Quirino Memorial Medical Center – Quezon City, Philippines 2nd Blog

Posted by Ricci Sylla, MD  (a third year OBGYN resident from Kaiser Permanente, Santa Clara while on a global health elective in Quezon City, Philippines at Quirino Memorial Medical Center).

Some major differences in the way medicine is practiced in the Philippines is due to the laws. The Philippine population is over 85% Roman Catholic, and abortion is illegal. Therefore, misoprostol, a very cost-effective and inexpensive medicine to treat postpartum hemorrhage, is extremely restricted because of its possible use as an abortifacient. In addition, carboprost was pulled from use a few years ago so only oxytocin and methergine are available along with carbetocene which is not available in the United States. It is unfortunate because the maternal mortality rate in the Philippines is approximately 260 per 100,000 deliveries, mostly due to postpartum hemorrhage. The Philippine Secretary of Health set a goal to decrease the mortality rate by 75% by 2015. However, it is unlikely that they will meet this goal. A large part of the problem is due to geography. Nations such as Russia and Nepal were able to decrease their maternal mortality rate by 84%. However, for a developing island nation, transportation may require and available boat and good weather. One of the residents mentioned that her mother died of hemorrhage after her delivery as it took over two hours for her to get a plane ride to a hospital.

Currently, Quirino Memorial Medical Center (QMMC) where I am doing my rotation is one of several hospitals in the Metro Manila area who are providing training to nurses, midwives, and doctors from the outlying islands in order to decrease the maternal mortality rate. There is a group from Palawan that is currently here. Their training sessions include two days of didactics then nine days of observing and delivering patients.

Resident life continue to fascinate me. At Kaiser Permanente Santa Clara, we use Spectralink phones to get in touch with each other. At QMMC, residents use their cell phones to contact each other at all times. Also, there are four residents chosen to be the chief during their year, and they rotate as chief three months at a time. For those three months, the chief lives in the hospital. They are here day and night at all hours. The only time they leave is to go to church, and that is only if the day is not too busy. In order to see their family, their families can visit them in the hospital. For laundry, there is a laundry service near the hospital. It is a grueling time though as chief, they get the choice to do any case that comes through. The chiefs are also thankful that they only do their term three months at a time as only a few years ago, there was just one chief chosen for the whole year.

For Philippine medical students, they start their clinical rotations during the fourth year of medical school. QMMC has rotating students from four local medical schools. They do a lot of jobs that technicians or nurses do in the U.S. For example, the med students take vital signs, learn to draw blood, and insert foley catheters. They are then responsible for walking the samples to the Pathology Department so they can be processed. For stat labs, they are also responsible for returning to Pathology to get the results and reporting back to the residents. In addition, there is only one electronic fetal monitoring machine (EFM) for all the patients. So patients get rotated next to the machine for monitoring during their labor. For further monitoring in between the times they are on the EFM machine, med students and residents listen to fetal heart tones with a stethoscope as the single hand-held Doppler is used in the triage area. The EFM machine does not have a working tocometer, so often med students have to do “labor watch” which means sitting next to a patient and charting frequency, length, and strength of contractions in order to assess if a patient requires augmentation.

 

Oxygen mask for baby

It is also interesting to note that in the U.S., I might quote treatment guidelines from the American Congress of Obstetrics and Gynecology. However, in the Philippines, guidelines from the World Health Organization are followed. Whereas fetal macrosomia would be 5000 grams in the U.S., 4000 grams would be enough to cause concern for possible shoulder dystocia. A great thing about the patient population here is that obesity rates are very low, and what the residents here might consider obese is quite mild to my eyes. I have also enjoyed the fact that at 5’ 3”, I tower over a lot of the patients and even a few of my fellow residents.

It has been impressive to watch the residents make diagnoses clinically rather than relying on tests which may or may not be available. I am not sure how well I can diagnose a breech presentation in a patient with an intact bag, though it is a daily occurrence here even in patients who are dilated only a centimeter. An interesting case came in the other night where a grand multiparous patient pregnant with her twelfth child came in completely dilated with an elbow sticking out in the vagina due to transverse presentation. She was taken straight to the operating room for a Cesarean section. Fortunately, her baby was a good weight and measured appropriately for a full term baby. This patient has had no menses over the past twelve or so years due to always being pregnant. Almost every pregnancy is dated by the last menstrual period which is often unreliable, so babies are diagnosed as either appropriate or small for gestational age.

The residents here are impressed that residents at Kaiser Permanente Northern California residency programs are given time to do international rotations. Though I miss little things such as disposable drapes, gowns, and booties, I have been thoroughly enjoying this amazing learning opportunity

 

Post Partum Ward

Quirino Memorial Medical Center – Quezon City, Philippines

Posted by Ricci Sylla, MD  (a thrid year OBGYN resident from Kaiser Permanente, Santa Clara while on a global health elective in Quezon City, Philippines at Quirino Memorial Medical Center).

Quirino Memorial Medical Center (QMMC) is a public hospital serving patients mostly from Quezon City. It is named after the second president of the Philippines. Over 70% of the patients are indigent. As a public hospital, several differences are immediately apparent from my experience at Kaiser Permanente Santa Clara. At Quirino, there are three triage beds separated by curtains. For patients admitted in labor, they go to the labor room which is a single room that can have up to 7 beds. For very busy days, patients may be sharing two people per bed. Patients’ families stay in the waiting area until delivery. Only 1 in 20 patients receive epidurals and those are usually the patients who bought an insurance plan through the government.

Health care in the Philippines is similar to the U.S. system where there is no nationalized health care system. Though this is a public hospital, patients are still required to pay a minimal amount for their care. For those patients who are unable to pay after their treatment and/or hospital stay, they go to a special ward. There are no beds in the ward, only chairs, and patients stay here until they are able to pay as they are not allowed to leave until their bill is paid. Patients can sometimes get their bills paid by petitioning a local politician or waiting until the social worker gets an outside donation so that they can go home.

Most of the patients labor quietly in their bed. Once they are at +2 station, they get transferred to the delivery room which contains three delivery beds next to each other. Every labor patient admitted pays

 for a delivery kit containing two sterile gloves (almost always size 7 only), one suture, three bottles of normal saline 500ml, a few sponges, and other small miscellaneous items like syringes. Because resources are limited, p

atients requiring operative delivery are all delivered with forceps. Vacuums are expensiveand expendable while forceps are reusable aft    er a quick autoclave. Multiparous patients are allowed to have a vaginal breech delivery depending on the clinical picture, but nulliparous patients get a Cesarean if they are found to have a breech presentation.

There are 27 Ob/Gyn residents at QMMC including four residents from Nepal who will return there after they finish their residency training. It has been very interesting to note the differences in the duty hours as there are no duty hour restrictions in the Philippines. I feel like I am experiencing residency as it used to be in the U.S. over fifteen years ago. All of the residents do a 24-hour call every three days, and residents cannot go home post-call until all the patients they took care of the day before have had their final disposition plans. For example, a patient who was admitted in the early morning who required a tumor debulking surgery got her case bumped for emergency cases so her surgery did not start until 5pm. The resident in charge of her case who was on-call the previous day and evening had to stay to do her case. So that resident did not go home until after 8pm on her post-call day, essentially working a 37-hour call day. Also, residents stay until the patients who require consults, such as from Pulmonology or Cardiology, receive their consultation. There is very little handoff for cases. It makes for great continuity of patient care though of course at the expense of resident quality of life. I look forward to working more shifts with the QMMC residents who demonstrate great temawork daily and I have appreciated how armly they have welcomed me into their fold

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Da Nang General Hospital and Da Nang Orthopedic and Rehabiliation Hospital – Da Nang Vietnam

Posted by Dhruv Verma, MD  (a third year Internal Medicine resident from Kaiser Permanente, San Francisco while on a global health elective in Da Nang, Vietnam at Da Nang General Hospital and Da Nang Orthopedic and Rehabilitation Hospital).

