Some thoughts on San Marcos from Mary Rappazzo-Hall, MD

There is little I can add to the wonderful and extensive descriptions that Cathy sent regarding our day to day activities. I am still trying to process all we did and the experience as a whole. The adult patients I saw had many of the chronic conditions I see in the US but at an earlier age and with none of the resources that are available even to the poorest in this country. The women seemed especially beaten down by their lives …..numerous pregnancies (not unusual to have as many as 7 to 10 and up to 16,)the burden of trying to care for these children and manage a home while cooking, farming, carrying wood etc. The people themselves are warm and caring with beautiful kind faces.  The lack of any basic education is very apparent as when trying to fit adults with glasses while most could not read.  Through out the time I continued to question how much I was really adding to their health care and could only repeat to myself that I could only offer them compassion and care but not cure.  Clearly the work Cathy is doing to bring them water and therefore sustainable gardens is some hope at least for their improved nutrition.
As an aside while there during my down time (mostly waiting for flights) I read The Short and Tragic Life of Robert Peace. It is the story of an African American young man raised in the drug infested city of Newark New Jersey and his attempt to rise above his circumstance. It occurred to me that so much of our life is determined by chance….where we were born and who raised us.  Although Newark is very different from San Marcos, the struggle to rise above our circumstances and create our own destiny is not so easy.

Final Thoughts

     This trip to San Marcos was one of the most difficult in that there was very little down time.  On previous missions, we have returned each night to our "home base," a hotel in the city of San Pedro/San Marcos were Luis has the clinic, and arisen early each morning to drive to the next village.    Coming back to the hotel provided a place to relax, shower - sometimes hot, sometimes not - prepare medications for the next day, and have dinner either in a restaurant or from things bought in the local market.  It separated the days and kept an order to the week.  This time, our destinations were a little more remote, and since this would be the first visits by medical providers, we stayed longer each day and spent two days in Sibinal.  Rather than driving two hours each way, Luis arranged rooms in a hotel in one municipality and in a "bed and breakfast" at the mayor's home in another.  Still, we traveled a little over 1300 miles during the week over winding, bumpy roads, some paved, many just narrow dirt tracks.  As we drove around each left-turning curve in the road, there was a loud grinding noise from the right back wheel that Luis explained away as something about a new tire.  A smell of burning rubber accompanied the noise, but the smell gradually diminished, and so did the noise. Though it never disappeared, it either got softer or we got used to it. Mary, whose car sickness can ground her even on the NY Thruway, managed to ride in the backseat without a hitch.  My theory is that terror over-rules nausea every time.
       The medical care we provided was similar to my previous trips and in general can be categorized as "less than a Band-Aid," as Mary neatly put it.  Although it's very frustrating to realize that, I'm at peace with what I do here.  I feel there is value just in coming, seeing the children, examining them, listening to the mother's concerns, and in reassuring them that their children are basically healthy.  Each time I come, there are a few children for whom I can make a life-changing difference, and that alone makes the trip worth it.  On the first trip it was two little boys who needed cornea transplants, and they are now, three years later healthy with normal vision in both eyes.  This time, I was able to connect with an organization out of Stanford University that comes to Guatemala to do volunteer orthopedic surgery, and they will take care of the three year old with bilateral congenital hip dislocation. The same doctor in Xela who did the corneal transplants will see a young boy with an injury related cataract, and finally, for $100, we were able to provide formula for a frail one year old who has been hospitalized three times since birth with respiratory infections.  She may have an immune deficiency or her problems may just be due to her mild prematurity, but either way, she needs nutrition, and her mother has been giving her tortilla water and coffee.
      Having Mary along on this trip really opened my eyes to the complexities of caring for adults.  Each patient she saw brought a lifetime of chronic illnesses layered upon the wear and tear of a hard life living in extreme poverty.  She saw hypertension, diabetes, arthritis, chronic lung disease, kidney and liver disease - all untreated for many years.  Some people knew they had these conditions, having seen a doctor at the government hospital in the past, but Mary made many first time diagnoses as well.  Though we brought 56 pounds of medications, she could generally give each patient only a month's supply of pills, and hope that they would be able to obtain a similar cheap alternative.   Luis explained that most people with chronic illness understand that they need lifelong medications, but just cannot afford the expense over time.  Mary found the week frustrating and heartbreaking, and on the way home we talked about what she felt was really needed, a project for adults.  It was similar to my reaction last year when I realized that the medical care I provided was very much secondary to what the children and their families really needed - food - and started the garden project.  Mary realized at once what the adults need.  Though I have no plans to take on another project at this point in my life, here it is:
      Get a grant to pay for a supply of generic medications for six to eight of the most common conditions, hypertension, diabetes, irritable bowel, arthritis, gastritis...Find a source for the drugs at some discount and make sure the grant is renewable so the drugs don't dry up.
      Recruit women from each village and bring them to San Marcos for a few days for training in taking blood pressure, reading urine glucose strips, giving and teaching insulin administration, discussing diet for diabetes and hypertension, etc and make them the keepers of the drugs.  They then become the providers for each village and see the patients gratis (perhaps with a small stipend from the grant,) every month or three months?, check pressures, urine glucose, and dispense medications.
That's it.  Not very complicated and it would make a huge difference for many.  Having the chance to share this experience with Mary was fantastic.  She is one of those doctors that everyone wishes they could find for themselves, kind and caring, knowledgeable and thorough.  She's also very straightforward and not a bit shy about saying exactly what she thinks.  When there was a discussion about whether we might see more patients on Saturday morning before heading to Guatemala City, it was Mary who, while not saying she wouldn't do it, tactfully made it clear that a half day meant noon, not 3:00 pm and that it seemed unlikely we would be able to close the door on a crowd of needy people to make an escape.  Bette and I who are always trying to accommodate Luis, might have done it, but hearing Mary lay it out made it clear how ridiculous it would have been, especially since the drive from the jungle to Guatemala City would have taken six hours.
     The biggest impact of this trip was the huge turn of events in the garden project.  My fears about sustainability and the ultimate impact the project would make are completely gone.  The three irrigation projects, two from natural springs and one from a river, will make large tracts of farm land arable for Tacaná, Sibinal and Malacatán.  Each of these municipalities has 100-150 villages and they are grouped closely enough to benefit from communal farmlands.  The land, some privately owned and some available  for rent from the government is being made available to the villagers because without irrigation, it is useless.  Since the villagers will own the irrigation pipes, pumps, etc, and be in charge of running it, the land owners have given them use of the land.  It helps that the owners have family connections within the municipality.  Luis estimates that each of the three irrigation projects will cost around $5000.00 dollars, but even if it is twice that amount, I feel confident that I can obtain grants.  Luis has hired a consultant to create a report with exact numbers on acreage, pipes, pumps, people, etc.
     So that's it.  I'll post a few final photos.  I'm unable to captions them all - something about Picasa. Thank you again for your interest.
   


