We left El Salvador in April, nearly two months ago. I count myself fortunate to have worked in Estancia. I count myself blessed to have gone there with Calla. I thought Calla was my Elizabeth Bennett, but I discovered she is so much more to me. I learned so much from her and am so proud of her.
I spent the first night away from Estancia crying. I cried because I was sad to leave. I cried because the people in estancia could not leave.
Now, two months later, I find myself back in Rochester and preparing for fourth year, as if I had never left. Despite the fact that my experience was the most significant and enlightening time of my life, my daily activities have a way of distancing this experience from myself.
When I think about all the different work I did, there is one common theme that saturated my whole experience. Poverty. The dehumanizing effect of poverty is like a stain that cannot be washed off, only ignored.
I was only able to spend 8 months in Estancia because I received a generous stipend. Helping others is one of the most truly satisfying and rewarding ways to spend time. It saddens me that the poor are generally excluded from this experience. When Calla and I left Estancia, we gave away the majority of our things to friends as presents.
We were also given goodbye gifts, usually a bag of beans. In addition to our gift of beans, people often apologized for how meager their gift was. I was so touched by these gifts because I knew how little our friends had to offer, but I was also saddened by the apology. Even though these people had given much more of themselves in their gifts of beans than I had with my used clothing, they were the ones who felt shame because of the stain of poverty.
I did not feel any “culture shock” as I returned to the wealth and excessiveness of America. I was struck by how successful the wealthy are at hiding poverty from every aspect of their life.
As a wealthy person living in Estancia, I was always aware that I had ten bucks in my pocket, while my neighbors made about three dollars a day for seven people. At the very least I was forced to feel uncomfortable, and it compelled me to do what I could to help them.
I went to med school to help people, but it took going to El Salvador to make me feel like I was. As a doctor, every patient is an opportunity to help someone. My lesson from Estancia is that if I am not helping the poor, then I do nothing to wash away the stink of poverty.
-- Bela
Sunday, June 13, 2010
Tuesday, June 8, 2010
Photos
1. Sunset
2. His grandfather is kicking a soccer ball to him
3. Playing race cars
4. and 5. Neighbors
6. Making protein meal for malnutrition program (Siete Semillas--Seven Seeds)
7. Neighbors
8. Town corn-grinding mill, owned by women's coop
9. Carrying cornmeal to the mill
10. I can only make baby tortillas
11. Town band
12. Etelvina
Final Thoughts
Bela and I have returned back to the United States. We spent a total of eight months in Estancia, and the time flew by. Part of me cannot believe that we are already back home, and part of me feels like the time went too fast to even be real. It is almost as if we haven't even left yet.
Our last few weeks in Estancia were spent in a macroscopic version of a sign-out. Every volunteer from Doctors for Global Health becomes attached to specific patients, and these patients, over the years, have come to be known as "special patients." These patients typically have both complicated medical histories and difficult social circumstances, and it is a main job of volunteers to advocate for these patients both within the health system in El Salvador and in the local community. Leaving is particularly hard in terms of signing over the care of these patients. I think that I speak for both Bela and myself when I say that the goodbyes were emotional and difficult. Luckily, Juan Carlos and Etelvina are still tirelessly working in the clinic--seeing patients, providing psycho-social support, and accompanying patients to the hospital or to specialist appointments when they are able.
In addition to saying goodbye, many people wanted to share with us their stories from the war in El Salvador. I can only speculate about motivations for sharing with us during our departure. I imagine that it was easier for people to talk with us, knowing we were to be leaving for a period of time (although it is our promise to return to visit within the year). I also imagine that people feel a need to not be forgotten, as a story shared is a story that lives on. I also hope that Bela and I earned a level of trust over the time that we were there. We both believe that the community, after surviving the war, surviving extreme poverty, and working together to change the future, deserves a tremendous amount of respect. We tried to let people know that we respect them, respect their generosity towards us, and respect their incredible capabilities and talents.