Da Nang General Hospital in Vietnam

Vietnamese (Tet) New Year

I landed in Da Nang on February 11^th 2013.  It was only days before I left for Vietnam did I find out that February 10^th was the Vietnamese New Year, the most popular holiday and festival in Vietnam. The New Year marks the arrival of spring and is based on the Lunar calendar and celebrated all across Southeast Asia.  I was expecting parades and a rowdy crowd however found the opposite. Most of the city shut down and people spent the whole week with their families drinking and eating at home. Most restaurants, bars, social hot spots were all shut down this week. Surprisingly, some hospitals were also closed. Patients actually preferred to be discharged and spent the week home with their families.  At the end of the week, patients came back and were re-admitted.

Vietnamese People

I was very fortunate to meet some of the nicest, warm, and kind souls out in Da Nang. First off one of the physicians took time away from the New Years celebrations, picked me up from the airport and took me straight to my hotel. The next day he picked me up from the hotel and gave me a tour of the hospital. In my first week I worked in the Emergency Room where I was fortunate to meet at least one person who spoke some English.  The next week I worked in the ICU where almost everyone spoke English. This is where I made some friendships that I know will last a lifetime. Almost every night I was invited to someone’s house for dinner. Almost every day after work someone would want to take me out around town and show me around.  There were countless house parties that I attended and I really felt like “part of the gang” out there with the ICU crew.

February 27^th, which was my last day in Vietnam, coincided with Vietnamese Doctor’s Day. Around 1pm, the hospital shut down and we ate food and had drinks in the main conference room. Nurses and other workers performed dances and sang songs praising doctors for their hard work and dedication to the people. And of course there was karaoke involved.

Medicine in Vietnam

After high school students, attend Medical College, which is 6 years. The first four years are lecture/theory based and are comparable to our first two years. The 5^th year is rotations and the 6^th year is equivalent to internship here. Student can attend medical college in any city they like but the majority of students attend colleges close to their hometown. After graduating from college students apply for jobs. Residency is optional if someone feels that they want additional training. It is mandatory that one only applies for a job in their hometown. For Example, someone from Da Nang, must apply for a job in the city of Da Nang even though they might have gone to a medical college in another city. Everyone works in the Emergency Room for the first 6 months, and it is here where the new physicians are evaluated and it is determined which specialty you will work with. Yes that is correct! The Director of the hospital decides which specialty you are fitted for. For example, one of the physicians in the ICU actually wanted to go into Orthopedic Surgery, however was placed in the ICU instead. If you disagree with the decision, you will have to work the Emergency Room for 6 more months (in addition to the 6 already required) and then “re-apply.” About 50% of the doctors I met, did not “choose” the specialty in which they worked.

Work in the Emergency Room (2/12/13 – 2/16/13)

Da Nang General Hospital, the biggest hospital in the city, is one that is not closed during the week of the Vietnamese New Year. Business is as usual in this hospital and the Emergency Room is quite busy.

The day after I landed I started work in the Emergency Room.  I worked here for the first week and my hours were 9am – 5pm. 6 days a week. Most of the patients I saw were trauma patients. Many Vietnamese people cannot afford cars and thus opt for “motors” (or scooters) instead and these scooter riders get into a lot of accidents. Over half of the patients admitted to the ED had intracranial hemorrhage as result of an accident.

Given the high volume (about 300 patients a day, with 5 doctors covering the ED) the ED works more like a triage unit. There was no time for procedures and initiation of much work up. Patients are quickly diagnosed and then the appropriate specialty is notified for admission.  In a patient with septic shock, Early Goal Directed Therapy will not be initiated and a central line will only be placed once a patient reaches the ICU. This transfer to the ICU could take up to 30 mins. If meningitis is suspected, the Emergency Medicine team will obtain a CT scan to rule out any intracranial pathology and the Neurology team will be notified to perform the Lumbar Puncture and admit the patient. Too many patients and not enough doctors, made it difficult to practice medicine in accordance with the standards that I have been accustomed to, but it was this challenge that made this rotation exhilarating and fun.

The ED also works as an urgent care clinic, especially during the week of Tet New Year, when most clinics are closed. Cases I saw varied drastically from Respiratory Distress to minor cuts and bruises, not unlike the Emergency Rooms here in the States.

Intensive Care Unit (2/17/13 – 2/24/13)

Next week was spent in the ICU which was the most exciting part my trip.  They have a 60 bed ICU/CCU with about 5 physicians on during the day and 2 on at night. The Junior Physicians were fresh out of medical school or were in their 2^nd or 3^rd year of practice and the Senior Physicians had been working in the ICU for 10+ years.  I was very impressed with all of the Junior Physicians. They spoke English well, were on top of the latest guidelines for the various disease processes, and were very comfortable with procedures and protocols (such has central line placement, intubations, and running Codes).

                    

On my first day on the job I performed my first two intubations and my first Ultrasound Free Subclavian Central Line.

The schedule in the ICU was also 9am – 5pm 6 days a week.

Most of the patients in the ICU were admitted for COPD. Because of the high rates of smoking and Tb, Vietnam has one of the highest rates of COPD in the world.  I also saw a lot of non-traumatic intracranial hemorrhage (due to aneurysm and hypertension).  Surprisingly there were lower rates of PE and DVT and higher rates of bleeds.

In my week in the ICU I performed 5 central lines, 3 LPs, and 2 intubations.

Orthopedics and Rehabilitation (2/25/13 – 2/27/13)

The Rehabilitation Hospital was one of the hospitals that was closed the week of Tet New Year, thus I did not work here until my last few days. I spent about 3 days here, mainly in the clinics, rehab facility, and one day in the OR.  I spent most of my time giving joint injections and learning the musculoskeletal exam, which was great because it was definitely something I needed work on. It was also great to see some ortho surgeries, which I had never seen before (mainly because my training is in Internal Medicine, and not surgery).

This hospital does not have a Rheumatology department thus, most arthropathies including Rheumatoid Arthritis and Gout are managed by the Orthopedics Department.

Presentations

I presented 4 power point presentations in my 17 days out there. For the ICU department I presented on septic shock and early goal directed therapy, Acute Respiratory Distress Syndrome, and The American Medical System. For the Orthopedic Department I presented on Rheumatoid Arthritis.

This was a once in a lifetime experience and I am very grateful to have had the opportunity to go out to Da Nang and work as a physician.

Indian Health Service – Fort Defiance, AZ – Navajo Nation

Posted by Sefanit Mekuria, MD (a  second year Pediatric MPH resident from Kaiser Permanente, Oakland while on a global health elective in Fort Defiance, Arizona a Navajo Nation with Indian Health Service).

MY IHS EXPERIENCE-  Navajo Nation

Pre-Trip Thoughts

Ever since I heard about the Indian Health Services in medical school I knew it was something that I wanted to be a part of.  I had always been interested in International Health and when I began to read more about the Health Disparities and depressed socio-economic condition within the Indian Reservation I knew that this would also be a place I would be interested in working.  I had been through Navajo nation before and knew that it is filled with a vast amount of beautiful landscape, small towns/communities, and occasionally larger towns.  I had done more research about the Navajo Tribe once I had decided on my location for my trip.