     

February 28: Final day and the drive to Guatemala City

We awoke this morning and packed in a leisurely fashion for the first time since our arrival.  Luis picked us up at 8:30 and we set off for Guatemala City with two planned stops, one in Xela and one in Antigua.  As we analyzed the mission, Mary commented that the whole week felt like one very long day.  She’s right.  Because we didn’t stay in San Marcos at night but moved to two other hotels, one very cold and noisy and the other inhabited by roosters and lacking window glass, there was never any time to relax or feel comfortable at the end of the day.  On past trips, after a long, often frustrating clinic, Bette and I would walk to a small restaurant or pick up some food and return to the hotel where we could relax and go over the day.  During this week, the meals were generally in the kitchens of the village elders or mayors and we were staying in lodging that had it’s own challenges.  Mary has been amazing through all of it, but she, like the rest of us is fairly beaten down.  The book is still out on how far down I am on her list of trusted friends.  Actually, we probably have to set the trust thing aside and just hope for the “friends” part.  There is some hope.  Bette’s been keeping a list of adult medications and supplies that Mary has been suggesting for future missions.  On more than one occasion, Mary let slip that “we” should bring this or that.  I take this to mean that she has an unconscious strong desire to join me again on a future medical mission.  She also has been answering with the Spanish, “Sí” instead of “Yes” when asked a question requiring the affirmative. Clues!
On the drive up today, my cell phone rang – an unexpected event since I did not enable the international feature and have not been using it.  The call was from Laura, the physician coordinator for operationrainbow.org, an organization of volunteer orthopedic surgeons whom I had contacted regarding the three year old with dislocated hips whom I had seen in Por Venir.  Laura informed me that indeed they would be happy to put her on their scheduled mission in either July or September at a private hospital they use in Guatemala City.  They have done this surgery before on children in Guatemala.  I was ecstatic as I wasn’t sure such a complex operation could be undertaken on a volunteer mission. Tomorrow Luis will call the coordinator in Por Venir for the mother’s contact information and get the process started.  It will totally change this child’s future from one of chronic arthritis and progressive disability to one of relatively normal orthopedic health.  When something like this comes together, I feel like all of the aggravations and inconveniences are completely worth it.  They are so small compared to the consequences of having not come and not been able to refer this child.  It’s not that I’m so special; any pediatrician would have recognized this gait at once.  But the reality is that there is not likely to be another pediatrician in Por Venir until Luis and Bette arrange another clinic, perhaps in another year or two; it’s off the beaten path, so to speak.  Though I completely agree with Mary that most of what I do on these missions is less than a Band Aid, occasionally I get to instigate something that will change one child’s life for the better, and that’s enough for me.
Along the way, we drove by the cultivated fields of the agricultural projects.  This is the area where the representative from all over the country will be coming in March to learn about cultivation techniques and seed selection from master farmers.  Luis will be choosing 10 representatives from the San Marcos region to take part, and they will return to their villages to teach others.  The plots were amazing with a great variety of vegetables.  I posted some photos on Picasa though we couldn’t get very close from our vantage point on the highway.  This all comes at a great time as it coordinates with the upcoming irrigation project for the fallow land.
We stopped in Xela for breakfast where we had eggs or fruit and yogurt and then drove to the city center to the shop where Bette buys indigenous items to re-sell for her foundation.  The owners know her and give a discount to all who are with her, which is great because you don’t have to think about bargaining. They recognize me as well now, so it was a nice reunion.  We all bought a few things for future gifts at reduced prices, and then Luis picked us up and we drove on to Antigua.  We walked around a little, continuously saying, “no, gracias,” to the vendors, and ended up in the building that houses the indigenous crafts and clothing.  Textiles are arranged by region, and there are also a variety of crafts, coffees and chocolates.
We drove on to Guatemala City to our hotel in a gated community.  Luis arranged our dinner and headed back to San Marcos.  We were all hungry, and when we came to the dining room, the waiter handed us a full menu but said only breakfast items were available, eggs, beans, toast, fruit and pancakes. Though not especially happy, we all ordered and as we were finishing, amazing odors of “not breakfast” came wafting from the kitchen.  Shortly afterwards, the waiter emerged with a plate overflowing with fried shrimp and onion rings for another diner.  When Mary’s jaw returned from it’s sudden drop into shocked dislocation, she turned to find Bette equally appalled.  Apparently Luis had paid for our dinner on the “light fare” plan, and had we known it we could easily have paid with our own money for something off the full menu.   It was one of those “last straw” moments that luckily put Bette below me on the bad list for now.  I have a feeling she’ll climb back up soon.
Tomorrow we fly back home via Miami and Charlotte.  I will be busy organizing the new information about the irrigation project to present to possible donors, and awaiting Luis’ detailed report on acreage to be irrigated, costs of pipes, labor, etc., etc. to include in my proposals.  Mary returns to her full work schedule plus her legislative work.  I’ll likely do one more wrap up blog in a couple of days, and perhaps add a few more photos to Picasa, but thank you all again for your interest and support in following my work in Guatemala.