However, the stories of the war were very difficult for me to listen to. People related incredible violence against themselves and their families. The histories were not related in a detached, emotionless way. Rather, it is apparent that the memories of the war are very clear, and very painful. Some things that were told were so awful that I had to try to calm my stomach in order not to vomit. Women endured rape. Children watched beheadings of their parents, and parents of their children. Hangings, shootings in the back of the head, torture of the elderly. War is not justice.
I had barely the amount of emotional strength needed to be able to listen to the stories. I am amazed and awed by the resiliency of the people of Estancia. To wake up every morning, to prepare food, to care for children, to farm, to endure day after day.
* * *
I also wanted to follow up on a few patients.
The man with anemia passed away two weeks ago. He was at home, comfortable according to his family, and surrounded by people who love him.
Following our trips to the hospital in December and January, he was able to be scheduled for an upper endoscopy, a procedure to look at the stomach to see if there is an ulcer or a cancer, in early February. The endoscopy was completely normal. Following the procedure I asked the gastroenterologist from San Miguel to please interview and examine the patient again, from scratch, as I was confused as to what could be his diagnosis. She spent about forty-five minutes with the patient, and then came out to speak with me, to clarify some parts of his history and share her thoughts.
She sat down to think. After awhile, she looked at me and said, “You know, I think he has kidney failure. It can look like so many other things, and would explain his severe anemia and mild congestive heart failure.” She agreed to admit him to the hospital in San Miguel to perform the necessary tests. After writing up a note and test recommendations, the physician had a long conversation with me about the clinical symptoms and signs of advanced kidney disease. As she talked, I thought about the patient, and all of things that I had assumed were not part of the main problem causing him to be so sick, and I reminded myself to read more about kidney failure.
Bela, Juan Carlos, and I spent the next month following up with tests, and accompanying the patient to outpatient appointments with the nephrologist in San Miguel. The trips were always difficult. Ramiro, the NGO director, would drive the patient and his oldest son (who was always at every appointment) up to the top of the hill and to Cacaopera, where we would catch a bus to Gotera. Once in Gotera, we would catch a bus to San Miguel, a trip of an hour and fifteen minutes. Once in San Miguel, we would take another bus from the terminal to the hospital, a trip of 20 minutes. At the end of the day we would make the trip in reverse, and the patient would be exhausted.
The nephrologist was a wonderful woman. She was very kind, and very respectful of the patient. On the day when she talked with the patient and his son about prognosis, she spent about forty minutes with us answering questions, and used simple language that the patient could understand. She explained at that visit that his options for treatment were limited to palliative care or dialysis. She encouraged the patient to have a family meeting to discuss options and goals. She made a follow-up appointment for three weeks later, and gave Bela and I her cell phone number, and told us to call if the family or we had any questions prior to that.
Before the leaving the office, the patient asked her, “Why did this happen.” The doctor pursed her lip, and said, “I’m sorry, I don’t know.” This answer did not satisfy the patient, and he repeated his question, and, after again receiving the same response, replied, “Well, you must have some ideas at least.” The doctor repeated that she didn’t know what had caused his kidney disease specifically, but she had seen a sharp increase in cases of kidney disease from the Morazán province. She explained that she was among a group of nephrologists who believe that it may have to do with the war. Morazán was heavily bombed during the war. In places like Estancia, bombs were dropped from airplanes almost daily for a number of years. A group in Mexico that studies environmental effects of war and conflict had tested some of the rivers in the area and found extraordinary levels of heavy metal contamination, and she explained that the lead levels were quite shocking. It is her concern that kidney failure might be an unrecognized long-term consequence of war. She then lowered her voice, “To me it is an injustice of the greatest magnitude.”
Following this discussion, there was a moving exchange between the patient, his son, and the nephrologist. The nephrologist displayed gratitude to the son for caring so well for his father, and to the patient for his service to the poor. The patient smiled. “I am poor. I am dirt poor. So these,” and he made a sweeping gesture in the direction of the waiting room, “are just my people. We look out for each other.”
