa Maria Tule, and the Sunday Market in Tlacolula.

I asked the guide, Daniel, if he was planning to vote, and he said no, because he had to work. He said this election probably more people were going to vote than previously because they had added a ´none of the above´option. That is, instead of voting for one of the candidates offered by a polictical party (there are six or eight different ones) there was also the option to vote for ´none of the above.´ Daniel thought that this option was a better reflection of most of his friends feelings and so some may feel motivated to vote now. He did not think that voting really would make a difference for him.

A tourist from England who had just spent 5 days in Mexico City commented that there seemed to be a lot more interest in the elections based on the amount of posters and billboards one saw about in Mexico City compared to Oaxaca. I hope that people in other parts of Mexico are more interested in the elections than here. I have been surprised at how little interest I find when I ask people.

In Tlacolula, there was a table to get your ballot with about six people working, two polling booths and a clear box to place the ballots. Then there was a line up of about 8 people watching the proceedings. This was all out side under a makeshift awning. I talked to one gentleman in this group, the only one without a seat. He said they were all representatives of different parties and watching to make sure that all was going well. He thought everything was fine, he thought the turnout was low, but no worse than previous elections. He explained that the ballot box was clear so that all could agree that it was empty when voting began.

I asked him which party he represented and he hesitated. Then he showed me a picture of his candidate. That was no help. I didn´t get it that there must be a rule against even mentioning a party or candidate that near to a polling place. Then he wrote ´PT´which I knew stands for Partido Trababjo or Labor Party, probably the most left wing of the choices. I knew this because I saw a march of PT supporters last weekend in Tehauntepec. The taxi driver I was with said that party had little chance of being successful in the elections.

On the TV News they talk about how PRI (in power for decades but currently out of power) was making a comeback and PAN (the party of President Calderon) needed to regroup. It seems like the announcers were all in favor of PRI in principle, so I don´t believe I have a good handle on what happened. President Calderon made an announcement about the elections at 10 PM. This morning the TV news featured election results but also gave time to the President of Honduras´troubles, ethnic problems in China and of course Micheal Jackson´s funeral. So, other news got through.

Tomorrow I return to the US. I will do a few follow up and evaluative blogs from there.

Vacunas and Bajos de Chila

On Monday, I followed Tere, a nurse at the main health center in Puerto Escondido as she did vaccines all day. She was busy. BCG is a vaccine that is given to newborns to prevent Tuberculosis (not used in the US.) It is only given on certain days, including Mondays, as it comes in a multidose vial that must be used that day. It is an intradermal, and that was just interesting to see and leaves a scar similar to the one the smallpox vaccine left.

A woman who came in for her second of five Rabies prophylaxis shots. She was bit by her pet squirrel, who was still her pet and healthy. Squirrels are rare here. I have seen three wild ones. The chart above shows all the vaccines that are given to children.

The whole set up was quite impressive. Big shiny refrigerators with external temperature displays. Smaller coolers for several doses of each vaccine (thus avoiding always opening the door of the big refrigerator) also with external display for the internal temps. A well organized table with everything Tere, the nurse, could need.

Each vaccine documented on three or four different charts, one which the patient or parent keeps. They give children all the vaccines children in the US receive except the vaccines for chicken pox, Hepatitis A (required only in certain states), Meningococcal Meningitis or HPV (the latter two for teenagers and HPV for young women.) They do have the most deadly and prevalent infant and early childhood diseases covered. I learned that the vaccines costs the government about $400 per child in Mexico. That is an impressive investment in the future of Mexico.

This week was a continuation of the national week of vaccine and so Tere was also distributing folic acid to any woman who came through who was of child bearing age, vitamin A drops to toddlers, multivitamins to older children, and oral polio vaccine to children with in a certain age range. I have tried to have a discussion with a doctor or nurse about why Mexico continues to use the oral polio vaccine (only during the vaccine campaign week) even though all the babies are receiving the injectable polio vaccine (like now in the US) and even though there has not been any polio in Mexico for decades. They all replied, ¨We always give the polio drops during the vaccine campaigns.¨ I do not know how long they have been giving the injectable form, but hopefully a public health planner has determined a date to stop giving the polio drops.

For the other four days of this week, I went to the clinic in Bajos de Chila. It is a town about six miles north of Puerto Escondido. It is in a low area on the coast with flat land that looks like it may be good for farming and may flood easily. The clinic is next to soccer fields and one Mixtec Pelota court. This is a modern adaptation of a sport that has been played for centuries in this part of Mexico which involves teams and a very heavy ball. The court is surrounded with a chain link fence like a tennis court might be to protect the spectators. The town is laid out with straight, wide roads.

At Bajos de Chila, I followed two young doctors, both who are doing their year of service. Starting Medical School at age 18, they had 5 years college, one year internship in a hospital, and are now doing their one year of service. They will soon be fully licensed physicians and will have no student loans to pay off. They both wants to specialize, and so must take a very difficult exam and be admitted to a residency program. There are limited spaces for specialists and those doctors who do not specialize become general practitioners. I read that Mexico has one physician for every 500 citizens.

Dr. Alfonso and Dra. Carla both live in the clinic, along with Dr. Alfonso´s sister who is a dentist and is also doing her year of service. They are on call night and day for births and walk in emergencies and probably have about 50 hours a week of clinic work. This clinic has one other doctor on staff but she is on maternity leave now. The other staff are two nurses, one nurse helper, three dentists (who work in shifts to keep the one dental chair and equipment busy 13 hours a day) and two health promoters. I am still not certain how the number of staff are determined for each clinic. Dr. Alfonso and Dr. Carla said they both chose to come to Bajos de Chila and that those with the best grades in Med School got to pick where they would go for their service with those with the lowest grades being assigned to the least favorite spots.

Both saw the same variety of patients and this was a week of complaints of fevers. After learning all about mosquito borne diseases, I was seeing lots of dengue or malaria while patients were listing their symptoms, but this did not turn out to be the case. Many mothers were very diligent brought their child within 12 hours of the onset of fever. I was proud that the doctors avoided giving antibiotics unless there was a strong indication. Mothers were instructed to insure adequate fluids intake, to bathe the child to reduce the fever, they were provided fever reducing medicine and told to bring their child back if there was a worsening of symptoms. Many attributed the increase in fevers to the recent start of rains (not daily) and therefore a reduction in the intensity of the heat. I can still work up a sweat if I am sitting still, so I doubt I am at risk for a fever due to the cooling conditions.