February 27th: Malacatán

Today was our last clinic day and was held at the site of the first Community Garden.  A big group of villagers was gathered at the “casita” close to the garden that Luis had renovated to be used for clinics or gatherings of the community.  As a “next to last” surprise, he showed me the sign he had erected in front of the clinic, RANCHO BARTLETT, in appreciation for my recognition of the need for gardens and initiation of the project.  So now if I feel like being snooty, I can tell people I have a ranch in the jungle in Guatemala.
We left Por Venir around 7:30 this morning after a quick breakfast of eggs, beans, tortillas and wonderful strong coffee, a rarity here. We arrived in Malacatán an hour later and unloaded our medications and equipment in two rooms at the casita.  Mary started seeing adults while Luis and I took a short hike to see the last surprise.  Of course the hike was straight down a steep hill with shallow steps hacked into the turf and spindly trees to grab for balance.  I made it down without breaking a leg and arrived at a farm where corn, beans and peanuts were growing.  There was a small house there, about 12x15 feet where a family of 10 were living.  There was a stone cook stove outside, a big tub for washing, and a latrine down a path out back.  Luis explained that this whole area used to be a large private farm that grew corn, but as part of a project to relieve poverty, the government had bought the land several years ago and broken it up into 1-2 acre parcels that to rent to the poor.  The only problem is lack of water.  Most of the land lies unused for lack of irrigation.  The surprise that Luis had brought me down the hill to see was a small tributary from a large river.  The lucky family that rented this parcel of land is able to irrigate their field and grow not only corn but beans and peanuts as well and therefore are well nourished.  With the seeds provided by the garden project, they will be able to harvest excess produce to sell, and eventually will rise from their current level of poverty.  The plan for Malacatán, like that for Tacaná and Sibinal, is to fund the placement of pipes and pumps to bring irrigation to the fields. All the unused fields will then be rented, seeds provided and families and the towns will be on the way to better lives.
As an aside, in Por Venir, we saw an organic garden and greenhouse that a family has used project money to build.  They have two goats and they add the droppings to a huge compost pile.  The greenhouse is full of lush tomato plants and the garden, watered from a well, is thriving. (see photos.)
When we arrived back at the clinic, there was a long line of mothers and children waiting for me.  Luis stood in the middle of the group and made a speech that made a huge difference for the day.  I should preface this by saying that because most people here have little or no access to health providers, their history always includes every present or past illness or injury in their lives.  A common history goes something like this: “ My son has a terrible cough and is so hot and has no interest in food, he’s so skinny and the doctor gave him some medicine when he was in the hospital and it helped him a little but I couldn’t fill the prescription as I had no money and then the infection came back and his rash is worse and it itches him so much and in school he has a terrible headache at school and is so dizzy and has failed two grades and the worms are making him throw up. I think he needs some vitamins and his legs hurt at night and he’s really coughing so much phlegm. I’m so worried because he was born too early.”  After many questions and side tracks, it might turn out that the boy was a month premature, setting up the mother’s worries, he perhaps had pneumonia two years ago, hence the history of medicine at the hospital and the discharge prescription she couldn’t fill.  He likely has worms, chronically, but that’s not really today’s complaint; mom just wants to be sure to get the antiparasitics she hopes I have.  Many of the kids here and at home have leg pains consistent with “growing pains;” pain only at rest and full out activity all day.  Finally, further questioning about the school issues revealed that the parents had taken him out of school for a couple of years to help at home and now he’s behind and embarrassed to be in a lower grade.  The point is that it takes a tremendous amount of time to sort through all of the history, reducing the number of patients that can be seen that day.  So Luis’ speech was about trying to be concise.  He began by saying that we would be working straight through without a lunch break until 4:00 but would then have to leave for San Marcos.  In order to see all of the patients, he asked that everyone please decide on just one or two problems and not ask about everything they could think of.  He did a wonderful job making his point without causing offense.  He was hopping around pointing to his toe and heel, his elbow, the back of his neck, pulling up his shirt to show his belly button, all to demonstrate a person finding 15 things to have the doctor check. He then shook his finger in the classic Latin American gesture for “No,” and indicated a person giving a small cough and then touching his forehead to indicate a headache.  There were smiles and laughs from the crowd, and they got it.  In general, the parents I saw today focused much more on the current illness and on one or two complaints.
