Jesuit walks

Isama II Classroom

The clinic saw 688 patients in house and an additional 340 out of clinic in the campo. Some of our more seriously ill patients received blood transfusions, nebulizer treatments with steroids, potent IV antibiotics, cat scans, and transfers to Santa Cruz hospitals. We visited 6 remote communities up to two hours by car from the clinic on roads that cross rivers and often see only oxen and motorcycles--roads that could realistically only be traveled on by Land Cruisers with competent drivers. This was all made possible by the Loyola Stritch School of Medicine's trip down here, which brought with it a small part of the additional funding the clinic really needs.

Erin Feller examining a boy from Los Carbones

The Loyola team constituted 7 first year med students, 1 second year med student, 1 emergency medicine attending, 1 family practice attending, 1 pediatrics and internal medicine attending, and 1 urogynecologist attending, and 1 Jesuit chaplain. The med students were sprightly youngings who adapted well to the chaos that is developing world medicine and were well supported by amazingly talented attendings with venerable amounts of experience in the field.

Fording the river with suitcases of meds on the roof

The mobile teams were coordinated with government workers from a local hospital. The health apparatus in these areas consists of a number of health posts manned by nurses and the occasional doctor. Their charge is vaccination, primary care and referral, emergency medical aid, and public health campaigns. It is underfunded, underperforming, and of inconsistent penetrence, mostly due to geography and lack of oversight of the health workers. Some post we attended at were well-stocked, clean, and showed evidence of successful public health interventions in communities, while others laid fallow, more or less a guise of medical care with clear signs of rot. Some communities we visited were beyond the reach of a post; these were far and away the communities suffering most from preventable, treatable diseases.

Scabies with Impetigo of a 3 year old in Isama II

One such community was our first, Isama II, a recently founded community encroaching the boundaries of Parque Nacional Amboro, that was overrun with scabies, lice, pica (kids eating dirt because they lack vitamins), impetigo, and bichos, or intestinal parasites (I think I may have scabies, and I have already had to de-worm myself once this trip). We went through almost our entire supply of treatment courses for these our first day in the communities and had to purchase even more from our pharm supplier. The town's water supply was a river 50 m from the center of the town. A few households have a car battery that they will use to light their homes a night, but other than that the town remains pre-Edison. Lack of running, potable water is one of the main roots of their maladies, resulting in poor hygiene, higher rate of re-infection, and malnutrition.

View from the water tower in Cheyu during el Dia de Cheyu and a public health fair

The village of Cheyu, the following day, was a clarion call for the importance of public health. Just kilometers down the river from Isama II, Cheyu had a wind-mill pumped water tower, a few solar panels to light the town at night, a poured concrete school, soccer/basketball court, cafeteria, and, greatest of all, a well kept, well stocked health post with a heroically dedicated, compassionate nurse. Hygiene and nutritional-related health problems were scant in comparison to Isama II. While there was some lice, most of the people who presented to us with primary care issues. Going through patients, we caught a significant amount of cases that needed follow-up or immediate intervention. As a way of example, a pregnant woman came into the clinic who was past her due date and with breach presentation of the baby. Dr. Fitzgerald suggested she be transferred. Rapidingo, caballingo, we were able to have her transferred to a hospital for a caesarean. Another elderly woman presented with an advanced

pterygium, or wing-like growth on the white of her eye that can worsen vision. We gave her Lindsay Lohan-esque sun glasses and referred her to some Cuban ophtamologists in Yapacani.

A healthy Bolivian family that is particularly beautiful

Voluntourism, a portmanteau of the words "volunteer" and "tourism", is a term that came up often while Loyola was here. The term has been used to market volunteer vacations, but also frequently been used with a pejorative tint, especially when used in medical mission settings. There is a wide array of literature of the subject, including sharp critiques of the field and how it potentially damages local efforts in the same camp.

Children striking a brushing pose for camera after Dental Hygiene presentation by the students

One of the standard arguments here is that the transient trip from the States, which is vastly better funded and better equipped, erodes interest, funding, and utilization of indigenous efforts. Local efforts are dwarfed by the ostentatious, once-a-year trip made by foreigners, which in turn stymies the growth of the local, sustainable, and potentially more efficacious work done indigenously. This sort of thing has been documented by the VSO, though exhaustive studies of the effects these trips have are still waiting.