Early Wednesday morning, a baby was born in clinic. On Tuesday, Dr. Carla was pretty sure this was going to happen as the woman came by twice during the day to be checked for the progress of her labor. She was 33 years old, this was her fourth child with the oldest being 14. I was sleeping soundly far away while all this was going on. Dr. Carla related that the birth proceeded without any problems, the baby was born about 1 am while the electricity was off due to a storm. They do have battery operated lighting. Earlier on Tuesday, Dr. Carla had given the mother a list of things to buy in preparation for the birth-diapers, sanitary napkins, and oxytocin. The latter is a medication which is routinely given after birth in the US to prevent severe uterine bleeding. As it is not provided by the Dept of Health, Dr. Carla suggested the mother buy it (and she did). The mother did receive an IV (in case of emergency) and clean sheets for herself and the basinet and a gown to birth in from the clinic. But no food, just water to drink.

Mothers and babies usually stay about 8 hours after birth, and this new Mom was hungry and more than willing to leave. As they had not signed up for Seguro Popular (government health insurance for the poor), the father paid about $20.00 for the birth before taking his wife and new baby home. It seems the process of applying for Seguro Popular is not easy and it is done at a central, distant location, not at the clinic. One receives a laminated card with picture once one is enrolled.

When I arrived in the morning, Dr. Carla was completing the paperwork for the birth. This was given to the parents, who can't read, to register the child for the birth certificate. I was interested to note that this paperwork did not have space for the name of the father nor the name of the baby (although all the proper statistics regarding the baby-sex, weight, length, gestational age- and mother-name, age, address, place of birth- were listed.) The mother related that she hadn´t chosen a name for her other children until they were about a month old. She said that was just how they did it and did not have a reason behind this. In the US hospitals I have learned to be concerned that the parents are not prepared for the baby if no name is quickly given. I noticed that children sometimes have a vaccination record and chart without their name (for instance-baby boy Rodriquez) and this must be why.

I also helped the doctors prepare a baciloscopia. This is a dry mount slide of a sputum specimen and key to diagnosing the presence of tuberculosis. The dried slide is sent to the lab and there it is stained and analyzed to check for the presence of tubercular bacilli. The whole process was involved as the concern for contagion to others was fairly high. We used gloves, masks, Clorox and flame all to get the slide prepared and dry so that it could be safely transported to the lab. Dr. Alfonso said that they do not always perform chest x rays on patients diagnosed with active tuberculosis as this is not covered by the Dept of Health and the patient may not have the money to pay for the x-ray. They do provide medications at no cost, and based on the results of sputum culture determine the length of treatment and whether to start the patient on four or five medications. Most of the patients receiving TB treatment come to the clinic three or six days a week to take the medicine in the presence of the nurse. I also learned that those who receive insulin for diabetes come to the clinic every day to receive their shots rather than give them the medicine and syringes to use at home.

And so ends my four weeks of learning about Mexican Public Health and improving my Spanish. I am really glad I came, I have learned a lot and I am happy to be close to headed home. Tomorrow early I leave for the 7 hour bus ride back to Oaxaca City. I plan to visit some more sights in Oaxaca Valley. Tuesday, July 7 I fly back to Missouri.

Sunday July 5, 2009 is election day here. Elections are always on Sunday in Mexico, the reason I was given is that fewer people have to work and so will be able vote. I really have not been able to find anyone willing to talk at any length about this upcoming election. The main open seat is for the national equivalent to the house of representatives. There are lots of parties, three main ones. I have had about 5 conversations with various people and no one has been willing to tell me who (which party or which candidate) they prefer.

Traditional Midwifery

My Spanish Class went to visit with a partera y curandera (traditional midwife and healer.) In Mexico, the practice of midwifery has long fallen to one or two women in a village who help the others give birth the women are called parteras or midwives. Likewise, there has usually been several people who developed skills in recommending herbs, in massage, and who know when cooling or warming a person would help most. These people are called curanderos or healers. Our teacher explained that we were going to meet a woman who learned her skills from another midwife (in this case her grandmother) but who took classes in basic health care from the government and became certified as a 'traditional midwife,' about 20 years ago. With this certificate, this midwife can also complete the paperwork needed to register the birth with the government and create the birth certificate and is able to provide ongoing birth control services to her clients.

We visited a Gertrudis, who has been living in Barra de Colotopec for about 70 years. She has been practicing midwifery that entire time. She is now in her 90s and continues her work as a midwife, having had four births in the month of June, 2009. She also has 35 women who come to her monthly to receive birth control injections (the most commonly used form of hormonal birth control used in Mexico.) Gertrudis was recently ill and is now recovering from a stomach ailment and her daughter from South Carolina was visting to help her mother recuperate.

Gertrudis greeted us and invited us to sit on chairs with her in her patio. Her family came and went, while she patiently answered our questions. She was bright and enthusiastic. She shared a good sense of humor with her daughter. The both frequently laughed when remembering different things that had happened in their lives. Our discussion was frequently interrupted by roosters crowing and she explained that her very nearby neighbors raised fighting cocks.

Her house was one of the more humble houses I have seen. It has openings for doors and windows, but no way to shut them. The roof is corrugated tin. The walls are either wood or a mixture of wood and mud wattle. The kitchen is on the porch and the stove is fueled by wood. Some of the floors are cement, others are dirt. There is no plumbing, but there is a separate building with shower and toilet. Gertrudis has a special room for births, with a bed with mosquito netting and a single light bulb hanging in the center of the ceiling.

She explained that she handled many different types of births with success in her birthing room. Sometimes she would go to the home of the laboring woman, but she preferred to that they come to her home. She does not use any kind of instrument nor does she use any medications during birth but does use herbs during labor. If she encountered problems now, she could refer the woman to the local health center or to a nearby private doctor or to the hospital which is a hour's drive away. Previously, she did not have these options.

We tried to get Gertrudis to explain the process to us. That is, to talk about how long labors last, how much women hurt and what she would do to relieve the pain, how she could tell that there was a difficulty about to occur, what she would do if a specific problem occurred. Gertrudis does not work in a world of dates, times, and facts. She was not able to state how long most labors last or how long the longest one lasted. She said that she provided massage to ease labor pains, an herbal tea and sometimes bathes the laboring mother. I feel certain if she was with a woman birthing, she would know that a contraction was about to begin, but she wouldn't be able to explain how she knew this. That's just how life is for Gertrudis.

Her patients come to her for prenatal checks with a focus on checking the unborn's size and location in the womb. If the baby was not in the preferred position (head down) she would treat the woman with massage to encourage the baby to change before the due date. She encourages women to take vitamins and iron during pregnancy. She said she had different herbs that she recommended to become pregnant, during pregnancy and during birth. Most she recommends in the form of a tea. Not all of the herbs she uses grow locally and she has friends living elsewhere who provide her with those she needs from the mountains.