Most of the kids today were relatively healthy compared to those in Tacaná and Sibinal.  The jungle climate makes for an easier life and a bit more food.  I saw a one year old girl who may have an immune deficiency or perhaps just bad luck.  She was hospitalized shortly after birth with pneumonia and has had two more three week hospital admissions since then for respiratory illnesses requiring IV antibiotics.  She’s thin and pale and behind in her development.  I don’t think she has any real developmental issues in that her neurological exam is normal and she seems bright and appropriately interactive, rather I think she’s delayed due to illness and time spent tied down to IVs.  The current problem is that the mother can’t afford milk or formula for the child.  She’s feeding her watered down juice from oranges stolen from a nearby plantation, and tortilla water, but the child isn’t gaining weight. ( Hmmmm… guess not.)  I Spoke to Luis and Políclinica, through Shuarhands will cover the cost of Encaparina,, a milk and grain based formula used here for the next three months and then reassess.  
Unlike the clinics in Tacaná, Sibinal and even Por Venir where we were dressed in layers and I was shivering, here in Malacatán we are all hot and sweating.  Since there is a very nice bathroom here we are trying to stay hydrated as we race through the patients.  At around two, Luis brought us each a bag of snacks based on what he thought we would like.  I got yogurt, and Savannah’s bag had Pepsi, two kinds of potato chips and some cookies.  I didn’t see what he brought Mary an Bette, but Savannah and I thought he got it just right for us. We packed up around 4:30 and drove back to San Marcos where it was quite a bit chillier.  We had dinner at our usual restaurant and Mary had a glass of the local beer, Gallo, Spanish for Rooster.  We all thought it was fitting since the roosters have been her alarm clock every morning this week.   While we were eating a man came to the table and Luis introduced him.  He owns the company where Luis purchased seeds for the garden project.  He is involved with the project I mentioned in an earlier blog where there are large plots of various vegetables planted along the highway and tended by master gardeners.  Once they are at their peak, representatives from all over Guatemala will be invited to come and learn from these masters about the vegetables and about cultivating them, and will take this knowledge back to their villages.  This man is the person who obtained the 10 slots for the villages of San Marcos, and Luis wills] choose who will come.  It’s amazing how everything has fallen into place.  I’m reminded one again of how important it is to have someone local, like Luis, withal of his connections and his commitment, for a project to succeed.  It may have been my idea to initiate the project and the fundraising, but without Luis, it would never have turned into what will become a life-changing agricultural project for multiple communities.  The credit for that goes to Luis and the teams of men and women who have grabbed this opportunity.  It’s hard for me to describe the mood of the people involved with the gardens.  When we visited the Nacimiento, grown men were leaning down to splash water into the air for the photographs.  They knew I would be sending the photos to possible donor and they wanted to be sure to show how “fresh and pure” the water was.  A week ago I was fretting about how to convince Luis to stop building new gardens and focus on sustainability while all this time he and his village teams have had a long term plan for the future all along.  A he explained it, the villagers have always been “campesinos,” they just haven’t had the means to buy seeds or the water to grow the crops for a long time.  Now that funds are available through the project, they know what needs to be done.
  After unloading the few leftover medications at the clinic and our luggage at the hotel, we took a quick tour through the town so Mary and Savannah could see the market and the ancient cathedral that sustained severe damage in the last earthquake. It will have to be demolished.  We stopped at the supermarket to get a price on the Encaparina; $100 will buy enough for three months, and then returned to the hotel to shower and head to bed.  Tomorrow we’ll leave for Guatemala City at about 8:30 with stops in Xela and Antigua, and then home on Sunday.