Here is the data from 2000 Census:

• Navajo Tribe has 300,000+ declared members throughout the US (largest declared tribe in 2000 census) with 180.000+ living in Navajo Nation- 50% under the age of 5.
• The Navajo and Hopi reservations encompass an area of about 15000 sq miles (about the size of West Virginia) and is primarily in Arizona and New Mexico, but also  goes into Southern Utah and Colorado
• Many reservation-based patients will travel over 100 miles round trip for clinic and being 50 miles from nearest paved road still not unusual
• Many improvements in reservation from 1990-2000
  • In 1990 only 50% of population had running water/indoor plumbing, but due to public works projects and housing shifts in 2000 about 80% had access to clean running water supplies
  • In 1990 only 20% had a telephone, but because of cell phones and housing regionalization many residents have access to telephone services
  • 33% of Navajo families and 28% of Hopi families live below the poverty line and up to 40% of families with minor child live in poverty
  • Population still with depressed socioeconomic condition, limited economic opportunity locally and almost 40% of Navajo tribe live off reservation
  • In 2000 census 64% of Navajos and 75% of Hopi over 25 had a high school diploma or equivalent- 15% increase over the decade, but only 7% Navajos and 11% Hopi have a bachelor’s degree of higher (national average 84% with HS diploma/equivalent and 27% with a bachelors or higher)

My First week (1/14-1/21)

So I finally landed in Albuquerque (the closest airport to Fort Defiance) and was excited to get going.  I was surprised how cold it was in Albuquerque (24 degrees).  Due to my delay and snow/ice on the roads during the night I stayed in Albuquerque and then drove up early the next day.  The drive was beautiful- filled with red rocks covered in snow.  There were small towns scattered here and there with one larger town at the border (~30 miles from Fort Defiance).  I arrived at the hospital and was actually impressed with how new/large it is- built in 1999/2000.  The hospital is more like a community hospital.  It has everything you would expect a small hospital to have- ED, small Radiology department, inpatient (the pediatrics share the inpatient area with Medicine and surgery), Ob/Gyn, OR, nutrition services, health education, etc.  The one unique thing about this hospital is that it has an adolescent Care Unit for patients 13-17 with psychiatric disorder and/or substance abuse or dependence. Within this unit they do everything you would expect an inpatient psychiatric unit to do (psychiatric diagnosis and treatment, psychosocial testing, therapy, wellness activities, plus they incorporate Najavo cultural teachings, traditional culture activities, and Navajo healing interventions).  I’m hoping to work/be in this area for a couple of days or a week.  The Pediatric inpatient is small and due to respiratory season right now is mostly respiratory kids that need some small amount of support.  They also can deal with bread/butter peds- r/o sepsis, bili babies, and other stuff that aren’t high acuity. Specialty patients, patients needing higher acuity of care, or other services have to go to Albuquerque (3 hours away) or Phoenix (5 hours away)- but referrals can easily be put in.  Delivers here are run by midwives and ob/gyn (they can do C-sections and regular deliveries), so there is a well baby nursery.  If a baby needs more support they could be stabilized and transferred out.   If the mother is known to be high risk she will be flown out before delivery, if time permits.  The Pediatric Clinic runs more as an Urgent care and there is a separate Well child visits clinic.  They take appointments and walk in, so the clinic have the potential to see a lot of patients in 1 day- this is where I will be spending most of my time.  I got a quick orientation to the system (they use an EHR much like the VA system) and how the day will go.  If you are Navajo/Native in this region you get free services from the hospital.

After getting everything set up I was in the clinic seeing the pace of things, then off to the housing unit that they provided.  I was impressed with how they made a community out of volunteers, permanent staff, contract staff, families, and other employees that is right next to the hospital. The neighborhood essentially looks like a suburban subdivision.  The house that I’m staying is a 4 bedroom house with other roommates (2 nurses).  My room has the bare minimum (Bed, night stand, closet), but works perfectly for me.

On my first day I was shocked how cold it was (-18 degrees), but quickly walked the 5 minutes to the hospital (Fort Defiance has an elevation of 6000 feet, so gets pretty cold).  The next couple days warmed up to the single digits.  In clinic the patients can have an appointment or they can walk in.  Different doctors are assigned walk-in, appointments, well child visits (a different side of clinic) so there is no real continuity with patients.  Many physicians are there under short contracts for loan repayment and the few doctors that have been there for a while have some dedicated patients.  Patients check in and charts are brought back with vitals and there complaint.  You also get a sheet with immunizations record and if they are up to date.  Many people are up to date because they receive letters when they have shots due and can come in just for immunizations.  My first week in clinic was pretty busy.  For the most part I saw kids with flus, coughs, viruses.  Many tests are run in the lab pretty fast- such as rapid strep, RSV and flu.  If the lab does not run it they can send that test out.  There is a pertussis outbreak on the reservation with several of the nurses and doctors already requiring a couple of post exposure treatments this winter.  Whenever I saw the complaint as prolonged cough- I made sure to wear a mask, but sometimes it only comes out in the history.  Luckily none of the patients I tested had a positive pertussis.  There was a good amount of asthma exacerbation from Viral URI that needed treatments in clinic.  Many people run out of their medications- several families wait until worsening symptoms due to distance and transportation.  Also, many people use wood burning stoves as the method for heating their home, which can make children’s coughs worse and asthma in worse control.

During my first week it became clear that the hospital staff were like family.  Everyone lives in the community and they often have gatherings.  I was invited to several pot-lucks some with the nurses and some with a lot of the staff.  There is a Mesh of people here.  Some of the workers are locals who came back to work, some from all over the country and few even from different parts of the world just working here- either under contract, doing loan repayment, or permanent.  Everyone is very friendly and welcoming.  I also learned of the small gym within the hospital, which I’m going to try to go every day.  I met a student from Dartmouth and we went the nearest larger town Gallup- about 40 minutes away.  We did some grocery shopping and had lunch.  Over the weekend I also got a chance to go to Canyon de Chelly- a national monument located within Navajo Nation.  It has some of the ancient Native Americans ruins within the vast made of red rocks.  Driving there I got to see part of the vast Navajo nation.  I ran into several locals on the canyon who were selling handmade pottery- one women had her families story written in Navajo- she lived in a Hogan in the canyon, which is where she makes her pottery.

Week 2 (1/21/13-1/27/13)

The week started off pretty busy.  There were some emergencies and illness, so a couple of the pediatricians were away.  I worked in the walk-in clinic again and saw many patients through the day.  In clinic we saw mostly flu like illness again.  Some had asthma attacks because of this, some needed fluids.  I have also seen a good amount of gastroenteritis in the clinic as well.  Even when the child is febrile or not feeling well the Navajo children are very cooperative and patient.  I’m impressed with them and their discipline.  I learned this week that Fort Defiance went to HMO services about 1.5 years ago, so they are no longer are run by the government, but it is still an IHS hospital.  Many natives have Medicaid and whatever is not covered the hospital will cover it.  If a family or individual does not qualify for Medicaid they will still get completely free services and medications from the hospital.  The hospital bills one base fee for all visits no matter what services, procedures, or labs were done during that visit.

Through my interactions with many families and other employees I have learned that many families on the reservation live in Hogans (traditional circular houses most of them are made of wood with a stove in the middle).  I also noticed many infants in a cradle board- a wood board that they swaddle their children on.