Gertrudis´s daughter has lived in South Carolina with her children, grandchildren and great grandchildren for years. The daughter explained that she does continue the work as a curandera (healer)-providing herbs and massage-but does NOT do midwifery in the US. She was cooking beans in a ceramic pot over an open fire and said she also has a stove like this outside of her trailer in South Carolina.

Mexico has many more births than can be accomodated in the existing health centers or hospitals. The government has chosen to recognize and to provide support to the traditional midwives who have worked this land for centuries. So, we find a woman in her nineties providing modern birth control to women. Although she does charge for births, she does not charge for birth control as she receives it from the government with this understanding. And even though this midwife stated that she did not really trust modern medicine or it´s doctors, she is implicitly a part of the modern medical system. I wonder what the next step is for midwifery in Mexico. There is not yet a formal education for midwives in Mexico, like for nursing and medicine.

Thoughts on Culture

Tomorrow, we have the final group meeting and we are to talk about the cultural differences we have each noticed. I think I have learned more about the differences in how our health systems work than I have noticed unexpected cultural differences.

One obvious one is that most women I have met in clinics are breast feeding their babies. Of course, women in the US also breastfeed. But as a nurse, I have spent a lot of time trying to convince American women to breast feed without success. Here, it is the norm and those who are bottle feeding stick out. Monday, I worked with the nurse giving immunizations. She instructed women to start breastfeeding their baby before she gave the shots so that the child would be most comfortable. Only one was bottle fed. One of the American participants in this program sarcastically commented, 'Nice, breastfeeding on the street', as we drove past a woman doing just that. She went on to say that she knew she should be supportive of breastfeeding but she was not comfortable with seeing women breastfeeding just anywhere. She went on to discuss how at some hospital in the US there are special rooms women can use to breastfeed. I think it's great, breastfeeding on demand of the baby. I don't see lots of babies in public places but those I do see are not crying.

Another area that I have been pondering is the lack of confrontation. On the bus or in the clinic, people will chose not to confront. If someone wants to get on the bus with two large boxes, others just make room. When the doctor gives instructions, the patients simply nod their heads. If they have just received instructions they don't understand, they don't ask for clarification. If they can't read and the doctor just hands them a sheet about how to take their medicine, they don't remind the doctor about their inability to read. It is that no one complains. But then, there is also little discussion about the issues as well.

For instance, Dra. Isabel, the doctor who arranges our clinic schedules changed my assignment to follow nurses in the main public health clinic here in Puerto Escondido this week. I didn't ask her why, I just expected that she had a good reason. After Monday, which was interesting, (read a future post) I called her because the nurse I followed said she would be doing the same thing (vaccines) for the entire week. I asked Dra. Isabel why she thought I would benefit from following the nurses. She didn't answer my question, but asked 'What's the problem?' I explained that I was concerned that the clinic work would prove repetitious and stated I would prefer to go to a rural clinic. She arranged for me to begin on Tuesday at Bajos de Chila. I still wonder a little if there was something going on at the main clinic that would have been really beneficial for me. This may be more of a personality issue rather than a cultural one.

The first week, I was with Dr. Pablo, who is no doubt under 30 years old. I noticed that when he made recommendations to his elderly patients he didn't make eye contact with them. He would make eye contact while asking about their symptoms or complaints. Then I noticed that he also avoided eye contact with me at certain times. This is probably a way to show respect. I haven't noticed this with the other doctors despite my seniority.

I have noticed that each doctor has focused on the patient in front of them and worked on that patient until they are finished with them. I have really appreciated this focus and I think the patients have also. Each doctor only has one exam room which also serves as their office. So, they rarely have patients waiting to be seen in other exam rooms. There are no phone calls from patients or pharmacies to deal with (indeed, I do not think the clinic has a phone.) Usually, they see the patient and do the charting while the patient sits and waits, then they write the prescriptions. If they are lacking some information, like the name of a drug the patient took for the same complaint two months ago or lab results from six months ago, there is no way to obtain that information within a day, and so a decision must be made with the available information.

Well woman care is handled differently. Paps are not done during pregnancy, indeed there is no pelvic exam at the start of pregnancy visits. And birth control is provided to women separately from Pap Smears. In the US, a prescription for a form of contraception is dependent upon getting a Pap Smear done. I believe this is because women wanting birth control in the US also are at an age where they should have regular Pap Smears. I really can make arguments for both systems. On one hand, it is better that all women have Paps and we know that no one will have health problems related to cervical cancer. On the other hand, some women certainly have chosen not to access birth control (resulting in an unwanted pregnancy) due to not wanting to have a Pap Smear done or due to lack of funds to have a Pap Smear done in the US.

There is a stereotype that Mexicans are not timely and not concerned about being on time. I have not experienced this. I see Estela, the woman with whom I have been living as very busy and not having enough time to complete her tasks, the same as a working mother of teenagers in the US. The patients come to clinic and miss appointments both, but that also happens in the US. There have been times when I thought someone was coming to work in clinic and they didn't come for the whole day. I suspect that this was due to reasons which they did not want to explain to me, not because of laziness or the like. I have observed that everyone is working hard when they are working.

There is also a stereotype that Mexicans are dirty. This is not at all true. Even the most humble people are clean. True, live is lived outside and everything outside gets dirty and dusty quicker. If windows are open all day, and the wind blows in dust, the place will quickly become dirty. But the places are also cleaned. There is a problem with garbage removal. People here also buy lots of bags of chips and bottles of water. There often are not sufficient waste bins in public places, so there is garbage about. But, when I have seen waste bins made available, they are used and those areas are cleaner. It´s more a matter of lack of infrastructure than it is the way people are.

While in public, people do stare at me at times. But if I smile and say 'Buenos Dias' to them while they are staring they quickly smile back and reply. It is a curious stare, not a distrustful or hateful stare. I just look different. No one seems upset when I am a woman alone. No one asks, 'Where is your husband?' I have heard women talking about machismo. One woman told me that when she is driving a scooter, some men are obviously upset and do not like the idea of a woman driving. I have seen men looking hardworking and tough. I have also seen older men talk with respect to young women doctors and accept care from them with grace and gratefulness.

I have not felt unsafe or threatened the entire time I have been in Mexico. I have not identified a part of Puerto Escondido where I felt unsafe. I have been in public transportation two to four times a day, and never felt worried for my safety or that there were others who were upset by my presence.

La Tehuana

This weekend I am Santo Domingo Tehuantepec, a six hour bus ride along the coast headed south toward Chiapas State. Like last weekend´s adventure in Juquila, this town is also known for it´s history and indigineous people. Here, many women continue to use tradtitional dress - a simple blouse with lots of embroidery (either geometric or flowered patterns) and a long skirt. The fashion has adapted itself to polyester fabric and machine stitching, but the concept is the same. I saw a local fabric store which had all of it's windows full of manikins in traditional dress made from the fabrics being sold currently.