February 26th: Por Venir

It’s 4:30 am in Por Venir, roughly translated, “The Future” or “Going Forward.”  Mary and I are in one of two small rooms at the back of the Mayor’s house and Bette and Savannah are next door in the other.  Like many families in poor areas of the world, the Mayor, has built this separate wing onto his house to accommodate visitors and add a little income.  It’s not quite finished; only one of our four windows has glass, but the sturdy wooden door has a dead bolt and a twist lock, and the room is clean and has a private bath with a huge shower.  Of course there are electric wires going from the overhead light to the showerhead with the live ends dangling down around where the spray emerges.  We both decided to brush off the dust and pretend we were clean.  At four this morning, a clock somewhere bonged the hour.  It was stunningly loud; I felt like it vibrated my bed.  It seems the bonging was the rooster’s alarm clock as he immediately began a call and response with several roosters across the yard. The chief rooster lives just below our window, which I would close if there were glass.  There’s a curtain, but alas, it’s not soundproof.  Amazingly, Mary seems to be sleeping through this raucous serenade; either that or she’s putting on a good show.
We left Sibinal around 7:30 yesterday evening after managing to see most of the patients.  Luis had to set a time limit so that the drive back to San Marcos wouldn’t be in total darkness.  Before we left, the mayor gave an impassioned speech about how grateful they were that we had come, but then went on to describe how many people were still waiting to have their health needs addressed.  Luis then announced that he will be bringing a team of doctors and nurses from San Marcos in a few weeks to carry out another mission, and a general cheer went up.
 Having Mary along opened my eyes to another huge medical issue, that of the lack of care for the middle aged and elderly adults.  I have always known, intellectually, that adults have many more issues, but seeing Mary in action with the adults here has been a real education for me.  As in the US, children here are generally “healthy,” and I see them for acute problems layered on chronic malnutrition.  There are always a few with serious, untreated conditions, but they are in the minority.  The patients Mary is seeing, like the adults in her practice in Albany, have multiple chronic problems in addition to the acute infection or injury that may have initiated the visit.   There are two big differences between her patients at home and those here.  In Albany, she knows her patients and manages their chronic illnesses, monitoring medications and giving ongoing care.  Her patients usually don’t’ stop their medications for lack of ability to pay for them.  Here, the patients have had these same chronic illnesses, sometimes for decades, and though they may have seen a doctor at one time in the past, most have not been able to afford return visits.  Any medications they might have taken have been dropped long ago for lack of money to pay for them.  Now Mary is faced with the dilemma of deciding whom to treat with what, knowing she can provide only a week’s worth of most medications.  Her main is  on educating the patient and any accompanying family members so they at least understand their conditions and can choose their care rationally.  She also gives a lot of practical advice about lifestyle changes that won’t cost anything.  I’m once again so grateful I chose pediatrics!
We drove back to San Marcos last night, arriving around 9 pm.  We were all too tired to go out to dinner, so we made do with ramen noodles and cheese crackers.  I tried to load some photos, but the WIFI was so slow that I gave up after 5 and went to bed.  We left San Marcos at 7:00 yesterday morning and drove down to the jungle region for our final two days of clinics.  As we drove, the temperature rose and the vegetation changed to a lush green from the dry mountain pines of Sibinal.  For the first time since our arrival, we were all shedding our jackets and sweaters and rolling down the windows to let in the tropical air.  We arrived at the Mayor’s house in Por Venir at 8:00 am and were served eggs, beans and tortillas for breakfast in his kitchen.  The clinic was held in a large room attached to his home.  Two years ago Bette and Luis and I were here and I held a clinic in a woodshed.  Since then, the waiting area has been improved and two exam rooms have been partitioned off with curtains at the end.  A real bathroom with toilet paper, a sink and a toilet complete with seat had been installed.  Having a clean workable toilet available changes the entire clinic day.  In San Antonio, the only available bathroom is the one used by the school kids.  It’s a long walk down a steep outside staircase with no railing, across a courtyard to a small, dank cubbyhole with an inch of (?) water on the floor, no seat, no paper and a bucket to flush.  I generally avoid drinking all day when I go to San Antonio.
It was lovely being side by side with only a curtain separating us.  I ended up consulting Mary twice and when I needed Bette to interpret a couple of times, she could step over quickly and then return to Mary with little disruption.  There were only two minor issues with the setup.  The first was the noise from the waiting room.  Take eighty kids waiting, sometimes for hours, plus an equal number of adults, many elderly with poor hearing, add in a few dogs, and the noise level is comparable to a rock concert.  The second issue was privacy.  The kids, waiting and bored, not only peaked around the edges of the curtains but frequently walked right in and stood in the middle of the someone else’s exam, scratching at bug bites  and  taking in the scene.
For just one day in such a small place, I saw several kids with serious medical problems.  The first was a nine month old girl, the first born to a twenty year old mother.  The baby had been born at term and seemed vigorous and healthy for the first two months.  The mother then began to notice that her daughter was not developing like her friend’s babies and became worried.  She took her daughter to the government hospital when she was four months old and was told told that she was fine, but with continued lack of development, she was became increasingly worried and therefore brought her to our clinic.  The baby was obviously severely brain damaged with spasticity (abnormal muscle tone,) signs of hydrocephalus (water on the brain,) and apparent blindness.  She did not vocalize, couldn’t roll over, hold her head up or make purposeful movements.  I explained to the mom that the baby needed an evaluation with a specialist to determine the cause of her condition in order to be able to determine the future, but that the baby’s muscles were weak and that her vision was quite poor.  I didn’t want to take away all of her hope at once, but the truth is that this baby has some devastating neurological problem and is unlikely to ever develop beyond her current state.

