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.
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