Women wear fancier dress on special days, hand embroidered on black velvet with a wide white underskirt below a velvet skirt with more embroidery. Frida Kahlo did a self portrait wearing traditional Tehuana clothes. I have seen this for sale, but not being worn. I even wandered into a store that rents the dress for special occasions. The Tejuanas are a traditionally matriarchial society, with the women owning the property and selling outside the home, while the men stay home with the children and makes things like hammocks to be sold.

The main attraction in Tehuantepec is the market which sells a the usual variety of foods a long with all the various choices for dress and other crafts. I enjoyed several hours just walking around. To get my attention, the women selling things would say, `Huera´ which means white woman.

This town has several churches, an nice city hall and an ex-convento (former monestary) that is nearly 500 years old. It seems the King of the Zapotecs, Cosijopi´ converted to Christianity around 1500 with Cortes and financed the creation of the first cathedral and monastery in this part of Mexico.

Vectores

This week I am doing a week of following Las Brigadas de Paludismo (Malaria Brigades.) The week is called Vectores or Vectors because we learn about the things or animals which transmit disease to humans. The focus is on mosquitos, with some talk about the chinche or assassin bug that spreads Chagas disease. This is real public health work, where the staff goes to houses to check for sources of mosquito growth and to educate those they meet about the importance of preventing mosquito growth. I wrote about doing similar work with a promotor de salud (health promoter) last week. I believe the difference is that all health promoters in all neighborhoods are working on the same prevention efforts this time of year and the Brigadas focus on neighborhoods that have had cases of malaria or paludismo recently. Dengue fever is another mosquito transmitted disease and it is more common, so both groups are also educating about this disease as well. The picture shows Alfonso, health dept staff and Luis, volunteer neighbor, both who have been working to eradicate Malaria for 4o years. It was a pleasure to listen to them share their memories of changes and improvements over the years.

Monday I went to the lab where the tests for malaria are evaluated. The test for Malaria used here is a blood smear and a ´gota gruesa' (thick drop) on a glass slide. In the lab, the slides are stained and then evaluated by techs via microscope. They are looking for the parasite which causes Malaria and for the changes that this parasite makes in red blood cells. The dry mounts last forever, so the techs were able to show me slides with the protozoa present in various stages of the disease. Apparently, one can also detect Chagas disease in this manner, but we did not get into that issue. The techs said they test more than 100 slides per week (they were having a hard time determining a number) for this section of Oaxaca and will get several positive every couple of weeks. All the positives and 10% of the negatives goes to the state level lab for evaluation and quality control.

I have had a fair amount of confusion understanding Malaria because all the health professionals I have met talk about Malaria and Paludismo as if they were different diseases. Here is the way I understand it currently, and I could be mistaken about this: There are several different parasites-Plamodium- in the same family that cause Malaria. Paludismo refers to a milder form of the same illness (perhaps caused by a different sub species) and although treated with the same medication, Paludismo requires a shorter duration of medication before the disease is eradicated from the body. Both diseases are spread by mosquito bites, both cause fever, headache and vomiting although if one gets the kind called Malaria, it may be deadly and one must take the medication for three years to eradicate the disease. If one gets Paludismo, it is gone after a few days of medication. Everyone insists that there is no Malaria in this area at all. There are cases of Paludismo, but 20 miles away from Puerto Escondido in more rural areas. So, around Puerto Escondido, vigilance is needed to prevent the return, but one need not worry.

Tuesday, I went out with Carmelo in his pick up truck, and he explained to me that there are five different groups that help with the detection and treatment of Paludismo. First, of course are the Government Hospitals and Clinics. To demonstrate this, we went to the clinic in Barra de Colotepec where I was last week. Carmelo offered to transport any specimens that they may have back to the Jurisdiccion or headquarters and asked if they had any concerning cases. They said no.

Then we went to another worker in the efforts to detect and treat Malaria, a traditional nurse/midwife. Her name was Denise and she owns a small shop that sells groceries, dry goods and pharmaceuticals. I do not think she has education in nursing in any way that I would recognize, but she does advise people to use medicine for specific complaints, can give shots and has had some training in collecting the blood smear and drop on glass slides and in giving neighbors the first dose of antimalarial medications if they present the appropriate symptoms. The government provides her with the supplies for doing the lab tests and the medication for Malaria at no cost. She in turn, does not charge for this service.

Our next stop was a public school. Someone on their staff is also trained in collecting the blood test and giving the first dose of medicine. They, too, had supplies, but no recent cause to test. The principal said they rarely do blood tests anymore as the health center is only half a mile away and the parents usually agree to take their child there to be evaluated and tested.

We stopped in to see a private doctor next. She, too, had no specimens to give us. She confirmed that she does not charge when her patients come to her with complaints consistent with Malaria or Paludismo and provides the testing and treatment as indicated. Her offices were quite simple, two rooms each with a door opening onto a wide porch which also served as the waiting room. The building also included her home, and a third door off the porch led to that.

The final provider of testing and treatment for Malaria is the 'respected neighbor.' This would be a housewife or someone whose business is also their home (so they are frequently at home) and who has received training in performing the blood test and in how to administer the first dose of medication. The woman we visited was in her sixties and had been providing this volunteer service for more than 25 years. She related that she had done this quite a bit more in the past. Carmelo said that as the disease is less common than previously, they are not enrollling any new 'respected neighbors.' They do continue to provide supplies and check with those already trained.

Wednesday I went out with Alfonso in his pick up and met the actual foot soldiers in this fight against the spread of diseases caused by mosquitoes. Alfonso has had his job for nearly 40 years and plans to retire this coming September. He related some of the changes over the years. We went to a neighborhood near the airport and met up with about six health workers, most of whom were proudly wearing their khaki public health uniform with Paludismo embroidered over the left hand chest pocket. They each took a section, and walked it documenting on a form each house and what condition they found it in. There are staff at headquarters who will enter this data, then an director will review it to determine where they need to check next. In addition to checking that there were no obvious sources for mosquito growth and educating people about keeping their patios clean and tidy; they provided those in need with a small plastic bag to keep in their cisterns and water tanks of an insecticide that does not cause any harm. We visited the not yet fully functional new governement hospital and the worker was kept busy by placing insecticide in at least 10 drains in the parking lot, none of which emptied fully. This insecticide does not make the water safe to drink, but one could drink it after treating it by boiling or adding some other chemical. Alfonso´s job is supervisorial . He shuttled the other workers around in his pickup truck (they had none), to remind them to have their name tag visible and to check up on them. He and I went around one block asking if someone had been by and received generally positive responses.

