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.