Next I saw a delightful three year old girl who walked in with the classic gait of a child with untreated bilateral hip dislocation.  The mother’s concern was not the hips though she did comment that her daughter walked with a little “jump in her steps.”  Mom brought her because she was shorter that her classmates.  An exam confirmed the hip dislocations and I discussed the implications with Mom.  Luis will see about setting up an evaluation and I will search the internet to see if I can find one of the orthopedic groups that travel to Central America on volunteer missions.  After several more patients, another three year old girl was brought in this time for lower abdominal pain. I asked if the child had been complaining of pain on urination, and while the mother was saying no, the little girl was nodding, yes.  So I asked the child directly, and she began to nod again, but when her mother denied the symptom again, her little head went from nodding yes to shaking no.  After a few more questions, the mother remembered that the child had been born with a kidney infection and was in the hospital for two weeks.  She subsequntly has had two more infections, with high fever and hospitalization for IV antibiotics, the most recent being in November of last year.   This whole scenario is not unusual here.  The patient’s records stay with the doctor and it’s very difficult for patients to access them.  They are not given much information about their conditions or treatment and have little understanding of how their bodies work or are affected by illness.
Just to lighten the tone of this report, I saw a family of three little boys, six, three and nine months.  The three year old was a little rascal, dancing around, picking up my instruments and bottles of medicine, crawling under the table and generally creating chaos.  While I was examining the 9 month old on his mother’s lap, the three year old sidled up and gave his brother a big pinch on the cheek.  The mother didn’t react at all to the baby’s sudden shriek, so I pulled the boy’s hand off and told him not to pinch his brother.  He danced away, grabbed a sharp stick from the six year old and handed it to the baby who promptly put it in his mouth.  I removed the stick and the three year old pinched the baby’s leg while the six year old snatched back his stick.  The final event of this Three Stooges circus was the six year old handing the baby a piece of wire with a computer chip on one end and a small light bulb on the other.  The baby tried to stuff the whole thing in his mouth, and the mother finally noticed and casually pulled it out and handed it to the three year old. It will be a miracle if these boys survive to adulthood.
The final “interesting patient” was a four year old girl who limped in, partially supported by her mother.  She had an ace wrap around her left knee and looked pale and tired.  The story was that she had fallen while playing outside with other children the day before.  No adult had been present to witness the fall, but the child had come home crying and the mother had cleaned a small puncture wound on her knee and wrapped it up.  She had passed a restless night and then come in.  On examination, the child had a hot, red swollen knee, but the infection did not appear to involve the joint.  The main area of tenderness was actually higher, at the lower end of the femur.  I asked Mary to come over to confirm what I had concluded, that the child likely had a fracture of her lower femur along with her cellulitis.  I carefully explained the situation to the mother, that the child likely had a small fracture in the bone and she needed an x-ray to confirm it.  I gave her antibiotics, and the Mayor volunteered to drive her to the government hospital in Malacatán in the morning. I stressed the importance of not letting her walk  as she could fall and have a worse fracture.  The mother appeared to understand, but when I turned away to prepare the antibiotic, she lifted the child down from the table and set her on her feet.  I stopped and again told her the child should be carried, but she seemed bewildered, saying the child had walked in.  We had another long discussion and she did leave carrying the child.  I can only hope she will go for the x-ray.
I have one last patient story that is actually from Sibinal.  A mother brought in her six year old son and stated that his compañero was climbing.  I asked her to please repeat, and she did, but luckily for me began undoing the child’s belt and pointing in the general direction of his genitals.  With his pants down, I could see that he had an inguinal hernia, and his “compañero” had indeed climbed up into his groin where it didn’t belong.  I started explaining about hernias to the mother using the word “testículo,” but she looked so puzzled that I switched to compañero, a great word.
So we’re on our way to Malacatán, and the last clinic day.  I have one observation about a difference between kids at home and kids here.  None of the kids here object to having me look in their ears.  It’s often a big deal in the US, babies and toddlers hate having their ears checked and often have to be muscled through the exam.  Kids here often cry and some try to twist away from the stethoscope, but when it comes time for the otoscopic exam, they all sit right up and cooperate.  Very Weird!