One woman asked me, after being introduced as an nurse from the USA who was here to learn how Malaria is controlled in Mexico: 'Are you going to replicate our system in your country? I really think it works.' She asked a good question. If there were a mosquito born illness in the US that was causing as much illness and death as Malaria and Dengue Fever has and does in Mexico, such a system would probably be wise.

That was all hot work, so Alfonso and I left the brigades to their tasks and went to visit one of the 'respected neighbors.' This gentleman had been living in the same property over 40 years and had been providing this service to his neighbors for that length of time. He was just over 70 and really enjoyed reminising with Alfonso about the changes they had seen. He reminded Alfonso that he was the last of the first health dept workers he met when they first set out to eradicate Malaria. This gentleman, named Luis, created a homestead for himself and his family just outside of Puerto Escondido and grew vegetables to sale in town. He recalled when the government had built the new Market, and people still wanted to do their shopping closer to the beach. He laughed, now no one remembers that we used to sell down there or grumbles about having to go out of their way to get to the Market. Now, the town extends past his land and he has sold off bits to others. Luis concluded by saying he was content with the changes and talked of enjoying his simple life with his wife, children and grandchildren nearby.

Dengue Fever is the mosquito spread disease that is more common these days. For most, it is a disease of fever, headache, malaise and bone pain lasting for about 2 weeks. For some, it progresses to severe bleeding and rarely, death. The presence of this disease is a big motivator for everyone to be vigilant in preventing mosquito growth. Dengue Fever is caused by a virus, requires a tube of blood to be sent to the state lab in Oaxaca City for definitive diagnosis. This complicates diagnosis, but there is no medication effective against Dengue except those that help alleviate the symptoms. The treatment is acetominophen for the fever and pain. Medications like Ibuprofen and Aspirin are avoided due to the concern for hemorrage, which those medications may worsen.

Friday I went out with Miguel, another worker. We went to Tomatal, a village along the coast but further still. There we looked at the streams and creeks to see where there was stagnant water. Right now, because it has rained recently and because it is the wet time of year, they mostly just check this. In September and until April or so they organize groups of volunteers from nearby communities to fill in ponds and pools or drain them.

We went to the beach in Tomatal and saw some lagoons, another great source of mosquito growth. It was beautiful with lots of bird, and we were able to see the top of a crocodile gliding along. Miguel said that if there is enough salt water mixed in with the fresh water mosquitos don´t grow, and they will sometimes make a passage for the salt water. While we were there I also saw a small preserve for tortoise nest eggs. Miguel said that these were maintained by a cooperative of volunteers. He said sometimes others come with guns to rob the eggs, which have small value as a human food source. Surrounding Tomatal were farms with Mangoes, Papaya, peanuts and corn growing.

We also visited a house where the last case of Paludismo occured in this village. Miguel intereviewed the girl for me to get the story. The ´patient´was a girl who is now about 12, she was sick 4 or 5 years ago. She took some medicine, got better then became ill again a time later (weeks, months? she couldn´t remember.) Another test was done, and found that she still had Paludismo (or perhaps, the more severe Malaria?) and so started her on the three year long medication regimen. She has just recently completed the treatment. In addition, the government white washed her house (previously is had a rough cement exterior.) Miguel explained that the mosquitos like to rest on the walls of the buildings, but tend to avoid painted walls more. I couldn´t tell whether it was the color of the paint, the smoothing effect that they paint had on the wall or the calcium and salt that is in the white wash that acted as a mild preventative. All of the workers I went out with pointed out houses where a resident had had either Dengue or Paludismo in the past. It is clear they are familiar with their neighborhoods.

That is what I have been doing. The weather this week has been interesting. Sunday and Monday it rained and poured. The streets began to look like rivers. I got drenched on the way to an early morning meeting on Monday and was in a bad mood the rest of the day. Tuesday was nice and cool. Wednesday, Thursday and Friday has been hot with rain in the evening which is the norm for this time of year.

I have enjoyed not having much that I needed to do. My breakfast and dinner are prepared for me by the family I stay with. I buy lunch someplace. I do not have to clean, and I do not have meetings scheduled several nights a week. I have my Spanish classes, Clinic visits and spend time planning what to do on the weekend. Really, pretty light duty. The one thing I am responsible for is my laundry. My hosts have kindly allowed me to use their washing machine and then line dry my clothes as they do. And the house also has the standard concrete washboard with faucet set up outside perfect for hand laundry, which I have also used. But with the rain and humidity, it takes more than 24 hours for the clothes hanging on the line to fully dry. I had accumulated enough to just want to get it all clean and dry. So, I set out to the lavanderia and thought that I could wash the clothes myself. Well, I was wrong, I could only leave all my clothes overnight and pick them up the next day. It all worked out, but this little change in plans through me for a loop. I was pretty upset for a moment, then I realized how silly it was for me to get upset about this one little thing.

Two weeks done, Two weeks to go

I have been with the program of visiting clinics and studying Spanish for two weeks now. I still have two weeks to go. Next week the other three participants and I will be working with the public health brigades who go into the community to eradicate stagnant water which are the sources for mosquito larval growth. After that, I will have one more week in a clinic. I think I am meeting my goals. I am doing fine on my Spanish vocabulary and still so very frustrated by the verb tenses. In class, when the teacher talks about two or three kinds at once, I can not keep them straight. But in real life, one does use more than one tense at a time, so I need to get with it. I am really pleased with the clinic time as well. I have seen other practitioners and how they operate. It is interesting to see the array of complaints that are different (more gastrointestinal, tropical disease, less upper respiratory and complaints of pain) and those that are the same (pregnancy, high blood pressure, diabetes.) Hopefully, by the end of the next two weeks, I will have crossed over some kind of barrier that seems to exist regarding me and the Spanish verb.

The Virgin of Juquila

I am off on another weekend adventure. This time to the hill town and age old pilgrimage destination of Juquila. This is a place where a local virgen is worshiped and one may ask her assistance in personal issues. Bill has asked me to ask for a decent health care plan for the United States, which I plan to do. Bill is in Fulton collecting signatures for a petition for a decent health plan. I am in Mexico petitioning for a decent health plan for Americans.

Juquila is inland about three hours by bus from Puerto Escondido. I am not great at distances, but I would guess it is about 75 miles. The reason it takes so long is that the road was up, up, up with lots of curves. We went through different types of landscape with palm trees being replaced with pines and it getting obviously cooler. The mountains were cloud capped and at one point the bus was up in the cloud. The bus continued on to Oaxaca City, and four of us headed to Juquila transferred to a camioneta (a pickup converted to handle passengers) to continue our journey. The other three pilgrims were an elderly couple, she with long double braids of gray hair and a gingham apron over her yellow flowered dress, he with pants well repaired and a sturdy felt hat. The third was Hugo, a gentleman about my age who lived in Wisconsin for 8 years mostly working in a machine shop. All three agreed that it was a beautiful thing that I was willing to make this pilgrimage.