We arrived back in Cacaopera after dark, long past the departure time of the latest bus in the evening. Ramiro came to pick us up, and we set up a time to come back and meet with the family. At the meeting, we tried to listen to everyone and answer questions. The patient seemed reluctant to attempt dialysis. His wife and son seemed to want him to try. We encouraged them to keep talking as a family. When we left, we told them that to us, whatever decision they came to as a family was the right decision. We explained that the patient had to choose what was best for him, and that it was Bela’s and my job to support that choice.
The follow-up appointment with the nephrologist occurred after Bela and I had returned to the States. We called the family the next day, and they told us that the patient had decided to not pursue dialysis. I asked to speak with the patient. I asked him how he was feeling. “Scared, but ok. I want to be at home, with my family.” I tried to validate his decision, but told him that he had the right to change his mind. “That’s funny,” he said, “The doctor said that too. She wants to see me in San Miguel every month to check up on me.”
Three weeks later, a few days before his next appointment, Victorino, the administrator of Campesinos para el Desarrollo Humano, left us a message in the afternoon. The patient had passed away in the morning. We called the family right away. Juan Carlos had arrived at the patient’s bedside in the morning, and had been very supportive of the family. The patient’s brothers had been notified and were traveling in from the coast. The son was stoic on the phone. “He knew it was going to happen. He called us together two days ago to say goodbye. He was very sleepy after that.” His wife was crying. “I miss him right now. I am so sad. But I am so glad that he is here with us, and that he didn’t die alone in a hospital.”
* * *
Following the death of the woman with congestive heart failure, Bela and I continued to visit the family. Her husband is a frail man, in his mid-eighties, and blind. He has an incredible sense of humor, and every time we visited had a new riddle or a joke for Bela.
The couple’s daughter lives in a neighborhood that is closer to Cacaopera, and, after a lot of family deliberation, it was determined that the man would go and live with them in their house.
He moved a week and a half before we left El Salvador. As we didn’t know that neighborhood very well, Abraham, the community health promoter for CDH, agreed to take us to the house. We had a wonderful visit with him and his family, and it broke my heart to say goodbye.
* * *
The woman who we took to the hospital with shortness of breath stayed there for a little over two weeks. When she was discharged, she went to stay at her daughter’s house in Cacaopera, to continue her medical treatment of antibiotic therapy for pneumonia (the tuberculosis tests that were done were negative). She returned to Estancia after that. Bela and I saw her about once a month, and ran into her grandchildren often. She is spry and funny, and very hard of hearing. Her grandchildren are very energetic and very polite, and it was always a pleasure to see them and chat.
* * *
What I learned:
Relationships matter. The relationship with Etelvina, the health promoter in charge of the clinic, was so important. I miss her terribly now that I am back in the States. She was fun to work with, and she is great mentor and teacher. She is in the community, of the community. She knows everyone, and keeps strict confidences. Seeing patients with her was enlightening and inspiring. I was able to sit with her in a visit from a woman with post-partum depression, in visits by farmers for physical therapy, do home visits with her, etc. etc. She is professional and kind, and is always trying to learn more about medicine and health care. Additionally, no patient care would be possible without the relationships. Working in such a tight-knit community made this so apparent.
Follow-up matters. I saw so many examples of this. We were lucky to be able to work closely with Abraham, the community health promoter. He was able to follow-up with many of our patients, and would report back how people were doing with medicines, or psycho-socially. If he thought someone was having a hard time with a certain treatment, or thought a certain treatment wasn’t working well, he would go with to see the patient again in their home, or bring the patient in to the clinic. Keeping in contact with the specialists in the public system was important as well, and helped our patients get the follow-up care they needed.
Palliative care matters. Over the course of our time in Estancia, three chronic patients passed away. All three patients wanted to die at home, and all three were able to do that. I believe that in two cases, the families were prepared for the deaths, and in once case, the family was less prepared. I think that Bela and I got better at having family discussions about care goals as the year went on. Etelvina is very good those conversations, and taught us a lot. Unfortunately, there is not much access to the kind of medical palliation available in the United States. I believe that better access to these treatments is necessary.
