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.