Week 3 1/28/13-2/3/13

The week again was busy with many people with cold/cough/flu.  I did get a chance to do a couple of well child checks.  During the 9mo, 12mo, 15mo, and 24m each child gets a fluoride varnishes, so I got to apply several varnishes during the visits.  The water in the community is also fluorinated, but many people do not drink the tap water.   Dental health is an issue in the reservation.  Many children have carries, decay, or silver caps.  One of the pediatricians told me they saw sliver caps on a 9mo old.  During the week I did see one patient with a murmur that we wanted evaluated, so we referred to the Cardiologist (closest is in Flagstaff which is a 3 hour drive).  There was also one 2 week old baby in clinic for a newborn visit with seizures, but otherwise acting well in between these episodes.  Due to these we had to arrange helicopter transport to Albuquerque for further work up/management/neurology.  The clinic gets many children who come in for walk-in for physical for head start or other organizations.  During these or urgent care visits I often brought up healthy lifestyles.  There is an obesity problem on the reservation, so they do have a program for overweight children called fit families.  One of the Pediatricians runs this program, which is a 12 week program entailing nutrition education, active play, and cooking classes.  Transportation is a problem in the area so although they usually get a lot of kids enrolled; there is a large dropout rate.

Walking around the community I see many stray dogs.  Many families in the community will take in the strays and make them their pet, but there are so many still on the streets.  There have been several dog attacks in the community and one ER doctor told me that in the last 2 months 2 children have died from dog attacks.  I saw a teenager in clinic this week that had a large scar on his forehead that was from a dog attack when he was little.

I have also noticed driving around the community that there are several hitchhikers.  I was talking with one physician this week and he had told me several people have been hit while hitchhiking. You see people at night when it is pitch black on the side of the highways hitchhiking.  Sometimes they are partially in the road to get people’s attention, and the people hitchhiking maybe drunk.  When talking to the ER doctor they told me that the number one thing they see in the ER is conditions due to alcohol- drunk driving, other accidents, and people found down in the cold.  There is a large alcoholism problem on the reservation.

Week 4 2/5/13-2/7/13

I can’t believe how fast my time here has gone- It is already the end of my last week her on the reservation.  During my last week I got the chance work both in the clinic and the Adolescent Care Unit.   The clinic was very busy filled with cough/cold/flu/RSV again.  Several children did require admission for oxygen need.  The cut off for admission here is 90%- due to the elevation.  There was one teen that came in with a knee abscess after falling, which I I&D’d it.  I had gotten use to speaking English during my clinic visits, but one visit during my fourth week made me realize that I needed to make sure that everyone understood what was said.  I had a teenage patient complaining of a sore throat who had come in with his grandmother.  Most people on the reservation speak English, but some older people only speak Navajo.  I had talked with them, explained things, and asked if they had questions.  The teenager and Grandmother both said no, so I let them go.  Soon a nurse came to me and said the grandmother was complaining that she did not get any explanation for what was going on.  I was a little confused because I had explained everything, but soon the nurse told me she spoke Navajo.  I was so embarrassed and felt bad that I did not realize this.  The teenager was answering all the questions, as do many teenagers during their visits.  I immediately brought them back and got a translator to explain things.  After this visit I made sure to ensure that everyone understood what was explained to them.

Most of my week was spent in the Adolescent Care Unit.  In the Adolescent Care Unit I learned a lot about Navajo Culture and traditions.  The teens that are in treatment spend 2 weeks there mixed with inpatient treatment and traditional Navajo traditions.  You can tell the teens really enjoy learning more about their culture and find it comforting/healing.  For example, they do a blessing every morning in which they pray, sing, and burn herbs.  Once a week they do a tobacco ceremony in the Hogan, for mediation.  For the ceremony they wrap tobacco in corn husk and in doing this they are rolling their anger, regrets, or whatever they are feeling into the husk with the tobacco.  They then smoke away those thoughts.  It is suppose to help them with direction, identity and several other things depending on the tobacco.   They also do cultural teachings in the morning.  Along with these traditional teachings there are also group sessions focusing on several topics, such as anger and substance abuse.  There is also a family day when families also receive counseling and advice to help their teenager.  They have individual sessions as well with the counselor.

Each week there is also a Sweat Lodge, which I got the opportunity to participate in.  The Sweat Lodge takes about 3 hours and consists of 4 rounds.  The first round is introductions, the second round is Prayer for yourself, the third round is something you want to leave behind with the rocks- a negative way of thinking, something that has been bothering you whatever it is, and the fourth round is a positive thing for you.  After each round songs are sung.  You sit in a circle in a small circular hut around hot rocks.  With each round more rocks are added to the pit.  Once the door is closed it is pitch black in the lodge.  Water is thrown with a sage brush onto the rocks making the lodge hot and filled with steam after each person is done talking.  You can tell the girls really enjoy this.  There was something beautiful, soothing, and therapeutic about the steam from the rocks- almost like a release/cleanse of everything that may have been bothering these girls, their troubles, and what they were saying.

The next day I turned in my keys and drove back to Albuquerque for my flight to Oakland.  I can’t believe how fast my time on the reservation went.  I set out to learn more about the Navajo nation, the community, and the hospital and I feel that I have done that.  The clinic was really busy and I’m glad that I got the chance to work there/help out seeing all the patients.  I really like my experience and think that it would be a valuable experience for others.

PINCC: El Salvador and Peru

Posted by Tara Hulbert, MD  (a fourth year OBGYN resident from Kaiser Permanente, Oakland while on a global health elective in San Salvador, El Salvador and  Puno, Peru with Prevention International: No Cervical Cancer PINCC).

International healthcare carries many ethical challenges.  Seven guiding principles have been developed to address these challenges: mission, collaboration, education, service, teamwork, sustainability, and evaluation.

During my recent strip to El Salvador and Peru, I experienced the truly sustainable nature of Prevention International No Cervical Cancer (PINCC) and how this organization follows the seven guiding principles of international healthcare.  The mission of PINCC is to create sustainable programs that prevent cervical cancer by educating women, training medical personnel, equipping facilities in developing countries, utilizing proven, low cost, accessible technology methods.

What makes PINCC strong is their collaboration with each individual country’s ministry of health to establish a long-term collaboration.  This allows the healthcare professionals we train to be available for the weeks when PINCC comes.

My first week in San Salvador was spent working with healthcare professionals who had been trained by PINCC during several trips over the last 5 years. The goal of our education program during this visit was to help the already trained healthcare providers to teach other providers, the “trainees”, in the World Health Organization’s “See and Treat Method” of cervical cancer screening.  This is esentially a naked eye colposcopy where any lesions seen can be treated or followed up in the same visit.  In low resource settings when patients often have considerable challenges in getting to a clinic, this method can significantly reduce a women’s risk of getting cervical cancer with only one clinic visit.

Our group spent one day rehearsing how we would train the “trainers” with challenging clinical scenarios.  As a resident, I am an active trainer and trainee, which contributes to my understanding of the importance of  adequate teaching.  We observed approximately 20 “trainers” throughout the week assessing their ability to teach the trainees.   We gently guided them to ask their trainees clinical questions rather than give up the answer, have patience while the trainee struggled through the procedure, and knowing when to take over when it was clinically appropriate for the patient’s comfort or safety.

We had a great week and the ministry of health put on a ceremony at the end of the program. We certified five trainers and felt that the group was strong enough to continue the training process on their own, thus completing PINCC’s mission in El Salvador.  The plan is to continue checking in every 3-6 months with decision for another visit dependent on their progress and maintenence of the program.