February 25th: Second Day in Sibinal

Because of our extended lunch break yesterday, visiting gardens and greenhouses, we saw fewer patients than planned, 64 children and 53 adults.  The physicians who are reading this are probably aghast that we would consider these numbers low.  Mary’s comment of providing less than a Band-Aid sometimes feels uncomfortably true.  However, one of the house calls we made today was on a man in his 40’s who had suffered a stroke two years ago.  Although he had received acute care, the family had long ago run out of resources to continue seeing doctors or therapists or to buy medication for his high blood pressure.  He lives with his wife and four children and has no loss of speech or cognition.  After taking a history and finishing her exam, Mary gathered the patient, his wife and grown son and had a frank discussion about the likelihood of a second stroke unless his blood pressure was under better control.  We left him with aspirin and an antihypertensive and a list of lower cost medications.  At a minimum he will be able to continue the aspirin.  Mary made a real difference for this man and his family in that they now understand what happened to him and why taking the medication is important.  Before her visit all was a mystery.
 I think we touch many people in small ways on these trips.  This time, in response to an email sent out at my former practice, Northampton Area Pediatrics, and requests to friends, Mary and I took 75 pairs of reading and sunglasses with us.  Any patient who said they had trouble with vision and who didn’t have cataracts or some other problem that reading glasses wouldn’t fix, was sent to a local volunteer who had a local paper and a pile of glasses arranged by strength.  The patient would pick out some glasses and read or look at the letters, switching glasses until they found a pair that worked.  The exclamations of amazement coming from the “lenses corner” could be heard even above the chatter of the waiting children.  I gave out three pair to pre-teens who complained of trouble reading, and they were delighted.  I’m so grateful to those of you who donated your unused glasses.  It may have seemed a small thing, but it brought joy to the recipients.  I have some wonderful photos of young and old trying on and showing off their new glasses, so when I get to a useable WIFI, I’ll upload them to Picasa.
After another cold night, improved by the extra blankets but definitely not cozy, we were all up and ready to go by 5:30 when the trucks and cats set up their choruses.  Departure time wasn’t until 7:00am so I used the time to go through photos and work on Word documents for the Blog.    We stopped for breakfast at Marcos’ house and were surprised to find a big bowl of, wait for it, Fruit Loops on the table.  Obviously they were trying hard not to give us the same thing every day, but Fruit Loops??  There was a pitcher of hot milk to pour over them and we each had a big mug of Encaparina, a milkly wheat based cereal drink that is usually given to babies.  It tastes like milky cream of wheat – delicious actually.  Bette made sure to get a photo of Mary eating Fruit Loops to send to her boys as blackmail as they had been a forbidden food in the Rappazzo-Hall household.
Both Mary and I had some interesting patients today although interesting often translates into tragic when there are no resources to care for the patient.  A very sad example was a 19 year old young woman I saw who was completely healthy until two years ago.  Her parents carried her in and gently settled her in a chair and wrapped a blanket around her.  She was very thin and pale and trembling with pain.  Her father explained that she had been active and athletic when she began to develop pain in her legs.  They saw several doctors but received no diagnosis until six months ago when it became clear that she had rheumatoid arthritis.  She was treated briefly with prednisone, but the family couldn’t afford more visits or medication.  Now, she has severe arthritis with involvement of all of her joints.  Her hips and knees are frozen at 90 degrees, her hands are rigid, her jaw barely opens.  In the US there are now biological that are changing the lives of patients with severe arthritis, but here in Guatemala, for a patient living in poverty, there is nothing.  I brought Mary in and we ended up giving the girl Medrol.  Mary will see if she can obtain Methotrexate for her on a compassionate basis, but there is already much damage to the joints.
Next I saw a 17 year old boy who came in with his father.  He had been treated the year before for hypertension and “inflamed kidneys,” but had stopped visits and medication due to lack of money.  He was having headaches and fever
 And back pain, so he came in to be checked.  His blood pressure was very high and he had tenderness over his kidneys and pain on urination.  I again relied on Mary’s expertise and we discussed hypertension with the boy and his father – the reasons why he needed to stay on medication and continue follow up.  He left with medications for his hypertension and infection and I hope he will continue both.  The big problem here is that people who have chronic conditions, diabetes, hypertension, arthritis, who need medication for life, just can’t afford it.  They buy it for as long as they are able, and then they stop.  Food comes first, then shelter, clothing, and if there is anything left, maybe medicine.
Mid-afternoon, a comatose 17 year old girl was carried in by her frantic family members.  The jumbled story was that she was prone to some sort of “spells,” and a natural healer came to the house regularly to give her injections of vitamins.  She usually felt much better after these injections, and had received one the night before.  This morning, she “slept in,” and this afternoon, they couldn’t wake her.  She was completely unresponsive, even to deep pain, limp and floppy.  She was breathing and had her protective reflexes and the family was, of course very reluctant to take her to the hospital.  After some discussion, we agreed they could watch her for four hours and if she had not wakened they would take her to the hospital.  I assume she woke up as we heard no more.  I wish I know what was in that shot!
On a lighter note, there are a couple of very nice customs in Guatemala.  The first is (and I apologize if I’m repeating myself,) the youngest son in the family is charged with greeting each guest personally.  Each day when we come to Marcus’ home, the 8 year old son greets each of us with a handshake and “Buenos Días”, shyly but politely.  The second is that even very young toddlers are taught to greet people by coming over and bowing their heads.  Many times when a family entered the exam room, the mother would urge the two or three year old forward to bow a greeting to us.  They stay bowed and silent until their greeting is acknowledged.  It’s very sweet.
Two final stories and then I’m done:  I saw two brothers, 8 and 9 years old.  The history given by the mother was that they both had pain in their entire bodies all the time, weakness and fatigue, and yellow eyes since they were toddlers.  It was there every day, at rest or while active.  I examined them both carefully while they competed to see who could climb up and down from the exam table the fastest, who could slither off the table while I tried to listen to their hearts with the most finesse and who could jump the highest when I asked them to try.  They were both a bit chubby and though I looked very hard, I couldn’t find a speck of yellow in their eyes.  I had to tell their mother that despite their past history they looked healthy today, Great News!!  She left a bit disappointed.
Finally, I saw two kids today who complained of headaches and “burning eyes” when they were reading at school or doing homework.  They tried on various pairs of the donated reading glasses and picked their favorites. I have some great photos of them that I’ll post when I have WIFI.
That’s it for now. More tomorrow.