Dr. Mary Pat Fitzgerald, the trail-blazing Urogynecologist who has done fistula repair in Niger and is a personal heroine

I understand this argument, but it really lacks teeth until you start getting into the tailoring of a trip to the needs and wants of the volunteers, and not the host community. Then, the argument goes, there is a not-so-subtle shift from commitment to helping the members of the host community that transforms them into pawns in a pious, manicured celebration of charity. Any volunteer, like any person, has right to protect themselves from harm while on these trips. Almost equally, though, volunteers on these trips must recognize that, by coming, they are engaged to helping these host communities. Medical treatment of this kind, like human rights, are not simply like old clothes that you give to the poor. If you go on one of these trips, you better be committed.

Dr. Tracy with Alicia Stapleton and Matt Egan and a family from Isama II

There are, of course, critiques of these critiques, which basically take aim at the fact that, in the zero-sum game that is simply living a day to day existence, people receive care that would otherwise go without it. It's a hard argument to follow and in a brutal way it's true. But without structural changes, things will remain the same, and someone will always be bound to another's wanton charity. These seem to be the valences within this discussion, and it doesn't seem right to sit at either end of them, but to use them as tools to evaluate how to improve such and such a program.

Healthy Mom with a Healthy Kid with a Healthy Hairstyle

The most disturbing sentiment I heard from people down here was that the communities we treat were "not poor enough". I'll let that comment speak for itself. I guess it's just an expectation, but it still makes my stomach turn.

Lauren Valbracht, Coordinadora la Exploradora (Como Dora)

Weeks before the Loyola group was down here, it was el Dia de Palacios. A live band with cumbia played well into the madrugada.

¡Bailando Brah!

May at CMHP: Chagas

Lauren, our previous coordinadora who we miss, and the Don Pepe.

Busy month. Clinic saw 448 patients. Multiple consults. A couple hospitalizations.

Many patients receive excellent care for chronic diseases in our clinic, such as diabetes and hypertension, but there are other illnesses for which we can provide only modest care. Foremost among them is Chagas disease, which I mentioned in a previous post below.

Two of our patients succumbed to the disease this month, dying from heart failure despite our best efforts to manage their condition, and another woman miscarried most likely due to complications from Chagas.

Chagas, like many diseases in the developing world, is a preventable disease. Though steps have been taken towards its prevention, with nets and insecticides, it remains an endemic, neglected disease without cure or even effective treatment. In South America, it is responsible for more deaths than malaria and many do not know that they have been infected until it is too late.

In public health, there is a metric known as the DALY, or the disability-adjusted life year. It is calculated by adding the "years of life lost" (YYL) and the "years lived with disability" (YLD) both other figures that measure premature mortality in a population. All this amounts to is essentially a fancy way of measuring how many healthy years of a person's life are lost due to disability or disease. Bolivia, the poorest country in South America, leads the world in DALY for Chagas, something that all too clear to us at CMHP, as by some estimates nearly 70% of the surrounding population that we treat is infected. Chagas disease has been recognized as a neglected disease by many global health organizations, and some have said that it is the most neglected of the neglected diseases.

Many of these infections occur because of poor infrastructure. The bug that spreads the disease (the vector) is called the vinchuca, or the more ominous sounding blood-sucking assassin bug, or the more innocuous sounding kissing bug in English. These bugs hide in the leaves of the motacú, which are used to construct many of the roofs here, and come out while the inhabitants are sleeping. They crawl onto the faces of the inhabitants to suck their blood and in doing so infect the sleeping person. This is the reason for their namesakes in English.