Juquila clings to a mountainside and many houses are built of wood planks with metal roofs. The center of town has the church with the Virgin and services for pilgrims all around. For the humble pilgrim, the church has palets for less than 50 cents a night in a room with others. A palet is actually floor space to create your palet. Surrounding the church is a market place with all kinds of goods for tourist/pilgrims as well. Lots of recuerdos-memories to take home and one can buy things to offer the Virgin as well: flowers and milagros small representations of the requests one may make of the Virgin: eyes, arms, legs, whole body, a man and a bottle represent giving up alcohol, and for those who have material needs: car, house, money. There are also water jugs for sale in case you forgot to bring one for the holy water available to all. In addition to the marketplace, where one can buy food to go, there are restaurants and hotels as well. I have a room with private bath and TV in a hotel just off the main plaza.

The sales people are friendly and relaxed, no push to buy. I enjoyed walking around the market, seeing the variety of items available for everyday use, for the Mexican tourist and as well as for the pilgrim. I am the only American I have seen all day. One shop person told me she knows an American who lives in a nearby village named Pablo. She wondered if I knew him. She said he can speak both Spanish and Chaitano-the language the indiginous people speak around here.
The church itself is quite big but simple with no pews. Right now it seems spacious because the special festival time for this Virgin is annually in early December, and so there are not so many pilgrims as could be accomodated. The Virgin is in the center of an alter that is mostly white with some gold gilding. This is in contrast to most of the bigger Mexican churches I have been to which have an entire back wall of all gold.

Sunday morning I awoke early to the tunes of a brass band complete with tuba and big loud drums. I was told this was special for as today is Fathers Day. The band played on and off until about noon, and once it was daylight they really did add a lot to the festive atmosphere.

I took a taxi to El Pedimento early on Sunday. This is a second pilgrimage place for the same Virgin. The taxi driver stopped so I could get a view of a creek he called Siete Honduras. This is where knowing Spanish but not being fluent in Spanish can get one in trouble. I think Siete Honduras means seven waterfalls, because there were seven. But it may mean something else. Anyway, the nearby indigineous people that the seven waterfalls represent the seven heads of a snake who live in a creek, according to the taxi driver. I believe the Hindus also have a seven headed snake god, interesting how certain themes reappear in relligions. It was wild rushing white water and could easily have been a river to my thinking but the taxi driver insisted it was a creek.

El Pedimento must be about 5 miles from town. Here, there is a small shrine with the Virgin again. All around the shrine and in the woods nearby woods are crosses and banners that families have left either to request certain benefits or to thank the Virgin for fulling their wishes. Some banners were simply to commemorate their sixth or tenth visit to Virgin. Some were simple hand lettered on paper, others hand sewn, others commercially made banners. Crosses were everywhere, in any space on the ground, in tree branches anywhere. People were kind and no one seemed upset that there was a foreigner in their midst.

I have been posting these blogs and responding to emails from public internet sites. I can use the computer with internet access for just under one dollar per hour. This seems like a great deal to me and I wonder why such sites do not exist in the US. Also, the system for cell phones seems more reasonable as well. Once you have paid the intitial fee, you can go to pharmacies or other stores and pay to have a time credit put on your cell. I have about five dollars worth of credit on the phone loaned me by the program I am here with. Public transportation seems to work fine, too. One hitch must be volume, we do not have the volume of people who are willing to pay 50 cents to ride from place to place given the inconveniences and uncertainties involved. Here, though it works great and I can get anywhere in Puerto Escondido within half an hour of leaving the house where I am staying.

Barra de Colotepec

This past week I worked with Dra. Antonia and Dra. Yazmin (Dra. is the abbreviation for doctora-the term for doctors who are women) in their Centro de Salud in the village of Barra de Colotepec. It is a coastal village a couple of miles distant from Puerto Escondido. Many who live in Barra have jobs in Puerto Escondido. It has schools through eighth grade, a city hall and a smattering of shops and restaurants.

Dra. Antonia was my assigned doctor, but I worked with Dr. Yazmin on Monday. She is in her forties, has been working as a doctor for some time and was quite comfortable in her role although clearly very tired of all the required paperwork. One great surprise was that she had an air conditioned office. I found the time with her a great respite from the heat. It is so muggy sometimes, I work up a sweat just sitting still if there is no wind or fan. She did a couple of pap smears and I was surprised by the little differences in technique. Nothing that would change any results, just a different routine.

Monday, Dra. Antonia did not come to work. Wedsnesday, Thursday and Friday the nurse did not come to work and then Friday Dra. Yazmin did not come to work. Both Doctors were gone on Thursday for meetings at the Health Dept. Headquarters. Ericka, the nurses assistant, who was there everyday said she did not know why they did not come to work and that she thought they would be at work. This ongoing stress of adapting to the staffing situation provided me with an interesting week, but certainly not any routine.

In addition to these four women, there was a psychology intern doing his year of service named Guillermo. In Mexico, if you are admitted to to a professional program there is no cost to attend, but each graduate does a year of service at the end of their education. This is true for those in clinical professions like nursing, medicine and psych counseling at least. So, Guillermo lives in a room with a bed, a refridgerator and a camp stove on the grounds of the Centro de Salud. He has appointed himself caretaker in addition to providing what little psych counseling the local people are willing to accept. Thursday, while the Doctors were at the meeting, he and I returned to the school to distribute liquid multi vitamins to all of those over the age of ten. This was a part of the National Week of Health which was all of last week.

Dra. Antonia is around 30 years old and has quite abit of confidence in her manner with patients. She is building herself a house nearby the clinic and as director of the clinic has plans for expanding services provided from there. Right now, she lives with her parents.
I saw some interesting cases this week. On Tuesday, we saw a 8 year old child presented with classic symptoms of appendicitis. He was referred to the local hospital and had surgery, confirming that he did have appendicitis. His mother was quite distressed especially because this child has an older brother who had appedicitis and an appendectomy just over a year ago. The mother wanted to know if she had done something wrong for both her children to have appedicitis. Dra. Antonia was quite reassuring and said that there is no specific prevention for appendicitis. I saw the grandmother on both Wednesday and Friday and was informed that he is doing fine and home from the hospital.