PINCC’s program director and I then headed off to the mountains of Peru where we would meet another group of volunteers.  At an altidude of 12,000 feet,  I immediately felt short of breath and palpitations as my body acclimated.  After arrival, we met with the new group of volunteers and were greeted by our hosts.  This was PINCC’s initial visit to Puno so we all braced ourselves for a challenging week.  The first day we were greeted by over 40 excited students invested in women’s health and anxious to start the process of reducing cervical cancer in the area.  The students were  nurse midwives along with a few doctors from the surrounding areas.  We spent the first few hours going through the basics of cervical anatomy, the progression of cervical dysplasia, and the evidence behind and purpose of VIA (Visual Inspection with Acetic Acid).   The challenges of the week included altitude adjustment which was impossibleto ignore,  figuring out a way to teach a large amount of  students in an effective manner, and recruiting patients to screen!  Our hosts in Puno did a great job with advertisement and by the end of the week, we had over 100 patients waiting outside the door to be screened. At this point, we had found an efficient way to make sure all of our students learned what they needed to start the process of getting certified to perform VIA on their own.  We didn’t certify anyone that first week, but we developed the structure needed to come back later and continue the training. Our students inspired us with their tenacity and eagerness to learn.  It was clear they were truly dedicated to their community and patients.  This kept us motivated during the long work week and PINCC is very excited to start a longstanding program with the community.

Our week was full of great Peruvian food and friends.  We ended our week with a night out with the trainees singing Karaoke and a wonderful day trip on Lake Titicaca visiting the famous islands.

My second trip with PINCC proved to be more inspiring than the first.  I witnessed the full process of the training program from Puno where we met with brand new students to El Salvador where we finished the training program after PINCC visits for the last 5 years.

Mayan Medical Aid – Lake Atitilan – Santa Cruz, Guatemala

Posted by Harmony Schuttler, MD  (a second year OBGYN resident from Kaiser Permanente, San Francisco while on a global health elective in Santa Cruz, Guatemala with Mayan Medical Aid).

January 2013

The clinic I worked at in Santa Cruz, Guatemala, was the clinical center for several small pueblos in the mountains around Lake Atitilan whose population was comprised of indigenous Mayan people who, until the clinic opened 8 years ago, had no medical care. The clinic is at Santa Cruz three days a week and the other two days a week the providers of the clinic travel to smaller surrounding pueblos via small boats and/or by hiking into the mountains while carrying all their supplies in suitcases. The available diagnostic tests are very limited, with most tests needing to be sent to a larger city and taken by courier on a boat. The available antibiotics are purchased by the physician who started and runs the clinic every week in Antigua with his own funds and the money provided by rotating students and residents for their rotation.

More specific to my field, a large portion of the clinical volume of consists of prenatal care as most Mayan women in the area have their first baby before age 18 and most have >4-5 children in their lifetime. Contraception is available in variable forms, but there are multifactorial reasons that it is not often used including: cultural perception, extremely Catholic religious persuasion, misperceptions about contraception, lack of education, and lack of other roles/opportunities for women other than childbearing. The Mayan population has a different perception of time than most western countries, and patients often don’t present for care until well into their 2^nd or 3^rd trimester, and so dating is often inaccurate. Malnutrition is a very large issue for both adults and children. The area also used to be one of the highest in maternal and neonatal mortality given the majority of the births take place in the homes with the women either alone or with a midwife and there is little access to hospitals for complicated labor and or cesarean sections. Over the last few years the maternal morbidity has improved significantly, however neonatal mortality is still very high. The clinic providers are in the process of working with the midwives and the surrounding hospitals to help set up a system of triaging complicated pregnancies to hope to improve the neonatal morbidity.

Much of what I did was prenatal care and prenatal ultrasounds to help with dating. One of the most satisfying things I did during my rotation involved teaching providers at another clinic facility how to use their ultrasound and how to do basic prenatal ultrasound. The facility at the center of the county had a new, very modern ultrasound machine that was purchased by the Ministry of Health in 2010, however it was not being used when I arrived because none of the clinic staff, including doctors, nurses, and aides, knew how to work the machine. I put together a PowerPoint presentation on basic prenatal ultrasound including: establishing pregnancy, dating by crown rump length, estimating gestation in later pregnancy, fetal heart rate, and amniotic fluid index. With the help of the interpreter it was translated into Spanish. I then presented the PowerPoint to 20 healthcare providers at the clinic and spent over 6 hours doing “hands on” practice with the providers with pregnant women at the clinic that day. It was very gratifying to feel like I was providing something that might influence and help the patient population in the long term, beyond my limited time there.

Community for Children – Harlingen, Texas

Posted by Elizabeth Losada, MD (a third year Pediatric resident from Kaiser Permanente, Oakland while on a global health elective in Harlingen, Texas with Community for Children).

Week 4 – Community for Children
Our last week was a whirlwind of activity. I made a brief but fun and wonderful trip home over our third weekend. We hit the ground Monday morning with the ladies of ARISE South Tower. When we arrived, there was a large group of women participating in a crafts class. They were using magazines to cut out pictures to make collages. The theme of the collages was relationships, in particular the characteristics of healthy relationships. Themes of equality, good communication, and healthy boundaries were discussed.

Several women took breaks from their crafting to come and speak with us about health issues in their communities. At this point, we were getting much better at conducting our interviews. It was nice to realize how much my Spanish had improved, and also to recognize that we were much better at keeping the interviews on track by re-directing the discussions as needed.

One lady’s story was really striking. She had no health insurance and did not qualify for any government programs. In the past she had gone to Mexico for management of her diabetes. She’d had diabetes for about 12 years, and over the last several years her sugars had gotten increasingly out of control. However, with the escalation in border violence she was unable to get to Mexico to see a doctor or to buy medications there. Medications were too expensive in the U.S. She had been waiting months for an intake appointment at a local, low-income clinic. Meanwhile, her sugars were routinely above 300 and she was taking random diabetes pills that relatives sent from Mexico. She was starting to have visual changes and numbness in her hands. It seemed that likely her disease had progressed and she needed insulin to control her sugars. She desperately needed a clinic appointment. We both wished we could have done more to help her. All we could do was urge her to be persistent at following up with the clinic to get seen.

Another woman in the group then shared a very sad story of another women in the community who had died from uncontrolled diabetes in her 20′s, leaving behind a young daughter. She had routinely been getting hypoglycemic episodes during which her daughter would wake up in the night to check on her and find her unconscious. The little girl would then call 911 and the woman would be treated in the ED and released. One morning the girl woke up to find her mother dead. We were saddened and outraged by this story.

We left ARISE after the interviews so that we could get home and work on the many presentations we had to prepare as our rotation came to a close. That night I prepared a talk on dog bites and the problem of dangerous dogs in the community to give to the ladies in the health groups at ARISE. It was a bit of a challenge to prepare a Powerpoint presentation in Spanish, but I also felt accomplished that I was able to do it.

Over the next 2 days I gave my talk to two different groupos de salud. At both groups the talk inspired a lot of conversation among the ladies about the dangerous dogs in the community. We learned about a particular intersection at which children were threatened by menacing pitbulls while waiting for the school bus. One lady told a story of a neighbor’s pitbull jumping over the fence, killing her dog, and her fear that one of her children would be mauled next. Another talked of having to have a family dog put down after it bit her son several times. We handed out some resources for community and government organizations that could be of assistance with the removal of dangerous dogs and that offer low-cost spay and neuter services. We also presented the idea that the women involve their community PTA with helping to deal with the threatening dogs at the school bus stops.
Our project concluded rather ironically with a dangerous dog encounter. As we left the ARISE center for the last time, a pack of wild dogs was roaming the streets, growling at all of the dogs in nearby yards. These dogs were muscular—pitbulls, boxers, and a tiny Chihuahua bringing up the rear. For awhile we could not safely get to our car. A group of high school students on a mission trip were painting the center and wanted to go out and see the dogs. We warned them not to. These are not the type of dogs to play with.