Recently I had the privilege of presenting a class on first aid, with the help of Dr. Macneil, an ER doctora volunteering down here, to the new group of community health leaders that are being trained here in clinic every Saturday. As the primary health resource for many of the surrounding villages, I thought basic first aid skills would be useful to them. The course covered how to treat shock, wounds, choking, drowning, and ended with a practice session in CPR. The following week splinting and emergency transport was covered. There was a short, very difficult pop quiz afterwards, which I sort of feel bad about because a couple people had trouble just reading it (that said, Bolivia's literacy rate on the books is pretty good). Afterwards, we briefly read a section of the following poem, with the idea that the best medicine is in prevention. I've included it below in its entirety as my way of celebrating getting into medical school, and because it speaks to the fact that the root cause for many of the diseases we treat are symptoms of larger social problems, such as poverty and inequality.

"A worker's speech to a doctor" by Bertolt Brecht

We know what makes us ill.

When we’re ill word says

You’re the one to make us well

For ten years, so we hear

You learned how to heal in elegant schools

Built at the people’s expense

And to get your knowledge

Dispensed a fortune

That means you can make us well.

Can you make us well?

When we visit you

Our clothes are ripped and torn

And you listen all over our naked body.

As to the cause of our illness

A glance at our rags would be more

Revealing. One and the same cause wears out

Our bodies and our clothes.

The pain in our shoulder comes

You say, from the damp; and this is also the cause

Of the patch on the apartment wall.

So tell us then:

Where does the damp come from?

Too much work and too little food

Make us weak and scrawny.

Your prescription says:

Put on more weight.

You might as well tell a fish

Go climb a tree

How much time can you give us?

We see: one carpet in your flat costs

The fees you take from

Five thousand consultations

You’ll no doubt protest

Your innocence. The damp patch

On the wall of our apartments

Tells the same story.

(thank you Amo)

Contributions to Chagas research here:

http://www.treatchagas.org/

Mother's day in Bolivia featuring skits about domestic abuse, patriotic songs to the mother's of the nation, and this awesome dance with one of the volunteers from the clinic:

Diversiones

Disclaimer: Unfortunately I do not have many pictures of the clinic to post, so I am posting pictures from recent travels away from the clinic. The next post will talk more about how things have been going sans pictures, which I will have to spend more time writing since the text won't have the pictures to use as a crutch.

Weird Fruit #14. Name forgotten. Eaten on a whim in Cochabamba.

Qechuan cholita gathering dry flowers. Cochabambino parque ruins picture from the upper left.

Hut people live in at +4000m. Llamas and rocks and dogs and grit.

Feeling the altitude on the 5200m ascent that we failed to climb. Began raining/hailing/snowing. ER doc becomes hypothermic and the lack of climatizing to altitude catches up with us.

Possible leishmaniasis ulcer that has been growing for the past six months on patient's right hand to be biopsied and treated. Diagnosed by the acclaimed ID specialist Dr. Johnson, former president of the Anaerobe Society.

http://www.anaerobe.org/

¡¡Quinceñero!!

Things were mellow at the clinic this week as there were no American volunteers down here. The clinic relied on a Bolivian doctor or two a day with a cut back to the number of patients that could be slated to come. Luckily it was May Day on Saturday and people were busy barbequing and we could close the clinic.

This is a picture of the new crop of community health volunteers that are being trained. It's a twelve week course held every Saturday at the clinic, except this last Saturday was May day and it got moved to Friday. In the background you can catch a glimpse of one of our patients who arrived to the clinic in DKA, or diabetic ketoacidosis, a potentially fatal complication of diabetes that she is seen receiving treatment for. One of the virtues of the clinic is ability to provide long term, meaningful care to people who would otherwise not have access. At the same time, acute cases can be managed at the clinic or can be transferred to hospitals nearby, like in Portachuelo. This patient was interned in Portachuelo for observation, treatment, and diabetes education.

Mumi's son Lalo turned fifteen, which is a big deal in Latin America, so they had a quinceñero party for him. Lorenzo enjoyed the cake.

The mayor, Bladimir, of the closest major town, Buena Vista, stopped by with a case of beer and a couple friends. The road to clinic was discussed as his alcaldia had recently had a tractor groom the dirt road to the clinic. He mentioned a French experiment during World War II with termite saliva to bind soil in passing and then it was generally agreed that the road should be fixed in the manner leading up to the nearby bridge, without which the clinic would truly be out of reach.

By the end of the night things had gotten a little out of hand, as this photo shows.