My happiness matters. Sometimes I needed a break. I love Estancia, and I love the work, but there were times when I was a little overwhelmed. I did the best work when I was happy. Our neighbors helped so much in this regard. After a long day, hanging out with them made me excited for the next day again. Swimming with them in the river on the weekends was relaxing, super fun, and helped me to not get burnt out. On particularly quiet days, Bela and I would take a break in the late afternoon to go for a walk, or to go buy freshly made semitas, a sweet cornbread, and sit and eat the bread and drink coffee while watching the sunset. I started running sometimes with a nine-year old (and extra-fast!) girl named Angelica. Sometimes her brothers or other neighborhood kids would come too, but she was always the fastest. And visiting families was always fun and a nice break from work. I think that we had a better experience because we made a little bit of time for ourselves.
Poverty matters. Poverty and illness go hand in hand. People who are poorer have less access to both curative and preventative health care. Poverty means no access to clean water, less environmental protection, less access to education, less nutritious food, more anemia, more malnutrition, more hunger (or, in the US, more obesity, but that is another story for another blog), more violence, etc. It is our duty to advocate for the poor, to change their situation. I don’t know the best way to do that, but I think all of us in medicine must try.
Coming home is harder than leaving. But this is something I learned before!
Thank you to my friends and family for supporting me during this year. Thank you to the University of Rochester and Doctors for Global Health for providing us with this opportunity. Thank you to the community of Estancia, for giving us the privilege and honor of working with you
--Calla
Bela and I have returned back to the United States. We spent a total of eight months in Estancia, and the time flew by. Part of me cannot believe that we are already back home, and part of me feels like the time went too fast to even be real. It is almost as if we haven't even left yet.
Our last few weeks in Estancia were spent in a macroscopic version of a sign-out. Every volunteer from Doctors for Global Health becomes attached to specific patients, and these patients, over the years, have come to be known as "special patients." These patients typically have both complicated medical histories and difficult social circumstances, and it is a main job of volunteers to advocate for these patients both within the health system in El Salvador and in the local community. Leaving is particularly hard in terms of signing over the care of these patients. I think that I speak for both Bela and myself when I say that the goodbyes were emotional and difficult. Luckily, Juan Carlos and Etelvina are still tirelessly working in the clinic--seeing patients, providing psycho-social support, and accompanying patients to the hospital or to specialist appointments when they are able.
In addition to saying goodbye, many people wanted to share with us their stories from the war in El Salvador. I can only speculate about motivations for sharing with us during our departure. I imagine that it was easier for people to talk with us, knowing we were to be leaving for a period of time (although it is our promise to return to visit within the year). I also imagine that people feel a need to not be forgotten, as a story shared is a story that lives on. I also hope that Bela and I earned a level of trust over the time that we were there. We both believe that the community, after surviving the war, surviving extreme poverty, and working together to change the future, deserves a tremendous amount of respect. We tried to let people know that we respect them, respect their generosity towards us, and respect their incredible capabilities and talents.
However, the stories of the war were very difficult for me to listen to. People related incredible violence against themselves and their families. The histories were not related in a detached, emotionless way. Rather, it is apparent that the memories of the war are very clear, and very painful. Some things that were told were so awful that I had to try to calm my stomach in order not to vomit. Women endured rape. Children watched beheadings of their parents, and parents of their children. Hangings, shootings in the back of the head, torture of the elderly. War is not justice.
I had barely the amount of emotional strength needed to be able to listen to the stories. I am amazed and awed by the resiliency of the people of Estancia. To wake up every morning, to prepare food, to care for children, to farm, to endure day after day.
* * *
I also wanted to follow up on a few patients.
The man with anemia passed away two weeks ago. He was at home, comfortable according to his family, and surrounded by people who love him.
Following our trips to the hospital in December and January, he was able to be scheduled for an upper endoscopy, a procedure to look at the stomach to see if there is an ulcer or a cancer, in early February. The endoscopy was completely normal. Following the procedure I asked the gastroenterologist from San Miguel to please interview and examine the patient again, from scratch, as I was confused as to what could be his diagnosis. She spent about forty-five minutes with the patient, and then came out to speak with me, to clarify some parts of his history and share her thoughts.