The nurse assistant, Ericka, encouraged a woman to bring in her child who was clearly quite ill. The family is very poor (they looked poorer than anyone else I saw) and transient, homeless, I guess. They had spent the night next door to Ericka and all the neighbors were kept awake by the cries of this baby. Then, before lunch the baby started crying again and blood started coming out of her right ear. When the baby (10 months old) was examined there was an obvious superficial skin infection all around the right ear extending into the scalp. Dra. Yazmin, cleaned the area and then began to rinse out the ear canal. This caused the baby a lot of pain. We were concerned that there might be an object or a bug in the ear. Nothing was seen, but it was not normal. Dra. Yazmin wanted the family to take the baby to the hospital for a better examination of the ear and IV antibiotics. The family refused due to lack of funds for the bus trip and previous bad experiences at that hospital. So, she provided the mother with an oral antibiotic and tylenol. Dra. Yazmin was going to also give the mother an antiseptic soap to use, but decided against it as she was concerned that the illitierate mother would mix up the soap with the antibiotic and give the child soap to drink by mistake. The next day Ericka reported that a couple of hours after the clinic visit one or two dark worms or larvae craweled out of the ear. All at the clinic assured me that this was not a typical event and none had had an experience such as this before. Good news is that this child received the care she did in the clinic even though the family had not enrolled in the government sponsored insurance program for low income people and the family was not charged anything for the service they did receive. The family left Barra de Colotopec the next day, so there was no way to follow up on the child.

Dr. Antonia saw a woman and her one year old daughter for well checks. Participants in a program called Opportunidades are required to receive periodic check ups and health screenings. After establishing that both the mother and daughter were doing well, the doctor asked why the mother had not come in for her monthly birth control medication for several months. The mother related that she did not need birth control now as her husband had left to seek work in Kentucky several months ago. He has not yet found any, but she is hopeful he will soon. She related that they had discussed leaving their child with the grandparents and both going to Kentucky in search of work, but this mother did not feel she could leave her baby and instead chose to live separately from her husband. She hopes to be able to join him with their daughter in a year or so. She went on to discuss the stress she was experiencing related to this separation and not knowing how he was doing day to day. She has support in Barra de Colotopec from her family and is not overwhelmed by local responsibilities. The doctor was very sympathetic and encouraged the mother to take some time for herself, taking a walk daily, going to visit a girlfriend without her daughter, something. I found it interesting to hear the other side of the story. I have had women as patients in Missouri who were suffering greatly because their children were in their native country with their grandparents and they were trying to manage the behavior or health problems of the child over the telephone.

Then, on Friday, Dra. Antonia had planned to give a talk to all the participants in the program Opportunidades, which is a government sponsored program that pays a stipend to families in whose children are up to date on their immunizations, requres all family members have well check ups and health screenings and to attend clinic sponsored talks about issues of health and well being. She was very busy in clinic as both doctors were gone Thursday and had shortened a clinic to distribute antiparasitic medications to all the school children in town on Wednesday.
Just as Dra. Antonia was done with the last patient, and was headed to the large tree shaded area with about 100 mothers and their children waiting, a mother came up and asked the doctor to refer her baby to the hospital as his diarrhea continued even though she had given him the medicine for three days. Dra. Antonia tried to explain to the mother that one does not go to the hospital when diarrhea is the only complaint, but rather gives rehydration solution deligently at home. The mother was quite insistent that her child be evaluated and insisted that Dra. Antonia talk with her husband by cell phone, who also felt the child needed hospitalization. The husband must have said something, because the attitude of the doctor totally changed halfway through the call and she headed into the exam room with the mother and baby. Meanwhile, there are still 100 or so waiting for her talk outside in the shade with threats of rain.

The baby, about 8 months, was sleeping peacefully, had easy respirations, good skin color and tone. I did not see anything to worry about and wondered what the father had said to convince her to evaluate this child. Dra. Antonia had a worksheet for determining what to do with babies with diarrhea and vomiting. The sheet had a check list and points assigned to different symptoms depending on the worrisome nature. As this child had no fever, no vomiting, no signs of dehydration based on this scale, he did not need to go to the hospital, but rather needed close observation and fluids at home. The mother was insistant that the child should be referred. So, Dra. Antonia started the referral form, which is really quite detailed with lots of slots for various information and a central area requiring a two to three paragraph clinical history. When the form was almost completly filled out, Ericka entered to say it was starting to rain and could the 100 people still waiting outside please come and seek shelter in the waiting room. Dra. Antonia agreed.

As the one mother was leaving with her one baby here came another 60 or so with their babies and the snacks they had brought to share. Really quite a sight. I left just then because I needed to get to my Spanish class.

I am learning from and enjoying this experience. Next week we will spend with the public health brigades that work on reducing the presence of mosquitoes and other insects that can spread disease. It seems incredibly relevant as the wet season is just now starting, so there will soon be new places for mosquitoes to prosper. I have have been assured there is no slogging through crocodile ridden swamps, but in any case, wish me luck.

Checking the water and going to school

This week I am at a clinic in Barra de Colotepec, which is basically a suburb of Puerto Escondido. The Clinic is staffed once again by two doctors, a nurse and her helper. At Barra they are all women. And then there is an psychologist/counselor who is fresh out of college and has his offices there as well. More on all that in my next post; I want to tell about my adventures in the village of Barra de Colotepec rather than in the clinic.

Today, I went with Rudolfo, a health promotion specialist (promotor de salud) for the Dept. of Public Health. His job is educate families about the various public health initiatives. Right now, he is going to houses and evaluating the water systems and the orderliness of their patios and yards to be certain there are no standing water sources which would foster mosquito growth and therefore help to spread Dengue Fever and Malaria. July begins a time of year in which it rains daily, and so now is the time for each household to be certain they are not harboring any sources of mosquito production. In addition to talking with people and checking for worrisome sources of standing water; he collects data which he reports to the health dept. I imagine they will collate this data and then determine where the need is greatest and then focus on those areas.

Rudolfo would go to a house and greet the residents (usually women and usually already outside doing chores outside.) He would explain his purpose and check the tanks of water that are common in the yard to see if the are cleaned regularly. Several he tested for the presence of chlorine, a good sign that the water is safer. It is each household´s reponsibilty to chlorinate the water they receive from the municiple wells. He would check the yards and patios for sources of standing water: trash, opened coconuts, tires and the like. He would politely ask the residents to make the corrections and educate them on the reasons behind the request - reducing the risk of mosquitoes and there fore the risk of spread of disease.