There was lots of dancing and in the morning we rode the horses back to the clinic at sun up to pick up two ER attendings that will be here for some weeks. They are great!

There will be blood transfusions

Another week of unpredictable work in Bolivia.

Last Tuesday night I received a phone call that a seventeen year old boy from one of our communities was involved in a very serious motorcycle accident that had resulted in serious brain injury. The health leader for a village called El Torno asked me to see if I could go and speak with the family about possible organ donation. Though I would have much preferred that someone else went to the hospital, my Spanish would enable me to communicate best with the patient’s family. I asked Micaela to come along because she has years of experience in the ICU and ER. Burak Gezen, who is a resident going into palliative care, counseled me on how to have that type of conversation and reminded me that the goal of such of talk is not to “get” the organs but to gain the family’s trust and confidence so that the family can make an informed decision on what their family member would have wanted.

We arrived at Hospital San Juan de Dios at eight at night with only the name of the patient—let’s call him Julio Choque Basala. It’s dirty, poorly lit, and muggy throughout the halls of the hospital. Micaela and I bounce from one ward to the next, wandering from room to room to see if we can find the poor kid with the traumatic brain injury. At this point I realize things are getting pretty heavy and also, for some reason, I’m reminded of a Cortazar story, La Noche Boca Arriba. After having checked in the ER, the neurology ward, the pre-op, I am ready to leave and chalk this up to misinformation. After all, this is a whisper down the lane situation and I’m not even sure we are at the right hospital or have the right name. Micaela doesn’t demur, however, and we end up outside of intensive care, ringing the bell every two minutes until someone appears behind the frosted glass door. I ask if a boy is being held inside by the name of Julio Choque Basala when a woman comes up to us in tears saying that this is her son. We get half the story from her and then half from the doctor caring for Julio. The prognosis is much better considering the severity of the crash and injury, and thankfully we can avoid the organ donation conversation for the moment. Instead, Micaela and I need to give blood for the surgery to manage the hematoma that is growing and pushing the brain across the midline of the skull.

In Bolivian medicine, any operation that is scheduled that may require a blood transfusion needs to have a sort of down payment of blood made by the patient’s friends or family. This more or less works as a quid pro quo for blood—one unit in, one unit out. For instance, the fact that I am A+ and the patient’s blood type was O+ makes no difference because there is no net loss to the blood bank. The next day we line up at around seven, after which they take us in and draw samples to test for blood-born infectious disease, primary among them in Bolivia being Chagas disease.

Chagas is caused by protozoa that invade the body and over the course of years enlarge the heart pathologically, often causing it to become overgrown and loose the ability to pump blood effectively. It also irritates the esophagus, which dilates to become a cavernous, atrophied trunk, inhibiting proper swallowing and absorption. The colon undergoes the same, causing constipation, cramping, and sometimes requiring interventional surgery. It is acquired by a bite by the kissing bug, which attacks mainly the lips and eyelids of sleeping animals. Despite knowledge of the disease process and it’s impact in South America, there is no cure for Chagas. Chagas is a disease of the poor and will likely remain without a cure for some time.

Luckily, Micaela and I do not have Chagas and were able donate for Diego. I filled up my bag in just under 4 minutes, which is not my best time but not bad. Micaela did quite well considering she usually faints when giving blood. She was even in good enough shape to throw a line in one of the volunteers who was need some IV meds once we got back to the house. By the time we leave the blood bank, we are a little faded and what little conversation we do have moves along like we are both day-dreaming out loud. Micaela asks me if I'm going to be writing the foundation newsletter report, (or some similar-sounding thing, I forget what it's called), and I respond with an "oh yeah I forgot about that thing." She mentions how we should include what we just did, that a dramatic presentation, one that includes phrases like, "gave blood in order to save the patient's life", is the type of story people like to hear. She's right, but I can't bring myself to write stuff like that.

The week at the clinic was busy despite a rain day on Friday. Thursday we made it out to a government health post with some of the doctors to see patients that are perhaps too delicate to make the trip to the clinic. One patient in particular had an advanced lesion on his hand that is could be a metasisis of his melanoma from a couple years ago, which has left a 3 cm open wound right between his eyes. I am working on getting surgery for him this week.