She sat down to think. After awhile, she looked at me and said, “You know, I think he has kidney failure. It can look like so many other things, and would explain his severe anemia and mild congestive heart failure.” She agreed to admit him to the hospital in San Miguel to perform the necessary tests. After writing up a note and test recommendations, the physician had a long conversation with me about the clinical symptoms and signs of advanced kidney disease. As she talked, I thought about the patient, and all of things that I had assumed were not part of the main problem causing him to be so sick, and I reminded myself to read more about kidney failure.
Bela, Juan Carlos, and I spent the next month following up with tests, and accompanying the patient to outpatient appointments with the nephrologist in San Miguel. The trips were always difficult. Ramiro, the NGO director, would drive the patient and his oldest son (who was always at every appointment) up to the top of the hill and to Cacaopera, where we would catch a bus to Gotera. Once in Gotera, we would catch a bus to San Miguel, a trip of an hour and fifteen minutes. Once in San Miguel, we would take another bus from the terminal to the hospital, a trip of 20 minutes. At the end of the day we would make the trip in reverse, and the patient would be exhausted.
The nephrologist was a wonderful woman. She was very kind, and very respectful of the patient. On the day when she talked with the patient and his son about prognosis, she spent about forty minutes with us answering questions, and used simple language that the patient could understand. She explained at that visit that his options for treatment were limited to palliative care or dialysis. She encouraged the patient to have a family meeting to discuss options and goals. She made a follow-up appointment for three weeks later, and gave Bela and I her cell phone number, and told us to call if the family or we had any questions prior to that.
Before the leaving the office, the patient asked her, “Why did this happen.” The doctor pursed her lip, and said, “I’m sorry, I don’t know.” This answer did not satisfy the patient, and he repeated his question, and, after again receiving the same response, replied, “Well, you must have some ideas at least.” The doctor repeated that she didn’t know what had caused his kidney disease specifically, but she had seen a sharp increase in cases of kidney disease from the Morazán province. She explained that she was among a group of nephrologists who believe that it may have to do with the war. Morazán was heavily bombed during the war. In places like Estancia, bombs were dropped from airplanes almost daily for a number of years. A group in Mexico that studies environmental effects of war and conflict had tested some of the rivers in the area and found extraordinary levels of heavy metal contamination, and she explained that the lead levels were quite shocking. It is her concern that kidney failure might be an unrecognized long-term consequence of war. She then lowered her voice, “To me it is an injustice of the greatest magnitude.”
Following this discussion, there was a moving exchange between the patient, his son, and the nephrologist. The nephrologist displayed gratitude to the son for caring so well for his father, and to the patient for his service to the poor. The patient smiled. “I am poor. I am dirt poor. So these,” and he made a sweeping gesture in the direction of the waiting room, “are just my people. We look out for each other.”
We arrived back in Cacaopera after dark, long past the departure time of the latest bus in the evening. Ramiro came to pick us up, and we set up a time to come back and meet with the family. At the meeting, we tried to listen to everyone and answer questions. The patient seemed reluctant to attempt dialysis. His wife and son seemed to want him to try. We encouraged them to keep talking as a family. When we left, we told them that to us, whatever decision they came to as a family was the right decision. We explained that the patient had to choose what was best for him, and that it was Bela’s and my job to support that choice.
The follow-up appointment with the nephrologist occurred after Bela and I had returned to the States. We called the family the next day, and they told us that the patient had decided to not pursue dialysis. I asked to speak with the patient. I asked him how he was feeling. “Scared, but ok. I want to be at home, with my family.” I tried to validate his decision, but told him that he had the right to change his mind. “That’s funny,” he said, “The doctor said that too. She wants to see me in San Miguel every month to check up on me.”