Feb 24: Sibinal Day One

Feb 24: Sibinal

I have a little catching up to do about our very long day in San Antonio (the village in Tacaná.  After leaving the school at 7:30, all of us except Luis thought we were headed for a restaurant and then our hotel.  What we didn’t know is that there are no restaurants in the wilds of rural Guatemala.  People don’t go out to eat as a social event, generally because no one has money to throw away on frivolities.  But another reason is that when you are living so close to the edge, food is seen as fuel, not as something to fulfill various sensory and emotional needs.  Where we might be looking forward to perusing a menu and choosing something that appeals to each of us, the local people would be thinking only of assuaging their hunger.  Of course they want their food to taste good and there is conversation at meals about the spiciness of the sauces and the great tortillas, but the extraneous things such as setting, choice and variety, that we count on to enhance our dining adventures, are not part of their experience.
All of this leads to where we actually ended up after our first clinic day, and particularly, after Mary’s first day.  I’m sure she was feeling some sense of relief, and certainly exhaustion, and was looking forward to relaxing over dinner.  The mood in the care was jocular and everyone was a discussion about large alcoholic beverages, and the values of gin versus tequila when Luis announced that we would be stopping to see a “sick man whose family was trying to decide whether to take him to the hospital,” i.e. we were going to do a house call.  As there was only one internist in the group, this meant that Mary was going to be doing a house call.  To her amazing credit, Mary did not reach over and bop Luis on the head, nor did she let loose with a string of Italian curses.  Instead, she said, “You’ve got to be kidding!” Of course, Luis was not kidding, and after another winding drive up and down dirt roads we arrived at the man’s house.  Mary, true old- fashioned full service physician who does house calls on her patients in Albany, put on her kindly, no non-sense doctor face and did a thorough history and physical on a middle aged man who turned out to have a viral infection.  When she was finished and we thought we would be on our way to the restaurant, Marcos, a young man who is the local director of the garden project, appeared from the back of the house and invited us to dinner.  It turns out the “restaurant” was right there and the patient was Marcos’ father, hence the house call.
Marcos’ wife and mother have been paid to provide our meals while we are in Sibinal.  In lieu of restaurants, families often run these “restaurants” in their kitchens and feed visitors.  They also provide meals for single young men who live in the village, usually in a single room without cooking facilities.  We all trailed after Marcos into the kitchen, Mary muttering about the wisdom of eating in the house where a sick person was lying on a mattress in the next room, germs swirling through the air, contagious family members making and serving the food.  We asked to wash our hands and were directed outside where we waited while Marcos’ wife hunted down a bowl filled with cool water.  Bette asked for soap, and after a longer wait, a bottle of liquid soap was produced.  Bette acted as “faucet,” pouring water over our hands as we took turns washing and shaking our hands “dry.”  Towels are not generally part of the hand washing experience here.  We then trouped back in, Mary having resigned herself to mouthfuls of virus along with her meal.  We sat at a long table where four mugs of hot water and a box of tea bags were waiting.  Bette’s mug had some extra protein, a floating fly, which she offered up for exchange, but none of us felt the need for insect sustenance so she got a new mug.  The dinner was delicious – huge plates of scrambled eggs, beans, Guatemalan tamales (no filling) and hot sauce.
After dinner we drove just two blocks to the hotel.  By Guatemalan standards it was quite comfortable and clean with plenty of hot water.  The main drawback besides the noise in the morning and the lack of WIFI is the lack of central heating – normal for Central America.  We were all very cold.  I slept in my clothes and added a few layers from my suitcase.  Mary woke periodically to add layers.  For tomorrow night, the manager promises more blankets.
So on to Tuesday, the first of two days in Sibinal.  The clinic was held in a large house and Mary and I each had a large upstairs room.  The local officials had everything organized so the patients moved in and out smoothly.  Savannah worked with me today, bagging medications and writing out directions in the basic Spanish she learned yesterday working with Mary and Bette.  She also gave out stickers and school supplies to the kids, both of which I was doing yesterday, making my work more efficient.  The patients in Sibinal were not as desperately poor as in Tacaná, though they are still classified as extremely poor.  There is only one health center for the whole municipality, a huge area with dozens of villages spread over many miles.  Families have no money for doctor visits or medications, and no transportation other than a few very old communal pick up trucks, so most have not had medical care for years if at all.  Mary took the brunt of this, seeing adults with untreated hypertension, diabetes, arthritis, heart disease and various other chronic diseases.  Layered on top of these were the basic deteriorations of hard fought aging.  All appointments were long and complex.
I saw many children with complaints of headache and stomach ache “for years.”  They all had normal exams and seemed to be thriving, but the mothers seemed truly concerned.  I also saw a four year old for “red face and runny nose when he’s angry,” and an eight year old boy for rapid heart beat only when he listens to the radio.  In the midst of these rather mundane patients, a thirteen year old girl was carried in by four men.  She was “unconscious” in their arms, carefully maneuvering her head and arms as they came through the narrow doorway to avoid a collision with the wall and then going limp again when the way was clear.  Following the men and their burden was a gaggle of her classmates, all in their white gym clothes.  Apparently the girl had been running in gym class and had collapsed on the turf.  She had been scooped up by the bystanders and carried to he exam room.  After a reassuring exam, I let her friends gather around and “observe her while she gradually “woke up,” and gave them the job of offering her small sips of Pepsi and wiping her face with a cool cloth until I rechecked her and let her go.  It was a high drama they all enjoyed and will remember.  Only the parents will suffer ill effects.
Just after my young fainter, a 14 year old boy was brought in by his concerned father.  The story was confusing, typical here as the history is never given chronologically.  A parent will begin by saying their six year old child had pneumonia but the treatment didn’t work as the child is coughing and has fever and also diarrhea.  After much questioning, coming at the problem from various angles, it will turn out that the child had pneumonia in infancy and recovered but still gets colds and coughs (the treatment didn’t work.) Starting yesterday, the child developed a cough and fever but has had diarrhea for a week.  Anyway, the father stated that he had four sons and this one had never had the same energy as the others and lately, whenever he exerted himself, his chest would hurt, his heart would race and he would feel faint.  The boy looked a little off color, and tired and was thin.
When I examined the boy, his heart rate was 42 and his oxygen saturation was 80%, both abnormally low.  Further questioning revealed that he had actually fainted several times with mild exertion.  The family is from a small village and didn’t have money to see a doctor nor a means of transportation. When they heard we were coming, they made the trek to Sibinal.  Mary and I saw the boy together and Luis will make arrangements for him to see a cardiologist.
We stopped for lunch and returned to Marcos’ house.  Lunch was veggies and chicken, tortillas and cheese and tea.  There is a very nice custom in Guatemala; the youngest son of the house greets each guest when they arrive.  Marcos’ son is eight and he performs this ritual without fail, an embarrassed little smile adorning his face.   After lunch we drove around Sibinal to see the gardens and greenhouses.  Though created only three months ago and not yet producing vegetables, they are thriving.  In one area, they have been able to bring water from the Nacimiento to the garden, and the growth is amazing.  Next to this garden is one that receives only rainfall, and the contrast is amazing.  We also saw a greenhouse with organic tomatoes.  Sheep are penned nearby and provide manure for a giant compost pile.
Because of our lunch excursion, we got back to the clinic late and ended up seeing only 64 children and 53 adults.  Wednesday will be a full day to try to see as many of the remaining patients as possible.  Dinner was at the house again, and I did the house calls, this time on the two children in the house.  Both had mild colds, adding their germs to the general atmosphere.  We returned to the hotel after dinner, and true to his word, the owner had provided large thick blankets for Mary and me.  Now if he could just put up a roadblock to keep the trucks away in the morning…..