Guatemala 9/2014: the work

Apparently my pre-trip communication was a major fail, and many of you didn’t know I was leaving until I was packing.  This trip was six months in the making and was a follow-up to the trip we made last fall as a family.

The University of Colorado and Children’s Hospital Colorado have partnered with the Banasa banana plantation to improve the health of twelve small communities (a few would be big enough to call towns) in the south-west corner of Guatemala, near the border with Mexico. Banasa’s interest is mainly in the health of their workers, but the clinic is open to everyone in the community.  There are other national “health posts” in the area, but the nearest hospital is an hour or more away by car, depending on the rain, and most folks’ main mode of transportation is their feet.  Motorcycles are also popular, but it’s hard to ride on a motorcycle when you’re in labor…

So anyway, they built a clinic (staffed by a family physician and residents from Colorado; open since April) and a two-bed birth center (not yet open). They also have a community maternal-child health program that focuses on nutrition, child development, and prevention of maternal complications.  Currently, the community health workers drive out into the communities to find pregnant women by word of mouth. Then they provide free (individual) prenatal care, education, post-partum and newborn visits, and then group visits for moms and babies until age three.  Pam and I went to teach group care.

are we there yet?

A team of midwives and physicians has been working on the content for four visits, and then we worked with the community health workers to show how those visits could be interactive, instead of lecture-based.  The health workers jumped right in, quickly appreciating how group visits could streamline the huge amount of time they spend traveling back and forth between their communities.  Likewise, group care can ameliorate some of the isolation experienced by the women. But it will be a huge shift for this community, where women mostly stay at home– like really at home–  and few of them have phones to ease communication.

getting to know one another

The second day of our teaching,  Pam and I got to go out into some of the communities to make home visits.  We saw first-hand how much time the community health workers spend driving.  We had to make several stops to locate one woman who had moved.

We also made an unscheduled bathroom stop at the home of our colleague’s sister, where Pam got a tamale-making lesson.

On day three, the community health workers hosted a sample group for nine traditional birth attendants (TBAs). The health workers did an amazing job of making the group model their own. I was so impressed by their confidence, their professionalism, and their enthusiasm. That group had several goals: transparency (the patients for whom we care are attended during labor by these TBAs, and we want them to know we are not trying to supplant them); education (the only formal training the TBAs receive are periodic lectures from the Ministry of Health) and community building (the goal is for the birthing center to be an alternative and safer location for the TBAs to attend their patients).  While the group went really well, we discovered that every time our center has hosted them in the past, the TBAs have received gifts, which was their expectation and something for which we were not prepared. Despite that I think it went well, but we’ll see how many show up to the next teaching.

after our pilot group

driving the TBAs back to their communities

We spent time on day four discussing the cases we had visited on Wednesday.
a Pictionary-esque review of what we’ve learned together

Each of the women we visited were at major risk for some obstetrical complication, and our unpacking of that gave us hours of fruitful teaching.  In a tiny country where two women die every day from obstetrical complications, preventing maternal hemorrhage becomes invaluable.

simulating Leopold’s maneuvers on my make-shift pregnant abdomen

So, to sum up, I learned so much this trip. I have deep admiration for those who are there day-in and day-out, making this program work. It was a privilege to teach and learn and get to know these women.

Grateful: Home Safe

Hello, friends.  I’m home today and grateful for a really good trip.  I’ve so much to be grateful for:

:: for the five community health workers we had an opportunity to get to know

:: for their commitment to education and the health of their community

:: for laughter

:: for the gift of Spanish, which was indispensable this trip

:: for the tour bus of Salvadoran physicians who spontaneously gave us a ride to Antigua

:: for the kind couple who drove us from the bus station to our hotel

:: for Pam, whose company and partnership were such blessings

:: for Kim and Kelly, our house-mates, who are working there another week (and who humored my desire for game nights)

:: for the refrigerator that held the milk that Kelly made that made my morning tea work

:: for all the prayers that traveled with us (including those of a lovely prayer warrior sitting next to us on our plane down to Houston who had a pre-existing love for the people of Guatemala)

:: for all the love lavished on my family while I was away
More details to come, I promise!

Guatemala, Part 2

 
If you missed Part 1, you can find it here.

Sam’s goal for this trip was harder than mine: he was to explore possibilities for collaborative research and to work on his Spanish.  That required him to make connections with doctors in Guatemala, for which he was dependent on our contacts here.  But the timing of our trip was determined by my work and placed us in Guatemala during the holidays, so the person he was supposed to meet in the teaching hospital in Guatemala City was out of town. Strike one.