Three weeks later, a few days before his next appointment, Victorino, the administrator of Campesinos para el Desarrollo Humano, left us a message in the afternoon. The patient had passed away in the morning. We called the family right away. Juan Carlos had arrived at the patient’s bedside in the morning, and had been very supportive of the family. The patient’s brothers had been notified and were traveling in from the coast. The son was stoic on the phone. “He knew it was going to happen. He called us together two days ago to say goodbye. He was very sleepy after that.” His wife was crying. “I miss him right now. I am so sad. But I am so glad that he is here with us, and that he didn’t die alone in a hospital.”
* * *
Following the death of the woman with congestive heart failure, Bela and I continued to visit the family. Her husband is a frail man, in his mid-eighties, and blind. He has an incredible sense of humor, and every time we visited had a new riddle or a joke for Bela.
The couple’s daughter lives in a neighborhood that is closer to Cacaopera, and, after a lot of family deliberation, it was determined that the man would go and live with them in their house.
He moved a week and a half before we left El Salvador. As we didn’t know that neighborhood very well, Abraham, the community health promoter for CDH, agreed to take us to the house. We had a wonderful visit with him and his family, and it broke my heart to say goodbye.
* * *
The woman who we took to the hospital with shortness of breath stayed there for a little over two weeks. When she was discharged, she went to stay at her daughter’s house in Cacaopera, to continue her medical treatment of antibiotic therapy for pneumonia (the tuberculosis tests that were done were negative). She returned to Estancia after that. Bela and I saw her about once a month, and ran into her grandchildren often. She is spry and funny, and very hard of hearing. Her grandchildren are very energetic and very polite, and it was always a pleasure to see them and chat.
* * *
What I learned:
Relationships matter. The relationship with Etelvina, the health promoter in charge of the clinic, was so important. I miss her terribly now that I am back in the States. She was fun to work with, and she is great mentor and teacher. She is in the community, of the community. She knows everyone, and keeps strict confidences. Seeing patients with her was enlightening and inspiring. I was able to sit with her in a visit from a woman with post-partum depression, in visits by farmers for physical therapy, do home visits with her, etc. etc. She is professional and kind, and is always trying to learn more about medicine and health care. Additionally, no patient care would be possible without the relationships. Working in such a tight-knit community made this so apparent.
Follow-up matters. I saw so many examples of this. We were lucky to be able to work closely with Abraham, the community health promoter. He was able to follow-up with many of our patients, and would report back how people were doing with medicines, or psycho-socially. If he thought someone was having a hard time with a certain treatment, or thought a certain treatment wasn’t working well, he would go with to see the patient again in their home, or bring the patient in to the clinic. Keeping in contact with the specialists in the public system was important as well, and helped our patients get the follow-up care they needed.
Palliative care matters. Over the course of our time in Estancia, three chronic patients passed away. All three patients wanted to die at home, and all three were able to do that. I believe that in two cases, the families were prepared for the deaths, and in once case, the family was less prepared. I think that Bela and I got better at having family discussions about care goals as the year went on. Etelvina is very good those conversations, and taught us a lot. Unfortunately, there is not much access to the kind of medical palliation available in the United States. I believe that better access to these treatments is necessary.
My happiness matters. Sometimes I needed a break. I love Estancia, and I love the work, but there were times when I was a little overwhelmed. I did the best work when I was happy. Our neighbors helped so much in this regard. After a long day, hanging out with them made me excited for the next day again. Swimming with them in the river on the weekends was relaxing, super fun, and helped me to not get burnt out. On particularly quiet days, Bela and I would take a break in the late afternoon to go for a walk, or to go buy freshly made semitas, a sweet cornbread, and sit and eat the bread and drink coffee while watching the sunset. I started running sometimes with a nine-year old (and extra-fast!) girl named Angelica. Sometimes her brothers or other neighborhood kids would come too, but she was always the fastest. And visiting families was always fun and a nice break from work. I think that we had a better experience because we made a little bit of time for ourselves.
Poverty matters. Poverty and illness go hand in hand. People who are poorer have less access to both curative and preventative health care. Poverty means no access to clean water, less environmental protection, less access to education, less nutritious food, more anemia, more malnutrition, more hunger (or, in the US, more obesity, but that is another story for another blog), more violence, etc. It is our duty to advocate for the poor, to change their situation. I don’t know the best way to do that, but I think all of us in medicine must try.