The last 2 days of the week were spent wrapping up with the other CfC participants. On Thursday we had some lectures on global health and had a nice lunch hearing about the experiences of a PICU doctor who has done trips all over the world. On the last day we all gathered at Marsha and Mike’s home and gave presentations on our projects. It was really interesting to learn about what the others had been doing for 4 weeks. Their work ranged from teaching health classes to undocumented, unaccompanied minors in immigration detention to designing biking initiatives for the city of Brownsville. The scope of the projects illustrated how multifaceted community health truly is.

Afterwards, we all shared personal reflections on the experience. There was singing, poetry, and letters to government officials. We had all been deeply impacted by this experience and the wonderful people we met along the way. Despite the hardships, from the language barriers to the car accident, the work we did was some of the most inspiring that I have done during residency. It was amazing to be so welcomed into a community and to be able to learn so much about the lives of the women we worked with. Seeing such poverty within our own country gave us all perspective on how fortunate we are. There is still so much work to be done, and I hope to return someday.

Community for Children – Harlingen, Texas

Posted by Preeti Dave, MD (a third year Pediatric resident from Kaiser Permanente, Oakland while on a global health elective in Harlingen, Texas with Community for Children).

Week 4

The last week was a whirlwind. We wrapped up at the three ARISE sites and prepared to present our work. On Monday, we went back to ARISE South Tower and conducted more interviews. We also saw the women in the Clase de Salud work on collage projects to talk about good and bad relationships with significant others, family members, and other people. The interviews continued to go well, and we heard more about the dog problem we’ve been working on. Two mothers mentioned the same street corner having trouble with a local dog that was sometimes behind a fence and scaring children waiting for school, and other times loose on the street and scaring them. Elizabeth had prepared a talk on dog bites, so she gave them a handout with information on resources in the community. Maria, the animadora for the Clase de Salud, was kind enough to arrange a time for her or another volunteer to take around two of the medical students in CFC working on a project with the juvenile justice system. They wanted to tour “Little Mex”, which apparently is the colonia the South Tower site is located in. After leaving, we worked on completing data collection and creating the final presentation and abstract in the afternoon.
On Tuesday, we again visited the Las Milpas Clase de Salud, where a nurse was talking about diabetes. She had a great handout in Spanish on diabetes. Although I had a little quiz on diabetes to go over with the group, time was short, so we decided Elizabeth’s talk on dog bites would be more useful. The participants got so worked up about this issue. Many had a child that had been bitten by a dog, and Nasaria the animadora or coordinator of the class even told a story about being fined by animal control and her dog being quarantined after biting her son. Since it was the second bite, they didn’t go back for the dog, but she and her son were heartbroken to lose him. In the afternoon, Elizabeth went to her career development session with Cathy Monserrat, a psychologist and expert in the field, not to mention long time friend of the CFC course director Dr. Marsha Griffin. I tried to do some more work on the projects, as well as deal with our ongoing post-car accident saga. We had Marsha and Cathy over for dinner, which was really fun.
On Wednesday, after a little mishap where our car’s GPS took us down a dirt road to an empty field full of trash and a boat full of tires, we arrived at ARISE Muñiz, but there was no Clase de Salud scheduled, as they were wrapping up all the classes for the block until after the holidays. Esperanza had brought in some of the women from the class to talk with us, and so we chatted about diabetes and Elizabeth gave her dog bite talk, which she was getting really good at in Spanish.
In the middle, a group of high school students walked in, on a tour with one of the animadoras, who was explaining in Spanish that we’re pediatricians talking to a group of women about diabetes. There was some “lost in translation” with the student trying to explain to the rest of the group what was going on, as in the translation was, “well clearly they’re having some sort of meeting”, so I stepped in and gave a little background. They were from a Lutheran school in North Dakota down in the Rio Grande Valley to do missionary work, so today they were going to repaint the community center at Muñiz. We wrapped up with the women, and I even was able to talk briefly with Ramona, our go-to person from ARISE about our project and follow up on the car accident.
We met a very nice sociology doctoral candidate working on her thesis about immigrant women in the Rio Grande Valley. She too really appreciated ARISE’s status in the community. Women trust ARISE, so they’re more likely to talk to her for an interview if introduced by ARISE. We also have been repeatedly impressed by their leadership and community involvement. We didn’t have time to stay for lunch sadly, as there were still final projects to be done and my career development session. As we hurriedly left, I paused at the chain link fence between the yard outside the community center and the road. There were loose dogs. The dogs behind fences were barking at them, marking their territory. We paused, and the pack meandered down the street. They were a large pack of 6-8 muscular mean looking dogs, plus a Chihuahua. One of the high school students tried to call the Chihuahua, and we explained that there was no guarantee the dogs were vaccinated, and they could bite him. The students had seen a lot of dogs around in the few days they had been in the Rio Grande Valley, but hadn’t realized what an issue it was. Once the dogs passed, we got into our car and we felt a bit safer. Those dogs scare me. After my career development session (which was great, of course), I joined Elizabeth who was working on our projects again, as the days were counting down.
Thursday morning was our last Spanish class. The daily Spanish classes were done, and I was sad to see them end. Mark the teacher, and Marcela the assistant and Mexican society expert (she did her thesis on professional women in the lower classes of Mexico), have been great. I know I didn’t talk about them every week, but being able to focus on Spanish grammar, speaking, writing, and just chatting one hour a day was really helpful. After Spanish class, we had a few lectures from Dr. Minnette Son, a pediatric intensivist and co-creator of CFC. She talked about international medicine and her work abroad, followed by taking us out to lunch. Thursday afternoon was a combination of finishing work, going for “buy one get one free holiday Starbucks” as a group and creating a huge line because of our confusion, and trying to go to the gym one last time before meeting the rest of the group for dinner. Dinner was fun, we played “high-low” and talked about the highs and lows each of us experienced in the month. It was good to know that some things that bothered me also bothered other people. We didn’t always take time to reflect as a group during the month. We had gone to a chain restaurant with gluten free options so Elizabeth could eat, but dinner was a generalized disaster for all of us (I found a piece of plastic in my soup), and the restaurant ended up “comp-ing” us for all the food. We tried to tip on what the food would have been because some in the group had worked in food service before and felt the waitress shouldn’t be short-changed because of the kitchen. Thursday night was the generalized panic of packing and preparing for the last day.
Friday morning we didn’t have time to bring our luggage to class, so we decided to come back to the apartment afterwards. The last session was great. We all ate, presented our community advocacy projects, turned in abstracts, and presented our reflection pieces. I talked about how it was hard to conceive of families living on a single income of $30 per day, and the things one could buy with $30 a day. It was hard for us all to say goodbye, we had become a big family, and now just to go back to work (or to interviews for the fourth year medical students) was difficult. Elizabeth and I made our last trip to our apartment before heading to the airport, the last time we will likely be roommates in addition to co-workers and friends. As I sit on a plane back to Oakland, I am grateful for this opportunity I had to learn about the Texas-Mexico border, to meet and work with so many amazing people, including faculty, participants, everyone at ARISE, and everyone who opened their homes, clinics, and lives to us. It was better than I could have imagined.