He rallied well, though, and was game to do some home visits with us, so on Wednesday, we went down the mountain to Chiquirines and began visiting Hilda’s list of kids with hard cases.  First up: a child with an infection on his face.  (This should have been right up Sam’s alley, right?)  One of the pediatricians who had visited a month prior had given the child an antibiotic which had improved the infection, so when we saw him, he was a three year-old with fistulas on his cheeks, just under his eyes, which were draining pus.  I have never seen this before. 

Turns out Sam had never seen it before either, which always makes me feel better (though it didn’t help his confidence any).  We took a history: at birth he had had blocked tear ducts [my diagnosis, not the mother’s], and at 18 months old, he had developed an infection in one eye, which lad led to the development of the fistula.  Six months later, the same had happened to the other eye.  We don’t see this in the states, because babies here with congenitally blocked tear ducts (a relatively common condition) are referred to ophthalmology and undergo stent placement, which prevents fistula formation.   So we explained that he needed to go to ophthalmology (which the mother had never heard of) and Hilda said she would come back with the referral information.

It was like this all day.  Case after case, often found in a house full of barefoot children and poultry, of children with bad complications of relatively simple conditions.  Congenital herpes infection.  Ocular herpes.  Blindness from a congenital cataract.  So many things I had only read about– or, in the case of the fistulas, that I had to reason out based on my knowledge of anatomy, since I had neither encountered it before nor read it.

We also visited the pediatrics ward at the regional hospital.  There was a child with a neck mass Hilda wanted us to see; he had been waiting at the hospital for 3 days to have a biopsy.  In the states, it would have been scheduled as an outpatient surgery, but that doesn’t happen there.  So he was walking around the pediatrics ward in his pants and robe, waiting.  We saw a child with a huge abdominal mass, and another with EBV.  Sam met the residents and the head of pediatrics and arranged to come back the next day to do some teaching.

On our way back to the coffee farm after our day of home visits, we had to stop at the mall for Marco (the doctor who will run the pediatric clinic when it opens) to get his wifi connection working.  While we were there, the other doctor “just happened” to run into a childhood friend (whom he hadn’t seen for thirty years) who is a local ophthalmologist.  Marco told his friend about the child with the fistula and the child with the ocular herpes.  His friend said he would be happy to see both children without charge if Marco sent them over.  It was this moment of pure grace that gave me hope for this project, and that reminded me that relationship are really what make everything work.

Sam spent the following morning rounding with the peds residents and teaching them.  This was medical relationship-building.  The more we can contribute to the quality of care and teaching at the hospital, the better care our patients will get when they are referred there, and the more likely they are to take our cases. (I do the same dance here, with how I build goodwill at the hospital so that they will take my uninsured patients.)  Sam did this all in Spanish, which was so good for him–he knows so much Spanish but really doesn’t get a chance to practice it.  That day was Spanish boot camp.  He and Marco brainstormed about the laboratory needs and capacity available locally.

When I look back at the trip, I feel frustrated with how much time we spent trying to get “so little” done.  The efficient part of me strains against the pace of international work.  I find myself apologizing to those who sent us to Guatemala with their prayers and financial support, because it was so much money to accomplish “so little” medically.  But this is how it is.  And the relationships we built with the Guatemalans doing this work every day– Marco and Hilda and Ada and Millie– are what will endure, and encourage them to keep going despite the weight of hopelessness that pervades in a setting of poverty.

Thoughts on Guatemala, Part 1

Let’s talk about our time in Guatemala, shall we?

This trip had so many facets– my work, Sam’s work, building bridges for future work, the kids’ experience, and our experience as a family– that I haven’t really known where to start the conversation.  But I think I’ll break it up just like this, and then we’ll see how the threads come together.

My job was to teach the postpartum exam and warning signs to two tecnicas (health outreach workers) and their supervisor.  It’s work I do myself all the time, so the material was intimately familiar.  Even in Spanish.  But I was preparing to teach an unknown audience, and that was hard.  I didn’t have a sense of their knowledge level or experience, and I found myself over thinking it.  The OB resident who was finishing her time there was reassuring, “You know this.  They’re nice. Don’t stress.” But I did anyway.

So after a weekend stressing, I taught for a morning. Of course the tecnicas wanted to learn, and I wanted to teach, so we had a lot of good will in the room.  It went well.  Then we moved on to home visits, which was the best part of my work.

Each home visit takes about an hour, with transport time in between.  The project serves about 3000 families so far (with an eventual goal of 25,000 families), with almost 200 women enrolled in the prenatal piece.  Almost 100 of those have delivered since the beginning, and we visited fourteen of them (and their babies) in three days.