Coming home is harder than leaving. But this is something I learned before!
Thank you to my friends and family for supporting me during this year. Thank you to the University of Rochester and Doctors for Global Health for providing us with this opportunity. Thank you to the community of Estancia, for giving us the privilege and honor of working with you
--Calla
Wednesday, March 17, 2010
9 March 2010
An organization called Asociacion de Mujeres Salvadoreñas, contracted by the Ministry of Health, works in Estancia to provide preventative health care for women and children. AMS holds monthly medical brigades in CAIPES to perform well-child checks, and community health promoters visit pregnant women, women who have just given birth, and neonates. Silvia, Ramiro’s wife, is one of the community health promoters.
On the day following International Women’s Day, Silvia asked me to accompany her to see two women who had just returned home from giving birth in the hospital. Both were young women in their twenties, and both had delivered via cesarean section about a week ago. I agreed to go with her, help with the initial post-delivery evaluation, and remove their stitches from the surgery.
I met Silvia at her house early in the morning, and we began the hike to the two houses. She warned me early in the walk that we would be going straight up hill, and she was right. However, as we walked, she would turn back to point out various landmarks, especially sites that had been important during the war. She showed me the top of one mountain, where a giant massacre of civilians had taken place, and as we walked we talked about how much the community had suffered, but how much the community has also overcome.
We arrived at the first house. The mom was resting on the hammock with her baby girl, and Silvia and I worked together to examine them both. Part of Silvia’s work is to make sure that babies are gaining weight and are breastfeeding, and she evaluates the feeding of every newborn. She and I checked the C-section wound, and I took out the stitches. We talked to the mom for a while about feeding, emotions after giving birth for the first time, and things to expect over the next couple of days. Silvia made an appointment with the family; she would come back to visit in three days to check up.
The second house was a little more removed. The mom had given birth before, but this was her first C-section. Once again, we set about examining the mom and her new son. Both were doing well, and the wound was closed and without signs that made us worry about infection, and we took the stitches out. Once again, we spent time talking with the parents about what to expect. Silvia also talked with this family about obtaining a birth certificate, as this process had not yet been completed.
When we finished, Silvia walked me back to the road that leads to the clinic. She continued on, as she had three pregnant women to visit before the end of the day.
--Calla
Thursday, February 18, 2010
14 February 2010
To culminate the fiestas of Cacaopera, the nearest town, a race was held on Sunday morning. Men were to run 10 kilometers, and the women 6, along the highway that runs to the northern part of the country. The highway cuts up and down the mountains, and cars often have difficulty making it up the last hill into town.
I decided to participate. The winner of the men and women each received $100, and the director of CDH, Ramiro, asked me to win and donate the money to buy more medicine. I explained that it was faulty logic to put his hopes on me, as I haven`t really run since arriving in the country. He said, "It doesn`t matter, just run as fast as you can!"
So on Sunday morning Bela and I woke up at 5 am, before the sun came up, and hiked 45 minutes straight up hill to get to the highway. We arrived, sweaty and tired, to wait for the start.
14 women participated; all were over a decade younger than me. It was a really hard run, straight down and straight up, alternating, the whole way. I ran with two high-school age girls, and when we arrived into town, I let them know that I would follow them in but they had to run fast. We all three finished together, which to me was an accomplishment given the terrain!
Bela was there waiting at the finish. He rode in the official race car of the mayor`s office. A girl from Estancia won, her second time in a row.
I feel really good about the race for two reasons. One, I finished, and was not too sore or tired at the end. Two, the race has been happening for many many years, but in August the government decided to allow women to participate. Therefore, this race was only the second that women have been able to run.