Other news:

Sharon, a social worker who comes down now and then dug up some old intake forms she was working on to try and stratify the aid that families are able to receive for procedures.

Dr. Marianne Tschoe, Burak Gezen, Jerry Lu, Michael Chan, Andrew Read, and Rachel Macorie saw around 60 patients this week with the help of Dr. Vargas. Micaela left for Port Au Prince for six weeks but will probably make it back down here for the Palacios village party. Ibania, one of the girls from Palacios who is now in med school, gave birth to her first child on Saturday night and there is now a baby in the house.

This is some of the fish Don Pepe caught with a beet salad, garlic aioli and pasta with sauce.

Your eminence, Burak.

Fade into Bolivian...with Centro Medico Humberto Parra

The following is a brief recap of a typical Saturday at the clinic. I'll be posting more pictures of our tooth brushing campaign with the local kids (really cute stuff) and other related public health shenanigans. Enjoy!

I have a really complex camera that I still do not know how to use so many of the pictures came out blurry or too dark. The real documentary stuff is done by pros that come down here, like Brenden Walsh aka "90210", who left last week and is dearly missed but who shot some really great stuff with the people down here and will be posting the video to be shown at the Global Health Initiative fundraiser in Chicago sometime in the coming months. While I'm learning to use this infernal camera please have patience with the quality of the images.

The night before we left for Palacios we decided to rotisserie chicken hearts marinated in port wine and soy sauce. They were delicious and accompanied by heartbreakingly bad puns.

The clinic attended over 60 people on Saturday, not including the number the dentist ended up seeing. They come by any means necessary, micro bus, packed hatch-backs with four people in the front seat, or motorcycle, typically with at least three people--though sometimes a small child or two seated on the gas tank.

They also come on horseback.

This Saturday was the second training session for the new wave of community health leaders, the majority of whom are women, with our senior nurse Maria Cespedes instructing the proper method of taking a blood pressure. There are no CVSs around the corner here so these community leaders will be the ones responsible for hypertension management in each of their own small villages.

Although we do utilize electronic medical records for many patient charts, a written registry of patients and which communities they come from is still the Bolivian gold standard in "real-time" analysis.

This is Rudy, the dentist. He is extremely nice and has a sick motorcycle that he rallies up to the clinic on each Saturday. He also is very thorough and creative. Once when attending patients at the government health post in La Arboleda because the road to the clinic was impassable he was seen pulling teeth out of a kid's mouth on a porch while some stray dogs lapped up the blood. Let's just say he brings the romance back to dentistry.

It's called lunche (okay, it's actually called almuerzo) and it's where we discuss whether agua con gas is more or less liable to explode after thawing and the likelihood ratio that the amazing pork we ate last Sunday will give us neurocysticercosis.

This is Mumi, who almost always is smiling or cracking jokes. Here she is preparing empanadas for patients and probably laughing about how I screamed like a little girl when I went fishing with her son Alek and thought a fish was biting my butt cheek. The notorious muerde-nalgas fish (g-translate that if you don´t speak Spanish).

Though changes in diet can vastly improve outcomes for patients with hypertension and diabetes, Marcelo, Mumi's son, merrily tends the skin frying in oil so it comes out with lush golden brown hues.

Sometimes you have to pick your battles.

The front desk at the clinic, with 15 year old volunteer Georgina at the helm. Burak and Andrew discuss a case.

Interpretation of the day's lab results with the patient.

Micaela gets smiley and sentimental and perhaps a little teary-eyed as she looks over her last patient's chart on her last clinic day at Centro Medico HP before returning to work in Haiti's Port Au Prince.

The clinic empties out for the day as patients board the micro for Yapacani. Many of the patients from the clinic speak Qechua as their first language and come from places whose names translate to "Viper field" and this is their only real access to medical care.

Alek and I being flojo before going out with the net to fish. By the way, fish head soup makes a very nutrition and complete breakfast.

Don't you worry about Blog, let me worry about blog.

I have since given up my post at Centro Medico. Entonces: here is my new blog: www.therealityinstitute.net

mike!