Sunday, June 28, 2009

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.

Thursday, June 25, 2009

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.

Sunday, June 21, 2009

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.

Saturday, June 20, 2009

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.

Wednesday, June 17, 2009

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.

Sunday, June 14, 2009

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.

Friday, June 12, 2009

En la Clinica de Salud

A few years ago, Mexico started anew public health initiative to provide the most basic clinic services to all citizens, among other initiatives. Toward that end, neighborhood clinics were started which provide prenatal care, immunizations, treatment of infectious diseases, regular health checks including screening for high blood pressure or diabetes and other basic primary care services. I doubt that the system is perfect. From my experiences this week, it does seem to be helping and make a difference.

I was in a public health clinic in the same neighborhood where I am staying, Colonia Lazaro Cardenas. I walked about half a mile to the clinic in the morning, ate an early lunch with the clinic staff and left in time to catch a collectivo-a shared taxi- to my two hour Spanish lesson. Then, I ran a couple of errands and went home to find that my hostess Estela had created another wonderful meal which is shared with her family. I enjoy her sons teasing each other. It is a nice routine.

I observed Dr. Pablo Garcia, who treated and saw a wide variety of people. From pregnant, to recently born, to lots of children and women, a few men and a few elderly. There were less respiratory infections and more gastrointestinal complaints, many of which he diagnosed as either an infection or an infestation depending on the symptoms. The clinic is very basic with exam rooms (one for each of the two doctors), a front porch for waiting, a reception area for the nurse and his helper and one other room for overflow and storage. Dr. Pablo brought his stethoscope and otoscope and used mostly his interview and physical exam skills to determine what the patient´s problems were and how to help them.

Those with chronic diseases such as diabetes and hypertension are usually seen monthly and often go to the central public health office to have basic lab work done the day before the visit, wait for the results and then bring those results for Dr. Pablo to review. No computer, fax, messenger service or clinic telephone to share results. The clinic staff each had their personal cell phones as did many of the patients. Dr. Pablo used the calender in his cell to calculate when his clients needed to return or due dates for pregnant women. He used the calcluator to establish BMI and to confirm dosage of medication for children.

If a patient which presented with a problem requiring some lab work, Dr. Pablo usually diagnosed the problem and started treatment and then asked them to go quickly to the lab or to wait until the treatment was complete to do a ´test of cure´. Pregnancy tests, urinanalysis, blood counts, blood sugars and stool samples are all available at the central lab. This process does not seem easy or quick. I imagine that many do not follow up on this requested post illness testing.

The clinic is well stocked with generic drugs which are provided to the patient directly. The variety available is sufficient to meet the needs of most patients. The doctor writes his prescription on special NCR triplicate paper, and the original becomes the property of the patient. The nurse using this, dispenses the medications and the patient can use the prescription as the directions for how to take the medications. Dr. Pablo did not order anything ás needed´ but rather even pain medications and fever reducers were ordered for a specific number of days. Dr Pablo saved the other two copies of the prescription and he said he uses them to create reports and manage inventory; which he said he does on weekends. Sometimes he would prescribe something not available in their stock of medications and ask the patient to buy it from a pharmacy. Sometimes this to relieve a symptom that particularly bothered the patient in which case, he would simply ask them to buy it. If the medication was to cure or control the condition and so very important, he would give a little talk about this and stress the need to purchase the medicine.

The visit with the doctor, the medicines provided in clinic and the lab work all are provided without any requirement for payment. Some qualify for serguro popular and somehow that helps with the cost of the clinic. But if someone is over income or if they haven´t gotten around to applying for the basic health care insurance provided by the government, they still seen and there is still no cost. There is a donation box and with this money they are able to buy the 'extras' for the clinic-writing paper, file folders for charts, salary for the nurse´s helper. Currently, they are saving to buy another electric fan as the clinic only has one. That would be quite a luxury.

With Dr. Pablo, I saw patients with Chagas disease(14 mos old, sent to pediatrician to be sure she could start treatment), TB and syphilis (same patient, 26), severe asthma (12 year old), renal failure(sodium very low, referred to hospital with request for two day admission), a poorly healing but not infected incision after a cesarean (her fourth-she did get her tubes tied.)