Community for Children – Harlingen, Texas

Posted by Elizabeth Losada, MD (a third year Pediatric resident from Kaiser Permanente, Oakland while on a global health elective in Harlingen, Texas with Community for Children).

Week 3 – CfC

We started the week in Edinburgh with a grupo de salud at the ARISE center.  The ladies in the group ranged in age and were all mothers and grandmothers.  Just as had happened in past groups, the ladies started peppering us with questions about the health of their own children once they found out we were pediatricians.  For many of the mothers we have met, access to basic pediatric services is very lacking.  If their children were born in the United States, they qualify for programs like Medicaid and CHIP (A Texas program for children’s healthcare).  But if the children were not born in the U.S. and are undocumented, they do not qualify for these programs.  Many families are blended, with some children who were brought into the country by their parents and others who were born here.  In these families the mothers face a difficult situation in which some of their children can see a pediatrician and the others cannot.

As in the other groups, the women brought up multiple issues that impact the health of the children in their communities, including obesity, lack of exercise, and dangers in the streets – ie, dogs, gangs.  Challenges getting to grocery stores lead to poor access to produce and other healthier foods.   School lunches that include foods like chicken nuggets, pizza and nachos were also cited as barriers to health y eating.  This group was very talkative had gave us a lot of ideas for programs that could benefit their families, such as nutrition classes for elementary aged children, supervised after school exercise programs, and more efforts to get dangerous dogs out of the streets.

The following day was November 6, Election Day.  We drive out to Pharr, Texas to attend the grupo de salud and were greeted with a march to get out the vote at the ARISE center.  Dozens of women in yellow shirts, which read “mi voto=mi voz,” were marching the street, chanting, and carrying signs.  The media was there taking pictures and filming the march for the evening news here and in Mexico.  We were beckoned to join the march and walked with the ladies to the nearest polling station several blocks away.  It was so inspiring to see these women, some of whom are not even able to vote in this country, working to turn out their community.  From the honks of the cars driving by, it was clear the efforts were appreciated.

We left the vote early to go and meet with the grupo de salud.  There was a visiting nurse from a local university who was teaching the ladies about signs of diabetes to watch out for.  We chatted and did some interviews with some of the ladies about their health concerns for the community.  The energy that morning was very good as everyone was excited about the election.  After the grupo ended we headed back to the center to have lunch.

Unfortunately, our mood and luck were drastically changed on the way to lunch.  We had pulled up to park on the street near the center when our car was hit by an elderly man driving a large, old truck.  He was attempting to turn into his driveway, turned short, hit our car on the front left side, and ripped the bumper off our rental car.  Luckily, no one was hurt.  This set of a course of events that would take over the rest of the day and cause us to miss all of the election results and excitement.

The situation was very tense because the man was very angry, cursing in Spanish, saying he had no insurance, and refused to let us fully assess the damage to the cars.  Once the director of the center came out and started to speak with him, things went a bit more smoothly.  However, since we were in a rental car we needed to call the police and file insurance claims.  In the end the police came, cited the man, and re-attached the bumper to our car so that we could drive to the airport to get a new rental car.  Multiple people thanked us later for having the police come since the man had hit other cars outside the ARISE center in the past.

I think the accident caused both of us to hit a low point in the experience in Texas.  We were now emotionally exhausted, homesick, and feeling frustrated about the whole situation.  The next day we did not have any visits scheduled with ARISE and instead took a tour of several local pediatric practices.  Dr. Marsha Griffin, the head of our CfC program, works at a federally qualified health center in Brownsville.  The clinic was in a gorgeous new building that also housed multiple other medical specialties and supporting departments.  We met the clinic director, who has been involved in community activism for decades.  She gave us an overview of the clinic’s unique promotora program, which trains volunteers to do health outreach and promotion work within their own communities.  The model is very effective, as we have seen when working with the promotoras at ARISE.  Not only does it give community members access to health information and basic health maintenance (blood pressure checks, weight check, etc), but it also empowers the volunteers to become leaders in their own communities.  Later in the day we visited Harlingen Pediatric Associates, a private practice that sees a mix of privately and publically insured patients.  The clinic was very efficient and moved the patients in and out very quickly.  Everyone working there had a clear sense of their duties and worked together to keep everything flowing.  It was interesting to see a small independent practice since it is a model that is not very common in the Bay Area anymore.

We wrapped up the week by spending 2 days with a former state senator from El Paso, Eliot Shapleigh, and his wife, Joyce Feinberg, who had a long career with the Y doing AIDS work in Africa.  They were both very interesting people, and Eliot inspired all of us to get involved in public service.  He had a very good way of breaking down what needs to get done to make change politically – get a diverse group of people together in a room and get them to outline their vision for the future.  In the cases where he has seen it happen, people usually come to most of the same conclusions and can then work together to form a plan to accomplish the vision.  We also met with Dr. Rose Gowan, an Ob-Gyn in the community who got elected to the Brownsville City Commission.  She is using the experience she had in her clinic, while working with patient on obesity issues, to push for changes that will make the city more healthy – bike lanes, sidewalks, hiking trails.  It was nice to see how changes can be made on a local and state level to positively impact the lives of many people.  And it was good for us to end the week on such an inspirational note.

Community for Children – Harlingen, Texas

Posted by Preeti Dave, MD (a third year Pediatric resident from Kaiser Permanente, Oakland while on a global health elective in Harlingen, Texas with Community for Children).

Week 3

After the child abuse conference, we headed back to Harlingen to quickly hit the gym and pack up for the long drive to San Antonio for the weekend. We’ve been pretty good so far about going to the gym at least 3-4 times each week, Elizabeth of course a little more so than me. When we headed out on our long drive, it was definitely getting dark.  We had heard the drive was a bit treacherous, in part due to truck drivers that drove slowly and a little oddly. Overall, it was true, in part due to construction, and random left turns people could make across the highway that one had to watch out for. We wanted to keep working on our Spanish, so we had a Spanish language station on and tried to give each other directions in Spanish. We kept waiting for the border patrol check point to come on our path. I know it sounds strange, we’ve told you guys that we weren’t leaving the continental United States for this trip (and honestly we haven’t), but apparently a lot of the South Texas border is regarded as a fluid area. So the checkpoints are farther north, I guess to keep illegal immigrants in the Rio GrandeValley and from getting into the rest of Texas. Apparently that has been an issue, where an infant is airlifted to a medical center further north, and the parents can’t go to the hospital because they fear deportation at the border patrol check point. Anyways, back to the drive. The check point finally arrived. We jokingly decided it was fine Elizabeth forgot her passport in the apartment, if they were going to ask documents of anyone, it would be me. As we drove up, there was a large dog (we really can’t get away from dogs in Texas apparently), probably the drug sniffing kind. He had not interest in our car and was tugging strongly towards the car behind us. The agent just asked us if we were American citizens, and in our best American English (yes, we switched back to conversing in English and turned off the radio as we waited in line), we told him we are in fact citizens, and he let us continue onward.