Most who had problems, were in agreement with and able to do the changes he requested. Nothing expensive or laborious, simple and standard cleaning. I think the majority were already doing fine. We saw one take which the family had placed fresh water shrimp (perhaps really small crawfish.) These animals eat the moss and mosquito larvae and so is one way to take care of this problem. Another family had an electric device that was collecting mosquitoes (and they would eventually die.) This was a trial of this invention and depending on the number and type of mosquitoes collected the manufacturer may decide to start marketing it´s product in the area.
In one morning, we visited or observed (for the vacant houses) a total of 23 houses. All on foot. A lot of the walking was on paths rather than roads, and some households could only access their property by crossing through someone else´s yard. The ´laundryroom´, ´kitchen´ and ´living area´were all located outside. This seems really reasonable, given the heat. Some were cooking with gas but most were cooking over open wood fires. One woman had a home business of creating pinatas. She was making about 8 Winnie the Poohs when we visited this morning. They were assembled and awaiting decoration to see that they were bears, right now just newpaper papier mache. Another woman had a business of making tortillas and neighbors were droping by to buy them. She had the dough (masa) mixed up, used a metal device to flatten them and had a large flat round ceramic built over her open fire to cook them on. That´s hot work. We met one man, Patrick, who is from the United States and married to a local woman. At 9:30 am he was most of the way through a 40 ounce bottle of beer and seemed drunk and ill. He was probably the sickest looking person I saw.

I saw the grandmother of an 8 year old boy who the doctor sent to the hospital yesterday with suspected apendicitis. The boy had had surgery, the apendicitis was confirmed, and he is now doing better. He should come home tomorrow. It was fun to run into someone who I had met Yesterday, the mother was quite distressed that this son apparently had appendicitis as his older brother had appendicitis less than one year ago and had some complications. More on that in my next post.

After returning to the clinic, I went to the neighborhood primary school and helped the doctors distribute anti parasite medicine. One dose for each child. That was fun, which a few ethical twinges: each child took the dose whether he wanted it or not and the parents were not informed that their children would be receiving this medicine today. Neither the teachers nor the doctors had any second thoughts about making this choice for the parents and it was done. Apparently, one needs to take a de-worming type medicine every so often if living in Mexico. I was a little surpised to see doctors doing this work, as it is a taks which did not require the skill of a doctor. One dcotor keep a running tab of the number and age of those receiving a dose.

This is the second of three annual weeks of vaccinations. Normally, this week falls in May and it was postponed until now as school was cancelled in May due to the whole Swine Flu issue. This health clinic doesn´t have extra vaccine to distribute and the vaccination system in place works without the need of campaigns and blanket vaccination of a certain age group. I recall when I was a school nurse in California (late 1980´s), I was told by parents whose children had received their vaccines in Mexico that health professionals would come to a village and give vaccine to all who were a certain age. So, we gave the kids oral anti parasite medicine instead of vaccinations.

Tortoises, Mangroves and a Storm

This weekend, I have come about 30 miles along the coast from Puerto Escondido to San Agustinillo, a little village directly on a cove with quieter waves than Puerto Escondido. I found a room right on the beach and have open air restaurants on either side of me. The room is simple: lots of wood slatted shutters, a double bed, a mosquito net a bathroom with shower and a hammock outside. It is directly on the beach and about 25 feet from the ocean.

Saturday getting to San Agustinillo I got to ride in an air conditioned second class bus for just over an hour. That was great. Then I went to visit La Ventanilla-an eco tourist site owned by a cooperative and the Mexican National Center for the Tortoise in nearby Mazunte. The cooperative in La Ventanilla receives no government funding and maintains a lagoon with mangrove trees and saves tortoise eggs by collecting the recently laid eggs and keeping them in a protected area until hatching. I didn´t see anything about the tortoises as that all happens before dawn except for their nests are protected and marked with a stick. I was told that about 7,000 (as I recall) baby tortoises hatch a year for their efforts.

In the mangroves, I saw the trees, a cocodrile, lots of egrets (smaller than in Missouri, both white and blue), the finely woven nests of flycatcher birds and a termite colony-looking like a mud hut up in a tree. I was rowed through the mangrove in a launch. It was all very impressive, beautiful and hot. Apparently, the entire mangrove forest was ruined during a hurricaine in 1997 and so all the trees have grown up since then. They seemed plenty big to me, but I guess they should be bigger. Mangrove trees produce seeds that are about 1/2 an inch in diameter and 2 feet long. They have a pointy end aimed at the ground and when they fall from the parent tree into the mud; they are planted.

The members of the cooperative support themselves through tourism and donations and so I was told that they were lacking in funds. There was a bus full of women of my age, apparently a club outing and a fancy van full of foreign tourists from the nearby fancy resort, but perhaps they are used to more travellers coming in. They had some displays explaining their work, including the fact that they catch and tag the cocodriles in their lagoon. A recent census of cocodriles shows there are considerably more males than females. The guide attributed this to golbal warming as nests of cocodrile eggs incubate at warmer temperatures, more of the eggs will develop to be male. He said they were considering finding cocodrile nests and collect then incubate the eggs at a temperature that develops an equal number of females as males.

After that, I went to the Mexican Center for the Tortoise in Mazunte. This is a tortoise rehab and incubating place, and I am pretty sure it is run by the government. A primary income of this villiage was to catch and process tortoise. This practice was outlawed in 1990. It seems that this center was created partly to recompense the town for the loss of it´s main industry. So, they have lots of tortoises and turtles growing in water and like in a zoo. Apparently, there are 8 species of sea tortoise and seven are found in Mexico. Most sea tortoise do spend most of their lives in the open ocean, though. Beyond the chain link fence of the center, I could see boys on boogie boards having a great time with the waves.

I had a conversation with one of the taxi drivers I met yesterday. He said he lived in Oregon, doing basic labor and agricultural work for two years. He couldn´t remember the name of the city, but that it was the largest. So, he agreed that it was Portland when I named that. He didn´t really like it as it was too wet (while we are both drenched in sweat!) and cold. Also, he wasn´t able to get a good job as he couldn´t speak English. Then he said, "I need to learn English." Dr. Pablo, the guide at La Ventinilla also said they needed to learn English, but then when asked for details had no plans to get going with that idea.

I returned to San Agustinillo about 4:00PM. These places are less than 5 miles apart even though they have different names. I had a nice wrestle with the waves and sat down to a nice meal of calimari. About the time I was finishing with my meal, it began to rain. Then, thunder and lightening started. Then there was a deluge. All together, it lasted about two hours. At the end of one hour, I was in the open air restaurant and there was about an inch of water rushing through there to the sea. I got drenched going the 25 feet to my room. Then the electricity went out and so I sat in my room waiting for the rain to end, workng on Spanish homework and the differences of Por y Para by the twilight of the storm. The sea was amazing colors of muddy brown and light green. The waves were bigger then smaller and then again bigger.

The water from the hillside behind us created lots of streams of water going into the sea. There were occasional lightning strikes out at sea, straight from high in the sky into the water. Despite all the storm, it seems the worse that happened is the electricity being out, coconuts and seaweed washed up on shore and sand being deposited where it should not be (the main street, the floor of the open air restaurant.) I have not seen any buildings or trees or branches that have fallen. I am still in San Agustinillo and there still isn´t any electricity most places. This internet cafe must have a generator.