Dr. Pablo was thorough and complete with his instructions and advice. He explained the purpose of each medicine, how to take it and advised on diet and activity to manage that patient´s specific problem. Many were advised to increase exercise and avoid sweets/fats to loose weight. Basically, he did all the same work that I would expect in a primary care clinic in the United States. I was pleased to see how much he was able to do with so little.

Dr. Pablo is young, he finished his medical education about four years ago, then had one year of internship and another year of mandatory service. He has been at this clnic almost two years. He also has a private practice in the evening in which he works 4 hours more each day (so five 12 hour days per week.) He does not attend patients in the hospital nor does he take call. He said one reason he works so much is because the pay is so poor. He has plans to take a test to be accepted into a residency program and complete a residency and become specialized in one part of medicine rather than do primary care. He would like to become an anesthesiologist. This makes me a little sad, as he displayed so much patience and has a great bedside manner. I know he will use these skills in anesthesia as well, but not to the degree that he does at this time.

Sunday, June 7, 2009

!Estoy Aqui!

Today is Sunday and I am in Puerto Escondido. It is HOT! I arrived yesterday evening and met my host family: La familia Corzo-There are four in this family Daniel, father from USA, Estela, mother who keeps everyone on their toes, Christian, a grown son who is a competitive surfer and Naum, about 12 who is friendly and outgoing. All are surfers-as Puerto Escondido has great surfing. I had dinner and breakfast with them and enjoyed both. The photo shows Estela and two of her friends. We are waiting to watch the sunset. There is still plenty I do not know and will learn in the next few weeks. I have a room with a bath that is in a cottage adjacent to the house and it is quite comfortable. I do not plan on surfing, but do plan on some boogie boarding and body surfing.

Earlier this afternoon I met with Soledad, the coordinator of language school and home stays and two other program participants. Soledad showed us bus stops that we will need to use to visit the various clinics. We will be going to clinics in outlying villages, changing weekly. She also oriented us to the town. The taxis, called collectivos, cost less than 50 cents and go by frequently. Because the town is situated along the coast and backs up to some mountains, most things go north south and it is easy to be oriented to getting from place to place.

Tomorrow, we meet with Dra. Isabel (first name) at 7 am to discuss how our clinical experiences will go forward. This evening, two other participants in the program are arriving.

Yesterday, I took the bus from Oaxaca to here. I took the first class bus, a lot because I had heard about the amazing luxury involved, and so it took me 11 hours. To get from Oaxaca to here, one must go down nearly a mile in altitude. The big fancy bus does not go the more direct route due to the curves and turns. The bus was luxurious, air conditioned, clean, with 11 hours of movies. There were at least three with a dragon theme. The landscape was really breathtakingly beautiful and the windows tinted and not allowing me to take any photos. First it was dry with trees and huge cacti. There were lots of agave plants being grown to become mescal liquor . Then, it became more forested. Trees with big leaves and the occasional tree with lots of gorgeous flowers. Finally, along the coast, besides being hilly, there were areas where cattle were grazing or where cultivation was happening. I did not see a dominant crop. I was surprised at how much of this very hilly territory was unpopulated and seemed very wild.

Friday, I spent the morning in Monte Alban. This is an ancient Zapotec ruin which was abandoned long before the Europeans arrived. Bill reminded me that it was featured on the cover of the junoir high Spanish text we both had: Entender y Hablar. There were Big pyramids with steps, a ball court, impressive stone carving. It was build on top of a mountain, which overlooks modern day Oaxaca and the designers flattened the top of that mountain to create their ceremonial city. I was struck by the similarities between Monte Alban and Cahokia Mounds, near Collinsville, IL. There are huge differences, of course, and it is likely that the Zapotec culture was more developed that the pre Mississppian culture of Cahokia, but the layout of the town and the ceremonial or religious meaning applied to the pyramids or mounds were striking.

In the afternoon, I went to a home that offers tours of it´s cochineal cultivation business. Cochineal is a ruby red dye made from the dried carcasses of little insects that grow on the leaves of cactus. They have to be tended and cultivated by people in order to collect an adequate amount for dye. The whole process is fascinating and has been done in Oaxaca for thousands of years.

And now it starts: to Clinic tomorrow and it is still hot.