After the race, when the cash prize was being distributed, one of the workers in the mayors office came over to chat with me. He asked what sports women are allowed to play in the States. I explained, "All of them." He then borrowed the microphone from the mayor, who was distributing the prize, and said, "I think we have seen today that women can play sports. It is time to stop punishing our daughters if they go out to run, or play soccer, because one day they might be great athletes, like the two-time winner of the women`s race." I looked over, and the winner`s mom had a huge smile on her face.
--Calla
Saturday, January 30, 2010
28 January 2010
There is a patient who has been coming to the clinic for about a year with rheumatoid arthritis, a nasty painful disease requiring very toxic medications to control its progression. To properly treat this disease, the patient needs to see a rheumatologist, a specialist that can only be found in San Miguel, about a four hour journey from the clinic. The patient had last seen the rheumatologist in December. At that visit, the doctor told him to come back in a month with some lab studies and gave him medicine only for one month. The problem came when the patient tried to make the appointment with the nurse. She said the earliest he could get in with the doctor would be in July and there was nothing that could be done.
A month later when the patient was without medication and his pain was increasing he came into our clinic. Luckily we had some pills that could tide him over for the moment, but he still needed to get back in with the rheumatologist. I decided to call the rheumatologist just in case his schedule had opened up. He was super friendly and said he would make space for the patient the following Tuesday, we just had to get there by nine in the morning.
Where we live, it is impossible to arrive to San Miguel before ten in the morning. As I explained the situation to the patient, he promptly invited me to stay at his house in Cacaopera, which is closer to the hospital. It was a perfect plan.
I left the clinic the following Monday afternoon to catch the final bus to Cacaopera. We met in front of the town’s equivalent to a grocery store and walked to his house. His family was incredibly gracious and hospitable to me, and it meant a lot to me. We spent the evening eating fried fish and talking about life in El Salvador during the civil war.
A neighbor walked by while we were chatting out in front of his house. She heard there was a health care worker here and had a question. Her 7 year-old son had a painful ear that had been draining blood for about 2 months. She wondered if I could take a look at it. I happily agreed, but I couldn’t do much without my otoscope to look inside ears. I told her I would be back on Wednesday and would make sure to bring my equipment to properly assess his ear.
I recently read the book, Mountains Beyond Mountains, by Tracy Kidder. It is about Paul Farmer, a doctor that works in Haiti. He often walks miles to see a patient. In the book he remarked that when he goes to see one patient and happens to come across another, he feels like his visit was a “good cast”. For some reason I really like this fishing metaphor. It reminds of reading the New Testament in college, where Jesus called himself a fisher of men. While I have no religious inclinations, I always liked this idea. Anyway, when I saw this boy I felt like my visit had been a good cast because I had the opportunity to help two people when I had only anticipated one. I ended up coming back two days later and removed a ball of dirt about the size of a jelly bean from his ear, and I also gave him some antibiotics. I recently went back to the house. The kid was at school, but his mom told me that the ear was no longer bleeding and he was without pain. A success.
But getting back the original patient, we woke up the next morning at 4:30 to catch the 5 o’clock bus to San Miguel. The doctor was great and saw the patient with minimal delay. We were able to secure four months of medication for the patient and got him a follow-up appointment for four months as well. I got back to clinic Tuesday evening. I was exhausted but satisfied.
--Bela
29 January 2010
On Wednesday, 27 January 2010, the patient with heart failure passed away. She was at home, surrounded by friends and family. She died at five in the morning, and her family prepared her body for burial, which took place on Thursday.
She died 22 days after we met. I hope that she spent her last few weeks more comfortable based on our treatment. I think that she did, as she seemed to be drowning when I met her. She spent the last week of her life saying goodbye. Her extended family all came to visit, and members of the community held numerous ad hoc church services in her home. I visited her 10 times over the 22 days, and in that time got to talk with her, her husband, and her daughter a lot. She and her husband were married for 65 years. Additionally, in the last week of her life, her oldest great-grandson got married. She was too sick to attend the wedding, but the bride and groom came to the house after the ceremony, and brought the rice that had been served to the guests. The wedding rice was the last real food that the patient ate, and her evaluation was that it was “bien buena, un arroz tan rico como nunca he comida.”
--Calla
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