Home visiting is so different from working in the clinic.  Granted, my being in one place means I can see three to four people per hour at the clinic.  It is efficient.  But visiting someone means you also see their neighbors, and their home.  Homes in this part of Guatemala are concrete block, with open concrete work (often in the geometric shapes like leaves) above the windows. The windows had metal shutters and sometimes screens, but I didn’t really see the point when the eaves and decorative concrete works let bugs in anyway.  The houses had metal doors to the outside, but most of the rooms inside the houses were without doors.  Some homes had beds; a few had hammocks instead so that one room could serve as living-, dining-, and bedroom all at the same time.  Because most of the cooking seemed to be  done over wood fires, the kitchen was always a separate area, even if it was only a space outside the back door.  Soot stained many walls.  In the more affluent houses, pigs, chickens, and turkeys wandered in and out.  Dogs with exposed ribs were present whether the house had a source of protein to eat or not.

The moms were very hesitant to let the babies get cold, so the shutters were often closed, and the babies were all wearing multiple layers and hats.  It was above ninety and very humid; all the adults were sweating freely.  Everyone looked so tired.  The schools are on vacation in Nov-Dec, so that the older children can help with the coffee harvest, so there were lots of younger children underfoot. 

So we’d come in, Ada would introduce us to the family (usually mom, baby, mother-in-law or mom’s mom, and a sister or two with her children) and Ada would explain why we were there.  We examined mom and baby, and then the real work began: helping to correct cultural norms which are dangerous.

Cross-cultural work is hard.  The goal is to slearn what we can, share our commonalities, appreciate our differences, and only change habits or customs that are dangerous.  I do the same thing in my office all the time (and in fact, many of the custom I see are the same).  So we didn’t point out that no one needs to be wrapped in a fleece blanket when it’s 90 degrees out.  Instead, we focused on the custom of giving babies water-with-honey instead of breast milk.  Feeding babies water (with or without honey) in the first months contributes greatly to rural Guatemala’s childhood malnourishment and is a frequent cause of diarrheal illness, which is a top killer of children under 5 in the developing world.  But it is firmly ingrained (in fact, all but one of the families we visited was practicing this custom) and hard to change.

The need was overwhelming.  One mother’s experience in the hospital was so bad that when she went home and her Cesarean section wound reopened, she didn’t go back to the hospital.  Instead, it healed on its own with a large hernia, which was incarcerated when I saw her.  As we traveled, Hilda collected a mental list of kids for Sam to see when we brought him down.  Hilda, the tecnicas’ supervisor, seemed to know everyone around and certainly knew how to help them access care, which she did with skill and sensitivity, but it was often too late to prevent serious complications.   I felt comfortable signing off, as it were, on Ada’s and Hilda’s skills with their patients, and the work they were doing.

I think that’s enough for today.  Next time: Sam’s work.  Thanks for supporting us.

We’re going to Guatemala!

Sam and I have been invited to work with a very exciting global health project.  The University of Colorado is starting a primary care clinic and maternal-child health project in rural Guatemala, and both our skill-sets are going to be useful.

Not only that (but wait, there’s more!), but we will be able to take our whole family, at least on this first trip.  We are hoping to hire a language teacher (Spanish) to work with the kids, and we are going to bring a friend’s homeschooled daughter to do nature study and geography with the kids in the afternoons.

The project is an answer to prayer not only for the people of this impoverished region of Guatemala, where the infant mortality rate is nearly five times ours, but also for our family.  We have prayed (thanks, Jen!) and waited for a global health project that would use Sam’s teaching gifts.  And my passion for maternal-child health.  And Sam’s research experience.  And our Spanish.   Not only all these things… but also, to be a place where we can return year after year to serve, both individually and as a family.

Of course I have no illusions that everything will be perfect (remind me to tell you about the giant pincer bug that bit me in the latrine in Haiti… or maybe that’s TMI?) or that the children are as enamored of the idea as we are.  Jonah asked, “Why would we want to leave the country?”  Exactly.  That’s why.

I want our children to see the more of the world than their little corner.  When I was growing up, we traveled a little.  When I saw Baskin Robbins in London, I thought, “How nice! There’s a Baskin Robbins in Boulder, and one in London.”  I had no idea how big the world was, or how rich my little corner was.  Our children have experienced some of the world’s size– and its connectedness– through our Sam’s and my trips to Honduras and Haiti and Thailand.  But it is very dear to my heart to let them learn culture and see its beauty through God’s eyes.  This is my prayer for them.

Already the trip is coming up fast– we leave November 14.  The children’s passports have arrived, and plane tickets have been purchased.  Thank you so much for your prayers: for language skills (esp for Sam), for the children (including our friend who will travel with us), for our fund-raising, and for safe travels.  I’ll keep you updated as we get closer.