Thursday, June 4, 2009

Lorena en Oaxaca


I arrived last night and spent the day seeing the historical district and one museum. The picture is from the museum (and former monastery) and looking toward it´s adajacent Church. While the town of of Oaxaca has charm and beauty in the way the Spanish Colonial towns do, the most wonderful part of today has been becoming aquainted with the bed and breakfast where I am staying: The Oaxaca Learning Center. Gary Titus has set up a place for secondary school students to receive tutoring and college students to earn stipends by providing the tutoring. It is really quite special to be welcomed into the midst of all this activity and sharing.
I also toured an 'ethnobotanical' garden which showed many plants indigenous to Oaxaca. I learned that Marigolds are a new world flower. I would have guessed Asia, as common as they are in India. I saw a 1,000 year old cactus. It was transplanted in the garden as it was growing right where a freeway interchange needed to be. You can´t tell by the photo, above, but it it at last 5 feet tall and twice as wide.



Tuesday, June 2, 2009

Thoughts on goal setting

Each participant has been asked to write some personal goals for our time in Mexico. Here are mine:
1. To revitalize my Spanish and conduct a patient interview in Spanish.
2. To gain insight into the changes I will need to accept if I were to accept a long term employment as a nurse in another country.
3. To learn more about the culture and people of Oaxaca.

My bags are packed, I'm ready to go. My next post will be from an internet cafe. !Hasta luego!

Monday, June 1, 2009

Have I ever done something like this before?

While I was in an undergrad studying nursing in 1981, I went with a 'medical team' organized by the campus minister at my school, DePauw University to Port Au Prince, Haiti for three or four weeks. We 7 undergrads were poorly prepared to do much medical service. We brought a physician, a nurse practitioner and a dentist with us and they were able to provide service. To round out our group, we also had a Catholic Priest and DePauw's ROTC officer. We brought donated medications (mostly samples.) Prior to going to Haiti, we had spent weekends organizing and getting these ready to transport. The medications weren't very helpful. Medications that need any monitoring such as blood pressure checks or blood testing were not useful in the context of those clinics. We brought some purchased medicines which our hosts had specifically requested (antibiotics and vitamins) and those were received with thanks.

We worked in clinics and programs run by the Missionaries of Charity (Mother Teresa's order.) We saw poverty. The most common problems could not be fixed in a clinic setting: children with malnutrition or diarrhea, and scabies related to little access to bathing. Clinically, it was interesting: the doctor thought he found man with leprosy, he suspected tuberculosis in others, and he treated one case of typhus. We saw young people who had signs of surviving polio. I helped the physician drain two large abscesses. The dentist coached each of us on pulling teeth when he needed to give his shoulder a rest. I had some opportunities to do basic nursing in both the hospice and children's home that the sisters managed. I realized I was learning more than I would be helping and I accepted that fact. The term 'service learning' had not yet been coined, but that is what we were doing.

The other students and I had interesting discussions with the sisters about the needs of their neighbors, the poorest of the poor. We Americans wanted to fix it. We wanted to make plans. We needed to be doing something. The sisters did not have a goal of eliminating poverty. Their aim was to make someone's life better for today. They worked hard and they worked cheerfully. It was really wonderful to see their contentedness in the face of the poor side of Port Au Prince, Haiti.

I also expect to learn more than I can give this coming month in Puerto Escondido. I am excited at the prospect. I hope that I can also help make someone's day better.

Why am I going to Mexico?


I decided a year ago that it would be great to travel, improve my rusty Spanish and get some experience with health care provision in another country. Last summer I worked at both Fulton State Hospital and Jefferson City Medical Group to earn extra funds to allow me to go while on my break from my student health job at William Woods University this summer.

This winter, I searched the web and asked those who may know about projects in Mexico and Central America where I could study Spanish and provide some service in a clinic setting. I expect to learn more than I can ever provide to the host community. Bill and I have may want to work in another country someday. This is me testing out this idea.

I found wonderful programs in Guatemala, Honduras, Mexico and Nicaragua. Each had advantages and disadvantages. I corresponded with the different organizations and settled with a program sponsored by Child Family Health International (CFHI) in Puerto Escondido, Oaxaca, Mexico. CFHI provides service learning programs for students in health professions in many different countries. The staff of CFHI was kind enough to overlook my lack of student status and allow me to participate in their program. CFHI provides liaison to the language school, to clinics and arranges a homestay with a local family.

So, I am going to Mexico to learn more Spanish and to try out working in health care in another country. I am going this summer because my children don't need me on a day to day basis and I have the luxury of time off from my primary job and funds from my secondary jobs. I am very fortunate for all of these blessings.