The rest of the drive was not that exciting. It was dark, and we kept seeing dark shapes on the side of the road, which we couldn’t decide if there were that many tires or if some were armadillos. Along the way, we told each other stories in Spanish. It was actually fun, and we both stayed awake for the 4 hour drive. We stopped halfway in Corpus Christi, and decided there’s a little more ethnic diversity there. We arrived at the hotel in San Antonio pretty late at night, and were informed that the hotel was full, so the room they gave us was all we would get. The next day, we explored the city with Elizabeth’s friend from college. She took us to a farmer’s market. It satisfied our need for fresh vegetables and Elizabeth’s for some gluten-free items. It was also nearby a part of the river-walk that wasn’t so touristy. We went to a gluten-free bakery for brunch, which was also great, though we may have over-eaten. On the way to the Alamo, a bee stung Elizabeth (I’m telling you, the bees are crazy here). She got ice for her finger from a very nice shaved ice vendor. The Alamo was interesting, although clearly presenting a one-sided view of history. Next we saw a toursity part of the riverwalk and later went to dinner at an awesome place called The Cove. It’s part dive, part carwash, part laundromat, and part playground. The food was great, as me the vegetarian and the two gluten-free people had several options each. Sunday we headed back to Harlingen with the food we had collected.

Monday we started working on the subjunctive in Spanish class. It was a special request amongst many of us, and the Spanish teacher had noted we weren’t that good with using the subjunctive appropriately in our presentations. Afterwards, we went to the third site, ARISE Muñiz. We have been getting better at the interviewing and handling a group, although we’re still working on redirecting the group. Obesity and diabetes are big issues again. Main points seemed to be again the access to fresh vegetables without “chemicals”, lack of safety outdoors due to roaming dogs and cars driving too fast, and kids only wanting to eat certain foods.  Many of the participants have worked in or have family members that work in “labor”, meaning in the fields harvesting crops. They reported that they used to be able to take some of the harvest home to their families and some of it would appear in local markets. Now they could lose their jobs if they’re found with any of the crops, which are shipped off in large trucks. Also, the soil in the area isn’t good for growing a sustainable garden in their own yards; apparently the big farmers bring in special soil, etc to grow their crops. They also complained about paying what they thought were hospital bills for surgeries, etc, and years later having collections agencies after them for apparently unpaid hospital bills plus lots of interest. Many of them still trust having their medical care in Mexico when safe to cross the border to do so.

We went on a great home visit this morning as well. We interviewed a great-grandmother, and she told us about her family, and how they came to have the home they have now. Apparently they used to rent land, and pay exorbitant prices for the water and electricity bills to the owner. The family did not earn much as laborers, and it was hard to get ahead. One of her sons was deported for breaking a window, but at the time she couldn’t be watching him all the time because she always had to work in the fields with everyone else to feed the family. Recently, Proyecto Azteca, formed by local community groups, has helped them and many other families (about 35-60 homes per year on their website) own their own land and build their own homes. Señora Tere reported that they had helped them secure land with a low-interest loan, and helped with the building of the home, which seems to surpass code. The program sounds a lot like Habitat for Humanity for those familiar with that, in that the family helped build their own home. Now, she reports they pay less for their water bill and not much more for electricity despite now having air-conditioning. Proyecto Azteca even put a ramp up to the front door so that when Señora Tere is no longer able to walk, she can still gain access to her home. She even has an amazing oven to bake bread, grows some vegetables, and had gallos and gallinas (roosters and hens) running around the yard with a few well-behaved dogs keeping an eye on the proceedings. She even pointed out a few of the other homes in the area built by Proyecto Azteca. They are sturdy, built above ground likely to avoid flooding common in this area. Señora Tere was wearing a “Best Grandma” T-shirt, but had never known what it said until we translated it for her to Spanish.

Tuesday started out great. After Spanish class, we went to the Las Milpas site for ARISE, and found at least 50 people starting a march from the site down the street, replete with reporters from American and Mexican news channels, newspaper reporters, etc. Tuesday was election day as you may have guessed, and they were marching to remind people the importance of voting. We were supposed to find someone to direct us to the Salud class, but incorrectly assumed that it must be cancelled for the class. So when someone invited us to join the march, we did. It was empowering, they walked several blocks down to a polling station. Ramona, the coordinator of civic involvement, realized we were there, and told us that Nasaria and the rest of the ladies in the health group were waiting for us. So we headed back to that house from last week, and again met many of the same women again, this time with more direct questions for them. There was a nurse from UT PanAmerican (aka PanAm) that had been talking about diabetes to the group. So we skipped formalities since everyone else knew us, and started quickly interviewing people individually or in small groups. Most people reported similar information, that HEB or Junior’s was their access to fresh vegetables, if they didn’t have a car, a neighbor could take them since the public transportation system in the area is essentially nonexistent or at least not accessible or useful to most. There was discussion again about the dogs and drivers not heeding children, especially on the weekends.

We headed back to the Las Milpas site for lunch with the big group, and that’s when things took a turn for the worse. We parked across the street from the site, completely legally in the spot, when an 89 year old uninsured driver without his glasses decided to make a tight right turn in to his driveway and hit our front left bumper. But he didn’t stop. He just kept turning, and pulled the left side of our bumper out. He then parked in his driveway, and came out yelling at us as if it was our fault for existing. Ramona appeared, and helped mediate the situation. She calmly told him that he had hit at least 4 of their parked vehicles before, which he tried to deny. His stepson, however, confirmed he had been hitting parked vehicles, and was even followed recently by the police for weaving on the street. The Pharr Police came right away, found him at fault and issued him citations, but we still spent the rest of the day dealing with insurance companies and our car rental company, instead of working on our projects. We felt bad we couldn’t do home visits, but there was just so much to do (and still is). The only positive aspects of this incident is that hopefully this man will be off the road now that his license was taken away from him, which will prevent him from hitting a child and possibly killing them. Also, we saw a bit of McAllen on the way to the airport to trade in our car, including some grandiose mansions with mega security. Later we realized that we had both been bitten several times by bugs, likely mosquitos.

Wednesday through Friday we had various visits with all the participants of CFC. We visited Dr. Griffin’s office at BrownsvilleCommunityHealthCenter, a federally qualified health center, and learned about how it worked. It was a beautiful new building, but my cell phone service provider decided I was in Mexico and therefore roaming (again, I promise all of you we’ve stayed in the United States). We also visited a private pediatric clinic where Dr. Fisch works in Harlingen. It was good to hear about all the things people have to think about in terms of efficiency and economy when running their own practice. Thursday and Friday we met with Senator Eliot Shapleigh, former Texas state senator from El Paso, Texas, and his accomplished wife Joyce Feinberg. It was a great experience, and he really got into how a community works towards improvements in their health, such as giving people options other than the payday advance companies that charge 1150% interest on payday loans (yes, I did mean 1150%, or paying back more than $3400 for a $300 loan), how to start a medical school in the area and how that can help jobs and the economy, and overall how to address problems in the community. We went to another federally qualified health center, Su Clinica in Brownsville and met with Dr. Rose Gowen, an Ob/gyn there as well as Brownsville’s current city commissioner. She talked about her work, such as convincing the city bike lanes and sidewalks were needed and helpful to the community. We also crossed the border wall again (but were still in the United States). We went to a preserve called Sabal Palm Sanctuary and learned about the native plants and animals, as well as took a little walk. Thankfully that had free deet and deet-free bug spray to use. Thursday evening there was a dinner party with Senator Shapleigh and many like-minded people from the Brownsville Community. Friday we went to a meeting in Mercedes of several community groups working together to provide affordable housing amongst other issues. We saw Ramona and Esperanza from ARISE there! It was a great surprise. These past few days have been great to see how much people can do when they work together, and that it is a frustrating process many times, with special interests and bureaucracy obstructing the way to positive changes in the community. Elizabeth and I have been making calls these past few days, trying to catch up from the day lost on Tuesday. We’ve been gathering information from hospitals on dog bites seen in the local ERs and on laws and resources available in the community. We’re hoping it all comes together next week.